Every finding on record at El Reno Post-Acute Rehabilitation Center

Based on observation, record review, and interview, the facility failed to provide privacy covers for indwelling catheters for two (#8 and #15) of two sampled residents reviewed for dignity. The DON identified three residents with indwelling catheters resided in the facility. Findings: The Catheter Care policy, revised 09/21/23, read in part, Residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy also read, .Catheter drainage bags will be covered at all times while in use. 1. Resident #8 had a diagnosis of retention of urine. A physician's order, dated 02/16/24, documented to change catheter once monthly. On 05/19/24 at 8:35 a.m., Resident #15 was observed on the hallway in a wheelchair. There was no privacy cover on the catheter drainage bag. On 05/19/24 at 11:56 a.m., Resident #15 was sitting in the dining room waiting for lunch. There was no privacy cover on the catheter drainage bag. On 05/20/24 at 11:26 a.m., Resident #15 was sitting by the nurse's station. There was no privacy cover on the catheter drainage bag. 2. Resident #8 had diagnoses which included urinary incontinence and frequency of micturition. A physician's order, dated 05/17/24, documented to change suprapubic catheter every day shift starting on the 1st and ending on the 5th of every month for infection prevention. On 05/20/24 at 9:29 a.m., Resident #8 was observed going out to smoke. The Resident was holding the catheter in their hand. There was no privacy cover on the drainage bag. On 05/20/24 at 1:31 p.m., Resident #8 was observed at the nurse's station holding the catheter in their hand. There was no privacy cover on the drainage bag. On 05/20/24 at 1:55 p.m., LPN #1 stated Resident #8 and Resident #15 did not have a privacy cover for their catheter drainage bag. They stated not having a privacy cover could affect a resident's dignity.

Based on record review and interview, the facility failed to notify the physician of an abnormal blood sugar level as ordered for one (#36) of five sampled residents reviewed for unnecessary medications. The Administrator identified 40 residents resided in the facility. Findings: The Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification policy, revised 11/24/21, read in part, The facility must promptly notify the attending physician .of lab results that fall outside of clinical reference ranges in accordance with facility policies and procedures .or per ordering physician's orders. Resident #36 had a diagnosis of type two diabetes mellitus. A physician's order, dated 09/01/23, documented novolog injection solution 100 units per milliliter subcutaneously four times a day related to type two diabetes mellitus. Inject as per sliding scale, if FSBS is greater than 451 notify physician. Resident #36's May 2024 TAR documented FSBS of 476 and the number four on 05/18/24. On 05/23/24 at 9:03 a.m., the DON stated Resident #36's blood sugar was 476 on 05/18/24. They stated the order was to notify the physician if blood sugar was above 451. On 05/23/24 at 9:08 a.m., the DON stated the number four on the TAR meant outside of parameters. On 05/23/24 at 9:42 a.m., the DON stated they could not locate any documentation the physician was notified of Resident #36's abnormal blood sugar level.

Based on record review and interview, the facility failed to ensure MDS assessments were accurate for two (#42 and #43) of 12 sampled residents MDS were reviewed. The Administrator identified 40 residents who resided in the facility. Findings: 1. Resident #43 discharged to an assisted living facility. The discharge assessment, dated [DATE], documented discharge return anticipated, planned discharge, and that there was no discharge planning occurring. On [DATE] at 9:33 a.m., the Administrator stated planning for the discharge started months ago and they had been working with a third party agency. On [DATE] at 2:26 p.m., the Administrator stated they had worked on the discharge and did not anticipate Resident #43 to return to the facility. On [DATE] at 2:45 p.m., MDS Coordinator #1 stated they anticipated the resident to return to the facility and stated they did not document information that stated the resident was anticipated to return. MDS Coordinator #1 further stated there was active discharge planning occurring for the resident and that it was not accurately coded on the discharge MDS and they were to do a correction. 2. Resident #42 was transferred to the hospital on [DATE]. The discharge assessment, dated [DATE], documented discharge return anticipated. A nurse's note, dated [DATE] at 4:17 p.m., documented the hospital called the facility to let them know the resident expired. A death in the facility resident assessment, dated [DATE], documented Resident #42 was deceased on [DATE]. Resident #42 did not expire in the facility. On [DATE] at 2:41 p.m., MDS Coordinator #1 stated a death in the facility was to be completed if the resident was admitted to the hospital and expired within 3 days. 48344

Based on observation, record review, and interview, the facility failed to ensure a care plan was revised: a. quarterly and as needed to include wound care for one (#9); and b. to include the use of side rails for one (#12) of 12 sampled residents whose care plans were reviewed. The Administrator identified 40 residents resided in the facility. Findings: A Care Plan Revisions Upon Status Change policy, dated 05/23, documented the comprehensive care plan will be revised as necessary, when a resident experiences a status change. 1. Resident #12 had diagnoses which included unsteadiness on feet and mild cognitive impairment. A bed rail assessment, dated 08/14/23, documented left and right side bed rail use. A bed rail informed consent, dated 08/14/23, documented the resident was bed bound. Resident #12's care plan, revised 05/19/24 did not document the use of side rails. On 05/19/24 at 11:36 a.m., Resident #12 was observed in bed with two round shaped rails on each side of the upper part of the bed. The Resident stated staff put them up so they can use them to assist with positioning. On 05/22/24 at 1:37 p.m., CNA #1 stated Resident #12 used the rails [name withheld] for turning left and right during care. On 05/22/24 at 1:56 p.m., the DON stated the side rails [name withheld] were not documented on the Resident's care plan. 2. Resident #9 had diagnosis which included pneumonia, COPD, dm type 2. There was no diagnosis of a wound on the diagnosis section of the EMR. A care plan, dated 06/13/23, had a revision date of 11/03/23. There was no care plan for a wound found. A skin assessment, dated 12/8/23, documented a popped blister to left heel. There were no measurements. An MDS assessment, dated 03/18/24, documented diabetic foot ulcer. A physicians' order, dated 05/13/24, documented wound care to left heel Monday, Wednesday, Friday, and prn. On 05/21/24 at 11:29 a.m., MDS Coordinator #1 stated all the care plans had been updated. On 05/21/24 at 1:26 p.m., MDS Coordinator #1 stated they did not know the policy and procedure for updating care plans. They stated their process for updating care plans was quarterly and as needed. On 05/21/24 at 1:35 p.m., MDS Coordinator #1 stated the care plan for Resident #9 was not done quarterly. MDS Coordinator #1 stated there was not a care plan for the wound and the care plan was not accurate to Resident #9 level of care. 48344

Based on observation, record review, and interview, the facility failed to ensure food items in the refrigerator were properly labeled and had identified use by dates during the initial kitchen tour. The Administrator identified 40 residents resided in the facility and the DON verified all 40 residents received food from the kitchen. A Date Marking for Food Safety policy, revised 04/24, read in part, The facility adheres to a date marking system to ensure the safety of ready-to-eat, tie/temperature control for safety food. The policy also read, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time of the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. On 05/19/24 at 8:13 a.m., during the initial tour of the kitchen, the refrigerator was observed to have a white plastic bin which contained 10 cups with clear liquid inside and six cups with a red liquid inside and two empty cups, at the back of the bin, with residue at the bottom. None of the cups had a cover, date, or identification on them. On 05/19/24 at 8:22 a.m., the Dietary Manager stated the drinks were prepared that morning and the cups should have a date and there was no date. They stated the policy was they should have been dated. They took the cups while stating they were going to dump them and was observed to empty them into the sink.

Based on observation, record review and interview, the facility failed to ensure the dietary staff had the competencies to carry out the food services for four (#3, 8, 9, and #10) of four residents reviewed for dietary services. The Midnight Census Report form, dated 11/02/23, documented the census was 42. A Diet Type Report, dated 11/02/23 documented Residents #3, 9, and #10 were to be served pureed diets, and Resident #8 was to be provided a renal diet. A menu, approved by the RD/LD, documented on 11/02/23, the menu to be served was as follows: a. the puree/level 4 diets were to be served a #8 scoop of pureed oven fried chicken, #8 scoop of pureed Au Gratin potatoes, #8 scoop of pureed spinach/sauteed onions, #12 scoop of pureed cornbread with margarine, and a #12 scoop of pureed yellow cake with caramel icing. A note at the bottom of the menu, documented pureed and mechanical soft diets were to be served gravy or sauce if needed. b. Regular diets were to be served: 3 ounces of oven fried chicken, a #8 scoop of Au Gratin potation, #8 scoop of spinach with sauteed onions, one each of cornbread with margarine, and one square of yellow cake with caramel icing. The menu did not contain instructions for a renal diet. On 11/02/23, at 11:25 a.m., the steam table set up and serving of the noon meal was observed. The DM was observed to obtain the proper sized serving utensils and stated, the facility did not have the correct sizes and was trying to decide which size would be the most appropriate. The DM referred to the extended menu for reference to the portion sizes to be served. On 11/02/23 at 11:45 a.m., the DM identified the pureed items on the steam table to be chicken, potatoes, and spinach. DA #1 assisted the DM to prepare chocolate cake for the pureed diets. The DM stated three residents are to receive pureed diets. The steam table contained oven fried chicken, Au Gratin potatoes, and spinach. A large tray of corn bread remained on top of the oven and single servings of cake were on the prep table On 11/02/23 at 11:54 a.m., Cook #1 entered the kitchen, sanatized their hands, and began to fill plates to be served. At 12:45 p.m., Cook #1 prepared a plate to be served which contained a piece of oven fried chicken and a square of cornbread. The cook stated Resident #8, could not have potatoes, and does not like spinach, or chocolate. No attempt was made by the staff to provide alternate items for the renal diet. On 11/02/23 at 1:05 p.m., the DM was asked how were staff provided orientation and training to ensure residents were served the menus to meet the required nutritional values for each resident. The DM stated, the facility planned on sending the DM to a class but has not been hired long enough. They stated they filled out an application to work in the kitchen, the former manager quit, and they were moved to cook and manager position without training.

Based on observation, record review, and interview, the facility failed to ensure pureed menus were followed and an extended menu was available and prepared for a renal diet for four (#3, 8, 9, and #10) of four residents reviewed for dietary services. The Midnight Census Report form, dated 11/02/23, documented the census was 42. A Diet Type Report, dated 11/02/23 documented Residents #3, 9, and #10 were to be served pureed diets, and Resident #8 was to be provided a renal diet. A menu, approved by the RD/LD, documented on 11/02/23, the menu to be served was as follows: a. the puree/level 4 diets were to be served a #8 scoop of pureed oven fried chicken, #8 scoop of pureed Au Gratin potatoes, #8 scoop of pureed spinach/sauteed onions, #12 scoop of pureed cornbread with margarine, and a #12 scoop of pureed yellow cake with caramel icing. A note at the bottom of the menu, documented pureed and mechanical soft diets were to be served gravy or sauce if needed. b. Regular diets were to be served: 3 ounces of oven fried chicken, a #8 scoop of Au Gratin potation, #8 scoop of spinach with sauteed onions, one each of cornbread with margarine, and one square of yellow cake with caramel icing. The menu did not contain instructions for a renal diet. On 11/02/23, at 11:25 a.m., the steam table set up and serving of the noon meal was observed. The DM referred to the extended menu for reference to the portion sizes to be served. On 11/02/23 at 11:45 a.m., the DM identified the pureed items on the steam table to be chicken, potatoes, and spinach. DA #1 assisted the DM to prepare chocolate cake for the pureed diets. The DM stated three residents are to receive pureed diets. The steam table contained oven fried chicken, Au Gratin potatoes, and spinach. A large tray of corn bread remained on top of the oven and single servings of cake were on the prep table On 11/02/23 at 11:54 a.m., Cook #1 was observed to enter the kitchen to assist with the meal service. Cook #1 began to fill plates to be served. At 12:45 p.m., Cook #1 prepared a plate to be served which contained a piece of oven fried chicken and a square of cornbread. The cook stated Resident #8, could not have potatoes, and does not like spinach, or chocolate. No additional food items were placed on the tray sent to be served to Resident #8. No attempt was made by the staff to provide alternate items for the renal diet. On 11/02/23 at 1:05 p.m., the DM was asked if the how did the pureed diets receive the corn bread that was on the menu. They stated, they should have pureed cornbread, but the pureed diets today did not receive cornbread. The DM was asked if gravy was prepared and available for the pureed diets per the approved menu. They stated, gravy had not been prepared. The DM was asked if a resident has a renal diet ordered, how is it determined the nutritional needs are being provided by the facility. The DM stated, I'm not sure. The DM was asked if the facility had provided a menu for the renal diet. They stated, I'm not sure.

Based on observation, record review and interview, the facility failed to ensure an extended menu was available to ensure dietary needs were met for an ordered renal diet for one (#8,) of one sampled resident reviewed for a renal diet. The Midnight Census Report form, dated 11/02/23, documented the census was 42. A Diet Type Report, dated 11/02/23 documented Resident #8 was to be provided a renal diet. A menu, approved by the RD/LD, documented on 11/02/23, the menu to be served for regular diet orders was as follows: a. three ounces of oven fried chicken, b. a #8 scoop of Au Gratin potatoes, c. a #8 scoop of spinach with sauteed onions, d. one each of cornbread with margarine, and e. one square of yellow cake with caramel icing. The menu did not contain instructions for a renal diet. On 11/02/23, at 11:25 a.m., the DM referred to the extended menu for reference to the portion sizes to be served. On 11/02/23 at 11:45 a.m., the steam table contained oven fried chicken, Au Gratin potatoes, and spinach. A large tray of corn bread remained on top of the oven and single servings of cake were on the prep table On 11/02/23 at 11:54 a.m., Cook #1 entered the kitchen, sanitized their hands and began to fill plates to be served. At 12:45 p.m., Cook #1 prepared a plate to be served which contained a piece of oven fried chicken and a square of cornbread. The cook stated Resident #8, could not have potatoes, and does not like spinach, or chocolate. No attempt was made by the staff to provide alternate items for the renal diet. On 11/02/23 at 1:05 p.m., the DM was asked if a resident has a renal diet ordered, how is it determined the nutritional needs are being provided by the facility. The DM stated, I'm not sure. The DM was asked if the facility had an extended menu to follow for renal diets. They stated, they were not sure.

Based on record review and interview, the facility failed to ensure heart rate monitoring was completed as ordered prior to the administration of Carvedilol for one (#2) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 42 resident resided in the facility. Findings: A Medication Administration policy, dated 02/21/23, read in parts, .Medications are administered .as ordered by the physician and in accordance with professional standards .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . Resident #2 had diagnoses which included essential hypertension. A Physician Order, start date 04/11/22, documented Carvedilol tablet 12.5 mg give 12.5 mg by mouth twice a day, hold medication if systolic blood pressure was less than 110 or heart rate was below 60. The February 2023 MAR did not document Resident #2's heart rate was checked prior to the administration of the Carvedilol. The March 2023 MAR documented one instance where Resident #2's heart rate was checked prior to the administration of the Carvedilol. There was no other documentation of Resident #2's heart rate being checked prior to the administration of the Carvedilol for the month of March 2023. On 03/29/23 at 3:20 p.m., LPN #1 was asked the policy for medication administration. They stated staff were to ensure it was the right resident, right medication, right dose, and were to administer medication as ordered by the physician. LPN #1 was asked when a medication had orders for heart rate monitoring, where was the information documented. They stated on the MAR. On 03/29/23 at 3:20 p.m., LPN #1 was asked to review Resident #2's February and March 2023 MAR and determine if the resident's heart rate was documented with the Carvedilol medication administration. LPN #1 stated they did not see any. LPN #1 stated they knew to hold the medication if it was below the ordered parameters, but had not identified a concern with the heart rate not being documented.

