Every finding on record at Emerald Care Center Claremore

Based on record review and interview, the facility failed to ensure bathing was provided for 3 (#3, #4 and #6) of 3 sampled residents reviewed for activities of daily living. The DON identified 106 residents resided in the facility.Findings: A care plan for Resident #3, dated 05/18/26, showed the resident had a functional deficit with current activities of daily living related to chronic obstructive pulmonary disease, diabetes mellitus, and congestive heart failure, and required assistance with personal hygiene. An undated Bath List showed Resident #3 was to receive baths weekly on Monday, Wednesday, and Friday. Shower Sheets for Resident #3 showed the resident received baths on the following dates:a. 06/03/26, andb. 06/17/26. 2. An undated Bath List showed Resident #4 was to receive baths weekly on Monday, Wednesday, and Friday. Shower Sheets for Resident #4 showed the resident received baths on the following dates:a. 06/01/26, b. 06/10/26, andc. 06/19/26. 3. A care plan for Resident #6, dated 06/16/26, showed the resident had a functional deficit with current activities of daily living related to osteoarthritis, and required partial assistance with bathing. An undated Bath List showed Resident #6 was to receive baths weekly on Monday, Wednesday, and Friday. Shower Sheets for Resident #6 showed the resident received baths on the following dates:a. 06/03/26, b. 06/10/26,c. 06/19/26,d. 06/22/26,e. 06/24/26, andf. 06/29/26.On 07/01/26 at 2:25 p.m. the DON stated residents should receive a shower three times weekly. The DON stated some residents were scheduled for showers two days weekly, but this had been care planned and scheduled. The DON stated the expectation was that the nurse offered a bed bath if the shower was refused and that there would be documentation of the refusal. On 07/01/26 at 3:10 p.m., CNA #1 stated they had attempted to provide showers when they were assigned, but there were times they were missed or the resident refused. CNA #1 stated they were supposed to notify the nurse on the hall, but they did not think that happened very often. They stated they usually just did not turn in a shower sheet.On 07/02/26 at 12:06 p.m., RN #3 stated residents generally had showers on the evening shift. RN #3 stated shower sheets were completed by CNAs and turned into the charge nurse on the hall to be reviewed. RN #3 stated if a resident refused their shower, the nurse would talk with them and follow up with family, if needed, to ensure they received the needed care. RN #3 stated they did not know why the shower sheets had not been completed for Resident #3, Resident #4, and Resident #6. They stated it appeared the showers had not been given.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for 1 (#1) of 5 sampled residents reviewed for medication administration. The DON stated 106 residents received medications from the facility.Findings: A policy titled Medication Administration and General Guidelines, dated 2021, read in part, medications are administered at the time they are prepared .observes the resident take the medications. A progress note for Resident #1, dated 06/26/26 at 6:40 p.m., showed the resident had drunk coffee with medications in it that belonged to another resident. A medication administration record for Resident #2, dated 06/26/26, showed Resident #1 received the following medications: Rexulti (a medication for agitation) half of a 4 mg tablet, buspirone HCI (a medication for anxiety) 10 mg, and alprazolam (a medication for anxiety) 0.5 mg.On 07/01/26 at 2:38 p.m., the DON stated medications should always be observed during medication administration to ensure the resident has taken all of their medication, as well as ensuring another resident did not take the medications.On 07/01/26 at 2:50 p.m., CMA #2 stated they did not watch Resident #2 take their medications on 06/26/26. CMA #2 stated they gave Resident #2 their medications in coffee and did not observe them drink the coffee with the medications in it.On 07/02/26 at 10:35 a.m., Physician #1 stated they were notified when Resident #1 had taken medications that belonged to Resident #2. Physician #1 stated they reviewed the medications that Resident #1 had taken, and provided orders to hold the evening medications, monitor vital signs, and perform assessments on Resident #1. Physician #1 stated they did not feel the medications Resident #1 received had an impact on the resident's condition.

Based on observation, record review, and interview, the facility failed to follow the dietician approved menu for 3 of 3 meal services observed.The administrator identified 112 residents who received their meals from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings:On 12/15/25 at 12:15 p.m., serving of the lunch meal was observed. The lunch meal consisted of meatballs, mashed potatoes with gravy, boiled mix vegetables, and yellow cake with cream cheese frosting.On 12/16/25 at 11:45 a.m., preparation of the lunch meal was observed. The lunch meal consisted of kielbasa sausage, mashed potatoes, creamed corn, and Jello.On 12/16/25 at 4:50 p.m., a sample dinner tray was provided from the kitchen per request. The dinner meal consisted of beef pot pie, boiled squash, cornbread, and peach cake.A Food Preparation Guidelines policy, dated 11/2017, read in part, The cook, or designee, should prepare menu items following the facility's written menus and standardized recipes.A Week 3 facility menu, dated 2025 through 2026, showed residents would be served sliced ham, crispy cubed sweet potatoes, seasoned greens, cornbread, and chocolate cream pie for Monday's lunch meal on 12/15/25.A Week 3 facility menu, dated 2025 through 2026, showed residents would be served glazed meatloaf, red roasted potatoes, southern green beans, honey kissed roll, and gelatin parfait for Tuesday's lunch meal on 12/16/25.A Week 3 facility menu, dated 2025 through 2026, showed residents would be served tuna melt sandwich, steak fries, mixed green salad, and apple crisp for Tuesday's dinner meal on 12/16/25.On 12/15/25 at 10:50 a.m., cook #1 stated the food service director had instructed them to prepare meatballs for lunch. They stated sometimes the food service supervisor would change the menu at the last minute, but was not sure why. [NAME] #1 stated they thought it had to do with not having enough quantity of food items to prepare the meal on the written menu.On 12/16/25 11:50 a.m., the food service director was asked why the lunch meal listed on the written menu had not been prepared. The food service director stated they decided on an alternative lunch meal due to not having all the food items available to prepare the meal listed on the written menu.On 12/16/2025 at 1:21 p.m., during a resident council meeting, the residents stated the menus that have been posted were often not the menus that were served.On 12/16/25 at 5:02 p.m., the administrator stated they were not aware the written menus were not being followed. They stated the kitchen staff should have all the food items required to ensure the meals are followed daily according to the dietician approved menus.On 12/17/2025 at 9:55 a.m., the dietician stated the written menus should have been followed per regulations. They stated the food service director had not made them aware of the changes in the menu this week.

Based on observation, record review, and interview, the facility failed to ensure food served from the kitchen was attractive and palatable for 1 of 1 test trays obtained. The administrator identified 112 residents who received their meals from the kitchen. One resident received nutrition and hydration solely through a feeding tube.Findings:On 12/16/25 at 4:50 p.m., a dinner tray was sampled for palatability. The dinner meal consisted of beef pot pie, boiled squash, cornbread, and peach cake. The meal was observed as one large scoop of mixed vegetables and ground beef topped with slightly browned biscuits. The scoop of pot pie was surrounded by water and pieces of squash. The pieces of squash were mushy in texture and bland to taste. The water from the boiled squash had soaked into the biscuit topping for the pot pie. The biscuit topping was soggy in consistency and bland in taste.A Food Preparation Guidelines policy, dated 11/2017, read in part, Food should be palatable, attractive, and at the proper temperature, as determined by the type of food, to ensure resident's satisfaction and meet individual needs.Resident council meeting minutes, dated November 2025, showed residents were concerned the food was not being cooked properly and seemed to be getting worse. The minutes showed the residents felt their dietary concerns were not being addressed.Resident council meeting minutes, dated December 2025, showed residents were concerned the food was not being cooked properly and seemed to be getting worse. The minutes showed the residents felt their dietary concerns were not being addressed.On 12/15/25 at 11:49 a.m., Resident #29 stated they ate most of their meals in their room. They stated the food never tasted good and the vegetables were always mushy.On 12/15/25 at 12:08 p.m., Resident #22 stated the food was bad and the facility rarely offered alternatives.On 12/15/2025 at 1:46 p.m., Resident #62 stated the food served at the facility was not good. They stated the food was never appetizing in appearance. Resident #62 stated the vegetables were always served mushy and the food was either too salty or too bland in taste.On 12/16/25 at 1:21 p.m., during a resident council meeting, the residents voiced concerns regarding the palatability of the meals served. On 12/16/25 at 5:02 p.m., the administrator was shown the sample dinner tray and asked to sample the meal. The administrator stated the meal tasted ok. They stated they would rate the meal 5/10 for taste and appearance. They stated the food service director had already left the facility for the day.On 12/17/25 at 9:25 a.m., the food service director was made aware of the dinner meal observations. The food service director stated they felt the meals they served were appetizing and palatable. They stated the residents complained the meals were seasoned too much or not enough making it difficult to prepare tasty meals consistently.

Based on record review and interview, the facility failed to ensure a fall with major injury was reported to the OSDH for 1 (#97) of 3 sampled residents reviewed for falls.The administrator identified 112 residents resided in the facility. Findings:A document titled Long Term Care Reportable Incidents - Regulatory Requirements, dated 06/28/22, read in part, All reports to the Department shall be made within twenty-four (24) hours of the reportable incident unless otherwise noted .The facility shall report to the Department incidents that result in: fractures, injury requiring treatment at a hospital, a physician's diagnosis of closed head injury or concussion, or head injuries that require more than first aid.A November 2025 medication administration record showed Resident #97 was taking Warfarin Sodium 4mg (a blood thinner) every Monday, Wednesday, Thursday, Friday, Saturday, and Sunday. Resident #97 was taking Warfarin Sodium 2mg every Tuesday.A Nurse's Note, dated 12/01/25, read in part, Head to toe assessment completed and found bleeding from frontal area of forehead and on the left side of [their] skull. The nurse's note showed Resident #97 was sent to the emergency room via ambulance for a fall.A Neurosurgery Consult Progress Note, dated 12/02/25, read in part, [Resident #97] with atrial fibrillation on Warfarin who was reported to have a ground level fall at [their] facility today. The progress note showed Resident #97 had diagnoses of a T12 (thoracic 12th vertebrae) fracture and bilateral subdural hematomas.A MDS [minimum data set], dated 12/05/25, showed Resident #97 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation, heart failure, and thrombophilia (a blood disorder that causes one to be prone to blood clots).On 12/17/25 at 1:01 p.m., the ADON was asked who was responsible for reporting incidents to OSDH. They stated anything other than abuse would be themselves or the DON. The ADON was asked for the incident report pertaining to Resident #97's fall on 12/01/25.On 12/17/25 at 1:06 p.m., the DON stated Resident #97's fall on 12/01/25 was not a reportable incident. They stated, [They] received no stitches or anything, no major injury. The DON was asked if a T12 fracture and bilateral subdural hematomas were considered a major injury. They stated, No, because [they] were discharged with no treatment recommendations. The facility's incident reporting policy was requested from the DON.On 12/17/25 at 1:20 p.m., the DON showed the document regarding LTC reportable incidents. They stated, We go by Chapter 675 [Federal Regulations for LTC facilities] and I should've reported it.

Based on record review and interview, the facility failed to ensure an advance directive acknowledgment form had been completed for 2 (#2 and #11) of 23 sampled residents reviewed for advance directives. The administrator identified 112 residents resided in the facility. Findings:A policy titled Advance directive policy and procedure, dated 01/2024, read in part, Upon admission, identify if the resident has an advanced directive and if not, determine if the resident wishes to formulate an advanced directive.All advanced directive document copies will be obtained and located in the resident chart.1.A physician's order, dated 12/09/24, showed Resident #2 was a full code. An order summary report, dated 12/16/25, showed Resident #2 admitted to the facility on [DATE]. There was no advanced directive acknowledgment form located in the medical record. 2.A physician's order, dated 09/08/25, showed Resident #11 was a full code.An order summary report, dated 12/16/25, showed Resident #11 admitted to the facility on [DATE]. There was no advanced directive acknowledgement located in the medical record. On 12/16/2025 at 1:42 p.m., the admission director stated they did not have the acknowledgements because they were waiting for the families to provide.

Based on record review and interview, the facility failed to perform annual nurse aide competency reviews for two (CNA #3 and CNA #4) of 2 sampled employee files reviewed for annual competencies.The administrator identified 112 residents resided in the facility. Findings:1.An undated staff roster showed CNA #4 was hired on 10/13/23. There was no documentation an annual competency review was completed for 2025.2.An undated staff roster showed CNA #3 was hired on 04/17/24. There was no documentation an annual competency review was completed for 2025.On 12/17/25 at 10:13 a.m., the HR director was asked for annual competencies for CNA #3 and CNA #4. The HR director stated, We may not have them. We try to get them done, but sometimes we don't.On 12/17/25 at 10:23 a.m., the HR director stated, We do not have reviews for those two CNAs. We will have them completed in January or February. A policy for annual competencies was requested and the HR director stated they did not have one.

Based on record review and interview, the facility failed to ensure a resident was administered a medication as ordered by the physician for 1 (#124) of 6 sampled residents reviewed for medication administration.The administrator identified 112 residents resided in the facility. Findings:An admission assessment, dated 11/12/25, showed Resident #124 was admitted to the facility on [DATE] with a diagnosis of thrombocytopenia, a deficiency of platelets in the blood. A Physician's Order, dated 11/14/25, showed Resident #124 was prescribed eltrombopag olamine oral tablet, (a platelet stimulating agent), 50mg tablet by mouth at bedtime for thrombocytopenia.A medication administration record, dated November 2025, showed Resident #124 was not administered eltrombopag olamine oral tablet on 11/14/25.A Nurse Note, dated 11/14/25, read in part, Pharmacy won't dispense.A medication administration record, dated November 2025, showed Resident #124 was not administered eltrombopag olamine oral tablet on 11/15/25.An Incident Report, dated 11/14/25, was received by the Oklahoma State Department of Health on 12/08/25. The incident report read in part, It was reported to the administrator that [Resident #124] did not receive medication (eltrombopag olamine) for two days (11/14 and 11/15.) The medication was received on 11/14/2025 and was locked in the narcotic box on the medication cart.A Nurse Note, dated 11/15/25, read in part, Waiting on delivery.A Witness Statement, dated 12/04/25 and signed by CMA #1, read in part, There was a medication for [Resident #124] that I could not find. I must have overlooked it.An email, dated 12/04/25, from CMA #2 to the ADON read, I do not recall if said medication was given.A document titled Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment, Misappropriation of Property, dated 12/08/25, showed CMA #2 was terminated from the facility in part due to not administering Resident #124's medication on 11/14/25.On 12/16/25 at 2:28 p.m., CMA #1 was asked what the process was when a medication was listed on the medication administration record but not found on the cart. CMA #1 stated they would look for the medication, call pharmacy to check on the delivery, and would notify the nurse that the medication was not in the building. CMA #1 was asked to recall the missed medications for Resident #124 on 11/15/25. They stated, I looked everywhere for it and couldn't find it. [Resident #124's family member] wanted medications right then, so I just marked it as not in the building. CMA #1 was asked what they should have done differently. They stated, I should have called [ADON].On 12/16/25 at 3:13 p.m., the ADON was asked what the process was when a medication could not be found in the building. They stated the medication aides were to notify the nurse and the nurse was to notify the physician. The ADON was asked if CMA #2 still worked for the facility. They stated no, the medication error led to CMA #2's termination. The ADON stated they counted Resident #124's medication with CMA #2, so they were not sure why CMA #2 did not give the medication on 11/15/25.

