Every finding on record at English Village Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure a care plan was accurate for 1 (#110) of 1 sampled resident reviewed for dialysis. The administrator reported two residents received dialysis treatments. Findings: On 04/02/25 at 11:37 a.m., Resident #110 was observed to return from dialysis. The transportation staff reported they would let the charge nurse know the resident was back and would provide the nurse with the form from dialysis. Resident #110 had diagnoses which included dependence on renal dialysis and end stage renal disease. A care plan for Resident #110, dated 04/02/25, showed: a. resident needed hemodialysis related to renal failure, b. resident would have no signs/symptoms of complications from dialysis through the review date, c. monitor AVF for signs symptoms trauma and/or infection as ordered by physician, d. no blood pressure, labs or lifting in arm with AVF/AVG as ordered by physician, e. remove AVF dressing four hours after dialysis treatment as ordered by physician, f. schedule visits to the dialysis center and coordinate care accordingly, g. encourage the resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, and Friday, h. monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth or drainage, and i. obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure immediately. On 04/03/25 at 10:12 a.m., the DON reported Resident #110 had a port and had just started dialysis treatments. The DON reported the resident would have an AVF placed if they continued dialysis treatments, but currently only had a port to the left chest. On 04/03/25 at 10:19 a.m., the MDS coordinator reported they had entered the information about an AVF on Resident #110's care plan. The MDS coordinator reported the information was not accurate and they had entered standard dialysis orders instead of the person-centered information related to the resident's port.

Based on record review and interview, the facility failed to refer a resident with newly diagnosed mental illness to the OHCA for level II PASARR evaluation for 1 (#23) of 1 sampled resident reviewed for PASARR. The administrator reported 62 residents resided in the facility. Findings: A policy titled Pre-Admission Screening and Resident Review (PASRR), dated 03/01/06, read in part, Status change after admission .Significant change Level 1 screenings will be completed for residents who receive a mental diagnosis after admission or residents who begin to receive medications that could be used to treat mental illness after admission .The D.O.N. or other designee must complete a significant change Level 1 screening at the time of the new diagnosis or medication order and place a call to the LOCEU [Level of Care Evaluation Unit] Unit in order to verify whether a Level 2 screening is required at that time. Resident #23 had diagnoses which included bipolar disorder and schizoaffective disorder. A PASARR form, dated 02/03/15, showed Resident #23 had a diagnosis of serious mental illness of which included a diagnosis of bipolar disorder. Resident #23's clinical record showed the resident received a new diagnosis of schizoaffective disorder on 01/13/17. There was no evidence the resident was re-evaluated for a PASARR Level II. A MDS annual assessment, dated 02/06/25, showed Resident #23 was cognitively intact with a BIMS score of 15. The assessment showed the resident received antipsychotic and antidepressant medications. On 04/02/25 at 1:45 p.m., the administrator reported they were trying to find out if the OHCA was called, or how it was handled, when Resident #23 received the new diagnosis. The administrator reported the facility was purchased by a new owner so it was difficult to know what the previous process was. On 04/02/25 at 4:07 p.m., the administrator reported they spoke with their corporate office to see if there was any documentation related to a PASARR II for Resident #23. The administrator stated they were unable to find documentation to show OHCA was contacted at the time of the resident's new diagnosis.

Based on observation, record review, and interview, the facility failed to implement a plan of care with interventions for 1 (#110) of 1 resident reviewed for a dialysis care plan. The administrator reported two residents received dialysis treatments. Findings: On 04/02/25 at 11:37 a.m., Resident #110 was observed to return from dialysis. The transportation staff reported they would let the charge nurse know the resident was back and would provide the nurse with the form from dialysis. Resident #110 had diagnoses which included dependence on renal dialysis and end stage renal disease. Resident #110's care plan, dated 04/01/25, showed the resident was admitted to skilled services on 03/19/25 for acute kidney failure. The care plan contained no documentation related to dialysis treatments, care before or after dialysis treatments, or care of the resident's port. On 04/02/25 at 11:40 a.m., LPN #2 reported they would enter the information into the computer from the dialysis form. LPN #2 reported the resident had a port to the right upper chest. On 04/02/25 at 4:24 p.m., LPN #4 reported they followed the resident assessment instrument for policy regarding care plans. LPN #4 reported the facility did not have a care plan policy.

Based on observation, record review and interview, the facility failed to implement EBP for 1 (#33) of 3 sampled residents reviewed for EBP. The quality control manager reported 18 residents required EBP. Findings: On 04/01/25 at 12:09 p.m., Resident #33 was observed to have a catheter flowing to gravity connected to the side of the bed. There was no signage observed to indicate the resident required EBP. An Infection Control and Isolation Policy revised date 03/28/24, read in part, EBPs are indicated with any of the following .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO [multi drug resistant organism] . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Resident #33 had diagnosis which included obstructive and reflux uropathy. Resident #33's quarterly assessment, dated 02/21/25, showed the resident's cognition was intact with a BIMS score of 15. Resident #33's care plan for an indwelling catheter, dated 03/03/25, showed: a. change the indwelling catheter bag twice monthly on the 1st and 15th and as needed, b. intake and output every shift for the indwelling catheter, and c. position catheter bag and tubing below the level of the bladder and away from entrance room door. A physician order for Resident #33, dated 04/02/25, showed EBP would be implemented related to the indwelling catheter. On 04/02/25 at 8:15 a.m., certified medication aide #2 reported Resident #33 did not have EBP in place. On 04/02/25 at 1:49 p.m., Resident #33 reported staff did not use a gown the previous day when they emptied their catheter. Resident #33 reported the nurse told them they would be using one today. On 04/02/25 at 1:58 p.m., LPN #3 reported they requested the order for EBP today. LPN #3 reported the resident's indwelling catheter was placed on 03/03/25. LPN #3 reported if a resident had an indwelling catheter they should have EBP in place.

Based on record review and interview, the facility failed to electronically submit MDS assessments to CMS within the required timeframe after completion for four (#1, 5, 18, and #23) of four residents reviewed for resident assessments. The DON reported 62 residents resided in the facility. Findings: 1. Resident #1's quarterly assessment, dated 10/22/23, was documented as transmitted. The final validation report documented the assessment was submitted to CMS on 12/08/23. 2. Resident #5's annual assessment, dated 10/20/23, was documented as transmitted. The final validation report documented the assessment was submitted to CMS on 12/08/23. 3. Resident #18's quarterly assessment, dated 10/20/23, was documented as transmitted. The final validation report documented the assessment was submitted to CMS on 12/08/23. 4. Resident #23's quarterly assessment, dated 10/12/23, was documented as transmitted. The assessment documented as rejected by CMS on 10/30/23. The final validation report documented the assessment was submitted to CMS on 12/08/23. On 12/14/23 at 3:00 p.m., the Regional MDS Consultant reported the cooperate office submitted the assessments to CMS. The Regional MDS Consultant reported that the EMR used by the facility was not transmitting properly to CMS, which resulted in assessments being rejected. The Regional MDS Consultant reported the cooperate office stopped transmitting assessments to CMS until the error was fixed and they had time to go back over all assessments. On 12/18/23 at 3:45 p.m., the MDS Coordinator confirmed the identified resident assessments were not completed and submitted with 14 days of completion as required. The MDS Coordinator reported that the facility did not have an MDS transmission/submission policy.

