Every finding on record at Four Seasons Rehabilitation & Care

Based on record review and interview, the facility failed to ensure the physician responded to monthly medication regimen reviews (MMR) for 3 (#4, 5 and #21) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 42 residents who resided in the facility. Findings: A Medication Monitoring policy, dated 10/01/18, read in parts, For non-Urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident- but no later than their next routine visit to assess the resident- and the Attending Physician should document in the medical record .If the Attending Physician fails to address a recommendation or document a rationale for rejecting a recommendation: The DON, Medical Director or designee should review the incomplete documentation with the Attending Physician. 1. An undated face sheet showed Res #4 had diagnoses which included major depressive disorder and insomnia. A physician order, dated 01/16/23, showed to administer temazepam (hypnotic) 15 mg at bedtime for insomnia. A physician order, dated 12/27/23, showed to administer citalopram (antidepressant) 40 mg daily for major depressive disorder. A MRR report, dated 05/14/24, showed the consulting pharmacist had requested a gradual dose reduction of the citalopram 40 mg. There was no documented response from the physician on the MRR report or in the medical record. An annual assessment, dated 05/19/24, showed the resident had a BIMS score of 15 and was cognitively intact. The assessment showed the resident had no depression symptoms or behaviors and received hypnotic and antidepressant medications. A MRR report, dated 06/13/24, showed the consulting pharmacist had requested a gradual dose reduction of the temazepam 15 mg. There was no documented response from the physician on the MRR report or in the medical record. 2. An undated face sheet showed Res #21 had diagnoses which included major depressive disorder and insomnia. A physician order, dated 02/22/23, showed to administer trazadone (antidepressant) 150 mg at bedtime for insomnia. A MRR report, dated 05/14/24, showed the consulting pharmacist had requested a gradual dose reduction of the trazadone 150 mg. There was no documented response from the physician on the MRR report or in the medical record. A MRR report, dated 08/14/24, showed the consulting pharmacist had requested a gradual dose reduction of the trazadone 150 mg. There was no documented response from the physician on the MRR report or in the medical record. An annual assessment, dated 11/16/24, showed the resident had a BIMS score of 13 and was cognitively intact. The assessment showed the resident had mild depression symptoms, no behaviors, and received hypnotic and antidepressant medications. On 05/15/25 at 9:55 a.m., the DON stated the physician should have addressed the monthly medication reviews. They stated no physician response to the reviews could be located. 43023 3. Res #5's undated diagnoses list showed diagnoses which included insomnia and post traumatic stress disorder. A physician's order, dated 02/15/24, showed temazepam 15mg two capsules at bedtime. A MRR, dated 05/14/24, showed Res #5 currently received temazepam (hypnotic) 30mg (2x15mg) once daily at bedtime for Insomnia. There was no documented response from the physician on the MRR report or in the medical record. A MRR, dated 8/14/24, showed the resident currently receives temazepam (hypnotic) 30mg (2x15mg) once daily at bedtime for Insomnia. There was no documented response from the physician on the MRR report or in the medical record. A MRR, dated 11/13/24, showed the resident currently receives temazepam (hypnotic) 30mg (2x15mg) once daily at bedtime for Insomnia. There was no documented response from the physician on the MRR report or in the medical record. On 05/15/25 at 9:57 a.m., the DON reported the request should have shown a response from the physician.

Based on record review and interview, the facility failed to implement their abuse policy for one (#1) of four residents reviewed for allegations of abuse. The administrator identified four allegations of abuse in the last six months. Findings: The facility policy titled Abuse Investigation and Reporting documented in parts .The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation . Resident #1 had diagnoses which included muscle weakness, altered mental status, and anxiety. An incident report, dated 08/06/24, documented an allegation of abuse. The report documented an employee inappropriately touched themselves in the resident's room. The report documented the employee was immediately suspended pending the investigation. An employee timecard, dated 08/06/24, documented CNA #1 clocked in at 2:49 p.m., clocked out at 4:49 p.m., clocked back in at 5:22 p.m., and clocked out again at 11:10 p.m. On 09/19/24 at 11:19 a.m., the administrator reviewed CNA #1's timecard. The administrator stated the timecard had been altered to reflect time paid during the suspended time pending the investigation. The administrator could not provide documentation the staff was not working during the time of the investigation. The administrator stated they were unsure what time the staff member was allowed to return to work.