Based on record review and interview, the facility failed to ensure pharmacy recommendations for adding hold parameters to blood pressure medications were followed for 1 (#11) of 5 sampled residents reviewed for unnecessary medication. The administrator identified 112 residents resided in the facility. Findings: A policy titled Drug Regimen Review-With Consultant Agreement only, dated 2021, read in part, Drug Regimen Review consists of reviewing and analyzing prescribed medication therapy and medication use, including nursing documentation of medication ordering and administration.Findings and recommendations are reported to the Administrator, Director of Nursing, the Primary Physician, and the Medical Director, where appropriate.Nursing personnel provide a written response to the review within two weeks after the report is received. A physician's order, dated 09/05/25, showed nifedipine extended release (blood pressure medication) 24 hour 30 mg at bedtime for blood pressure. The order did not have parameters for administration. A Director of Nursing Report (pharmacy recommendation), dated 09/17/25, showed nifedipine order needed hold parameters. A physician's order, dated 09/19/25, showed amlodipine besylate (blood pressure medication) 5 mg one time a day. The order did not have parameters for administration. A Director of Nursing Report (pharmacy recommendation), dated 10/08/25, showed amlodipine order needed hold parameters. A physician's order dated, 11/25/25, showed amlodipine besylate 10 mg one time a day for hypertension. The order did not have parameters for administration. An order summary report, dated 12/16/25, showed Resident #11 had diagnosis which included hypertension. On 12/17/25 at 12:47 p.m., the DON stated they were responsible for the pharmacy reviews. The DON stated they gave those that the physician needed to see, to the physician, and then put the order in the electronic record if needed. On 12/17/25 at 12:48 p.m., the DON reviewed the request on 09/17/25 for the nifedipine and Resident #11's medication list and stated they must have missed it. On 12/17/25 at 12:50 p.m., the DON reviewed the request on 10/08/25 for the amlodipine and Resident #11's medication list and stated they must have missed it. The DON stated they both did not have parameters and they should have.

Based on record review and interview, the facility failed to ensure residents were provided the right to refuse medication for two (#1 and #2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Resident Rights policy, dated November 2017, read in part, The resident has the right to be informed of, participate in, his or her treatment, including .The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate and [sic] advance directive. 1. Resident #1 had diagnoses which included Alzheimer's disease. An Incident Report Form, dated 11/09/24, documented LPN #1 had allegedly forced Resident #1 to take medication against their will. An undated attachment to the incident report documented the facility staff had determined the incident had occurred and LPN #1's employment had been terminated. A printed copy of an email from visitor #1 to the facility ADON, dated 11/11/24, documented visitor #1 had observed LPN #1 forcibly medicate Resident #1 after they had verbally stated they did not want to take the mediation. They stated LPN #1 put the medication combined with pudding into the resident's mouth and when Resident #1 attempted to spit them out LPN #1 held a cup of water to the resident's mouth to which the resident pushed the water away. The email documents visitor #1 had told LPN #1 to allow the resident to drink the water on their own and the LPN put down the water and departed from the resident. On 11/27/24 at 8:45 a.m., visitor #1 stated on 11/09/24 they had observed LPN #1 force Resident #1 to take some unknown medications. They stated they observed Resident #1 verbally tell the LPN they did not want to take the medications. They stated LPN #1 mixed the medicine into pudding and forced the resident to take the mediations. They stated when the resident attempted to spit out the medicine LPN #1 held a cup of water to the resident's mouth even though they continued to object and say no. 2. Resident #2 had diagnoses which included vascular dementia. A narcotic count sheet for lorazepam (antianxiety medication) 2 ml syringes for Resident #2, documented CMA #2 signed out one syringe of the medication on 11/08/24 at 6:00 p.m. An Incident Report Form incident date 11/09/24, documented LPN #1 had allegedly forced Resident #2 to take medication against their will. An undated attachment to the incident report documented the facility staff had determined the incident had occurred and LPN #1's employment had been terminated. A handwritten statement, dated 11/11/24, documented CMA #1 had witnessed LPN #1 forcibly administer Resident #2 the antianxiety medication lorazepam. The documented stated Resident #2 physically resisted taking the medication and LPN #1 held the resident's arms while they were given the medication. On 11/25/24 at 2:45 p.m., CMA #1 stated that on 11/08/24 after 5:00 p.m., they had been instructed by LPN #1 to bring Resident #2 some lorazepam to calm them down. CMA #1 stated when they attempted to administer the medication into their mouth Resident #2 put up their arms to resist taking the medication. CMA #1 then stated they observed LPN #1 hold the resident's arms and the CMA then administered the medication into the mouth of Resident #2. On 11/27/24 at 10:10 a.m., the ADON stated Resident #1 and Resident #2 had the right to refuse taking their medications and LPN #1 and CMA #1 had violated the residents' rights to refuse treatment.

Based on observation, record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#3) of three sampled residents reviewed for pressure ulcers. The administrator identied 103 residents resided in the facility. Findings: A facility policy titled Care Plan Process, revised 9/2019, read in part, The plan of care must describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and social well-being .Purpose .To ensure a care plan will be developed that is appropriate for each resident's needs and/or wishes based on assessment and reassessment. Resident #3 has diagnoses which included a pressure ulcer to the sacral region and hypertension. A physician order, dated 11/13/24, documented Resident #3 was to receive wound care to the coccyx/sacrum three times a week. A quarterly assessment, dated 11/20/24, documented Resident #3 had an unstageable pressure ulcer. On 11/26/24 at 11:15 a.m., a pressure ulcer was observed on Resident #3's sacrum. A review of Resident #3's care plan did not document interventions related to pressure ulcers. On 11/26/24 at 12:35 p.m., RN #1 stated pressure ulcers should be addressed on the care plan. On 11/26/24 at 12:40 p.m., LPN #2 stated interventions for pressure ulcers should be included on the care plan. On 11/26/24 at 12:45 pm, the ADON stated pressure ulcers should be care planned.

Based on observation record review, and interview, the facility failed to ensure catheter bags were not on the floor for one (# 2) of four sampled residents reviewed for catheters. The roster matrix, date printed 11/15/24, documented nine residents in the facility had catheters. Findings: Resident #12 had diagnoses which included obstructive and reflux uropathy. A quarterly assessment, dated 09/09/24, documented Resident #12 had an indwelling urinary catheter. On 11/25/24 at 1:50 p.m., Resident #12 was observed seated in a recliner. Their catheter bag was observed on the floor next to the recliner. On 11/26/24 at 10:30 a.m., Resident #12 was observed seated in a recliner. Their catheter bag was observed on the floor next to the recliner. On 11/26/24 at 12:35 p.m., RN #1 stated catheter bags should not be on the ground. On 11/26/24 at 12:45 p.m., the ADON stated catheter bags should not be allowed to touch the floor.

Based on record review and interview, the facility failed to ensure a resident was not physically restrained for one (#2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Abuse, Neglect, and Exploitation: policy, dated November 2017, read in part, The facility must ensure the resident is free of from physical or chemical restraints imposed for the purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. Resident #2 Resident #2 had diagnoses which included vascular dementia. An Incident Report Form, dated 11/09/24, documented LPN #1 had allegedly forced Resident #2 to take medication against their will. An undated attachment to the incident report documented the facility staff had determined LPN #1 had physically restrained Resident #2's arms while attempting to administer medications to the resident. The document stated the facility staff determined the incident had occurred and LPN #1's employment had been terminated. On 11/25/24 at 2:45 p.m., CMA #1 stated that on 11/08/24 on the evening shift Resident #2 had repeatedly stood up from their wheelchair. They stated they would ask the resident to sit back down and they would, but would soon repeat the behavior. They stated Resident #2 then stood up and used the frame of the window of the nurses' station to walk to the nurses' station door. They stated at that point LPN #1 held the resident by their shoulders and moved them back into their wheelchair. They stated the LPN then pushed the wheelchair to a table in the common area and stood behind the chair so the resident could not stand. They stated the resident tried to push away from the table, but LPN #1 pushed them back. CMA #1 then stated LPN #1 held the resident's arms so they could not push away the medicine CMA #1 attempted to administer. On 11/27/24 at 10:10 a.m., the ADON stated LPN #1 had violated the rights of Resident #2 by using physical restraints to restrict their movements. They stated facility policy forbid such restraints and LPN #1 had been terminated.

Based on record review and interview, the facility failed to ensure a chemical restraint was not used to keep a resident from repeatedly standing from their wheelchair for one (#2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Abuse, Neglect, and Exploitation: policy, dated November 2017, read in part, The facility must ensure the resident is free of from physical or chemical restraints imposed for the purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. 1. Resident #1 had diagnoses which included Alzheimer's disease. A narcotic count sheet for lorazepam (antianxiety medication) 2 ml syringes for Resident #2, documented CMA #2 signed out one syringe of the medication on 11/08/24 at 6:00 p.m. An Incident Report Form, dated 11/09/24, documented LPN #1 had allegedly forced Resident #2 to take medication against their will. An undated attachment to the incident report documented the facility staff had determined the incident had occurred and LPN #1's employment had been terminated. On 11/25/24 at 2:45 p.m., CMA #1 stated on 11/08/24 on the evening shift Resident #2 repeatedly stood from their wheelchair and had to be reminded to not walk, but sit back down in the wheelchair. They stated the resident would smile and sit back down, but later repeat the behavior. They stated the resident would always sit back down when asked. They stated at one point Resident #2 stood again, but that time used the window frame at the nurse's station to lean on and began walking toward the door of the nurse's station. They stated LPN #1 asked them if the resident had an order for lorazepam which they replied to LPN #1 they did. They stated LPN #1 told them to get the medication and they attempted to administer the medication, but the resident blocked the medication with their arms. They stated LPN #1 then held the resident's arms as they administered the medication. They stated when the resident tried to spit the medication out of their mouth LPN #1 held their hand over the mouth of the resident or one or two minutes. They stated LPN #1 then removed their hand and stated that was probably enough to calm the resident down. On 11/27/24 at 10:10 a.m., the ADON stated LPN #1 and CMA #1 had violated the rights of Resident #2 by using a chemical restraint to restrict their movements instead of less restrictive means. They stated facility policy forbid such restraints and LPN #1 had been terminated. They stated they were unaware CMA #1 had administered the medication and they had now been sent home pending an investigation.

Based on record review and interview, the facility failed to ensure an employee reported an allegation of abuse in the mandated time frame for one (#2) of three sampled residents reviewed for abuse. A daily census record, dated 11/15/24, documented 103 residents resided in the facility. Findings: The facility's Abuse, Neglect, and Exploitation: policy, dated November 2017, read in part, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not late than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #2 had diagnoses which included vascular dementia. An Incident Report Form, dated 11/09/24, documented when investigating another incident it was discovered the same alleged perpetrator, LPN #1, had been involved in an incident of forcing Resident #2 to take medications against their will. A handwritten statement, dated 11/11/24, documented CMA #1 had witnessed LPN #1 forcibly administer Resident #2 the antianxiety medication lorazepam on 11/08/24 sometime between 5:30 p.m. and 7:00 p.m. On 11/25/24 at 2:45 p.m., CMA #1 stated on 11/08/24 after 5:00 p.m., they had observed what they believed to have been abusive behavior from LPN #1 toward Resident #2. They stated they did not report the incident until 11/10/24 at 9:40 a.m. when they informed the ADON. On 11/27/24 at 10:10 a.m., the ADON stated CMA #1 had not followed the facility abuse policy by not reporting the allegation of abuse until more than 24 hours after they witnessed the incident.

Based on record review and interview, the facility failed to conduct a thorough investigation into a missing container of narcotic pain medications. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: A facility policy titled Controlled Medication - Ordering and Receipt, dated 2001, documented medications were to be checked upon arrival to ensure all medications on the packing slip were received. A pharmacy manifest, dated 08/23/24, documented 168 tablets of Oxycodone/APAP (pain medication) 10-325 mg was delivered to the facility and represented a 28-day supply of the medication. The manifest was signed by facility nurse LPN #1. On 10/14/24 at 11:23 a.m., the ADON stated they had investigated 60 unaccounted for Oxycodone/APAP 10-325 mg tablets. They stated they had attempted to reorder the medication on 09/13/24 and were informed by the pharmacy that it was too soon to reorder. They stated that was when they realized there were missing pills. They stated they attempted to contact LPN #1 since that time, but they had not returned their calls or worked at the facility. They were asked to provide their documentation of the investigation they had conducted into the unaccounted medication. They stated they did not have documentation other than the incident report. They stated they had no documentation of interviews with any staff regarding the missing medication, the police officer declining to investigate the missing medication, or of the attempts to contact LPN #1. They stated they did not know what has happened to the missing pain medication. On 10/14/24 at 1:08 p.m., LPN #1 stated they worked at the facility only occasionally. They stated they were unaware of the missing medications. They stated no one from the facility had attempted to contact them regarding the missing medications. On 10/16/24 at 11:39 a.m., the ADON stated they had completed the investigation with the information they had to work with. They stated they never found out what had happened to the medications.

Based on record review and interview, the facility failed to notify a resident's representative when a new antipsychotic medication had been ordered for one (#3) of five sampled residents reviewed for notifications of change. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: A facility policy titled Notification of Change Policy, dated 05/2017, read in part, It is the policy of this facility that changes is resident's condition or treatments are immediately shared with the resident and/or the resident's representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Resident #3 had diagnoses which included delusional disorder. A physician's medication order, dated 01/11/24, documented Resident #3 was to be administered risperidone (antipsychotic medication) 0.5 mg tablet by mouth at bedtime for delusional disorder. The order was documented as discontinued on 06/13/24. A physician's medication order, dated 06/14/24, documented Resident #3 was to be administered risperidone 0.5 mg tablet by mouth at bedtime for delusional disorder. The order was documented as discontinued on 06/15/24. A physician's medication order, dated 06/14/24, documented Resident #3 was to be administered Nuplazid (antipsychotic medication) 34 mg tablets by mouth once daily for delusions and psychosis. A review of the progress notes for Resident #3 did not document the resident's representative had been notified of the medication changes. On 10/15/24 at 9:41 a.m. the ADON stated they did not find any documentation Resident #3's family had been notified of the change of antipsychotic medications. They stated their policy stated they should have been made aware.

Based on record review and interview, the facility failed to prevent a medication administration record from erroneously recording a resident received a medication when the medication was not available for administration for one (#3) of six sampled residents reviewed for medication administration. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: A MAR, dated 06/01/24 through 06/30/24, documented Resident #3 had been administered Nuplazid (antipsychotic medication) 11 times between 06/14/24 and 06/30/24. A MAR, dated 07/01/24 through 07/31/24, documented Resident #3 had been administered Nuplazid five times between 07/01/24 and 07/26/24. On 10/15/24 at 9:30 a.m., CMA #1 stated they had reviewed the June and July MARs for Resident #3 and found they had documented they had administered Nuplazid to the resident on multiple dates. They stated those entries were in error as that medication had never arrived in the building because of an insurance issue. On 10/15/24 at 9:53 a.m., the ADON stated documents from their contracted pharmacy showed Resident #3's Nuplazid had never arrived at the facility and the documentation in the June and July 2024 MARs that indicated the medication was administered to the resident were errors.