Based on record review and interview, the facility failed to have an effective method for ordering and obtaining medications in a timely manner, to provide adequate pain management for a resident, which resulted in a hospital visit for one (#1) of three sampled residents reviewed for pain. The Resident Census and Conditions of Residents, dated 07/20/23, documented 64 residents resided in the facility and 36 residents were on a pain management program. Findings: A facility policy, Nursing Protocols - Pain, revised 09/10/07, documented in part, .Believe the resident's report of pain. This should be the primary source of assessment .pain is subjective .the function of non-drug interventions is usually to augment, not replace, medications .non-pharmacologic interventions are intended to supplement, not substitute pharmacologic interventions . Res #1 had diagnoses which included kyphosis, arthropathy, congestive heart failure, peripheral vascular disease, and anxiety. An annual MDS assessment, dated 04/22/23, documented the resident was cognitively intact. The assessment documented the resident was independent with most activities of daily living. The assessment documented the resident was on scheduled pain medication, and the worst level of pain in the previous five days had been an 8 on a scale of 1-10. A care plan, dated 05/11/23, documented the resident was at risk for pain related to osteoarthritis, arthropathy, and kyphosis to the thoracolumbar region. The care plan documented to administer pain medications as ordered, and to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. An incident report, dated 07/15/23 at 6:30 p.m., documented in part, .It was noted that resident's routine pain medication did not come in from pharmacy as expected. Medication was ordered on 07/12/23 .MD made aware and sent script to the pharmacy emergent refill .stated it could be picked up 10 am the next morning .resident offered other pain interventions such as volteren gel, Flexeril and Tylenol .resident declined .sent to the ER for pain management . A progress note, dated 07/15/23 at 7:41 p.m., documented the resident requested to be sent to the emergency room for pain treatment. The note documented the resident was offered PRN Flexeril and Tylenol, but the resident and family declined PRN medications. The note documented the physician was notified and orders received to send the resident to the emergency room for evaluation and treatment per the resident and family request. An ER visit record, dated 07/15/23, documented the resident was seen for acute leg pain and acute exacerbation of congestive heart failure. A progress note, dated 07/16/23 at 3:58 a.m., documented the resident returned from the ER accompanied by family. The note documented new orders were received for a 1.5 liter fluid restriction daily, continue home medications and Lasix, and follow-up in two days with the physician. The July 2023 MAR, documented the resident had an order for Percocet 5-325 mg, one tablet every six hours for pain. The MAR documented the resident missed the 6:00 p.m. dose on 07/15/23, and was out of the facility for the 12:00 a.m. dose on 07/16/23, and did not receive the 6:00 a.m. dose on 07/16/23. An ER physician's order, dated 07/16/23 at 2:53 a.m., documented the resident would continue home medications and Lasix, would have a fluid restriction of 1.5 liters per day, and documented, make sure she gets pain meds in AM. On 07/20/23 at 10:45 a.m., CMA #1 was interviewed regarding the facility's process for re-ordering medications. The CMA stated she was aware Res #1 had missed a pain medication and thought someone might have forgotten to order it on time. The CMA reported she and other staff were in-serviced to ensure this wouldn't happen again and they had put a new process in place for re-ordering medications. On 07/20/23 at 3:14 p.m., during a phone interview with resident #1's family member, it was reported the resident had called the family member the previous week on Saturday (07/15/23), and stated the facility had ran out of the resident's pain medication and would not be able to get the medication until the next day. The family member reported they drove to the facility in order to take the resident to the emergency room to ensure the resident received pain control. The family member reported the facility did arrange transportation to the emergency room after the family arrived. The resident was no longer present at the facility at the time of survey. The administrator provided documentation of in-services conducted on 07/15/23 through 07/17/23. The in-services included nursing staff and addressed ordering of medications, re-ordering of narcotics, and notifying the charge nurse and physician when there were issues with medication refills. Nurses and CMAs were interviewed and were knowledgeable of the process related to medication refills, ordering, and obtaining medication. The administrator also provided a copy of ongoing compliance rounds, initiated on 07/15/23 at 8:00 p.m. The compliance rounds were conducted by the DON and charge nurses to ensure medication carts were checked for re-orders and notification of hard scripts to the physicians. On 07/20/23 at 4:30 p.m., the DON reported they were aware their process for reordering medications needed to be improved. The DON stated when they ran out of Res #1's pain medication, they immediately in-serviced staff to prevent a recurrence and started compliance rounds to ensure the process was working. The DON stated part of the new process involved working direct with the pharmacy to order and re-order medications electronically. The DON reported the process was in place and would be complete when the facility received scanning equipment which had been ordered.

Based on observation, interview, and record review, the facility failed to dispose of retractable needles in a puncture resistant container for one (#6) of two sampled residents observed for insulin administration. The administrator reported a census of 60 residents. Findings: A facility infection control and isolation policy, revised date 06/23/17, read in part, .Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate impervious, puncture resistant containers, which are located as close as practical to the area in which the items were used . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 50 units subcutaneously two times a day related to type 2 Diabetes Mellitus with [CONDITION(S)]. A Care Plan for resident #6, dated 11/03/21, documented the resident had Type II DM with [CONDITION(S)]. The care plan documented to administer [MEDICATION(S)] as MD ordered and Novofine pen needles were to be used with the insulin pen as ordered. On 11/04/21 at 8:45 a.m., LPN #1 prepared the resident's insulin pen for administration. The LPN injected 50 units of [MEDICATION(S)] insulin into the resident's abdomen. The LPN removed the needle from the insulin pen and rolled the retractable needle into her gloves and disposed both of them into the regular trash. The LPN was asked about the insulin needle and she stated it was a retractable. The LPN stated she would put syringe needles in the sharp containers. The infection preventionist was asked about retractable sharps and reported all used sharps should be disposed of in the appropriate sharps containers.

Based on observation and interview, the facility failed to store and serve food and ice to maintain food service safety. The Administrator reported 60 residents resided in the facility and 58 residents received food and ice from the kitchen. Findings: On [DATE] at 10:50 a.m., a tour of the facility kitchen was conducted. Approximately 20 containers of Med Pass 2.0 was observed to be expired on [DATE] and [DATE]. Approximately eight containers of Ready Care Dairy Drink was observed to be expired on [DATE]. The expired items were reviewed with Assistant Cook #1 and she agreed the items were expired and should have been disposed of. On [DATE] at 11:05 a.m., two ice machines were observed to have a layer of dust on the outside of both machines. The larger ice machine was observed to have a brown residue inside the machine at the top of the machine. On [DATE] at 9:52 a.m., both ice machines were observed to be free of dust but the brown residue in the larger ice machine remained. The cook on duty observed the ice machine and stated the machine needed to be cleaned. On [DATE] at 8:35 a.m., the Dietary Manager reported there had been challenges keeping the ice machines clean during the facility construction taking place in the building but both should be cleaned on a regular basis.

Based on interview and record review, the facility failed to provide adequate supervision to prevent elopement for one (#60) of three residents reviewed for elopement. The Administrator reported 60 residents resided in the facility. Findings: Resident #60 was readmitted to the facility on [DATE] with diagnoses which included depression and [CONDITION(S)]. A Wandering Risk Scale Assessment, dated 12/27/20, documented no history of wandering and the resident had not wandered from the facility. A Smoking Safety Screen Assessment, dated 12/27/20, documented the resident was safe to smoke with supervision. The assessment documented the resident required supervision due to smoking all cigarettes then becoming angry with staff when the cigarettes were gone. The resident's quarterly MDS Assessment, dated 01/01/21, documented the resident was cognitively intact and required minimal assistance with activities of daily living. The resident's Care Plan, dated 01/04/21, documented a diagnosis of depression with interventions to allow the resident to vent feelings and redirect the resident to positive thoughts. The care plan documented to monitor behaviors every shift, note any evidence of targeted behaviors, and to notify the physician of findings. The care plan documented the resident was a smoker. The care plan did not address the resident's preference not to be checked every two hours during the night. A Behavior Note, dated 02/01/21 at 9:21 p.m., documented the resident called the local police department to discuss legal matters. The police arrived at the facility and spoke with the resident. The resident's guardian was made aware. A Progress Note, dated 02/14/21 at 12:06 p.m., documented the nurse went to assess the resident's temperature and oxygen levels at 7:26 a.m. The note documented the resident's door was closed and upon entering the room, the lights and television were noted to be off. The nurse called out for the resident but there was no response and the resident was not observed in the room. The note documented the nurse asked staff if the resident had been seen that morning and staff began searching the facility. The note documented the nurse checked the resident's room a final time and found a letter on the resident's pillow stating her intentions to leave. The note documented all on-call staff, police, the physician, the resident's family, and the facility administrator was notified. A final Incident Report (ODH Form 283), dated 02/22/21, read in part, .A missing resident (resident #60) on 02/13/21 .Video footage was reviewed and showed the resident went out to the courtyard at 11:18 p.m. on 02/13/21 and did not return inside the facility . Staff were interviewed and reported they did not check on the resident due to resident not wanting to be bothered at night. A Discharge Summary, dated 02/22/21, documented resident #60 was admitted to the facility on [DATE] from another long-term care facility. The summary documented during the resident's stay she enjoyed being outside in the courtyard. The summary documented the resident had exhibited some behaviors which included verbal aggression and verbal outbursts. The summary documented the resident had attempted to have her guardianship revoked without success, and the resident wanted to leave the facility to obtain a house and get a job. The summary documented on 02/14/21, the charge nurse went to the resident's room at approximately 7:30 a.m. and the resident was not in her room. The charge nurse questioned other staff as to the resident's whereabouts. Facility staff searched the facility and premises and the resident was not located. The summary documented the charge nurse went to the resident's room a final time and found a letter on the resident's pillow which stated she was leaving the facility and revoking her POA and responsibility from the facility of her care. All appropriate notifications were made and an official law enforcement investigation and search was conducted. On 02/20/21, the resident was located in another town and was found to be safe. The resident did not return to the facility. On 11/05/21 at 9:45 a.m., LPN #2 reported supervised smokers would have a staff member go out with them, and they were allowed to go out any time of the day or night when they requested. The nurse reported unsupervised smokers could go out any time of the day or night as they desired. On 11/05/21 at 12:08 p.m., the ADON reported all residents were required to have visual checks every two hours unless otherwise care-planned. The ADON reported resident #60 did not want to be checked or bothered during the night. The ADON reported staff were aware resident # 60 was wanting to leave the facility but stated the resident never gave any indication she might elope. The LPN reported all residents should be checked every two hours, even during the night hours. The LPN reported resident #60 did not want to be checked during the night, and when the resident had her door shut, she was not checked through the night.

Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan, to address the resident's preference and choice, related to not wanting to be disturbed at night, for one (#60) of three residents reviewed for person-centered care plans. The Administrator reported 60 residents resided in the facility. Findings: Resident #60 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wandering Risk Scale Assessment, dated 12/27/20, documented no history of wandering and the resident had not wandered from the facility. An MDS Assessment, dated 01/21/21, documented the resident was cognitively intact and required minimal assistance with activities of daily living. The Care Plan for resident #60, dated 01/24/21, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented to monitor behaviors every shift, note any evidence of targeted behaviors, and to notify the physician of findings. The care plan documented the resident was a smoker. The care plan did not address the resident's preference not to be checked every two hours during the night. A Progress Note, dated 02/14/21 at 12:06 p.m., documented the nurse went to assess the resident's temperature and oxygen levels at 7:26 a.m. The note documented the resident's door was closed and upon entering the room, the lights and television were noted to be off. The nurse called out for the resident but there was no response and the resident was not in the room. The note documented the nurse asked staff if the resident had been seen that morning and staff began searching the facility. The note documented the nurse checked the resident's room a final time and found a letter on the resident's pillow stating her intentions to leave the facility. On 11/05/21 at 12:08 p.m., the ADON reported all residents were required to have visual checks every two hours unless otherwise care-planned. The ADON reported resident #60 did not want to be checked or bothered during the night. The ADON reported this resident's care plan should have included and addressed the resident did not want visual checks during the night.

Based on observation, interview, and record review, the facility failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator reported 60 residents resided in the facility. Findings: A Self-Administration and Storage of Bedside Medications policy, dated 02/07/02, read in part, .an assessment of the resident will be conducted by the interdisciplinary team prior to a resident keeping medications at the bedside .certain conditions will be met for beside storage to occur, to include a written order in the resident's medical record .all nurses and aides will be required to report to the licensed nurse on duty any medications found at the bedside not authorized for bedside storage. Resident #26 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS Admission Assessment, dated 09/05/21, documented the resident was independent with most activities of daily living. A Care Plan, dated 09/07/21, documented the resident was cognitively impaired related to Alzheimer's dementia. The care plan contained no documentation regarding self-administration of eye drops. On 11/02/21 at 12:34 p.m., the resident was observed in her room and noted to have eye drops sitting on the nightstand. The resident stated she was fairly independent and liked to do things for herself. On 11/03/21 at 8:41 a.m., eye drops were noted to remain on the resident's nightstand. On 11/04/21 at 8:40 a.m., eye drops were not noted on the resident's nightstand. The resident stated she had her eye drops in her purse and showed the surveyor two different types of over-the-counter drops. The resident reported one of the eye drops was quite expensive. The resident stated she needed both drops for her right eye and reported she had used them for quite some time. On 11/04/21 at 8:52 a.m., LPN #1 reported she didn't know the resident had any eye drops in her room. The LPN checked the resident's clinical record and stated there was no order for eye drops on this resident. The LPN was asked about residents having over-the-counter eye drops at their bedside. The LPN stated, it doesn't matter, we still need an order and I'll take care of that right now.

Based on observation, record review, and interview it was determined the facility failed to maintain an infection control program and implement measures to provide a safe environment to help prevent the development and transmission of COVID-19. The facility failed to ensure staff caring for quarantined residents were wearing appropriate personal protective equipment (PPE). The facility failed to post signage near quarantined residents' doors to inform staff of the required PPE usage. The director of nurses (DON) reported seven quarantined residents in the facility. Findings: The Center for Disease Control guidance titled, Preparing for COVID-19 in Nursing Homes documented, .All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown . The State Operations Manual, Appendix PP, documented, F880 .When a resident is placed on transmission-based precautions, the staff should implement the following: Clearly identify the type of precautions and the appropriate PPE to be used; Place signage in a conspicuous place outside the resident ' s room such as the door or on the wall next to the doorway identifying the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne), instructions for use of PPE, and/or instructions to see the nurse before entering . On 12/30/20 at 10:02 a.m., certified nursing aid (CNA) #1 was observed to enter a resident's room on the quarantine unit. The CNA was observed wearing a surgical mask. The CNA did not don any other PPE. The CNA assisted the resident with repositioning her bedside table and positioning her chair. The CNA was asked if any additional PPE was required to be worn while providing direct care to a resident on quarantine. She said we do not wear full PPE while taking care of residents on the quarantine unit. We only wear full PPE on the COVID unit. On 12/30/20 at 10:12 a.m., CNA #2 was observed to enter a resident's room on quarantine. The CNA was wearing a surgical mask. The CNA assisted the resident with removing her coat and gave her a blanket. The CNA was asked if any additional PPE was required to be worn while providing direct care to a resident on quarantine. She said we do not wear full PPE back here only on the COVID unit. On 12/30/20 at 10:35 a.m., the DON was asked what PPE should be worn while staff were caring for a resident on quarantine. She said if they are providing direct patient care, staff would be expected to wear full PPE. She said, if they are just going in and out, they should have on a facemask, face shield, and gloves. On 12/30/20 at 10:45 a.m., licensed practical nurse (LPN) #1 was asked what PPE should be worn by staff providing care to residents on quarantine. She said on a quick trip in and out the staff should be wearing a facemask, face shield and gloves. She said for full resident care. The staff should be in full PPE. On 12/30/20 at 11:30 a.m., the surveyor observed the quarantine unit without proper signs posted for proper PPE usage on the unit or on the residents' doors. On 12/30/20 at 12:20 p.m., the DON and assistant administrator was notified the staff on the quarantine unit were not wearing appropriate PPE for direct patient care. They were also informed there were no signs posted for appropriate PPE on the quarantine unit or near the doors of the quarantined residents.