Based on record review and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#16) of one sampled residents for assistance with bathing. The administrator identified 44 residents who resided in the facility. Findings: Res #16 had diagnoses which included myotonic muscular dystrophy, lack of coordination, muscle weakness, schizoaffective disorder, and major depressive disorder. A physician order, dated 03/25/22, documented nail care to be provided on bath days Monday, Wednesdays, and Fridays on the three to eleven shift. A care plan, last revised on 10/09/23, documented the resident required the assistance of one for bathing. A quarterly assessment, dated 01/09/24, documented the resident was moderately impaired with cognition and required setup or clean up assistance to partial assistance with most ADLs. The assessment documented the resident required substantial to maximal assistance with bathing. The resident was scheduled for thirteen baths in December 2023. The bathing sheets were reviewed and documented the resident missed six of the thirteen scheduled baths. The resident should have received eleven bathes through the 25th of January 2024. The resident's bathing sheets were reviewed and documented the resident had missed seven baths in January. On 01/23/24 at 11:34 a.m., Res #16 stated they had to wait a while for assistance. They did not feel the facility had enough staff because at times they missed their shower. On 01/29/24 at 11:15 a.m., CNA #2 stated when staff call in, the residents may not get all get their scheduled baths. CNA #2 stated today they had a CNA call in but they have one staff to answer call light and the other two staff were assisting each other to transfer and shower the residents. On 01/29/24 at 11:46 a.m., CNA #1 stated they get assigned showers by the nurses. They fill out the assessment documentation for the skin which is the shower sheet. CNA #1 stated they only fill the sheet out when a shower is given. CNA #1 stated the resident was showered in on 3-11 shift Monday, Wednesday and Friday. CNA #1 stated the resident did not have a problem taking a bath for them. On 01/29/24 at 1:39 p.m., the DON stated they were monitoring bathing once a week on Fridays. The DON stated they had not noticed the resident had not been getting their scheduled baths. The DON stated they had noticed in audits some residents had missed baths. When they found bathing issues they would have the staff to give the bath to the ones who had missed one. The DON stated they had missed doing the audit's at times.

Based on record review and interview, the facility failed to ensure OHCA was contacted when residents had serious mental illnesses for two (#11 and #29) of two residents reviewed for PASRR assessments. The DON identified 44 residents resided in the facility. Findings: 1. Res #11 was admitted to the facility on [DATE] and had diagnoses which included major depressive disorder. A PASRR level I, dated 04/04/18 did document the resident had diagnosis of serious mental illness. On 08/13/21, the physician diagnosed the resident with schizoaffective disorder. On 01/25/24 at 10:29 a.m., the MDS coordinator stated that the OHCA was not notified of the new diagnosis of schizoaffective disorder. 2. Res #29 was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder and recurrent depressive disorder. A PASRR level I, dated 09/11/18 did document the resident had diagnosis of serious mental illness. On 08/17/21, the physician diagnosed the resident with schizoaffective disorder. On 01/25/24 at 10:29 a.m., an interview with the MDS coordinator was conducted and she stated that OHCA was not contacted regarding the new diagnosis of schizoaffective disorder.