Based on record review and interview, the facility failed to ensure physician ordered labs were obtained for two (#2 and #4) of five sampled residents reviewed for laboratory services. The Resident Census and Condition of Residents report, dated 03/29/23, documented 42 residents resided in the facility. Findings: A Laboratory Services and Reporting policy, dated 11/24/21, read in parts, .The facility must provide or obtain laboratory services when ordered by a physician .in accordance with state law .The facility must provide or obtain laboratory services to meet the needs of its residents .The facility is responsible for the timeliness of the services .All laboratory reports will be dated .and will be filed in the resident's clinical record . 1. Resident #4 had diagnoses of mixed hyperlipidemia, major depressive disorder, and malignant neoplasm of the large intestine. A Physicians' Order, dated 04/21/21, documented to obtain serum LFT's, valproic acid, and CBC with differential every six months. On 03/29/23, at 4:42 p.m., the DON was asked for the results for the labs ordered every six months. They stated there was no LFT or valproic acid for the month of December 2022. They were asked what the process was for obtaining labs as ordered. They stated it was put on the TAR and the nurse was to verify the lab came out to draw. The DON further stated they would make sure all the lab was done on the same day. 2. Resident #2 had diagnoses which included essential hypertension, COPD, hypothyroidism, and type two diabetes mellitus. A Physician Order, dated 12/22/20, documented obtain serum hemoglobin A1C due to long term use of diabetic therapy one time a day every three months starting on the 22nd. A Physician Order, dated 12/22/20, documented obtain serum thyroid profile and TSH to monitor current thyroid therapy every 12 months starting on the 22nd. On 03/29/23 at 2:46 p.m., the DON was asked to provide Resident #2's lab results for hemoglobin A1C every 3 months, serum thyroid profile and TSH every 12 months. On 03/29/23 at 3:44 p.m., the DON stated she was unable to locate the thyroid or hemoglobin A1C labs. 45583

Based on record review and interview, the facility failed to ensure a significant change resident assessment was completed when a resident admitted to hospice services and discharged from hospice services for one (#2) of 11 sampled residents reviewed for resident assessments. The Resident Census and Conditions of Residents report, dated 03/29/23, documented no residents received hospice services and 42 residents resided in the facility. Findings: Resident #2 had diagnoses which included COPD. A Physician Order, dated 12/28/22, documented evaluation and treatment for hospice services for COPD. A Revocation of Hospice Benefit form, dated 03/02/23, documented Resident #2's hospice election date was 12/28/22, and revocation date was 03/02/23. There were no significant change resident assessments located in the clinical record when Resident #2 admitted to hospice or when the resident discharged from hospice services. On 03/30/23 at 8:51 a.m., MDS Coordinator #1 was asked to explain when they would complete a significant change resident assessment. They stated they had a 14 day look-back period to determine if a resident had experienced an significant change. They stated two changes in two areas of the MDS would warrant a significant change assessment. MDS Coordinator #1 stated a sudden decline in health, failure to thrive, weight loss, and changes in activities of daily living were all areas that were considered when determining if a significant change assessment should be completed. MDS Coordinator #1 was asked if a significant change assessment was completed when a resident elected hospice or discharged from hospice services. They stated they were not aware a significant change assessment had to be completed when a resident elected hospice or discharged from hospice. They stated they thought if the resident's baseline hadn't changed, a significant change assessment did not have to be completed. They reviewed Resident #2's record and stated a significant change assessment was not completed when they elected hospice benefits in December 2022 or when they discharged from hospice in March 2023.

Based on record review, and interview, the facility failed to ensure resident assessments were accurate for one (#10) of 11 sampled residents reviewed for accuracy of assessments. The Resident Census and Condition of Residents form, dated 03/29/23, documented 42 residents resided in the facility. Findings: Resident #10 had diagnoses of muscle weakness, morbid obesity, and acute respiratory failure. A Physicians' Order, dated 04/25/21, documented to give 10 units Novolog insulin. The order was discontinued on 04/26/21. A Physicians' Order, dated 04/26/21, documented to use a sliding scale. The order was discontinued on 04/26/21. A Physicians' Order, dated 04/26/21, documented to use Novolog solution per sliding scale. The order was discontinued on 06/24/21. Resident #10's quarterly assessment dated [DATE] documented the resident received insulin injections seven days of the seven day look- back period. On 03/29/23 at 12:23 p.m., MDS Coordinator #1 was asked how they determined what to code for insulin injections on the MDS. They stated they would pull residents' records and document insulin if they received it during the seven day look-back period. They were asked what information was used to code the insulin injections for Resident #10 for the resident assessment dated [DATE]. They stated, [Resident #10] doesn't get insulin. The MDS coordinator then proceeded to look at the MDS and the orders. On 03/29/23 at 12:26 p.m., the MDS Coordinator was asked if the assessment dated [DATE] accurately reflected the residents' status. They stated, No, because [Resident #10] does not receive insulin. They stated, The MDS was incorrect and will be corrected immediately.

Based on record review, observation, and interview, the facility failed to ensure staff utilized eye protection while in COVID-19 positive rooms for two (#4 and #6) of three sampled residents reviewed for infection control. The Administrator identified 36 residents resided in the facility and three residents were positive for COVID-19. Findings: An Infection Control policy, revised 09/30/22, read in part, .HCP who enter the room of a resident with suspected or confirmed [COVID-19] infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection . 1. Resident #4 had diagnoses which included COVID-19. 2. Resident #6 had diagnoses which included COVID-19. On 02/07/23 at 12:46 p.m., RN #1 was observed wearing an N95 mask, put on shoe covers, a gown, and gloves, then entered Resident #4's room. RN #1 did not utilize eye protection. On 02/07/23 at 12:50 p.m., LPN #1 was observed wearing an N95 mask, put on gloves and a gown, then entered Resident #4's room. LPN #1 did not utilize eye protection. On 02/07/23 at 12:51 p.m., CNA #1 was observed wearing an N95 mask, put on a gown and gloves,then entered Resident #6's room. CNA #1 did not utilize eye protection. On 02/07/23 at 12:55 p.m., LPN #1 was observed to exit Resident #4's room. On 02/07/23 at 12:58 p.m., LPN #1 was observed to put on a gown and gloves, then entered Resident #4's room. LPN #1 did not utilize eye protection. On 02/07/23 at 2:16 p.m., CNA #1 was asked what PPE was required when in a COVID-19 positive room. They stated gowns, a mask, gloves, shoe covers, and a face shield. On 02/07/23 at 2:43 p.m., the DON was asked what PPE was required when providing care to a COVID-19 positive resident. She stated staff should use gloves, gowns, face shields, booties, and N95 masks. The DON was made aware of the above observations of staff not utilizing eye protection.

Based on observation and staff interview, it was determined the facility failed to ensure food products were properly labeled in the kitchen. The facility identified 33 residents who received nutrition services through the kitchen. Findings: On 08/02/21 at 11:00 a.m., a freezer in the kitchen was observed to have three unlabeled packages of meat products. The dietary manager was shown the bags of raw meat in the freezer. She identified them as chicken patties, chicken strips and bacon. She was asked the policy for labeling food items. She stated when food was received and when it was opened. She was shown the unlabeled food items. She acknowledged the findings.

Based on observation, record review and staff interview, it was determined the facility failed to ensure staff prepared the posted alternative menu for one of two meal service observed. The facility identified 33 residents who received meals from the kitchen. Findings: The noon menu, for 08/03/21, documented lemon baked chicken, au gratin potatoes, peas with pimento, roll/margarine, strawberry pear cup, milk and a beverage. The alternative menu documented roast beef, gravy, noodles and a tossed salad with dressing. The dry erase board at the entrance to the dining room documented the lunch menu for August 3, 2021 was lemon baked chicken, au gratin potatoes, peas with pimento, roll and fruit cocktail. It documented the alternative was roast beef with gravy, noodles and a side salad. On 08/03/21, at 10:15 a.m., during the lunch meal preparation in the kitchen, there was no observation of roast beef with gravy, noodles or side salad. At 11:05 a.m., the cook was asked about the alternative menu items. She stated roast beef was not an alternate today because her boss told her not to prepare any. She stated her boss told her no one had requested the roast beef and if not one requested it by 10:30 a.m., not to prepare it. She was asked what they would do if residents did not like the lemon chicken. She stated they had other food items they could offer like a (frozen) quesadilla or a sandwich.

Based on record review and staff interviews, it was determined the facility failed to ensure routine COVID-19 screens and monitoring had been conducted for three (#1, 2 and #3) of three sampled residents reviewed for infection control. The facility identified 37 residents who resided in the facility with 21 of those residents currently positive for COVID-19. Findings: A facility policy, titled Coronavirus Surveillance, documented,: Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents . Residents will be monitored for signs and symptoms of coronavirus illness at least 3 times a day: fever, cough, shortness of breath or difficulty breathing .headache, sore throat, new loss of taste or smell .vomiting, diarrhea . The CDC guidance titled, Symptoms of Coronavirus, documented, .People with these symptoms may have COVID-19: Fever or chills .Cough .Shortness of breath or difficulty breathing .Fatigue .Muscle or body aches .Headache .New loss of taste or smell .Sore throat .Congestion or runny nose .Nausea or vomiting .Diarrhea . Resident # 1 had [DIAGNOSES REDACTED]. There was no record which indicated the resident had been screened for COVID-19 symptoms. Resident #2 had [DIAGNOSES REDACTED]. There was no record which indicated the resident had been screened for COVID-19 symptoms. Resident #3 had [DIAGNOSES REDACTED]. There was no record which indicated the resident had been screened for COVID-19 symptoms. On 11/17/20 at 9:18 a.m., LPN (licensed practical nurse) #1 was asked how staff conducted resident screenings for COVID-19. She stated only temperature checks and oxygen saturation were monitored every shift. She was asked if residents were monitored for signs and symptoms of COVID-19. She stated residents were not routinely screened. At 2:13 p.m., the DON (director of nurses) was asked if facility had implemented their surveillance plan to screen and monitor residents for respiratory illness and or other signs and symptoms of COVID-19. She stated the facility had the tools but did not see they were utilized. She stated screening of signs and symptoms of COVID-19 was not being done.

Based on observation and staff interview, it was determined the facility failed to ensure the appropriate personal protective equipment was worn by staff during the provision of care to residents in a quarantine whose COVID-19 status was unknown, ensure residents who received services outside the facility were quarantined and ensure precautions were posted to alert staff of the need for appropriate personal protective equipment (PPE). The facility identified 40 residents resided in the facility, one resident was in quarantine and one resident received outside [MEDICAL TREATMENT] services. Findings: The Center for Disease Control guidance titled, Preparing for COVID-19 in Nursing Homes documented, .Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown .HCP (health Care Provider) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . On 06/19/20 at 9:35 a.m., the director of nursing (DON) was asked if the facility had any residents in quarantiine. She stated they currently had one resident in quarantine due to being readmitted to the facility. She was asked if they had any resident who received outside [MEDICAL TREATMENT] services. She stated they had one. The DON was asked if the [MEDICAL TREATMENT] resident was in quarantine. She stated, No. She stated, He has a roommate. She stated, Honestly, I never really thought about it. The DON stated the [MEDICAL TREATMENT] resident was bed bound and required a lift for transfers. At 10:00 a.m., a tour of the facility was conducted. There was no PPE outside the [MEDICAL TREATMENT] resident's room or signage to indicate quarantine/isolation precautions. At 10:20 a.m., the administrator was made aware of the above. He acknowledged the findings.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure interventions were implemented and adequate supervision was provided to prevent or decrease falls for one (#1) of five sampled residents reviewed for falls. This resident had 19 falls from 08/13/19 - 01/05/20. Two of the falls resulted in the resident being sent to the emergency room after sustaining head injuries (sutures/staples were required). The facility identified 50 residents resided in the facility. Findings: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A comprehensive resident assessment, dated 04/26/19, documented the resident had severe cognitive impairment and required extensive assistance of one person for transfers and ambulation. A fall risk assessment, dated 06/14/19, documented the resident was at high risk for falling. An incident report, dated 08/13/19 at 3:00 a.m., documented, .Witnessed Fall .resident presents sitting on his bottom in the hall way .vitals wnl (within normal limits) for resident. no s/s (signs/symptoms) of head injury at this time. no pain voiced or noted by resident .resident toileted and assisted back into bed .Predisposing Physiological Factors .Confused .Predisposing Situation Factors .Ambulating without Assist . An incident report, dated 08/29/19 at 5:30 a.m., documented, .Witnessed Fall .resident presents walking down the hall this nurse and both on shift cnas (certified nurse aides) on opposite hall, started to walk towards resident, resident began to fall landing on his left side hitting the side of his face on the ground .teaching with resident on calling with call bell system when needing help .Predisposing Physiological Factors .Confused .Predisposing Situation Factors .Ambulating without Assist . An incident report, dated 08/30/19 at 8:28 p.m., documented, .Witnessed Fall .Resident seen on the floor in the living room .No injuries noted .Reinforced teaching to use call light when needing assistance. Resident understood .Predisposing Physiological Factors .Confused .Drowsy .Incontinent .Predisposing Situation Factors .Wanderer . An incident report, dated 09/07/19 at 6:22 a.m., documented, .Witnessed Fall .Resident's Room .nurse notified pt (patient) on floor in private room .pt assisted into living area so staff could keep an eye on pt .no injuries observed at time of incident .Predisposing Physiological Factors .Gait Imbalance .Predisposing Situation Factors .Wanderer .pt blind . An incident report, dated 09/13/19 at 9:30 a.m., documented, .Un-witnessed .resident presents with blood coming down face in his room door way .resident sat in chair .open gash noted to right eyebrow region, open gash to top of forehead with moderate bleeding noted .per (family) to send to .hospital for further evaluation. neurological record started to continue once resident is back from hospital .sent to hospital .Predisposing Situation Factors .Ambulating without Assist .resident is legally blind . A progress note, dated 09/13/19 at 1:39 p.m., documented, Returned to facility from ER (emergency room ) escorted by family .Stitches intact to above eye brow and top of head .Resting in bed. bed in low position and call light is in reach . An incident report, dated 09/28/19 at 5:49 p.m., documented, .Witnessed Fall .this nurse witnessed resident fall side ways to his bottom resident did not hit head .no new injuries noted at this time .Predisposing Physiological Factors .Confused .Predisposing Situation Factors .Ambulating without Assist . An incident report, dated 09/29/19 at 8:06 a.m., documented, .Witnessed Fall .Pt was trying to use the restroom in living area and before nurse could catch him pt fell to floor on his bottom .Pt taken to private room to use the restroom and pt placed in bed. No skin tears noted Predisposing Physiological Factors .Confused .Incontinent .Gait Imbalance .Impaired Memory .Predisposing Situation Factors .Ambulating without Assist .Wanderer .Pt blind . An incident report, dated 10/09/19 at 4:55 a.m., documented, .Witnessed Fall .nurse was down the hall and aide yelled out, 'he just fell ' .Pt was examined for any skin tears, none noted pt taken to restroom and placed in living area with staff at side .Predisposing Physiological Factors .Confused .Incontinent .Recent change in Medications .Gait Imbalance .Impaired Memory .Predisposing Situation Factors .Ambulating without Assist .pt was walking without assistance and pt is blind and tried to sit down . An incident report, dated 10/10/19 at 5:28 p.m., documented, .Witnessed Fall .An aide came and told this nurse resident fell in lounge area. This fall was witnessed by another employee. Resident did not hit head his head. His knees gave way and he kneeled to the ground with his left knee and gently laid himself on the ground .No injuries observed at time of incident .Predisposing Physiological Factors .Gait Imbalance .Predisposing Situation Factors .Wanderer . An incident report, dated 10/13/19 at 3:16 a.m., documented, .Un-witnessed .nurse was notified that pt was observed on floor in private room .pt assisted off floor, brief changed, skin assessed and assisted back into bed .Predisposing Physiological Factors .Confused .Incontinent .Gait Imbalance .Predisposing Situation Factors .Ambulating without Assist .pt blind and gets up without assistance, pt unable to hit call light to ask for assistance from staff . An incident report, dated 10/15/19 at 8:42 a.m., documented, .Witnessed Fall .Resident presents sitting in room doorway on bottom. Witness stated resident was standing in doorway when residents legs started shaking and resident fell to the floor on his bottom .Staff assisted resident onto side of bed .No new injuries noted at this time .started neuro (neurological) checks Predisposing Physiological Factors .Confused .Incontinent .Impaired Memory . An incident report, dated 10/18/19 at 7:27 a.m., documented, .Witnessed Fall .stated pt was on the floor .No injuries observed at time of incident .Predisposing Physiological Factors .Confused .Incontinent .Gait Imbalance .Impaired Memory .Predisposing Situation Factors .Ambulating without Assist . An incident report, dated 10/19/19 at 12:00 p.m., documented, .Un-witnessed .this nurse was approached by resident's (family member) stated that he has a spot to his eyebrow .this nurse did not note a fall at this time, resident has history of falls and had a fall the previous day. skin tear to left eyebrow area scabbed .neurological record started . An incident report, dated 10/27/19 at 2:00 a.m., documented, Un-witnessed .nurse was in living area and heard pt fall to ground and yell out .Resident Unable to give Description .pt skin assessed and placed back into bed .Predisposing Physiological Factors .Confused .Incontinent .Gait Imbalance .Impaired Memory .pt blind and unable to comprehend to ask for assistance when needed . An incident report, dated 10/29/19 at 6:46 p.m., documented, .Witnessed Fall .This nurse witnessed resident stumble out of his room lost his balance and fell to the floor on his right hip .Head to toe assessment preformed (sic) .This nurse and another aide assisted resident up from off the floor .Resident was transferred to his bed .Res (resident) is already on Neuro checks from prior fall .Predisposing Physiological Factors .Gait Imbalance . An incident report, dated 11/01/19 at 6:32 a.m., documented, .Un-witnessed .NURSE WENT TO CHECK ON PT AND PT WAS OBSERVED ON FLOOR .ASSISTED BACK INTO BED, NO SKIN TEARS NOTED .Predisposing Physiological Factors .Confused .Drowsy .Incontinent .Gait Imbalance .Impaired Memory .Weakness/Fainted .Predisposing Situation Factors .Ambulating without Assist .PT ALSO BLIND . An incident report, dated 12/04/19 at 10:54 p.m., documented, .Witnessed Fall .(another resident) came and got this nurse to inform me he just witnessed res fall on his bottom .When I walked into res rm (room) he was sitting on his bottom on the floor .No injuries observed at time of incident . An incident report, dated 12/18/19 at 9:45 a.m., documented, .An aide came and told this nurse resident was lying on his bedroom floor .abrasion to lt (left) cheek .assisted resident back into his w/c (wheelchair). Neuro checks started . An incident report, dated 12/24/19 at 10:30 p.m., documented, .Un-witnessed .This nurse was walking down hall and heard resident say 'can you help me?' Entered residents room, resident was laying on the floor parallel to bed bleeding from the left side of the head .This nurse assessed residents injuries, with the help of staff assisted resident off floor into a chair .held pressure to head wound .Resident Taken to Hospital .Y (yes) .Predisposing Physiological Factors .Confused .Incontinent .Impaired Memory .Predisposing Situation Factors .Wanderer . A progress note, dated 12/25/19 at 2:56 a.m., documented, .Resident was taken to (local hospital) for evaluation . A progress note, dated 12/25/19 at 11:52 a.m., documented, follow up to previous day fall .Staples (times) 3 noted to left forehead are intact . An incident report, dated 12/29/19 at 12:00 p.m., documented, .Un-witnessed .resident presents laying on the floor back down with head against trash can with bleeding noted to right eyebrow area .resident transferred from floor to bed .per MD (medical doctor) to apply steri-strip to area .Predisposing Physiological Factors .Confused .Weakness/Fainted .Predisposing Situation Factors .Ambulating without Assist . An incident report, dated 01/05/20 at 3:00 a.m., documented, .Witnessed Fall .resident presented walking towards tv (television) by this nurse then fell back landing on his bottom .transferred back to bed .No injuries observed at time of incident .Predisposing Physiological Factors .Weakness/Fainted .Predisposing Situation Factors .Ambulating without Assist . A care plan, last revised 01/07/20, documented, .Focus .(Resident) is at risk for falls r/t (related to) weakness, unsteady gait, use of [MEDICAL CONDITION] medication .Multiple falls since admission .Interventions .Be sure (resident's) call light is within reach and encourage the resident to use it for assistance and as needed. (Resident) needs prompt response to all requests for assistance . This was the only intervention for the resident's falls. The resident was blind, had severe cognitive impairment and was unable to use a call light. On 01/07/20 at 5:25 a.m., the resident was observed sitting on the edge of his bed with a staff member assisting him with incontinent care and getting dressed. The resident was observed to have a green colored bruise to the right side of his head next to his eye and an abrasion to the outer right eyebrow. The resident was assisted to sit in a chair on the other side of the room. At 6:40 a.m., the resident was asked if he had any recent falls. He stated, Yes. He was asked what staff had done about his falls. He did not reply. He was observed going through the motions as though he were putting on a shirt or [NAME]et. He was not observed to have anything in his hands. At 7:37 a.m., the resident was observed ambulating in his room unattended. observed On 01/08/20 at 10:30 a.m., the minimum data set (MDS) coordinator was asked to identify what interventions were in place related to falls. She stated the resident's bed was to be in the low position, his call light was to be in reach and to check on him every two hours. She was asked if new interventions had been implemented. She stated, As far as I know, yes. She reviewed the care plan and stated there were no new interventions. On 01/09/20 at 11:40 a.m., the DON was made aware of the above falls and was asked when new interventions should be implemented for falls. She stated, Should be with every fall. She was made aware no new interventions had been implemented. She acknowledged the findings. At 1:35 P.M., the DON was asked if the facility had investigated why the resident was falling. She stated therapy had evaluated him when he was first admitted . She was asked if staff had increased supervision since he had sustained the falls. She stated he had been moved to a room closer to the nurses' station because of the falls. She was asked when was he moved to that room. She stated he had been in that room for approximately one year.