Based on observation and interview, it was determined the facility failed to ensure catheter bags were covered for two (#72 and #92) of two residents whose records were reviewed for catheter care/dignity. This had the potential to affect six residents with indwelling catheters according to the Resident Census and Conditions of Residents form. Findings: 1. Resident #72's quarterly assessment documented he required total dependence with toileting. His [DIAGNOSES REDACTED]. On 05/14/19 at 2:59 p.m., the resident was observed in the common area with his catheter tubing coming out of the top of his pants with the bag hanging on the edge of the wheelchair (w/c) by the arm rest. It was not covered. On 05/15/19 at 2:04 p.m., the resident was observed in the hallway in his w/c with his catheter bag uncovered. 2. Resident #92 was admitted with [DIAGNOSES REDACTED]. The resident's annual assessment, dated 05/09/19, documented the resident had an indwelling catheter. On 05/15/19 at 1:34 p.m., the resident was observed in the dining room with the catheter collection bag, uncovered, and hanging from her walker. At 2:43 p.m., the resident was observed leaving her room and entering the hallway with her walker. The catheter collection bag was visible and hanging on the walker. She was asked if it bothered her to have the bag exposed. She stated, Yeah, it kind of does. At 2:52 p.m., licensed practical nurse #1 stated the residents should have covers on their bags. At 2:58 p.m., certified medication aide #1 stated the catheter bags should have been covered. At 3:03 p.m., the director of nurses stated the staff should have noticed the bags uncovered and covered them.

Based on record review and interview, it was determined the facility failed to ensure a significant change assessment was completed after a resident had elected hospice services for two (#9 and #94) of two residents reviewed for hospice services. This had the potential to affect six residents receiving hospice services according to the Resident Census and Conditions form. Findings: 1. Resident #9 was admitted to hospice services on 04/24/19. The clinical record had not contained a significant change assessment since that date. 2. Resident #94 was admitted to hospice on 03/16/19. The clinical record had not contained a significant change assessment since that date. On 05/21/19 at at 10:11 a.m., the director of nurses stated in an interview that a significant change assessment should have been completed within 14 days after the residents had elected hospice services.

Based on record review and interview, it was determined the facility failed to have an appropriate [DIAGNOSES REDACTED].#79) of five residents whose records were reviewed for unnecessary medications. This had the potential to affect 12 residents who receive an antipsychotic medication. Findings: Resident #79 was admitted on [DATE]. An admission assessment, dated 04/24/19, documented his cognition was severely impaired. He required extensive assistance with his activities of daily living. He was frequently incontinent of bowel and bladder. He received an antipsychotic on his 7-day medication look back period. The physician order [REDACTED]. A monthly pharmacy consult, dated 04/28/19, documented [MEDICATION NAME] 50 mg tablet needed a corresponding diagnosis/condition documented in the resident's clinical record. The clinical record was reviewed and it documented [MEDICATION NAME] Tablet 50 mg was to be given for [MEDICAL CONDITION]. On 05/20/19 10:51 a.m., the director of nursing stated in an interview that [MEDICAL CONDITION] was not an appropriate [DIAGNOSES REDACTED].

Based on observation, record review and interview, it was determined, the facility failed to ensure halls remained clutter free to help prevent falls for one (#25) of six residents whose records were reviewed for accidents. This had the potential to affect 106 residents who reside in the facility. Findings: Resident #25 had [DIAGNOSES REDACTED]., anxiety disorder, [MEDICAL CONDITIONS], diabetes and arthritis. An admission assessment, dated 04/20/18, documented the resident's cognition was severely impaired. She required limited assistance with locomotion. She required extensive assistance with all other activities of daily living. She had delusions. She was frequently incontinent of bladder and always incontinent of bowel. She had two falls since her prior assessment. An incident report, dated 05/22/18, documented a certified nurse aide stated the resident was attempting to go around the hoyer lift in the hall and lost her balance and fell on her buttocks then went straight back and hit her head on the lift. The intervention for the resident's fall was, staff was to have been in-serviced to keep all items, for example, desk, lifts, barrels, carts, wheelchairs all on the same side of hallway to keep paths clear. The care plan, updated 05/23/18, documented a new intervention to keep hallways and pathways clutter free as much as possible. On 07/23/18 at 9:30 a.m., the facility hall ways were observed to have wheel chairs, stools, stands, tables and various patient equipment lined up going down the halls. They were observed to be this way all day long. This blocked access to the hand rails. On 07/24/18 at 12:53 p.m., a certified nurse aide was asked about this resident's numerous falls and about her fall where she hit her head on a Hoyer lift in the hallway. She stated she liked grabbing a hold of the stuff in the hall and pushing it around. At 1:30 p.m., the 200 hall way was observed to be full of clutter. There were two wheel chairs, a sit to stand lift, a hoyer lift, a geri chair and a stool in the hall lined up on the right side. The resident's doorway was halfway down the hall. The other halls were also observed to have numerous chairs and equipment up and down the halls. At 2:03 p.m., the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed and asked about all the clutter in the hallway that could cause falls. They were both in agreement that the clutter should not be in the hallways, They said they had limited space and really didn't have anywhere to put the equipment and chairs and carts.

Based on observation, record review, and interview, it was determined, the facility failed to ensure: ~ the care plan was updated with new interventions, for one (#25), ~a nutrition/weight loss care plan was developed for one (#42), ~ the care plan was followed for one resident (#69), ~ and root cause analysis were done after numerous falls for three (#25, #69 and #253) of six residents whose records were reviewed for accidents. This had the potential to affect 106 residents who reside in the facility. Findings: 1. Resident #25's [DIAGNOSES REDACTED]. An admission assessment, dated 04/20/18, documented the resident's cognition was severely impaired. She required limited assistance with locomotion. She required extensive assistance with all of her other activities of daily living. She had delusions. She was frequently incontinent of bladder and always incontinent of bowel. She had 2 falls since prior assessment. The resident's care plan was reviewed. It had not been updated for 6 of her recent falls, one on 05/17/18, 06/24/18, 07/01/18, and three falls she had on 07/13/18, The resident's incident report for her fall on 06/12/18 documented .Bed alarm placed at this time . This intervention had not been added to the interventions on the care plan. Her clinical record was reviewed no root cause analysis was found. On 07/24/18 at 2:03 p.m., the director of nurses (DON) and the assistant director of nurses (ADON) were interviewed and asked about no new interventions having been added to the care plan for this resident and about the bed alarm not having been added to the care plan. They were asked if a root cause analysis had been done to determine why this resident was having so many falls. They were both in agreement a root cause analysis should have been done and the care plan should have been updated with new and different interventions. 2. Resident #42 had [DIAGNOSES REDACTED]. A significant change assessment, dated 05/11/18, documented the resident had moderately impaired cognition. He was dependent for staff for assistance with transfers, locomotion, toileting and bathing. He had no range of motion limitations and was frequently incontinent of urine. He had experience a weight loss not prescribed by the physician. A Nutrition/Dietary Note, dated 6/28/2018, documented Nutrition follow-up regarding weight loss .intake is fair and sporadic. Spoke with (name withheld) who reports that he would try mighty shakes to supplement his intake . Current weight of 168# Weight on 5/23 of 168# Weight on 4/24 of 172.8# Weight on 3/14 of 185.6# Indicating weight loss of 17# in 3 months .Recommend mighty shakes TID (three times daily secondary to weight loss and fair intake . The (MONTH) (YEAR) physician orders [REDACTED]. His prescribed diet was regular texture and consistency. The care plan had not contained documentation in regard to the resident's weight loss. On 07/30/18 at 1:00 p.m., the assessment coordinator was asked if a care plan regarding the resident's nutrition and weight loss should have been developed. She stated, Yes. 3. Resident #69 [DIAGNOSES REDACTED]. She had a quarterly assessment, dated 06/06/18, which documented the resident's cognition was severely impaired. She required extensive assistance with all of her activities of daily living. She was always incontinent of bowel and bladder. The resident had a fall with major injury. The resident's care plan for falls, documented the call light was to be in reach, bed alarm, educate family about safety, appropriate footwear, room clutter free, and frequent visual checks. The resident had two falls in (MONTH) (YEAR), two falls in (MONTH) (YEAR), one in (MONTH) (YEAR) with major injury and one in (MONTH) of (YEAR). Interventions were put in place with each fall. A pressure alarm was added with her (MONTH) (YEAR) fall. No root cause analysis could be found for this resident's multiple falls. On 07/25/18 at 1:15 p.m., the resident was observed sitting in her room in her wheel chair. She had no pressure alarm under her in her wheel chair. On 07/25/18 at 1:33 p.m., the DON was shown the resident sitting in her wheel chair with no pressure alarm under her. She was in agreement the care plan had not been followed and a root cause analysis should have been done to determine why the resident was having so many falls. 4. Resident #253 her [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/30/18, documented the resident's cognition was severely impaired. She required limited assistance with eating and locomotion. She required extensive assistance with all of her other activities of daily living. She was frequently incontinent of bowel and bladder. The resident had a fall in (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) of (YEAR). She had one in (MONTH) (YEAR), two in (MONTH) (YEAR), and two in (MONTH) (YEAR). All of the falls were reviewed, interventions had been put in place but were they not new interventions. They were the same interventions over and over. No root cause analysis was found for her multiple falls. On 07/30/18 at 9:13 a.m., the ADON was asked if a root cause analysis had been done. She stated, No, we will start doing them. At 9:22 a.m., the DON was interviewed and asked about a root cause analysis not having been done. She was in agreement that one should have been done.

