Every finding on record at Drumright Nursing Home

On 09/18/25, an IJ situation was determined to exist related to the facility's failure to protect residents from physical abuse.On 09/18/25 at 2:59 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 09/18/25 at 3:06 p.m., the administrator was informed of the existence of an IJ for abuse and the IJ template was provided.On 09/19/25 at 10:39 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 RemovalResident #28 has been referred for inpatient geri-psych services. Until such time that the resident departs the facility, the resident was immediately placed on one-on-one supervision.All staff will receive inservice training regarding abuse prevention including resident to resident abuse. Specifically, staff will receive training to intervene when resident to resident abuse occurs, report abuse immediately to the Administrator, to assess or evaluate the resident who sustained abuse for injury and document those findings in the resident record. An intervention(s) will be established for each episode of resident-to-resident abuse at the time of the occurrence, the intervention will be communicated to the staff and updated to the resident's care plan. An intervention communication form will be used to communicate to staff all new occurrences and interventions.All staff received inservice either in person or by phone call. For any staff member that could not receive inservice in person or by phone, they will be required to receive inservice before their next scheduled shift.Inservice education will be provided by the DON, RN [registered nurse], and Care Plan CoordinatorAll staff will receive inservice training by 11:59 pm on 9.18.2025All above components of the plan will be in place by 11:59 pm on 9.18.2025Resident #28 had no access to any other resident outside of the memory care unit. All residents on the memory care unit were safe from abuse immediately when one on one supervision was established for resident #28. Resident #28 was transferred via EMSA [Emergency Medical Services Authority] from the building for geri-psych services at approximately 7:00 pm on 9.18.2025By 12:00 pm on 9.19.2025 each resident on the memory care unit will receive a head to toe assessment for injury and will be asked about their safety.The Plan of Removal will be completed by 1:00 pm on 9.19.2025The IJ was lifted, effective 09/19/25 at 1:00 p.m., when all components of the plan of removal had been verified as completed. Documentation one on one supervision was provided for Resident #28, staff education regarding abuse and dementia, resident assessments for injury/head to toe assessments were reviewed. Interviews with staff were conducted to ensure education was provided regarding abuse, dementia, and the process for reporting abuse. The deficient practice remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility to ensure residents were protected from physical abuse for 3 residents (#33, 37, and #41) of 3 sampled residents reviewed for abuse.The DON identified 48 residents resided in the facility.Findings:A policy titled Policy and procedure regarding prohibition of resident abuse including corporal punishment, neglect and exploitation, revised 10/11/22, read in part, The facility will implement the seven key components for abuse prohibition which include Screen, Train, Prevent, Identify, Investigate, Protect and Report/Respond in an effort to prevent abuse, neglect and misappropriation from occurring, taking corrective action as needed and monitoring outcomes.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Physical abuse which includes but is not limited to hitting, slapping, punching, biting and kicking.Prospective residents will be screened prior to placement to determine if the facility has the capability to provide the necessary care and services to the resident.The Administrator or designee may consult with law enforcement during the course if any investigation.The facility will identify, and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses or anyone who may have knowledge of the allegation. The results of all investigations will be documented, including statements written for or by others and maintained in the administrative offices.Staff will increase supervision of the alleged victim and perpetrator and all other residents that may be impacted. If necessary, the alleged victim or perpetrator may be relocated to another room or part of the facility in an effort to protect the resident.All staff are required to report all allegations of abuse.to the Administrator, OSDH [Oklahoma State Department of Health] and local law enforcement.1. An undated order summary for Resident #28 showed diagnoses of dementia and Alzheimer's. An initial INCIDENT REPORT FORM, dated 07/04/25, showed Resident #28 slapped Resident #37 while trying to push them in their wheelchair. There was no education noted and law enforcement and the resident's family was not contacted. The investigation did not show safe surveys were conducted.A care plan for Resident #28, updated 07/04/25, showed to adjust the environment, determine situation, establish routine, refer to senior psych evaluation, and staff to learn the subtle changes. An admission MDS assessment, dated 07/07/25, showed Resident #28 had a BIMS of 9 indicating moderately impaired cognition, physical behaviors towards others, and verbal behaviors towards others. The assessment showed they were independent with mobility.An initial INCIDENT REPORT FORM, dated 07/12/25, showed Resident #28 started yelling at Resident #33 while they were walking down the hall. The form showed Resident #28 slapped Resident #33 to the floor causing them to hit their head making a knot form. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.An initial INCIDENT REPORT FORM, dated 08/04/25, showed Resident #28 slapped Resident #37 in the face in the hallway. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.A care plan for Resident #28, updated 08/22/25, showed to administer medication as ordered, assess and anticipate resident's needs, give as many choices as possible, when agitated intervene before agitation escalates, document observed behavior and attempt interventions, and physical and verbal cues to alleviate anxiety.An initial INCIDENT REPORT FORM, dated 09/06/25, showed Resident #28 slapped Resident #33 on the left cheek. The form showed redirection, one on one activity with staff, ABH gel, continue medication management, and monitor were the interventions. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.An initial INCIDENT REPORT FORM, dated 09/09/25, showed Resident #28 entered Resident #41's room to attempt to take their walker. The form showed Resident #41 stated to let it go and Resident #28 picked up a shoe and hit Resident #41 in the face with it.The form showed PRN medication for agitation and anxiety was administered. The form showed 15 minute checks were initiated for Resident #28 and Resident #41 was monitored for safety by staff. There was no education noted and law enforcement was not contacted. The investigation did not show safe surveys were conducted.A care plan for Resident #28, updated 09/09/25, showed to apply ABH gel and to give medication. 2. An undated order summary for Resident #33 showed diagnoses of Alzheimer's and dementia.A quarterly MDS assessment, dated 06/15/25, showed Resident #33 had a BIMS of 00 which indicated severe cognitive impairment, no behaviors, and independent with mobility.An Incident Note, dated 07/12/25, showed a CNA alerted the nurse to report to the memory unit where Resident #33 was on the floor lying parallel to the bed in Resident #28's room. The nurse witnessed Resident #28 standing over Resident #33 while they laid on the floor.Resident #33's care plan was not updated to reflect the incident on 07/12/25. 3. An undated order summary for Resident #37 showed diagnosis of Alzheimer's disease.A quarterly MDS assessment, dated 05/28/25, showed Resident #37 had a BIMS of 00, indicating severe cognitive impairment, no behaviors, and independent with mobility.An Incident Note, dated 07/04/25, showed Resident #37 was smacked in the head above their ear by Resident #28.Resident #37's care plan was not updated to reflect the incident on 07/04/25.4. An undated order summary for Resident #41 showed diagnosis of vascular dementia.A quarterly MDS assessment, dated 07/02/25, showed Resident #41 had a BIMS of 9, indicating moderately impaired cognition, no behaviors, and independent with mobility.A care plan, initiated 09/09/25, showed Resident #41 had a physical altercation with Resident #28.A physician visit note, dated 09/10/25, showed Resident #41 was seen by the nurse practitioner and had soreness in their face when they were hit by another resident (Resident #28).On 09/17/25 at 4:20 p.m., CNA #1 stated Resident #28 had punched Resident #33 in the eye. They stated they did not receive any education following the incident. They stated Resident #41 had been smacked with a shoe by Resident #28. They stated they did not receive education following the incident. They were not aware of incidents with Resident #37.On 09/17/25 at 4:32 p.m., LPN #2 stated Resident #41 had been hit in the face with a shoe by Resident #28. They stated Resident #33 had two altercations with Resident #28 in the hallway on the way to the dining room. LPN #2 stated Resident # 28 attempted to kiss Resident #37 in the hallway and they slapped each other.On 09/17/25 at 5:03 p.m., the administrator stated they and the DON completed investigations. They stated the process for investigating resident to resident abuse was the staff always called the administrator and they sent in the state reportable to adult protective services. The administrator stated if there were any objective physical injuries like bleeding or a fracture, they would send out for medical evaluation. The administrator stated they would make sure the residents were separated and them conduct a 30 minute watch. The administrator stated they made sure the nurse called the doctor, family, Adult Protective Services, administration, and the DON. They stated in the memory care they just had slaps, but nothing serious.On 09/17/25 at 5:16 p.m., the administrator stated local law enforcement was notified if a resident to resident altercation resulted in a major injury, missing money, missing something of value, physical abuse, financial abuse, and sexual abuse. The administrator stated they were aware of the rules, and they were informed at a seminar conducted by the Centers or Medicare and Medicaid Service that they did not have to call the police every time as they would not do anything. The administrator stated they made a determination if the incident was significant enough for them to be notified.On 09/17/25 at 5:20 p.m., the administrator was asked where the documentation of local law enforcement being contacted for the resident to resident incident between Resident #28 and #37. They stated if it was a slap on the wrist then most likely not.On 09/17/25 at 5:30 p.m., the administrator stated Resident #41 was slapped on the head. They stated law enforcement was a waste of time and they did not do anything. They stated they did not call on this incident. They stated there were no safe surveys as there was nothing to follow up on as there were no injuries. They stated the safe surveys and education was a nursing thing that they were not sure of was done.On 09/17/25 at 5:46 p.m., the administrator asked LPN #2 if they had educated staff following the incident with Resident #28 and #37. LPN #2 stated they did not document anything and did not know to call law enforcement.On 09/17/25 at 5:52 p.m., the IP stated they did not have a QA for the incident with Resident #28 and #37.On 09/17/25 at 5:58 p.m., the administrator was asked if local law enforcement was contacted for the incident with Resident #28 and #33. They stated apparently not.On 09/17/25 at 6:13 p.m., the administrator stated they did not contact law enforcement. The administrator stated there were no safe surveys, no education, no QA, and no new interventions for the incident with Residents #28 and #37.On 09/17/25 at 6:15 p.m., the administrator stated they did not contact law enforcement. The administrator stated there were no safe surveys, no education, no QA, and no new interventions for the incident with Residents #28 and #33.On 09/17/25 at 6:16 p.m., the administrator stated they did not contact law enforcement. The administrator stated there were no safe surveys, no education, no QA, and no new interventions for the incident with Residents #28 and #41.On 09/17/25 at 6:38 p.m., the administrator stated Resident #28 had not been seen by counseling.

Based on record review and interview, the facility failed to:a. prevent a fall during transportation for 1 (#2); andb. ensure interventions were initiated after a fall for 1 (#9) of 3 sampled residents reviewed for accidents.The DON identified 48 residents resided in the facility. Findings:An INCIDENT POLICY AND PROCEDURE policy, revised 03/31/23, read in part, The charge nurse will complete an incident report including all information known about the incident as well as immediate corrective measures implemented.1. Resident #2's admission resident assessment, dated 08/14/25, showed the resident had diagnoses which included severe protein-calorie malnutrition and adult failure to thrive. The assessment showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident was dependent on staff assistance for on activities of daily living and transfers. A hospital After Visit Summary, dated 09/11/25, showed Resident #2 had diagnoses which included fall, injury of head, and laceration of right lower extremity.A combined Initial and Final State Reportable Incident form, dated 09/12/25, showed certain injuries. The incident form showed Resident #2 slid out of their wheelchair and had a laceration to their right lower leg during transportation of the resident to their doctor's appointment. The incident report showed the resident was taken to the nearest hospital and had seven sutures to their right lower extremity. The incident report showed during investigation, the transport van did not have working seatbelt for the transportation of residents in a wheelchair.On 09/15/25 at 1:19 p.m., Resident #2 stated they fell in the transport van on 09/11/25 on their way to an appointment because they were not buckled in correctly. They stated they were taken to the emergency room and received six to seven stitches on their right shin. Resident #2 stated the transport driver was instructed to take them to the nearest hospital instead of calling 911.On 09/17/25 at 12:35 p.m., transporter #1 stated they started transporting residents the week of 09/08/25.On 09/17/25 at 12:36 p.m., transporter #1 stated Resident #2 was in a wheelchair and there were four buckles to secure the wheelchair to the van. They stated they were not aware the resident needed to be secured.On 09/17/25 at 12:38 p.m., transporter #1 stated they were not educated on what was needed for transportation of residents.On 09/17/25 at 12:39 p.m., transporter #1 stated they had slowed down due to construction on the road and heard Resident #2 yell. They stated they looked back and saw the resident's leg had hit the ledge in front of them and was bleeding. They stated they were going at a speed of about 10 miles per hour. Transported #1 stated they pulled over into a safe area, unhooked the resident's wheelchair, and laid them on the floor of the van. Transporter #1 stated they called the IP and was instructed to take the resident to the nearest hospital which was about three to four minutes away.On 09/17/25 at 2:22 p.m., the administrator stated maintenance personnel, transporter #1, and themselves were responsible for transporting residents. They stated transporter #1 started transporting residents in September 2025.On 09/17/25 at 2:27 p.m., administrator stated the facility did not have any specific routine safety checks for the transport van prior to the incident onOn 09/17/25 at 2:36 p.m., the administrator stated the van did not have a wheelchair seatbelt because they could not find the other strap. They stated transporter #1 did not notify the administrator of the missing wheelchair seatbelt and proceeded to transport the resident to their appointment. The administrator stated transporter #1 failed to secure Resident #2 during transport.2. A fall incident report, dated 08/09/25 at 9:30 a.m., showed Resident #9 was found lying on their back at the corner of the foot of the bed. The incident report showed the resident was unable to give reason for the fall and there were no injuries.There was no documentation any interventions were implemented to prevent future falls related to the fall incident on 08/09/25.A fall incident report, dated 08/15/25 at 7:15 a.m., showed Resident #9 was trying to get out of their wheelchair unassisted and slid to their buttock with the feet rest of the wheelchair under the resident. The incident report showed the resident sustained a skin tear above their right elbow and was not wearing nonskid socks.There was no documentation any interventions were implemented to prevent future falls or injury related to the fall incident on 08/15/25.A fall incident report, dated 08/26/25 at 10:00 a.m., showed Resident #9 was found sitting on the floor. Resident #9 stated they scooted themselves down onto the floor on the edge of their bed. The incident report showed the resident stated they hit their head. Neurological checks were initiated, and the resident was put on one on one until they became sleepy.There was no documentation any interventions were implemented to prevent future falls or injury related to the fall incident on 08/26/25.Resident #9's significant change in status resident assessment, dated 09/02/25, showed the resident's cognition was severely impaired with a BIMS of 03.A care plan, revised 09/11/25, showed Resident #9 had diagnoses of dementia in other diseases classified elsewhere, moderate, without disturbance, psychotic disturbance, mood disturbance, and anxiety, history of falling, and unsteadiness on feet. The care plan showed Resident #9 was a high risk for falls related to confusion, gait and balance problems, and unaware of safety needs.On 09/18/25 at 1:46 p.m., LPN #1 stated nurses initiated fall interventions based on the root cause of the fall.On 09/18/25 at 2:46 p.m., the ADON stated there were no fall interventions for the above dates. They stated interventions could include the use of a fall mat, remove footrest, and keep the bed low.

Based on record review and interview, the facility failed to ensure PRN psychotropic medications were limited to 14 days for 2 (#9 and #28) of 5 sampled residents reviewed for unnecessary medication.The DON identified 48 residents resided in the facility. Findings: An undated facility policy titled Other drugs needing special handling and attention, read in part, Psychotropics drugs effective 11.28.17 PRN orders for psychotropic drugs are limited to 14 days, unless the physician believes that it is appropriate for the PRN to be extended beyond 14 days. The physician will document their rationale in the resident's medical record and indicate the duration of the PRN order. 1.Resident #9's physician's order, dated 07/25/25, showed lorazepam (antianxiety medication) 0.5 mg tablet. Give 0.5 mg by mouth every six hours as needed for anxiety related to dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #9's order for lorazepam had no stop date. An August 2025 MAR showed lorazepam was administered 14 times past the 14 days. The MAR showed the medication was administered on 08/09/25, 08/11/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25, 08/19/25, 08/21/25, 08/23/25, 08/27/25, and 08/28/25. Resident #9's significant change in status resident assessment, dated 09/02/25, showed the resident's cognition was severely impaired with a BIMS of 03. A care plan, revised 09/11/25, showed Resident #9 had diagnoses of dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The care plan showed the resident received antianxiety medication. A September 2025 MAR showed lorazepam was administered four times. The MAR showed the medication was administered on 09/02/25, 09/03/25, and 09/04/25. On 09/19/25 at 9:39 a.m., the DON stated PRN use of psychotropics was limited to 14 days unless the physician documented a rationale in the resident's medical record. On 09/19/25 at 9:40 a.m., the DON stated Resident #9's lorazepam order had no stop date. On 09/19/25 at 9:46 a.m., the DON stated the pharmacist consult, dated 08/14/25, showed the physician needed to evaluate the PRN use of lorazepam for Resident #9. They stated the physician's response, dated 08/18/25, showed no changes and no rationale was provided for the continuation of PRN lorazepam. On 09/19/25 at 9:50 a.m., the DON stated Resident #9 received lorazepam three times in July 2025, 18 times in August 2025, and four times in September 2025. 2. Resident #28's admission assessment, dated 07/07/25, showed the resident's cognition was moderately impaired with a BIMS of 9. Resident #28's physician's order, dated 08/27/25, for Ativan/lorazepam 2mg/1ml apply to neck/wrist topically every six hours as needed for anxiety/refusal to take PO meds for 60 days. The stop date for the Ativan was for 10/26/25. Resident #28's physician's order, dated 09/08/25, for ABH (Ativan-antianxiety medication, Benadryl-antihistamine medication, Haldol-antipsychotic medication combination used for severe agitation) gel apply to neck/wrist topically every six hours as needed for agitation/refusal PO meds for 60 days. The stop date for the ABH was for 11/07/25. A care plan, revised 09/09/25, showed Resident #28 had diagnoses of disruptive mood dysregulation disorder, anxiety disorder, mild cognitive impairment, disorientation, manic episode, behavioral disturbance related to Alzheimer's and dementia. The care plan showed the resident received psychotropic medications. Resident #28's August 2025 MAR showed lorazepam was administered six times. The Ativan had been administered after the 14 days from when it was ordered on 08/27/25. The stop date did not meet regulatory standard of 14 days then reevaluate. Resident #28's September 2025 MAR showed ABH gel was administered one time and the lorazepam was administered seven times. The stop date did not meet regulatory standard of 14 days then reevaluate. On 09/19/25 at 2:38 p.m., LPN #2 stated the ABH gel was ordered on 09/08/25 with an end date of 11/07/25. They stated it was to be for no more than 14 days. LPN #2 stated the order was for 60 days. LPN #2 stated they were required to have an assessment after 14 days. LPN #2 stated Resident #28 received the ABH gel on 09/09/25 which was within the 14 days, but it did not meet the 14 day requirement. On 09/19/25 at 2:46 p.m., LPN #2 stated the Ativan PRN was started on 08/27/25 with a stop date of 10/26/25. They stated it was ordered for 60 days. They stated it had exceeded 14 days. They stated PRN psych medications needed to be assessed after 14 days. LPN #2 stated Resident #28 received Ativan five days in August 2025. They stated on the 27th, 28th, 29th, 30th, and 31st. LPN #2 stated Resident #28 received Ativan five days in September 2025. They stated on the 1st, 2nd, 3rd, 4th, 5th, and 8th. On 09/19/25 at 2:52 p.m., LPN #2 was asked if there was a rational for both PRN medications to exceed the 14 days. They stated if the person putting in the order did not put to reassess, then it would default to the 60 days.

Based on record review and interview, the facility failed to ensure a resident's discharge assessment was transmitted for 1 (#24) of 12 sampled residents whose assessments were reviewed.The DON identified 48 residents resided in the facility. Findings:Resident #24's discharge assessment return not anticipated, dated 05/31/25, showed the resident had a planned discharge on [DATE].There was no documentation the discharge resident assessment was transmitted.On 09/22/25 at 10:03 a.m., the ADON stated the registered nurse was responsible for transmitting the completed resident assessments.On 09/22/25 at 10:06 a.m., the IP stated they tried to transmit resident assessments within five days of completion.On 09/22/25 at 10:09 a.m., the IP stated Resident #24's discharge assessment dated [DATE] was not transmitted.

Based on observation, record review, and interview, the facility failed to ensure a nebulizer mask and tubing was stored in a manner to prevent cross contamination for 1 (#58) of 1 sampled resident reviewed for respiratory care.The DON identified 48 residents resided in the facility. Findings: On 09/15/25 at 12:42 p.m., a nebulizer mask was observed laying on Resident #58's nightstand.On 09/22/25 at 10:46 a.m., a nebulizer mask was observed laying on Resident #58's nightstand. The part of the tubing that connected to the machine was laying on the floor by the resident's bed.An undated facility policy titled POLICY AND PROCEDURE REGARDING CLEANING AND MAINTENANCE OF NEBULIZERS, OXYGEN SUPPLIES AND METERED DOSE INHALERS, read in part, when the equipment is not in use, it may be stored in a plastic container or covering.Resident #58's physician's order, dated 09/08/25, showed ipratropium-albuterol inhalation solution (a breathing treatment) 3mg/3ml, inhale one vial orally four times a day for wheezing.Resident #58's admission resident assessment, dated 09/12/25, showed the resident's cognition was severely impaired with a BIMS of 06.A care plan, dated 09/15/25, showed Resident #58 had diagnosis of unspecified chronic obstructive pulmonary disease and received breathing treatments.On 09/15/25 at 12:41 p.m., Resident #58 stated they received nebulizer treatments daily.On 09/22/25 at 10:48 a.m., LPN #1 stated after nebulizer treatment, they would clean the nebulizer mask, set it on a paper towel, and leave it on the sink to air dry in the resident's room. They stated they would leave the mask at the sink until the next treatment.On 09/22/25 at 10:52 a.m., LPN #1 stated Resident #58's nebulizer mask and tubing was not stored appropriately. They stated the tubing was on the floor.On 09/22/25 at 10:55 a.m., the DON stated the nebulizer mask should be cleaned with soap and water, air dried, and stored in a plastic container or covering when not in use. They stated the container or covering should be labeled with the resident's name.