Based on record review, and interview, the facility failed to update a comprehensive care plan for three (#8, 11, and #29) of three sampled residents reviewed for revision of care plans. The facility failed to update care plans related to: a. pressure ulcers for Res #8, b. bed rails and low air mattress for Res #11, and c. schizoaffective disorder for Res #29. The administrator identified 44 residents who resided at the facility. Findings 1. Resident #8 was admitted on [DATE] with diagnoses of multiple sclerosis, overactive bladder, chronic pain, chronic kidney disease, and diabetes mellitus type II. A revised care plan, dated 09/18/23, documented skin was intact and without evidence of redness, irritation, maceration, or open areas. The care plan also documented the resident was at risk for pressure ulcers. A significant change assessment, dated 12/11/23, documented the resident was moderately impaired with cognition and required extensive assistance with most ADLs. The assessment also documented the resident had two stage III pressure ulcers, one unstageable pressure ulcer, one venous, and an arterial ulcer. A physician progress note, dated 12/13/23, documented the resident had a blister (non thermal) to the left lower leg. A physician progress note, dated 01/02/24, documented the resident had a stage III pressure ulcer on the right buttock. A physician order, dated 01/21/24, documented, sacral stage III pressure ulcer, cleanse with wound cleanser, apply skin prep peri-wound, cover with silicone border gauze dressing daily. A physician order, dated 01/21/24, documented, an unstageable pressure ulcer to right ischial, cleanse with wound cleanser, apply skin prep peri-wound, cover with silicone border gauze dressing daily. A physician order dated 01/21/24 documented, an unstageable pressure ulcer to left ischial, cleanse with wound cleanser, apply skin prep peri-wound, cover with silicone border gauze dressing daily. On 01/25/24 at 11:44 a.m., the MDS coordinator stated the care plan had not been updated with the pressure ulcers. 46909 2. Res #11 was admitted on [DATE] with diagnoses of diabetes mellitus with diabetic nephropathy, idiopathic peripheral autonomic neuropathy, acute embolism and thrombosis of unspecified deep veins of right lower extremity, anxiety, and schizoaffective diagnoses. A physician order, dated 09/27/23, documented the resident may have U-rails for bed mobility. A side rail assessment and consent, dated 09/27/23, was signed by the resident to utilize U-rails for positioning. A care plan, dated 11/02/23, did not document the resident was utilizing a low air mattress with U-rails. A quarterly assessment, dated 11/13/23, documented the resident's cognition was severly impaired. Res #11 required assistance with all ADLs. On 01/23/24 at 11:43 a.m., the resident was observed lying supine in the bed sleeping with their head leaning on the U-bar bed rail while on an air mattress. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 01/24/24 at 3:53 p.m., an interview was conducted with the DON and they stated they did not know the resident was on a low air mattress. The ADON stated the low air mattress was not on the care plan. On 01/24/24 at 9:40 p.m., an interview was conducted with the MDS Coordinator and they stated the bed rails were not added to the care plan at the time of the consent and assessment was conducted. They also stated the low air mattress was not added to the care plan but they would add it to the care plan now. 3. Res #29 was admitted to the facility on [DATE] and had diagnoses which included end stage renal disease, anxiety disorder, diabetes mellitus, and recurrent depressive disorder. On 08/17/21, the physician diagnosed the resident with schizoaffective disorder. On 08/17/21, the diagnoses of schizoaffective disorder was added to the care plan at the time of diagnosis but there were no intervention added for the new diagnosis. On 01/25/24 at 10:29 a.m., an interview with the MDS coordinator was conducted and they stated the care plan was not updated with interventions after the new diagnoses of schizoaffective disorder.

Based on observation, record review, and interview, the facility failed to maintain proper catheter bag placement to prevent urine back flow for one (#2) of one resident who was reviewed for catheters. The DON identified five residents who had catheters. Findings: The form titled Catheter Care, Urinary documented .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder . The resident was admitted with diagnoses which included retention of urine, urinary incontinence, and history of urinary tract infections. The care plan, dated 08/21/23, documented the resident had a catheter and was at risk for infections. The goal was for the resident to remain free from infection times 90 days. The approach was to maintain the catheter tubing below the level of the bladder. The quarterly assessment, dated 11/07/23, documented the resident was moderately impaired cognitively and required maximum assistance with ADLs. The assessment documented the resident had a catheter. The assessment documented the resident did not have an infection and was not receiving an antibiotic. On 01/23/24 at 12:03 p.m., the resident was sitting in dining room in a electric wheelchair. The resident's catheter bag was hanging to the left side of the chair at waist level or slightly higher. On 01/24/24 at 3:14 p.m., the resident was sitting in their electric wheelchair in the dining room playing bingo. The resident's catheter was positioned on the side of the wheelchair at waist level. On 01/24/24 at 3:45 p.m., the resident was sitting in their wheelchair with the catheter tubing stretched across the bed and the bag was hanging on the other side of the bed. The resident stated they could hang the catheter bag on the side of the bed, but could not see to place the catheter bag on their wheelchair. The resident stated the staff had to position the catheter bag when in the wheelchair. On 01/25/24 at 7:55 a.m., the charge nurse/LPN #2 was with the resident in the dining room after breakfast. The ambulance crew was preparing the resident for transport. The charge nurse stated the resident's potassium was high and they had a urinary tract infection. The location where the resident's catheter was identified. The charge nurse stated the location was not below the bladder. The charge nurse stated the resident had a surgery scheduled a couple of months ago, but has been unable to have surgery due to continuous urinary tract infections.