Based on record review and family and staff interviews, it was determined the facility failed to ensure reasonable room accommodations per a resident/resident's legal representative preference for one (#1) of three sampled residents reviewed for accommodation of needs related to their rooms. The facility identified 50 residents resided in the facility. Findings: A resident representative policy, revised (MONTH) (YEAR), documented, .The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative .The facility will treat the decisions of a resident representative as the decisions of the resident . Resident #1 had [DIAGNOSES REDACTED]. A durable special power of attorney document, dated 07/18/18, documented the resident had an attorney-in-fact, who was the resident's family member, appointed by the county court system. On 01/07/20 at 5:15 a.m., the resident's room was observed. The resident's bed was observed to be away from the wall with an oxygen concentrator in the corner of the room between the bed and the wall. At 12:20 p.m., the resident's family member stated the vice president of operations (VPO) had been so mad that she wanted her family member's bed up against the wall. The VPO had instructed the staff to screw a chest to the wall. She stated her family member liked the bed up against the wall so he could sit on the bed and lean up against the wall. A chest was observed in the corner where the oxygen concentrator had been observed earlier that day. On 01/08/20 at 8:10 a.m., the administrator (ADM) and the director of nursing (DON) were asked the reason the chest had been secured to the wall. The ADM stated the VPO and the family member had argued back and forth about it. They were asked what the facility policy was for resident preferences. The DON stated it wasn't the resident's preference to have the bed against the wall but it was the power of attorney's (POA). The ADM stated if a resident couldn't get up by themselves the bed had to be away from the wall to allow staff to roll the resident from side to side. He was asked if the beds rolled. He stated yes but they are locked. The DON was asked if the beds could be locked or unlocked. She stated, Yes. At 12:10 p.m., the family member stated the VPO had been mad for having the bed against the wall. She stated the VPO told her he was going to kick her loved one out of the facility or trespass her if they didn't move the bed away from the wall. She stated she felt like they were discriminating against her family member. She stated two other residents on another hall had their beds against the wall. On 01/09/20 at 7:20 a.m., the DON was asked about the resident's and power of attorney's room preferences. She stated we tried to explain it's for their safety to keep the bed out from the wall. She stated, It's just easier for us to take care of them if the bed is not up against the wall.

Based on record review and staff interviews, it was determined the facility failed to notify the residents' family/legal representative and/or their physician of a change in condition for four (#1, 2, 3 and #9) of four sampled residents reviewed for change in condition. The facility identified 50 residents resided in the facility. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. An incident report, dated 08/30/19 at 8:28 p.m., documented the resident sustained [REDACTED]. An incident report, dated 10/10/19 at 5:28 p.m., documented the resident sustained [REDACTED]. An incident report, dated 10/27/19 at 2:00 a.m., documented the resident sustained [REDACTED]. There was no documentation the resident's family member had been notified. A progress note, dated 11/02/19 at 7:55 a.m., documented, Resident presents with a large firm mass on the left lower buttock . There was no documentation the resident's family member had been notified. A progress note, dated 12/12/19 at 11:36 a.m., documented, New order obtained do (sic) discontinue [MEDICATION NAME] QHS (every night) as a reduction attempt due to increase in falls . There was no documentation the resident's family member had been notified of the new order. A physician's orders [REDACTED]. There was no documentation the resident's family member had been notified. An incident report, dated 12/18/19 at 9:45 a.m., documented the resident sustained [REDACTED]. There was no documentation the resident's family member had been notified. On 01/08/20 at 8:15 a.m., the director of nursing (DON) was asked what the policy was for notifying families. She stated they should be notified of all changes. She was made aware of the above incidents with no family notification. She acknowledged the findings. On 01/09/20 at 7:20 a.m., the DON was asked if the resident's family had been notified of the [MEDICATION NAME] discontinued on 12/12 and 12/23/19. She stated, She should have been, but if it's not documented. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's weight, dated 07/05/19, was documented as 168 lb (pounds). A physician's orders [REDACTED].Regular diet Mechanical Soft texture, Nectar consistency . The resident's weight, dated 10/14/19, was documented as 151 lb. A nutrition/dietary note, dated 10/14/19, documented, .Annual nutritional assessment. High risk d/t (due to) sig (significant) wt (weight) loss, dx (diagnoses) dysphagia, extensive assistance. Oct (October) wt 151 (pound) .Sig wt loss 10.1% (percent) x (times) 3 mos (months), 11.4% x 6 mos. Notify PCP (primary care physician). Noted, resident's medications are being decreased, most likely cause of wt loss. Good PO (by mouth) intake. Mechanical soft, NTL (nectar thick liquid) diet. HS (health shake) PRN (as needed). Skin intact. Rx: (prescription) no nutritional implications. Continue P[NAME] (plan of care) . On 01/08/20 at 10:21 a.m., licensed practical nurse (LPN) #2 was asked if the resident's physician and family had been notified of the resident's weight loss. She was observed to review the nursing progress notes from (MONTH) 2019 to (MONTH) 2020. She stated, I don't know where they would put that. She asked LPN #3 where the documentation would be located. LPN #3 stated, I assume they are in the progress notes. There was no documentation the family or physician had been notified of the resident's weight loss. At 11:30 a.m., the DON was made aware of and acknowledged the above findings. 3. Resident #3 had [DIAGNOSES REDACTED]. The resident's face sheet documented a family member was the resident's responsible party and emergency contact #1. An order note, dated 09/08/19, documented the resident had been vomiting a brown liquid with foul odor. The physician ordered a kidney, ureter, and bladder (KUB) X-ray. There was no documentation the resident's family had been notified. An order note, dated 09/09/19, documented the physician received the results from the KUB and there were new orders for magnesium [MEDICATION NAME] and Milk of Magnesia. There was no documentation the resident's family had been notified. A nutrition/dietary note, dated 09/12/19, documented the resident had a significant weight gain 6.2 percent in one month. There was no documentation the resident's family had been notified. A skin/wound note, dated 09/17/19, documented the resident had a blister to the left posterior heel and there were new orders to treat. There was no documentation the resident's family had been notified. A behavior note, dated 09/18/19, documented the resident removed her (percutaneous endoscopic gastrostomy)PEG tube and it was replaced per facility policy. There was no documentation the resident's family had been notified. An order note, dated 09/19/19, documented the physician had been in the building making progress rounds. There were new orders for [MEDICATION NAME] 20 milligrams by mouth via PEG tube, a KUB and a urine analysis with culture and sensitivity. There was no documentation the resident's family had been notified of the orders or the results. Behavior and health status notes, dated 09/20/19, documented the resident had removed her PEG tube at two separate times and there were new orders for magnesium [MEDICATION NAME] and Milk of Magnesia. There was no documentation the physician and the resident's family had been notified regarding the PEG tube. There was no documentation the resident's family had been notified of the new orders. A health status note, dated 10/03/19 at 7:18 p.m., documented the resident had removed her PEG tube and it had been replaced per facility policy. There was no documentation the resident's family had been notified. A behavior note, dated 10/04/19 at 4:26 p.m., documented the resident had removed her PEG tube at two separate times. There was no documentation the resident's family had been notified. Behavior and health status notes, dated 10/08/19, documented the resident removed her PEG tube at three separate times. The physician ordered for the resident to be transported to the hospital for PEG tube reinsertion after it was first removed. There was no documentation the resident's family had been notified. An incident note and an incident report, dated 12/05/19, documented the resident rolled out of bed onto the floor. There was no documentation the resident's family had been notified. A health status note, dated 01/04/20 at 7:04 p.m., documented the resident had difficulty clearing her throat and catching her breath and the physician ordered to transport the resident to the hospital. It was documented an attempt was made to contact the family. There was no documentation the resident's family had been notified. A behavior note, dated 01/08/20 at 2:40 a.m., documented the resident threw herself on the floor in her room. There was no documentation the resident's physician or family had been notified. On 01/08/20 at 11:50 a.m., the DON was made aware the resident's face sheet documented the resident's responsible party/emergency contact #1 was a family member. She was asked what would be a reason for notifying the family. She stated anytime there was a change in her condition, a fall or for order changes. She was asked what would be a reason for the physician to be notified. She stated if there was a change in her condition, a fall or behaviors. She was made aware of the progress notes and incident reports where the physician and family had not been notified. She acknowledged the findings. 4. Resident #9 had [DIAGNOSES REDACTED]. An order of permanent guardianship, dated 06/18/14, documented two persons were granted guardianship of the resident. An incident report, dated 10/18/19, documented the resident had a fall in the shower and hit his head. There was no documentation the resident's legal guardians had been notified. On 01/13/20 at 8:20 a.m., the DON was asked who was notified if the resident had a fall. She stated she believed it was a family member who was his legal guardian. She was made aware there was no documentation the resident's legal guardian had been notified of the resident's fall. She acknowledged the findings.