On 06/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent a resident with a cognitive deficit and a history of exit seeking behaviors from eloping from the facility. An order note, dated 03/08/25, showed Resident #1 tried to get out the front door. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). A wander risk assessment, dated 04/12/25, showed Resident #1 was a high risk (score 15) for wandering. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. Resident #1 made it one block down the road to Cimarron before worker realized they were gone. Staff assisted the resident into their car and drove the resident back to the facility. A care plan for the resident's elopement risk was not created until 05/12/25. A heath status note, dated 05/30/25, showed Resident #1 exhibited exit seeking behaviors. A combined initial and final facility reported incident, dated 06/01/25, showed Resident #1 escaped the building through the front door of the facility. Resident #1 was seen walking down the highway by the nursing home in the opposite direction. On 06/01/25 from 3:53 p.m. to 6:53 p.m., the outside temperature in [NAME] Oklahoma was 84 degrees Fahrenheit. Highway OK-33 is located in front of the facility, approximately 25 feet from the entrance door. The facility is surrounded by residential roads on the other three sides. A behavior note, dated 06/23/25 at 10:38 a.m., showed Resident #1 had attempted to exit the front door. An initial facility reported incident, dated 06/23/25, showed LPN #1 was called to the front door. The reported incident showed Resident #1 was walking across the facility lawn. The reported incident showed LPN #1 and two CNAs went to the resident and directed them back into the facility and into bed. On 06/23/25 from 9:53 a.m. to 12:53 p.m., the outside temperature in [NAME] Oklahoma ranged from 85 to 100 degrees Fahrenheit. The care plan was not updated after the resident's elopement on 06/01/25 and 06/23/25. On 06/25/25 at 4:21 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 06/25/25 at 4:50 p.m., the administrator and DON were notified of the IJ situation. On 06/27/25 at 10:53 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Effective immediately, one on one staff assignment has been made for Resident #1. Staff will remain within 10-15 feet of the resident at all times. Other interventions include prevent resident #1 from exiting the building and engage resident in a meaningful activity. Resident #1's care plan will be updated to reflect each episode of exiting the facility and will reflect the intervention described above. All other residents identified as exit seeking have had their care plan updated to reflect interventions when demonstrating exit seeking behaviors. All current staff on duty will receive inservice training that will include the intervention of one on one for resident #1, the identification of any other current resident who demonstrates exit seeking behavior, how to identify exit seeking behavior in any other current resident, to notify the nurse immediately when any resident demonstrates exit seeking behavior or elopes the facility. Staff were instructed to prevent each resident with exit seeking behavior from leaving the building and to attempt to engage the resident in a meaningful activity. All remaining staff will be inserviced either in person or by phone by 10 pm on 06.25.2025 on the above information. For those staff members inserviced by phone or otherwise unable to contact, those staff members will receive additional in person inservice at the start of their next shift. The IJ was lifted, effective 06/25/25 at 10:00 p.m., when all components of the plan of removal had been verified as completed. This was verified by observing the location of residents at risk for exit seeking behaviors, staff interviews, review of in-service information, and a review of resident records to ensure interventions were in place for residents who exhibited exit seeking behaviors. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide supervision to prevent a resident with a cognitive deficit and a history of exit seeking behaviors from eloping from the facility for 1 (#1) of 3 sampled residents reviewed for elopement. The infection control nurse identified six residents at risk for elopement resided in the facility. Findings: 1. On 06/25/25 at 9:03 a.m., as the surveyor was standing in the parking lot of the facility, they observed two semi trucks pass by on the highway that was located approximately 25 feet from the entrance of the facility. There were also a large set of stairs outside the facility entrance door that led to the parking lot. On 06/25/25 at 10:21 a.m., Resident #1 was observed lying in bed, then sat up independently on the side of their bed. Resident #1 started touching their blanket, giggled, then pointed to their gold colored blanket. The resident began to speak, but the words were nonsensical. On 06/25/25 at 10:25 a.m., Resident #1 moved their bedside table to the side and laid back down in their bed independently. There were no staff present in the resident's room. On 06/25/25 at 12:16 p.m., Resident #1 was observed standing in their room. CNA #2 brought the resident their meal tray and asked if the resident wanted to sit in their chair. Resident #1 walked over to the sink and obtained a napkin. On 06/25/25 at 12:17 p.m., CNA #2 opened the bathroom door and Resident #1 walked into the bathroom. CNA #2 opened the resident's meal tray and cut up the enchilada, opened the dessert, and opened the cups of liquids. On 06/25/25 at 12:19 p.m., Resident #1 exited the bathroom walked toward the surveyor and talked about their head. CNA #2 had to direct the resident on how to get soap on their hands and the resident rubbed their hands together and rinsed them in the sink. On 06/25/25 at 12:21 p.m., Resident #1 walked over to the recliner, sat down, and CNA #3 pulled the bedside table over, and put sour cream on the enchilada. The resident thanked CNA #3. CNA #3 cleaned up the resident's room, handed the resident a call light, and told the resident they would be out in the hallway if they needed anything. On 06/25/25 at 12:25 p.m., CNA #2 exited Resident #1's room. An undated procedure for locating and reporting missing residents, read in part, It shall be the plan of this facility to locate a missing client/resident as quickly as possible and return him/her to the facility to prevent an accident or any type of actual harm that might occur .Upon discovery that there is a missing client/resident, this facility will .Make a thorough search of the building for the missing client/resident and request any information from any of client/resident or visitor who may have observed any actions or have any comments concerning the missing client/resident .Make a thorough search of the grounds and land adjacent to the building .If not found, notify administrator if available. If Administrator cannot be located within 30 minutes then the next person in charge will be located and notified .Send one employee as a minimum to search the vicinity .If not found within two hours the police department is to be notified and supplied with the name and description of the client/resident along with the description of the clothing worn by the client/resident when last seen .The next of kin, responsible part, or individual who visits the client/resident shall be notify of the missing client/resident within two hours .When the client/resident is determined to be missing the Oklahoma State Department of Health will be notified by verbal or written report within 24 hours of the approximate time that the client/resident was discovered missing. An order note, dated 03/08/25, showed Resident #1 tried to get out the front door. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). The assessment showed Resident #1 had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder. A wander risk assessment, dated 04/12/25, showed Resident #1 was a high risk (score 15) for wandering. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. The note showed the resident made it down to Cimarron one block down the road before a worker realized they were gone. The note showed CNA #3 brought the resident back in their car and took the resident back down to their room. The note showed no injuries were found. A care plan for the resident's elopement risk was not created until 05/12/25. Resident #1's care plan, dated 05/12/25, showed the resident had the potential for elopement/exit seeking wandering. The approaches showed staff were to complete the wander risk inventory on admission, quarterly, and as needed, and staff were to ensure exit doors were activated/alarmed. The care plan showed if wandering/exit seeking was observed, staff were to remain with Resident #1, engage them in a meaningful activity or redirect the resident. It showed staff would instruct family, visitors, and residents to not open the door for others without checking with nursing staff. The care plan did not document the actual elopement on 05/10/25. A heath status note, dated 05/30/25, showed Resident #1 exhibited exit seeking behaviors. A combined initial and final facility reported incident, dated 06/01/25, showed Resident #1 escaped the building through the front door of the facility. Resident #1 was seen walking down the highway by the nursing home in the opposite direction. The facility reported incident showed the resident was placed on 15 minute checks to ensure safety. On 06/01/25 from 3:53 p.m. to 6:53 p.m., the outside temperature in [NAME] Oklahoma was 84 degrees Fahrenheit. Highway OK-33 is located in front of the facility, approximately 25 feet from the entrance door. The facility is surrounded by residential roads on the other three sides. The care plan was not updated after the resident's elopement 06/01/25. The forms provided to the surveyor for the every 15 minute checks following the incident were: a. one completed status location form dated 06/02/25 from 6:45 a.m. through 11:45 a.m.; b. one completed status location form dated 06/03/25 from 12:00 a.m. to 8:15 a.m.; c. one unlabeled, undated form that started at 5:00 p.m. and went through 11:45 p.m. There were blanks for the 6:30 p.m. and 6:45 p.m. checks; and d. one unlabeled, undated form that started at 12:00 p.m. and went through 11:45 p.m. There were blanks from 3:30 p.m. through 6:45 p.m. for the every 15 minute checks. A behavior note, dated 06/23/25 at 10:38 a.m., showed Resident #1 had attempted to exit the front door. An initial facility reported incident, dated 06/23/25, showed LPN #1 was called to the front door. The facility reported incident showed Resident #1 was walking across the facility lawn. The facility reported incident showed LPN #1 and two CNAs went to the resident and directed them back into the facility and into bed. The form was completed by LPN #1. On 06/23/25 from 9:53 a.m. to 12:53 p.m., the outside temperature in [NAME] Oklahoma ranged from 85 to 100 degrees Fahrenheit. The care plan was not updated after the resident's elopement on 06/23/25. On 06/25/25 at 10:08 a.m., family member #1 stated there were confused residents in the facility who tried to enter their loved one's room. They stated when they visited the facility, residents were in their wheelchairs at the front door, but family member #1 had not experienced them trying to leave the facility when they entered or left the facility. On 06/25/25 at 10:17 a.m., LPN #1 stated Resident #1 was a high elopement risk. They stated the resident had dementia and an altered mental status. They stated Resident #1 walked independently. On 06/25/25 at 1:04 p.m., family member #2 stated Resident #1's mind was not 100 percent. They stated at times, Resident #1 did not know family member #2's name. On 06/25/25 at 1:08 p.m., family member #2 stated they had been called several times over the past month and a half by the facility regarding exit seeking behaviors. They stated on two occasions Resident #1 did get out of the facility. Family Member #2 stated on one occasion Resident #1 went toward the residential neighborhood and someone had brought them back in a car. They stated the other time Resident #1 went right out the front door towards the highway. On 06/25/25 at 1:11 p.m., family member #2 stated the facility told them they were watching for where Resident #1 was at in the building. They stated the facility was doing what they could to care for Resident #1. On 06/25/25 at 1:21 p.m., CNA #1 stated if a resident did go outside the building, they would do their best to try to get them back inside. They stated they would notify the DON and administrator depending on how far they got. On 06/25/25 at 1:26 p.m., CNA #1 stated the facility doors were locked and required a code to open. They stated if you pushed on the door too long, it would open after about 15 seconds. They stated that was probably how the residents were getting out. On 06/25/25 at 1:27 p.m., CNA #1 stated Resident #1's cognition was not the best. They stated the resident was not oriented to person, place or time. They stated the resident would often ask where they were and what was going on. On 06/25/25 at 1:28 p.m., CNA #1 stated they were not working at the time, but had heard Resident #1 had escaped the building a couple of times. They stated staff were to check on the resident every fifteen minutes and document what they were doing. On 06/25/25 at 1:32 p.m., CNA #1 stated Resident #1 walked independently. On 06/25/25 at 1:32 p.m., the administrator stated Resident #1 had severe dementia. They stated in the last month, the resident was smart enough to know if they pushed on the door 15 seconds it would open. The administrator stated they could not afford to have a guard standing at the gate 24 hours a day to guard the door. On 06/25/25 at 1:34 p.m., the administrator took the surveyor down a hall where no residents resided. There was a double door at the end of the hall the administrator explained this was going to be the memory unit at the facility. They stated Resident #1 would be the first resident when it opened and it would be a locked unit. On 06/25/25 at 1:36 p.m., the administrator stated once the facility got the memory unit opened in the next seven to 14 days, Resident #1 would not be able to get out anymore. They stated that was their plan of correction. On 06/25/25 at 1:39 p.m., the administrator stated they were proactively dealing with Resident #1. On 06/25/25 at 2:18 p.m., CNA #2 stated the past couple of times a resident had eloped the facility had completed every fifteen minute checks on Resident #1. They stated they were here when Resident #1 escaped on 06/23/25. CNA #2 stated staff went outside, redirected the resident, sat them outside, and brought them in through the door of the skilled unit. CNA #2 stated Resident #1 had been wandering all morning that day. They stated a coworker redirected the resident to the dining room. CNA #2 stated when they came back from the bathroom, kitchen staff alerted them Resident #1 was outside because they could see them through the windows in the dining room. CNA #2 stated that was when they went and got the resident from outside. On 06/25/25 at 2:22 p.m., CNA #2 stated they took Resident #1 to the bathroom, laid them down, and were completing every fifteen minute checks on the resident to prevent them from eloping again. CNA #2 stated the resident was pretty drained because it was pretty hot outside. CNA #2 stated the resident was near the [NAME] Nursing Home sign by the highway when they got them. On 06/25/25 at 2:25 p.m., CNA #2 stated they had not received training related to elopement. They stated the door was locked and a code was needed to open it. They stated if you held the door long enough, it would open. They stated they believed that was with every door. On 06/25/25 at 2:49 p.m. CNA #3 stated they did not know the policy for elopement. They stated they knew elopement was when a resident was exit seeking. They stated if a resident did exit the building, they would first assess the situation and make sure they were ok. They stated they would speak to them calmly and try to redirect them in the right direction. On 06/25/25 at 2:51 p.m., CNA #3 stated they had not received any training related to elopement. 06/25/25 at 2:52 p.m., CNA #3 stated the facility had doors that locked and required security codes to keep residents from exiting the building. They stated they believed the memory care unit that was opening would help. On 06/25/25 at 2:54 p.m., CNA #3 stated on 05/10/25, they saw Resident #1 walking down the road when they got off work. CNA #3 stated they brought the resident back to the facility in their car. On 06/25/25 at 2:58 p.m., CNA #3 took the surveyor outside and pointed to [NAME] the road directly behind the skilled unit. CNA #3 stated they believed Resident #1 was on Pine and thought Resident #1 got out through the skilled door but no one knew for sure. CNA #3 stated Resident #1 had been trying to go out the skilled door earlier on their shift and they had to redirect them that night before they left. CNA #3 stated Resident #1 made it another block and a half. They stated they picked Resident #1 up at Pine and Cimarron. CNA #3 stated they were doing 15 minute checks on the resident, but was not sure if they were still in place. They stated they were unsure if the resident had gotten out another time but, We all know [the resident] has attempted it. On 06/25/25 at 2:34 p.m., LPN #1 stated the policy for elopement was to get the resident safe and into the facility if possible, notify the physician, DON, administrator and family. They stated they had been completing 15 minute checks and were working on a policy for how long the facility was going to complete the 15 minute checks. They stated staff tried to keep as many eyes on the resident to keep them safe and prevent elopement if possible in the future. On 06/25/25 at 2:36 p.m., LPN #1 stated they did not think they had received specific training on elopement. They stated if a resident exhibited exit seeking behaviors they would try to redirect them with an activity, snack, or some alone time in their room. They stated they would also increase the amount of times they were checking on them. On 06/25/25 at 2:37 p.m., LPN #1 stated the facility had double doors with a lock system on them and staff were at the desk most of the time to keep an eye on the door. On 06/25/25 at 2:38 p.m., LPN #1 stated Resident #1 was only alert and oriented to self. They stated the resident often times looked for their family. They stated the resident was confused and needed help finding their room. They stated the resident walked on their own. On 06/25/25 at 2:39 p.m., LPN #1 stated they were only present for Resident #1's elopement on 06/23/25. They stated prior to the elopement, the resident was exhibiting exit seeking behaviors. LPN #1 stated staff took the resident to their room, changed their clothes, got them a drink in the dining room and took them to the television room. LPN #1 stated Resident #1 seemed comfortable in the dining room. LPN #1 stated they had to go complete blood sugars and heard a scream and observed Resident #1 walking on the lawn. They stated they along with two other staff members got the resident back inside through the side door. LPN #1 stated they believed Resident #1 pushed the door for the 15 seconds and it opened. On 06/25/25 at 2:41 p.m., LPN #1 stated they resident agreed to go to bed because they were tired and wanted to go home. They stated once the resident was able to see their personal belongings, they recognized their room. LPN #1 stated they obtained the resident's vital signs, looked the resident over, and placed the resident on 15 minute checks. On 06/25/25 at 2:45 p.m., LPN #1 stated they were aware of other elopements and believed Resident #1 had eloped two or three times in the past month or two. On 06/25/25 at 3:03 p.m., the infection control nurse stated RN #1 who completed the facility reported incident on 06/01/25 was the former DON. They stated RN #1 had not been at the facility since 06/15/25. On 06/25/25 at 3:06 p.m., the infection control nurse stated to their understanding, if a resident got out of the facility and did not leave the property, they completed an internal incident report and notified the administrator and DON. They stated if the resident left the property including getting to the highway, a State reportable incident should be completed and the administrator, DON, family, and physician should be notified. They stated staff would go and look for the resident, and once located and brought back, then everyone would be notified. On 06/25/25 at 3:08 p.m., the infection control nurse stated they had not received training related to elopement. They stated Resident #1 was always looking for their family member. They stated when Resident #1 left, they were trying to find their family member. On 06/25/25 at 3:09 p.m., the infection control nurse stated the facility had locked doors. They stated if the doors did not shut all the way, an alarm would sound so staff would know it was open. They stated the facility did have a couple exit seeking residents. On 06/25/25 at 3:10 p.m., the infection control nurse stated Resident #1 had full blown dementia and did not know they were in a nursing home. They stated the resident did know their name and knew who their family member was. They stated the resident walked on their own and went to the bathroom on their own. On 06/25.25 at 3:12 p.m., the infection control nurse stated the elopement they knew about for Resident #1 was on 05/10/25. They stated the only way they knew about the one on 06/23/25 was LPN #1 came in and said there was a commotion in the dining room. They stated another resident was hollering for staff because they were in the dining room and saw Resident #1 was outside. They stated Resident #1 was in the front lawn towards the highway. They stated they did not know about the one on the highway, but was told about it. On 06/25/25 at 3:16 p.m., the infection control nurse stated as of now the facility was going to continue the 15 minute checks on Resident #1 until the memory care unit was opened on 07/01/25. On 06/25/25 at 3:19 p.m., the DON stated they had just looked up the elopement policy. They stated staff were to look around the building grounds and if the resident was missing two hours, they were to notify the police. They stated staff were to notify the family immediately. They stated they were to give a description of the resident, complete a State reportable within 24 hours, and complete an incident report. On 06/25/25 at 3:20 p.m., the DON stated they had not received or provided any training related to elopement, but it was on the list. They stated when residents were exhibiting exit seeking behaviors, staff were to redirect or distract them by taking them to the television room, giving them an activity to do, or give them a snack. They stated staff were to be notified when residents exhibited exit seeking behaviors and the information was to be passed on in report. On 06/25/25 at 3:22 p.m., the DON stated the facility had coded doors and a different code to enter and exit the building. They stated they were break away doors and if you held them long enough they would open. The DON stated if a resident did elope, staff were to notify the DON and the administrator, complete a head to toe assessment to make sure there were no injuries, and complete frequent checks. They stated it was not in the policy, but they usually completed every 15 minute checks. On 06/25/25 at 3:23 p.m., the DON stated Resident #1 was very confused and oriented to self only. They stated the resident ambulated independently most of the time. On 06/25/25 at 3:25 p.m., the DON stated they were unable to find the every 15 minute checks for the 05/10/25 or the 06/01/25 elopement of Resident #1. They stated the every fifteen minute checks were to be documented on the status location forms. The DON stated the 06/01/25 facility reported incident did document Resident #1 was on every fifteen minute checks to ensure safety. The DON stated Resident #1 was on 15 minute checks now. On 06/25/25 at 3:28 p.m., the DON stated Resident #1 was on every 15 minute checks for 24 hours, then the facility was completing every 30 minute checks. The DON stated they spoke to the facility nursing specialist who instructed them to go ahead and keep the resident on 15 minute checks because they were such a high risk. On 06/25/25 at 3:30 p.m., the infection control nurse brought in the every 15 minute checks and every 30 minute checks for Resident #1 for the elopement on 05/10/25 and 06/01/25. There were forms dated 05/10/25 through 05/12/25 completed. For the 06/01/25 elopement, they provided two forms with no dates, one form dated 06/02/25 and one form dated 06/03/25. The infection control nurse stated there were no dates on the two pages and if it was not dated they did not know when it was done. The infection control nurse identified the blanks in documentation on one of the undated forms from 3:30 p.m. through 6:45 p.m. On 06/25/25 at 3:32 p.m., the infection control nurse identified the blanks in documentation for 6:30 p.m. and 6:45 p.m. on the other undated form. On 06/25/25 at 3:54 p.m., the DON stated Resident #1's most recent wander risk assessment was completed on 04/12/25 and showed the resident was a high risk to wander. On 06/25/25 at 4:16 p.m., the administrator stated the facility did not have a specific elopement policy. They stated they had a missing persons policy. They stated when staff realized a resident was missing, it was all hands on deck and everyone looked for them. They stated if they could not locate them, they would notify the police and fire department to complete an area search. They stated most of the time they would catch them on the property, bring them back inside and complete every 15-30 minute checks on them to watch them more closely. On 06/25/25 at 4:20 p.m., the administrator stated they completed orientation with new employees and they assumed elopement was discussed in the training procedure. They stated you did not need any formal training, it was common sense if someone was wandering staff needed to keep an eye on them. The administrator stated when Resident #1 first exited the building, the nurse was the former DON. The administrator stated they would think they would know to send something into the State. The administrator stated when they returned to the facility the following Monday after 05/10/25, they asked staff if they completed a report to the state and they said no. The administrator stated they instructed them to complete one. They stated they did not think RN #1 even put anything in the nurses' note. On 06/25/25 at 4:26 p.m., the administrator stated the nurses and aides were busy. They stated they could see Resident #1 one minute and three minutes later they were out the door. They stated they wished they could lock the door where they could not get out, but due to life safety, they could not. They stated they were shocked Resident #1 was cognitive enough to push on the door until it opened. The administrator stated they facility was keeping a close eye on the resident and documenting every 15 minute checks. They stated prior to 05/10/25 they had no problems, and all of a sudden Resident #1 escapes three times. The administrator stated the DON was new, but the infection control nurse would know what assessment they used to identify residents at risk for elopement. The administrator stated they were unable to remember if QAPI was involved in the elopements and to ask the infection control nurse to verify. On 06/25/25 at 4:36 p.m., the infection control nurse stated the facility completed a wandering risk under the assessment tool to determine a resident's elopement risk. They stated they were completed quarterly. On 06/25/25 at 4:38 p.m., the infection control nurse stated QAPI had not had any involvement with the elopements. 2. A quarterly resident assessment, dated 03/30/25, showed Resident #8's BIMS score was 15 (cognitively intact). On 06/25/25 at 10:34 a.m., Resident #8 stated the door to the facility was supposed to be locked. They stated a couple days ago, a resident got out. Resident #8 stated they did not know what the resident was doing playing on the highway. They stated there were two or three residents who liked to get out of the facility because their minds weren't right. Resident #8 stated they did not know the names of the residents. 3. An annual resident assessment, dated 05/29/25, showed Resident #9's BIMS score was 15 (cognitively intact). On 06/25/25 at 10:41 a.m., Resident #9 stated there were residents who wandered in the facility. They stated they had to keep their door to the bathroom locked so Resident #1 and Resident #2 would not wander into Resident #9's room.

Based on record review and interview, the facility failed to ensure a resident's care plan was updated to reflect each time the resident eloped from the facility for 1 (#1) of 3 sampled residents reviewed for elopement. The infection control nurse identified six residents at risk for elopement resided in the facility. Findings: A resident care plan policy, revised 03/27/17, read in part, The comprehensive care plan will be reviewed and updated by the IDT [interdisciplinary team] after each quarterly and annual assessment thereafter. A quarterly resident assessment, dated 03/15/25, showed Resident #1's BIMS was 06 (severe cognitive impairment). The assessment showed Resident #1 had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder. An incident note, dated 05/10/25 at 7:35 p.m., showed Resident #1 escaped the facility at approximately 7:00 p.m. The note showed the resident made it down to Cimarron one block down the road before a worker realized they were gone. The note showed CNA #3 brought the resident back in their car and took the resident back down to their room. The note showed no injuries were found. A care plan for the resident's elopement risk was not created until 05/12/25. Resident #1's care plan, dated 05/12/25, showed the resident had the potential for elopement/exit seeking wandering. The approaches showed staff were to complete the wander risk inventory on admission, quarterly and as needed and staff were to ensure exit doors are activated/alarmed. The care plan showed if wandering/exit seeking was observed, staff were to remain with Resident #1, engage them in a meaningful activity or redirect the resident. The care plan showed staff would instruct family, visitors, and residents to not open the door for others without checking with nursing staff. The care plan did not document the actual elopement on 05/10/25. A combined initial and final facility reported incident, dated 06/01/25, showed Resident #1 escaped the building through the front door of the facility. Resident #1 was seen walking down the highway by the nursing home in the opposite direction. The facility reported incident showed the resident was placed on 15 minute checks to ensure safety. The care plan was not updated after the resident's elopement on 06/01/25. An initial facility reported incident, dated 06/23/25, showed LPN #1 was called to the front door. The reported incident showed Resident #1 was walking across the facility lawn. The facility reported incident showed LPN #1 and two CNAs went to the resident and directed them back into the facility and into bed. The form was completed by LPN #1. The care plan was not updated after the resident's elopement on 06/23/25. On 06/25/25 at 1:08 p.m., family member #2 stated they had been called several times over the past month and a half by the facility regarding exit seeking behaviors. They stated on two occasions Resident #1 did get out of the facility. Family Member #2 stated on one occasion Resident #1 went toward the residential neighborhood and someone had brought them back in a car. They stated the other time Resident #1 went right out the front door towards the highway. The person responsible for updating care plans was unavailable for interview on 06/25/25 because they were in a training session. On 06/25/25 at 3:47 p.m., the DON reviewed Resident #1's care plan and stated they did not find any updates to the care plan after the resident eloped form the facility. On 06/25/25 at 4:26 p.m., the administrator stated the ADON was at the State completing classes and was responsible for care plans and assessments. They stated if a resident had a history of elopement, it needed to be care planned. They stated they were assuming Resident #1's elopements were care planned. On 07/02/25 at 1:27 p.m., the ADON stated they would update a resident's care plan when they were on an antibiotic, if they fell, and with any diagnoses, they would update the care plan. They stated the dashboard on the computer told them when a care plan needed to be completed and reviewed.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of abuse from staff for 2 (#1 and #2) of 3 sampled residents reviewed for abuse. The administrator identified 45 residents resided in the facility. Findings: A Policy and procedure regarding prohibition for resident abuse including corporal punishment, neglect and exploitation, revised 10/2022, read in part, Interviewing by standers, witnesses et. as soon as possible .Staff will increase supervision .and all other residents that may be impacted . All staff are required to report .OSDH, law enforcement and/or adult protective services. 1. Resident #1 had diagnoses which included major depressive disorder, schizoaffective, and paranoid disorder. Resident #1's quarterly resident assessment, dated 02/24/25, showed a BIMS score of 15, indicating the resident's cognition was intact. An OSDH initial incident report form, dated 03/09/25, did not show adult protective services was notified of the allegation. An attachment to the initial incident report, dated 03/09/25, and labeled Part B; OSDH, showed statements from staff of Resident #1 stating Resident #1 was scared to go to bed because CNA #1 was rough and rushed them. An attachment to the initial incident, dated 03/10/25, signed by the administrator, showed they were notified and had interviewed Resident #1 about the allegation against CNA #1. The attachment showed there was no evidence of any specific abuse towards the resident. There were no other resident interviews located for the incident dated 03/09/25. On 03/17/25 at 6:12 p.m., Resident #1 stated they were not fearful of anyone and had not experienced abuse. 2. Resident #2 had diagnoses which included major depressive disorder. Resident #2's quarterly resident assessment, dated 01/03/25, showed a BIMS score of 9, indicating the resident's cognition was moderately impaired. An OSDH initial incident report form, dated 02/11/25, Part B, showed, the morning of 02/12/25 during evening rounds the night before the CNA for that hall came into Resident #2's room and stated they needed to check them. The report showed the resident stated they did not want to be changed. The report showed the CNA informed them they wanted to check them and proceeded to check them. The report showed Resident #2 was upset and wanted to report that they did not want to be changed or checked and did not want the CNA working their hall any longer. The initial incident report sent to OSDH on 02/11/25 did not show APS or Nurse Aide Registry notification of the allegation. On 03/17/25 at 6:20 p.m., Resident #2 stated they were not fearful of anyone and had not experienced abuse. On 03/17/25 at 8:06 p.m., CNA #2 stated Resident #2 was very particular with their care. They stated they had a fall out the other day because they were rushing that morning and Resident # 2 did not like that. They stated they apologized to Resident #2 and they were all good now. On 03/18/25 at 10:27 a.m., CNA #2 stated they went to check Resident #2 on rounds. CNA #2 stated Resident #2 had stated they were not wet. CNA #2 stated they asked the Resident #2 again and they stated they were not wet. CNA #2 stated Resident #2 made a vulgar statement so they thought the resident was joking. CNA #2 stated they proceeded to check the resident's pad with their hand. CNA #2 stated the Resident #2 then hit their hand and said they were going to report them. CNA #2 stated they had to write a statement and were not to go into Resident #2's room anymore. On 03/18/25 at 12:01 p.m., the DON stated the process for reporting abuse was for staff to call them immediately. The DON stated the administrator was the abuse coordinator and they typically did the report to state. The DON stated they contact the family, send to state, interview other residents, and interview the staff. The DON stated they interviewed a little bit of everybody. The DON stated they do not contact anyone outside of the facility except the family. On 03/18/25 at 12: 03 p.m., the DON stated APS was not notified about the allegation involving Resident #1 on 03/09/25 or Resident #2 on 02/11/25. The DON stated there were no resident interviews for the allegation/incident on 03/09/25 and there was no notification to the nurse aide registry for the allegation/incident on 02/11/25. The DON stated the investigations on 02/11/25 and 03/09/25 were not thoroughly completed.