Based on record review and interview, the facility failed to ensure significant medication errors did not occur for one (#16) of five residents whose medications were reviewed. The administrator identified 44 residents who resided in the facility. Findings: Res #16 had diagnoses which included type two diabetes mellitus with hyperglycemia, myotonic muscular dystrophy, schizoaffective disorder, and major depressive disorder. A physician order, dated 12/07/21, documented Levemir insulin administer 15 units subcutaneous at bedtime for diabetes mellitus with hyperglycemia. A care plan, last revised 10/09/23, documented the resident was a diabetic and to administer insulin as directed. The care plan documented the staff wound monitor for signs and symptoms of hyperglycemia. The care plan documented the staff would notify the physician of a FSBS less than 60 or greater than 400. A physician order, dated 12/14/23 Novolin R FlexPen (insulin regular human) insulin pen administer five units subcutaneous with meals for diabetes mellitus with other diabetic ophthalmic complication at 6:00 a.m., 12:00 p.m., and 4:00 p.m. A quarterly assessment, dated 01/09/24 documented the resident was moderately impaired with cognition and required setup or clean up assistance to partial assistance with most ADLs. The assessment documented the resident received insulin seven days during the look back period. A review of the January 2024 MAR documented the Levemir 15 units at bed time was held on 01/15/24 and 1/23/24. The Novolin R insulin to administer five units with meals was observed to be held 20 times on the January MAR. The orders did not have parameters to hold the insulin documented. On 01/26/24 at 12:16 p.m., the DON stated they were not able to find any documentation where the physician was notified of holding the resident insulin. The DON stated the Levemir orders do not have parameters and if the nurses hold insulin they should notify the physician. On 01/26/24 at 12:28 p.m., LPN #2 stated when insulin was held they should call the physician. On 01/26/24 at 1:00 p.m., LPN #3 stated if they held insulin they would contact the physician when parameters were not on the order. On 01/29/24 at 10:42 a.m., the ADON stated they received orders from the physician to hold the insulin when the residents blood sugar was less than 70.

Based on record review and interview, the facility failed to follow the menu and make changes changes with the dietitian approval for the residents. The dietary manager identified 41 residents received meals prepared by the kitchen. Findings: A policy titled Menu Substitutions documented, .menu will be served as written unless an emergency situation arises .If a specific item is not available, the cook will consult with the Nutrition & Foodservice Manager or consultant RDN/NDTR regarding an appropriate substitution .substitutions will be made in accordance with the Menu Substitution Guide .The dietitian will initial off the Menu Substitution Form after review . On 01/23/24 at 10:30 a.m., the DM stated the menu documented roast beef for the lunch menu, but was rejected by the food purchase company and they substituted pork roast. The DM stated substitutions happened a lot and they would not know until the food order arrived. The DM stated they were unsure who approved the substitutions from the original order, but it as always been that way. On 01/23/24 at 10:31 a m., dietary cook #1 stated the desert had been changed from a brownie to fruit at the request of about 10 residents. The cook was asked was their a resident meeting about the desert change and was the dietitian informed. The cook stated the DM was told, but no one else. On 01/23/24 at 11:30 a.m., the corporate DM stated the menus are approved by the dietitian. The corporate DM stated the facility DM was to follow the menu and if changes needed to be made they were to notify the corporate DM or the dietitian.

Based on observation, record review, and interview, the facility failed to store and distribute food in a sanitary manner for the residents. The dietary manager identified 41 residents who received meals from the kitchen and three residents who received nutrition via tube feeding. Findings: The Ice Machines and Ice Storage Chests policy documented .To help prevent contamination of ice machines .a. Limit access to ice machine or ice storage chests/containers to employees only; g. Maintenance department will disassemble the ice machine for deep cleaning monthly or as indicated per manufacture instructions; h. Dietary department will perform weekly sanitizing of the ice bin . On 01/23/24 at 10:15 a.m., a tour of the kitchen was completed. The ice machine located in the resident dining room was unlocked, dirt was observed on the inside and around the outside of the door. Where the ice falls to the ice bin, there was a pink slim when checked. On 01/23/24 at 10:16 a.m., the DM observed the ice machine. The DM stated the ice machine should have been locked and the ice machine was cleaned by the maintenance staff monthly. The DM stated their was dirt on and around the door and did not look like it was cleaned last month. On 01/23/24 at 10:40 a.m., a Styrofoam cup was observed lying in the sugar bin. On 01/23/24 at 10:41 a.m., the DM stated the Styrofoam cup should not have been used to scoop the sugar or left in the bin. On 01/23/24 at 10:45 a.m., a second observation of ice machine was completed and the lock was noted to be through the lock slot, but not locked. On 01/24/24 at 8:52 a.m., the maintenance staff reviewed the monthly maintenance checklist for January 2024. The checklist documented Ice machine cleaned and checked for mold with initials identified as completed on 1/3/24. The staff reviewed the log and stated they did not clean the ice machine, just change filters and things. The maintenance staff stated a company cleans and services the ice machine every six months.