Based on record review and interview, the facility failed to assess and promptly treat a resident following an unobserved fall for one (#6) of two sampled residents reviewed for falls. A resident listing report, dated 10/14/24, documented 109 residents resided at the facility. Findings: Resident #6 had diagnoses which included hemiplegia and hemiparesis. A Falls Management policy and procedure, dated 04/2015, read in part, In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. Remain with the resident while calling for assistance, if at all possible. A progress note, dated 04/15/24 at 10:36 a.m., documented Resident #6 complained of pain in their right hip when they moved their right leg. The note documented the nurse observed the resident's right leg externally rotated and the resident was unable to straighten their leg. It further documented a nurse practitioner was in the building and ordered the resident to be sent to an emergency room . The note stated the resident and their family member were aware of the order to go to the emergency room . A hospital history and physical report, dated 04/15/24 at 4:20 p.m., documented Resident #6 reported they had fallen at the nursing facility and had decreased feeling in their lower right leg. A hospital consultation report, dated 04/15/24 at 5:37 p.m., documented an X-ray of Resident #6's pelvis found a fracture right hip fracture. An incident report, dated 04/22/24, documented a former administrator of the facility had substantiated a complaint lodged by family members of Resident #6 on 04/22/24. The former administrator's investigation documented on the report LPN #2 had stated they had conducted a head-to-toe assessment of the resident after a fall and found no issues and no report of pain. The document further stated the ADON and nurse practitioner assessed the resident the next day and found them to be in pain and their right leg was obviously externally rotated. The report documented LPN #2's employment was terminated. On 10/16/24 at 10:40 a.m., the ADON stated the resident had fallen the night of 10/14/24 and was not assessed adequately by LPN #2 which caused the resident to not receive treatment until the next day. They stated they stand by the statements documented on the incident report dated 04/22/24. On 10/16/24 at 12:45 p.m., the ADON presented documentation of the facility's actions to correct the deficiency they had identified regarding fall assessments and interventions. They included documentation nursing staff were in-serviced on the facility's fall protocols which included assessment and interventions post fall, monthly monitoring of falls by the ADON in April, May, and June of 2024, and QAPI meeting in May and June demonstrating the teams monitoring of the situation and a five percent decline in falls at the 06/14/24 meeting. Interviews with nursing staff during the survey confirmed the in-service had occurred and the content of the training.