Based on observation, record review, and interview, the facility failed to ensure a resident received treatment and monitoring of a newly developed pressure ulcer for one (#51), and provide treatment and services to prevent worsening of a pressure ulcer for one (#49) of three sampled residents reviewed for pressure ulcers. This resulted in worsening of both resident's pressure ulcers. The DON identified six residents with pressure ulcers. Findings: A facility POLICY AND PROCEDURE FOR THE PREVENTION AND TREATMENT OF PRESSURE ULCERS, revised 08/28/08, read in part, .Should a resident have an existing pressure ulcer or develop a pressure ulcer post admission, the facility will implement procedures to evaluate the ulcer regularly .The facility will evaluate the ulcer at least weekly, utilizing a flow sheet that notes the location of the ulcer, the stage, presence of eschar, size, color odor, drainage, tunneling/sinus tract/undermining if present .The facility will notify the physician upon the onset of the ulcer an obtain treatment orders .The facility will notify the physician if the ulcer appears to be deteriorating or if no improvement is noted in 2-4 weeks of the initial treatment orders . 1. Res #49 admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease and amputation of right lower leg. A skin assessment, dated 03/13/24, documented a new stage II pressure ulcer measuring 1.0 cm x 1.0 cm x 0 cm to the left heel as facility acquired. A physician order, dated 03/14/24, documented to cleanse wound on left heel with normal saline, pat dry, apply Betadine, and leave open to air every day shift. A wound assessment, dated 03/20/24, documented the wound to the heel was a stage I pressure ulcer facility acquired measuring 0.5 cm x 0.5 cm x 0.1 cm. A wound assessment, dated 03/27/24, documented the wound to left heel was a stage I facility acquired measuring 0.5 cm x 0.4 cm x 0.1 cm. The resident was admitted to the hospital from 04/01/24 through 04/19/24. A wound assessment, dated 04/19/24, documented the resident readmitted with a SDTI to the left heel with 85% slough/necrosis tissue measuring 0.5 cm x 0.5 cm x 0 cm. A wound assessment, dated 04/26/24, documented the heel wound as an admitted SDTI with 40% slough/necrosis measuring 0.5 cm x 0.5 cm x 0 cm. A physician order, dated 04/26/24, documented to cleanse the wound to the heel with normal saline, pat dry, apply collagen silver and cover with bandage each day shift. The TAR and skilled nursing notes for April 2024 were reviewed. There was no documentation wound care was performed 04/26/24 through 04/28/24. A wound assessment, dated 05/01/24, documented an admission SDTI wound to the left heel with 75% slough/necrosis measuring 0.25 cm x 0.5 cm x 0 cm. The TAR and skilled nursing notes for May 2024 were reviewed. There was no documentation wound care was performed 05/01/24 through 05/06/24. A wound assessment, dated 05/06/24, documented an admission SDTI to the left heel with 75% necrosis measuring 0.5 cm x 0.5 cm x 0.25 cm. A nurse progress note, dated 5/6/2024 at 7:16 p.m., documented staff attempted to send the resident to the hospital for significant changes to the left heel wound. It was documented the resident declined transfer. On 05/07/24 at 9:30 a.m., LPN #3 was observed performing wound care to the resident's left heel. The wound was not covered with a dressing upon removal of the sock. The wound bed was pink with approximately 50% yellow slough covering. The wound was not measured, but was approximately the diameter of a dime with depth. On 05/07/24 at 11:26 a.m., LPN #3 stated wound care was documented on the TAR. On 05/07/24 at 11:32 a.m., the DON stated the wound care was not completed according to the documentation for 04/26/24 through 05/01/24. They stated based on the measurements of the wound it had worsened. On 05/07/24 at 11:39 a.m., the ADON stated the wound could not be a SDTI if it was open. 33097 2. Res #51 had diagnoses which included type 2 diabetes mellitus, pain, pressure induced deep tissue damage of the right heel, and a stage I pressure ulcer of the right heel. An admit/readmit screener, dated 02/14/24, documented the resident had bruising to the right antecubital and right hand. It was documented the resident had an abrasion to the right elbow and redness to the chest and left and right iliac crest. It was documented the resident had a stage II pressure wound measuring 3 cm x 1.5 cm x 0.2 cm to the coccyx. A weekly wound observation tool, dated 02/18/24, documented the resident had a stage I pressure wound to the right heel. It was documented the wound measured 4.5 cm x 4 cm x 0 cm. It was documented the wound was acquired during the resident's stay at the facility. A five day admission assessment, dated 02/20/24, documented the resident was dependent for assistance to roll from their back and side to side. It was documented the resident was frequently incontinent of urine and was always incontinent of bowel. The assessment documented the resident had one stage I pressure ulcer and one stage II pressure ulcer that was present on admission. A weekly wound observation tool, dated 02/22/24, documented the resident had a stage II pressure wound to their coccyx measuring 1 cm x 1.5 cm x 0.1 cm. It was documented the resident's wound had worsened. A health status note, dated 03/08/24, documented treatment was to continue to the open coccyx wound measuring 2.0 cm x .5 cm x 0.1 cm. It was documented staff was to continue treatment for the abrasion to the left posterior knee 0.8 cm x 1.3 cm x 0.1 cm. and to the right heel with dark hard necrotic tissue measuring 4.5 cm x 4.0 cm x no depth. A weekly wound observation, dated 03/13/24, documented the resident had an in facility acquired pressure wound stage I measuring 4.5 cm x 4.0 cm x unknown. A physician order, dated 04/01/24, documented the resident was to use turn rails if able to assist with bed mobility and turning every two hours. A health status note, dated 04/07/24, documented a 0.5 cm x 0.5 cm round pressure wound was found below the existing coccyx wound. It was documented treatment was in place and every two hour repositioning. There was no treatment order or weekly wound assessment for the pressure wound found on 04/07/24 below the coccyx wound. A weekly wound assessment, dated 04/09/24, documented the stage II to the right heel had been resolved. A physician order, dated 04/24/24, documented Calmoseptine Externam Ointment 0.44 - 20.6% was to be applied to the buttocks topically every shift for preventative. A physician order, dated 04/25/24, documented staff were to cleanse the area to the coccyx with normal saline, apply collagen alginate to the wound bed, and cover with a dressing every day. It was documented staff were to remove the dressing and brief at bedtime to allow for airing out. On 05/06/24 at 10:55 a.m., the resident was observed lying in bed. They were moaning and stated their buttocks hurt. They rated their pain at a nine on a pain scale from zero to 10. Staff stated the resident had a wound on their buttock. On 05/07/24 at 9:20 a.m., LPN #2 performed wound care for the resident. They gathered their supplies to perform the treatment. They measured the coccyx wound. LPN #2 was asked about the wound to the buttock and the wound to the right heel observed. They did not respond to the question. There was no documentation regarding the coccyx treatment or the identified wound to the buttock and right heel. On 05/09/24 at 10:15 a.m., the ADON conducted a skin assessment for the resident. They stated the resident had two pressure ulcers. A stage II pressure ulcer to the buttocks and the right heel pressure ulcer had returned. The ADON stated no assessments or treatment orders had been documented or obtained. On 05/09/24 at 12:52 p.m., the ADON stated there was no documentation regarding repositioning the resident every two hours. The ADON stated they relied on staff to reposition the residents every two hours per physician orders.

Based on record review and interview, the facility failed to ensure the individual functioning as the social worker met the required qualifications for a facility with more than 120 beds. The administrator identified 54 resident resided in the facility. Findings: An Oklahoma State Department of Health Nursing Facility License, issued on 11/07/22, documented the facility was licensed for a maximum of 133 beds. On 05/08/24 at 10:00 a.m., the ADON and DON were asked if they had a qualified social worker on a full time basis. They stated they did have a full time social worker and they would check on their qualifications. On 05/08/24 at 12:06 a.m., the DON stated their social worker had an associate in arts and had six years of experience as a case manager at a prison. They stated they did not have a bachelors degree. They stated they were licensed for 133 beds, but they did not have that many beds.

Based on observation, record review, and interview, the facility failed to prepare and serve food in a sanitary manner. The DM identified 52 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: An undated Spectrum Advance Hand Sanitizer Gel safety data sheet, read in part, .Flammable liquid and vapor .Keep away from heat/sparks/open flames/hot surfaces .Keep product and empty container away from heat and sources of ignition .Do not eat, drink or smoke when using this product . On 05/07/24 at 11:45 a.m., dietary aide #1 was observed preparing drinks for the lunch meal in the dining room. They entered the kitchen for a container of coffee, then returned to the dining room to prepare drinks. They did not wash their hands when entering the kitchen. Dietary aide #1 was observed entering the kitchen and preparing the coffee maker to make more coffee. They exited the kitchen and continued to prepare drinks for the meal. They did not wash their hands when entering the kitchen. Dietary aide #1 was observed entering the kitchen for a third time and obtained a gallon of milk from the refrigerator. They exited the kitchen and continued preparing drinks. They did not wash their hands when entering to kitchen. On 05/07/24 at 11:55 a.m., dietary cook #2 was observed serving the lunch meal. They were working from a steam table and the oven was to their left with food items being heated on top of the stove. A dispenser of Spectrum Advance Sanitizer was hung on the wall between the oven and the steam table. Dietary cook #2 was observed wiping their nose and the sweat from their forehead, then used the hand sanitizer from the dispenser on the wall. They repeated this process two times, did not wash their hands, and continued to serve the meal. Dietary cook #1 stated the sanitizer was an alcohol based hand cleaner. On 05/07/24 at 12:04 p.m., the DM stated they did not know hand sanitizer could not be used in the kitchen. The DM stated everyone who entered the kitchen should wash their hands with soap and water.

Based on observation, record review, and interview, the facility failed to maintain an infection control program to help prevent the transmission of infections for two (#2 and #51) of three sampled residents reviewed for pressure ulcers. The DON identified six residents with pressure ulcers. Findings: An undated facility WOUND DRESSINGS policy, read in part, .Gather supplies: 3 or more pairs of Gloves; Wax paper; .Anything brought into the room must be cleaned or discarded .Place wax paper on a clean, dry surface next to where you will be working. Set up supplies on waxed paper . 1. Res #2 had diagnoses which included severe sepsis, need for assistance with personal care, pain, and personal history of other diseases of the musculoskeletal system and connective tissue. A physician order, dated 04/01/24, documented cleanse the area to the inner left foot with Betadine and cover with a protective dressing daily. On 05/08/24 at 9:40 a.m., LPN #2 was observed performing wound care for the resident. They gathered their supplies, placed them in a metal pan, and entered the resident's room. They moved a box of markers off a stack of coloring pages and placed the metal pan on the coloring sheets sitting on the resident's bedside table. LPN #2 completed the wound care, gathered their supplies, and washed their hands. They placed the metal pan used in the resident's room on the treatment cart. They charted on the computer and placed the metal pan in the third drawer of the treatment cart with other supplies. LPN #2 did not clean the surface of the metal pan that touched the resident's personal belongings and bedside table. On 05/08/24 at 10:30 a.m., the DON stated LPN #2 should have cleaned the pan when leaving the resident's room and with contact with the resident's personal belongings. 2. Resident #51 had diagnoses which included type 2 diabetes mellitus, pain, pressure induced deep tissue damage of the right heel, and a stage I pressure ulcer of the right heel. On 05/07/24 at 9:20 a.m., LPN #1 was observed performing wound care for the resident. Near the resident's door there was a three drawer container that contained PPE supplies. A sign on the container documented enhanced barrier precautions. LPN #1 stated gloves, a gown, and a mask must be worn when wound care was performed for infection control. They gathered their supplies and placed them in a metal pan. They entered the resident's room and placed the metal pan on the resident's bedside table. They did not clean the bedside table or provide a clean barrier. LPN #1 completed the wound care and placed the metal pan on the resident's bed to gather the trash. They exited the room and placed the metal pan on the three drawer container, then on top of the treatment care, and then in the third drawer of the treatment cart with clean supplies. LPN #1 did not clean the surface of the metal pan that touched the resident's bedside table and bed before returning it the supply drawer. On 05/07/24 at 10:40 a.m., LPN #1 stated they should have cleaned the metal pan after touching the resident's personal belongings.

Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature and palatable. The DM identified 52 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: 33148 1. A quarterly resident assessment, dated 02/20/24, documented Res #5's cognition was intact. On 05/06/24 at 7:45 a.m., the resident was asked how was the food. They stated some of the food was not good. They stated they ate in their room and sometimes the food was cold. 2. A quarterly resident assessment, dated 04/29/24, documented Res #7 was moderately impaired in cognition. On 05/06/24 at 9:27 a.m., the resident stated the food was not good. They stated the food was cold all the time and sometimes it was so salty it would cross your eyes. They stated the facility would provide a sandwich as an alternative. They stated the biscuit served for breakfast was so hard they could not eat it. 3. A quarterly resident assessment, dated 04/28/24, documented Res #14's cognition was intact. On 05/06/24 at 8:17 a.m., the resident was asked how was the food. They stated they ate in their room and the food was cold when they received it. 4. A quarterly resident assessment, dated 02/17/24, documented Res #22's cognition was intact. On 05/06/24 at 8:41 a.m., the resident was asked how was the food. They stated the food was always cold. 5. A quarterly resident assessment, dated 02/28/24, documented Res #30's cognition was intact. On 05/06/24 at 7:57 a.m., the resident was asked how was the food. They stated the food was always cold. 6. An admission assessment, dated 04/22/24, documented Res #40's cognition was intact. On 05/06/24 at 8:23 a.m., the resident was asked how was the food. They stated the food was not good. They stated they ate in their room and their food was cold by the time they got it. 7. An annual assessment, dated 04/27/24, documented Res #155's cognition was intact. On 05/06/24 at 9:33 a.m., the resident was asked how was the food. They stated the food was not good. On 05/07/24 at 1:01 p.m., a food test tray was received from the kitchen. The breaded squash served was luke warm and had no flavor. The temperature of the breaded squash was 108 degrees Fahrenheit with a hand held thermometer. 46387

Based on record review and interview, the facility failed to ensure a PRN psychotropic medication was limited to 14 days for one (#3) of five sampled residents reviewed for unnecessary medications. The DON identified five residents who had orders for PRN psychotropic medications. Findings: Res #3 had diagnoses which included anxiety and agitation. A physician order, dated 12/01/23, documented Ativan suspension (benzodiazepine medication) 1 mg/ml. Give 0.5 ml sublingually every fours hours as needed for 14 days. The February 2024 MAR document Ativan was administered on 02/26/24 and 02/28/24. The March 2024 MAR documented Ativan was administered on 03/03/24, 03/11/24, and 03/21/24. On 05/08/24 at 10:07 a.m., the ADON and DON were made aware of the resident's Ativan order. The ADON stated the order should have stopped and been reassessed. )

Based on record review and interview, the facility failed to ensure a resident discharged from Part A skilled services, with benefit days remaining, was issued a SNF ABN and/or NOMNC notice for one (#53) of four sampled residents reviewed for beneficiary notices. The Beneficiary Notice worksheet identified eight residents were discharged from Part A skilled services with benefit days remaining in the past six months. Findings: Res #53 was admitted to the facilty for skilled services on 02/27/24 with diagnoses which included COPD, heart failure, CKD, type 2 diabetes mellitus, amputation of toes, and history of falling. An undated Benefit Eligibility Details report, documented as of 04/01/24 the resident had five days of skilled service remaining. Health status notes, dated 04/01/24, documented the resident's oxygen saturation dropped and the breathing treatment administered was ineffective. It was documented the nurse listened to the resident's lung sounds and wheezing was noted to the right lower lobe and the left lobe was diminished. It was documented the resident was sent out to the hospital and admitted . A social service note, dated 04/02/24, documented the resident's family member was contacted and advised the the resident was in the hospital past their discharge date from skilled nursing services. It was documented it would be up to the resident's family member and the hospital to arrange the resident's transportation home. There was no documentation a SNF ABN and/or NOMNC notice was provided to the resident and/or their legal representative. On 05/08/24 at 10:01 a.m., the ADON and DON were asked when was the resident's last day of skilled service and if beneficiary notice forms were provided to the resident and/or their legal reprentative. On 05/08/24 at 11:38 a.m., the ADON stated the resident had five days of skilled service left when they went to the hospital. They stated they did not know the reason the resident's family member was informed they had no skilled service days remaining. They stated once the resident returned to the facility they should have been provided beneficiary notice forms. They stated they were to give a two day notice.

Based on record review and interview, the facility failed to ensure a discharged resident's clinical record contained a discharge summary for one (#54) of one sampled resident reviewed for facility initiated discharge. The administrator identified 54 residents resided in the facility. Findings: Res #54 had diagnoses which included COPD, heart failure, type 2 diabetes mellitus, panic disorder, and major depressive disorder. A physician order, dated 02/29/24, documented the resident was discharged home. There was no documentation a discharge summary was completed. On 05/07/24 at 11:07 a.m., the ADON was asked if a discharge summary had been completed for the resident. On 05/07/24 at 11:57 a.m., the ADON stated they had 30 days to complete a discharge summary and a discharge summary was not completed.

Based on record review and interview, the facility failed to notify a resident and/or their representative of the resident's discharge in writing 30 days before the resident was discharged for one (#54) of one sampled resident reviewed for discharge. The administrator identified 54 residents resided in the facility. Findings: Res #54 was admitted to the facility on [DATE] with diagnoses which included COPD, heart failure, type 2 diabetes mellitus, panic disorder, and major depressive disorder. A social service note, dated 01/24/24, documented the resident had been denied nursing home Medicaid due to not sending in verification. It was documented the resident's family member was notified. A social service note, dated 02/22/24, documented the facility contacted DHS about the resident's long term care. It was documented the resident's case was still pending. A health status note, dated 02/29/24, documented the resident was discharged home. On 05/07/24 at 11:57 a.m., the ADON was asked the reason for the resident's discharge. They stated the resident did not have payer source. They were asked if a discharge notice was provided to the resident and/or their representative. On 05/07/24 at 12:08 p.m., the ADON stated there was no written notice provided. They stated the administrator gave a verbal 30 day notice.

Based on record review and interview, the facility failed to ensure a resident's code status was accurate for one (#7) of one sampled resident reviewed for advance directives. The administrator identified 54 residents resided in the facility. Findings: Res #7 was admitted to the facility on [DATE] with diagnoses which included heart disease, COPD, presence of a pace maker, chronic pain, and CKD, A DNR consent form, dated [DATE], documented the resident gave consent for DNR. A physician order, dated [DATE], documented CPR. On [DATE] at 10:02 a.m., the ADON and DON were asked to verify the resident's code status. On [DATE] at 11:05 a.m., the ADON stated the resident had a DNR on file and they were supposed to be a DNR.

Based on record review and interview, the facility failed to refer a resident with a newly evident or possible serious mental illness to the OHCA for a level II PASRR evaluation for one (#28) of two sampled residents reviewed for PASRR's. The administrator identified 54 residents resided in the facility. Findings: A level I PASRR, dated 06/27/23, documented Res #28 did not have evidence or diagnosis of a serious mental illness. On 07/28/23, the resident had a new diagnosis of bipolar type schizophrenia disorder. On 07/29/23, the resident had new diagnosis of borderline personality disorder and mood disorder due to known physiological condition with depressive features. There was no documentation the resident had been referred to the OHCA for a level II PASRR evaluation. On 05/08/24 at 10:04 a.m., the ADON and DON were made aware the resident had a negative level I pre-screen and was later identified with newly evident of possible serious mental illness. They were asked if the resident was referred to the OHCA for a level II PASRR evaluation. On 05/08/24 at 11:36 a.m., the ADON stated the resident was not referred to the OHCA for a level II PASRR evaluation.