On 02/13/19, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent pressure ulcers (PU's) and pressure injuries (PI's) and to consistently and completely assess and intervene in a timely manner for the PU's/PI's. The resident was assessed to have no pressure ulcers upon admission to the facility on [DATE]. The resident's skin started breaking down on 11/22/18. The resident was sent to the hospital on [DATE] and was still in the hospital at the time of the survey. Hospital physician's records documented the resident was admitted with a very severe presacral and coccygeal pressure sore with erosion into the presacral space. She was in septic shock and required prolonged IV (intravenous) antibiotics. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 1:25 p.m., the administrator and director of nursing (DON) were notified of the IJ situation. At 4:20 p.m., an acceptable plan of removal was provided. The plan of removal documented: Following is the actions to be taken by the facility to remove the immediate jeopardy. 1. All facility employees will be in-served on facility policy and procedure for wound care and management in person. All employees will be called into facility for in-service. Employees not in-serviced due to illness or vacation will be in-serviced before returning to work. All new hires will be in-serviced before beginning employment. To be completed by 8:00 a.m. 02/14/19. 2. All facility employees will be in-serviced on facility policy and procedure for nutrition and hydration in person. All employees will be called into facility for in-service. Employees not in-serviced due to illness or vacation will be in-serviced before returning to work. All new hires will be in-serviced before beginning employment. To be completed by 8:00 a.m. 02/14/19. 3. Facility will complete skin assessment on every resident to identify any unknown issues. Physician will be notified of any found previously unknown skin issues and orders obtained that day. Orders will have precise location and description of treatment to be provided and the duration for the treatment. To be completed by 8:00 a.m. 02/14/19. To be completed weekly thereafter. 4. Facility will document, describe, stage if appropriate, and measure each wound identified. Results will be placed in the medical record. To be completed by 8:00 a.m. 02/14/19. 5. Facility will complete nutrition and hydration assessment on each resident identified with skin issues. Facility will also review the nutrition and hydration assessments of all residents with peg (percutaneous endoscopic gastrosomy) tubes. To be completed by 8:00 a.m. 02/14/19. 6. Facility will review all MDS (minimum data set) assessments for all residents with identified skin issues and all residents with peg tubes and catheters for appropriate assessment. Any residents needing new assessments will have one completed. To be completed by 8:00 a.m. 02/14/19. 7. Facility will establish intake and output monitoring for all residents with catheters and peg tubes who receive all nutrition and hydration via peg tube. To be completed by 8:00 a.m. 02/14/19. The immediate jeopardy was removed on 02/14/19 at 8:00 a.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: ~ put interventions in place to prevent pressure ulcers (PU's) and pressure injuries (PI's); ~ perform ongoing, thorough and consistent skin and pressure ulcer assessments; ~ provide nutrition and hydration interventions to meet the resident's needs in a timely manner to aid in the prevention and healing of PU's and/or PI's and ~ obtain physician's orders [REDACTED]. for one (#1) of three sampled residents reviewed for pressure ulcers. The facility identified three residents with skin breakdown. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment documented no skin issues. physician's orders [REDACTED]. The comprehensive resident assessment, dated 11/14/18, documented the resident was at risk for skin breakdown and had no pressure ulcers. It documented the resident's cognition was severely impaired and the resident was totally dependent on staff for all care. The baseline care plan, dated 11/05/18, documented the resident was totally dependent for all care. It documented the resident did not have impaired skin integrity on admission to the facility. A comprehensive care plan, dated 11/16/18, documented the resident had potential for pressure ulcer development related to immobility and incontinence. It did not document interventions were in place to prevent pressure ulcers. A dietary/nutrition note, dated 11/22/18, documented a wound to the back of the left calf (stage two blisters). Receives a TF (tube feeding) of 2Cal HN, one can Q6H (every six hours) four times a day with H20 (water) flushes 30cc (cubic centimeters) ac/pc (before/after) medications two times a day. Needs are 2150 calories; 85g (grams) protein (1.2g/Kg (Kilogram) for wound healing), 1775ml (milliliters) fluids. TF provides 948ml formula (100% percent RDAs (recommended daily allowances), 1896 calories (88%), 80g protein (94%), 664ml free water plus 120ml flushes. Total fluids 783ml (44%). Recommend 40ml/h H20 or 250ml Q6H to meet fluid needs. This is the first mention of any wounds. 1896 calories did not meet the 2150 caloric needs. The resident was receiving 254 less calories than needed per day. Total water flushes of 664ml plus 120cc flushes was 784cc and did not meet the standard of 30cc/kg/day which would have been 2130cc based on the resident's weight of 157 pounds. A skin assessment tool, dated 11/22/18, documented a left ear pressure wound 3cm (centimeters) x 2cm, an upper back shear area 3cm x 3cm x 0.1cm, and left inner lower leg shear of 5cm x 3cm x 0.1cm. A physician's orders [REDACTED]. The resident had some skin integrity issues so the low air loss mattress was now a medical intervention. No thick sheets or barriers between resident and mattress cover material. A skin assessment tool, dated 11/25/18, documented a right buttock shear 5cm x 2cm x 0.01cm, an upper left back shear 3cm x 4cm x 0.01cm, shear near the sacrum 4.5cm x 1.5cm x 0.01cm, right calf shear 5cm x 3cm x 0.01cm, right ear pressure wound 4cm x 1cm x 0.01cm, left ear pressure wound 4cm x 1cm (unstageable). No staging of the wounds was documented. A health status nursing note, dated 11/25/18, documented right and left ear lobes were red, warm, swollen and had serosanguineous drainage. Skin protectant was applied. The physician was notified, no new orders were received. A physician's orders [REDACTED]. A skin assessment tool, dated 12/01/18, documented left scapula shearing 3cm x 4cm x 0.01cm, a right ear pressure wound 4cm x 1cm stage one, a left ear pressure wound 4cm x 1cm unstageable, a right buttock shear 5cm x 2cm x 0.01cm, a left buttock shear 4.5cm x 1.5cm x 0.01cm, and a left lower leg (calf) wound 5cm x 3cm x 0.01cm. No staging of the wounds was documented. Eight days elapsed from the first mention of any wounds (11/22/18) and treatment orders being obtained (12/01/18). A physician's orders [REDACTED]. A physician's orders [REDACTED]. ~ Santyl ointment 250 unit/gm (gram) - apply to left buttocks black scabs topically one time a day. Discontinue (D/C) when scab dissolves or falls off. ~ Santyl ointment 250 unit/gm - apply to left ear black scab topically one time a day. D/C when scab dissolves or falls off. ~ Santyl ointment 250 unit/gm - apply to right buttocks black scab topically one time a day. D/C when scab dissolves or falls off. ~ [MEDICATION NAME] liquid - apply to right ear topically every six hours as needed for shear. ~ [MEDICATION NAME] liquid - apply to sacral area topically every six hours as needed for shear. ~ [MEDICATION NAME] liquid - apply to sacral area topically two times a day for shear. ~ [MEDICATION NAME] liquid - apply to left ear, left lower shin, left upper scapula, right ear, sacral area. ~ apply house stock moisture barrier after skin dressing and PRN (as needed) after activities of daily living (ADLs) care every six hours. ~ apply house stock moisture barrier after skin dressing and PRN after ADL care two times a day for skin breakdown prevention. ~ give one extra can of 2Cal tube feeding via PEG tube at midnight until all skin issues resolved. ~ give 250ml of free H20 with TF administration every eight hours as tolerated. ~ left buttocks - clean site with normal saline or sterile water then apply house stock hydrogel to areas that started out as shear to left buttocks. Use Santyl thin and sparingly to black scab tissue until dissolved or falls off. Cover with non-stick four by four gauze or ABD (abdominal) pad then [MEDICATION NAME] or paper tape. D/C treatment when resolved. One time per day. ~ place bilateral heel/ankle protectors on at all times while in bed. ~ place indwelling urinary catheter today secondary to resident obtunded and having shear areas on left and right buttocks, right lower calf and left upper back. ~ right buttocks - clean site with normal saline (NS) or sterile water then apply house stock hydrogel to areas that started as shear. Use Santyl thin and sparingly to black tissue until dissolved or falls off. Cover with non-stick cover, four by four gauze, or ABD pad, [MEDICATION NAME] or paper tape. D/C treatment when resolved. One time per day. ~ turn every two hours to prevent further skin breakdown. The (MONTH) (YEAR) treatment administration records (TARs) did not document the added 250ml of free water with tube feeding administration every eight hours. There was no documentation to show the extra water had been administered as ordered. A physician's orders [REDACTED]. The comprehensive care plan was updated on 12/08/18, and documented interventions which included: ~ [MEDICATION NAME] packet give one packet via [DEVICE] (gastrosomy) two times a day for wounds. ~ apply house stock moisture barrier after skin dressing and PRN after ADL care two times a day for skin breakdown prevention and every six hours as needed. ~ follow facility policies and protocols for the prevention and treatment of [REDACTED]. ~ place bilateral heel protectors at all times while in bed but charge nurse may give periods of breaks two hours at a time. ~ resident is on low air loss mattress, do not use thick sheets or pads. ~ turn every two hours to prevent further tissue breakdown. A skin assessment tool, dated 12/10/18, documented a left scapula shear (unspecified) 3cm x 4cm x 0.01cm, a right ear pressure wound 4cm x 1cm stage one, a left ear pressure wound 4cm x 1cm unstageable, a right buttock shear 5cm x 2cm x 0.01cm, a left buttock shear 4.5cm x 1.5cm x 0.01cm, and a left lower leg (rear) shear 5cm x 3cm x 0.01cm. Not all areas indicated the stage of the wound. A skin assessment tool, dated 12/17/18, documented no change in wound measurements from 12/10/18. No other wounds were documented. A skin assessment tool, dated 12/30/18, documented left scapula shearing - right ear, pressure - left ear, pressure - right buttock - left lower leg, shearing - left buttock, shear, 4.5cm x 1.5cm x 0.5cm - left lower leg (rear), shearing. No other information about the wounds was documented. A skin/wound note, dated 01/01/19, documented a wound to the right buttock, the wound bed was pink and moist with bloody drainage noted, surrounding tissue was fragile, no odor or s/s (signs/symptoms) of infection noted. An order was received to place a negative pressure wound vac. A skin assessment tool, dated 01/03/19, documented coccyx shear 3cm x 2cm x 1cm. The stage of the wound was blank. This was the first mention of the coccyx. A physician's orders [REDACTED]. A skin assessment tool, dated 01/08/19, documented coccyx shear 6cm x 5cm x 1cm without a stage documented. There were no other sites documented. A health status nursing note, dated 01/10/19 at 11:07 a.m., documented, resident with an increased temperature today of 102 degrees Fahrenheit (F) and wound to coccyx with odor. Wound to coccyx is draining large amount of purulent drainage, wound was dark, but soft to touch. The physician was notified and ordered a CBC (complete blood count), a CMP (comprehensive metabolic panel) and a UA (urine analysis). A physician's progress note, dated 01/10/19 (no time documented) documented, Wound vac in place - wounds are improving however coccyx wound with rapid change - could smell and fever - plan reviewed we felt best sent to higher level of care. A health status nursing note, dated 01/10/19 at 3:39 p.m., documented, the doctor was here today, he was awaiting lab and UA and will send (to the hospital) as soon as results are received. A health status nursing note, dated 01/10/19 at 4:49 p.m., documented, resident had a low grade temperature, Tylenol was given and temperature was down to 99.2 F. There was no documentation to show the resident's temperature was taken for 17 hours from 01/10/19 at 4:49 p.m. to 01/11/19 at 10:13 a.m. A health status nursing note, dated 01/11/19 at 10:13 a.m., documented the resident had a 104.2 F., axillary temperature. The respirations were 32 per minute, the urine was dark and thick, the wound to the coccyx continued to have a foul odor, the wound bed was dark, but mushy and purulent drainage was on the old dressing. Wound care was performed per orders and Tylenol was given per PEG for fever. The doctor was notified of the resident's condition. At 10:22 a.m., a health status nursing note documented spoke with the doctor and he wants the resident sent out via EMS (emergency medical service) to ER (emergency room ). The comprehensive care plan was updated on 01/11/19, and documented the resident had a wound on her coccyx with current measurements of 6cm x 5cm x 2cm. Interventions included: ~ obtain CBC, CMP and UA with C&S (culture and sensitivity) if indicated today due to increased temperature and odor to wound. ~ [MEDICATION NAME] of [MEDICATION NAME] to bilateral ears to provide protective coating to help prevent shear areas. ~ wound care to coccyx cleanse with normal saline or sterile water, pat dry, apply skin prep to surrounding skin, cover wound with [MEDICATION NAME], cover with dressing and secure with tape. Change daily and as needed for soilage or removal. This treatment was ordered on [DATE]. An emergency room physician's note, dated 01/11/19 at 2:39 p.m., documented .labs reviewed, CT (computed tomography) and x-ray reviewed. The patient has a very severe presacral and coccygeal pressure sore with erosion into the presacral space. I discussed this with radiology and there is nothing to be drained and nothing would be amenable to surgical intervention at this point. The patient is going to need prolonged IV (intravenous) antibiotics. She is in septic shock. This is secondary to the wound most likely and secondarily to the UTI (urinary tract infection) . On 2/12/19 at 1:30 p.m., the DON was asked to describe the resident's wounds on her buttocks. She stated it was a large wound with a foul odor, with greyish tissue around it and a large amount of serous drainage. The DON was asked what shearing meant on the skin assessment tool, and what it looked like. She stated it looked like the skin was peeled away, sheared off. She was asked if these shear areas were open. She stated not initially, but eventually they did open. The DON was asked how the resident acquired shearing. She stated from being pulled up and down in the bed. The DON was asked what type of mattress the resident was placed on and if the mattress was rated for pressure wounds. She stated it was called a pressure relieving mattress, or low air loss mattress. She was asked how the facility determined what mattress to use when a resident was admitted . She stated because the resident was comatose they immediately placed her on an air mattress. The DON was asked if the same air mattress was used for all residents admitted with the same or similar diagnoses. She stated, Yes. The DON was asked about the wounds first being described on the skin sheets as on the right and left buttocks. Then the wound changed to the coccyx. The DON was asked if the two wounds merged into one. She stated they had gotten so big they had merged together. The DON was asked why there was not consistent documentation describing the wounds. She stated there had been no wound nurse at the facility. She stated skin observations were done and nurses' notes put in, but there was no daily documentation describing the wounds. The DON was asked if the resident should have been re-assessed to be turned more frequently than every two hours. She stated not necessarily because she was on an air mattress. The DON was asked how often the dietician assessed a resident with tube feedings and wounds. She stated, usually one time per month, or as needed. She was asked how often a resident should be re-assessed by the dietician. She stated someone with bad wounds, initially and then a couple of weeks later. The DON was shown the (MONTH) (YEAR) TARs and asked how staff knew when to give the resident free water and how much to give the resident. She stated they would not know since it was not documented. She was asked to provide intake and output sheets for the resident's tube feeding, free water and indwelling catheter. She stated, per the corporate nurse, the facility does not do I (intake) and O (output) sheets. She was asked how the facility tracked residents with tube feedings and catheters to ensure they had enough intake and output. She stated, We can't. The DON was asked why the resident had not been sent to the emergency roiagnom on [DATE], after the physician visit, and the resident's temperature was 102 F and the coccyx wound had an odor. She stated the doctor wanted to wait for labs and the UA results before sending her out. She was asked if the labs had been ordered STAT (immediately). She stated she did not think they were because the lab person was coming to the facility that day. The resident was not sent to the ER until the next day on 01/11/19.