Based on observation, record review, and interview, the facility failed to: a. ensure scoops were not stored inside the bins of flour and corn starch for two of two bins observed; b. ensure foods stored in the refrigerator were labeled and dated for one of one walk in refrigerators observed; c. ensure the dish machine reached minimum specifications for sanitation for one of one dish machines observed; d. ensure the ice machine was maintained in a sanitary manner for one of two ice machines observed; e. ensure the proper use of hair restraints, including facial hair; f. ensure infection control was maintained when plating meals for one (the noon meal) of one meal service observed; and g. ensure kitchen equipment, surfaces, and floors were maintained in a sanitary manner. The ADON identified 111 residents who received meals from the kitchen. Findings: The Food Preparation Guidelines policy, dated November 2017, read in part, .Food should be protected from contamination while being stored . The Ice Machine and Ice Storage Chests policy, dated January 2024, read in parts, .Ice machines .will be used and maintained to assure a safe and sanitary supply of ice .Our facility has established procedures for cleaning and disinfecting ice machines .which adhere to the manufacturer's instructions . The undated, Food Safety Requirements policy, read in part, .Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes . 1. The Nutrition Services Visit, dated 03/02/24, read in part, .Areas for Corrective Action .Scoops inside flour bags . The Nutrition Services Visit, dated 04/02/24, read in part, .Areas for Corrective Action .Scoop stored in the flour bin . The Nutrition Services Visit, dated 05/01/24, read in part, .Areas for Corrective Action/Recommendations .Flour and sugar scoops need to be placed in sealed bags when not in use . On 05/13/24 at 8:32 a.m., a large container with a bag of flour and a large container with a bag of corn starch was observed in the dry storage room. Scoops were observed inside the bag of flour and corn starch. On 05/14/24 at 12:30 p.m., scoops were observed inside the bag of flour and bag of corn starch inside the bins in the dry storage room. On 05/14/24 at 2:23 p.m., dietary aide #1 stated scoops were to be stored in zip top bags on top of the bins of flour and corn starch. On 05/14/24 at 2:33 p.m., the dietary manager stated they stored the scoops inside the flour and corn starch bins but should not store them in the bags. 2. On 05/13/24 at 8:29 a.m., the walk in refrigerator was observed to contain an undated sheet pan of corn bread; three undated, uncovered, trays of dessert with whipped topping; two undated, uncovered pans of red gelatin; and an undated, unlabeled, zip top bag with five pieces of fish in a liquid. On 05/13/24 at 8:38 a.m., the dietary manager stated the items in the walk in refrigerator should be covered and dated. The dietary manager stated staff must have made the red gelatin last night, the dessert with whipped topping was from the weekend, and the cornbread was from Saturday. The dietary manager stated they had a problem with staff not covering or dating food items. 3. The Dish Machine Temperature Log, dated March 2024, documented out of 93 opportunities to monitor the wash temperature, there were nine blanks and 76 times the documented temperature was less than 120 degrees F. The log documented out of 93 opportunities to monitor the rinse temperature, there were nine blanks and two times the documented temperature was less than 120 degrees F. The Dish Machine Temperature Log, dated April 2024, documented out of 90 opportunities to monitor the wash temperature, there were 16 blanks and 59 times the documented temperature was less than 120 degrees F. The log documented out of 90 opportunities to monitor the rinse temperature, there were 16 blanks. The Dish Machine Temperature Log, dated 05/01/24 through 05/13/24 at breakfast time, documented out of 37 opportunities to monitor the wash temperature, there were 32 times the documented temperature was less than 120 degrees F. The log documented out of 37 opportunities to monitor the rinse temperature there were three times the rinse temperature was less than 120 degrees F. On 05/13/24 at 8:44 a.m., the dish machine was observed with the dietary manager. The specifications on the label of the dish machine documented the minimum wash and rinse temperature was 120 degrees F. The dietary manager ran the dish machine. The wash temperature was observed to reach 100 degrees F and the rinse temperature was observed to reach 120 degrees F. The dietary manager stated they had recently had the dish machine serviced but was unaware the dish machine had not reached the minimum temperature. On 05/13/24 at 11:15 a.m., the maintenance supervisor stated they monitored the dish machine every Friday but would need to call the company for a service visit. 4. On 05/13/24 at 8:57 a.m., the ice machine was observed with the maintenance supervisor. The deflector panel was observed to contain a red, orange, and brown substance when wiped with a white napkin. The maintenance supervisor stated the maintenance department was responsible to clean the ice machine and it was last cleaned in April 2024. 5. The Nutrition Services Visit, dated 04/02/24, read in parts, .Areas for Corrective Action .All food service employees are wearing hats that do not completely restrain hair . On 05/13/24 at 8:29 a.m., dietary aide #1 and the dietary manager were observed in the kitchen preparing/serving the morning meal without facial hair restraints. On 05/14/24 at 11:55 a.m., the dietary manager and dietary aide #1 were observed to prepare the noon meal without facial hair restraints. Dietary aide #5 was observed with approximately four inches of hair hanging out of the back of their hair restraint. Dietary aide #4 was observed with approximately three inches of hair hanging out of the back of a stocking cap. On 05/14/24 at 12:04 p.m., dietary aide #1, dietary aide #4, and dietary aide #5 were observed to plate the noon meal without facial hair restraints. On 05/14/24 at 2:23 p.m., dietary aide #1 stated they always wore hair restraints. They stated they were not required to wear facial hair restraints if their beard was short. Dietary aide #1 stated their facial hair was long enough they should have worn a facial hair restraint. On 05/14/24 at 2:33 p.m., the dietary manager stated the dietary staff utilize hair restraints but did not know why the dietary staff had not covered their facial hair. On 05/17/24 at 12:34 p.m., the administrator stated the dietary staff were supposed to wear hair nets correctly and cover their facial hair as well. 6. On 05/14/24 at 12:07 p.m., dietary aide #1 was observed to don gloves and touch plates, ladle handles, the counter top, styrofoam containers, tortillas, and chips with the same gloved hands throughout the noon meal service. On 05/14/24 at 12:09 p.m., dietary aide #4 was observed to don gloves and touch plates, the counter, ladle handles, tortillas, chips and shredded cheese with the same gloved hands throughout the noon meal service. On 05/14/24 at 12:14 p.m., the dietary manager was observed to don gloves and touch plates, ladle handles, a cloth towel, a package of tortillas, and chips with the same gloved hands throughout the noon meal service. On 05/14/24 at 12:15 p.m., dietary aide #3 was observed to don gloves and touch the counter top, ladle handles, tortillas, shredded cheese, shredded lettuce, and diced tomatoes with the same gloved hands throughout the noon meal service. On 05/14/24 at 12:35 p.m., dietary aide #6 was observed to don gloves and touch the fryer basket handles, plates, counter top, and oven doors then obtain cooked french fries from the fryer basket and obtained two slices of bread from a loaf with the same gloved hands. On 05/14/24 at 2:23 p.m., dietary aide #1 stated they did not know how they maintained infection control with meal service when they touched multiple items/surfaces then food with the same gloved hands. They stated they were supposed to use tongs. On 05/14/24 at 2:33 p.m., the dietary manager stated they should use utensils to maintain infection control during meal service. 7. The Nutrition Services Visit, dated 03/02/24, read in parts, .The stainless steel counter and ice dispenser need to be cleaned .The drain and wall behind the drain for the dishwasher is starting to grow mold . The Nutrition Services Visit, dated 04/02/24, read in parts, .The stainless steel counter and ice dispenser need to be cleaned .The drain under the dish machine counter is heavily soiled and starting to grow mold .Action Plan .Recommend deep clean of drain under dish machine . On 05/13/24 at 8:32 a.m., the warmer oven, stove, stand mixer, under the dishwasher, under the serving counter, plate warmer, and deep fryer were observed to have a build up of a dark substance on the surfaces of the equipment. The floor in the kitchen was observed to have a sticky build up. On 05/14/24 at 12:43 p.m., the warmer oven, stove, stand mixer, under the dishwasher, the wall behind the dishwasher, under the serving counter, plate warmer, and deep fryer were observed to have a build up of a dark substance on the surfaces of the equipment. The floor in the kitchen was observed to have a sticky build up. On 05/14/24 at 2:23 p.m., dietary aide #1 was asked what the cleaning schedule was for the kitchen. They stated they did not have a schedule. Dietary aide #1 stated they usually just cleaned what they could. On 05/14/24 at 2:33 p.m., the dietary manager stated they had a cleaning list but the weekend shift had not completed the cleaning.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and failed to implement interventions to aid in the prevention of falls for two (#2 and #12) of three sampled residents reviewed for falls. Resident #12 experienced sixteen falls resulting in sutures to a laceration on her forehead, staples to lacerations on her head three times, a suspected fracture of her right elbow, a fractured left elbow, and a [MEDICAL CONDITION]. Resident #2 experienced eight falls resulting in a [MEDICAL CONDITION]. The DON identified 42 residents who had experienced falls in the last six months. Findings: A Fall Protocols policy, revised 03/08/19, documented: Residents' will be assessed for fall risk upon admission, readmission, with a significant change in medical condition. In the event of an actual fall, an attempt will be made to eliminate causal factors and prevent further falls. Guidelines . Residents experiencing an actual fall will have the following interventions: One Fall .An incident investigation will be completed to determine root cause of fall and/or if the event was isolated in nature. Immediate Preventative measures will be implemented prior to end of shift based on the incident investigation findings . The fall shall be reviewed at the next interdisciplinary meeting to assure that the interventions are appropriate and to evaluate the need for any additional preventative measures . The care plan will be revised for any new fall prevention interventions. Two Falls (within 90 days) Repeat the above steps and: Determine if new interventions are necessary Interdisciplinary Team to review all documentation and findings related to previous falls and discuss with resident/family and physician . Document any refusals related to recommended safety interventions. Three Falls (within 90 days) .Request attending physician/pharmacist or other clinical designee to review falls, medications, and plan of care for additional recommendations. Discuss repeat falls with resident and/or responsible party and any refusals or non-compliance associated with recommended safety interventions. 1. Resident #12 had [DIAGNOSES REDACTED]. A care plan focus, documented the resident was at risk for falls related to Alzheimer's, dementia, gait or balance problems, impaired safety awareness, and the resident took [MEDICAL CONDITION] medications. The goal was for the resident to be free of major injuries related to falls through the next review. Interventions: Administer medications and treatments as ordered. Monitor/document for side effects and effectiveness. SEE MAR/TAR for current regime. Assit with transfers to/from surfaces as needed to the degree needed. Consult physician for medication review and make appropriate changes. Ensure call light within reach and reorient to call light if necessary. 5/5/17 - Actual fall with major injury If resident is displaying wandering behaviors - staff to redirect to a safe sitting activity 6/17/17 - Actual fall with major injury Therapy to evaluate for assistive devices 9/26/17 - Actual fall with no injury -increased toileting frequency 10/16/18 - Acutal fall with minor injury Isolated incident - staff to continue to monitor An incident report, dated 01/26/19 at 8:50 a.m., documented, .LPN & CNA heard res moan 'OOHH' from room .Upon entering the room res was laying supine on the floor Res has old scattered bruising to all extremities at various stages of healing and old skin tears approximated with steri strips .Increase agitation observed; night nurse reported that res was up on night shift & leaning to the left while ambulating. Staff had to provided (sic) 1:1 due to residents very unsteady gait & leaning posture; w/c provided .Notified (physician) with orders to obtain x-ray to R elbow (res c/o pain to R arm during monitoring) and L hip (CNA reported during repositioning res grabbed her L hip and moaned) . A final state reportable incident report form, dated 01/26/19, documented, .(Received x-ray results 1) Left hip- no acute boney fx/injury 2)R elbow-suspected FX of radial head .resident will be splinted for 1-10 days .Resident will be evaluated by therapy for gait and Ambulation. Staff to monitor resident. Resident foot wear will be inspected to ensure they are in good condition as well as no trip hazards in residents room. An update to the care plan, dated 01/26/19, documented, Actual fall with major injury. Therapy to eval for gait and ambulation. No documentation of a therapy evaluation was found. An incident report, dated 02/01/19 at 9:00 p.m., documented the resident was found lying in the hallway. No injuries were noted. An update to the care plan, dated 02/01/19, documented, Actual fall with no injury Contact PCP to review recent medical changes. A resident therapy screening form, dated 02/04/19, documented the resident had sustained two falls in the past month. One resulted in a fracture. The form documented for recommendations, PT/OT to eval & tx as indicated. No documentation of a therapy evaluation was found. An incident report, dated 02/17/19 at 10:35 a.m., documented the resident was found sitting on her buttocks beside the bed. The bed had been in a high position. The incident report documented the staff assisted the resident with incontinent care as brief was soiled. An update to the care plan, dated 02/17/19, documented, Actual fall with no injury Therapy eval. No documentation of a therapy evaluation was found. A resident therapy screening form, dated 02/18/19, documented the resident had a fall next to the bed. The form documented for recommendations, PT to eval & tx as indicated. No documentation of a therapy evaluation was found. An incident report, dated 02/22/19 at 8:30 p.m., documented an unwitnessed fall of the resident on the floor of her bathroom. The incident report documented the resident had steri-strips applied to a skin tear on her left elbow; a scratch was observed on the left side of her forehead with a slight bruise underneath. The incident report documented that non-skid socks were placed on her feet. A progress note, dated 02/22/19 at 8:30 p.m., documented a helmet was provided to wear, and the resident was redirected to a reclining wheelchair at times as she paced constantly. An update to the care plan, dated 02/22/19, documented, Acutal fall with minor injury Provide resident with helmet and encourage to wear. A progress note, dated 04/12/19 at 12:26 p.m., documented the resident was in another resident's room, both were tugging on a stuffed animal. The other resident fell on to resident #12 resulting in a hematoma to the back of the resident's head. The incident report documented the resident was sent to the hospital for evaluation. No documentation for the fall on 04/12/19 was found in the state reportable incident reports or in the care plan. An incident report, dated 04/18/19 at 5:45 p.m., documented a witnessed fall by the resident while in the dining room, with several staff members nearby. The incident report documented the resident was observed lying flat on her back next to the table with blood on the floor and the right sleeve of her shirt. The incident report documented the CNA reported that the resident had tripped over another resident's walker. The incident report documented the resident had skin tears to her right hand and right upper arm, a large abrasion to the middle of her back and a hematoma to the right side of her forehead. An update to the care plan, dated 04/18/19, documented, Acutal fall with minor injury Rearrange dining room furniture to decrease clutter. A resident therapy screening form, dated 04/19/19, documented the recommendation was to rearrange the furniture for safety and to decrease clutter. An incident report, dated 04/25/19 at 2:05 a.m., documented the resident had an unwitnessed fall on 04/24/19 at 10:00 p.m., in the bathroom beside the toilet, no injuries were noted. The incident report documented the resident's husband requested a care plan meeting. An update to the care plan, dated 04/25/19, documented, Acutal fall with no injury Care plan meeting with family to discuss intervention options. The intervention initiated on 5/5/17, which documented, If resident is displaying wandering behaviors - staff to redirect to a safe sitting activity, was documented as resolved on 04/25/19. An incident report, dated 06/06/19 at 10:00 p.m., documented the resident was found lying on the floor in her room. The incident report documented the resident had redness to her left shoulder and a bump on the back of her head. A progress note, dated 06/06/19 at 10:00 p.m., documented an intervention to encourage periods of rest as the resident paced and wandered continuously. An update to the care plan, dated 06/06/19, documented, Acutal fall with minor injury. Encourage periods of rest for resident. An incident report, dated 06/11/19 at 10:00 p.m., documented the resident was found lying in another resident's doorway on her back, probably pushed by another resident. The incident report documented the nurse noted an indention and laceration to the back of the resident's head with a puddle of blood that soaked the towels; pressure was applied until the resident was transported to the ER. A final state reportable incident report form, dated 06/11/19, documented, Both residents, (resident #12) and (resident #16) were observed on floor in resident's (#16) room near doorway .Both residents reside within secure unit in facility .Resident (#12) was sent to ER for eval/treat. Resident returned to facility with staples to back of head related to laceration .Resident (#16) was transferred to memory unit in other Emerald facility to ensure residents remain apart and have no further altercations . An update to the care plan, dated 06/11/19, documented, Acutal fall with head injury Attempt to deter from other resident's rooms with stop signs if needed. A resident therapy screening form, dated 06/12/19, documented, .resident pushed c fall & [MEDICAL CONDITION] Recommendations: stop signs on doors . A progress note, dated 06/13/19 at 5:25 p.m., documented the resident was found lying on her back on the floor, in another resident's room, with bleeding to the back of her head. The progress note documented the resident was sent to the hospital for the [MEDICAL CONDITION] to be stapled. The progress note documented an intervention: Encourage the resident to wear helmet, consult the family regarding music preferences for possible music therapy, bed in low position, fall mat and call light to be used. A final state reportable incident report form, dated 06/13/19, documented, Resident observed ling on the floor in entryway of another resident's room. Resident with head injury noted. Resident was laying flat on her back .Resident went to ER and returned to facility with staples to back of head .Resident has been provided protective head gear helmet .Resident returned to facility with 5 staples to back of head .Resident encouraged to wear soft protective head gear helmet . An update to the care plan, dated 06/13/19, documented, Acutal fall with head injury Encourage resident to wear protective head gear Consult family regarding music preferences for possible music therapy. An incident report, dated 06/16/19 at 2:25 p.m., documented the nurse was summoned back to the unit where the resident was sitting on her bottom in front of her chair in the dining room. No injuries were noted. The incident report documented the CNA's were asked to toilet the resident and to keep her supervised. A progress note, dated 06/16/19 at 2:30 p.m., documented a fall with therapy to screen. An update to the care plan, dated 06/16/19, documented, Actual fall with no injury Therapy to screen resident. A physical therapy note, dated 06/21/19, documented a PT evaluation was done. The resident was able to safely ambulate 200 feet using handheld assist with contact guard assist. An incident report, dated 06/25/19 at 6:00 p.m., documented the resident had an unwitnessed fall near the locked entrance door with no obvious injuries. An update to the care plan, dated 06/25/19, documented, Actual fall with no injury Therapy to continue. An incident report, dated 07/08/19 at 6:01 p.m., documented an unwitnessed fall of the resident in room near the bathroom. A skin tear was found to the left elbow that was open and bleeding. No other injuries were observed. Resident ambulates herself to the point of exhaustion and res leans to the side when this happens, causing her to be off balance, resident will not stop ambulating even at this point of exhaustion d/t her Alzheimer's progression and disease process . A progress note, dated 07/08/19 at 6:15 p.m., documented multiple interventions in place, the resident had been refusing to wear protective head gear; was unable to be educated related to cognition. The progress note documented Action: Continue with Part B attempt to prevent major injury with fall. An update to the care plan, dated 07/08/19, documented, Actual fall with minor injury Attempt to prevent majory injury with fall. A Physical therapy progress report, dated 07/08/19, documented the resident had a current goal met as of 07/08/19 to safely ambulate on level surfaces of 300 feet with contact guard assist. A combined initial and final state reportable incident report form, for an incident date of 07/08/19, documented, .Actual fall with minor injury occurred in resident's restroom on 7/8/19. Skin tear to left elbow .On 7/9/19, resident noted to have swelling and tenderness to elbow. New order to x-ray. X-ray shows moderately displaced [MEDICAL CONDITION] ulna. New order received to send resident to hospital for further evaluation. Resident returned with splint to left arm and orthopedic appointment. An incident report, dated 07/10/19 at 7:30 p.m., documented an unwitnessed fall of the resident in another resident's room, with resident #12's head lying next to the dresser in a pool of blood. The incident report documented the resident was sent to the ER. An ED physician note, dated 7/10/19, documented treatment of [REDACTED]. A progress note, dated 07/10/19 at 8:15 p.m., documented the residents daughter called requesting a care plan meeting related to falls in the past week. An update to the care plan, dated 07/10/19, documented, Acutal fall with major injury Purchase and implement weighted blanket for resident to remind not to get up without assist. A progress note, dated 07/11/19, documented a care plan meeting where the family suggested a medication review, which the DON would set up with the pharmacy and the physician. The progress note documented the staff suggested a weighted blanket, possibly an activity blanket to redirect her, and music therapy; the family agreed to get headphones and music for the resident. The progress note documented a Broda chair was mentioned. A therapy resident screening form, dated 07/16/19, documented the resident had a recent fall on 07/09/19, and recommended 24 hour supervision. A physical therapy discharge summary, dated 07/18/19, documented the resident required constant guard assist for transfers and ambulation on level surfaces. The summary documented the resident was seen for PT from 06/21/19 through 07/18/19. A progress note, dated 07/30/19, documented a medication review was done by the pharmacist and reviewed by the physician; an order for [REDACTED]. A progress note on 08/01/19 at 3:31 a.m., documented the staff was 1:1 with the resident while in the geri-chair as she was fidgety. A progress note on 08/01/19, documented the physician's assistant increased the [MEDICATION NAME] to 0.5 mg to TID. An annual assessment, dated 08/16/19, documented the resident was severely impaired cognitively, required ADL supervision of oversight, encouragement or cueing with set up help only, for ambulation in room and in the hallway; required limited assistance of one staff for bed mobility, transferring and dressing; and required extensive assistance of one for toileting, hygiene and bathing, and was at risk for falls. An incident report dated 09/01/19 at 4:40 p.m., documented an unwitnessed fall in the hall with head jerking motions with a large amount of bleeding observed on the left side of head and face; a laceration to the left forehead was noted and the resident was sent to the ED. A progress note, dated 09/01/19 at 4:40 p.m., documented an intervention to encourage the resident to sit in the Broda chair and offer the weighted blanket. An ED final report, dated 09/01/19, documented the resident had required eight sutures to the left forehead. An x-ray of the left elbow was compared to a previous x-ray on 07/09/19, resulting in the findings of a chronic displaced olecranon fracture with marginal [MEDICAL CONDITION] now present suggesting nonunion, with a 1.5 cm of diastases of the fracture fragments. An update to the care plan, dated 09/01/19, documented, Unwitnessed fall with major injury Encourage resident to sit in Broda chair and offer weighted blanket. A progress note, dated 09/03/19 at 5:10 p.m., documented the resident had expressed pain when her left leg or left hip was moved or when transferred and an order for [REDACTED].>An incident report, date 09/03/19 at 6:14 p.m., documented the resident had fallen in her room, with a deep, bleeding laceration observed to the middle of her forehead, along with a skin tear to her right elbow and right hand and knee. The incident report documented the resident was sent to the ED. An update to the care plan, dated 09/03/19, documented, Unwitnessed fall with major injury Sent to ER for eval/treat. A hospital discharge records, dated 09/06/19, documented the resident had a proximal left femoral fracture with nonsurgical management; ordered non-weight bearing to left leg, to turn resident every two hours, a Foley catheter and hospice care. A progress note, dated 09/06/19 at 4:30 p.m., documented the resident was readmitted to the facility with Hospice ordered. A significant change assessment, dated 09/16/19, documented the resident was severely impaired cognitively, required ADL supervision of oversight, encouragement or cueing with set up help only, for ambulation in room and in the hallway; required limited assistance of one staff for bed mobility, transferring and dressing; and required extensive assistance of one for toileting, hygiene and bathing, was at risk for falls, and was placed on hospice services. An undated update to the care plan documented, Resident refuses to wear helmet even after encouragement. On 09/18/19 at 11:22 a.m., the resident was observed lying in a low bed, a fall mat beside the right side of the bed. She was awake, made eye contact, but was unable to form words. She made a continuous repetition of sounds. On 09/23/19 at 10:00 a.m., the resident was observed recumbent in a Broda chair in the dining area of the locked unit. Her eyes were closed and she did not respond when called by her name. At 1:00 p.m., CNA #1 was asked to describe the resident. She stated the resident walked all the time, going into other resident's rooms. They did not know how to keep her out of other rooms, even closing the doors did not help. She was asked how they kept her safe from falling. She stated they made sure she had her shoes on and replaced her long blanket that she liked to carry, with a shorter one so she would not get tangled up in it. She was asked if the resident had fallen very often. She stated yes, the past few months she had fallen a lot; had cracked her head and broken her hip. She was asked if she felt there was enough staff for supervision of the residents. She stated day shift usually had enough staff but not usually on evenings or nights. She stated staff frequently call in and they cannot get enough staff to cover. At 2:00 p.m., the ADON was asked if they had done any root cause analysis on the resident's falls. She stated they had morning stand-up meetings with the staff every Monday through Friday and they discussed how to help identify falls and what they can do. She was asked what they do to prevent falls. She stated they had offered this resident a helmet, had physical therapy, rearranged furniture and tried stop signs, but the resident would still carry stuff and get tripped up. She was asked if any of the interventions had been effective. She stated somedays yes, but the resident would not wear the helmet, and took it off as soon as it was placed. She was asked how they decide to do 1:1 supervision for the resident. She wasn't sure. She was asked if any medication changes were enacted, or any medication reviews were done by the physician, specifically after the care plan note of it on 02/01/19. She stated she could not locate any other documentation other than 07/30/19, when [MEDICATION NAME] was decreased, but then increased again the following day. On 09/24/19 at 10:30 a.m., LPN #1 was asked if she felt there were enough staff on the locked unit for supervision to prevent falls. She stated sometimes, but not always. Sometimes only one staff member, a CNA, was on that hall, usually on the evening shift, as other staff members covered other halls in addition to the locked unit, especially Burgundy, which was a heavy hall. She was asked how often the locked unit only had one CNA, and no other staff present for a shift. She stated it was not very often, but it had occurred several times. She was asked if she thought supervision of residents by staff would have helped prevent falls. She stated extra personnel would always help, but this resident walked until she was exhausted, she was hard to redirect, then she would fall. On 09/24/19 at 11:41 a.m., the ADON was asked if music therapy was attempted, as mentioned in the progress notes dated 07/11/19. She provided documentation of the group music, which had been ongoing since admission, but no music by headphones. She was asked if there had been a care plan meeting after the fall on 04/24/19, as requested by the family. She was able to produce a signature page for that date, but no documentation of the meeting's discussion. She was asked why there was no documentation. She stated she did not know. At 12:43 p.m., the DON was asked if she thought staffing was adequate for the locked unit. She did not answer. She was asked who had the authority to increase the staffing numbers. She stated Corporate. She stated she did not have the authority to increase the staffing numbers. 2. Resident #2 was admitted on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 03/08/19, documented the resident was severely impaired cognitively, was independent with most activities of daily living, had no falls, received an antipsychotic medication seven days out of the seven day look back period, and received an antidepressant medication two days out of the seven day look back period. A care plan, dated 03/20/19, documented: Focus The resident is at risk for falls related to Alzheimer's/dementia, gait or balance problems, impaired safety awareness, and taking [MEDICAL CONDITION] medications. Goal The resident will be free of major injuries related to falls through the next review date. Interventions Administer medications and treatments as ordered. Monitor/document side effects and effectiveness. Assist with transfers to/from surfaces as needed to the degree needed. Ensure the call light is within reach and reorient to the call light if necessary. An incident report, dated 06/23/19 at 5:26 a.m., documented staff were called to the resident's room and found the resident sitting on the floor on his buttocks with his knees bent and his feet behind him. The report documented the resident had no injuries. The report documented there were no interventions to prevent future falls. An update to the care plan, dated 06/23/19, documented Actual fall with no injury Pending Part B eval. Date initiated: 06/25/2019. A quarterly assessment, dated 06/27/19, documented the resident had long and short term memory loss and was moderately impaired in cognitive skills for daily decision making, required limited assistance for most activities of daily, had one fall with no injury, received an antidepressant, an antipsychotic, and an antibiotic seven days out of the seven day look back period. An incident report, dated 07/07/19 at 12:50 a.m., documented the resident was sitting in his wheelchair in his room about to be put to bed when the resident rolled out of his wheelchair. The report documented there were no injuries. The report documented there were no interventions to prevent future falls. An incident report, dated 07/07/19 at 10:29 p.m., documented the resident was found on the floor in the private dining room. The report documented there were no injuries noted. The report documented there were no interventions to prevent future falls. An incident report, dated 07/08/19 at 7:45 p.m., documented the resident was found sitting on the floor in front of his bed. The report documented there were no injuries. The report documented there were no interventions to prevent future falls. An update to the care plan, initiated on 07/09/19, documented: 7/7/19 - Fall with no injury. 7/7/19 - Fall with no injury. 7/8/19 - Fall with no injury. Encourage periods of rest during wandering behavior. Encourage to sleep in bed during night hours. Encourage resident to sit in an elevated chair when fatigued. An incident report, dated 07/19/19 at 11:24 p.m., documented, Resident was found crawling around on hands and knees stating 'pick that up'. The report documented there were no injuries. The report documented there were no interventions to prevent future falls. An update to the care plan, initiated on 07/19/19, documented: Actual fall - no injury Resident possibly placed self in floor to 'pick something up'. Will continue to monitor resident and meet his needs to assist him with staying in w/c. An incident report, dated 08/19/19 at 6:18 p.m., documented, Resident was observed by this LN and CNA to be on the floor in the sun rroom area of the dining room, resident had previously been ambulating around dining area, both staff were in dining area but heard no commotion, CNA spotted res on floor on his right side attempting to get back up on his own .found new appearing bruising to R elbow. No other injuries noted . The report documented there were no interventions to prevent future falls. An update to the care plan, initated on 08/20/19, documented: 8/19/19 - Unwitnessed fall with minor injury Monitor effects of recent medication changes An incident report, dated 08/22/19 at 8:06 p.m., documented the resident was found on the floor on his right side beside his bed. The report documented the resident had a skin tear to his right elbow. The report documented the wound was cleansed and the skin was approximated, steri-strips were applied and the wound was covered with a non- stick dressing. The report documented the resident was assisted back to his bed. The report documented there were no interventions to prevent future falls. An incident report, dated 08/22/19 at 9:30 p.m., documented the resident was found lying on his right side with his head bleeding. The report documented the resident had a one inch laceration on his right forehead about one half inch above his right eyebrow. The report documented the resident was assisted to his Geri-chair where the wound was cleansed, steri-strips were applied, and a nonstick dressing was applied. The report documented the intervention was the resident was moved to the television area in his Geri-chair for observation. An update to the care plan, initiated on 08/23/19, documented: 8/22/19 - Unwitnessed fall with minor injury 8/22/19 - Unwitnessed fall with minor injury Contact PCP for lab and medication review to assess for possible underlying condition An incident report, dated 08/24/19 at 8:45 p.m., documented the resident was found on his floor mat next to his low bed. The report documented the resident had scrapped his right elbow on his low bed metal bedframe causing a 5 centimeter scratch with minimal bleeding. The report documented the wound was cleansed with normal saline and was covered with a dressing. The report documented the resident had no complaints of pain and was able to move all four extremities within normal limits. The report documented the resident was assisted to the Geri-chair and was brought to the nurses' station for supervision. The report documented oncoming staff would be notified and would continue to monitor. An update to the care plan, initiated on 08/26/19, documented: 8/24/19 - Unwitnessed fall with minor injury Send for imaging as ordered Therapy to eval A final state reportable incident form, dated 08/26/19, documented the resident had complained of pain after a fall. The form documented an order for [REDACTED]. The form documented imaging at the hospital (name deleted) showed a right subcapital femoral neck fracture. The form documented the resident had a right hip arthroplasty while in the hospital. The form documented the resident returned to the facility and was to receive skilled nursing and therapy services. The form documented the resident's room was rearranged to align the bed along the wall. A hospital history and physical, dated 08/26/19, documented, .He has had multiple falls in the past at the nursing facility. Recently he fell out of bed x2. Recently patient has been complaining of right hip discomfort at which time x-rays were ordered and patient was diagnosed with [REDACTED].Radiological exams done showed right subcapital femur fracture. Patient is now being admitted for higher level care. He is cleared for surgery . On 09/18/19 at 12:10 p.m., the resident was observed in the assisted dining room in a Broda chair. On 09/19/19 at 10:14 a.m., the resident was observed in bed lying on his back in a low bed. The resident had a fall mat next to his bed, a pillow between his knees, and had heel protectors in place. On 09/23/19 at 12:26 p.m., CNA #2 was asked about the resident's falls. She stated the resident constantly wandered. She stated she would try to offer a snack or coffee. She stated she worked on the day shift and the resident fell in the evening or night. On 09/23/19 at 1:11 p.m., CNA #1 was asked about the resident's falls. She stated the resident usually fell on a different shift. She stated she worked days and felt they had enough staff on her shift. She stated she thought the locked unit had more call-ins in the evening. She was asked about interventions to prevent falls for this resident. She stated he wore non- skid socks. She stat