Based on record review and interview, the facility failed to ensure a resident was permitted to return to the facility after they were hospitalized for one (#53) of one sampled resident reviewed for hospitalization . The administrator identified 54 residents resided in the facility. Findings: An undated Notice of Bed Hold policy, read in part, .It will be the facility's policy that any resident who is transferred to a hospital for a period of less than five days will have the right to return and expect the bed and room which he/she resided at the time of his/her transfer .If a resident who is transferred with an expectation of returning to the facility cannot return to the facility, the resident will be discharged according to policy . Res #53 was admitted to the facilty for skilled services on 02/27/24 with diagnoses which included COPD, heart failure, CKD, type 2 diabetes mellitus, amputation of toes, and history of falling. Health status notes, dated 04/01/24, documented the resident's oxygen saturation dropped and the breathing treatment administered was ineffective. It was documented the nurse listened to the resident's lung sounds and wheezing was noted to the right lower lobe and the left lobe was diminished. It was documented the resident was sent out to the hospital and admitted . A social service note, dated 04/02/24, documented the resident's family member was contacted and advised the the resident was in the hospital past their discharge date from skilled nursing services. It was documented it would be up to the resident's family member and the hospital to arrange the resident's transportation home. 05/08/24 at 11:38 a.m., the ADON was asked about the resident's discharge and their bed hold policy. They stated the resident had five days of skilled service left when they went to the hospital. They stated they did not know the reason the resident's family member was informed they had no skilled service days remaining. They stated their bed hold policy was five days. They stated the resident had no payer source after skilled days.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician of worsening pressure ulcers. The resident was admitted to the facility on [DATE] with one stage II pressure ulcer on the right buttock that measured 2 cm x 3 cm. The resident subsequently developed additional pressure ulcers on the left buttock and the sacrum. The resident was sent to the hospital on [DATE], with increasing weakness, decreased oxygen saturation levels, and worsening pressure ulcers. Hospital records documented upon arrival to the hospital, the resident was found to be septic with an advanced stage III to IV sacral pressure ulcer with active drainage, necrotic tissue, bone exposure, and tunneling into the right and left gluteal muscles and pelvic area. The pressure ulcer required a 10 cm x 10 cm x 7 cm surgical debridement with [DEVICE] treatment. Biopsies of the debrided area revealed [MEDICAL CONDITION] of the soft tissue and osteo[DIAGNOSES REDACTED] in the sacral bone. The resident expired in the hospital on [DATE]. At 12:41 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 12:44 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to notify the physician of worsening pressure ulcers. On [DATE] at 2:33 p.m., an acceptable plan of removal was provided. The plan of removal documented, .1. Physician Notification: In service will be conducted to all nurses regarding physician notification including, but not limited to ~ When and how soon the physician should be notified ~ Where physician notification should be documented ~ Why the physician is being notified ~ Notifying the DON and Admin of all changes in condition A change in notification form will be completed by the nurses for the DON and Admin to monitor daily in stand up. The weekend RN will monitor these forms on Saturday and Sunday if there are any, and then they will be addressed in stand up. This form will include date, time, resident's name, the stated change in condition, and the physician's response/new orders, physician/DON/Admin notified, and if it was documented in the chart . This plan of removal will be completed on [DATE] by midnight (12:00 am). The immediate jeopardy was removed on [DATE] at 11:15 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to notify the physician of worsening pressure ulcers and the development of new pressure ulcers for two (#3 and #4) of four sampled residents who had pressure ulcers. Resident #3 was admitted to the facility on [DATE] with one stage II pressure ulcer. The resident was sent to the hospital on [DATE], and was found to be septic, with an advanced stage III to IV sacral pressure ulcer with active drainage, necrotic tissue, bone exposure, and tunneling into the right and left gluteal muscles and pelvic area. The pressure ulcer required a 10 cm x 10 cm x 7 cm surgical debridement with [DEVICE] treatment. Biopsies of the debrided area revealed [MEDICAL CONDITION] of the soft tissue and osteo[DIAGNOSES REDACTED] in the sacral bone. The resident expired in the hospital on [DATE]. Resident #4 developed a facility acquired unstageable pressure ulcer to the left buttock. The facility had knowledge of the pressure ulcer and did not notify the physician of the pressure ulcer for a minimum of three days. The facility identified 50 residents as residing in the facility and no residents with pressure ulcers. Findings: The facility's policy for notification of changes, dated ,[DATE], documented, .Except in a medical emergency or when a resident is incompetent, this facility will consult with the resident immediately and notify the resident's physician .when there is: .A significant change in the resident's physical, mental, or psychosocial status . The facility's policy and procedure for the prevention and treatment of [REDACTED].The facility will notify the physician upon the onset of the ulcer and obtain treatment orders . The facility will notify the physician if the ulcer appears to be deteriorating or if no improvement is noted in ,[DATE] weeks of the initial treatment orders . Orientation/training forms, dated [DATE], for RN #1 and LPNs #1, #2, #3, #4, and #5 documented, .Knows procedure for completion of wound care, collection of wound characteristic data and required documentation . The forms were signed by the director of nursing. 1. A hospital wound care team progress note for resident #3, dated [DATE], documented, .Pressure Ulcer Stage .II .Sacral .Length 3 cm Width 2 cm Depth 0.1 cm . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden Scale form, used for predicting pressure sore risk and dated [DATE], documented the resident scored a 14. The form documented, .Total score of 12 or less represents HIGH RISK . An untitled facility form, dated [DATE], documented the resident had three open areas on the buttocks/sacral area. The form had the image of a body on it, and there were three circles drawn on the body image, with two on the right buttock and one on the sacral area. It was documented, .Open areas . There were no measurements or descriptions of the areas. A nurse's note, dated [DATE] at 1:35 p.m., documented, .(right) buttock c a 3 cm x 1.5 cm open area also gaulding to buttock . The note did not contain any other documentation related to pressure ulcers. A wound flow sheet, dated [DATE], documented the resident had a stage II pressure ulcer on the right buttock. It was documented the pressure ulcer measured 2 cm x 3 cm and was pink in color. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Admission physician orders, dated [DATE], documented the resident was to receive Prostat, a protein supplement, 30 ml daily and B-complex vitamins daily as a supplement. The orders documented to clean the right buttock daily with normal saline and apply Venelex ointment and cover with [MEDICATION NAME] border. It was also documented the resident could have a urinary catheter due to impaired skin integrity. An informed consent form for the use of an indwelling urinary catheter, dated [DATE], documented, .may have foley catheter d/t impaired skin integrity . The form was signed by the resident, the physician, and a member of the facility staff. A physician's progress note, dated [DATE], documented, .(right) buttock 2 x 3 cm open area . A skilled nurse's note, dated [DATE] and untimed, documented, .Tx done on (right) buttock. 8 cm long x 0.25 cm wide open area noted to coccyx area. Call made .N.O. apply Venelex (and) cover c [MEDICATION NAME] .Staff reminded to reposition q 2 (hours) and encourage resident to get (up) . A physician's telephone order, dated [DATE], documented to use Venelex ointment for all open areas on the buttocks. A wound flow sheet, dated [DATE], documented the resident had a stage II pressure ulcer to the coccyx. It was documented the pressure ulcer measured 8 cm x 0.25 cm, was red, and had some bleeding. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. A skilled nurse's note, dated [DATE] at 7:00 p.m., documented, .Lying in bed c eyes open. c/o (left) hip pain. PRN pain medication given .Asked if resident would like to sit (up) in chair for a little while. Resident very hesitant afraid it will make her hurt more . A skilled nurse's note, dated [DATE] at 6:45 p.m., documented, .Buttocks are red c open areas . A physician's telephone order, dated [DATE], documented the resident was to receive Vitamin C, 500 mg daily and Zinc, 220 mg daily for wound healing. A wound flow sheet, dated [DATE], documented the resident had a stage II pressure ulcer on the left buttock. It was documented the ulcer measured 3 cm x 3 cm and that Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. There was no documentation to show the physician was notified of the new open area to the left buttocks. Medication administration records, dated [DATE], documented the resident did not receive the ordered Prostat. It was documented, .not in . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. An admission assessment, dated [DATE], documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, and toileting. It was documented the resident had occasional pain that was very horrible and limited her activities. It was also documented the resident was at risk for pressure ulcers; had one stage II pressure ulcer; and had pressure relieving devices for her bed and chair. A wound flow sheet, dated [DATE], documented the right buttock pressure ulcer was a stage II ulcer that measured 1 cm x 1 cm. An additional measurement of 2 cm x 2 cm was documented. It was documented the ulcer was raw and pink, and Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. A physician's progress note, dated [DATE], documented, .Buttocks .wounds .open 3 x 4 cm area . A physician's telephone order, dated [DATE] documented, .Air mattress to bed Gel cushion to w/c . A skilled nurse's note, dated [DATE] at 9:30 a.m., documented, .n.o. for air mattress to bed and gel cushion to w/c . A skilled nurse's note, dated [DATE] at 6:00 p.m., documented, .Redness/open areas to pannus/buttocks . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. A skilled nurse's note, dated [DATE] at 4:00 a.m., documented, .Buttocks c redness, excoriation to anal area .c/o buttocks pain. given prn order of [MEDICATION NAME] . An undated physician's telephone order, signed by the physician on [DATE], documented to clean the open area to the left buttocks, apply Venelex, and cover daily. The order was listed on the physician telephone order sheet between an order written [REDACTED]. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. The resident's care plan, dated [DATE], documented a problem related to impaired skin integrity. The goal was the resident would have healing of skin over the next 90 days. Approaches were to perform dressing changes as ordered; gel cushion to the wheelchair; turn and reposition every two hours; avoid supine position; use care when applying lotions over bruises; and a low air loss mattress to the bed. A social services progress note, dated [DATE] at 6:48 a.m., documented, .Got a few words and a laugh out of her. However she did me (sic) her backside was bothering her . A skilled nurse's note, dated [DATE] and untimed, documented, .able to move side ways - c/o pain when moved differently .tx to buttocks areas red, raw .Has gel cushion in w/c .call to (physician name withheld) - orders to dc f/c (after) 24 (hour) bladder training . A physician's telephone order, dated [DATE], documented to discontinue the resident's urinary catheter after 24 hours of bladder training. A wound flow sheet, dated [DATE], documented the right buttock pressure ulcer was a stage II ulcer that measured 3 cm x 3 cm and was raw and red. It was also documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Another wound flow sheet, dated [DATE], documented the left buttock pressure ulcer was a stage II ulcer that measured 5 cm x 3 cm, was red and raw, and had slight drainage. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. There was no documentation to show the physician was notified of the worsening of the wounds. There was no wound flow sheet dated [DATE] for the coccyx pressure ulcer. A skilled nurse's note, dated [DATE] and untimed, documented, .@ 1615 (4:15 p.m.) cath was dc'd . A wound flow sheet, dated [DATE], documented the right buttock pressure ulcer was a stage II ulcer that measured 1.5 cm and 1 cm and 2 cm wide. It was documented the ulcer was triangular in shape, with red and raw edges. It was documented there was slight drainage and Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Another wound flow sheet, dated [DATE], documented the left buttock pressure ulcer was a stage II ulcer that measured 3.5 cm x 3 cm, was pink with red edges, and had slight drainage. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Another wound flow sheet, dated [DATE], documented the coccyx pressure ulcer was a stage II ulcer that measured 4 cm x 1 cm x 0.5 cm, was red with a dark center to the side, and had slight drainage. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. There was no documentation to show the physician had been notified that all three wounds had drainage. A skilled nurse's note, dated [DATE] and untimed, documented, .Pt is confused at times, dressings on buttocks are clean (and) intact . There was no documentation to show the physician was notified of the resident's confusion. A skilled nurse's note, dated [DATE] at 4:45 a.m., documented, .Open wounds to buttocks et coccyx. Has been turned from side to side. Foley catheter dc'd [DATE]. Has started becoming incontinent . A urinalysis, dated [DATE], documented the resident's urine sample contained large amounts leukocyte esterase (normal - none), was positive for [MEDICATION NAME] (normal - negative), and 4+ bacteria (normal - none). It was documented the urine was sent for a culture and sensitivity test. A physician's telephone order, dated [DATE], documented the resident was to receive Cipro, an antibiotic, 500 mg twice daily for a urinary tract infection. A skilled nurse's note, dated [DATE] at 7:00 p.m., documented, .Buttocks/coccyx area red - irritated - open areas . A skilled nurse's note, dated [DATE] at 2:00 a.m., documented, .Buttocks, coccyx, peri-area all red/irritated A skilled nurse's note, dated [DATE] at 9:00 a.m., documented, .Sitting (up) in w/c eating breakfast. c/o some dizziness .c/o of buttocks pain. Wants to lay back down (after) breakfast . A skilled nurse's note, dated [DATE] at 6:30 p.m., documented, .does c/o buttocks pain . A skilled nurse's note, dated [DATE] at 4:00 a.m., documented, .continues to have reddened, irritated to peri area .Buttocks c several open areas tx provided. Coccyx decubitus draining serosanguinous fluid on drsg from tx provided. Resident is incontinent (dribbles) of urine .c/o pain to buttocks . There was no documentation to show the physician was notified of the drainage from the wound or the pain to the resident's buttocks. A skilled nurse's note, dated [DATE] at 9:30 a.m., documented, .Tx done to buttocks .cont to c/o pain, states prn meds given earlier 'helped some' . There was no documentation to show the physician had been notified of the resident's partially relieved pain. A urine culture report, dated [DATE], documented the urine contained greater than 100,000 org/ml of [DIAGNOSES REDACTED] bacteria. A skilled nurse's note, dated [DATE] at 2:30 a.m., documented, .dressing to coccyx (changed) due to it was soiled. Buttocks very red. [MEDICATION NAME] applied @ this time. c/o buttocks et lower back pain . A skilled nurse's note, dated [DATE] at 10:00 a.m., documented, .tx to buttocks and coccyx area Tolerated well. Want to stay in bed .Call to (physician name withheld) re: resident (increased) weakness, (not) eating, unable to stand .wanted to go back to bed . A skilled nurse's note, dated [DATE] at 2:00 p.m., documented, .orders to send to (hospital name withheld) . A physician's telephone order, dated [DATE], documented to send the resident to the hospital. A certificate of medical necessity for nursing home transport, documented, .What medical condition exists that makes transport by ambulance necessary? (Increased) weakness, (decreased) sats, (no) appetite = needs fed, decubs to coccyx . A nursing home to hospital transfer form, dated [DATE], documented, .reason(s) for transfer (decreased) sats, (increased) weakness, (decreased) appetite, (increased) decubs . It was documented the resident had pressure ulcers on the buttocks and coccyx. A discharge summary, dated [DATE], documented the resident was discharged due to decreased oxygen saturation levels, increased weakness, and decreased appetite. It was documented the resident's condition on discharge was poor. An ambulance record, dated [DATE], documented the ambulance arrived at the facility at 2:52 p.m. It was documented transportation to the hospital began at 3:03 p.m., and the resident arrived at the hospital and was given over to hospital care at 4:02 p.m. Hospital laboratory results, dated [DATE] at 4:40 p.m., documented the resident's white blood cell count was 18.91. Normal values were 4.00 to 10.50. A computerized tomography scan result, dated [DATE] at 6:13 p.m., documented, .There is moderate subcutaneous induration overlying the coccyx, and there is a decubitus ulcer, with air tracking into both gluteal muscles, worse on the right side. Air also tracks into the deep pelvis along the right side of a rectal sling .Impression .New subcutaneous induration and bubbles of air are identified adjacent to the coccyx, tracking into the gluteal muscles, more evident on the right, and also into the pelvis along the right side of the anal sling. The changes are thought to be due to a decubitus ulcer with tracking of air into the adjacent soft tissues . An emergency room nurse's note, dated [DATE] at 7:41 p.m., documented, .Pts perineal area very red and swollen. Pt has an approx 2 inch (5 cm) open pressure wound on her sacrum that appears to have tunneling. Pt also has green, lose (sic) stool . A hospital history and physical note, dated [DATE] at 8:16 p.m., documented, .Chief complaint:[MEDICAL CONDITION] .was discharged last month from (hospital name withheld) after she was treated for [REDACTED]. The patient was discharged to nursing home. She reportedly was brought in from the nursing home today by the family who reports that she has failure to thrive. She has some generalized weakness and fever and she also being treated for [REDACTED]. She was seen in the emergency room and was found to have elevated white count and was started on antibiotics. She had a CAT scan of her abdomen and pelvis, which revealed a possible gases tissue, which is concerning her either necrotizing fascitis or deep decubitus ulcer .I examined the patient. At this point, the concern for necrotizing fascitis is less likely and this is probably from tunneled wound, which is advanced stage probably ,[DATE] decubitus ulcer. She also has some [DIAGNOSES REDACTED] and redness in the perineal area. She does have incontinence of both stool and for urine. She reports that she has been getting on and off physical therapy; however, she feels as if she is having generalized weakness. Her vitals revealed a temperature of 36.1 (degrees Celsius, 96.98 degrees Fahrenheit) and blood pressure of ,[DATE] .Assessment: 1.[MEDICAL CONDITION], present on admission, likely secondary to decubitus ulcer. 2. Advanced stage III-IV decubitus ulcer with tunneled wound and active drainage . A pressure ulcer consultation note, dated [DATE] at 9:06 a.m., documented, .sacral ulcer present with necrotic tissue and bone exposed underlying and tunneling present, multiple areas of ulceration from friction and shear with full-thickness skin loss .Assessment: 1. Stage IV pressure ulcer to sacrum, questionable necrotizing fascitis per CT as of yesterday. 2.[MEDICAL CONDITION] .We will continue n.p.o .The patient may have surgery today .possible debridement . Review of hospital CT scan results, emergency room nurses' notes, wound consultant report, and hospital physician history and physical notes revealed documentation of the resident's sacral pressure ulcer that was inconsistent with the last noted pressure ulcer documentation from the facility. An operative note, dated [DATE] and untimed, documented, .Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedures: 1. Excisional debridement of skin, subcutaneous tissue and sacral bone with sharp excisional debridement measuring 10 cm width x 10 cm length x 7 cm depth. 2. Debridement of sacral bone with bone biopsy and bone excision for cultures .Findings: Extensive sacral decubitus, full thickness, down to sacral bone at the depth. The exposed bone was debrided with a rongeur and sent for biopsies and cultures . A pathology report, with a collection date of [DATE] and a verified date of [DATE], documented, .A. Bone, sacral region, debridement - [MEDICAL CONDITION] and acute osteo[DIAGNOSES REDACTED] involving reactive and degenerating bone and soft tissue. B. Soft tissue, sacral region, debridement - skin and soft tissue necrosis with associated [MEDICAL CONDITION] and abscess . A discharge summary, dated [DATE], documented .Discharge Diagnoses: [REDACTED].Advanced stage III-IV decubitus ulcer that was tunneled with active drainage, questionable [DIAGNOSES REDACTED] per CT, status [REDACTED].MRI of the pelvis showed positive developing osteo .patient .was recently discharged from (hospital name withheld) in April for [MEDICAL CONDITION] and urinary tract infection. The patient was discharged to a nursing home. Apparently , her family went to visit her at the nursing home and reported the patient continued to get weaker and have failure to thrive. She was found to have a fever and a urinary tract infection .There was concern that her [MEDICAL CONDITION] is also worsening and that she was developing a wound in the sacral region. Therefore, she was sent to the Emergency Department, found to have an elevated white blood count and immediately started on antibiotics. A CT of her abdomen and pelvis was obtained, which revealed possible [MEDICATION NAME] tissue, concern for [DIAGNOSES REDACTED] or deep decubitus ulcer. She was found to have a decubitus tunneled wound in the sacral region, stage III-IV. Therefore, General Surgery was consulted and the patient is now status [REDACTED].(physician name withheld) with Infectious Disease was also consulted due to the extensiveness of this wound and the patient'[MEDICAL CONDITION] on admission. An MRI was obtained, which showed a concern for developing osteo[DIAGNOSES REDACTED]. Therefore, the patient will need to be on IV antibiotics, [MEDICATION NAME] for the next 6 weeks. [MEDICATION NAME] was started on [DATE] .The patient has chronic debility and weakness. She is bedridden. Therefore, she has required a Foley catheter as well as a rectal tube for healing of her sacral decubitus ulcer .The patient has done well with all these procedures and her mentation has improved over the course of her hospital stay .She is now currently stable and will be discharged .for further care and treatment of [REDACTED]. A hospital history and physical, dated [DATE] at 11:03 p.m., documented, .This is a patient that was recently discharged on [DATE] to (facility name withheld) for chronic care of large sacral decubitus with osteo[DIAGNOSES REDACTED], found to have [DIAGNOSES REDACTED], the patient was on meropenem. She was also known to have a history of [MEDICAL CONDITION], on [MEDICATION NAME] and oral iron. They noted yesterday that the patient had a hemoglobin of 6.1. They transfused her and transferred her here for further evaluation of her [MEDICAL CONDITION]. This has been worked up thoroughly. There is no obvious source of her [MEDICAL CONDITION] with no obvious signs of bleed. the patient is an elderly woman with multiple ecchymosis. Her large sacral decubitus has areas of bleeding during debridement and this may possibly be a source of chronic [MEDICAL CONDITION]. She was initially admitted on [DATE] [MEDICAL CONDITION] secondary to the large sacral decubitus .She did present with a Foley catheter and a rectal tube .Past Medical History: [MEDICAL CONDITION] .recent [MEDICAL CONDITION] with UTI, sacral decubitus with osteo[DIAGNOSES REDACTED], positive for [DIAGNOSES REDACTED] .chronic [MEDICAL CONDITIONS] .Review of systems: The patient is seen lying in bed complaining of pain from sacral decubitus. She notes it hurts to roll over .She does complain of continued chronic weakness .She has a very large sacral decubitus that is covered with a wet-to-dry dressing noted. There are some areas of bleeding .The sacral decubitus is nonodorous at the moment . A death summary, dated [DATE], documented, .Discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION] from osteo[DIAGNOSES REDACTED] .Hospital Course: .was admitted with severe [MEDICAL CONDITION] and worsening sacral decubitus ulcer with osteo[DIAGNOSES REDACTED]. She had a prolonged hospitalization with involvement of multiple consultants. The patient underwent EDG and colonoscopy during this admission. She was started on broad-spectrum antibiotics for her osteo[DIAGNOSES REDACTED]. She, however, continued to develop progressively worsening [MEDICAL CONDITION] due to uremia [MEDICAL CONDITION]. She became hypotensive and had to be transferred to ICU; given her multiple comorbidities, after discussion with the family; In accordance with patient's wishes physicians placed the patient on comfort measures and she passed away this morning . The resident's death certificate, with a certification date of [DATE], documented, .Cause of Death . Part I .Immediate Cause (Final disease or condition resulting in death .[MEDICAL CONDITION] . Sequentially list condition, if any, leading to the cause listed on line a. b. End Stage [MEDICAL CONDITION] . Enter the UNDERLYING CAUSE (disease Or injury that initiated the events resulting in death) LAST. c. Sacral Decubitus Ulcers with [DIAGNOSES REDACTED] . Part II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I Acute on chronic systolic and diastolic [MEDICAL CONDITION] exacerbation, severe malnutrition, [MEDICAL CONDITION], and [MEDICAL CONDITION] from osteo[DIAGNOSES REDACTED] . On [DATE] at 1:00 p.m., LPN #1 was asked if she remembered resident #3. She stated yes. She was asked why the resident was sent out to the hospital. She stated her pressure ulcer had opened up over the weekend. She was asked if she had notified the physician. She stated yes. She stated the doctor had ordered her to send the resident to the hospital. LPN #1 was asked if she could see the resident's sacral bone when the ulcer opened up. She stated, No. She stated the ulcer had progressed from a superficial ulcer to a stage II. LPN #1 was asked if the DON had looked at the resident's ulcers. She stated, No. She stated the DON did not look at ulcers. On [DATE] at 3:29 p.m., RN #1 was asked if she remembered resident #3. She stated yes. She was asked if the resident had pressure ulcers. She reviewed clinical records and stated yes. She stated the resident had right arm [MEDICAL CONDITION] and sores on her buttocks. She stated the resident was noncompliant. She stated staff would try to turn her but she would go right back to her back. RN #1 was asked where the resident's pressure ulcers were. She stated there was one on the coccyx. She stated it looked like the buttock fold had split open. She was asked what stage the ulcer was. She stated it was a stage II or III. She stated it kept trying to split open. RN #1 stated the ulcer was not that bad until her urinary catheter was taken out. She stated staff could not keep her dry. RN #1 stated the ulcer started gaping pretty good as soon as the urinary catheter was removed. RN #1 was asked if she notified the physician when the ulcer began to worsen. She stated, No, I didn't. I work the ,[DATE] shift. RN #1 was asked if the resident had pain with her ulcers. She stated the resident would say her bottom hurt, and then it was her legs. She stated she had petechiae on her legs, and there was some swelling. RN #1 was asked if there had been a concern with the resident being left on the bed pan an excessive amount of time. She stated, Yes. She stated the resident had asked to be put on the bed pan, and when she was rolled over, the bed pan was already there. She was asked how long the resident had been left on the bed pan. She stated she did not know. She was asked at what time it was identified the resident was on the bed pan. She stated it was maybe 4ish (4:00 a.m.). RN #1 was asked what day this occurred on and who the aide was assigned to the resident. She stated she did not remember. RN #1 was asked what she did when the resident was found on the bed pan. She stated she counseled the aide. She was asked if she reported the incident to the DON. She stated, No. On [DATE] at 4:29 p.m., RN #1 was asked if the resident had requested the bed pan to urinate or to have a bowel movement. She stated she did not know. RN #1 stated when she had counseled the aide, the aide had told her the resident had not been on the bed pan very long. RN #1 stated the event occurred during the time the resident was getting confused. On [DATE] at 8:51 a.m., CNA #1 was asked if she had cared for the resident. She stated, Yes. She was asked if the resident had pressure ulcers. She stated yes. She stated there was one on the right buttock and one in the coccyx area. She stated the gluteal fold was cracked. CNA #1 stated, It seemed to me when the catheter came out, it seemed like it aggravated the situation. She stated the resident wanted the catheter out and had asked for it to be removed for about a week and a half. She stated the resident had been emphatic about it. She stated, I don't know if it hurt her or was just annoying. CNA #1 was asked if she saw the pressure ulcers. She stated she helped the nurse when treatments were completed, and it appeared the ulcers would get better and (TRUNCATED)