Based on observation, interview and record review, it was determined the facility failed to ensure residents with percutaneous endoscopic gastrosomy (PEG) tubes were provided adequate nutrition and/or hydration for two residents (#1 and #11); intake and output was monitored for one resident (#1) with an indwelling urinary catheter, and weights were monitored for one (#3) of three sampled residents reviewed for adequate nutrition and hydration. Resident #1 was not provided with sufficient protein, calories and hydration. The resident was ultimately admitted to the hospital with [REDACTED]. The facility identified 3 residents with PEG tubes and 3 residents with indwelling urinary catheters resided in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment documented no skin issues. physician's orders [REDACTED]. The comprehensive resident assessment, dated 11/14/18, documented the resident was at risk for skin breakdown and had no pressure ulcers. It documented the resident's cognitition was severely impaired and the resident was totally dependent on staff for all care. The resident's care plan, dated 11/16/18, did not include the resident was NPO, the tube feeding order, or the revision (update) of an additional midnight feeding which was ordered on [DATE]. A dietary/nutrition note, dated 11/22/18, documented, a wound to the back of the left calf (stage two blisters). Receives a TF (tube feeding) of 2Cal HN, one can Q6H (every six hours) four times a day with H20 (water) flushes 30cc (cubic centimeters) ac/pc (before/after) medications two times a day. Needs are 2150 calories; 85g (grams) protein (1.2g/Kg (Kilogram) for wound healing), 1775ml (milliliters) fluids. TF provides 948ml formula (100% percent RDAs (recommended daily allowances), 1896 calories (88%), 80g protein (94%), 664ml free water plus 120ml flushes. Total fluids 784ml (44%). Recommend 40ml/h H20 or 250ml Q6H to meet fluid needs. This was the first mention of any wounds. 1896 calories did not meet the 2150 caloric needs. The resident was receiving 254 less calories than needed per day. Total water flushes of 664ml plus 120cc flushes was 784cc and did not meet the standard of 30cc/kg/day which would have been 2130cc based on the resident's weight of 157 pounds. A skin assessment tool, dated 11/22/18, documented a left ear pressure wound 3cm (centimeters) x 2cm, an upper back shear area 3cm x 3cm x 0.1cm, and left inner lower leg shear of 5cm x 3cm x 0.1cm. A skin assessment tool, dated 11/25/18, documented a right buttock shear 5cm x 2cm x 0.01cm, an upper left back shear 3cm x 4cm x 0.01cm, shear near the sacrum 4.5cm x 1.5cm x 0.01cm, right calf shear 5cm x 3cm x 0.01cm, right ear pressure wound 4cm x 1cm x 0.01cm, left ear pressure wound 4cm x 1cm (unstageable). A health status nursing note, dated 11/25/18, documented right and left ear lobes were red, warm, swollen and had serosanguineous drainage. Skin protectant was applied. The physician was notified, no new orders received. A physician's orders [REDACTED]. A skin assessment tool, dated 12/01/18, documented left scapula shearing 3cm x 4cm x 0.01cm, a right ear pressure wound 4cm x 1cm stage one, a left ear pressure wound 4cm x 1cm unstageable, a right buttock shear 5cm x 2cm x 0.01cm, a left buttock shear 4.5cm x 1.5cm x 0.01cm, and a left lower leg (calf) wound 5cm x 3cm x 0.01cm. A physician's orders [REDACTED]. A physician's orders [REDACTED]. ~ give one extra can of 2Cal tube feeding via PEG tube at midnight until all skin issues resolved. ~ give 250ml of free H20 with TF administration every eight hours as tolerated. The resident went from 11/05/18 until 12/01/18 without adequate protein and calories. The extra 250ml of water three times per day increased her daily fluid intake to 1534cc. This still did not meet her minimal needs of 2130cc per day. The (MONTH) (YEAR) treatment administration records (TARs) did not document the added 250ml of free water with tube feeding administration every eight hours. There was no documentation to show the extra water had been administered as ordered. A skin assessment tool, dated 12/10/18, documented a left scapula shear (unspecified) 3cm x 4cm x 0.01cm, a right ear pressure wound 4cm x 1cm stage one, a left ear pressure wound 4cm x 1cm unstageable, a right buttock shear 5cm x 2cm x 0.01cm, a left buttock shear 4.5cm x 1.5cm x 0.01cm, and a left lower leg (rear) shear 5cm x 3cm x 0.01cm. A skin assessment tool, dated 12/30/18, documented a left buttock shear 4.5cm x 1.5cm x 0.5cm. A skin assessment tool, dated 01/03/19, documented coccyx shear 3cm x 2cm x 1cm. A skin assessment tool, dated 01/08/19, documented coccyx shear 6cm x 5cm x 1cm. A health status nursing note, dated 01/10/19 at 11:07 a.m., documented the resident with an increased temperature today of 102 degrees Fahrenheit (F) and wound to coccyx with odor. Wound to coccyx is draining large amount of purulent drainage, wound was dark, but soft to touch. The physician was notified and ordered a CBC (complete blood count), a CMP (comprehensive metabolic panel) and a UA (urine analysis). A physician's progress note, dated 01/10/19 (no time specified), documented, Wound vac in place - wounds are improving however coccyx wound with rapid change - could smell and fever - plan reviewed we felt best sent to higher level of care. A health status nursing note, dated 01/10/19 at 3:39 p.m., documented the doctor was here today, he was awaiting lab and UA and will send (to the hospital) as soon as results are received. A health status nursing note, dated 01/10/19 at 4:49 p.m., documented resident had a low grade temperature, Tylenol was given and temperature was down to 99.2 F. A health status nursing note, dated 01/11/19 at 10:13 a.m., documented the resident had a 104.2 F., axillary temperature. The respirations were 32 per minute, the urine was dark and thick, the wound to the coccyx continued to have a foul odor, the wound bed was dark, but mushy and purulent drainage was on the old dressing. Wound care was performed per orders and Tylenol was given per PEG for fever. The doctor was notified of the resident's condition. At 10:22 a.m., a health status nursing note documented spoke with the doctor and he wants the resident sent out via EMS (emergency medical service) to ER (emergency room ). An emergency room physician's note, dated 01/11/19 at 2:39 p.m., documented, .The patient is going to need prolonged IV (intravenous) antibiotics. She is in septic shock. This is secondary to the wound most likely and secondarily to the UTI (urinary tract infection) . On 2/12/19 at 1:30 p.m., The DON was asked how often the dietician assessed a resident receiving tube feeding and had wounds. She stated usually one time per month or as needed. She was asked how often a resident should be re-assessed by the dietician. She stated someone with bad wounds, initially and then a couple of weeks later. The DON was shown the (MONTH) (YEAR) TARs and asked how staff knew when to give the resident free water and how much to give the resident. She stated they would not know since it was not documented. She was asked to provide intake and output sheets for the resident's tube feeding, free water and indwelling catheter. She stated, per the corporate nurse, the facility does not do intake and output sheets. She was asked how the facility tracked residents with tube feedings and catheters to ensure they had enough intake and output. She stated, We can't. 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. ~ NPO diet ~ enteral feed order every six hours bolus one can 2Cal. ~ enteral feed order every six hours bolus 350ml water with feedings and medications. A care plan, dated 09/03/17, documented tube feeding: required tube feeding r/t NPO status, dysphagia and a swallowing problem. Interventions included 300ml of H20 every six hours with medications and feedings. On 11/07/18 the resident weighed 122.0 pounds. A quarterly assessment, dated 12/12/18, documented the resident's cognition was severely impaired. The resident required extensive to total assistance for all ADLs, including nutrition and hydration. A nutrition/dietary note, dated 12/17/18, documented no (MONTH) weight was available. Weight had been stable over six months. Skin is intact. Caloric needs 2179 calories, 55g protein, 1375cc fluids. One can of 2Cal every six hours. 1896 calories (87%) RDA, 80g protein (145% RDA), 664cc free H20 plus 1400cc H20 from 350ml four times a day flushes equals 2064 hydration (150% RDA). Needs are being met. 1896 calories did not meet the 2179 caloric needs per day. Resident was receiving 283 calories less than needed per day. On 12/18/18, the resident weighed 111.8 pounds which was a 10.2 pound weight loss from the prior month. On 01/04/19, the resident weighed 109.8 pounds which was an additional two pound weight loss. A nursing health status note, dated 01/05/19, documented the resident was seen by the doctor. There were no new orders. A nutrition/dietary note, dated 01/29/19, documented, 109.8 pounds. Slow loss of 8.5% past six months noted. Receives a TF of 2Cal HN one can Q6H with 350ml H20 Q6H. No labs noted. Skin intact. Needs are 1825 calories (weight stabilization). 50g protein, 1750 ml fluids, (35ml/Kg). TF provides 948ml formula (100% RDA) 1896 calories (104%), 80g protein (160%), 664ml free water plus 1400ml fluids for total fluids of 2064 (118%). Needs are met continue P[NAME]. A physician's orders [REDACTED]. On 02/20/19 at 8:02 a.m., the DON was asked if she could explain the resident's weight loss of 10.2 pounds from 11/07/18 to 12/18/18. She stated, We don't really know. The resident is more active with moving around now. I don't really know, the feeding has been the same. The DON was asked if the dietician had been notified of the resident's weight loss after the weight was obtained on 12/18/18. She stated, No, I don't think so. The DON was informed the resident's feedings were not increased until (MONTH) 2019 and asked why the resident had not been re-evaluated after the 12/18/18 weight loss. She stated, I don't know. 3. Resident #3 had [DIAGNOSES REDACTED]. The resident was receiving hospice services. The resident's weight on 11/07/18 was documented as 140 pounds. The resident's weight was not documented for (MONTH) (YEAR). A nutrition/dietary note, dated 12/17/18, documented a (MONTH) weight of 138 pounds with no significant weight change in six months. The resident's weight was not documented for (MONTH) 2019. The resident's weight on 02/14/19 was documented as 122.4 pounds. The resident lost 17.6 pounds or 12.5% in 98 days. On 02/19/19 at 12:30 p.m., the DON was asked about the resident's missing weights for (MONTH) (YEAR) and (MONTH) 2019 and the weight loss. She stated she thought the (MONTH) (YEAR) weight was wrong. She stated she had problems with the weights and the person taking them. The DON stated she believed the 02/14/19 weight was correct. She was asked if the resident had been reweighed. She stated, No. She was asked where the dietitian had obtained the (MONTH) (YEAR) weight since there were no weights documented in the electronic health record. The DON stated she did not know.