Based on observation, record review and interview, it was determined the facility failed to ensure the care plan was followed for obtaining FSBS's (fingerstick blood sugars) for one (#38) of four sampled residents. The facility identified 23 residents who received insulin. The facility Resident Census and Conditions of Residents identified 107 residents who resided in the facility. Findings: Resident #38 was admitted to the facility, on 04/24/12, with [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/08/18, documented the resident had moderately impaired cognition, understood, was understood by others, and received insulin on seven of the seven days prior to the assessment. The resident's care plan, last updated on 05/18/18, documented the following interventions for the resident's [DIAGNOSES REDACTED].> .Diabetes medication as ordered by doctor . [MEDICATION NAME] SOLUTION INJECT 6UNITS (sic) SUBQ (subcutaneously) BID (twice daily) AT 1200 (12:00 p.m.) and 1700 (5:00 p.m.) . Current physician orders, dated 07/30/18, documented: .[MEDICATION NAME] Solution 100 UNIT/ML (milliliter) (Insulin [MEDICATION NAME]) Inject 6 unit subcutaneously two times a day (order date) 07/17/2015 . [MEDICATION NAME] Solution 100 UNIT/ML (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 150 - 190 = 1 UNIT; 191 - 231 = 2 UNITS; 232 - 272 = 3 UNITS; 273 - 313 = 4 UNITS; 314 - 350 = 5 UNITS; 351+ =5 UNITS, subcutaneously in the morning .IF > 350 GIVE 5 UNITS SQ (subcutaneously) Q2H (every 2 hours) UNTIL LESS THEN (sic) 350 THEN RESUME TESTING AS ORDERED. IF FSBS > 350 AFTER 2 DOSES THEN NOTIFY MD .(order date) 01/05/2017 . There was no order for a FSBS to be performed with the twice daily [MEDICATION NAME] 6 units. The (MONTH) (YEAR) treatment administration record documented the resident was to receive [MEDICATION NAME] Solution 100 units/ml 6 units subcutaneously two times daily at 12:00 p.m. and 5:00 p.m. There was no documentation of a FSBS to be performed with the insulin. On 07/30/18 at 12:35 p.m., licensed practical nurse (LPN) #1 was observed to perform a FSBS prior to administering [MEDICATION NAME] 6 units SQ to resident #38. On 07/31/18 at 10:20 a.m., LPN #1 was asked what the resident's orders were for obtaining FSBS's. After looking in the computer, she stated the resident was to have one done in the morning prior to her sliding scale insulin. She was asked if the resident was to have a FSBS performed before the [MEDICATION NAME] 6 units at noon. After looking in the computer, she stated, No. The LPN was asked if she was following the resident's care plan. She stated, No.

Based on observation, record review and interview, it was determined the facility failed to ensure physician orders [REDACTED].#38) of four sampled residents. The facility identified 23 residents who received insulin. The facility Resident Census and Conditions of Residents identified 107 residents who resided in the facility. Findings: Resident #38 was admitted to the facility, on 04/24/12, with [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/08/18, documented the resident had moderately impaired cognition, understood, was understood by others, and received insulin on seven of the seven days prior to the assessment. The resident's care plan, last updated on 05/18/18, documented the following interventions for the resident's [DIAGNOSES REDACTED].> .Diabetes medication as ordered by doctor . [MEDICATION NAME] SOLUTION INJECT 6UNITS (sic) SUBQ (subcutaneously) BID (twice daily) AT 1200 (12:00 p.m.) and 1700 (5:00 p.m.) . Current physician orders, dated 07/30/18, documented: .[MEDICATION NAME] Solution 100 UNIT/ML (milliliter) (Insulin [MEDICATION NAME]) Inject 6 unit subcutaneously two times a day (order date) 07/17/2015 . [MEDICATION NAME] Solution 100 UNIT/ML (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 150 - 190 = 1 UNIT; 191 - 231 = 2 UNITS; 232 - 272 = 3 UNITS; 273 - 313 = 4 UNITS; 314 - 350 = 5 UNITS; 351+ =5 UNITS, subcutaneously in the morning .IF > 350 GIVE 5 UNITS SQ (subcutaneously) Q2H (every 2 hours) UNTIL LESS THEN (sic) 350 THEN RESUME TESTING AS ORDERED. IF FSBS > 350 AFTER 2 DOSES THEN NOTIFY MD .(order date) 01/05/2017 . There was no order for a FSBS to be performed with the twice daily [MEDICATION NAME] 6 units. The (MONTH) (YEAR) treatment administration record documented the resident was to receive [MEDICATION NAME] Solution 100 units/ml 6 units subcutaneously two times daily at 12:00 p.m. and 5:00 p.m. There was no documentation of a FSBS to be performed with the insulin. On 07/30/18 at 12:35 p.m., licensed practical nurse (LPN) #1 was observed to perform a FSBS prior to administering [MEDICATION NAME] 6 units SQ to resident #38. On 07/31/18 at 10:20 a.m., LPN #1 was asked what the resident's orders were for obtaining FSBS's. After looking in the computer, she stated the resident was to have one done in the morning prior to her sliding scale insulin. She was asked if the resident was to have a FSBS performed before the [MEDICATION NAME] 6 units at noon. After looking in the computer, she stated, No. The LPN was asked if she was following the physician's orders [REDACTED].

Based on observation, interview and record review, it was determined the facility failed to ensure care plans were being followed for two (#45 and #109) of two sampled residents reviewed for therapeutic diets. This had the potential to affect 15 residents with orders for therapeutic diets according to the assessment coordinator. Findings: 1. Resident #45 was admitted with [DIAGNOSES REDACTED]. An annual assessment, dated 05/12/17, documented the resident was cognitively intact, required extensive assistance of one staff with all activities of daily living except eating. It documented he only needed set-up and supervision with eating. It also documented the resident was on a therapeutic diet. A care plan, dated 05/12/17, documented the resident was to be served a Healthy Heart 2 gram sodium diet as ordered with five helpings of vegetables everyday. It also documented he refused his noon meal most of the time because he stated he ate a big breakfast. The resident's physician's orders [REDACTED]. On 05/24/17 at 8:30 a.m., the resident was observed in the dining room. He had been served 2 eggs, toast, 2 slices of bacon and had already eaten his cold cereal. His diet card by his plate documented he was on a regular diet. On 05/24/17 at 11:30 a.m., the dietary manager was asked for the expanded menus from the kitchen which listed all the different diets. The dietary manager stated he would have to go to his office to get the menus. He was asked how his dietary staff knew what to serve residents on therapeutic diets. He stated, Oh, they have served them so much they know what all the diets are. The expanded menus were reviewed. The Healthy Heart 2 gram sodium diet had not called for bacon to be served. The dietary manager was shown the menu. He was in agreement the resident should have been offered the items on the menu. He was also in agreement the resident's care plan had not been followed for his Healthy Heart 2 gram sodium diet. 2. Resident #109 was admitted with a [DIAGNOSES REDACTED]. An admission assessment, dated 03/29/17, documented the resident was cognitively intact, required extensive assistant of one staff with dressing, personal hygiene and bathing. It documented he required set-up and supervision with eating. It also documented the resident was on a therapeutic diet. A care plan, dated 03/29/17, documented the resident was to be served a renal 60 gram sodium diet. The resident's physician's orders [REDACTED]. On 05/24/17 at 12:43 p.m. the resident had just returned from [MEDICAL TREATMENT]. His lunch tray was served. The diet card had Renal 60 gram sodium diet. His tray had 2 slices of ham with brown gravy, steamed cabbage, macaroni and cheese and jello. The expanded menus were reviewed. The renal 60 gram sodium diet had not listed for ham, gravy or macaroni and cheese to be served. At 1:45 p.m., the dietary manager was shown the menu. He was in agreement the resident should have been offered the items on the menu. He was also in agreement the resident's care plan had not been followed for the residents renal 60 gram sodium diet.