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have an effective system for the care of a resident with pressure ulcers. The facility failed to implement medical and nutritional interventions to promote the healing of pressure ulcers and aid in the prevention of new pressure ulcers; conduct accurate and thorough pressure ulcer assessments; notify the physician of worsening pressure ulcers; and ensure nursing staff had the necessary skills sets to care for residents with pressure ulcers. The resident was admitted to the facility on [DATE] with one stage II pressure ulcer on the right buttock that measured 2 cm x 3 cm. The resident subsequently developed additional pressure ulcers on the left buttock and the sacrum. The resident was sent to the hospital on [DATE], with increasing weakness, decreased oxygen saturation levels, and worsening pressure ulcers. Hospital records documented upon arrival to the hospital, the resident was found to be septic, with an advanced stage III to IV sacral pressure ulcer with active drainage, necrotic tissue, bone exposure, and tunneling into the right and left gluteal muscles and pelvic area. The pressure ulcer required a 10 cm x 10 cm x 7 cm surgical debridement with [DEVICE] treatment. Biopsies of the debrided area revealed [MEDICAL CONDITION] of the soft tissue and osteo[DIAGNOSES REDACTED] in the sacral bone. The resident expired in the hospital on [DATE]. At 12:41 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 12:44 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failures in caring for a resident with pressure ulcers. On [DATE] at 2:33 p.m., an acceptable plan of removal was provided. The plan of removal documented, .2. Pressure Ulcers: CNAs will be inserviced on residents with pressure sores, placing them on bed pans, and that timeliness is a factor. They will be educated on how quickly skin breakdown can occur. CMAs will be in serviced on notifying the nurse when something on the MAR indicated [REDACTED]. In service will be conducted to all nurses regarding pressure ulcers including, but not limited to ~ Measuring wounds and proper wound description documentation ~ Who is responsible for ordering items such as Pro Stat ~ Interventions and timely implementation (same day) ~ Notifying the physician if an order can not be obtained and implemented the same day so alternate interventions may be implemented A head to toe skin assessment will be performed on all residents. A change in notification form will be completed by the nurses for the DON and Admin to monitor daily in stand up. The weekend RN will monitor these forms on Saturday and Sunday if there are any, and then they will be addressed in stand up. This form will include date, time, resident's name, the stated change in condition, and the physician's response/new orders, physician/DON/Admin notified, and if it was documented in the chart. The DON /RN will observe random wound care each week to ensure nurses are properly treating and documenting all wounds and then document in the residents chart. This plan of removal will be completed on [DATE] by midnight (12:00 am). The immediate jeopardy was removed on [DATE] at 11:15 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ perform initial and ongoing thorough skin and pressure ulcer assessments; ~ notify the physician of new pressure ulcers or the worsening of existing pressure ulcers; ~ implement medical and nutritional interventions to aid in the healing of pressure ulcers; ~ obtain physician orders [REDACTED]. ~ ensure staff was competent in their skills sets for the delivery of pressure ulcer treatments and management for two (#3 and #4) of four sampled residents who had pressure ulcers. The facility identified no residents as having pressure ulcers. Resident #3 was admitted to the facility on [DATE] with one stage II pressure ulcer. The resident was sent to the hospital on [DATE], and was found to be septic, with an advanced stage III to IV sacral pressure ulcer with active drainage, necrotic tissue, bone exposure, and tunneling into the right and left gluteal muscles and pelvic area. The pressure ulcer required a 10 cm x 10 cm x 7 cm surgical debridement with [DEVICE] treatment. Biopsies of the debrided area revealed [MEDICAL CONDITION] of the soft tissue and osteo[DIAGNOSES REDACTED] in the sacral bone. The resident expired in the hospital on [DATE]. Resident #4 developed a facility acquired unstageable pressure ulcer to the left buttock. The facility had knowledge of the pressure ulcer and did not notify the physician of the pressure ulcer for a minimum of three days. Findings: The facility's policy and procedure for the prevention and treatment of [REDACTED].Upon admission, the facility will evaluate each resident for factors that may put the resident at risk for the development of pressure ulcers. The facility will utilize a tool that identifies risk factors including sensory perception, moisture, activity level, mobility, nutrition, friction and shear .The risk factor tool will be completed upon admission and then may be completed additionally at intervals during the first four weeks post admission .Additional factors that may place a resident at risk for the development or to not heal pressure ulcers include: ~ Impaired/decreased mobility and decreased functional ability ~ Co-morbid conditions, such as [MEDICAL CONDITIONS] disease or diabetes mellitus . ~ Resident refusal of some aspect of care and treatment . ~ Exposure of skin to urinary and/or fecal incontinence . Should a resident have an existing pressure ulcer or develop a pressure ulcer post admission, the facility will implement procedures to evaluate the ulcer regularly, implement treatment measures to promote healing and prevent and/or treat infection and to manage any pain experienced by the resident . The facility will evaluate the ulcer at least weekly, utilizing a flow sheet that notes the location of the ulcer, the stage, presence of eschar, size, color, odor, drainage, tunneling/sinus tract/undermining if present, the notation of a culture if signs of infection are present, treatment including dressing, antibiotic, debridement and pain management. The facility will notify the physician upon the onset of the ulcer and obtain treatment orders . The facility will notify the physician if the ulcer appears to be deteriorating or if no improvement is noted in ,[DATE] weeks of the initial treatment orders . In order for a pressure ulcer to heal, the wound bed must be clean, moist, free of infection and with adequate blood supply. Interventions should be directed toward achieving this end. Additionally, removing/preventing pressure to the ulcer area and adequate nutrition and hydration will promote healing. Pain is often associated with the presence of a pressure area. Evaluate the resident for the presence of pain . Orientation/training forms, dated [DATE], for RN #1 and LPNs #1, #2, #3, #4, and #5 documented, .Knows procedure for completion of wound care, collection of wound characteristic data and required documentation . The forms were signed by the director of nursing. 1. A hospital wound care team progress note for resident #3, dated [DATE], documented, .Pressure Ulcer Stage .II .Sacral .Length 3 cm Width 2 cm Depth 0.1 cm . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden Scale form, used for predicting pressure sore risk and dated [DATE], documented the resident scored a 14. The form documented, .Total score of 12 or less represents HIGH RISK . An untitled facility form, dated [DATE], documented the resident had three open areas on the buttocks/sacral area. The form had the image of a body on it, and there were three circles drawn on the body image, with two on the right buttock and one on the sacral area. It was documented, .Open areas . There were no measurements or descriptions of the areas. A nurse's note, dated [DATE] at 1:35 p.m., documented, .(right) buttock c a 3 cm x 1.5 cm open area also gaulding to buttock . The note did not contain any other documentation related to pressure ulcers. A wound flow sheet, dated [DATE], documented the resident had a stage II pressure ulcer on the right buttock. It was documented the pressure ulcer measured 2 cm x 3 cm and was pink in color. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Admission physician orders, dated [DATE], documented the resident was to receive Prostat, a protein supplement, 30 ml daily and B-complex vitamins daily as a supplement. The orders documented to clean the right buttock daily with normal saline and apply Venelex ointment and cover with [MEDICATION NAME] border. It was also documented the resident could have a urinary catheter due to impaired skin integrity. An informed consent form for the use of an indwelling urinary catheter, dated [DATE], documented, .may have foley catheter d/t impaired skin integrity . The form was signed by the resident, the physician, and a member of the facility staff. A skilled nurse's note, dated [DATE] at 6:00 p.m., documented, .Butt paste to open area on buttocks . A physician's telephone order, dated [DATE] at 10:00 p.m., documented, .DC Vitamin B complex caps . A physician's progress note, dated [DATE], documented, .(right) buttock 2 x 3 cm open area . Medication administration records, dated [DATE] through [DATE], documented the resident did not receive the ordered Prostat. It was documented not in for each day. Treatment records, dated [DATE] through [DATE], documented treatments were completed to the right buttock pressure ulcer as ordered by the physician. A skilled nurse's note, dated [DATE] and untimed, documented, .Tx done on (right) buttock. 8 cm long x 0.25 cm wide open area noted to coccyx area. Call made .N.O. apply Venelex (and) cover c [MEDICATION NAME] .Staff reminded to reposition q 2 (hours) and encourage resident to get (up) . A physician's telephone order, dated [DATE], documented to use Venelex ointment for all open areas on the buttocks. A wound flow sheet, dated [DATE], documented the resident had a stage II pressure ulcer to the coccyx. It was documented the pressure ulcer measured 8 cm x 0.25 cm, was red, and had some bleeding. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. A skilled nurse's note, dated [DATE] at 7:00 p.m., documented, .Lying in bed c eyes open. c/o (left) hip pain. PRN pain medication given .Asked if resident would like to sit (up) in chair for a little while. Resident very hesitant afraid it will make her hurt more . A skilled nurse's note, dated [DATE] at 6:45 p.m., documented, .Buttocks are red c open areas . A physician's telephone order, dated [DATE], documented the resident was to receive Vitamin C, 500 mg daily and Zinc, 220 mg daily for wound healing. A wound flow sheet, dated [DATE], documented the resident had a stage II pressure ulcer on the left buttock. It was documented the ulcer measured 3 cm x 3 cm and that Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. There was no documentation to show the physician was notified of the new open area to the left buttocks. Medication administration records, dated [DATE], documented the resident did not receive the ordered Prostat. It was documented, .not in . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. An admission assessment, dated [DATE], documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, and toileting. It was documented the resident had occasional pain that was very horrible and limited her activities. It was also documented the resident was at risk for pressure ulcers; had one stage II pressure ulcer; and had pressure relieving devices for her bed and chair. A wound flow sheet, dated [DATE], documented the right buttock pressure ulcer was a stage II ulcer that measured 1 cm x 1 cm. An additional measurement of 2 cm x 2 cm was documented. It was documented the ulcer was raw and pink, and Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. A facility invoice, dated [DATE], documented one case of Prostat was ordered on [DATE]. A packing slip documented the ship date was [DATE]. Medication administration records, dated [DATE], documented the resident did not receive the ordered Prostat. It was documented, .not in . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. A physician's progress note, dated [DATE], documented, .Buttocks .wounds .open 3 x 4 cm area . A physician's telephone order, dated [DATE] documented, .Air mattress to bed Gel cushion to w/c . A skilled nurse's note, dated [DATE] at 9:30 a.m., documented, .n.o. for air mattress to bed and gel cushion to w/c . A skilled nurse's note, dated [DATE] at 6:00 p.m., documented, .Redness/open areas to pannus/buttocks . A durable medical equipment invoice, dated [DATE], documented an air mattress and pump were ordered. It was documented the requested ship date was [DATE]. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. Medication administration records, dated [DATE] and [DATE], documented the resident did not receive the ordered Prostat. It was documented not in for each day. A skilled nurse's note, dated [DATE] at 1:00 a.m., documented, .redness/irritation to .buttock areas c txs in progress . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. A skilled nurse's note, dated [DATE] at 4:00 a.m., documented, .Buttocks c redness, excoriation to anal area .c/o buttocks pain. given prn order of [MEDICATION NAME] . An undated physician's telephone order, signed by the physician on [DATE], documented to clean the open area to the left buttocks, apply Venelex, and cover daily. The order was listed on the physician telephone order sheet between an order written [REDACTED]. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock and coccyx pressure ulcers. There was no documentation the resident received a treatment to the left buttock pressure ulcer. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] and untimed, documented, .Buttocks c excoriation et reddened skin care given et txs in progress . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. The resident's care plan, dated [DATE], documented a problem related to impaired skin integrity. The goal was the resident would have healing of skin over the next 90 days. Approaches were to perform dressing changes as ordered; gel cushion to the wheelchair; turn and reposition every two hours; avoid supine position; use care when applying lotions over bruises; and a low air loss mattress to the bed. A social services progress note, dated [DATE] at 6:48 a.m., documented, .Got a few words and a laugh out of her. However she did me (sic) her backside was bothering her . A skilled nurse's note, dated [DATE] and untimed, documented, .able to move side ways - c/o pain when moved differently .tx to buttocks areas red, raw .Has gel cushion in w/c .call to (physician name withheld) - orders to dc f/c (after) 24 (hour) bladder training . A physician's telephone order, dated [DATE], documented to discontinue the resident's urinary catheter after 24 hours of bladder training. A wound flow sheet, dated [DATE], documented the right buttock pressure ulcer was a stage II ulcer that measured 3 cm x 3 cm and was raw and red. It was also documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Another wound flow sheet, dated [DATE], documented the left buttock pressure ulcer was a stage II ulcer that measured 5 cm x 3 cm, was red and raw, and had slight drainage. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. There was no documentation to show the physician was notified of the worsening of the wounds. There was no wound flow sheet dated [DATE] for the coccyx pressure ulcer. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] and untimed, documented, .(left) buttock red raw and peeling, (right) buttock (dressing) dry .coccyx red c (dressing) . A skilled nurse's note, dated [DATE] and untimed, documented, .@ 1615 (4:15 p.m.) cath was dc'd . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] at 5:00 a.m., documented, .Pt has dressings x 3 on buttock x 3 CDI . A wound flow sheet, dated [DATE], documented the right buttock pressure ulcer was a stage II ulcer that measured 1.5 cm and 1 cm and 2 cm wide. It was documented the ulcer was triangular in shape, with red and raw edges. It was documented there was slight drainage and Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Another wound flow sheet, dated [DATE], documented the left buttock pressure ulcer was a stage II ulcer that measured 3.5 cm x 3 cm, was pink with red edges, and had slight drainage. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. Another wound flow sheet, dated [DATE], documented the coccyx pressure ulcer was a stage II ulcer that measured 4 cm x 1 cm x 0.5 cm, was red with a dark center to the side, and had slight drainage. It was documented Venelex ointment and a [MEDICATION NAME] dressing were used for daily dressing changes. There was no documentation to show the physician had been notified that all three wounds had drainage. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] and untimed, documented, .Pt is confused at times, dressings on buttocks are clean (and) intact . There was no documentation to show the physician was notified of the resident's confusion. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] at 4:45 a.m., documented, .Open wounds to buttocks et coccyx. Has been turned from side to side. Foley catheter dc'd [DATE]. Has started becoming incontinent . A urinalysis, dated [DATE], documented the resident's urine sample contained large amounts leukocyte esterase (normal - none), was positive for [MEDICATION NAME] (normal - negative), and 4+ bacteria (normal - none). It was documented the urine was sent for a culture and sensitivity test. A physician's telephone order, dated [DATE], documented the resident was to receive Cipro, an antibiotic, 500 mg twice daily for a urinary tract infection. A skilled nurse's note, dated [DATE] at 7:00 p.m., documented, .Buttocks/coccyx area red - irritated - open areas . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] at 2:00 a.m., documented, .Buttocks, coccyx, peri-area all red/irritated A skilled nurse's note, dated [DATE] at 9:00 a.m., documented, .Sitting (up) in w/c eating breakfast. c/o some dizziness .c/o of buttocks pain. Wants to lay back down (after) breakfast . A skilled nurse's note, dated [DATE] at 6:30 p.m., documented, .does c/o buttocks pain . Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] at 4:00 a.m., documented, .continues to have reddened, irritated to peri area .Buttocks c several open areas tx provided. Coccyx decubitus draining serosanguinous fluid on drsg from tx provided. Resident is incontinent (dribbles) of urine .c/o pain to buttocks . There was no documentation to show the physician was notified of the drainage from the wound or the pain to the resident's buttocks. A skilled nurse's note, dated [DATE] at 9:30 a.m., documented, .Tx done to buttocks .cont to c/o pain, states prn meds given earlier 'helped some' . There was no documentation to show the physician had been notified of the resident's partially relieved pain. A urine culture report, dated [DATE], documented the urine contained greater than 100,000 org/ml of [DIAGNOSES REDACTED] bacteria. Treatment sheets, dated [DATE], documented the resident received the physician ordered dressing changes to the right buttock, coccyx, and left buttock pressure ulcers. A skilled nurse's note, dated [DATE] at 2:30 a.m., documented, .dressing to coccyx (changed) due to it was soiled. Buttocks very red. [MEDICATION NAME] applied @ this time. c/o buttocks et lower back pain . A skilled nurse's note, dated [DATE] at 10:00 a.m., documented, .tx to buttocks and coccyx area Tolerated well. Want to stay in bed .Call to (physician name withheld) re: resident (increased) weakness, (not) eating, unable to stand .wanted to go back to bed . A skilled nurse's note, dated [DATE] at 2:00 p.m., documented, .orders to send to (hospital name withheld) . A physician's telephone order, dated [DATE], documented to send the resident to the hospital. A certificate of medical necessity for nursing home transport, documented, .What medical condition exists that makes transport by ambulance necessary? (Increased) weakness, (decreased) sats, (no) appetite = needs fed, decubs to coccyx . A nursing home to hospital transfer form, dated [DATE], documented, .reason(s) for transfer (decreased) sats, (increased) weakness, (decreased) appetite, (increased) decubs . It was documented the resident had pressure ulcers on the buttocks and coccyx. A discharge summary, dated [DATE], documented the resident was discharged due to decreased oxygen saturation levels, increased weakness, and decreased appetite. It was documented the resident's condition on discharge was poor. Review of facility clinical records revealed no documentation the resident's pressure ulcers had been thoroughly assessed per current standards of practice. There was no documentation to show: ~ why the facility did not have the physician ordered Prostat supplement; ~ if the air mattress was placed on the resident's bed; ~ the facility attempted to educate the resident on the importance of the urinary catheter due to her impaired skin integrity; or ~ why the resident did not receive a treatment to the left buttock pressure ulcer for five days after it was first identified. An ambulance record, dated [DATE], documented the ambulance arrived at the facility at 2:52 p.m. It was documented transportation to the hospital began at 3:03 p.m., and the resident arrived at the hospital and was given over to hospital care at 4:02 p.m. Hospital laboratory results, dated [DATE] at 4:40 p.m., documented the resident's white blood cell count was 18.91. Normal values were 4.00 to 10.50. A computerized tomography scan result, dated [DATE] at 6:13 p.m., documented, .There is moderate subcutaneous induration overlying the coccyx, and there is a decubitus ulcer, with air tracking into both gluteal muscles, worse on the right side. Air also tracks into the deep pelvis along the right side of a rectal sling .Impression .New subcutaneous induration and bubbles of air are identified adjacent to the coccyx, tracking into the gluteal muscles, more evident on the right, and also into the pelvis along the right side of the anal sling. The changes are thought to be due to a decubitus ulcer with tracking of air into the adjacent soft tissues . An emergency room nurse's note, dated [DATE] at 7:41 p.m., documented, .Pts perineal area very red and swollen. Pt has an approx 2 inch (5 cm) open pressure wound on her sacrum that appears to have tunneling. Pt also has green, lose (sic) stool . A hospital history and physical note, dated [DATE] at 8:16 p.m., documented, .Chief complaint:[MEDICAL CONDITION] .was discharged last month from (hospital name withheld) after she was treated for [REDACTED]. The patient was discharged to nursing home. She reportedly was brought in from the nursing home today by the family who reports that she has failure to thrive. She has some generalized weakness and fever and she also being treated for [REDACTED]. She was seen in the emergency room and was found to have elevated white count and was started on antibiotics. She had a CAT scan of her abdomen and pelvis, which revealed a possible gases tissue, which is concerning her either necrotizing fascitis or deep decubitus ulcer .I examined the patient. At this point, the concern for necrotizing fascitis is less likely and this is probably from tunneled wound, which is advanced stage probably ,[DATE] decubitus ulcer. She also has some [DIAGNOSES REDACTED] and redness in the perineal area. She does have incontinence of both stool and for urine. She reports that she has been getting on and off physical therapy; however, she feels as if she is having generalized weakness. Her vitals revealed a temperature of 36.1 (degrees Celsius, 96.98 degrees Fahrenheit) and blood pressure of ,[DATE] .Assessment: 1.[MEDICAL CONDITION], present on admission, likely secondary to decubitus ulcer. 2. Advanced stage III-IV decubitus ulcer with tunneled wound and active drainage . A pressure ulcer consultation note, dated [DATE] at 9:06 a.m., documented, .sacral ulcer present with necrotic tissue and bone exposed underlying and tunneling present, multiple areas of ulceration from friction and shear with full-thickness skin loss .Assessment: 1. Stage IV pressure ulcer to sacrum, questionable necrotizing fascitis per CT as of yesterday. 2.[MEDICAL CONDITION] .We will continue n.p.o .The patient may have surgery today .possible debridement . Review of hospital CT scan results, emergency room nurses' notes, wound consultant report, and hospital physician history and physical notes revealed documentation of the resident's sacral pressure ulcer that was inconsistent with the last noted pressure ulcer documentation from the facility. An operative note, dated [DATE] and untimed, documented, .Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedures: 1. Excisional debridement of skin, subcutaneous tissue and sacral bone with sharp excisional debridement measuring 10 cm width x 10 cm length x 7 cm depth. 2. Debridement of sacral bone with bone biopsy and bone excision for cultures .Findings: Extensive sacral decubitus, full thickness, down to sacral bone at the depth. The exposed bone was debrided with a rongeur and sent for biopsies and cultures . A pathology report, with a collection date of [DATE] and a verified date of [DATE], documented, .A. Bone, sacral region, debridement - [MEDICAL CONDITION] and acute osteo[DIAGNOSES REDACTED] involving reactive and degenerating bone and soft tissue. B. Soft tissue, sacral region, debridement - skin and soft tissue necrosis with associated [MEDICAL CONDITION] and abscess . A discharge summary, dated [DATE], documented .Discharge Diagnoses: [REDACTED].Advanced stage III-IV decubitus ulcer that was tunneled with active drainage, questionable [DIAGNOSES REDACTED] per CT, status [REDACTED].MRI of the pelvis showed positive developing osteo .patient .was recently discharged from (hospital name withheld) in April for [MEDICAL CONDITION] and urinary tract infection. The patient was discharged to a nursing home. Apparently , her family went to visit her at the nursing home and reported the patient continued to get weaker and have failure to thrive. She was found to have a fever and a urinary tract infection .There was concern that her [MEDICAL CONDITION] is also worsening and that she was developing a wound in the sacral region. Therefore, she was sent to the Emergency Department, found to have an elevated white blood count and immediately started on antibiotics. A CT of her abdomen and pelvis was obtained, which revealed possible [MEDICATION NAME] tissue, concern for [DIAGNOSES REDACTED] or deep decubitus ulcer. She was found to have a decubitus tunneled wound in the sacral region, stage III-IV. Therefore, General Surgery was consulted and the patient is now status [REDACTED].(physician name withheld) with Infectious Disease was also consulted due to the extensiveness of this wound and the patient'[MEDICAL CONDITION] on admission. An MRI was obtained, which showed a concern for developing osteo[DIAGNOSES REDACTED]. Therefore, the patient will need to be on IV antibiotics, [MEDICATION NAME] for the next 6 weeks. [MEDICATION NAME] was started on [DATE] .The patient has chronic debility and weakness. She is bedridden. Therefore, she has required a Foley catheter as well as a rectal tube for healing of her sacral decubitus ulcer .The patient has done well with all these procedures and her mentation has improved over the course of her hospital stay .She is now currently stable and will be discharged .for further care and treatment of [REDACTED].

Based on 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 (#1) of six sampled residents reviewed for falls. Resident #1 sustained a 9 cm laceration to his forehead as a result of a fall, which required 15 staples for closure. The facility identified twelve residents who were high risk for falls. Findings: An undated Accident Prevention Policy documented, .Each resident will receive adequate supervision and assistive devices to prevent accidents .Accident prevention shall be, but not limited to the following .Make sure the wheelchair is locked during transfer .Make sure the bed is in the lowered position so that residents may easily get in and out .Be sure all wheelchairs and other assistive devices are in good repair and are adjusted for the resident . Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An incident report, dated 03/01/16, documented the resident had fallen from a toilet riser in his bathroom. A final report, dated 03/07/16, documented, .Upon assessment by charge nurse it was noted that (Name Withheld) had a skin tear to his right upper forearm, right elbow, and right wrist. He also received a hematoma to right forehead and temple area .send to ER for evaluation and treatment. Resident returned to facility a short time later that same day. There were no fractures. No other injuries were noted .It was noted in the resident's bathroom that the toilet riser was loose .It was replaced with a potty chair frame over the commode with arm stabilizers . A fall risk evaluation, dated 03/26/16, documented a total score of 12 which represented the resident was at high risk for falls. An incident report, dated 05/04/16 at 2:00 a.m., documented the resident was found on the floor beside the roommate's bed. The report documented the resident was ambulatory, confused, and did not know what had happened. The resident had sustained skin tears on both arms. Documentation was not provided that indicated the facility had implemented any new interventions after the fall in attempts to keep the resident safe. An incident report, dated 05/04/16 at 5:30 a.m., documented the resident was yelling out and found on the floor in front of his bathroom sink. The resident was ambulatory, confused, and had removed the dressings from the skin tears he had received from a previous fall that day. Two new skin tears were observed. Dressings were reapplied to the skin tears. No documentation was provided that indicated the facility had implemented any new interventions after the fall in attempts to keep the resident safe. A nurse's note, dated 05/06/16 at 1:50 p.m., documented a PT evaluation was completed with recommendations for PT 3 x week x 30 days. An incident report, dated 05/13/16 at 1:30 a.m., documented, Description of incident .Unwitnessed fall - Found on floor beside his bed - Confused - Denies hitting head .No injuries noted .No lumps noted on head . Corrective action taken .Reinforced instructions on use of call light and he demonstrated use .Staff to check frequently . A social service progress note, dated 05/25/16, documented a family member had expressed concerns regarding the resident's falls. The note documented the Social services director would contact PT and follow up with the family member about the resident's care. A social service progress note, dated 05/27/16, documented they had sent the family member a text message concerning the resident and what PT was doing to improve his quality of life. A nurse's note, dated 06/09/16 at 10:50 a.m., documented, .resident lying on L side in sitting position c w/c on its side resident had spilled water on the floor .he had 2 skin tears one each to bilateral F.A. (forearm) - he was asked if in pain -stated yes my back hurts .order to send to hospital .called hosp. - admit .does not show any fx . An incident report, dated 06/09/16, documented the resident was found in his room on the floor with his wheelchair on top of him. The resident complained of pain in his lower back and coccyx area. The report documented the resident was hospitalized . The hospital records indicated X-rays were negative for injuries and the resident was hospitalized for [REDACTED]. No documentation was provided that indicated the facility had implemented any new interventions after the fall in attempts to keep the resident safe. An incident report, dated 06/13/16, documented the resident was found on the floor in his room with feces on the floor and his bed. The resident was assisted to stand and ambulate to the shower. No injuries were noted. The corrective action taken was to toilet the resident at least every two hours. No documentation was provided to show the staff had toileted the resident every two hours. A fall risk evaluation, dated 06/25/16, documented a total score of 16 which represented the resident was at high risk for falls. An incomplete pain assessment, dated 06/25/16, documented, .Pain Frequency .Does not process questions . Two daily skilled nurses notes, one dated 08/10/16 and one dated 08/29/16, documented, .Propels self in (wheelchair) - Oriented to name only . A physician's orders [REDACTED]. Pt 5 x week x 30 days of There ex, there act, neuro re-ed . The annual assessment, dated 08/16/16, documented the resident's cognitive skills were moderately impaired for daily decision making, the resident required limited assistance with transfers and toilet use, and required one person assistance. The assessment documented the resident had no falls since the prior assessment. The Care Area Assessment Summary of the annual assessment triggered falls as a care area of concern with indication for a plan of care. An incident report, dated 09/20/16, documented, .Resident was up in (wheelchair) in hallway ambulated into another (resident) room (and) fell . Corrective action taken .(every) 1 (hour) check (times) 72 (hours) then re-eval . No injuries were noted. A care plan form, dated 09/20/16, documented, .Problem .Actual fall up in (wheelchair) in hallway. He ambulated unassisted into another resident's room. Found on floor on his bottom (no) injuries noted . Goal . 1. Resident will have no further falls . 2. Resident will have no significant injury related to falls . Approaches .Assess for injury, notify physician and responsible party with any fall . A hand written note on the care plan documented, .He has a (diagnosis) of dementia . A physician's orders [REDACTED]. A nurse's note, dated 11/11/16 at 6:35 a.m., documented, Resident in DR in W/C. (Name deleted) came to tell this nurse he fell . Questioned resident stated 'I wanted to lie down et get warm' .(no) apparent injury noted. Transferred back to W/C et provided blanket for warmth. An incident report, dated 11/11/16, documented the resident was in the dining room, stood from his wheelchair and fell to the floor. The report documented the resident was confused at times with no injuries noted. The corrective action taken was put warm clothes on resident or cover with a blanket. A care plan form, dated 11/11/16, documented: .Problem Actual Fall Stood up from WC to ambulate. He stated he was going to go lay down. He then fell to the floor (No) injuries noted at the time. Goal 1. Resident will have no further falls. 2. Resident will have no significant injury related to falls. Approaches Assess for injury, notify physician and responsible party with any fall. He has a dx of Dementia A quarterly assessment, dated 11/16/16, documented the resident's cognition was severely impaired, the resident required two person assistance with transfers, was not steady but able to stabilize with staff assistance when moving from seated to standing position, walking, and surface-to-surface transfer. The resident required a walker or wheelchair for mobility. The assessment documented the resident had fallen once with no injury since the prior assessment. A care plan, dated 11/16/16, documented a problem of impaired thought processes related to a [DIAGNOSES REDACTED]. A care plan, dated 11/16/16, documented, .Problem .Trauma, Potential for R/T Dx of Dementia R/T at Risk for Falls with Hx of Actual Falls . Goal .Is Free From Falls Thru Environmental (and) Equipment Safety Maintenance . Approach . (1) Respond to call light promptly keep call light within reach . (2) Fall risk assessment performed quarterly . (4) Part B Therapy in place for strengthening/balance . (5) 2 person assist for all transfers . A nurse's note, dated 11/25/16 at 6:10 a.m., documented, Resident found lying in floor in his room beside his bed. When asked what happened he stated 'I don't know.' Has large cut on top head on (L) side and large tear on (L) arm. Large amt blood on floor beside him .Transported via amb. (ambulance) to (hospital name deleted) for further Tx . An incident report, dated 11/25/16, documented, .Description of incident .Resident found lying in floor beside his bed when asked what happed (Sic) he said 'I don't know.' Has large cut on top his (Sic) head on (left) side and a large tear on (left) arm .Corrective action Personal safety alarm lower (sic) bed (with) mat on floor . The form documented the resident was hospitalized . There was no documentation to indicate a personal safety alarm, low bed, and/or floor mat had been used. A final incident report form for the incident of 11/25/16, documented, .Resident was admitted to (hospital name deleted) and kept for observation after head trauma. Resident POA has moved resident to (facility name deleted.) . The History and Physical report from the hospital, dated 11/25/16, documented the resident had a [DIAGNOSES REDACTED]. The report documented there was a 9cm laceration on his forehead with a hematoma to the forehead. The report documented the laceration was closed with 15 staples. The next nurse's note, dated 11/30/16 at 7:00 p.m., documented, Family member here picking up residents (Sic) belongings. On 01/05/17 at 1:30 p.m., the DON was asked if the facility had a fall program. She stated the facility did not have a fall program. She stated she was aware and had concerns regarding falls in the facility. She was asked what the facility's protocol was for residents at risk for falls. She stated a fall risk assessment was completed, assess if one or two staff members are required for assistance, and get the root cause for the falls. She was asked how the facility identified what individualized interventions were initiated for residents at risk for falls. She stated by assessing the root cause of the fall such as what the resident was doing and the time of the falls. She was asked what interventions had been implemented for resident #1. She stated they had attempted several interventions but resident #1 often wandered into other residents' rooms. She was asked where that was documented. She stated, It's probably not. She stated the resident would take his personal alarm off and on one occasion he took it off, threw it against the wall and broke it. She stated she was aware that a personal alarm was considered a restraint. She was asked where these interventions were documented. She stated they probably were not documented. She was asked to describe the mental status of resident #1. She stated he was confused most of the time. She was asked if instruction on use of the call light was an appropriate intervention for resident #1. She stated no, the resident would not have understood the use of the call light. She was asked to review the facility's documentation of interventions identified as approaches for safety related to falls for the resident. She was asked if after review of the documentation had the facility done all they could in supervision of care to prevent injury related to falls for resident #1. She stated, No.