Based on record review and resident and staff interviews, it was determined the facility failed to notify a physician when a resident experienced a change in condition for skin integrity for one (#52) of 3 sampled residents reviewed for pressure ulcers. As a result, the resident developed an unstageable pressure ulcer to her left ankle which required surgical debridement. The wound became infected and required antibiotic treatment. The Resident Census and Conditions of Residents report, dated 05/24/17, documented two residents with pressure ulcers. Findings: 1. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission summary, dated 05/01/17, documented, .Resident states she has pain in her left ankle and says that its a sprain. Skin CDI (clean dry intact) . A weekly skin screening, dated 05/01/17, documented in the comments section, [MEDICAL CONDITION] and bruising to left ankle from sprain. A weekly skin screening, dated 05/08/17, documented an X next to the words no change. No additional comments were on this date. A physician's orders [REDACTED]. An admission resident assessment, dated 05/14/17, documented the resident was at risk for pressure ulcer development and had no unhealed pressure ulcers. The May 2017 treatment administration record (TAR) documented the ace wrap was applied two times a day on the 10th, 11th, 12th and 13th. It documented the resident refused the ace wrap the morning of the 14th and the ace wrap was applied on the evening shift. It documented the ace wrap was discontinued on 05/15/17. A weekly skin screening, dated 05/15/17, documented in the comments section, Red open area to top of left ankle from blood blister. A wound care specialist's initial evaluation, dated 05/15/17, documented, .She presents with an unstageable DTI (deep tissue injury) of the left, anterior ankle of at least 4 days duration. There is light serous exudate . ETIOLOGY (QUALITY): Pressure .STAGE: Unstageable DTI - wound .WOUND SIZE (L (LENGTH) X (BY) W (WIDTH) X D (DEPTH) 4.6 x 2.7 x Not measurable cm (centimeters) .EXUDATE: Light Serous .THICK ADHERENT DEVITALIZED NECROTIC TISSUE: 90% (percent) .SKIN: 10% . ADDITIONAL INFORMATION: wrap injury .PROCEDURE: SURGICAL EXCISIONAL DEBRIDEMENT . The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique, curette was used to surgically excise 11.18 cm (squared) of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied . Continue: Dry Protective Dressing - Once Daily .Add: Xeroform - Once Daily .Recommendation: Secure with lightly wrapped stretch gauze and sock .HBA1C (glucosylated hemoglobin), [MEDICATION NAME] recommended on 05/15/17 . Plan to discuss patient's abnormal BMI (body mass index) with current dietician (sic). If the patient does not currently have a dietician (sic) following, recommend dietary consultation for abnormal BMI . This document was electronically signed by the wound care physician. There was no documentation the resident's primary physician was notified by facility staff of this change in the resident's condition, the recommended laboratory orders (HBA1C and [MEDICATION NAME]) or the recommended dietary consult made by the wound care physician. There was no documentation of this lab having been obtained or of the dietitian having been consulted. A physician's orders [REDACTED]. It documented the reason the ace wrap was discontinued was D/C (discontinue) due to Blister on top of ankle. A wound care specialist's evaluation, dated 05/22/17, documented, .Unstageable (Due To Necrosis) Of The Left, Ankle .STAGE: Unstageable .WOUND SIZE: 4.2 x 2.8 x Not Measurable cm . PERIWOUND RADIUS: [DIAGNOSES REDACTED] .EXUDATE: Moderate Sero - sanguinous .THICK BLACK NECROTIC TISSUE (ESCHAR): 100% .WOUND PROGRESS: Deteriorated . UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT, ANTERIOR ANKLE - DETERIORATED DUE TO INFECTION . Discontinue: Dry Protective Dressing - Once daily .Continue: Xeroform - Once Daily .Add: Santyl - Once Daily, Calcium Alginate - Once Daily . Recommendation: Antibiotic: keflex 500 mg (milligrams) tabs (tablets) 1 PO (by mouth) QID (four times daily) x 10 days, do not wrap . This document was electronically signed by the wound care physician. There was no documentation the resident's primary physician was notified of this change in the resident's condition from facility staff. A physician's orders [REDACTED].*do not wrap* one time a day for unstageable wound to left anterior ankle. A care plan, dated, 05/27/17, documented, (resident) has actual impairment to skin integrity of the right dorsal ankle cause by water blister rupture .Interventions .Encourage good nutrition and hydration in order to promote healthier skin .Follow facility protocols for treatment of [REDACTED]. On 05/31/17 at 1:42 p.m., LPN #2 was asked if the wound care physician was the person who measured the wounds. She stated, Yes. She was asked how often wounds were measured, She stated, Weekly. She stated he did not come this week because he comes on Mondays and Monday was a holiday. She was asked to explain the discrepancy with the location of the wound. She reviewed the records and stated some nurses document a different terminology but it's just the one wound. She was asked to explain the role of the wound care physician. She stated, We got him for his specialty. She stated, So he can give us more insight on wound care and treatment of [REDACTED]. She stated, Yes. She stated the wound care physician's documentation was received by the facility weekly. She stated staff went by what the wound care physician documented on his notes for orders. She was asked what the facility did with the information he documented under recommendations. She stated staff would communicate the information with physician #1, and he would instruct us whether or not to do what was recommended. LPN #2 was asked if the resident admitted to the facility with any wounds. She stated the resident had bruising to her left ankle from a sprain, but no wounds. She stated the resident had just fallen at home, went to the emergency room and then admitted to the facility. She stated her guess was the bruising developed after the fall. She was asked if the resident came to the facility with an ace wrap. She stated, No. She stated the ace wrap was an order after she arrived to the facility because she was complaining of her foot hurting really bad from the sprain. She was asked to confirm there was no documentation in the resident's clinical record to explain the events surrounds the ace wrap order. She stated, Right. She was asked if the record documented the wrap was discontinued due to a blister on the top of her ankle. She stated, in report she was told she had what looked like a water blister on top of her ankle over the weekend. She stated, And that it had busted. She stated, So we called the doctor because we didn't want to continue to wrap the ankle because it had busted. She was asked if there was any documentation of this. She stated, No. She was asked if the blister was caused by the ace wrap. She stated, I'm not sure. She was asked to review the wound care specialist's initial evaluation, dated 05/15/17. She was asked if it documented, under additional information, wrap injury. She reviewed the record and stated, Yes, it does. She was asked if the injury was avoidable. She stated, Yes. LPN #2 was asked if the evaluation documented a recommendation of HBA1C and [MEDICATION NAME]. She stated, Yeah, it says it was recommended. She was asked if the laboratory (lab) work had been drawn on the resident. She stated she would have to see on the resident's hospital record if the labs were drawn already. She stated if the hospital had already drawn them, the facility would not redraw the labs. She was asked to review the hospital record located in the resident's record and identify if the lab had been drawn. She stated, Nope, I don't see it in here. She was asked if staff should have called physician #1 and notified him of this recommendation to see if he wanted the labs drawn. She stated, Yes. She was asked, to her knowledge, did they. She stated, I don't believe so. LPN #2 was asked if the wound physician's note, dated 05/22/17, documented an unstageable wound to the resident's left anterior ankle was deteriorated due to infection. She stated, Yes. She was asked if the resident was started on antibiotics. She stated, Yes. At 2:10 p.m., LPN #2 was asked to locate any documentation physician #1 had been notified of the resident's blister. At 2:11 p.m., just one minute later, she returned and stated, No, I can not. She was asked what the policy was for notifying a physician. She stated, Notify the doctor of change if you need a new order. She was asked how the wound care physician was notified of the resident's wound. She stated staff would call the physician to notify him of the blister. She stated then they would notify him in person upon his arrival to the facility during his weekly visits. She was informed there was no documentation of this process or how he was notified. She stated, Right. At 3:01 p.m., physician #1 was interviewed via telephone and asked to clarify the reason the ace wrap was ordered for the resident. He stated the resident reported she had sprained her ankle, so the wrap was used to decrease swelling and apply pressure. He stated there was no significant findings on x-ray. He was asked if the resident had a wound on admission. He stated, Not that I'm aware of. He was asked if he was aware the resident had developed a blister on her left ankle and was seen by a wound care physician on 05/15/17. He stated staff usually notified him on back line (texting system). He stated, I don't recall. He stated, Doesn't mean they didn't. The phone connection was lost at this time. On 06/01/17 at 7:44 a.m., the resident was asked if her pressure ulcer developed in the facility. She stated, Yeah. She was asked if she knew how it occurred. She stated, I think it was when they wrapped the elastic thing around my foot. She was asked if she had any pain with her wound. She stated, I do sometimes. She stated, But they put me on antibiotic. She stated it was hard to tell if the pain was from her wound or her sprain. She stated she didn't experience much pain during wound care. At 8:00 a.m., physician #1 was again interviewed by phone and asked if he had been notified by the facility when the blister to the resident's left ankle appeared. He stated, I honestly can't remember. He stated sometimes he was notified by receiving a copy of the wound care physician's note. He was asked if this was a change in the resident's condition. He stated, Yeah. He stated, If she developed a blister, yeah. He was asked if the staff should have notified him. He stated, I'm assuming they should have, they usually do. He was asked if the facility had notified him when the wound care physician saw the resident on 05/15/17 and documented wrap injury. He stated, Honestly. no. He stated just because he couldn't remember, doesn't mean it didn't happen. He stated typically staff would notify him of a wound and the wound care physician would see the resident. He was asked if this injury was avoidable. He stated, I would say all injuries are avoidable. He stated for this injury, I can't say. He stated if the wrap was placed where it put pressure on the skin, it could have caused an injury. He stated the resident could always run the risk because the ankle was swollen and bruised. He was asked if staff should monitor for swelling and circulation when utilizing an ace wrap. He stated, They should. Physician #1 was asked if the facility notified him the wound care physician had recommended a HBA1C and [MEDICATION NAME] on the 05/15/17 evaluation. He stated, I don't know. He stated, It may have come up on rounds, I don't recall. He was asked if staff should have notified him of this. He stated, I guess, ok. He was asked if the facility notified him on the 05/22/17 wound care physician's visit he documented the pressure ulcer was unstageable due to necrosis of the left anterior ankle and had deteriorated due to infection. He stated, Again, I can't remember. He was asked if the staff should have notified him of this change in condition. He stated the staff send him back line text all of the time. He stated, Back line doesn't count for the medical record. He stated, They would have to put in the note. He stated staff had the electronic charting and paper charting and should document notifications. He stated, If it's not documented, it didn't happen. He was informed there was minimal documentation from the facility staff on the resident's wound and no documentation of the staff having notified him of the changes in the resident's condition. He stated the documentation was the first thing that needed to change. At 8:17 a.m., the DON was asked what the policy was for physician notification. LPN #3 was also present during the interview. She stated staff were to notify the physician when a resident was sent out, when there's a fall or incident, when the resident was complaining of something we do not have orders for and when a resident refused a medication. LPN #3 stated staff notified the physician of abnormal labs. The DON stated new complaints and abnormal vital signs would be reported. She stated, Anything out of the ordinary. She was asked if staff notified the physician with changes in a resident's skin. She stated, Yes. She was asked what role the wound care physician had with the residents in the facility. The DON stated he came once a week and assessed any resident who was reported to him to have a change in skin condition. She stated he would see the resident to assess the skin and order treatment. She was asked to review the admission note, dated 05/01/17, and identify whether or not the resident admitted to the facility with a wound on her foot. She stated it documented pain in the resident's left ankle from a sprain and the skin was clean dry and intact. The DON also reviewed the weekly skin screening and stated it documented on admission [MEDICAL CONDITION] and bruising to the left ankle from a sprain. She was asked to explain the reason for the ace wrap order dated 05/10/17. She reviewed the printed order and the resident's electronic records and stated, I don't see a progress note. She stated LPN #3 was the nurse who put the order in (by this time LPN #3 had exited the interview). The DON was observed exiting the room for a brief moment and returned. She stated LPN #3 had emailed her through her phone the information. She stated it documented on 05/10/17 LPN #3 sent the physician a message using the back line (a way of communicating information about the resident to the physician). She stated the message just said doctor and did not specify which doctor it was sent to. The DON was asked if the back line was part of the resident's clinical record. She stated, No. She stated, I don't know if there's a way to do that. She was asked if staff should have documented in the clinical record to support the reason the ace wrap was used. She stated, Absolutely. She was asked if she could locate anywhere in the resident's clinical record documentation of the reason the wrap was used and what staff notified the physician of, if anything, prior to the ace wrap order. She stated, No. She was asked to identify the reason the ace wrap was discontinued on 05/16/17. She reviewed the record and stated, This says dc'd due to blister on top of ankle. She stated she didn't see that there was any way to print the back line. She was asked if the weekly skin sheet documented a red open area to the top of the left ankle from a blood blister on 05/15/17. She stated, Yes. The DON was asked if the wound care specialist's initial evaluation, dated 05/15/17, documented an unstageable deep tissue injury of the left anterior ankle measuring 4.6 x 2.7 x not measurable and under the additional information did it document a wrap injury. She reviewed the record and stated, Yes. She was asked if this was an avoidable injury. She stated, Yes. She was asked if the initial evaluation documented a recommendation of a HBA1C and a [MEDICATION NAME] on 05/15/17. She stated, Yes. She was asked if she had any documentation the information from the wound care physician's visit had been communicated to physician #1. She stated, No. She was asked if physician #1 should have been notified of the change in the resident's condition. She stated, Yes. She was asked if the wound care specialist's evaluation, dated 05/22/17 documented an unstageable pressure ulcer due to necrosis of the left anterior ankle deteriorated due to infection. She reviewed the record and stated, Yes. She was asked if there was any documentation of physician #1 having been notified of the wound care physician's findings. She stated, I do not.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to: ~ assess a resident who had orders for an ace (all cotton elastic) wrap for one (#52) of three sampled residents reviewed for pressure ulcers. As a result, the resident developed an unstageable pressure ulcer to her left ankle which required surgical debridement. The wound became infected and required antibiotic treatment, ~ ensure a resident with a pressure ulcer had routine skin assessments completed and was monitored for one (#39) of three sampled residents reviewed for pressure ulcers, and ~ ensure a resident with a pressure ulcer was provided treatment for one (#33) of three sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 05/24/17, documented two residents with pressure ulcers. The facility identified no residents with orders for an ace wrap. Findings: 1. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission summary, dated 05/01/17, documented, .Resident states she has pain in her left ankle and says that its a sprain. Skin CDI (clean dry intact) . A weekly skin screening, dated 05/01/17, documented in the comments section, [MEDICAL CONDITION] and bruising to left ankle from sprain. A weekly skin screening, dated 05/08/17, documented an X next to the words no change. No additional comments were on this date. A physician's orders [REDACTED]. An admission resident assessment, dated 05/14/17, documented the resident was at risk for pressure ulcer development and had no unhealed pressure ulcers. The May 2017 treatment administration record (TAR) documented the ace wrap was applied two times a day on the 10th, 11th, 12th and 13th. It documented the resident refused the ace wrap the morning of the 14th and the ace wrap was applied on the evening shift. It documented the ace wrap was discontinued on 05/15/17. A weekly skin screening, dated 05/15/17, documented in the comments section, Red open area to top of left ankle from blood blister. A wound care specialist initial evaluation, dated 05/15/17, documented, .She presents with an unstageable DTI (deep tissue injury) of the left, anterior ankle of at least 4 days duration. There is light serous exudate . ETIOLOGY (QUALITY): Pressure .STAGE: Unstageable DTI - wound .WOUND SIZE (L (LENGTH) X (BY) W (WIDTH) X D (DEPTH) 4.6 x 2.7 x Not measurable cm (centimeters) .EXUDATE: Light Serous .THICK ADHERENT DEVITALIZED NECROTIC TISSUE: 90% (percent) .SKIN: 10% . ADDITIONAL INFORMATION: wrap injury .PROCEDURE: SURGICAL EXCISIONAL DEBRIDEMENT . The wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique, curette was used to surgically excise 11.18 cm (squared) of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied . Continue: Dry Protective Dressing - Once Daily .Add: Xeroform - Once Daily .Recommendation: Secure with lightly wrapped stretch gauze and sock .HBA1C (glucosylated hemoglobin), [MEDICATION NAME] recommended on 05/15/17 . Plan to discuss patient's abnormal BMI (body mass index) with current dietician (sic). If the patient does not currently have a dietician (sic) following, recommend dietary consultation for abnormal BMI . This document was electronically signed by the wound care physician. There was no documentation the resident's primary physician was notified by facility staff of this change in the resident's condition, the recommended laboratory orders (HBA1C and [MEDICATION NAME]) or the recommended dietary consult made by the wound care physician. There was no documentation of this lab having been obtained or of the dietitian having been consulted. A physician's orders [REDACTED]. It documented the reason the ace wrap was discontinued was D/C (discontinue) due to Blister on top of ankle. A wound care specialist evaluation, dated 05/22/17, documented, .Unstageable (Due To Necrosis) Of The Left, Ankle .STAGE: Unstageable .WOUND SIZE: 4.2 x 2.8 x Not Measurable cm . PERIWOUND RADIUS: [DIAGNOSES REDACTED] .EXUDATE: Moderate Sero - sanguinous .THICK BLACK NECROTIC TISSUE (ESCHAR): 100% .WOUND PROGRESS: Deteriorated . UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT, ANTERIOR ANKLE - DETERIORATED DUE TO INFECTION . Discontinue: Dry Protective Dressing - Once daily .Continue: Xeroform - Once Daily .Add: Santyl - Once Daily, Calcium Alginate - Once Daily . Recommendation: Antibiotic: keflex 500 mg (milligrams) tabs (tablets) 1 PO (by mouth) QID (four times daily) x 10 days, do not wrap . This document was electronically signed by the wound care physician. There was no documentation the resident's primary physician was notified of this change in the resident's condition from facility staff. A physician's orders [REDACTED].*do not wrap* one time a day for unstageable wound to left anterior ankle. A care plan, dated, 05/27/17, documented, (resident) has actual impairment to skin integrity of the right dorsal ankle cause by water blister rupture .Interventions .Encourage good nutrition and hydration in order to promote healthier skin .Follow facility protocols for treatment of injury .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . On 05/30/17 at 7:53 a.m., the wound care for the resident was observed being performed by licensed practical nurse (LPN) #1. LPN #1 was observed obtaining a role of [MEDICATION NAME] tape off of the treatment cart. He used a sharpie to put the date, time and his initials on the tape. He placed the sharpie back in his pocket. He walked over to the storage room located behind the nurses' station and obtained a box of individually wrapped 4 x 4 gauze and three 110 ml (milliliter) bottles of normal saline. He returned to his treatment cart, placed two of the bottles in the cart and kept one out. He obtained one 4 x 4 xeroform petroleum dressing, one 4 x 4 [MEDICATION NAME] alginate dressing, one 30 gram tube of Santyl (which was contained in a box) and four individually wrapped 4 x 4 gauze from the treatment cart. He placed all of the supplies, except the saline and tape, into a clear Ziploc bag. He was observed using the alcohol hand gel located in a motion activated container on the wall and sanitized his hands. He then donned a pair of gloves, picked up his supplies, knocked on the resident's door and entered the room. LPN #1 explained the procedure to the resident. He then removed the resident's breakfast meal tray from her bedside table and placed the dressing supplies on her bedside table. He failed to disinfect the resident's bedside table prior to placing the wound care supplies on it. He continued to have the same pair of gloves he donned prior to entering the resident's room and removed the resident's blanket and dressing located on her left foot/ankle. He placed the dressing in the small trash can located in the resident's room. The resident's wound was observed to have black tissue present with a slightly lighter shade of black tissue in the center. The edges of the wound were observed to be a light pink color. There was no odor or drainage noted to the wound at that time. Using the same pair of gloves, LPN #1 removed the 4 x 4 gauze from the Ziploc bag and opened the bottle of saline. He was observed opening one of the gauze packages, dipped the gauze in the saline, and patted the resident's ankle wound from top to bottom and passing back over the center he used a circular motion to clean from the center of the wound out. He threw the gauze away. He opened another gauze, dipped it in the saline, dabbed the center of the wound with the gauze, then dabbed from the center of the wound up, then dabbed down the entire wound and with the same gauze dabbed the outer edges of the wound in a circular motion and threw the gauze away. LPN #1 took a 4 x 4 gauze, dabbed the center of the wound dry and worked his way to the outer edges of the wound and then back to the center with the same gauze. He was observed obtaining a piece of the [MEDICATION NAME] dressing, took out the box of Santyl, removed the tube of Santyl out of the box and applied the Santyl directly to the [MEDICATION NAME] dressing. He continued to have the same pair of gloves on he had donned prior to entering the resident's room. LPN #1 placed the [MEDICATION NAME] with Santyl directly on the resident's wound. He was asked to identify the size of the [MEDICATION NAME] dressing. He stated it was about 1 x 3. He then placed the Santyl back into the box. He then opened the Xeroform, folded it to fit the size of the [MEDICATION NAME] and placed it on top of the [MEDICATION NAME]. He opened another 4 x 4 gauze and placed it on top of the Xeroform. He took the roll of tape, tore off the appropriate sized square and secured the dressing with the tape. LPN #1 was observed replacing the resident's blanket with his gloved hands. He then took the box of Santyl and placed it back in the Ziploc bag. He threw the other dressing supplies away in the resident's trash can (excluding the saline and roll of tape). He removed his gloves and threw them away. He then poured the remaining saline out in the resident's bathroom and placed the resident's trash can on the right side of the resident's bed on the floor. LPN #1 failed to wash/sanitize his hands or change his gloves throughout wound care. LPN #1 exited the room, placed the clear Ziploc bag with Santyl on his treatment cart and sanitized his hands. He then placed the Ziploc bag and tape inside his treatment cart. LPN #1 was asked if he washed or disinfected his hands prior to gathering his wound care supplies. He stated, No. He was asked if he donned gloves prior to entering the resident's room. He stated, Yes. He was asked if he removed a breakfast tray from the resident's bedside table. He stated, Yes. He was asked if he washed his hands prior to wound care. He stated, yes, just before he walked into the resident's room, he foamed his hands prior to putting on his gloves and entering the resident's room. He was asked if he cleaned the bedside table prior to and after completing wound care. He stated, No. LPN #1 was asked if he used the same pair of gloves throughout wound care. He stated, Yes. He was asked if he removed the wound care supplies out of the Ziploc bag, remove the Santyl from the box, replaced the Santyl into the box then into the Ziploc bag and back into his treatment cart. He stated, Yes. He was asked if he took the tape from his cart, used it during wound care with gloved hands and placed it back into his treatment cart. He stated, Yes. He was asked if it was clean. He stated, I guess not. He was asked what the facility policy was for washing/disinfecting hands when providing a resident with wound care. He stated, We have a foam in, foam out policy. He was asked if he meant staff foamed their hands prior to entering the resident's room and once staff have exited the resident's room. He stated, Yes. He was asked what the policy was for changing gloves and sanitizing hands during wound care. He stated, I'm not personally aware of policy, but I'm assuming that's the case. LPN #1 was asked how long he had been providing wound care to the residents. He stated, About four months. He was asked if the resident's dirty dressing and wound care supplies were left in the trash can in the resident's room. He stated, Yes. He was asked what the facility policy was for the disposal of trash during wound care. He stated, As far as I know, I don't know there is a policy to do with that. He stated, The aides do go in and change trash cans frequently, I'm not real sure. At 8:40 a.m., the director of nursing (DON) was asked what the facility handwashing policy was for wound care. She stated, Wash hands before gloving. She stated staff should be washing hands before removing an old dressing, they should be washing hands before gloving up and after wound care. She stated, if staff had to get supplies after they have started wound care, they needed to wash their hands. She was asked if it was ever acceptable for staff to disinfect their hands with gel, donn gloves, then enter the resident's room for wound care. She stated, No ma'am. She was asked if it was ever acceptable for staff to use the same pair of gloves throughout wound care. She stated, No. The DON was asked if staff were instructed to do anything with a resident's bedside table before and after use when using it for wound care. She stated, Disinfect it with Lysol or Clorox wipes. She was asked what the policy was for cleaning a wound with 4 x 4 gauze and saline. She stated staff needed to have clean gloves on, dampen the 4 x 4 and pat the wound. She stated, most of the time, you don't rub. She was asked if there was a certain direction. She stated, You should always pat from the inside and work out. She was asked if it was ever acceptable for staff to use a saline soaked 4 x 4 gauze, clean the center of the wound, then pat from top to bottom of the wound then pat the outer edges of the wound. She stated, No. She was asked what the policy was for drying the wound with gauze. She stated, Same thing. She stated, Always start at the center and work your way out. She was asked if it was ever acceptable for staff to pat the center of the wound, then pat around the edges, then back to the center with the same gauze. She stated, No. She was asked if it was ever acceptable for staff to remove Santyl from a clear Ziploc bag and box with the same gloves used throughout wound care, apply Santyl to the [MEDICATION NAME] dressing, place the [MEDICATION NAME] with Santyl on the resident's wound, place the Santyl back into the box and bag and place the bag back into the treatment cart. She stated, No, it's not ok. She stated when using Santyl, I would apply it to the wound first. She stated, You can't ensure coverage if you just put it on the dressing. She was asked if it was ever acceptable for staff to take a roll of [MEDICATION NAME] tape, use it during wound care with the same pair of gloved hands throughout wound care, and return the roll to the cart. She stated, Never. The DON was asked what staff were instructed to do with the trash after wound care. She stated, Tie it up and dispose of it. She was asked if it was ever acceptable for staff to leave the soiled items used during wound care in the resident's trash can next to their bed after wound care completion. She stated, No. She was asked if staff should adjust a resident's linens with the same gloves used throughout wound care. She stated, No. On 05/31/17 at 1:42 p.m., LPN #2 was asked if the wound care physician was the person who measured the wounds. She stated, Yes. She was asked how often wounds were measured, She stated, Weekly. She stated he did not come this week because he comes on Mondays and Monday was a holiday. She was asked to explain the discrepancy with the location of the wound. She reviewed the records and stated some nurses document a different terminology but it's just the one wound. She was asked to explain the role of the wound care physician. She stated, We got him for his specialty. She stated, So he can give us more insight on wound care and treatment of wound care. She was asked when his notes documented what treatment to add on dressings, and his electronic signature was present on the document, was this an order. She stated, Yes. She stated the wound care physician's documentation was received by the facility weekly. She stated staff went by what the wound care physician documented on his notes for orders. She was asked what the facility did with the information he documented under recommendations. She stated staff would communicate the information with physician #1, and he would instruct us whether or not to do what was recommended. LPN #2 was asked if the resident admitted to the facility with any wounds. She stated the resident had bruising to her left ankle from a sprain, but no wounds. She stated the resident had just fallen at home, went to the emergency room and then admitted to the facility. She stated her guess was the bruising developed after the fall. She was asked if the resident came to the facility with an ace wrap. She stated, No. She stated the ace wrap was an order after she arrived to the facility because she was complaining of her foot hurting really bad from the sprain. She was asked to confirm there was no documentation in the resident's clinical record to explain the events surrounding the ace wrap order. She stated, Right. She was asked if the record documented the wrap was discontinued due to a blister on the top of her ankle. She stated, in report she was told she had what looked like a water blister on top of her ankle over the weekend. She stated, And that it had busted. She stated, So we called the doctor because we didn't want to continue to wrap the ankle because it had busted. She was asked if there was any documentation of this. She stated, No. She was asked if the blister was caused by the ace wrap. She stated, I'm not sure. She was asked to review the wound care specialist's initial evaluation, dated 05/15/17. She was asked if it documented, under additional information, wrap injury. She reviewed the record and stated, Yes, it does. She was asked if the injury was avoidable. She stated, Yes. LPN #2 was asked if the evaluation documented a recommendation of HBA1C and [MEDICATION NAME]. She stated, Yeah, it says it was recommended. She was asked if the laboratory (lab) work had been drawn on the resident. She stated she would have to see on the resident's hospital record if the labs were drawn already. She stated if the hospital had already drawn them, the facility would not redraw the labs. She was asked to review the hospital record located in the resident's record and identify if the lab had been drawn. She stated, Nope, I don't see it in here. She was asked if staff should have called physician #1 and notified him of this recommendation to see if he wanted the labs drawn. She stated, Yes. She was asked, to her knowledge, did they. She stated, I don't believe so. LPN #2 was asked if the wound physician's note, dated 05/22/17, documented an unstageable wound to the resident's left anterior ankle was deteriorated due to infection. She stated, Yes. She was asked if the resident was started on antibiotics. She stated, Yes. At 2:10 p.m., LPN #2 was asked to locate any documentation physician #1 had been notified of the resident's blister. At 2:11 p.m., just one minute later, she returned and stated, No, I can not. She was asked what the policy was for notifying a physician. She stated, Notify the doctor of change if you need a new order. She was asked how the wound care physician was notified of the resident's wound. She stated staff would call the physician to notify him of the blister. She stated then they would notify him in person upon his arrival to the facility during his weekly visits. She was informed there was no documentation of this process or how he was notified. She stated, Right. At 3:01 p.m., physician #1 was interviewed via telephone and asked to clarify the reason the ace wrap was ordered for the resident. He stated the resident reported she had sprained her ankle, so the wrap was used to decrease swelling and apply pressure. He stated there was no significant findings on x-ray. He was asked if the resident had a wound on admission. He stated, Not that I'm aware of. He was asked if he was aware the resident had developed a blister on her left ankle and was seen by a wound care physician on 05/15/17. He stated staff usually notified him on back line (texting system). He stated, I don't recall. He stated, Doesn't mean they didn't. The phone connection was lost at this time. At 3:12 p.m., the wound care physician was asked if necrotic tissue was typically removed during a debridement. He stated, Usually. He was asked if he could explain the documentation of the resident's wound having 100% of necrotic tissue on 5/22/17 when he debrided the wound on the 15th. He stated he would have to review the resident's record, but usually, when a wound is debrided and eschar has come back, there's not enough exudate and drainage for moist wound healing. He stated he would usually change the dressing orders to prevent the wound from drying out. He stated he would review the resident record and follow up. On 06/01/17 at 7:44 a.m., the resident was asked if her pressure ulcer developed in the facility. She stated, Yeah. She was asked if she knew how it occurred. She stated, I think it was when they wrapped the elastic thing around my foot. She was asked if she had any pain with her wound. She stated, I do sometimes. She stated, But they put me on antibiotic. She stated it was hard to tell if the pain was from her wound or her sprain. She stated she didn't experience much pain during wound care. At 8:00 a.m., physician #1 was again interviewed by phone and asked if he had been notified by the facility when the blister to the resident's left ankle appeared. He stated, I honestly can't remember. He stated sometimes he was notified by receiving a copy of the wound care physician's note. He was asked if this was a change in the resident's condition. He stated, Yeah. He stated, If she developed a blister, yeah. He was asked if the staff should have notified him. He stated, I'm assuming they should have, they usually do. He was asked if the facility had notified him when the wound care physician saw the resident on 05/15/17 and documented wrap injury. He stated, Honestly. no. He stated just because he couldn't remember, doesn't mean it didn't happen. He stated typically staff would notify him of a wound and the wound care physician would see the resident. He was asked if this injury was avoidable. He stated, I would say all injuries are avoidable. He stated for this injury, I can't say. He stated if the wrap was placed where it put pressure on the skin, it could have caused an injury. He stated the resident could always run the risk because the ankle was swollen and bruised. He was asked if staff should monitor for swelling and circulation when utilizing an ace wrap. He stated, They should. Physician #1 was asked if the facility notified him the wound care physician had recommended a HBA1C and [MEDICATION NAME] on the 05/15/17 evaluation. He stated, I don't know. He stated, It may have come up on rounds, I don't recall. He was asked if staff should have notified him of this. He stated, I guess, ok. He was asked if the facility notified him on the 05/22/17 wound care physician's visit he documented the pressure ulcer was unstageable due to necrosis of the left anterior ankle and had deteriorated due to infection. He stated, Again, I can't remember. He was asked if the staff should have notified him of this change in condition. He stated the staff send him back line text all of the time. He stated, Back line doesn't count for the medical record. He stated, They would have to put in the note. He stated staff had the electronic charting and paper charting and should document notifications. He stated, If it's not documented, it didn't happen. He was informed there was minimal documentation from the facility staff on the resident's wound and no documentation of the staff having notified him of the changes in the resident's condition. He stated the documentation was the first thing that needed to change. At 8:17 a.m., the DON was asked what the policy was for physician notification. LPN #3 was also present during the interview. She stated staff were to notify the physician when a resident was sent out, when there's a fall or incident, when the resident was complaining of something we do not have orders for and when a resident refused a medication. LPN #3 stated staff notified the physician of abnormal labs. The DON stated new complaints and abnormal vital signs would be reported. She stated, Anything out of the ordinary. She was asked if staff notified the physician with changes in a resident's skin. She stated, Yes. She was asked what role the wound care physician had with the residents in the facility. The DON stated he came once a week and assessed any resident who was reported to him to have a change in skin condition. She stated he would see the resident to assess the skin and order treatment. She was asked to review the admission note, dated 05/01/17, and identify whether or not the resident admitted to the facility with a wound on her foot. She stated it documented pain in the resident's left ankle from a sprain and the skin was clean dry and intact. The DON also reviewed the weekly skin screening and stated it documented on admission [MEDICAL CONDITION] and bruising to the left ankle from a sprain. She was asked to explain the reason for the ace wrap order dated 05/10/17. She reviewed the printed order and the resident's electronic records and stated, I don't see a progress note. She stated LPN #3 was the nurse who put the order in (by this time LPN #3 had exited the interview). The DON was observed exiting the room for a brief moment and returned. She stated LPN #3 had emailed her through her phone the information. She stated it documented on 05/10/17 LPN #3 sent the physician a message using the back line (a way of communicating information about the resident to the physician). She stated the message just said doctor and did not specify which doctor it was sent to. The DON was asked if the back line was part of the resident's clinical record. She stated, No. She stated, I don't know if there's a way to do that. She was asked if staff should have documented in the clinical record to support the reason the ace wrap was used. She stated, Absolutely. She was asked if she could locate anywhere in the resident's clinical record documentation of the reason the wrap was used and what staff notified the physician of, if anything, prior to the ace wrap order. She stated, No. She was asked to identify the reason the ace wrap was discontinued on 05/16/17. She reviewed the record and stated, This says dc'd due to blister on top of ankle. She stated she didn't see that there was any way to print the back line. She was asked to review the resident's MAR (medication administration record) /TAR and identify when the ace wrap was on the resident. She stated, It looks like it was on the 10th through 14th except the am (morning) on the 14th when she refused it. She was asked if the weekly skin sheet documented a red open area to the top of the left ankle from a blood blister on 05/15/17. She stated, Yes. The DON was asked if the wound care specialist's initial evaluation, dated 05/15/17, documented an unstageable deep tissue injury of the left anterior ankle measuring 4.6 x 2.7 x not measurable and under the additional information did it document a wrap injury. She reviewed the record and stated, Yes. She was asked if this was an avoidable injury. She stated, Yes. She was asked if the initial evaluation documented a recommendation of a HBA1C and a [MEDICATION NAME] on 05/15/17. She stated, Yes. She was asked if she had any documentation the information from the wound care physician's visit had been communicated to physician #1. She stated, No. She was asked if physician #1 should have been notified of the change in the resident's condition. She stated, Yes. She was asked if the wound care specialist's evaluation, dated 05/22/17 documented an unstageable pressure ulcer due to necrosis of the left anterior ankle deteriorated due to infection. She reviewed the record and stated, Yes. She was asked if there was any documentation of physician #1 having been notified of the wound care physician's findings. She stated, I do not. At 11:25 a.m., the wound care physician stated his prior statement was correct related to the reason the necrotic tissue returned. He stated, with this resident, a couple of things had changed. He stated a dressing which included Santyl and Calcium Alginate was put in place and the antibiotic was started on the 22nd with moderate drainage noted. He stated the infection could have killed granulation tissue and caused the necrosis to come back. 2. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skilled charting note, dated 01/04/17, documented the resident had stage three pressure ulcers to bilateral heels and pressure ulcers to bilateral ischium and coccyx. No additional information regarding the wounds was documented. An admission resident assessment, dated 01/09/17, documented the resident was at risk for pressure ulcer development and had six stage three pressure ulcers present which were present upon admission. It documented the dimensions of unhealed stage 3 or 4 pressure ulcer largest surface area was 6.5 x 13.5 x 0.3 cm. There was no comprehensive care plan developed in conjunction with this admission assessment. The January 2017 weekly skin screening form documented on the human diagram no open areas and discolored on the spine region, a stage three clean granular tissue on the lower back region, two areas on the coccyx documented stage three, both heels were circled and a discolored area on the left outer area of the foot. All of the toes on the residents right foot were also circled with no words beside them. There was no additional documentation related to the resident's skin on the form. The February 2017 weekly skin screening form documented on the human diagram a discolored area in the spine region, stage three on lower back region, stage three on two areas near the coccyx, the bilateral heels were circled with nothing documented beside it and the left outer foot was circled with the word discolored written on it. There was no additional documentation related to the resident's skin on the form. A wound care specialist's initial evaluation, dated 03/09/17, documented, .Stage 3 pressure Wound Of The Left Heel .ETIOLOGY: Pressure . WOUND SIZE (L X W X D): 5.2 x 4.2 x 0.1 cm .EXUDATE: Moderate Sero - sanguinous .GRANULATION TISSUE: 33% .SKIN: 67% . Unstageable (Due To Necrosis) Of The Right, Posterior Heel .ETIOLOGY .Pressure .STAGE: Unstageable Necrosis .WOUND SIZE (L x W x D): 3.7 x 3.0 x Not Measured .EXUDATE: Light Sero - sanguinous THICK ADHERENT BLACK NECROTIC TISSUE (ESCHAR): 50% .SKIN: 50% . Stage 3 Pressure Wound Sacrum .ETIOLOGY .Pressure .STAGE: 3 .WOUND SIZE (L X W X D): 11.7 X 5.3 X 0.3 cm .EXUDATE: Moderate Sero - sanguinous .GRANULATION TISSUE: 100% . Stage 3 Pressure Wound Of The Left Hip .ETIOLOGY .Pressure .STAGE: 3 .WOUND SIZE (L X W X D): 3.0 x 2.1 x 0.1 cm .EXUDATE: Moderate Sero - sanguinous .GRANULATION TISSUE: 100% . The March 2017 weekly