On 08/05/15 2:00 p.m., an immediate jeopardy (IJ) was determined to exist due to the facility's failure to thoroughly assess, monitor and intervene in a timely manner after resident #1 experienced increased swelling and pain to his right lower extremity following an incident. At 2:10 p.m., the IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 2:20 p.m. the administrator and the director of nurses (DON) were notified of the above IJ situation. At 4:20 p.m., an acceptable plan of removal was presented. The plan of removal documented: .All English Village Manor staff will receive in-service training regarding pain recognition and reporting: when residents comment or complain of pain to any EVM employee of any department, beyond any usual, chronic pain they are known to experience, that comment or complaint incident will be reported to the Charge nurse. If an incident report is required, it will be done at that time, including a report to State if required, and also if required, an investigation will be conducted. The Charge nurse will complete a head-to-toe assessment and notify the Director of Nursing and disciplinary team. In-service training will begin at 3:00 PM on 8/5/15 and will be completed NLT (no later than) 10:30 AM on 8/6/15 . The IJ was removed on 08/06/15 at 5:00 p.m. after all the components of the plan of removal had been carried out. The deficient practice remained at a level of harm, at a pattern. Based on interview and record review, it was determined the facility failed to ensure a resident's condition was thoroughly assessed, monitored and interventions were provided for a resident's continued complaints of pain to his right lower extremity for one (#1) of three residents who were reviewed for assessing, monitoring and intervening by the facility. This resulted in actual harm. This had the potential to affect all 103 residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/14/15, documented the resident's cognition was moderately impaired. He required extensive assist with transfers, dressing and hygiene. He was frequently incontinent of bowel and bladder. His range of motion was impaired on both his lower extremities. A nurse's note written by licensed practical nurse (LPN) #3, dated 07/05/15 at 9:04 p.m., documented the resident was complaining of right ankle and foot pain. Noted 2+ [MEDICAL CONDITION] to bilateral lower extremities. Pedal pulse faint but present. Warm to touch, and noted right foot turning outward away from body. Resident is taking [MEDICATION NAME] as needed for pain. Resident states 'I am nauseated because it hurts so bad.' (Physician) faxed . The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documentation the pain medication was given any other time that day. A nurse's note, dated 07/06/15 at 4:02 p.m., documented, Resident continues to c/o right ankle pain. 2+ [MEDICAL CONDITION] noted and resident unable to bend his ankle .(physician) faxed . A fax, sent to the physician by LPN #4, dated 07/06/15 - time not legible documented, .Resident cont. (continues) to c/o pain rt (right) ankle and foot. 2+ [MEDICAL CONDITION]. Unable to bend his ankle. Cont. to take [MEDICATION NAME] prn . The July MAR indicated [REDACTED] A late entry nurse's note dated 07/07/15 at 8:12 a.m. documented, .Resident continues to c/o pain to right ankle. Redness and swelling noted. Resident Resident refusing to get out of bed to go to any activities, this is unusual behavior for him. (Physician) faxed to notify and this nurse asked if we could possibly get the foot x-rayed due to increased swelling and pain. Awaiting response . The July MAR indicated [REDACTED]. A fax, sent to the physician by LPN #1, dated 07/07/15 - without a time - documented, .Resident continues to c/o pain to R foot. He isn't getting up for any activities. Could we please get this X-rayed? . A late entry nurse's note dated 07/07/15 at 11:17 a.m., documented, Received response to previous fax r/t resident right ankle/foot pain. Responded as followed: To see (physician) on 07/13/15 at 10 AM, they will do x-ray at that time. A nurse's note, dated 07/07/15 at 10:15 p.m., documented, Returned fax this eve (evening) shift r/t (related to) right foot pain noted to cont pain meds and can see ortho (orthopaedic physician) if family desires. Cont care. A nurse's note dated 07/08/15 at 9:21 p.m., documented, Cont with increased swelling to right foot. C/O's of discomfort with movement, ROM (range of motion), Touch . The July MAR indicated [REDACTED] A nurse's note dated 07/09/15 at 9:09 a.m. documented, Cont with right ankle/foot pain. Resident c/o pain when this LPN touched ankle to determine [MEDICAL CONDITION]. 2+ [MEDICAL CONDITION] to BLE (bilateral lower extremities) . The July MAR indicated [REDACTED] A nurse's note dated 07/10/15 at 11:54 a.m., documented, Resident continues to c/o pain to R ankle/foot pain. Refused shower, bed bath provided . The July MAR indicated [REDACTED] A nurse's note dated 07/11/15, at 10:01 a.m., documented, Resident in bed c/o right ankle pain that radiates toward right knee. +2 [MEDICAL CONDITION] noted. Discoloration to area noted. Pain increases with movement. Unable to bend ankle. Right foot turned outward. Dr. (name withheld) (on-call for Dr. (name withheld)) notified and received orders to send to ER (emergency room ) for evaluation and treatment. Resident sent by EVM (English Village Manor) transportation. Family aware. The resident was not sent to the hospital at this time, as evidenced by the following nurse's note documented 3 hours and 21 minutes later: A nurse's note, dated 07/11/15 at 1:22 p.m., documented, Resident is crying with right foot and ankle pain. Continues with 2+ [MEDICAL CONDITION] to right lower extremity . Warm to touch, continues with it turned outward away from body. Family requests for resident to have x-ray and something else for pain. (LPN #1) notified Dr. (name with held) received verbal orders to transfer resident to (name withheld) ER for evaluation and treatment. Orders confirmed . The July MAR indicated [REDACTED]. A facility Incident Report dated 07/11/15, documented, .the resident (Res. #1) was extensive assist with transfers using sit-to stand lift. Resident unable to stand without lift. He is w/c (wheelchair) bound. On 7/5/2015 resident initially started to c/o (complain of) pain to right ankle. Resident was given pain medication .continued to c/o right foot pain radiating up toward his knee. +2 [MEDICAL CONDITION] was noted, pedal pulse present but faint and palpable, right foot turned outward, area warm to touch. Physician was faxed .resident also stated to staff on this day that he remembers his foot slipped off footrest on w/c and it bent backwards slightly on the 4th of July when being pushed outside to watch fireworks . On 7-6-2015 with no response from previous fax, another fax was sent stating that resident continued to c/o pain to right ankle and foot, [MEDICAL CONDITION] +2 noted and resident unable to bend ankle. Response from physician stated to continue with pain medication and resident can see ortho if family desires. On 7-7-2015 fax was sent to physician stating resident continues with right foot pain and refusing to get up for activities (unusual behavior) and asks if we could please have an order to x-ray right foot. Response to fax was to see Dr. (name withheld} ortho on 7-13-2015 at 10AM and they will do x-ray then. On 7-11-2015 resident continues to c/o pain and pain medication isn't as effective, nurse notified on-call physician and received order to send to ER (emergency room ) for x-ray and evaluation and treatment .Resident returned from the ER with dx. (diagnosis) trimaleolar right ankle fracture, . A facility 5-day Follow Up On (Res. #1) dated 7/11/2015, documented, .Staff also educated on using proper foot pedals on w/c and making sure they are working properly. The foot pedals on resident's w/c are broken, which causes his foot to slip off foot pedal, and have been replaced .Staff instructed to notify nurse whenever incidents occur . On 08/05/15 at 09:15 a.m., LPN #1 was interviewed and asked when she had first become aware of the resident's increased pain and swelling to his right foot. She said when she returned to work on the morning of the 7th, she heard the resident had started complaining of increased pain on the 5th, and on July 6th is when he said he had reported an incident that occurred on July 4th, causing increased pain to his right foot. She stated, I let the doctor know that his foot was swollen and he was in a lot of pain. Did you let the physician know that an incident in his w/c causing his right foot to be bent back had happened. I didn't tell the doctor that his foot may have been bent backwards while being pushed in his wheelchair. She was asked was the physician called? She stated, No, in the past when we call his office, they tell us to send them a fax, so we just fax them and not call. At 10:30 a.m., LPN #2 was interviewed and asked when had she first become aware of resident #1 having an incident involving his right foot. She said, when I returned to work on the morning of the 7th and he was in so much pain. I guess his foot slipped or something. His pain medication wasn't holding. He would hurt within 3 hours of receiving his pain medication. At 1:30 p.m., the director of nurses (DON) was interviewed and asked when she had first become aware of resident #1 having an incident involving his right foot, causing increased pain and swelling. She stated, I found out on Monday morning (07/06/15) in report. Staff thought his foot slipped off the pedal of the wheelchair. She was asked if she knew that the residents pain medication that he received during the time of his increased pain and swelling was not effective. She nodded her head up and down and said she was aware the pain medication had not been effective.