Based on observation, interview, and record review, it was determined the facility failed to: ~ prevent the development of multiple Stage II pressure ulcers; ~ complete weekly skin assessments for residents with pressure ulcers; ~ identify new areas of breakdown and worsening of existing areas of breakdown; and ~ revise the care plan to identify areas of breakdown and new interventions for one (#4) of four sampled residents with pressure ulcers. Resident #4 developed four Stage II pressure ulcers. The facility identified four residents with pressure ulcers. Findings: An undated facility policy, titled Policy and Procedure for the Prevention and treatment of [REDACTED].GOAL: To provide care and services necessary in an effort to prevent the development of pressure ulcers for any resident who enters the facility without a pressure ulcer .For individuals who enter the facility with a pressure ulcer .the facility will strive to provide care and services necessary to promote healing, prevent infection and prevent the development of new ulcers from developing .PREVENTION .Additional factors that may place a resident at risk for the development or to not heal pressure ulcers include: Exposure of skin to urinary and/or fecal incontinence .For individuals identified with risk factors, the facility will develop interventions necessary in an effort to prevent the development of pressure ulcers .It is essential to keep the resident clean and dry .Change wet or soiled linens and clothing immediately . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/20/15 documented: Problem .Skin Integrity, impaired: Potential R/T Skin fragile Goal .Will have skin intact Approach .Report any red or open areas .provide cushioning for any rigid surfaces in contact with the skin . An annual assessment, dated 11/16/15, documented the resident was cognitively intact, required limited assistance from staff for ADL's, was continent of bowel and bladder, and was not at risk for the development of pressure ulcers. A wound care flow sheet, dated 04/29/16, documented the resident had a Stage I pressure ulcer to the right lower ischial tuberosity that measured 3 cm long x 1.5cm wide. The form documented [MEDICATION NAME] ointment was to be applied to the area every shift. There was no wound assessment on the wound flow sheet for the week of 05/02/16. An entry on the wound flow sheet, dated 05/11/16, documented the wound to the right lower ischial tuberosity was a Stage I that measured 2.75 cm x 1.5 cm. The form documented [MEDICATION NAME] ointment was to be applied to the area every shift. A quarterly assessment, dated 05/13/16, documented the resident was moderately impaired in cognition for daily decision making, required limited assistance from staff for most ADL's, was occasionally incontinent of urine, and was at risk for the development of pressure ulcers. An entry on the wound flow sheet, dated 05/18/16, documented the wound to the right lower ischial tuberosity was a Stage I that measured 2cm x 1cm. The form documented [MEDICATION NAME] ointment was to be applied to the area every shift. An entry on the wound flow sheet, dated 05/25/16, documented the wound to the right lower ischial tuberosity was a Stage I that measured 2cm x 1cm. The form documented [MEDICATION NAME] ointment was to be applied to the area every shift. A physician's orders [REDACTED].APPLY [MEDICATION NAME] TO (R) LOWER ISCHIAL TUBEROSITY Q SHIFT . A wound care flow sheet entry, dated 06/09/16, documented a Stage I pressure ulcer on the right lower ischial tuberosity, which measured 2 cm by 1 cm. On 06/15/16 at 6:44 a.m., CNA #9 was observed checking resident #4 for incontinence. When the resident was rolled onto her left side and her brief was removed a strong urine odor was detected. Her brief was observed to be saturated with urine. CNA #9 checked the resident's bed linens and stated, You're a little more wet than I thought, your gown and pad are wet too. CNA #9 was asked how wet the resident's brief was. She stated it was pretty wet. On 06/15/16 at 7:20 a.m., CNA #9 was asked what her observation of resident #4's incontinent episode was. She stated the resident was checked every two hours but had urinated a lot in the morning hours, as she usually does. CNA #9 was asked if checking the resident every two hours was an adequate amount of monitoring for incontinence for her needs. She stated, No, probably not. On 06/15/16 at 10:58 a.m., CNA #1 assisted the surveyor to observe the resident's skin. An open, pink area was observed on the resident's right ischial tuberosity. CNA #1 was asked how long the open, pink area had been present. She stated a couple of weeks. Three open, pink areas were observed on the resident's coccyx. CNA #1 was asked how long the open areas on the coccyx had been present. She stated they were new wounds. On 06/15/16 at 11:02 a.m., LPN #1 was asked if resident #4 had any skin breakdown or wounds. She stated, As far as I know she didn't. LPN #1 was asked when was the last time she had assessed and observed her skin. She stated, When the girls give showers they report it to me if there is anything. LPN #1 was asked when was the resident's last shower. She stated she did not know. No showers were documented as given during June on the June 2016 ADL sheet. On 06/15/16 at 11:05 a.m., LPN #1 observed the resident's skin. Upon assessment, the LPN stated, This (LPN #1 pointed to the pink, opened area on the right lower ischial tuberosity) is pink. We've been doctoring this with [MEDICATION NAME] but it had not been opened like this. She was asked if the opened area on the resident's right lower ischial tuberosity had worsened. She stated, Yes. LPN #1 was asked how long the three opened areas on the coccyx had been present. She stated she did not know. LPN #1 was asked how she would describe the three areas on the coccyx. She stated, Stage II's because the whole layer is off the skin. She stated she observed the resident's skin on Monday but did not complete a full audit. She stated, I didn't know she had those Stage II's. The LPN documented the Stage II pressure ulcers on the wound care flow sheet as follows: ~ The first pressure ulcer, located to the upper left coccyx, measured 1.5 cm by 0.75 cm. ~ A second pressure ulcer, located beside the left upper coccyx, measured 1.75 cm by 0.5 cm. ~ The third pressure ulcer, located to the lower coccyx, measured 1.75 cm by 0.75 cm. A wound care flow sheet, dated 06/15/16, documented a Stage II pressure ulcer to the right lower ischial tuberosity, which measured 2.5 cm by 2 cm. On 06/16/16 at 2:52 p.m., the ADON was asked what the facility policy was for identifying pressure ulcers. She stated the nurses did skin assessments once a week and the nurse aides were to report any skin breakdown. The ADON was asked who was responsible to ensure the skin assessments were being completed. She stated the DON and ADON were responsible. She was asked where the skin assessments were documented. She stated they were in the resident's clinical record. She was asked how often skin assessments were completed. She stated they completed weekly skin audits once skin breakdown had been identified. There were no skin assessments or skin audits found for the resident. The ADON was asked when residents, who did not currently have identified skin breakdown, were assessed. She stated the nurses assessed them when they were admitted and the CNA's were to report any skin irregularities observed during showers. The ADON was asked why the skin breakdown for resident #4 had not previously been identified by the facility. She stated, I don't know, it should have been. On 06/16/16 at 3:15 p.m., the DON was asked what the facility policy was for identifying pressure ulcers. She stated they provided inservices to ensure the CNAs knew to notify the charge nurse of any skin breakdown. She was asked who was responsible to ensure the residents' skin was assessed. She stated, Myself. She was asked where skin assessments were documented. She stated in the residents' clinical record. The DON was asked who was responsible to complete skin assessments. She stated the charge nurses. She was asked how often skin assessments were completed by the nurses. She stated they were completed quarterly and anyone with an existing pressure ulcer was assessed weekly. The DON was asked why the skin breakdown on resident #4 had not previously been identified by the facility. She stated, I cannot say why. On 06/16/16 at 4:00 p.m., LPN #1 was asked if resident #4 had been identified as being at risk for the development of pressure ulcers. She stated, Yes. She was asked what interventions had been implemented to prevent the development of and/or worsening of pressure ulcers. She stated, The only thing we do is turn her at times. On 6/16/16 at 4:15 p.m., the DON was asked if resident #4 was at risk for the development of pressure ulcers. She stated, Yes. She was asked what interventions had been implemented to prevent the development of and/or worsening of pressure ulcers. She stated they repositioned the resident and provided incontinent care.

On 03/02/16, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision with smoking. Resident #5 had multiple burn holes in his clothing, had set the lawn on fire, had a history of [REDACTED]. [REDACTED]. The IJ situation was verified with the Oklahoma State Department of Health. At 5:22 p.m., the administrator, corporate RN, and DON was informed of the IJ regarding accident hazards related to smoking. On 03/03/16 at 9:49 a.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: Plan of Removal for alleged IJ regarding Accident Hazard related to unsupervised smoking, March 2, 2016, 5:20 pm. 1. The resident identified, (Initials withheld) as of 3-2-16 at 5:30 pm, has had his smoking materials removed, his smoking will be directly supervised, he will be encouraged to wear a smoking apron, his smoking material will be kept in the medication room at the nurses station. All nursing staff will be informed of these conditions. We are notifying all nursing staff present in the building at this time, by 6:21 pm on 3/2/16. We are notifying all off duty nursing staff by telephone, and will be completed by 11:59 pm on 3-2-16. Upon arrival at the facility, they will sign next to their name as noted that they have been informed. Any nursing staff we are not able to reach will be informed immediately upon arrival at the facility as well as any agency staff that are not identified at this time. In-Service presented by Corporate Nurse .Director of Nursing .and ADON. Non-nursing staff In-Serviced on 3-3-16 at 9:30 a.m. by Director of Nursing .Any non-nursing personnel who were not available for inservice will receive training prior to their next scheduled shift by .DON. 2. All smoking residents have been identified by the facility as of 5:40 pm on 3-2-16. 3. Each smoking resident will have a new smoking assessment completed by 11:59 pm on 3-2-16. These assessments will be completed by the RN. 4. Any changes to a residents current smoking ability will be relayed to the nursing staff upon completion of the assessment, as described above in item 1, by 11:59 pm on 3-2-16. 5. Each smoking resident's care plan will be updated to reflect their current smoking status, as identified by the assessment, by 11:59 pm on 3-2-16. 6. All nursing staff that are on duty and all nursing staff that are able to come to the facility will receive inservice training regarding accident hazards related to smoking and the requirement to report any identified hazard to the charge nurse immediately. The charge nurse will then notify the Director of Nursing. This inservice will be conducted by 11:59 pm on 3-2-16. Any staff member that cannot be reached by phone to attend the inservice, will receive training on the next available day that they can come to the facility, but prior to working. Any staff member that can be reached by phone, but cannot report to the facility, will receive this training by phone with there name and time noted, and will then sign the inservice sheet with date and time on the next available day they can come to the facility. An Inservice record, dated 03/02/16, documented, Accident Hazard Related to Smoking. This inservice was for all nursing staff. Thirty three direct care staff members attended the inservice. A facility statement, dated 03/02/16, documented, Subject: (Resident #5) - Smoking .(Name withheld) is to wear a smoke apron when he goes out to smoke. He is to be directly supervised each time he goes out to smoke. His cigarettes and lighters are to be taken from him when he comes back in and to be kept in the med room. A staff roster documented when staff was informed of the statement. Those staff members who were informed by telephone was documented. An Inservice record, dated 03/03/16 from 9:15 a.m. to 9:30 a.m., documented, Accident Hazard Related to Smoking. This inservice was for non-nursing staff. Nineteen non-nursing staff members and three direct care staff members attended. All residents who smoked were identified, smoking assessments were completed, and care plans were updated to reflect the resident's current status by 03/03/16 at 10:05 a.m. The IJ was removed on 03/03/16 at 10:05 a.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: A. Provide supervision with smoking for one (#5) of three sampled residents who were reviewed for smoking. Resident #5 had multiple burn holes in his clothing, had set the lawn on fire, had a history of [REDACTED]. [REDACTED]. The facility identified six residents who smoked and resided in the facility; B. Ensure residents who required the use of a lift and assistance with transfers were transferred in a safe manner to prevent accidents for one (#1) of five sampled residents who required assistance with transfers with a lift. Resident #1 required a two person assisted transfer utilizing a lift. The resident sustained [REDACTED]. The facility identified five residents who utilized a lift; C. Ensure residents were served food of the proper consistency for one (#1) of two sampled residents who required pureed diets to prevent choking and aspiration. Resident #1 developed aspiration pneumonia and respiratory failure, was hospitalized and required a ventilator. The facility identified 22 residents who had a physician's orders [REDACTED]. D. Provide supervision to prevent elopements for two (#2 and #5) of two sampled residents who had eloped out of the facility. The facility identified two residents who had eloped out of the facility in the last six months. Findings: An undated policy titled, Policy and Procedure for Residents Ability to Smoke, documented, .Each resident who chooses to smoke will be assessed on their ability to smoke safely at the time of admission to this facility, annually, and upon the determination that a resident may have experienced a significant change which may affect the residents mental and/or physical ability to smoke. The level to which a resident may smoke will be described on the plan of care 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Safe Smoking Assessment, dated 10/22/15, documented the resident did not have any visible burn marks on his clothing, was safe to smoke unsupervised, did not require 1:1 supervision while smoking, did not require smoking materials kept at the nurses' station, and did not require a fire-proof smoking apron while smoking. A nurse's note, dated 10/29/15, documented, CMA found resident in floor, he is very confused, oriented to name only. A care plan, dated 11/02/15, documented: .Problem (2) 11/2/2015 .Smoking Goal (1) 11/2/2015 .Resident will remain free of any harm while smoking (2) 11/2/2015 .Resident will have knowledge of safety measures while smoking. Approach (1) 11/2/2015 .Resident will smoke only in smoking areas (2) 11/2/2015 .Resident will put cigs up in safe place . A nurse's note, dated 11/03/15, documented, Resident outside smoking when laundry person witness (sic) a fire on the ground went to put it out resident states he's got it under control she came in told this nurse resident inside facility Dr. Dimmett called NO Only to smoke (with) assist A physician telephone order, dated 11/03/15, documented, Only to smoke (with) assist. The order was noted by the ADON. A physician progress notes [REDACTED].Multiple behavioral issues .Smoking in room .Set outside lawn on fire .Behavioral dyscontrol - threat to self (and) others, delusional .Nicotine abuse - (cigarettes) (with) risk - monitored smoking . A nurse's note, dated 11/13/15, documented, Res spoke (with) admin about going out to smoke unsupervised admin notified this nurse that res can have another chance to smoke unsuperviced (sic). Staff will keep cigs (and) liter (sic) (and) res will come and get them when he wants to go out and bring the lighter back to the staff. A physician's telephone order, dated 11/16/15, documented, May smoke unsupervised/admin. cig (and) lighter to stay in med room, Res to bring lighter back to staff. The order was noted by LPN #4. A nurse's note, dated 11/22/15, documented, Resident is confused this evening. Alert (and) oriented to name only (at) this time. Going to doors in the front of the building to 'go on home.' .thinks he's (at) a cafe . A nurse's note, dated 11/26/15 at 6:45 a.m., documented, Resident was found off of facility (sic) by a neighbor - he was in his (wheelchair) going down the street . A nurse's note, dated 11/26/15 at 6:45 a.m., documented, Dr. (Name withheld) called, new order to start elopement watch (and) he not (sic) to go outside to smoke by self - only (with) staff .administrator also called (and) informed of incident. An incident report, dated 11/26/15 at 6:45 a.m., documented, .Patient's condition prior to incident: Confused at times Semi-Ambulatory wheelchair .Description of incident .Resident out of facility - off of property going down the road .Corrective action taken: Resident is not to go outside to smoke by self - only (with) staff . The incident report was signed by the former DON and the Administrator, and dated 12/16/15. A physician's orders [REDACTED].Resident is not to go outside to smoke - he may go only (with) staff . The order was noted by LPN #3. A physician's orders [REDACTED]. He is not to go out unless with staff. A physician's progress note, dated 12/16/15, documented, .Pt with extensive behaviors and delusions. 11/26 found out on street left smoking area - was allowed to go out by self by administration and eloped .A&O x 2 (?) 3 Confused . An update to the care plan for smoking, dated 01/27/16, documented, (3) resident will smoke only with assistance of staff . A quarterly assessment, dated 02/01/16, documented the resident was cognitively intact, independent in activities of daily living, and required a wheelchair for mobility. A comprehensive care plan, dated 02/02/16, documented, Problem .Thought processes, impaired .Goal .Will indicate understanding of simple statements or commands by answering Yes No to questions .Approach .Minimize distraction .Reality orientation during waking hours do not support confusion .Resident is not to go outside to smoke by self onoy (sic) with staff . A comprehensive care plan, dated 02/02/16, documented: .Problem .2/2/2016 .Smoking Goal (1) 11/2/2015 .Resident will remain free of any harm while smoking (2) 11/2/2015 .Resident will have knowledge of safety measures while smoking . Approach (1) 2/2/2016 .Resident will smoke only in smoking areas (2) 2/2/2016 .Resident will smoke only with assistance of staff . On 03/02/16 at 2:18 p.m., the administrator was asked if resident #5 required supervision when smoking. She stated, I asked them to re-assess his smoking. She was asked if she was aware of the current physician order [REDACTED]. She stated, I asked them to re-assess him. She was asked what the cognitive status was for resident #5. She stated he was very aware and alert. She was asked if resident #5 ever appeared confused. She stated, No. At 2:33 p.m., the ADON was asked if resident #5 required assistance when he smoked. She stated, No. She was asked if she was aware of the current physician order [REDACTED].#5 when he smoked. She stated, No. She was asked if a smoking assessment would supercede a physician order. She stated, No. She was asked if she had ever observed the resident as being confused. She stated, No, he is very alert. At 3:15 p.m., the resident was observed outside in the resident smoking area smoking alone. He was observed wearing a pair of fleece pants. He had a burn hole on the front left pocket and on the left leg of the pants. He was asked what had happened the day he left the facility and was found going down the hill. He appeared confused as he attempted to remember the incident. He stated there were times he got very confused and could not remember but he had gone outside to smoke and thought he knew a shortcut. He stated, I don't know, I can't figure it out. At 3:30 p.m., two surveyors entered the resident's room and examined his clothing for burn holes. The following was found: ~ One shirt - five large and multiple small holes; ~ One pair of pants - one hole; ~ Gray jacket - two holes; and ~ Flannel jacket - a 2x 2 burn hole on the left sleeve, just above the elbow area. At 4:15 p.m., LPN #3 was asked if she was familiar with resident #5. She stated, Yes. She was asked if she had completed the incident report regarding resident #5 leaving the building and found going down the hill. She stated, Yes. She was asked what the cognitive status was for resident #5. She stated the resident was confused and disoriented at times. 2. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan addressed the problem of impaired physical mobility on 10/10/14. Interventions included, .10/10/2014 .Transfer with 2 person assist. Encourage to assist w/transfer .10/10/2014 .Transfer with Hoyer mechanical lift . A significant change assessment, dated 10/27/15, and a quarterly assessment, dated 01/27/16, documented the resident had a BIMS score of six which indicated the resident's cognitive status was severely impaired for daily decision making, was totally dependent on staff for transfers, and required two person assistance with all transfers. A facility incident report, dated 02/23/16 at 3 p.m., documented, .CNAs called this LPN to (room), noted on R (upper) arm Ant (anterior)to (and) Post. (posterior) a 12cm x 7cm (dark) purple bruise + behind (upper) R arm a 9cm x 6cm Dk purple bruise. Unknown origin. Dr informed (new order) for mobile x-ray to x-ray (upper) arm + shoulder DON notified + investigation started . This report was signed by LPN #1 and signed as reviewed by the DON on 02/29/16. A care plan, dated 02/23/16, documented the resident sustained [REDACTED]. An incident report, dated 02/24/16, documented, .February 24, 2016 INITIAL REPORT On February 23, 2016 CNAs that were caring for resident (#1) that he had dark purple bruising noted to his right upper arm. Upon assessment by LPN Charge nurse it was noted that there was purple bruising on right upper arm anterior to posterior. Resident grimaced even slight movement of right arm. When asked if his arm hurt, he stated, 'Yes'. Physician was notified and order was received for mobile x-ray. Resident was medicated with Norco 7.5 mg. The CNAs present in the room at the time of the Charge Nurse's assessment reported that there was a rumor that this had happened on Sunday, February 21, 2016. They stated that they had heard that a CNA that had worked on that hall on Sunday lifted the resident by herself and heard a pop when she moved him. The CNA that was working on that hall on Sunday had been interviewed. She stated that she did move resident by herself and did not use the lift. She stated that she did report it to the charge nurse. An investigation has been initiated. CNA .has been suspended pending results of investigation . This report was signed by the DON. A witness statement, signed by CNA #2, dated 02/24/16, documented, .On [DATE] I .made a transfer with my resident (#1) from the shower chair to his Geri chair without the proper equipment for his transfer. (CNA #3) help (sic) keep his chair from behind I heard a snap from his right arm sat him down on his chair didn't move him again until (LPN #5) and (LPN #6) came to check him out . A nursing inservice, dated 02/24/16, documented, .Subject .Abuse & Neglect, Elopement, Lift . The inservice was signed by 20 staff members. A nursing inservice, dated 02/25/16, documented, .Subject .How to use (brand name withheld) Lift & Gait Belt . The inservice was signed by 11 staff members. An undated witness statement, signed by LPN #5, documented, On March (sic) 21st around 3pm CNA #3 came and got me .to come check (resident #1's) arm. Went to shower room where CNA #2 stated she had lifted resident after shower and heard a pop from R arm. Assessed resident's arm. No obvious fracture noted. Called (physician) and told her about what happened. Was told to monitor resident and advise her of any further issue .Checked resident's arm several times. Able to move arm. No c/o pain or bruising noted . An undated witness statement, signed by LPN #6, documented, On Sunday [DATE]st I heard the east hall aide, (CNA #3) tell her nurse .that (CNA #2) needed her in the shower room. (CNA #2) had heard a 'pop' in (resident #1's) (R) arm during care. LPN #5 went down to the shower room. She then asked (this nurse) to observe (resident #1's) arm. Upon arrival to the shower room (resident #1) was sitting up in a chair. There was (no) bruising or swelling noted to (R) arm, (R) shoulder or (R) collar bone @ this time. There was (no) bone distortion noted to (R) shoulder, (R) collar bone or (R) arm. Resident did say 'ouch' when (R) arm was moved. He also said 'ouch' when (L) arm was moved. Which is sometimes typical for resident. (LPN # 5) told (this nurse) that (the physician) said to watch resident. If S/S of injury is later noted call her back. During the evening shift, (LPN #5) asked (this nurse) to observe resident's arm again. Resident was lying in bed. (No) facial grimaces noted. ROM to (R) arm was normal for resident. (No) bruising, swelling, distortions were noted to (R) arm, (R) collar bone, or (R) shoulder . An undated witness statement, signed by CNA #3, documented, On Sunday [DATE]st between 2pm & 3pm (CNA #2) yelled at me from the East Hall shower room where she had (resident #1). When I walked into the shower room (CNA #2) had (resident #1) picked up out of the shower chair so I went to pull up his pants. Before I had his pants pulled up we both heard (resident #1's) arm pop. I immediately went to the nurse station and told (LPN #5) to come to the shower room asap. Both (LPN #5) and (LPN #6) came to the shower room. I'm not sure what happen (sic) after that . On 03/03/16 at 2:09 p.m., CNA #1 was asked what the facility policy was for using the mechanical lift during a transfer. She stated they were to use two people for any transfer with a mechanical lift. On 03/03/16 at 2:43 p.m., CNA #3 was asked what occurred with resident #1's incident on 02/21/16 related to his fractured arm. She stated it happened between 2:00 p.m. and 3:00 p.m. She stated CNA #2 had him in the bathroom giving him a shower and she heard her ask for help. She stated CNA #2 bear hugged him around his upper torso. She stated she attempted to pull his pants up and they heard his right arm pop. She stated she left to notify the nurses and CNA #2 sat him in his chair. CNA #3 was asked how many people were required to assist with transfers for the resident. She stated, He's a total lift, two people. She was asked why two people did not transfer him when the incident occurred which resulted in a fractured arm. She stated, Couldn't tell you. She was asked what the facility policy was regarding the use of a mechanical lift. She stated, Two aides assisting. On 03/03/16 at 2:39 p.m., LPN #1 was asked what the facility policy was for the use of mechanical lifts. She stated she was not sure what the policy was. She was asked how many staff were required when using a mechanical lift. She stated, Two people. LPN #1 was asked what occurred when the resident was transferred on 02/21/16 which resulted in a fracture to his right arm. She stated she asked the CNA's to assist him with a shower and when they went into his room they noticed bruising to his right arm. She stated they reported the findings to her, she assessed him, called the physician, and received an order for [REDACTED]. She was asked why only one CNA had assisted him with the transfer on 02/21/16 which resulted in a fractured arm. She stated, I don't know. There should have been two persons there. LPN #1 was asked how staff was informed of the number of staff required for transfers. She stated, Above the bed it says L for lift, 1 for one person, 2 for two person and I is independent. On 03/03/16 at 2:59 p.m., the DON was asked what the facility policy was on the use of a mechanical lift. She stated, Supposed to be two person. She was asked who was responsible to ensure staff used two person assistance with a mechanical lift. She stated, My responsibility. She was asked how she monitored staff to ensure they were transferring residents and using the mechanical lift safely. She stated, Watching aides when doing lifts. We had physical therapy inservice staff on lift use. The DON was asked when the inservice by physical therapy was completed. She stated last week. The DON was asked what occurred on 02/21/16 during a transfer in the shower room with resident #1 which resulted in a fractured arm. She stated on 02/23/16, LPN #1 reported bruising, called the physician, and a mobile x-ray was ordered. She was asked what her assessment of the resident's arm was. She stated the resident verbalized pain when the arm was manipulated and she observed a little divot on the upper right arm. She was asked what type of skill competency evaluations were completed in the facility. She stated, I've not seen one that was done with any regularity. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 10/27/15, documented the resident had a BIMS score of six which indicated the resident was severely impaired in daily decision making, and received a mechanically altered diet during the seven day look back period. An endoscopic evaluation of swallowing, dated 11/25/15, documented, .Diagnosis: [REDACTED].Findings: Pt had decreased control of bolus in oral cavity with moderate pre-spill into pyriforms noted on every swallowing with decrease hyo-laryngeal elevation and slow retro-eppiglottic (sic) closer .Patient is noted to have moderate risk of aspiration .Recommendations: Puree with Honey thick liquids with crushed meds at this time as tolerated by patient and his stamina during meal .Compensatory strategy for small bite/sip, alternate bite/sip (2 bites to one drink ratio) recommended to decrease risk of penetration and aspiration .Staff must feed patient as patient is incapable of self-feeding . A quarterly assessment, dated 01/27/16, documented the resident had a BIMS score of six which indicated the resident was severely impaired in daily decision making, and received a mechanically altered diet during the seven day look back period. A dietary progress note, dated 01/04/15, documented, .Res received oral feedings of pureed (with) honey thick liquids during the day (with) generally 100% PO intake documented from 11/18/15 to 12/18/15 .On 11/18/15 swallow study was done-Res continued on oral feedings during the day and TF over night .Res demonstrated 100% PO oral intake consistently and on 12/18/16 MD ordered for TF to be d/c . A monthly tube feeding dietician review, dated 01/27/16, documented, .PO diet: Pureed Honey thick . A nurse's note, dated 02/02/16 at 6:00 p.m., documented, .Res coughing during meal .Instructed kitchen staff to thicken puree food d/t being runny .Res has crackles in (right upper) lobe of lung . A nurse's note, dated 02/03/16 at 2:10 a.m., documented, .Resident (with) congested lung sounds-coughing frequently .VS 98.7-97-40-129/81-O2 sat on R/A is 89%-91% .Has rapid shallow resp .Breath tx given-HOB .45 (degrees) .skin warm-dry . A nurse's note, dated 02/03/16 at 2:20 a.m., documented, .(physician) called-states to (increase) O2 to 3 (liters) .Give Norco per tube .Cough syrup also given .(Physician) states to transport to (hospital name withheld) if no improvement and give another breat. (sic) TX . A nurse's note, dated 02/03/16 at 3:00 a.m., documented, .Resp. status unchanged .40/min-very congested .O2 sat 93% on 3 (liters) of O2 .To send to hospital . A facility inservice, dated 02/05/16, documented, .TOPIC: Texture Modified Diets & Correct Use of Thickened Liquids .Trained Support Staff .Adequate Protein/Follow Menu .Palatability of the Food . A facility inservice, dated 02/08/16, documented, .SCOPE OF MEETING .Pureed food . A physician's orders [REDACTED].Diet: Jevity 1.2 cal @ 55ml/hr via continuous pump .Res is NPO . A physician's progress note, dated 02/15/16, documented, .02/03/16-02/13/16 (hospital name withheld) Asp pneumonia w/ resp failure vent .NPO-strict w/ pump feedings .Aspiration-NPO . On 03/03/16 at 9:30 a.m., the kitchen provided the survey team with a sample puree tray from the morning meal. The tray contained eggs, sausage, and gravy. The sausage was observed to be dry, grainy in texture, resembled crumbled corn bread and contained chunks of meat which were not thoroughly processed. On 03/03/16 at 10:51 a.m., cook #1 was asked what consistency pureed food was to be. She stated, Not too thick and dry but not too watery, like thick malt o' meal. She was asked what training she received on puree consistency. She stated a cook trained her. Cook #1 was asked what happened on 02/02/16 with the consistency of the pureed food at the evening meal. She stated she was not on duty during the incident, but on Monday during the morning meal the pureed eggs and gravy were too thin. On 03/03/16 at 2:43 p.m., CNA #3 was asked what was the consistency of pureed food. She stated, Like pudding. She was asked if the pureed diets were ever not the correct consistency. She stated, Sometimes they get them mixed up and give them not pureed food. CNA #3 was asked what she did if a resident on a pureed diet received the wrong consistency of food. She stated, Tell them about it. Sometimes it's really runny and some residents who are pureed gets choked up on it. She was asked how often was pureed foods too thin. She stated, I couldn't tell ya. On 03/03/16 at 2:47 p.m., LPN #1 was asked what was the consistency pureed foods. She stated, It's to be malt o meal consistency. I've had to take the malt o meal in there and thicken it myself. She was asked how often she had to thicken pureed foods for the residents. She stated, Twice last week. She was asked what would be the implications if residents were served pureed food which was not of the correct consistence. She stated, They could aspirate. LPN #1 was shown the pureed breakfast tray which was presented to the survey team at the morning meal. She was asked if the sausage would be considered pureed consistency. She stated, No, that's more thick ground up. On 03/03/16 at 3:13 p.m., the DON was asked what the consistency of pureed foods should be. She stated, I know we had a problem with it being too runny and I know that's not appropriate. I'm not real sure. She was asked what the implications were if a resident was served pureed food which was not the correct consistency. She stated, Choking. Aspiration. The DON was asked how often the puree was too thin. She stated, Sometimes. She was asked if any other residents coughed or choked related to the puree being too thin. She stated, Not that I'm aware of. She was asked who was responsible to ensure puree food was of correct consistency. She stated the dietary manager and the nursing staff. The DON was shown the pureed breakfast tray which was provided to the surveyors. She was asked what her observation was of the pureed sausage. She stated, Not puree like I would want to give someone. On 03/03/16 at 3:35 p.m., the dietary manager was asked what consistency pureed food was. She stated, Nectar thick. She was asked who was responsible to ensure pureed foods were of the correct consistency. She stated, I am. The dietary manager was asked who was responsible to ensure the pureed food was of the correct consistency when she was off duty. She stated the morning and evening cooks. She was asked what kind of training had been provided to the dietary staff regarding correct consistency of pureed food. She stated the dietician provided an inservice to the kitchen staff. On 03/03/16 at 5:56 p.m., the administrator was asked who was responsible to ensure the pureed food was of the correct consistency. She stated, The cook. She was shown the pureed breakfast tray which had been provided to the surveyors. She was asked what her observation was of the pureed sausage. She stated, A little dry. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 01/28/16, documented the resident's cognition was severely impaired in daily decision making, the resident had no wandering behaviors, and was independent in ADLs. A facility incident report, dated 02/12/16 at 7:00 p.m., documented, .DESCRIPTION OF INCIDENT .Res got out of N hall door and walked into the kitchen on her own. (No) injuries noted. (No) c/o voiced . CORRECTIVE ACTION TAKEN .Time that resident's sitter arrives has been changed to later in the day. Staff is doing frequent visual checks when sitter is not present . A nurse's note, dated 2/15/16 at 9:30 p.m., documented, .Late entry for 2.12.16 @ 1900 (7:00 p.m.) - Res went out N Hall door & ambulated into kitchen from the outside. (No) injuries were noted. (No) c/o voiced . A care plan, dated 02/16/16, documented, .Problem .At risk for elopment (sic) R/T WANDERING .Approach .Asure (sic) doors are locked and alarmed .Check residents location at least hourly . A facility incident report, dated 02/21/16 at 7:15 a.m., documented, .DESCRIPTION OF INCIDENT .When Housekeeper drove into North parking lot saw (resident #2) come out North door and was standing on sidewalk. She escorted (resdient #2) back into building . CORRECTIVE ACTION TAKEN .CNA to (check) on her frequently . The nurses's notes revealed no documentation of the elopement on 02/21/16. On 03/02/16 at 9:45 a.m., the medical director was asked if she had been informed resident #2 had eloped. She state