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene in a timely manner for a resident with constipation for one (#5) of eight sampled residents whose records were reviewed. The resident required removal of impacted stool at the hospital The administrator identified 105 residents resided in the facility. Findings: Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 03/09/18, documented the resident was moderately impaired cognitively, was independent with most ADLs, and was continent of bowel. A care plan, dated 03/09/18, documented: Problem: Constipation Goal: Resident will have a normal bowel movement every three days. Interventions: Monitor vital signs as ordered. Notify physician of any abnormal unexplainable reading. Monitor/document/report PRN s/sx of complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, [MEDICAL CONDITION], abdominal distention, vomiting, small loose stools, fecal smearing, bowel sounds, diaphoresis, abdominal tenderness, abdominal guarding, abdominal rigidity, and/or fecal impaction. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow-up as indicated. A bowel elimination record, dated (MONTH) (YEAR), documented, the resident had no bowel movements between 03/02/18 and 03/22/18. A Medication Administration Record, [REDACTED] interventions had been initiated for bowel elimination. A bowel elimination record, dated (MONTH) (YEAR), documented, the resident had no bowel movement between 04/01/18 and 04/09/18, and 04/19/18 through 04/30/18. A Medication Administration Record, [REDACTED]. A bowel elimination record, dated (MONTH) (YEAR), documented, the resident had no bowel movement between 05/01/18 through 05/06/18, 05/11/18 through 05/20/18, and 05/22/18 through 05/31/18. A Medication Administration Record, [REDACTED]. A bowel elimination record, dated (MONTH) (YEAR), documented, the resident had no bowel movement betweeen 06/02/18 through 06/05/18, 06/07 through 06/10/18, and 06/19/18 through 06/25/18. A Medication Administration Record, [REDACTED]. A progress note, dated 06/10/18 at 2:19 p m., documented, .received new order for [MEDICATION NAME], which was then called into the pharmacy by (physician) resident is currently not on any stool softeners. dr (name deleted) to order stool softener as well . A Medication Administration Record, [REDACTED]. A progress note, dated 06/18/18, documented the resident had been admitted to hospice services. A significant change assessment, dated 06/19/18, documented the resident required limited to extensive assistance with most ADLs, was always incontinent of bowel. A progress note, dated 06/27/18, documented the resident had been removing feces from his brief and digging at his rectum. The note documented the staff had been checking on the resident every 15-20 minutes and the resident had been continuously digging at his brief. A bowel elimination record, dated (MONTH) (YEAR), documented the resident had no bowel movement between 07/04/18 through 07/08/18, 07/17/18 through 07/20/18, and 07/23/18 through 07/27/18. A Medication Administration Record, [REDACTED]. A bowel elimination record, dated (MONTH) (YEAR), documented the resident had bowel movements every three to four days throughout the month. A hospice skilled nurse note, dated 08/10/18, documented the resident had smeared fecal matter on himself and his blankets. A Medication Administration Record, [REDACTED]. The Medication Administration Record [REDACTED]. A Medication Administration Record, [REDACTED]. The Medication Administration Record [REDACTED]. A progress note, dated 09/02/18, documented the resident had been more anxious, more confused, and had been digging in his rectum. A progress note, dated 09/03/18 at 1:40 p.m., documented, resident having episodes of trying to dig bowl (sic) out of rectum resident covered in bm x3 today, having increased confusion. Resident having x1 episode of vomiting .Resident also requesting to go to hospital x2 after resident vomited he got choked alittle (sic) this nurse was called to room and resident was breathing normal but had decreased loc. contacted (name deleeted) from hospice and family - family requested resident be sent to (hospital) for eval and tx with ct of stomach to eliminate obstruction. Resident does have sluggish bowl (sic) sounds vs 98/62 pulse 100 - notified don. Emergency department triage vitals on 09/03/18 at 2:16 p.m., documented the resident's blood pressure was 63/31. An emergency room record, dated 09/03/18 at 2:09 p.m., documented: .wood manor stated that yesterday noticed fecal matter hanging out of anus and that pt. (sic) Was digging at it. States threw up yesterday and appeared brown . Pt. is groaning with lower abdominal pain, while holding abdomen . An emergency room note, dated 09/03/18 at 4:40 p.m., documented .dug out a huge amount of hard feces from patient's rectum A radiology report, dated 09/03/18 at 5:40 p.m. through 5:49 p.m., documented, .CT abdomen pelvis without contrast 9/3/2018 Indication: Abdominal pain. Severe stomach pain and moderate stool . Findings: .a very large amount of stool is impacted in the rectum with rectal wall thickening. moderate constipation seen in the sigmoid colon as well. distended fluid-filled loops of small and large bowel proximal to the sigmoid colon . Conclusion: Very large amount of impacted stool in the rectal vault. This appears to cause a pseudoobstruction with some distended fluid-filled loops of bowel proximal to this, including small and large bowel . An emergency room note, dated 09/03/18 at 5:56 p.m., documented, CT showed a large amount of stool and pseudoobstruction. Patient has had 2-3 large bowel movements since I disimpacted him. I feel if he continues to clear out this stool burden he will improve. If he does not she will use enemas. She will bring him back if he has increased pain abdomen becomes distended vomiting Cetera. A progress note, dated 09/03/18, at 8:28 p.m., documented, resident arrived back to facility LTC via (name deleted) EMS, nurse notes resident is lethargic and smells of feces .he is picking at the air and covers . A progress note, dated 09/03/18 at 8:30 p.m., documented, resident's daughter called facility and was very upset. She reported she was upset 'no one had dug him out and the facility is who let him get dehydrated cause they no one (sic) ever gives him fluids or allows him to have access to them' . The next entry in the electronic medical record was dated 09/04/18 at 9:33 a.m., and was an interdisciplinary team note regarding a fall that occurred on 09/01/18. It did not include any information regarding the resident currently. The next progress note, dated 09/04/18 at 2:00 p.m., documented, Aprox (approximately) 0945 (9:45 a.m.) said resident not responding to stimuli, resp shallow and vs 94/80, 70 o2 (oxygen) unable to obtain, pupils sluggish. notified hospice nurse (name deleted) on her way to facility .1400 (2:00 p.m.) resident had 0 resp (respirations) 0 pulse 0 b/p (blood pressure) . The resident's death certificate documented the immediate cause of death [MEDICAL CONDITION] with Parabacteroides Species. Significant condition contributing to his death included + Fecal Impaction. On 09/26/18 at 11:40 a.m., CNA #1 was asked what the facility bowel protocol consisted of. She stated if a resident had no bowel movement in three days, the computer flags the resident. She stated at this point the nurse was notified and the nurse would then notify the CMA to give the resident medication for their bowels. CNA #1 was asked if any staff member had checked the resident related to constipation. She stated she could visualize stool in the rectum and the resident had been sent to the hospital. On 09/26/18 at 2:07 p.m., LPN #1 was asked what process was in place for a resident who had no bowel movement after three days. She stated the CNAs document, the CMAs treat, and the nurses supervise. She stated the nurse computer charting does not automatically flag if a resident has not had a BM. She stated the information is available in another area of documentation. She stated in order to access the information, the nurse must go to that section specifically. The nurse was asked how she ensures she receives the information. She stated she depended on the CNAs to inform her of those residents that had no BM after three days. On 09/26/18 at 2:27 p.m., CMA #1 was asked what process was in place for a resident who was not having bowel movements. She stated the nurse aides document and then inform the nurses if a resident had gone three days without a bowel movement. She stated the nurse then informed them and medication would be administered. The CMA was asked if a notice appeared on their computer when giving medications to inform them if a resident has had a bowel movement. She stated the information is there, however the resident is not flagged. She stated she would have to go to the specific area of documentation to be able to review the bowel movements. The CMA was asked if she was aware the resident had been consitpated. She stated the nurse had asked her if the resident had anything ordered for his bowels. She stated she informed the nurse the resident had nothing ordered. She stated she had not monitored the resident's bowel movements. The CMA was asked if she was aware the resident had been removing stool from his rectum. She stated she was aware but did not know if the resident was constipated or had been exhibiting a behavior related to his dementia. On 09/26/18 at 2:50 p.m., CNA #3 was asked what process was followed for a resident who had no bowel movement. She stated after three days the computer notified the CNA who then reported it to the nurse. She was asked if she had cared for the resident. She stated she had and his behavior had changed and he had appeared to be in pain. She stated the resident had been having regular bowel movements that were soft. On 09/26/18 at 3:10 p.m., CMA #2 was asked what process was followed when a resident has no bowel movement. He stated the CNAs were the first to be aware. He stated the nurse would probably tell him to administer a medication to the resident if the resident had no bowel movement after three days. The CMA was asked how he discovered if a resident has had no bowel movement. He stated he did not know how to find the information in the computer. He stated he expected the CNA to inform the nurse and she would then tell him to administer medication to the resident. The CMA was asked if he had given the resident any medication for constipation. He stated he had but could not remember what medication it was. The CMA was asked if he was aware the resident had been removing BM from his rectum. He stated he was increasingly doing it and he thought it was possibly behavior related. On 09/26/18 at 3:30 p.m., the director of nursing was asked what she expected the nurses to do if a resident was having hard stools. She stated she would expect the nurses to notify the physician and obtain an order for [REDACTED]. The director of nursing was asked if the resident had ever received a stool softener. She stated no. She was asked if she knew why the stool softener was not ordered as documented at the time the pain medication had been ordered. She stated the physician contacted the pharmacy regarding the pain medication but must have overlooked ordering the stool softener. The director of nursing was asked what she would expect the nurses to do if a resident had no interventions in place for bowel elimination. She stated the nurses should have ensured the stool softener had been ordered. The director of nursing was asked if the resident had received medication for constipation. She stated the resident had an order for [REDACTED]. The director of nursing was asked why a second order for [MEDICATION NAME] was obtained on 08/17/18 to be given for five days and completed on 08/21/18. She stated she did not know. The director of nursing was asked what intervention she would expect the resident to have in place. She stated she would expect the resident to have a scheduled stool softener or laxative. The director of nursing was asked why the facility policy had not been followed. She stated she did not know.