On 08/05/15, an immediate jeopardy (IJ) was determined to exist due to the facility's failure to have a system in place to monitor for broken medical equipment. Resident #1 experienced his right foot being bent back while being pushed in his wheelchair with broken foot pedals. This resulted in a fractured ankle. At 2:10 p.m., the IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 2:20 p.m. the administrator and the director of nurses (DON) were notified of the above IJ situation. At 4:20 p.m., an acceptable plan of removal (POR) was presented. The IJ was removed on 08/06/15 at 5:00 p.m., when all the components of the POR had been carried out. The deficient practice remained at a level of harm that was isolated. The plan of removal documented: .All English Village Manor staff will receive in-service training regarding all durable medical equipment: all wheelchairs are being inspected now (3:00 PM, 8/5/15) for compliance with the standard of operating in sound and proper working order, to ensure all parts of such equipment are always in good working order before residents' use, and particularly that all wheelchairs have appropriate foot rests in good working order as required. Restorative staff will monitor all durable medical equipment, including all wheelchairs, weekly to ensure good working order and/or timely repair. Maintenance staff will maintain a log of all repairs made to all durable medical equipment. Housekeeping staff will remove all mats at all entrances to English Village Manor to ensure safe passage for all wheelchairs. In-service training will begin at 3:00 PM on 8/5/15 and will be completed NLT (no later than) 10:30 AM on 8/6/15 . Based on interview and record review, it was determined the facility failed to ensure a resident's wheelchair was maintained in good repair for one (#1) of one sampled resident reviewed for incidents. An incident occurred due to a broken wheelchair footrest. This resulted in actual harm. The resident sustained [REDACTED]. This had the potential to affect all 53 residents who used wheelchairs, as identified by the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/14/15, documented the resident's cognition was moderately impaired. He required extensive assist with transfers, dressing and hygiene. He was frequently incontinent of bowel and bladder. His range of motion was impaired on both of his lower extremities. A facility Incident Report dated 07/11/15, documented, .the resident (Res. #1) was extensive assist with transfers using sit-to stand lift. Resident unable to stand without lift. He is w/c (wheelchair) bound. On 7/5/2015 resident initially started to c/o (complain of) pain to right ankle. Resident was given pain medication .continued to c/o right foot pain radiating up toward his knee. +2 pitting edema was noted, pedal pulse present but faint and palpable, right foot turned outward, area warm to touch. Physician was faxed .resident also stated to staff on this day that he remembers his foot slipped off footrest on w/c and it bent backwards slightly on the 4th of July when being pushed outside to watch fireworks . On 7-6-2015 with no response from previous fax, another fax was sent stating that resident continued to c/o pain to right ankle and foot, pitting edema +2 noted and resident unable to bend ankle. Response from physician stated to continue with pain medication and resident can see ortho if family desires. On 7-7-2015 fax was sent to physician stating resident continues with right foot pain and refusing to get up for activities (unusual behavior) and asks if we could please have an order to x-ray right foot. Response to fax was to see Dr. (name withheld} ortho on 7-13-2015 at 10AM and they will do x-ray then. On 7-11-2015 resident continues to c/o pain and pain medication isn't as effective, nurse notified on-call physician and received order to send to ER (emergency room ) for x-ray and evaluation and treatment .Resident returned from the ER with dx. (diagnosis) trimaleolar right ankle fracture, . A facility's investigation documentation statement, dated 07/12/15, documented licensed practical nurse (LPN) #2 received report on the morning of 07/05/15, the resident had complained of pain to his lower extremities, .resident was scheduled to go to church .resident stated he was in too much pain and did not want to go. This is unusual for this resident. Upon assessment noted +2 edema to right lower extremity, noted tenderness and pain to palpation .noted foot was turned outward . A facility's investigation documentation by certified nurse aide (CNA) #1, dated 07/12/15, documented, .On July 4th, I cared for (resident #1) . I even took him outside and sat with him and brought him back in .one CNA pushed him while I held his feet up. A facility's investigation documentation by CNA #2, dated 07/15/15, documented, .On July 4th, 2015, as I was on my way in the door to clock in, (CNA #1) asked me for help to push (resident #1) in the door. I had helped her lift (resident #1's) wheelchair over the matt to ease him in . On 07/17/15, a 5 day follow up report signed by LPN #2 documented, .Staff also educated on using proper foot pedals on w/c and making sure they are working properly. The foot pedals on resident's w/c are broken, which causes his foot to slip off foot pedal, and have been replaced . On 08/05/15 at 09:15 a.m., LPN #1 was asked if she knew what happened to resident #1's foot on the 4th. She said the resident was at the nurses station after watching fireworks outside. Nobody knows how he got from outside to the nurses station. I asked everybody, except two people. He wasn't complaining till the next day, that's when he said it happened on the 4th. On 08/05/15 at 10:30 a.m., LPN #1 was asked about the resident's wheelchair and foot rests. She stated, He always uses his foot rests, he can't lift his feet. She was asked if she would be concerned if she saw a CNA pushing him without his foot rests. She stated, Oh, Yeah. She was asked if she had known what was causing the pain and swelling of his right foot on the morning of 07/05/15. She stated, I guess his foot slipped or something, his feet fall to the sides. One of his foot rests was broke and his foot kept slipping off of it. He didn't say anything to me about what happened. On 08/05/15 at 12:40 p.m., CNA #2 was interviewed and asked about helping CNA #1 bring resident #1 back in through the front door on 07/04/15. She stated, CNA #1 was struggling, trying to get the resident back in through the door. He can't lift his feet and there were no foot rests on the wheelchair. His feet were catching on the entry rugs, so I pushed him while (CNA #1) held his feet up. At 1:16 p.m., CNA #1 was asked if foot rests were needed on resident #1's wheelchair. She stated, Yes. She was asked if the resident's wheelchair had any foot rests on it when she had taken him outside on 07/04/15. She stated, No, when I went to get him, there were no foot rests on the wheelchair. I looked everywhere for them but couldn't find them. He even asked for them. She was asked why she had needed help bringing him back in from outside. She stated, His feet were catching on the rugs and the threshold of the door. She stated she had not reported the incident to anyone, but she should have. On 08/05/15, at 1:27 p.m. the residents wheelchair was observed to have no foot rests on it. It was observed again at a later time and it had two mismatched foot rests on the w/c. On 08/05/15 at 1:30 p.m. the director of nurses (DON) was interviewed, and asked when was she aware the resident was in pain and had an incident, She stated, I didn't find out until Monday morning on the 6th. We thought his foot slid off the pedal of the w/c. Were you aware that his footrest had not been kept on the w/c? I was not aware of the footrest not being kept on the w/c. The DON was interviewed about the facility's procedure for reporting and repairing broken equipment. She stated, The staff is supposed to report issues with equipment to the maintenance man. At 2:00 p.m. the maintenance man stated he would have receipts if new parts or replacements were needed. He denied he had received any reports for repairs on resident #1's wheelchair.