Based on observation, interview, and record review, it was determined the facility failed to prevent severe weight loss for one (#5) of one sampled residents with a peg tube. The resident had a severe weight loss of ten pounds or 5.8% in the past month. The resident census and conditions report identified one resident who received nourishment by peg tube. Findings: A policy, revised 02/2007, documented, .GASTROSTOMY TUBE FEEDING .GOAL .To furnish nourishment by the way of a tube which has been slipped through a surgically made opening through the abdominal wall and into the stomach . Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/10/15, documented the resident was severely impaired in cognition for daily decision making, and was totally dependent on staff for ADL's. The resident was readmitted from the hospital on [DATE]. A physician's orders [REDACTED].TUBE FEEDING 65ML/HR [MEDICATION NAME] 1.2 . A care plan, dated 10/13/15, documented, .Problem .NUTRITION ALTERED: LESS THAN BODY REQUIREMENTS .Approach .Has returned to G tube feeding following hosp stay .[MEDICATION NAME] 1.2 per pump per order . A weight variance report, dated 10/20/15, documented a weight of 169.8 pounds. This weight coincided with the return from the hospital weight reported by staff of 169.8 pounds. A significant change assessment, dated 10/27/15, documented the resident was severely impaired in cognition for daily decision making, and was totally dependent on staff for ADL's. The assessment documented the resident weighed 172 pounds, had no weight loss or gain in the last six months, did not have a feeding tube and received a mechanically altered diet. The assessment documented the resident received none of his calories through a feeding tube. A dietary progress note, dated 10/28/15, documented, .Current feedings via PEG tube of [MEDICATION NAME] 1.2 continuous @ 65ml/hr c 100ml H2O flushes every 4 (hours) .Feeding meeting needs .TF currently is his sole source of nutrition . A document, titled East Hall Monthly Weights, dated 10/28/15, documented the resident's weight at 164.4 pounds. This revealed a 5.4 pound weight loss since the residents return to the facility on [DATE]. On 11/16/15 at 11:00 a.m., the resident was at the nurses' station in a geriatric chair. LPN #3 was asked to identify the resident. She stated he was resident #5. She stated, He has lost a lot of weight, think it may have been a good thing as long as he isn't losing any more now. On 11/17/15 at 10:19 a.m., the resident was observed in bed. A bag labeled, [MEDICATION NAME] 1.2, with approximately 400mls in it, was hanging on the tube feeding pole above the pump. The monitor was flashing 65ml/hr and a green light was flashing at the bottom of the pump indicating dose complete. The tube feeding was not infusing. At 2:04 p.m., the resident was observed in bed. A bag labeled, [MEDICATION NAME] 1.2, with approximately 400mls in it, was hanging on the tube feeding pole above the pump. The monitor was flashing 65ml/hr and a green light was flashing at the bottom of the pump indicating dose complete. The tube feeding was still not infusing. At 2:20 p.m., the resident was observed in bed. A bag, labeled [MEDICATION NAME] 1.2, with approximately 400mls in it, was hanging on the tube feeding pole above the pump. The monitor was flashing 65ml/hr and a green light was flashing at the bottom of the pump indicating dose complete. The tube feeding was not infusing. At 2:55 p.m., LPN #3 was asked if she was assigned to care for resident #5. She stated yes. She was asked what care she had provided to him during her shift. She stated she administered his medications around 9:00 a.m., added a can of [MEDICATION NAME] to the bag of feeding at 11:00 a.m., and assisted the CNA's with turning and repositioning him at 2:00 p.m. At 3:10 p.m., LPN #1 was asked for the resident's current weight. The resident was weighed with a value of 159.8 pounds reported by staff. This value revealed a severe weight loss of ten pounds or 5.8% in the past month. On 11/18/15 at 9:38 a.m., the resident was observed in bed. The tube feeding was not infusing and was not attached to the port. The tubing was wrapped around the feeding pump. The label on the tube feeding was dated 11/18/15 at 1:00 a.m. There was approximately 400ml of feeding in the bag. At 11:01 a.m., the resident was observed in bed. The tube feeding was not infusing and was not attached to the port. The tubing was wrapped around the feeding pump. The label on the tube feeding was dated 11/18/15 at 1:00 a.m. There was approximately 400ml of feeding in the bag. At 1:03 p.m., the resident was observed in bed. The tube feeding was not infusing and was not attached to the port. The tubing was wrapped around the feeding pump. The label on the tube feeding was dated 11/18/15 at 1:00 a.m. There was approximately 400ml of feeding in the bag. At 1:47 p.m., LPN #3 was asked what were the current tube feeding orders. She stated, [MEDICATION NAME] 1.2 at 65ml/hr, continuous unless he has residual. She was asked when residual was last assessed. She stated with his feeding and flush. She was asked if he had any residual today. She stated, No. LPN #3 was asked who was responsible to monitor the resident's tube feeding to ensure it was infusing. She stated she checked it. She was asked when she monitored his tube feeding to ensure it was infusing during her shift. She stated, Randomly. She was asked when she last monitored the resident's tube feeding to ensure it was infusing. She stated, Between 12:00 (p.m.) and 12:30 (p.m.). She was asked what the status of his tube feeding was between 12:00 and 12:30 p.m. She stated, It was unhooked, I unhooked it. LPN #3 was asked what time she unhooked the resident's tube feeding. She stated, About 11:00 (a.m.) I think. LPN #3 was asked why the resident's tube feeding had been unhooked and not infusing since 9:38 a.m. She stated she unhooked the tube feeding so the CNA's could get him up around 9:00 a.m. She then stated, I thought it was around 9:00 (a.m.), I could be off on the time. At 2:04 p.m., LPN #3 accompanied the surveyor to the resident's room. The resident was observed in bed. The tube feeding was not infusing and was not attached to the port. The tubing was wrapped around the feeding pump. The label on the tube feeding was dated 11/18/15 at 1:00 a.m. There was approximately 400ml of feeding in the bag. LPN #3 was asked what the amount of tube feeding was that had infused. She stated, It says zero. LPN #3 stated when she was in the room at 9:00 a.m., the bag had 100ml, and she added a can of [MEDICATION NAME] at that time. She was asked where that was documented. She stated, I haven't documented anything. At 2:14 p.m., she was asked what documentation she completed for tube feedings. She stated she documented the kind of formula, rate, and residual. She was asked if she documented the volume infused during her shift. She stated, No. Not since I've been here. On 11/19/15 at 3:58 p.m., the medical director was informed of the surveyor's observations of the tube feeding being unhooked and not infusing. She stated the fact that the tube feeding had been off and not infusing was a big concern and she did not know why the tube feeding kept getting turned off. She stated when she saw the resident on 11/11/15 the tube feeding was turned off when she entered the room.

Based on observation, interview, and record review, it was determined the facility failed to ensure hot water temperatures were not an accident hazard for two (#24 and #26) of two alert but cognitively impaired sampled residents who wandered throughout the facility. The residents were able to turn the water on. This resulted in an immediate jeopardy situation related to hot water as an accident hazard. Findings: On 06/19/12 at 4:10 p.m., CMA #1 was observed completing a finger stick blood sugar in room #64. After completing the finger stick, CMA #1 turned on the water to wash her hands and stated, "You got some hot water there." The CMA finished washing her hands and proceeded to complete her finger stick blood sugars. She did not inform the administrator of the hot water. 1. On 06/19/12 at 4:55 p.m., the hot water temperature in room #64 on the north hall was checked. The temperature measured 131 degrees Fahrenheit (F.) instantaneously when the water was turned on. 2. At 4:59 p.m., the hot water temperature in room #63 on the north hall measured 126.2 degrees F. Resident #25 resided in this room. The resident was alert but cognitively impaired. 3. At 5:01 p.m., the hot water temperature in room #40 on the east hall measured 131 degrees F. 4. At 5:05 p.m., the hot water temperatures on the south hall were measured. There were no temperatures in excess of 125 degrees F. At 5:11 p.m., the administrator was asked if there were any wandering residents in the facility. The administrator identified residents #24 and 26. When asked if the residents were capable of turning the hot water on, the administrator stated, "Yes." Immediate Jeopardy Identified On 06/19/12, an Immediate Jeopardy (IJ) situation was identified related to instantaneous hot water temperatures of 131 degrees F. The facility failed to ensure hot water temperatures were below 115 degrees F. for two (#24 and #26) of two sampled residents who were identified as residents who wandered throughout the facility and were capable of turning the hot water on. At 5:32 p.m., the Oklahoma State Department of Health verified the existence of the IJ related to hot water as an accident hazard. At 5:34 p.m., the administrator and corporate nurse were informed of the IJ. The administrator stated a monitoring plan would immediately be put into place and the maintenance supervisor was coming to drain the hot water tanks. At 5:50 p.m., the administrator stated the monitoring system was in place and the aides on each hall were monitoring to ensure residents did not use the hot water. She stated the maintenance supervisor was emptying the hot water tanks and adjusting the mixing valves. At 6:38 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "Plan of Removal for alleged immediate jeopardy declared 6.19.2012 at approximately 5:30 p.m. OSDH survey team notes an alleged jeopardy situation regarding hot water temperatures. they note temperatures reported to be 126 degrees F and 131 degrees F. The facility had already notified maintenance staff at approximately 5:20 p.m. to check the water temperature, after OSDH surveyor had asked questions that indicated there may be a problems (sic) with hot water on the North hall. Staff had begun checking temperatures on the North wing. Temperature was noted to be 123 degrees F, in room 63. The administrator advised the maintenance staff to drain the hot water tank at that time and advised the aides on the North wing to not allow anyone to use the hot water until further instructed. After learning from the survey team of the immediate jeopardy, aides were posted on all three halls and instructed to not let anyone use hot water until further instructed. Staff obtained temperature readings of 115 degrees F in room 15, 90 degrees F East hall shower, 84 degrees in the handicap shower in the East halls, 112 degrees F in room 5 on the South Hall. These rooms are not the rooms indicated by OSDH surveyors, but are fed by the same tanks. Maintenance is draining all hot water tanks and adjusting the mixer valves. Maintenance will monitor temperatures every 15 minutes until hot water temperatures are at 115 degrees F or less and then every 15 minutes for 1 hour insure (sic) temperatures remain below 115 degrees F. Staff will continue to monitor hot water temperatures every 1 hour throughout the evening and night time hours on each hall to verify the temperatures do not exceed 115 degrees F. The administrator will be notified immediately if any temperature exceeds 115 degrees F so that further correction can be made. Hall monitors will again be put into place to insure (sic) no use of hot water until the temperature is at 115 degrees F or less. Further, all staff on duty for the evening shift, present in the building now will receive inservice training to immediately notify the administrator if water exceeds 115 degrees F or if it feels hot to the touch. Other staff will be notified by telephone and instructed in the same prior to their next work day, during this evening hours before midnight. Two residents were identified to OSDH staff as individuals who may wander. Staff are watching these residents to insure (sic) that they do not use water without supervision. No resident in the facility has been affected by hot water temperatures." On 06/20/12 at 9:30 a.m., documentation of hot water temperature checks revealed the water temperatures had remained below 115 degrees F. from 6:45 p.m. through 06/20/12 at 7:30 a.m. At 2:28 p.m., the corporate nurse provided documentation of hot water temperatures from 8:30 a.m. through 06/20/12 at 1:30 p.m. It was documented the hot water temperatures remained below 115 degrees F. Immediacy Removed The IJ was removed on 06/20/12 at 4:10 p.m., when the hot water temperatures had stabilized and the last staff member was inserviced on the process of putting a monitoring plan in place and notifying the administrator if the hot water temperature went above 115 degrees F. or if it felt too hot. On 06/20/12, staff were interviewed in regards to their knowledge of the inservice, to ensure their understanding of the hazards of high hot water temperatures. The staff verbalized understanding. The deficient practice remained at a pattern level with a potential for more than minimal harm.

Based on observation, interview, and record review, it was determined the facility failed to provide urinary incontinent care in a timely manner for one (#14) of four sampled residents with urinary incontinence. The failure to provide incontinent care in a timely manner resulted in skin maceration and erosion causing actual harm for the resident. Findings: The facility policy and procedure for incontinent care documented: "It shall be the policy of this facility to provide incontinent care to residents who are incontinent of bowel and/or bladder. It shall further be the policy of this facility to provide incontinent care in a method that is in conjunction with accepted standands of practice which will prevent cross contamination, promote preservation of skin integrity and will promote the individuals dignity. For residents who are identified as being incontinent of bowel and/or bladder: 1. Provide privacy. 2. Check for incontience at regular intervals over the course of the 24 hour period..." Resident #14 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The quarterly assessment, dated 04/23/12, documented the resident was moderately cognitively impaired, incontinent of both bowel and bladder, and required moderate to extensive assistance with activities of daily living. The careplan, dated 12/10/09, documented the resident had a toileting deficit related to weakness. The staff was to provide privacy for elimination and time for completion, respond to the call light promptly and assure the call bell was within reach, and toilet every 2 hours with pericare after each incontinence. On 06/22/12 at 6:01 a.m., resident #14 was observed in bed with CNA #4 preparing to perform incontinent care for the resident. Warm water and soap from the bathroom dispenser was observed placed in a clean wash basin. The resident was observed uncovered and a strong urine odor was present. The lower half of the resident's gown was observed to be saturated with urine. The bed pad was also observed to be saturated from top to bottom and side to side with urine, and dark urine rings were observed staining the right border of the bed pad. The bed sheet was observed to be saturated with urine and a 24 inch by 10 inch area of the protective bed cover appeared wet from urine. The resident's buttocks appeared excoriated and red in color with a bubbled area approximately 1centimeter (cm) x 2 cm observed on the right cheek of the buttocks. CNA #4 wiped the bubbled area twice. Each time, the resident was observed to jerk away from the CNA as he/she wiped the area. The area was dried twice and again the resident was observed to jerk away from the CNA as he/she wiped the area of the buttocks. CNA #4 was asked if the gown, bed sheet, and mattress were saturated with urine. CNA #4 stated, "Yes." The CNA was asked when the resident had been checked for incontinence. The CNA stated the resident was checked during rounds at 1:00 a.m., 3:00 a.m., and 5:00 a.m. CNA #4 was asked if incontinent care had been provided for the resident at 5:00 a.m. CNA #4 stated, "No." When asked the last time the CNA had provided incontinent care, the CNA stated he/she had not provided incontent care for the resident because the resident had not been soiled until now. At 8:58 a.m., LPN #2 was asked if he/she received any report on resident #14. LPN #2 stated he/she was in the dining room but that someone surely walked the halls today. At 9:02 a.m., LPN #3 was asked if he/she received report. The LPN stated no, that LPN #2 had received report today. At 9:05 a.m., LPN #1 was asked if he/she received report. LPN #1 answered "No." At 9:06 a.m., LPN #4 was asked if he/she received report on resident #14. The LPN stated "No." At 9:06 a.m., CNA #9 was interviewed. The CNA stated the resident was incontinent of both bowel and bladder. At 9:13 a.m., an observation of the skin of resident #14 was performed with LPN #3. The resident was observed up in the recliner with a thread bare gown on. The LPN stated the resident's skin over the buttocks and peri-area remained red despite the application of ointment twice daily, and the staff could not determine what was causing the continued excoriation. The surveyor showed LPN #3 the area of the resident's buttocks and asked if the area was open. The LPN stated yes and that it appeared the skin had peeled away.