On 06/10/13 at 11:00 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to prevent environmental hazards. The facility failed to maintain hot water temperatures at a safe level in sinks located in resident bathrooms, the sink in the shower room and the sink located in the whirlpool room for one (East hall) of two halls. The hot water temperatures ranged from 134 degrees Fahrenheit to 148.9 degrees Fahrenheit. This had the potential to cause serious harm to four residents identified as being cognitively impaired, able to move about the facility independently and able to access sources of hot water. At 3:55 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health. At 4:00 p.m., the administrator was notified of the existence of an IJ. At 6:40 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "Plan for Removal of IJ regarding Supervision/Accidents involving hot water temperatures. "1. Contacted (Name withheld) Plumbing regarding water issues. 2. Hot water will be turned off on East Hall until the plumbers get here around 6 p.m.. 3. Lock will be put on the door to the hot water tank. 4. Staff will be inservice on supervising residents in the shower and whirlpool and that baths will be given after water issues are resolved. 5. Staff will be inservice on safe water temperatures 6. All of the staff will be inservice on all issues by 6/11/13 by 3 p.m. The staff who cannot be reached, or who are out of town will be in serviced when they return for their shift. 7. Hot water tank on West hall will be replaced. 8. Water temperatures will be checked twice a day until the issue is resolved and then checked daily. 9. All aerators will be cleaned, and cartridges in showers will be replaced. 10. A circulating pump will be installed on the new hot water heater. 11. All of the plumbing issues will be resolved by 6/11/13." On 06/10/13 at 6:00 p.m., hot water temperatures were re-taken in five rooms on the East hall with an average temperature of 112.5 degrees Fahrenheit. The IJ was removed on 06/11/13 at 3:00 p.m., after all current staff had been inserviced regarding hot water temperatures and resident safety during bathing/showering and handwashing. Six staff members were interviewed regarding the inservices. They were asked to describe what was discussed during the training. All six staff members were able to verbalize what had been discussed during their inservice training in regard to hot water and resident safety. The deficient practice remained at a level of no actual harm with a potential for more than minimal harm, at a pattern. Based on observation, record review and interviews, it was determined the facility failed to maintain safe water temperatures for residents residing on the East hall. The temperature readings ranged from 134 degrees Fahrenheit to 148.9 degrees Fahrenheit. This had the potential to cause serious harm to three (#3, 6 and #10) of three sampled residents identified by the facility as being cognitively impaired and wandered about the facility with no awareness of their safety. The facility identified one other resident who wandered about the facility, without safety awareness. The facility also failed to ensure the commode in a bathroom shared by two rooms (9 E and 11 E) and three residents, was securely anchored to the floor. This affected one (#2) sampled resident and had the potential to affect three additional residents. Findings: 1. On 06/10/13 at 2:05 p.m. the water temperatures were taken from the hot water faucets of the hand sinks located in residents' bathrooms. The following temperatures were obtained: The bathroom sink shared by rooms 6 E and 8 E registered 144.5 degrees Fahrenheit An interview was conducted with Resident #15 at 2:30 p.m. regarding hot water temperatures in the sink in her bathroom. She stated, "The water comes out hot, but I've learned to dilute it with cold water." The bathroom sink shared by rooms 10 E and 12 E registered 144.5 degrees Fahrenheit. At 2:30 p.m. All surveyors calibrated their thermometers in ice water to check for accuracy. Four thermometers measured 32 degrees Fahrenheit and one measured 31.8 degrees Fahrenheit. Resident #14 (Room 16 E) was asked about the hot water in the bathroom sink. She stated, "Oh yes honey, it will scald you." She was asked if she told anyone about the hot water temperature. She stated she had not told anyone in charge, but did tell everyone who came in to work with her. At 2:35 p.m., the following temperatures were obtained: The bathroom sink shared by rooms 2 E and 4 E measured 145.2 degrees Fahrenheit; The bathroom sink shared by rooms 5 E and 7 E measured 146.1 degrees Fahrenheit; The bathroom sink shared by rooms 9 E and 11 E measured 145.2 degrees Fahrenheit; The bathroom sink shared by rooms 14 E and 16 E measured 144.2 degrees Fahrenheit. The hand sink located in the whirlpool room on the East hall measured 148.9 degrees Fahrenheit. CNA #1 was in the whirlpool room at the time the hot water temperature was obtained. She was asked to look at the gauge on the thermometer and tell the surveyor what the gauge read. She stated, "148.9." The hand sink located in the shower room on the East hall measured 134 degrees Fahrenheit. On 06/10/13 at 2:50 p.m., an interview was conducted with CNA #1. She was asked if any residents used the sink in the whirlpool room. She stated, "Yes, (Resident #16 and Resident #17) both use the sink to shave themselves." On 06/10/13 at 2:55 p.m., a list of cognitively impaired residents who wandered freely in the facility and entered other residents' rooms was requested from the administrator. Seven names were provided as being cognitively impaired, but only four wandered the facility independently, went in other resident's rooms and were able to access the bathrooms with elevated hot water temperatures. On 06/10/13 at 3:10 p.m., the maintenance supervisor was asked if he ever had elevated water temperatures. He stated, "Yes, don't know if because of old pipes, sometimes too hot, sometimes too cold." He also stated a new hot water regulator was installed about three months ago which worked fine for a month or two. He stated he then started seeing a gradual increase in hot water temperatures, which could return back to normal spontaneously. The maintenance supervisor was asked if he documented hot water temperatures. He provided a notebook to the surveyors with documentation of water temperatures up to 05/21/13. He stated he had taken random water temperatures that day and did not have any elevated temperatures. He was asked for his documentation. He provided a small, yellow sticky note, which was undated and untimed. The slip documented water temperatures in the kitchen as 140 degrees Fahrenheit, the whirlpool as 101 degrees Fahrenheit, the West shower room as 101 degrees Fahrenheit, room 6 East as 99 degrees Fahrenheit and room 4 West as 100 degrees Fahrenheit. On 06/10/13 at 3:48 p.m., the maintenance supervisor was asked how the facility's thermometer was calibrated. He stated, "It isn't. It's a laser and we keep fresh batteries in it." Both the surveyor and the maintenance supervisor entered the shower room on the East hall. The hot water at the sink was checked. The thermometers of both the surveyor and maintenance supervisor obtained a hot water temperature of 134 degrees Fahrenheit, simultaneously. 2. On 06/11/13 at 9:00 a.m., an environmental tour of the East hall was conducted. A shared bathroom located between rooms 9E and 11E was observed to have a commode which was not anchored securely to the floor. The commode was able to be moved from side to side with the slightest touch. Two of the three residents who used the bathroom were asked if the unanchored commode was a problem for them. One of the residents stated he was used to the commode moving and sat down easily. The second resident stated he used the wall to steady himself down onto the toilet.