Based on record review and interview, the facility failed to ensure MDS assessment accurately reflected the residents' status related to a GDR which was clinically contraindicated for one (#16) of five residents whose medications were reviewed. The administrator identified 44 residents who resided in the facility. Findings: Res #16 had diagnoses which included schizoaffective disorder, major depressive disorder, and anxiety disorder. A MRR, dated 12/13/23, documented the resident received Risperdal 0.5 mg twice a day for schizoaffective disorder. The MRR documented a request for a GDR. The physician signed the MRR on 01/02/24 and documented the resident was stable at present and did not want a reduction. A quarterly assessment, dated 01/09/24, documented the resident was moderately impaired with cognition and required setup or clean up assistance to partial assistance with ADLS. The assessment documented the resident received an antipsychotic, an antidepressant, and an antianxiety medication. The assessment documented antipsychotic's were received on a routine basis only and a GDR was clinically contraindicated on 03/22/23. On 01/26/24 at 11:54 a.m., the MDS coordinator stated they only saw the March MRR in the EHR the most resent MRR request for December had not been scanned into the record. They stated the DON was the one to let them know when there were recommendations or contraindications for the residents.

Based on record review, observation, and interview, the facility failed to develop a comprehensive care plan related to a dialysis port for one (#38) of two residents reviewed for dialysis. The DON identified 44 residents resided in the facility. Findings: Res #38 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, disorder of phosphorus metabolism, and dependence of renal dialysis. A nurse note, dated 07/27/23, documented to send the resident to the emergency room for evaluation and treatment of their dialysis port related to the resident pulling the port out. A physician order, dated 08/22/23, documented dialysis catheter right chest - observe daily for signs and symptoms of infection and to leave open to air. A physician order, dated 09/20/23, documented to observe dialysis catheter left chest -observe for signs and symptoms of infection and to leave open to air. On 01/23/24 an observation was made of the resident's dialysis catheter in their left chest. A communication note, dated 01/23/24, documented dialysis on Monday, Wednesday, and Friday, observe catheter left chest - observe for signs and symptoms of infection and to leave open to air. On 01/25/24 at 3:42 p.m., an interview was conducted with the MDS Coordinator and they stated the care plan was to check the fistula on the resident. They also stated they thought the resident had a fistula but now I know the difference. They stated they would change the care plan related to the chest port catheter instead of a fistula.

Based on record review and interview, the facility failed to provide an ABN notice for one (#18) of three residents who were reviewed for beneficiary notices. The administrator identified 19 residents who were discharged from Medicare Part A services with days remaining. Findings: Res #18 received Medicare Part A services from 09/01/23 through 09/18/23. On 01/24/24 at 11:46 a.m., the DON stated the therapy department should complete the ABN form and nursing should complete the NOMNC form. The DON stated they understood when a resident did not have therapy they did not need the ABN. The DON stated the MDS coordinator was responsible for the completion of the required forms. On 01/24/24 at 12:12 p.m., the MDS coordinator stated most of the time the beneficiary ABN forms were completed by therapy. They stated the resident did not have therapy, so therapy would not have completed an ABN form. They stated to their understanding if the resident did not have therapy, the ABN form was not required.

Based on record review and interview, the facility failed to complete a thorough investigation for one (#98) of one resident who was reviewed for allegations of abuse. The DON identified 11 allegations of abuse in past year. Findings: A form titled Abuse and Neglect - Administrative Protocol documented, The facility abuse coordinator will conduct and/or facilitate interviews of the direct resident(s) involved in the allegation, any interviewable residents, and any staff associated with the allegation, any visitors that have knowledge or witnessed the allegation. A written report or statement will be gathered and maintained on all interviews . Res #98 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease, impulse disorder, and personality disorders. A discharge return anticipated assessment, dated 12/27/23, documented the resident was moderately impaired cognitively and required set up assistance with most ADLs. On 01/24/24 at 9:55 a.m., the resident was sitting in the dining room in a wheelchair drinking a cup of coffee. The resident stated they had never been abused and denied problems with other residents. The resident denied ever being physically or verbally abused by staff. On 01/25/24 at 10:38 a.m., the corporate RN #2 reviewed the incident report for the abuse allegation on 03/02/23 regarding the resident. The RN stated the incident report did not document a detailed report of what had occurred with the resident. The RN stated there were no documented statements from the resident making the allegation or any residents in the facility. On 01/25/24 at 10:47 a.m., the DON provided a progress note dated 03/02/23 at 5:08 p.m. The note documented an employee to resident verbal abuse had been reported. The note documented the resident was interviewed, family notified, and provider notified. The DON stated no addition information could be provided. The DON stated per the documentation they could not determine what had occurred and thorough investigation had not been completed.