Based on observation, interview and record review, it was determined the facility failed to ensure residents did not develop pressure ulcers and received care and interventions to prevent and treat pressure ulcers by failing to: ~ ensure thorough and accurate assessments were performed of pressure ulcers; ~ consistently provide wound care treatments as ordered by the physician; ~ develop care plans for the prevention and treatment of [REDACTED].>~ monitor resident's weights as ordered by the physician; ~ notify the dietician of severe weight loss for a resident with pressure ulcers; ~ notify the physician of severe weight loss, the development of new areas of skin breakdown in a timely manner, or of recommendations by a wound care physician for needed laboratory testing; and ~ obtain a [MEDICATION NAME] lab test as recommended by the wound physician for one (resident #1) of six sampled residents with pressure ulcers. The resident developed an unstageable necrotic pressure ulcer with a wound infection, was transferred to the hospital and died ten days later due [MEDICAL CONDITION]. Findings: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician's admission order, dated [DATE], documented to obtain a weight every 72 hours for two administrations and to obtain a weekly weight for 4 weeks. A facility Weights and Vitals Summary sheet, dated [DATE], documented the resident weighed 142.7 pounds. A Nursing Admission Screening/History, documented the resident had two surgical incisions to the right hip, eight blisters to the bilateral lower extremities and one Stage I pressure ulcer to the right inner ankle. No areas of skin breakdown were identified to the buttocks, sacrum or coccyx areas. A skin observation tool, dated [DATE], documented the resident had shearing on her left and right buttocks. The tool documented the wound on the right buttock measured 1.0 centimeters (cm) long x 0.6 cm wide x 0.1 cm deep and the left buttock measured 1.8 cm long x 0.6 cm wide x 0.1 deep. A physician's telephone order, dated [DATE] at 9:50 a.m., documented apply Hydrogel and cover both buttock areas with dry dressing twice a day for shearing. The order summary sheet and the treatment administration record (TAR) documented the Hydrogel start date was to be on [DATE]. The [DATE] TAR was blank for the Hydrogel treatment to be provided on the evening shift on [DATE]. An [DATE] TAR documented, Obtain weight every 72 hours for 2 administrations -Order Date- [DATE] 1800 The TAR documented this was due on [DATE]. The area to document that the weight was obtained on [DATE] was blank. A facility WEEKLY PRESSURE SORE QI (quality indicator) LOG form, dated [DATE], documented the resident had a facility acquired stage II sacral wound with the treatment of [REDACTED]. A Treatment Administration Record (TAR), dated [DATE], did not contain documentation that wound care treatment had been completed on the day shift on [DATE]. A TAR for [DATE] documented the resident's weekly weight was to be obtained on [DATE]. The area to document the weight was obtained was blank. A Braden Scale for Predicting Pressure Sore Risk, dated [DATE], documented the resident was at risk for developing a pressure sore. An admission assessment, dated [DATE], did not contain documentation of the resident's cognitive status. The assessment documented the resident required extensive assistance with most activities of daily living including bed mobility and had one stage II pressure ulcer. A review of the clinical record documented no care plan had been developed that identified the resident to be at risk for pressure ulcers or to address her current skin breakdown and treatments. A Skin Observation Tool, dated [DATE], documented the resident had a raw area on her sacrum. The tool documented the area measured 3.2 cm long x 2.5 cm wide x 0.1 cm deep. There was no documentation of a full assessment of the resident's wound characteristics. There was no documentation to show the physician had been notified of the skin breakdown to the resident's sacrum. A facility Weekly Pressure Ulcer Sore QI Log, dated [DATE], documented the sacral wound measured 3.2 cm long x 2.5 cm wide x 0.1 cm deep. The log documented the wound had drainage but no odor. There was no documentation of a full assessment of the resident's wound characteristics. A TAR, dated [DATE] documented no wound care treatment had been completed on [DATE] on the evening shift. A TAR, dated [DATE] documented no wound care treatment had been completed on [DATE] on the day shift. A TAR for [DATE] documented the resident's weekly weight was to be obtained on [DATE]. The area to document that the weight was obtained was blank. A Skin Observation Tool, dated [DATE] at 7:25 p.m., documented the resident had an unstageable pressure ulcer to the coccyx that measured 6cm long x 5.8 cm wide with a depth of 1.5cm. There was no documentation of a full assessment of the resident's wound characteristics. A physician's orders [REDACTED].Apply to coccyx topically every day shift for wound cleanse wound to coccyx with wound cleanser, apply santyl and cover with dry dressing. A physician's orders [REDACTED]. A facility Weights and Vitals Summary, dated [DATE], documented the resident weighed 131 pounds. The summary documented the resident had an 11.7 pound weight loss since admission. This was a severe weight loss of 8.1% in 15 days. The weights and vitals summary report documented only two weights had been obtained for the resident, the weight of 142.7 on [DATE] and this weight of 131 on [DATE]. A facility Skin Observation Tool, dated [DATE] at 3:06 p.m., documented the resident had an unstageable pressure ulcer to the coccyx measuring 8.0 cm long x 5.0 cm wide, with a depth that was not measurable. There was no documentation of a full assessment of the resident's wound characteristics. A wound care specialist initial evaluation, dated [DATE], documented the resident had an unstageable (due to necrosis) pressure wound of the medial sacrum. The wound size was 8 x 5 x not measurable cm. There was moderate serous exudate and 100% thick adherent devitalized necrotic tissue. Recommendations included, Gel cushion to chair, group-2 mattress . The evaluation also documented the resident's appetite was poor, a [MEDICATION NAME] was recommended and the wound was foul smelling. A physician's orders [REDACTED].Give 1 tablet by mouth two time a day for Wounds for 28 Administrations. A nurse's note, dated [DATE] at 8:39 a.m., documented, Gel cushion has been ordered. Group 2 mattress is now on the resident's bed. A facility Weekly Pressure Sore QI Log, dated [DATE], documented the resident had a facility acquired pressure ulcer to the coccyx that measured 8.0 cm long x 5.0 cm wide. The log documented the depth was not measurable, the wound had an odor and drainage, and was treated with Santyl. A nurse's note, dated [DATE] at 7:45 a.m., documented, Heard resident hollering for help. Upon entering room found resident in a full body shiver and covered completely up. Resident denies being cold. Upon further assessment found resident to have purple hands bilaterally. V.S. (vital signs) T (temperature) - 99.3 temporal P (pulse) - 55 R (respirations) - 24 BP (blood pressure) - ,[DATE] O2 (oxygen) Sat (saturation) room air - 78%. Notified Dr. (name deleted). A progress note, dated [DATE] at 8:46 a.m., documented the resident was sent to the hospital. An Emergency Department record from the hospital documented the visit date was [DATE] at 10:02 a.m. A nursing progress note from the emergency department, performed on [DATE] at 10:30 a.m., documented, incontinent care provided - pt arrives from Nursing home with diaper with loose stool present - stool also present into lower section of deep open wound . An ED (Emergency Department) Physician Note, dated [DATE] at 10:45 a.m., documented: .Wound infection - complicated . dose weight 52.2Kg (kilograms) (114.8 pounds) . Large sacral ulcer: ,[DATE]cm x ,[DATE]cm area of deep ulceration with purulent drainage, very malodorous . A Discharge Summary from the hospital, dated [DATE], documented: .date of death : [DATE] at 04:06 (4:06 a.m.) Reason For Admission: Sepsis due to severe unstageable sacral decubitus wound. Cause of Death: 1. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] 2.[MEDICAL CONDITION], severe, secondary to unstageable sacral decubitus wound. 3. Sacral decubitus wound due to pressure ulceration; patient appeared to have been left in her own feces and urine for extended periods of time causing severe breakdown, not present at time of previous and recent discharge from the hospital. Hospital Course: The patient was a [AGE] year-old female who had recently been admitted for [MEDICAL CONDITION]. She was readmitted from the nursing facility that she had been discharged to. Upon arrival in the emergency room she was noted to have vital signs consistent with SIRS (Systemic [MEDICAL CONDITION] Response Syndrome) criteria and a source of infection from either significant diarrhea or the severe decubitus wound. The patient had a very large amount of necrotic tissue present in this wound that was extremely deep, likely to the level of the bone, but this could not be seen due to the large amount of stool that was in the wound at the time of the patient's presentation. Upon my visit in the emergency room , I discussed with the patient who is awake and alert and well oriented at the time that at her age and with her current nutritional status and overall health, I found it very unlikely that she would ever recover from such a wound and that it would likely require multiple surgeries, [DEVICE] and aggressive wound therapy to even make an attempt at this wound being healed. I also discussed aggressive management and treatment of [REDACTED]. Unfortunately the patient did not die in a quick manner but she was kept comfortable for the length of her stay . On [DATE], the resident's physician stated he was unsure if the resident was admitted with the wound to her coccyx. He stated he monitored the surgical wound and it was healing well. He stated that he was notified of the unstageable wound to the coccyx and immediately referred this to the wound physician. On [DATE] at 10:08 a.m., licensed practical nurse (LPN) #6 was contacted regarding the wound care she had provided for the resident. The LPN stated when the resident was admitted to the facility she had a red bottom. The LPN stated approximately two days later the resident's bottom looked like it was opening up and the skin was sloughing off. The LPN was asked if she had contacted the resident's primary care physician regarding the change in the resident's condition as the resident now had an open area on her bottom. She stated she had not notified the physician. The LPN stated she had been told by the director of nursing at that time to contact the wound care specialist. The LPN was asked when had she contacted the wound care specialist. She stated approximately one week later. On [DATE] at 11:15 a.m., the assistant director of nursing (ADON) was asked if a [MEDICATION NAME] lab test had been performed for the resident. The ADON stated she did not know but she would go and check. On [DATE] at 12:15 p.m., the certified dietary manager (CDM) was asked what happened when a resident experienced weight loss. She stated she was notified by nursing staff and she would immediately notify the dietician either by phone or fax. The CDM stated the dietician had remote access from home and was able to view the resident charts. The CDM stated the dietician would either write new orders or fax new orders to the facility as warranted. She stated she would then inform the nursing staff of order changes. The CDM was asked what interventions would be put in place for a resident who experienced weight loss until the dietician evaluated the resident. She stated she would wait for the dietician's recommendation. The CDM was asked if she had notified the dietician of the resident's weight loss. She stated she could not remember, but thought she had. She stated she would look for documentation related to notifying the dietician. The CDM was unable to produce any documentation that the dietician had been notified of the resident's weight loss. On [DATE] at 4:50 p.m., the dietician was asked if she had seen resident #1. She stated she had not visited the resident, however she had reviewed the resident's record on [DATE] when she made rounds. She stated she wrote progress notes on [DATE], but the resident had already been admitted to the hospital. The dietician was asked if she had been notified by the CDM by phone or fax regarding the resident's weight loss. She stated she had not been notified of the resident's weight loss. She stated the CDM had not been performing clinical duties until [DATE]. On [DATE] at 4:00 p.m., the ADON reported to the survey team that she could not find any documentation to show the resident's [MEDICATION NAME] lab test had been done. The ADON was asked if she knew why the [MEDICATION NAME] had not been done. The ADON was asked if a physician other than the resident's primary care physician (PCP) made a recommendation that a lab test be done would the staff carry out the order. She stated if another physician made a recommendation for a lab test the nursing staff would need to contact the PCP to ensure the PCP wanted to carry through with the recommendation. The ADON was asked if the resident's PCP had been notified of the wound specialist's recommendation that a [MEDICATION NAME] lab test be done. She stated she did not know.