Based on record review and interview, it was determined the facility failed to ensure: ~ Continued attempts were made (other than fax) to contact the physician concerning a resident's complaints of right foot and ankle pain for one (#1) of one resident who was reviewed for pain. This caused harm to the resident due to the prolonged time it took to obtain treatment for [REDACTED]. ~ The family was notified of a change in condition when a resident had increased swelling and increased pain to his right ankle for one (#1) of one resident who was reviewed for family and physician notification. This had the potential to affect all 103 residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/14/15, documented the resident's cognition was moderately impaired. He required extensive assist with transfers, dressing and hygiene. He was frequently incontinent of bowel and bladder. His range of motion was impaired on both of his lower extremities. A nurse's note written by licensed practical nurse (LPN) #3, dated 07/05/15 at 9:04 p.m., documented the resident was complaining of right ankle and foot pain. Noted 2+ [MEDICAL CONDITION] to bilateral lower extremities. Pedal pulse faint but present. Warm to touch, and noted right foot turning outward away from body. Resident is taking [MEDICATION NAME] as needed for pain. Resident states 'I am nauseated because it hurts so bad.' (Physician) faxed . A nurse's note, dated 07/06/15 at 4:02 p.m., documented, Resident continues to c/o right ankle pain. 2+ [MEDICAL CONDITION] noted and resident unable to bend his ankle .(physician) faxed . A fax, sent to the physician by LPN #1, dated 07/07/15 - without a time documented, .Resident continues to c/o pain to R foot. He isn't getting up for any activities. Could we please get this X-rayed? . A nurse's note documented as a late entry, dated 07/07/15 at 11:17 a.m., documented, Received response to previous fax r/t resident right ankle/foot pain. Responded as followed: To see (physician) on 07/13/15 at 10 AM, they will do x-ray at that time. A nurse's note, dated 07/07/15 at 10:15 p.m., documented, Returned fax this eve (evening) shift r/t (related to) right foot pain noted to cont pain meds and can see ortho (orthopaedic physician) if family desires. cont care. A nurse's note, dated 07/08/15 at 9:21 p.m., documented, Cont with increased swelling to right foot. C/O's of discomfort with movement, ROM (range of motion), Touch . A nurse's note documented, dated 07/09/15 at 9:09 a.m., Cont with right ankle/foot pain. Resident c/o pain when this LPN touched ankle to determine [MEDICAL CONDITION]. 2+ [MEDICAL CONDITION] to BLE (bilateral lower extremities) . A nurse's note, dated 07/10/15 at 11:54 a.m., documented, Resident continues to c/o pain to R ankle/foot pain. Refused shower, bed bath provided . A late entry nurse's note, dated 07/11/15, at 10:01 a.m., documented, Resident in bed c/o right ankle pain that radiates toward right knee. +2 [MEDICAL CONDITION] noted. Discoloration to area noted. Pain increases with movement. Unable to bend ankle. Right foot turned outward. Dr. (name withheld) (on-call for Dr. (name withheld)) notified and received orders to send to ER (emergency room ) for evaluation and treatment. Resident sent by EVM (English Village Manor) transportation. Family aware. The resident was not sent to the hospital at this time, as evidenced by the following nurse's note documented 3 hours and 21 minutes later: A nurse's note, dated 07/11/15 at 1:22 p.m., documented, Resident is crying with right foot and ankle pain. Continues with 2+ [MEDICAL CONDITION] to right lower extremity . Warm to touch, continues with it turned outward away from body. Family requests for resident to have x-ray and something else for pain. (LPN #1) notified Dr. (name with held) received verbal orders to transfer resident to (name withheld) ER for evaluation and treatment. Orders confirmed . Resident transferred to (name withheld, local hospital) . On 08/05/15 at 4:00 p.m., a family member was interviewed about the resident's ankle pain and stated, Dad called mom on Sunday (07/05/15) and told her that his right foot was hurting really bad. The staff did not even call her and let her know. She went to the facility on Monday (07/06/15) to see dad and look at his foot. She still had not received a call from the facility . The resident had documented complaints of pain to his right lower extremity from 07/05/15 through 07/11/15. Documentation showed the physician was faxed, not called, about pain and swelling to his right lower extremity on 07/5/15, 07/06/15, and 07/07/15. A physician was not contacted by telephone until 07/11/15, when orders were received for the resident to be sent to the ER. He was x-rayed and diagnosed with [REDACTED]. The clinical record contained no documentation the family had been notified of a change in condition.

Based on record review, observation and staff interviews, it was determined the facility failed to ensure one (#7) of five sampled residents who required supervision/assistance with eating was provided supervision/assistance when given a cup of hot coffee. The resident sustained [REDACTED]. The DON stated 104 residents required supervision and/or assistance with eating. Findings: Resident #7 had [DIAGNOSES REDACTED]. A "Swallowing Guide," dated 05/03/10, documented the resident was to receive "...assistance from nursing, constant supervision verbal/visual, thin liquids, chin neutral, body positioned in a 90 degree angle, no straws and may have small sips from cup/glass..." The significant change in status assessment, dated 08/14/12, documented the resident had moderate cognitive impairment and required extensive assistance with eating. The care plan, dated 08/16/12, did not address the resident's requirement for constant supervision with drinking as documented in the "Swallowing Guide," dated 05/03/10. A nurse's note, dated 09/12/12 at 5:20 p.m., documented: resident sitting in geri-chair at the north side nurses station drinking coffee. Resident (spilled) coffee on self. Received burn to right inner thigh area is reddened and swelling. Complained of pain 8/10. Lortab and (Xanax) given. (Physician) notified with new order to send to the ER (emergency room ) for (evaluation) and treatment. Family and oncall notified. Transportation notified. 5:45 p.m. (Out of facility) to ER with transportation staff. ER full and busy 4 hour wait will be seen by (primary care physician). Silvadene cream applied to right inner thigh. An incident report, dated 09/12/12, which was faxed to the Oklahoma State Department of Health on 09/13/12, documented: "(Resident #7) ...with the (diagnoses) of Dementia and Anxiety State. He is alert and oriented (times) 1. He is up in a geri chair, propelled by staff. On 9-12-12 at (5:20 p.m.) he was in the dining room. He had just gotten a cup of coffee. He spilled the hot coffee in his lap. He has a red blistered area to his right thigh. All parties notified. Staff will give him his coffee in a cup with a lid and cooled before he gets it..." A nurse's note, dated 09/13/12, documented the burn to the right thigh was 18 centimeters x 14 centimeters x 0.2 centimeters. The facility's skin/wound log, dated 09/24/12, documented the burn to the right thigh measured 15 centimeters x 5.0 centimeter and had yellow slough. The facility's policy and procedure for feeding residents documented staff were to identify the appropriate problem that prevented the resident from feeding himself/herself and to consider listing possible risks and complications. On 10/31/12 at 11:15 a.m., the surveyor asked LPN (licensed practical nurse) #2, who was on duty at the time of the incident, how the incident had occurred. He stated resident #7 was given hot coffee by staff # 8. The LPN stated the coffee was, "hot, she didn't cool it off." The LPN stated the resident, "is not always steady when he holds things. He is fidgety." When asked if the resident was supervised when drinking the coffee, the LPN responded, "No one was sitting next to him and observing him to watch him when the incident occurred." On 10/31/12 at 12:30 p.m., LPN #2 was asked from what type of cup the resident drank his coffee. The LPN showed the surveyor the cup. Examination of the coffee cup showed it to be made of thin plastic and had a lid that snapped into place. The cup was measured and was found to hold approximately eight ounces of fluid. The LPN stated he observed the resident take the lid off of the cup at times. The surveyor asked the LPN if he had observed the resident take the lid off prior to the incident and he replied, "Yes." On 11/01/12 at 10:50 a.m., the surveyor reviewed the above findings with the DON. The surveyor asked if the resident should have been given hot coffee and left unattended. The DON stated the resident should not have been given the hot coffee and left unattended. She stated the coffee should have been cooled.