On 09/12/12 at 4:45 p.m., an Immediate Jeopardy (IJ) situation was identified related to the failure of the facility to provide supervision for a resident with a history of assaulting other residents. At 4:55 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 5:45 p.m., the facility administrator, the corporate consultant, and the director of nursing (DON) were notified of the existence of an IJ pertaining to the lack of supervision of an aggressive resident. At 7:25 p.m., the plan of removal was received and accepted. The facility's "Plan of Correction (Removal)," documented, "1. CNA (certified nurse aide) or staff member assigned to 24 hour direct supervision. 2. CNA/staff member documenting resident's activity every 20 minutes. 3. If other staff member is supervising resident a CNA will be called to toilet resident or meet other personal needs. 4. Contacted (Hospital) for immediate admission, they have no female beds. 5. Contacted (Hospital) for immediate admission, they will accept her tonight, 09/12/12. 6. Three to eleven staff inserviced on twenty four hour supervision and a staff member is supervising her until she is discharged to (Hospital) tonight, 09/12/12. 7. Contacted (Hospital) and they have no female beds. 8. Will continue to do 24 hour monitoring until a bed at a psychiatric facility is available, and family will transport immediately. 9. Primary Care Physician, Psychiatrist, and Medical Director will be involved in resident's transfer and discharge from facility. Contacted Dr. (Physician), left message, contacted Dr. (Physician), left message, contacted Dr. (Physician), left message." On 09/13/12 at 8:20 a.m., the administrator and corporate consultant were informed the IJ had been lifted as of 6:15 p.m., 09/12/12, when the one on one supervision was initiated. The deficient practice remained at a level of actual harm at a pattern. Based on observation, record review and interview, it was determined the facility failed to prevent one (#8) of two sampled residents with physical behaviors from physically assaulting other residents. The facility identified no other residents with aggressive behaviors. Findings: Resident #8 had [DIAGNOSES REDACTED]. Her care plan, dated 04/14/11 and updated 07/13/12, documented: "Problem occasional disruptive behaviors r/t (related to) dementia Goal (Resident's) disruptive behavior will occur no more than 1x (times) daily Approach (1) Approach in non-threatening posture, talk slowly,... (2) Attempt to redirect (Resident's) behavior (3) ...take to different location...away from peer who is being disturbed (4) Offer alternative activity...book, t.v., 1:1 visits (5) Avoid long periods of inactivity...allow (Resident) to feel useful...folding linens, dusting 6/9/12 Cont. (continued) c (with) Dr. (Psychiatrist) q (every) monthly (6) Create home-like environment...07/10/12 Seroquel (an antipsychotic drug) 25mgs (milligrams) 03/27/12 Pt (patient) redirected to ask staff for assist c moving other pts (patients) out of way 8/3/12 offer res (resident) objects to hold to keep her occupied. Offer res a book to read or turn on res music (date illegible) Pt moved to different room... (8) Monitor closely for signs of increased frustration and anxiety; change caregiving approach and/or activity as needed... Comment ...4/3/12 Risperdal (an anti-psychotic drug) 1mg q hs (hour of sleep) 4/3/12 Res/Res (resident to resident) incident c redirection 4/16/12 DC (discontinue) risperdal order Risperdal 2mgs. PO (per mouth) 1x now Risperdal 2mgs PO every hs including this hs 4/17/12 sent to (Name) hosp (hospital) for eval (evaluate) and tx. (treatment) 6/9/12 had altercation c another res. 8/2/12 altercation with another res. 8/08/12 altercation c another resident 8/17/12 altercation c another resident... Problem Potential for disturbances of thinking, mood, or behavior; altered concept of reality, delusions, &/or hallucinations r/t (related to) dx (diagnosis): schizophrenia Goal (Resident) will be able to function in her environment safely qd (every day) Approach... (2) Discuss (Resident's) behavior in an open manner with the (Resident) as needed (3) Inform (Resident) of behavior expectations. Encourage appropriate behavior and redirect when inappropriate behavior/actions occur (4) Encourage/invite to participate in diversional activities of choice Q (every) day (5) ...Protect (Resident) and others from possible physical injury... (7) Monitor and record episodes of hallucinations, delusions, altered concept of reality..." A nurse's note, dated 02/20/12, documented the resident had multiple behaviors, calling another resident "fat a**." When the staff attempted to redirect the resident she cussed at them and Visteril 25mg was given for anxiety. A nurse's note, dated 02/21/12, documented the resident called the same resident names. The redirection was unsuccessful, as she started to call staff names and again Visteril 25 mg was given. A nurse's note, dated 03/03/12, documented the resident called staff names and told people to shut up; she thought it was funny. Staff were annoyed with the resident. A nurse's note, dated 03/26/12, documented the resident had multiple episodes of increased behaviors. She began by trying to hit a visitor and called the visitor a "b***h." When the staff attempted to redirect the resident, the resident slapped the staff member in the face. She refused to take the Vistaril. The resident's psychiatrist was notified and the staff requested a routine order for the resident's anxiety. A nurse's note, dated 03/27/12 at 11:20 a.m., documented the resident was in her wheelchair in the lobby. She asked a resident to move out of her way; then slapped the resident on the left side of her face. One on one was provided and the resident was redirected. The resident's psychiatrist issued a new order for Risperdal (an anti-psychotic drug) 0.25 mg to be given two times a day. An incident report, dated 03/27/12, documented the step taken to prevent any re-occurrance was to redirect the resident to ask staff for assistance when moving other residents out of the way. This incident was witnessed by staff. A nurse's note dated, 04/03/12 at 12:55 p.m., documented while in the common area the resident slapped another resident. The psychiatrist was notified and issued a new order to discontinue the current order for Risperdal and to give Risperdal 0.5 mg "now" and one mg every day at hour of sleep. An incident report, dated 04/03/12, documented the steps taken to prevent re-occurrance were to redirect the resident and teach the resident about inappropriate behaviors. This incident was witnessed by staff. A nurse's note, dated 04/16/12 at 3:00 p.m., documented the resident had her fist drawn back to hit another resident. The administrator intervened which prevented the other resident from being hit. The psychiatrist issued a new order to transfer the resident to a psychiatric unit but no beds were available. A nurse's note at 3:45 p.m., documented a new order to increase the Risperdal to 2 mg, to give one "now" and to give 2 mg hs. A nurse's note, dated 04/17/12 at 12:30 p.m., documented the resident was transferred to a psychiatric hospital by a private vehicle. A nurse's note, dated 04/30/12 at 12:05 p.m., documented the resident was back in the facility. A nurse's note, dated 05/02/12 (no time given), documented the resident attempted to hit another resident but was redirected before she actually hit the other resident. The resident was told the other resident didn't mean any harm, he was just trying to get by when the wheel of his wheelchair got hung up on hers. A nurse's note, dated 05/14/12 (no time given), documented the resident pulled the hair of another resident in the dining room. The staff intervened before she could hit the other resident. A nurse's note, dated 06/09/12 at 4:00 p.m., documented the resident hit another resident on the left side of her face with her fist. The resident said, "I punched her because she was in my way." An incident report, dated 06/09/12, documented another resident was going toward the nursing station and passed by resident #8. Resident #8 reached out; brought the other resident closer to her and then punched the other resident in the face. The step taken by the facility to prevent re-occurrence was to move the other resident away from the resident who assaulted her. A staff member witnessed the event and stated she couldn't get between the two residents fast enough. A nurse's note, dated 06/11/12 (no time given), documented the resident was up in her wheelchair and swung at another resident but did not make contact. She was redirected and counseled. A nurse's note, dated 07/07/12 at 11:45 a.m., documented while in the dining room the resident hit another resident in the stomach. She called a resident a fat "a**" and called her table mate a "b****." A nurse's note, dated 07/08/12 at 2:45 p.m., documented the resident was in the lobby arguing with other residents. She stated they were in her way. The resident was removed from the area. A nurse's note, dated 07/10/12 (no time given), documented the resident was seen by her psychiatrist. He ordered Seroquel (an anti-psychotic drug) 25 mg to be given every day at hs. A nurse's note, dated 08/02/12 (no time given), documented the resident grabbed another resident by her wrists. She was redirected and released the other resident's wrists. The other resident cussed at her and stated she would punch her. An incident report, dated 08/02/12, documented the resident was redirected and the care plan was amended to give the resident something to hold to keep her occupied. This incident was witnessed by staff. The resident's quarterly assessment, dated 08/08/12, documented she made herself understood and she usually understood others; was severely impaired in cognition; had verbal and physical behavioral symptoms directed toward others; was highly involved in locomotion and required limited assistance of one staff member. A nurse's note, dated 08/08/12 at 5:30 p.m., documented while seated in the dining room the resident attacked another resident. She scratched the other resident with her fingernails, pulled her hair and pinched her. In an attempt to defend herself the other resident hit resident #8. Resident #8 was removed from the area. A nurse's note at 6:15 p.m., documented the resident was in the hallway when she grabbed the neck of a [DIAGNOSES REDACTED] resident and made contact with his face. The resident was removed from the hall way. The primary care physician (PCP) was notified and issued a new order for Risperdal 1 mg to be administered every day at hs. This order was a lesser dose than her current routine order. An incident report, dated 08/08/12, documented the steps taken to prevent re-occurrence were to remove the resident from the area, provide one on one and her fingernails were clipped. This incident was witnessed by staff. A nurse's note, dated 08/09/12 at 12:45 p.m., documented the resident was transported from the facility to a psychiatric hospital. A nurse's note, dated 08/15/12 at 2:20 p.m., documented the resident had returned to the facility. A nurse's note, dated 08/17/12 at 11:00 a.m., documented the resident hit her roommate on her left arm and cussed at her. She called her roommate a "B****." The nurse's note documented the resident's roommate was changed. An incident report, dated 08/17/12, documented the steps taken to prevent re-occurrence were to redirect the resident and change her roommate. The resident was moved to another room. A nurse's note, dated 08/18/12 (no time given), documented the resident started calling the female residents "b******." The nurse's note documented the resident was removed from the area. A nurse's note at 5:00 p.m., documented the resident was in the dining room when she started calling her former roommate a "b****" and the resident became upset. Resident #8 was removed from the area. A nurse's note, dated 08/26/12 at 7:10 p.m., had a late entry dated 08/25/12, which documented the resident assaulted another resident at dinner. The resident scratched another resident on her left shoulder; spit at a different resident and then threw silverware at another resident. She raised her hand to strike another resident and was intercepted by staff. A nurse's note, dated 08/27/12 at 7:35 a.m., documented the resident was seen by her PCP and no new orders were issued. The PCP's progress note, dated 08/27/12, documented, "Agitation- Will likely need long term care in a psychiatric ctr. (center). She has repeatedly had outbreaks despite med (medication) adjustments." On 09/12/12 at 2:00 p.m., a group meeting was conducted with twelve cognitively intact residents. Six of the residents expressed fear of resident # 8 and stated they had expressed their concerns to the facility staff. The residents stated they had asked the staff why the resident had been allowed to remain in the facility. They stated the staff told them she seemed better and there was no place to send her. On 09/12/12 at 10:00 a.m., resident #8 was observed seated in her wheelchair in the lobby. At 12:25 p.m., licensed practical nurse #2 was asked if the facility had residents that were aggressive to other residents. She stated resident #8 and resident #9 had been aggressive to other residents. She stated it was not resident #8's fault. The other residents start yelling when she tried to move them out of the way and that upset her. At 12:30 p.m., certified nurse aide #2 said, "With (Resident #8) we keep hallways clear. They are afraid of her in the dining room." At 3:00 p.m., the resident was observed seated in her wheel chair in the hallway near the nurses' station. At 3:35 p.m., the assistant director of nurses stated the resident still ate in the dining room. She stated they had moved her around and they served her first; she ate first then left first. At 4:20 p.m., the resident was observed seated in the dining room. The certified dietary manager was asked about the order of serving residents. She stated they served table by table and started with the table nearest the kitchen. She indicated the table where resident #8 was seated would be the sixth table to be served. She added that no one resident was served first. She stated they usually fed the assisted table first, but there was no one available to feed them then, so they would feed them last. At 4:25 p.m., the resident indicated she needed to be toileted. She was transferred to her room. She was assisted to stand and used the walker to walk to the toilet and to transfer back to the wheelchair. At 4:50 p.m., she was transferred to the dining room by a staff member. Her table was being served and she was served her meal at that time. The first five tables had been served. At 5:20 p.m., she was observed self-propelling her wheelchair out of the dining room. A staff member approached her and transported her to the hallway near the nurses' station. At 5:30 p.m., the resident was asked if the food was good. She stated it was, "OK." She was asked her name and she recited her name. She was asked if she knew what month it was and she stated it was, "September." She was asked if she knew where she was and she answered she was in a nursing home. She was asked if she had a roommate and she stated she did not remember if she had ever had a roommate. She was asked if she had ever had a problem with other residents and she stated she didn't remember. She added the other residents are, "OK." She was asked if she had ever hit another resident. She stated she didn't remember hitting anyone. On 09/13/12 at 12:15 p.m., resident #12 was asked if she had problems with other residents. She stated resident #8 had hit her. She stated it was unprovoked. She stated she was just sitting there when the resident hit her. She stated resident #8 is O.K. for a while, then she starts up again. She stated she was afraid of her. She stated other residents had told the staff they were afraid of resident #8, but the staff had not done anything At 12:20 p.m., resident #13 was asked if she had problems with any of the residents. She stated resident #8 had hit her. She stated she was afraid of her and she went way around her. She stated the facility knew resident #8 had hit other residents, but the facility said she was better.