On 06-19-14 at 5:00 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to complete a thorough investigation for an allegation of sexual abuse and failure to ensure residents were protected until a thorough investigation was completed. On 06-19-14 at 5:20 p.m., Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. On 06-19-14 at 5:40 p.m., the administrator and director of nursing were notified of the IJ situation. On 06-19-14 at 8:00 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of Correction dated 06/19/14 DON (director of nursing) or designee will be in charge of completing in person or via phone an all staff in-service regarding abuse and neglect within the next 48 hours. All further reports of abuse and neglect will be monitored by the DON or designee for the next 3 months. Abuse Policy will be updated to include the following: Any employee reported for abuse, or suspected of abusing a resident will immediately be placed on un-paid suspension pending an investigation. Administrator will terminate employee in question, (name deleted) effective immediately. Staff has at this time been unable to notify him via phone. Shift supervisors will be alerted to direct him from the building should he come to the building. Administrator will complete pending investigation and faxed completed report to state. This investigation will be completed in the next 48 hours..." The IJ was removed on 06-20-14 at 4:30 p.m. after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to implement abuse policies and procedures for 1 (#1) of 3 sampled residents who were reviewed for abuse allegations. The facility failed to: a. thoroughly investigate in a timely manner an allegation of sexual abuse for resident #1. b. protect other residents in the facility during an investigation of an allegation of sexual abuse for resident #1. The administrator identified 118 residents in the facility. Findings: A facility abuse policy, undated, documented, "...It is the policy of (facility name deleted) that every resident has the right to be free from abuse...Residents may not be subjected to abuse by anyone...The facility procedure to follow upon witnessing, or receiving an allegation of resident abuse or an unusual occurrence that needs to be reported to State Department of Health and Department of Human Services is as follows...7. The Administrator or their designee will then suspend or place the accused employee in an area of non-patient contact, if abuse is the issue, until the allegations are thoroughly investigated and/or cleared..." A second facility abuse policy given to this surveyor during the investigation, undated, documented, "...The facility procedure to follow upon witnessing or receiving an allegation of resident abuse or an unusual occurrence that needs to be reported to the State Department of Health and Department of Human Services is as follows...8. The resident will be removed from potential harm during an investigation by transferring the resident to a hospital, suspending a suspected staff member, and/or removing the resident or reassignment of staff member from the immediate area..." Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 06-13-13, documented resident #1 was severely impaired cognitively, required extensive assistance with activities of daily living, did not ambulate, was incontinent of bowel and bladder, and had no episodes of [MEDICAL CONDITION] or behaviors. The resident's care plan, dated 06-17-13 and updated 12-20-13, documented the resident experienced a cognitive deficit related to decision making and periods of confusion. The care plan documented the resident was incontinent of bowel and bladder with interventions for staff to check and change the resident every two to four hours and as needed, and that the resident wore personal protection products for incontinence. A quarterly assessment, dated 03-13-14, documented resident #1 was severely impaired cognitively, required extensive assistance with activities of daily living, did not ambulate, was always incontinent of bowel and bladder and on a toileting program to manage bowel incontinence, had no episodes of [MEDICAL CONDITION] or behaviors, was usually able to make self understood, and could usually understand others. An initial incident report filed with the Oklahoma State Department of Health, dated 06-12-14, documented, "...(name deleted) requested a meeting with me regarding her mother, (resident #1). She reported that a man had been in her mother's room and had tried to touch her inappropriately. Both (name deleted) and resident #1 were unable to provide a for sure time line but thought it was this morning. With multiple male staff members on the shift in question and no clear description. For the safety of the resident in question, all male aides were instructed not to provide care to resident #1 until further notice..." A notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property, dated, 06-12-14, documented certified nurse assistant (CNA) #1 was not suspended or terminated pending investigation. On 06-19-14 at 12:15 p.m. the administrator was asked about the incident on 06-12-14. The administrator stated she was made aware of a statement by the resident to the assistant director of nursing (ADON) that resident #1 had been touched inappropriately. The administrator stated a meeting with resident #1 and her daughter had taken place that afternoon. The administrator was asked when she became aware of who the staff person was, did she suspend them. She stated no. The administrator stated she was placed on another care area and all males were instructed to not enter or care for resident #1 pending investigation. The administrator was asked why she waited 5 days to notify police of the investigation. She stated her initial investigation showed nothing inappropriate had happened and did not feel police involvement was necessary. The administrator was asked if she had interviewed other alert and oriented residents on the same hall as resident #1, and if they had observed anything suspicious or if they had experienced inappropriate touching. She stated no, only resident #1's roommate. The administrator was asked if the physician had been notified and asked to examine resident #1. She stated no. The administrator was asked if over the course of her investigation had she spoken with resident #1 about the allegation, her concerns, or her feelings. She stated no, that resident #1's family had asked her not to do this. The administrator was asked if she had finished her investigation within 5 working days. She stated she was continuing to investigate and had not completed the investigation. On 06-19-14 at 1:10 p.m., resident #1 was interviewed along with resident #2, her roommate. Resident #1 was observed sitting in her wheelchair in her room. She was asked about the events on 06-12-14. She stated, "I was getting ready to get up and he was doing something 'down there' and I yelled for him to stop and get out as I was married." Resident #1 stated she was very upset but did not tell the nurses. Resident #1 was asked if she recognized the person who touched her. She stated no, she had never seen him before. Resident #2 was observed sitting in her wheelchair in her room. Resident #2 stated she was asleep at the time and did not hear resident #1 yell. Resident #2 stated resident #1 was known to yell for help instead of using the call light for staff assistance. Resident #2 was asked if she recognized the CNA in question. She stated yes that he was a new employee and had taken care of her on several occasions during the night. Resident #2 was asked if he had touched her inappropriately. She stated no. On 06-19-14 at 2:40 p.m., a call was placed to the (name deleted) police department to obtain a copy of the police report. The officer who had responded to the call to investigate the complaint was not available at that time. The officer who answered the phone stated a return call to this surveyor by the lieutenant in charge of the division would take place that day. On 06-23-14 at 8:40 a.m., CNA #1 was interviewed regarding the alleged incident on 06-12-14. CNA #1 stated he was a float aide that night and was asked by the assigned CNA to get resident #1 up for the morning. CNA #1 was asked what did that mean. He stated between 5:00 a.m. and 6:00 a.m., resident #1 was awakened, taken to the toilet, and dressed for the morning. CNA#1 stated there was nothing unusual about that morning. He stated when resident #1 sat up on the side of the bed, he felt her brief to see if it was wet. CNA #1 was asked if resident #1 yelled for him to stop and get out of her room. He stated no. CNA #1 stated she was her usual self that morning and when he finished with her care, he pushed her to the front lobby by the nurses' station where she sat each morning. CNA #1 was asked when he touched resident #1's brief, did he put his hand inside the brief. He stated no, only the outside. CNA #1 was asked if he had cared for resident #1 in the past. He stated yes, on several occasions. On 06-23-14 at 12:35 p.m., a follow-up telephone call was made to the (name deleted) police department as no return telephone call had been received by this surveyor from the officer in charge. The phone call was re-directed to the records division and a copy of the police report was faxed to the surveyor that day. On 06-23-14 at 1:30 p.m., a police department report was obtained. The report showed documentation an officer responded to the facility on [DATE] at 10:08 a.m. to obtain information regarding the alleged incident. The police report contained only a summary of the incident as presented by the facility. The police report showed no documentation of a determination of findings.

On 06-19-14 at 5:00 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to complete a thorough investigation for an allegation of sexual abuse and failure to ensure residents were protected until a thorough investigation was completed. On 06-19-14 at 5:20 p.m., Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. On 06-19-14 at 5:40 p.m., the administrator and director of nursing were notified of the IJ situation. On 06-19-14 at 8:00 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of Correction dated 06/19/14 DON (director of nursing) or designee will be in charge of completing in person or via phone an all staff in-service regarding abuse and neglect within the next 48 hours. All further reports of abuse and neglect will be monitored by the DON or designee for the next 3 months. Abuse Policy will be updated to include the following: Any employee reported for abuse, or suspected of abusing a resident will immediately be placed on un-paid suspension pending an investigation. Administrator will terminate employee in question, (name deleted) effective immediately. Staff has at this time been unable to notify him via phone. Shift supervisors will be alerted to direct him from the building should he come to the building. Administrator will complete pending investigation and faxed completed report to state. This investigation will be completed in the next 48 hours..." The IJ was removed on 06-20-14 at 4:30 p.m. after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to: a. thoroughly investigate in a timely manner an allegation of sexual abuse for 1 (#1) of 3 sampled residents who were reviewed for abuse allegations. b. protect other residents in the facility during an investigation of an allegation of sexual abuse for 1 (#1) of 3 sampled residents who were reviewed for abuse allegations. The administrator identified 118 residents in the facility. Findings: A facility abuse policy, undated, documented, "...It is the policy of (facility name deleted) that every resident has the right to be free from abuse...Residents may not be subjected to abuse by anyone...The facility procedure to follow upon witnessing, or receiving an allegation of resident abuse or an unusual occurrence that needs to be reported to State Department of Health and Department of Human Services is as follows...7. The Administrator or their designee will then suspend or place the accused employee in an area of non-patient contact, if abuse is the issue, until the allegations are thoroughly investigated and/or cleared..." A second facility abuse policy given to this surveyor during the investigation, undated, documented, "...The facility procedure to follow upon witnessing or receiving an allegation of resident abuse or an unusual occurrence that needs to be reported to the State Department of Health and Department of Human Services is as follows...8. The resident will be removed from potential harm during an investigation by transferring the resident to a hospital, suspending a suspected staff member, and/or removing the resident or reassignment of staff member from the immediate area..." Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 06-13-13, documented resident #1 was severely impaired cognitively, required extensive assistance with activities of daily living, did not ambulate, was incontinent of bowel and bladder, and had no episodes of [MEDICAL CONDITION] or behaviors. The resident's care plan, dated 06-17-13 and updated 12-20-13, documented the resident experienced a cognitive deficit related to decision making and periods of confusion. The care plan documented the resident was incontinent of bowel and bladder with interventions for staff to check and change the resident every two to four hours and as needed, and that the resident wore personal protection products for incontinence. A quarterly assessment, dated 03-13-14, documented resident #1 was severely impaired cognitively, required extensive assistance with activities of daily living, did not ambulate, was always incontinent of bowel and bladder and on a toileting program to manage bowel incontinence, had no episodes of [MEDICAL CONDITION] or behaviors, was usually able to make self understood, and could usually understand others. An initial incident report filed with the Oklahoma State Department of Health, dated 06-12-14, documented, "...(name deleted) requested a meeting with me regarding her mother, (resident #1). She reported that a man had been in her mother's room and had tried to touch her inappropriately. Both (name deleted) and resident #1 were unable to provide a for sure time line but thought it was this morning. With multiple male staff members on the shift in question and no clear description. For the safety of the resident in question, all male aides were instructed not to provide care to resident #1 until further notice..." A notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property, dated, 06-12-14, documented certified nurse assistant (CNA) #1 was not suspended or terminated pending investigation. On 06-19-14 at 12:15 p.m. the administrator was asked about the incident on 06-12-14. The administrator stated she was made aware of a statement by the resident to the assistant director of nursing (ADON) that resident #1 had been touched inappropriately. The administrator stated a meeting with resident #1 and her daughter had taken place that afternoon. The administrator was asked when she became aware of who the staff person was, did she suspend them. She stated no. The administrator stated she was placed on another care area and all males were instructed to not enter or care for resident #1 pending investigation. The administrator was asked why she waited 5 days to notify police of the investigation. She stated her initial investigation showed nothing inappropriate had happened and did not feel police involvement was necessary. The administrator was asked if she had interviewed other alert and oriented residents on the same hall as resident #1, and if they had observed anything suspicious or if they had experienced inappropriate touching. She stated no, only resident #1's roommate. The administrator was asked if the physician had been notified and asked to examine resident #1. She stated no. The administrator was asked if over the course of her investigation had she spoken with resident #1 about the allegation, her concerns, or her feelings. She stated no, that resident #1's family had asked her not to do this. The administrator was asked if she had finished her investigation within 5 working days. She stated she was continuing to investigate and had not completed the investigation. On 06-19-14 at 1:10 p.m., resident #1 was interviewed along with resident #2, her roommate. Resident #1 was observed sitting in her wheelchair in her room. She was asked about the events on 06-12-14. She stated, "I was getting ready to get up and he was doing something 'down there' and I yelled for him to stop and get out as I was married." Resident #1 stated she was very upset but did not tell the nurses. Resident #1 was asked if she recognized the person who touched her. She stated no, she had never seen him before. Resident #2 was observed sitting in her wheelchair in her room. Resident #2 stated she was asleep at the time and did not hear resident #1 yell. Resident #2 stated resident #1 was known to yell for help instead of using the call light for staff assistance. Resident #2 was asked if she recognized the CNA in question. She stated yes that he was a new employee and had taken care of her on several occasions during the night. Resident #2 was asked if he had touched her inappropriately. She stated no. On 06-19-14 at 2:40 p.m., a call was placed to the (name deleted) police department to obtain a copy of the police report. The officer who had responded to the call to investigate the complaint was not available at that time. The officer who answered the phone stated a return call to this surveyor by the lieutenant in charge of the division would take place that day. On 06-23-14 at 8:40 a.m., CNA #1 was interviewed regarding the alleged incident on 06-12-14. CNA #1 stated he was a float aide that night and was asked by the assigned CNA to get resident #1 up for the morning. CNA #1 was asked what did that mean. He stated between 5:00 a.m. and 6:00 a.m., resident #1 was awakened, taken to the toilet, and dressed for the morning. CNA#1 stated there was nothing unusual about that morning. He stated when resident #1 sat up on the side of the bed, he felt her brief to see if it was wet. CNA #1 was asked if resident #1 yelled for him to stop and get out of her room. He stated no. CNA #1 stated she was her usual self that morning and when he finished with her care, he pushed her to the front lobby by the nurses' station where she sat each morning. CNA #1 was asked when he touched resident #1's brief, did he put his hand inside the brief. He stated no, only the outside. CNA #1 was asked if he had cared for resident #1 in the past. He stated yes, on several occasions. On 06-23-14 at 12:35 p.m., a follow-up telephone call was made to the (name deleted) police department as no return telephone call had been received by this surveyor from the officer in charge. The phone call was re-directed to the records division and a copy of the police report was faxed to the surveyor that day. On 06-23-14 at 1:30 p.m., a police department report was obtained. The report showed documentation an officer responded to the facility on [DATE] at 10:08 a.m. to obtain information regarding the alleged incident. The police report contained only a summary of the incident as presented by the facility. The police report showed no documentation of a determination of findings.

On 05-05-14 at 5:00 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure a resident was free of a significant medication error. The facility failed to discontinue an anticoagulant medication per the physician's orders [REDACTED]. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. On 05-05-14 at 5:15 p.m., the director of nursing (DON) was notified of the IJ situation. On 05-06-14 at 6:15 p.m., an acceptable plan of removal was presented to the survey team. The Plan of correction documented: "...1. Failure to transcribe physician orders [REDACTED]. A. This resident no longer resides in this facility. B. Review all current residents with orders for anticoagulants and audit for correct transcribing of medication, dosage and appropriate labs next 2 working days (May 6, 7) C. All new admission orders [REDACTED]. Immediate. D. Immediate plan to educate/in-service nursing staff on proper transcribing and to call for all clarification of orders. If orders are unreadable the charge nurse must call providing physician for further clarification. Before the employee next schedule shift to work...license Employees that are scheduled now will be inservice before leaving @ (at) 7 pm. All evening employees will be inserviced by (7:15 p.m.) and May 6(th) 7a-7p will be educated by 8 am on 5/6... E. This new system of ensuring proper transcribing will be followed by Quality Assurance/ADON and DON weekly for 90 days until it is proven that this process put in place is effective. Completion Date for this deficiency will be May 14, 2014" The IJ was removed on 05-06-14 at 9:05 a.m. when the components of the plan had been completed. The deficient practice remained at a level of actual harm at a pattern level. Based on interview and record review, it was determined the facility failed to ensure a resident was free of a significant medication error for 1 (#4) of four sampled residents who were receiving anticoagulant therapy. The facility failed to follow a physician's orders [REDACTED]. The facility continued to administer the anticoagulant six days after receiving the order to discontinue the medication for resident #4. A hospital discharge summary, dated 03-26-14, documented, "...The patient was admitted with lower [MEDICAL CONDITION]" The medical records staff member identified 17 residents who were receiving anticoagulant therapy. Findings: A facility physician orders [REDACTED]. Read and note physician orders [REDACTED]. 2. Transcribe the orders to the appropriate form, ie: treatment sheet, MAR (medication administration record), etc. Make sure to date and initial. 3. Notify appropriate departments, physician office if consult or referral is made, and chart in nurse's notes. 3. After noting orders, write noted with your name, date, and time. ADDENDUM: To NOTE an order signifies that you have documented and implemented all that is contained in the order." Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission/start-up order sheet, dated 12-04-13, documented to administer [MEDICATION NAME] 75 milligrams (mg) daily and aspirin 81 mg daily. An initial assessment, dated 12-11-13, documented the resident was cognitively intact, required limited to extensive assistance with activities of daily living (ADL), was occasionally incontinent of bowel and bladder, and had not received any anticoagulant medications in the last seven days of the look back period. A laboratory report, dated 12-23-13, documented a hemoglobin (Hgb) result as 10.2 with a normal range of 14.0 to 18.0. A skilled daily nurse's note, dated 01-31-14, documented, "...send to (hospital name deleted) for tx (treatment) (and) Eval (evaluation). Critical Hgb 7.0..." A care plan, undated, documented, "...PROBLEM...Anticoagulant." The care plan did not contain any documentation under the goal or approach section of the care plan. A skilled daily nurse's note, dated 02-27-14, documented, "...Aide noticed what appeared to be blood in Residents BM (bowel movement). Dr. (name deleted) notified N/O (new order) for Guiac stool x (times) 3..." A laboratory report, dated 03-02-14, documented resident #4's Guiac stool specimen was positive for occult blood. The report documented the results had been faxed to the physician on 03-04-14. A skilled daily nurse's note, dated 03-03-14 at 7:30 a.m., documented, "...small skin tear R (right) top of hand...pressure applied..." The note documented at 12:00 p.m. "...R top hand bleeding again reapplied pressure x 5 min. (minutes) Dr (name deleted) notified of bleeding. cont (continue) to hold pressure. bleeding stopped. will cont to monitor..." A quarterly assessment, dated 03-06-14, documented the resident was cognitively intact, required limited to extensive assistance with ADLs, was occasionally incontinent of bowel and bladder, and had received an anticoagulant medication seven of the last seven days of the look back period. A skilled daily nurse's note, dated 03-09-14, documented, "...Resident to DR (dining room) for Breakfast coughing up large amount of blood (and) C/O (complained of) SOB (shortness of breath)...Dr. (name deleted) notified...Res (resident) sent to (hospital name deleted)..." A hospital discharge to facility record, noted on 03-12-14, documented a physcian order to "...Stop [MEDICATION NAME]/Xeralto..." A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A skilled daily nurse's note, dated 03-18-14, documented, "...Aide reported blood in residents stools this AM. N/O to send to (hospital name deleted) for treatment and Eval..." A hospital admit history and physical, dated 03-18-14, documented resident #4 had been admitted to the hospital for rectal bleeding. A hospital gastrointestinal (GI) consult, dated 03-18-14, documented resident #4 had a hemaglobin of 5.1 when he was admitted to the hospital. A hospital history and physical, dated 03-18-14, documented, "...I instructed the nursing facility to stop all [MEDICATION NAME] and Xarelto secondary to hemoptysis...I am not sure why the nursing home had him on both [MEDICATION NAME] and Xarelto when both were contraindicated. This was made clear to the nursing home physician at the time of the last discharge..." A hospital discharge summary, dated 03-26-14, documented, "...The patient was admitted with lower [MEDICAL CONDITION]. Of note, he was on [MEDICATION NAME], Xarelto, and aspirin at the nursing home. This was against prior instructions given to them. The patient has a history of CABG (coronary artery bypass graft) and the nursing home was instructed to stop all antiplate agents on the last discharge. GI was consulted lower GI bleed. He received fresh frozen plasma. Hemoglobin is stabilized..." A laboratory report, dated 03-26-14, documented resident #4 had a Hgb of 10.1. A facility medication error report, dated 03-26-14, documented, "...Description of error...Xaralto was not D/C'd (discontinued)...Corrective action taken...med (medicine) D/C'd..." The report documented the resident's physician had been notified and the record had been signed by the person making the error and the director of nursing (DON). On 05-05-14 at 2:15 p.m., licensed practical nurse (LPN) #2 was asked about the 03-12-14 hospital discharge orders for resident #4. She stated the resident's [MEDICATION NAME] had been stopped on 03-12-14 but she stated the orders had been hard to read and she had just missed the order to stop the Xaralto. LPN #2 was asked when she discovered the mistake. She stated when the resident returned from the hospital on 03-26-14 the error had been brought to their attention. She stated the resident's physician had been notified and a medication error report had been completed. On 05-05-14 at 2:50 p.m., resident #4's physician was asked about the medication error involving Xaralto. He stated he had been made aware the facility had not followed the physician's orders [REDACTED]. The physician was asked if this had or could have caused harm to resident #4. He stated the medication affected the clotting factor in the blood and therefore could have increased the resident's risk for bleeding. On 05-05-14 at 4:12 p.m., the DON was asked about the medication error for resident #4. She stated she had been made aware of the transcription error when the resident had returned from the hospital on 03-26-14. She stated at that time the physician had been notified and a medication error report had been completed. The DON was asked if she had investigated and educated staff at that time. She stated yes, she had educated the nursing staff regarding transcribing orders. She stated she had also instructed the staff to call for clarification on any orders that were not clear. The DON was asked if she had documented the education she had done with staff. She stated no.