Based on observation, interview, and record review, it was determined the facility failed to report injuries of unknown source to the administrator for 2 (#1 and #4) of 2 sampled residents with cognitive impairment who had injuries of unknown source. The failure to report those injuries prohibited protection for the residents, a thorough investigation of the incidents, and reporting to officials as required by state law. This resulted in an Immediate Jeopardy situation. This had the potential to affect 31 residents identified by the facility as being cognitively impaired. Findings: The facility's undated policy on abuse and neglect documented, "...Injury of unknown origin: An injury to be classified as an 'Injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and, The injury is suspicious because of the extent of the injury or the location of the injury (E.g. the injury is located in an area not generally vulnerable to trauma) or the frequency of injury... Observations are to be reported to the Administrator or his designee immediately... Protect: Upon receipt of an allegation of abuse...the facility will immediately act to protect the resident/client. The person in charge of the facility shall have the authority to take all necessary steps to protect the resident/client... Investigate: The facility will thoroughly investigate all allegations concerning client/resident abuse...including injuries of unknown origin... Training shall include the need for reporting all incidents without regard to severity and situations that may be considered 'unreportable' to the state, but which should be reviewed to prevent possible incidents that would harm or have the potential to harm residents/clients... Any employee that is told of an allegation or observes abuse...shall report immediately to the individual who is in charge of the facility and the Administrator. An incident report shall be written and the report shall be filled out, containing the following information: The time, location, employee name, the client/resident name, or other person name and the details concerning the abuse...including the type. In case of physical abuse, the locations to the client/resident's body where the abuse was inflicted. A report shall be provided to the Administrator immediately. Upon receiving the report, the staff shall begin an internal investigation. If the allegation is one of physical abuse, the Director of Nursing or Nurse in charge and one other direct care staff person shall perform a focused assessment of the area of the alleged abuse to determine if any marks, scratches, abrasions or other marks are visible on the client/resident. If required, further examination will be made by a physician or by other team members... If the incident is an injury of unknown origin, weight and consideration will be given to the location of the injury...The extent and location of the injury will drive the direction of the investigation... Report/Respond: The facility is required by State Statute and Federal Regulations to report allegations of resident/client abuse...and injuries of unknown origin..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Summary Score of the MDS Brief Interview for Mental Status (BIMS), dated 12/20/10, documented the resident was cognitively intact, did not exhibit any behavioral symptoms, and was always incontinent of bowel and bladder. A RAP Summary, dated 12/20/10, documented, "...Due to...dx of [MEDICAL CONDITION] she has problems with both short and long term memory deficits as well as impaired decision making skills. She rquires (sic) cues and prompts at times to make decisions. Sometimes she cannot answer simple questions. She is at risk for her needs not being met and answering questions appropriately..." The care plan, last updated 12/20/10, documented a problem, "...Total incontinence..." Goals included, "...Keep skin clean (and) dry..." Approaches included, "...Toilet q 2 (hours) - pericare after each incontinent episode..." On 07/21/11 at 3:12 p.m., CNA #1 was observed performing incontinent care for the resident. The anterior portion of the resident's right labia minora was observed to be reddish purple the entire length, extending downwards on each side approximately 1/8th inch. A scratch was noted on the inner aspect of each labia majora, with each being approximately 1/4 inch long. CNA #1 was asked if the injury was new and if the discolored area had been reported to a nurse. CNA #1 stated, "The nurses came and looked at it. (LPN #1) came down and looked with (LPN #2)." CNA #1 was asked if she knew how the resident obtained the injury. She stated, "I don't know." CNA #1 was asked when the area had been observed. She stated, "Before state came in last week. Pretty sure it was Monday (07/11/11)." The resident was asked how she received the injury. She stated she didn't know. She was asked if someone had hurt her. She stated, "I don't think so. I would remember that, wouldn't I?" Review of the resident's clinical record revealed no documentation of the injury noted on the resident's labia minora. Review of facility records revealed no incident report related to the injury. There was no documentation to show the administrator had been notified of the injury, and there was no documentation of an investigation related to the injury of unknown source. On 07/21/11 at 3:44 p.m., the administrator and LPNs #1 and #2 were interviewed. LPN #1 was asked if the injury on the resident's labia minora was reported to her. She stated, "Yes, it was." She was asked what she did when it was reported to her. LPN #1 stated, "Honestly I went and looked at it. I went to the nurses' station and got sidetracked. Honestly, I don't know if I turned it in or not." The administrator was asked if she was aware of the injury. She stated, "Yes." The administrator was asked what she did when the injury was reported to her. She stated, "We went and looked at it. (Resident #4) is mean sometimes. I don't know if she scratched it." The administrator was asked for her investigation. She stated, "I didn't do one." When asked where the bruising was, the administrator stated, "The inner thigh. I don't remember what side." When asked what size it was, the administrator stated it was about the size of the end of the ink pen she was holding. She stated, "It was in the crease of the left leg." LPN #1 was asked if she reported an area on the left crease or on the labia minora. She stated, "I'm not sure. It could have been the labia minora. It's possible." The administrator was asked if there was anyone else who looked at the area with her. She stated, "Me and (LPN #1). I don't know if there was another nurse who looked at it." When asked what day the injury was observed, LPN #1 and the administrator stated, "I'm not sure." The administrator was asked if the injury she saw was on the resident's left leg crease. She stated, "Yes." When asked if she was aware of the injury on the resident's labia minora, the administrator stated, "No." LPN #1 was asked if she assessed the resident for bruising or injury during the last week (week of 07/11/11). She stated, "Yes." When asked how she assessed, LPN #1 stated, "Just looked at it." LPN #1 was asked if she separated the resident's labia to see the area of injury, she stated, "I don't know." The administrator was asked if the injury was of suspicious nature. She stated, "Yes." The administrator stated, "What I looked at was three weeks ago." LPN #2 was asked who reported the resident's injury to her. She stated, "(LPN #1)." When asked where the injury was, LPN #2 stated, "Around the labia area." LPN #2 was asked who she reported the injury to. She stated, "We talked about it but didn't report it." When asked if the injury was of a suspicious nature, LPN #2 stated, "Yes, could be." LPN #1 was asked if she had informed the administrator of the injury reported last week (week of 07/11/11). She stated, "I don't know." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 04/18/11, documented the summary score of the MDS Brief Interview for Mental Status (BIMS) documented the resident was severely impaired. A care plan, last updated on 07/12/11, documented, "...Problem...physical mobility, impaired r/t weakness...Approach...turn & reposition q 2 hrs...Problem...thought processes, impaired r/t decreased mental status...Problem...incontinence, total bowel and bladder r/t neuroligic (sic) dysfunction...approach...report areas of skin redness or breakdown...transfer c 2 person assist..." 0n 07/21/11 at 2:54 p.m., CNA #3 was asked if she had reported any suspicious bruising. She stated, "Yes, on one resident (resident #1)." She was asked who she reported the suspicious bruising to. She stated, "The charge nurse." She was asked what the charge nurse did. She stated, "As far as I'm concerned, they didn't do anything." At 3:10 p.m., resident #1's skin was observed with CNA #2. The resident was observed to have three 1cm x 1cm circular dark purple bruises on the inside of the left thigh and two 1cm x 1cm circular dark purple bruises on the inside of the right thigh. CNA #2 was asked if she had seen the bruises on the resident's inner thighs. She stated, "Yes, I reported them to (LPN #4, LPN #5, and LPN #6) over the weekend because it was bruising of unknown origin." She was asked what she thought the bruises looked like. She stated, "Fingers, to me." Review of the clinical record revealed no documentation of bruising to the resident's inner thighs. Review of the facility's incident reports revealed no documentation of bruising to the resident's inner thighs. At 3:57 p.m., LPN #2 was asked if she was aware of bruising on resident #1. She stated, "Yes, I have incident reports." She was asked if the resident had any new bruising. She stated, "No." She was asked if she was aware of the bruising on the resident's inner thighs. The administrator asked, "Does she have it now?" LPN #2 stated, "I didn't even know this." LPN #1 stated, "No, I was not. LPN #2 stated bruising had been reported on the resident but she thought it was old bruising so she did not assess the resident for new bruises. The administrator was asked if the incidents should have been reported to her. She stated, "You betcha." Immediate Jeopardy Identified On 07/21/11, an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to ensure that injuries of unknown source were reported immediately to the administrator, were thoroughly investigated and residents were protected for 2 (#1 and #4) of 2 sampled residents with cognitive impairment and injuries of unknown source. At 5:17 p.m., OSDH was notified and verified the existence of the IJ. At 5:24 p.m., the administrator was notified of the IJ situations and was informed this placed the facility in a partial extended survey. At 7:26 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "Incident's have been reported to the (city name withheld) Police Department to officer (officer name withheld). Physician's of these 2 residents have been notified and requested a physical exam. These incidents will be reported to the state immediately. 4-12 shift has immediately been inserviced on Abuse and Neglect policy and procedures. 8-4 shift remained in the building and will be inserviced on Abuse and Neglect policy and procedures. 12-8 shift will be called and advised to come into facility now for inservice of Abuse and Neglect. No staff member will be allowed to start their shift until inserviced on Abuse and Neglect. I began my investigation at 5:45 pm on July 21, 2011. Interviews and written statements are being obtained. If at any time during my investigation any staff member is identified to have had knowledge of the injuries of unknown source and did not report it the staff member will be immediately terminated. Form will be implemented to ensure that the administrator is notified of any allegation of abuse and neglect of any type including injuries of unknown source. This form will be implemented immediately, and included in the inservices." Immediacy Removed On 07/22/11 at 9:53 a.m., the administrator provided documentation ensuring all staff had been in-serviced on the facility's abuse and neglect policy and procedure, reporting allegations of abuse and neglect including injuries of unknown source, and the form implemented by the facility to ensure the administrator was notified of any allegations of abuse and neglect. The IJ was removed on 07/22/11, effective at 9:45 a.m. when the last staff member was inserviced, after staff were interviewed in regard to their knowledge of the facility's abuse and neglect policy, reporting allegations of abuse and neglect including injuries of unknown source, and the form to be used to ensure the administrator's knowledge of any allegations of abuse and neglect. The deficient practice remained at a pattern level with a potential for more than minimal harm. On 07/22/11 at 10:52 a.m., LPN #3 performed a BIMS for resident #4. The resident scored a 6. This documented the resident was severely impaired in cognition. LPN #3 stated, "There's definitely a memory problem."

Based on observation, interview, and record review, it was determined the facility failed to implement their policy and procedure on abuse and neglect when they did not report injuries of unknown source to the administrator for 2 (#1 and #4) of 2 sampled residents with cognitive impairment who had injuries of unknown source. The failure to report those injuries prohibited protection for the residents, a thorough investigation of the incidents, and reporting to officials as required by state law. This resulted in an Immediate Jeopardy situation. This had the potential to affect 31 residents identified by the facility as being cognitively impaired. Findings: The facility's undated policy on abuse and neglect documented, "...Injury of unknown origin: An injury to be classified as an 'Injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and, The injury is suspicious because of the extent of the injury or the location of the injury (E.g. the injury is located in an area not generally vulnerable to trauma) or the frequency of injury... Observations are to be reported to the Administrator or his designee immediately... Protect: Upon receipt of an allegation of abuse...the facility will immediately act to protect the resident/client. The person in charge of the facility shall have the authority to take all necessary steps to protect the resident/client... Investigate: The facility will thoroughly investigate all allegations concerning client/resident abuse...including injuries of unknown origin... Any employee that is told of an allegation or observes abuse...shall report immediately to the individual who is in charge of the facility and the Administrator. An incident report shall be written and the report shall be filled out, containing the following information: The time, location, employee name, the client/resident name, or other person name and the details concerning the abuse...including the type. In case of physical abuse, the locations to the client/resident's body where the abuse was inflicted. A report shall be provided to the Administrator immediately. Upon receiving the report, the staff shall begin an internal investigation. If the allegation is one of physical abuse, the Director of Nursing or Nurse in charge and one other direct care staff person shall perform a focused assessment of the area of the alleged abuse to determine if any marks, scratches, abrasions or other marks are visible on the client/resident. If required, further examination will be made by a physician or by other team members... If the incident is an injury of unknown origin, weight and consideration will be given to the location of the injury...The extent and location of the injury will drive the direction of the investigation... Report/Respond: The facility is required by State Statute and Federal Regulations to report allegations of resident/client abuse...and injuries of unknown origin... The facility shall notify the State Department of Health within 24 hours of the incident.... A report shall be made to the Health Department that the facility staff have received an allegation of abuse...injury of unknown origin as defined herein, within 24 hours of when the incident is reported or known about..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Summary Score of the MDS Brief Interview for Mental Status (BIMS), dated 12/20/10, documented the resident was cognitively intact, did not exhibit any behavioral symptoms, and was always incontinent of bowel and bladder. A RAP Summary, dated 12/20/10, documented, "...Due to...dx of [MEDICAL CONDITION] she has problems with both short and long term memory deficits as well as impaired decision making skills. She rquires (sic) cues and prompts at times to make decisions. Sometimes she cannot answer simple questions. She is at risk for her needs not being met and answering questions appropriately..." The care plan, last updated 12/20/10, documented a problem, "...Total incontinence..." Goals included, "...Keep skin clean (and) dry..." Approaches included, "...Toilet q 2 (hours) - pericare after each incontinent episode..." On 07/21/11 at 3:12 p.m., CNA #1 was observed performing incontinent care for the resident. The anterior portion of the resident's right labia minora was observed to be reddish purple the entire length, extending downwards on each side approximately 1/8th inch. A scratch was noted on the inner aspect of each labia majora, with each being approximately 1/4 inch long. CNA #1 was asked if the injury was new and if the discolored area had been reported to a nurse. CNA #1 stated, "The nurses came and looked at it. (LPN #1) came down and looked with (LPN #2)." CNA #1 was asked if she knew how the resident obtained the injury. She stated, "I don't know." CNA #1 was asked when the area had been observed. She stated, "Before state came in last week. Pretty sure it was Monday (07/11/11)." The resident was asked how she received the injury. She stated she didn't know. She was asked if someone had hurt her. She stated, "I don't think so. I would remember that, wouldn't I?" Review of the resident's clinical record revealed no documentation of the injury noted on the resident's labia minora. Review of facility records revealed no incident report related to the injury. There was no documentation to show the administrator had been notified of the injury, and there was no documentation of an investigation related to the injury of unknown source. On 07/21/11 at 3:44 p.m., the administrator and LPNs #1 and #2 were interviewed. LPN #1 was asked if the injury on the resident's labia minora was reported to her. She stated, "Yes, it was." She was asked what she did when it was reported to her. LPN #1 stated, "Honestly I went and looked at it. I went to the nurses' station and got sidetracked. Honestly, I don't know if I turned it in or not." The administrator was asked if she was aware of the injury. She stated, "Yes." The administrator was asked what she did when the injury was reported to her. She stated, "We went and looked at it. (Resident #4) is mean sometimes. I don't know if she scratched it." The administrator was asked for her investigation. She stated, "I didn't do one." When asked where the bruising was, the administrator stated, "The inner thigh. I don't remember what side." When asked what size it was, the administrator stated it was about the size of the end of the ink pen she was holding. She stated, "It was in the crease of the left leg." LPN #1 was asked if she reported an area on the left crease or on the labia minora. She stated, "I'm not sure. It could have been the labia minora. It's possible." The administrator was asked if there was anyone else who looked at the area with her. She stated, "Me and (LPN #1). I don't know if there was another nurse who looked at it." When asked what day the injury was observed, LPN #1 and the administrator stated, "I'm not sure." The administrator was asked if the injury she saw was on the resident's left leg crease. She stated, "Yes." When asked if she was aware of the injury on the resident's labia minora, the administrator stated, "No." LPN #1 was asked if she assessed the resident for bruising or injury during the last week (week of 07/11/11). She stated, "Yes." When asked how she assessed, LPN #1 stated, "Just looked at it." LPN #1 was asked if she separated the resident's labia to see the area of injury, she stated, "I don't know." The administrator was asked if the injury was of suspicious nature. She stated, "Yes." The administrator stated, "What I looked at was three weeks ago." LPN #2 was asked who reported the resident's injury to her. She stated, "(LPN #1)." When asked where the injury was, LPN #2 stated, "Around the labia area." LPN #2 was asked who she reported the injury to. She stated, "We talked about it but didn't report it." When asked if the injury was of a suspicious nature, LPN #2 stated, "Yes, could be." LPN #1 was asked if she had informed the administrator of the injury reported last week (week of 07/11/11). She stated, "I don't know." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 04/18/11, documented the summary score of the MDS Brief Interview for Mental Status (BIMS) documented the resident was severely impaired. A care plan, last updated on 07/12/11, documented, "...Problem...physical mobility, impaired r/t weakness...Approach...turn & reposition q 2 hrs...Problem...thought processes, impaired r/t decreased mental status...Problem...incontinence, total bowel and bladder r/t neuroligic (sic) dysfunction...approach...report areas of skin redness or breakdown...transfer c 2 person assist..." 0n 07/21/11 at 2:54 p.m., CNA #3 was asked if she had reported any suspicious bruising. She stated, "Yes, on one resident (resident #1)." She was asked who she reported the suspicious bruising to. She stated, "The charge nurse." She was asked what the charge nurse did. She stated, "As far as I'm concerned, they didn't do anything." At 3:10 p.m., resident #1's skin was observed with CNA #2. The resident was observed to have three 1cm x 1cm circular dark purple bruises on the inside of the left thigh and two 1cm x 1cm circular dark purple bruises on the inside of the right thigh. CNA #2 was asked if she had seen the bruises on the resident's inner thighs. She stated, "Yes, I reported them to (LPN #4, LPN #5, and LPN #6) over the weekend because it was bruising of unknown origin." She was asked what she thought the bruises looked like. She stated, "Fingers, to me." Review of the clinical record revealed no documentation of bruising to the resident's inner thighs. Review of the facility's incident reports revealed no documentation of bruising to the resident's inner thighs. At 3:57 p.m., LPN #2 was asked if she was aware of bruising on resident #1. She stated, "Yes, I have incident reports." She was asked if the resident had any new bruising. She stated, "No." She was asked if she was aware of the bruising on the resident's inner thighs. The administrator asked, "Does she have it now?" LPN #2 stated, "I didn't even know this." LPN #1 stated, "No, I was not. LPN #2 stated bruising had been reported to her but she thought it was old bruising so she did not assess the resident for new bruises. The administrator was asked if the incidents should have been reported to her. She stated, "You betcha." Immediate Jeopardy Identified On 07/21/11, an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to implement their abuse and neglect policy and procedure when injuries of unknown source were not reported immediately to the administrator, were not thoroughly investigated and residents were not protected for 2 (#1 and #4) of 2 sampled residents with cognitive impairment and injuries of unknown source. At 5:17 p.m., OSDH was notified and verified the existence of the IJ. At 5:24 p.m., the administrator was notified of the IJ situations and was informed this placed the facility in a partial extended survey. At 7:26 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "Incident's have been reported to the (city name withheld) Police Department to officer (officer name withheld). Physician's of these 2 residents have been notified and requested a physical exam. These incidents will be reported to the state immediately. 4-12 shift has immediately been inserviced on Abuse and Neglect policy and procedures. 8-4 shift remained in the building and will be inserviced on Abuse and Neglect policy and procedures. 12-8 shift will be called and advised to come into facility now for inservice of Abuse and Neglect. No staff member will be allowed to start their shift until inserviced on Abuse and Neglect. I began my investigation at 5:45 pm on July 21, 2011. Interviews and written statements are being obtained. If at any time during my investigation any staff member is identified to have had knowledge of the injuries of unknown source and did not report it the staff member will be immediately terminated. Form will be implemented to ensure that the administrator is notified of any allegation of abuse and neglect of any type including injuries of unknown source. This form will be implemented immediately, and included in the inservices." Immediacy Removed On 07/22/11 at 9:53 a.m., the administrator provided documentation ensuring all staff had been in-serviced on the facility's abuse and neglect policy and procedure, reporting allegations of abuse and neglect including injuries of unknown source, and the form implemented by the facility to ensure the administrator was notified of any allegations of abuse and neglect. The IJ was removed on 07/22/11, effective at 9:45 a.m. when the last staff member was inserviced, after staff were interviewed in regard to their knowledge of the facility's abuse and neglect policy, reporting allegations of abuse and neglect including injuries of unknown source, and the form to be used to ensure the administrator's knowledge of any allegations of abuse and neglect. The deficient practice remained at a pattern level with a potential for more than minimal harm. On 07/22/11 at 10:52 a.m., LPN #3 performed a BIMS for resident #4. The resident scored a 6. This documented the resident was severely impaired in cognition. LPN #3 stated, "There's definitely a memory problem."

Based on observation, interview, and record review, it was determined the facility failed to provide interventions to prevent an avoidable decline in range of motion for one (#6) of one sampled resident who had a decline in range of motion. This failure resulted in actual harm related to the resident's decline in range of motion and ability to ambulate. The facility's resident census and conditions of residents documented there were no residents with contractures on admission. This had the potential to affect 23 of 69 residents identified by the facility's resident census and conditions report to require assistance with ambulation. Findings: Resident #6 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A physical therapy (PT) form, dated 05/06/09, documented the resident's active range of motion was within full limits. The form documented the resident was alert, but confused. The form documented the resident was very cooperative and ambulated 75 feet using a rolling walker with contact guard assistance. A PT form, dated 10/30/09, documented the resident was able to ambulate 75-125 feet with a rolling walker or wheelchair with minimal or contact guard assistance. An annual assessment, dated 05/19/10, documented the resident had long-term memory loss, required limited assistance of one person with transfers and walking, and had no functional limitations with range of motion of the upper or lower extremities. An occupational therapy (OT) form, dated 06/10/10, documented the resident was referred to OT services to address bilateral upper extremity contractures and limited upper extremity active range of motion (AROM). A goal of the OT plan of treatment was to discharge the resident to a supportive living environment with restorative program implemented. A physician's orders [REDACTED]. A physician's orders [REDACTED].@ all x's (at all times)." A physician's orders [REDACTED]. A PT form, dated 09/08/10, documented the resident was to be discharged from the therapy service. The form documented the resident could ambulate 20-30 feet two times with moderate/maximal assistance of two people. An OT form, dated 09/24/10, documented the resident's family had been contacted regarding the use of bilateral upper extremity orthotic devices. The form documented the family member did not think the resident would wear the orthotics. The form documented nursing would be consulted regarding placement of hand rolls. The form documented the resident was discharged from OT services as of 09/24/10 secondary to meeting maximum rehabilitation potential. A quarterly assessment, dated 02/14/11, documented the resident was severely impaired related to cognition, required limited assistance of one person with transfers and walking. The assessment documented the resident had no functional limitations with range of motion of the upper or lower extremities. A physician's progress note, dated 05/09/11, documented the resident had contractures of the hands and that hand rolls were helping. An annual assessment, dated 05/15/11, documented the resident was severely impaired related to cognition and required limited assistance of one person with transfers and walking. The assessment documented the resident required limited assistance with dressing, toileting, and hygiene. The assessment documented the resident had no functional limitations with range of motion of the upper or lower extremities. The care plan, dated 05/15/11, documented the resident had physical mobility impairment related to contractures. The care plan documented the use of hand rolls daily. The July 2011 nursing assistant flow sheet record documented the resident was to have transfer assistance of two staff members. There was no documentation of active or passive range of motion being done with the resident. There was no restorative nursing notes found in the clinical record. Monthly behavior sheets were reviewed from 07/2010 to 06/2011. There were no consistent behavioral problems documented for the resident. On 07/13/11 at 8:20 a.m., the resident was observed sitting in her wheelchair with a lap buddy in place. Hand rolls were observed to be in use. At 10:22 a.m., the resident was observed sitting in her wheelchair. The resident was asked if she could remove the lap buddy. The resident looked at the surveyor, but did not attempt to touch the lap buddy. At 10:25 a.m., certified nurse aide (CNA) #1 was asked about the resident's physical mobility. The CNA reported the resident could open her pointer fingers on both hands, but the other fingers were limited in ability to open up. When asked if the resident was ambulated by anyone, the CNA reported, "Not that I know of." At 10:45 a.m., licensed practical nurse (LPN) #6 was interviewed regarding the resident's range of motion. The nurse stated the resident's hand contractures had increased over the past six months. The nurse, when asked, attempted to straighten the resident's right leg gently and was unable to obtain full extension. At 11:10 a.m., the director of nursing (DON) was asked why the resident was not on a restorative program and she stated, "She should be." On 07/13/11 at 2:45 p.m., the physical therapist assistant was interviewed regarding the resident's prior and current status. She reported the resident, when admitted , was walking with a wheelchair (pushing it) with contact guard assistance. She reported the resident's legs extended fully upon admission, in May 2009. The therapist assistant reported the resident was walking with assistance when discharged the last time from therapy. At 3:25 p.m., the administrator was asked to find restorative notes for the resident. She returned and stated she could not find any restorative documentation. On 07/14/11 at 3:45 p.m., the occupational therapist was interviewed regarding the resident's decline in range of motion. The therapist reported the right elbow had decreased in function since September 2010. At 3:45 p.m., the OT assistant was in the room also. She stated the resident was able to walk short distances with the assistance of two staff members in September 2010.