Based on observation, interview, and record review, it was determined the facility failed to intervene to prevent/reduce unintended severe weight loss which had occurred over a 3 month period. This affected 1 (#93) of 3 sampled residents whose clinical records were reviewed for nutritional status/significant weight loss. The facility identified a total of 4 residents who had experienced significant weight loss. Findings: Resident #93 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #93's vital signs record documented her weights were as followed: 01/23/12 - 162.8 pounds 02/05/12 - 159.6 pounds 03/05/12 - 155.8 pounds 04/05/12 - 152 pounds (a 6.2% weight loss since admission) 05/05/12 - 149.8 pounds (an 11.3% weight loss in 90 days) 06/05/12 - 144 pounds (a 7.57% weight loss in 90 days) 07/05/12 - 136.8 pounds (a 5% weight loss in 30 days, 10% in 90 days and 15.97% in almost 180 days). A physician's orders [REDACTED]. The care plan, dated 02/03/12, documented the resident had a problem regarding her nutritional status and the potential for decline. The care plan documented the goal was for the resident to "consume adequate (calories) to meet nutritional needs, maintain/gain weight without decline (for) 90 days." The care plan documented approaches included: "...Monitor her weight for significant loss or gain notify family and physician." The dietary progress note, dated 04/26/12, written by the certified dietary manager (CDM), documented: "(Weight) 146 (pounds) -10 (pound) in 30 days or 6% loss. -17 (pounds) in 180 days or 10% loss. (if (weight) is correct) Will monitor next months (weight) before doing any (changes)." There was no documentation the resident's physician was notified of the significant weight loss. The care plan revision, dated 05/02/12, documented: "No changes noted this quarter. Continue current (care plan times) 90 days." The dietary consultant report, dated 05/21/12, documented the resident had a nutritional problem of "inadequate calories." The report documented the etiology was "related to progressing Alzheimer's." The report documented the signs and symptoms were "related to low meal intake." The report documented interventions/monitoring/evaluation was documented as "Remains on (consistent) carbohydrate diet - Memo - would this be (discontinued)." The care plan revision, dated 05/31/12, made by the CDM, documented: "(Weight) 150 (down) 13 (pounds) in 180 days or 7%. Will ask (registered dietician and doctor) for recommendations." The dietary progress note, dated 05/31/12, documented: "(Weight) 150 - 13 (pounds) in 180 days or 7% loss. Will ask (registered dietician) to send recommendations to (doctor)." There was no documentation the resident's physician was notified of the significant weight loss. The dietary consultant report, dated 06/25/12, documented resident had a nutritional problem of "suboptimal oral intake." The report documented the etiology was "related to inability to feed self/unable to communicate with staff." The report documented the signs and symptoms were "evidence by weight loss of 11% since admit---only 3.5% last 30 days." The report documented the interventions/monitoring/evaluation as "Goal to remain at 144 (pounds). She is only 60 inches - What is the goal on the care Plan? DISCUSS." There was no documentation the resident's physician was notified of the significant weight loss. The care plan revision, dated 07/20/12, made by the CDM, documented: "Continues (with weight) loss. Difficulty (with) making needs known. Will continue to encourage resident to consume more calories (and) to drink fluids offered." The dietary consultant report, dated 07/23/12, did not document resident #93 on the list of residents with a nutritional problem. On 07/30/12 at 9:15 a.m., the CDM provided a list of residents who received physician-ordered supplements with meals. Resident #93's name was not on the list. On 07/30/12 at 11:56 a.m., the surveyor asked registered nurse #1 if the resident received a nutritional supplement, defined as a prescribed high protein, high calorie, nutritional supplement between or with meals. She reviewed the clinical record and stated, "No." On 07/30/12 during the noon meal the resident was observed to feed herself. There were no supplements observed to be given to the resident. The quarterly assessment, dated 08/01/12, documented the resident had severe cognitive impairment; was independent with bed mobility, locomotion on/off the unit, and eating; required limited assistance with transfer, ambulation, dressing, toilet use and personal hygiene; and required extensive assistance with bathing; was occasionally incontinent of bladder and bowel; had no swallowing disorder; was 60 inches tall and weighed 136 pounds; had experienced significant weight loss but was not on a physician-ordered weight-loss program; and had no dental problems. The care plan revision, dated 08/02/12, made by licensed practical nurse/minimum data set/care plan (LPN/MDS/CP) coordinator #1, documented: "Note change in diet. Continue current (care plan with) changes (times) 90 days. The clinical record documented no diet change for the resident at any time between 03/29/12 and 08/02/12. Physician's progress notes, dated 04/24/12, 05/24/12 and 07/10/12, were reviewed. There was no documentation to indicate the physician was aware of the resident's severe weight loss. The facility's policy/procedure for determining weights documented: "Suggested Standards for Evaluating Significance of Weight Loss use % of body weight loss Interval Significant Loss Severe Loss 1 week 1-2% more than 2% 1 month 5% more than 5% 3 months 7 1/2 % more than 7 1/2% 6 months 10% more than 10%" The facility's procedure for weighing documented: "When a resident has a 5% or more monthly weight difference: A. Reweigh to verify the weight. B. Highlight any with 5% or more weight difference, under (Ideal Body Weight) range...C. All with undesirable weight loss, poor appetites and under (Ideal Body Weight) range weights should be receiving supplements." On 08/03/12 at 11:20 a.m., the surveyor showed the resident's weight loss history to the director of nurses (DON). The surveyor asked if the physician had been notified of the resident's severe weight loss at any time. The DON stated, "Not specifically, no." The surveyor showed the care plan to the DON and asked if the care plan was followed to notify the physician of the severe weight loss. She stated, "No." The surveyor asked the DON what approaches had been initiated in an attempt to prevent/reduce further weight loss. The DON stated no approaches had been initiated. The surveyor asked if there a facility policy and procedure which documented what was to be done for residents with significant/severe weight loss. The DON stated, "No." The surveyor showed the DON the policy which documented all residents with undesirable weight loss should receive supplements and asked if the policy had been followed in regard to resident #93. The DON stated, "No." The surveyor asked the DON if the facility had intervened to attempt to prevent/reduce further weight loss for resident #93. The DON stated, "No." On 08/03/12 at 11:45 a.m., the surveyor asked the CDM about the communication with nursing service in regard to residents with significant/severe weight loss. The CDM stated she obtained the weights from the nurses and put them in her book. She stated she completed a weight loss sheet and asked the nurses to help her determine why the weight loss occurred. She stated she gave the weight loss sheet to several nursing staff, including the DON. The CDM provided copies of the weight loss sheets. The sheet, dated 04/13/12, documented the resident had lost 10 pounds in 30 days or 6% and 17 pounds in 180 days or 10%. The bottom of the sheet documented: "Nursing to notify family and (doctor) of weight loss or gain." The weight loss sheet, dated 06/08/12, documented the resident had lost 6 pounds in 30 days or 4% and 16 pounds in 180 days or 10%. The surveyor asked the CDM about the statement at the bottom of the sheet which documented nursing was to notify the physician and family of weight loss or gain. The CDM stated she did not notify the physician. She stated she gave the information to the nurses and "they need to notify and bring it back to me. It's a communication between me and the nurses."

Based on observation, record review, and interview, it was determined the facility failed to ensure the primary care physician was notified of a significant weight loss for 2 (#93 and #121) of 3 sampled residents whose clinical records were reviewed for weight loss. The facility identified 4 residents who had significant weight loss. The facility's Resident Census and Conditions of Residents form documented 123 residents resided at the facility. Findings: 1. Resident #93 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #93's vital signs record documented her weights were as followed: 01/23/12 - 162.8 pounds 02/05/12 - 159.6 pounds 03/05/12 - 155.8 pounds 04/05/12 - 152 pounds (a 6.2% weight loss since admission) 05/05/12 - 149.8 pounds (an 11.3% weight loss in 90 days) 06/05/12 - 144 pounds (a 7.57% weight loss in 90 days) 07/05/12 - 136.8 pounds (a 5% weight loss in 30 days, 10% in 90 days and 15.97% in almost 180 days). The care plan, dated 02/03/12, documented the resident had a problem regarding her nutritional status and the potential for decline. The care plan documented a goal was for the resident to "consume adequate (calories) to meet nutritional needs, maintain/gain weight without decline (for) 90 days." The care plan documented the approaches included: "...Monitor her weight for significant loss or gain notify family and physician." The dietary progress note, dated 04/26/12, written by the certified dietary manager (CDM), documented: "(Weight) 146 (pounds) -10 (pound) in 30 days or 6% loss. -17 (pounds) in 180 days or 10% loss. (if (weight) is correct) Will monitor next months (weight) before doing any (changes)." There was no documentation the resident's physician was notified of the significant weight loss. The dietary consultant report, dated 06/25/12, documented the resident had a nutritional problem of "suboptimal oral intake." The report documented the etiology was "related to inability to feed self/unable to communicate with staff." The report documented the signs and symptoms were "evidence by weight loss of 11% since admit---only 3.5% last 30 days." The report documented the interventions/monitoring/evaluation as "Goal to remain at 144 (pounds). She is only 60 inches - What is the goal on the care Plan? DISCUSS." There was no documentation the resident's physician was notified of the significant weight loss. The quarterly assessment, dated 08/01/12, documented the resident had severe cognitive impairment; was independent with bed mobility, locomotion on/off the unit, and eating; required limited assistance with transfer, ambulation, dressing, toilet use and personal hygiene; and required extensive assistance with bathing; was occasionally incontinent of bladder and bowel; had no swallowing disorder; was 60 inches tall and weighed 136 pounds; had experienced significant weight loss but was not on a physician-ordered weight-loss program; and had no dental problems. The physician's progress notes, dated 04/24/12, 05/24/12 and 07/10/12, were reviewed. There was no documentation to indicate the physician was aware of the resident's severe weight loss. On 08/03/12 at 11:20 a.m., the surveyor showed the resident's weight loss history to the director of nurses (DON). The surveyor asked if the physician had been notified of the resident's severe weight loss at any time. The DON stated, "Not specifically, no." 2. Resident #121 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 07/22/12, documented the resident understood others, was understood by others, and had no behaviors. The assessment documented the resident was independent with eating. The care plan, updated 07/23/12, documented the resident had a potential for decline in her nutritional status. The care plan documented the goal was for the resident to consume adequate calories to meet her nutritional needs and maintain her weight. The care plan documented an approach for the goal was to monitor her weight for significant loss or gain and notify the family and physician if the situation occurred. The vital signs record contained in the resident's clinical record documented the following weights: 04/13/12 - 226 pounds 05/09/12 - 210.4 pounds, for a weight loss of 7%, 06/05/12 - 225.2 pounds, and 07/05/12 - 225.4 pounds. The clinical record contained documentation the resident was transferred to the hospital on [DATE] and returned on 05/09/12. On 07/31/12 at 9:00 a.m., the resident was observed as she ate in her room. She fed herself without difficulty. A large number of snacks were noted on the resident's bed. She stated she was allowed to eat the snacks she wanted when she wanted them. She also stated she received enough food to eat and was able to make choices in the foods she ate. On 08/02/12 at 9:35 a.m., licensed practical nurse #2 was asked who was responsible for monitoring the residents' weights. She stated the certified nurse aide (CNA) took the weights and gave them to the nurses. The weights were also documented in the treatment book. For special residents who were monitored closely, the charge nurse documented the weights and notified the physician by phone or fax. At 11:20 a.m., the DON showed the vital signs record from the clinical record to the surveyor. The document indicated the physician had reviewed the resident's weight on 05/30/12. At 12:45 p.m., the DON was shown the document and asked if the physician had been notified of the resident's weight, taken on 05/09/12, prior to 05/30/12. She stated she was unable to find documentation the physician had been notified prior to 05/30/12. The DON was asked if 21 days was an acceptable period of time to wait before informing the physician of the weight loss. She stated it was not.