Based on interview and record review, the facility failed to complete a significant change assessment after the resident had a change in condition for one (46) of 16 residents whose assessments were reviewed. The administrator identified 44 residents who resided in the facility. Findings: Res #46 was admitted to the facility with diagnoses which included malignant neoplasm of overlapping sites of cervix, acute kidney failure, and urinary tract infection. An admission assessment, dated 10/23/23, documented the resident was severely impaired cognitively and required partial to moderate assistance with most ADLs. The assessment documented the resident did not have a life expectancy of less than six months to live and was not receiving hospice services. A physician order, dated 10/30/23, documented an order for Centric Hospice to evaluate and treat for hospice care. On 01/29/24 at 12:50 p.m., the MDS coordinator reviewed the resident's EHR and stated the resident started receiving hospice services on 10/31/23. The coordinator stated a significant change assessment should have been completed within 14 days after the resident stated receiving hospice services.

Based on observation, record review, and interview the facility failed to ensure a resident was free from accident hazards for one (#11) of three sampled residents reviewed for accidents. The DON identified 44 residents resides in the facility. Findings: Res #11 was admitted on [DATE] with diagnoses of diabetes mellitus with diabetic nephropathy, idiopathic peripheral autonomic neuropathy, acute embolism and thrombosis of unspecified deep veins of right lower extremity, anxiety, and schizoaffective diagnoses. A physician order, dated 09/27/23, documented the resident may have U-rails for bed mobility. A quarterly assessment, dated 11/13/23, documented the resident cognition was severly impaired. Res #11 required assistance with all ADLs. A care plan, dated 11/02/23, documented the resident may use bed rails for positioning. The care plan also documented the resident would use bed rails without adverse consequences. On 01/23/24 at 11:43 a.m., the resident was observed lying supine in the bed sleeping with their head leaning on the bed bed rail while on an low air mattress. An attempted to interview the resident was unsuccessful due to the resident's cognition. On 01/25/24 at 07:55 a.m., an interview was conducted with the DON and they stated there was a consent and assessment for the bed rails completed on 09/27/23. They also stated there should be more assessment in the chart. The DON stated the risk and benefits was not explained in detail to the resident. On 01/25/24 at 12:00 p.m., an interview was conducted with the MDS coordinator and they stated the air mattress should have been included in the bed rail care plan.

Based on record review and interview, the facility failed to complete a monthly medication regimen review for one (#8) of five residents reviewed for unnecessary medication. The administrator identified 44 residents who resided in the facility. Findings: Res #8 had diagnoses which included multiple sclerosis, a right buttock pressure ulcer stage III, pain, cirrhosis of the liver, chronic kidney disease, diabetes, depression, and urinary tract infection. A MRR, dated 04/18/23, documented a requesst for reduction of Celexa 20 mg daily and Cymbalta 60 mg daily. The physician signed and documented no changes on the form, but did not date the MRR. A MRR, dated 05/16/23, documented a request for reduction of Celexa 20 mg daily and Cymbalta 60 mg daily. The physician documented no changes, but did not document a rational for their response. A MRR, dated 06/16/23, documented a request for reduction of Celexa 20 mg daily and Cymbalta 60 mg daily. The form did not document a response from the physician. A significant change assessment, dated 12/11/23, documented the resident was moderately impaired cognitively and required substantial/maximal assist with most ADLs. The assessment documented the resident received an antidepressant, antibiotic, diuretic, and a opioid medication. The assessment documented antipsychotic medications were not received. On 01/25/24 at 12:20 p.m., the DON stated for the month of June 2023 the facility did not have the physician sign any of the MRR requests. On 01/25/24 at 4:06 p.m., the Corporate Nurse #2 stated the MRR should be dated by the physician.

Based on record review and interview, the facility failed to complete a baseline care plan for one (#21) of 16 residents whose care plans were reviewed. The administrator identified 44 residents who resided in the facility. Findings: Res #21 was admitted to the facility with diagnoses which included injuries of left hip, dementia, and depressive episodes. An admission progress note, dated 12/06/23, documented the resident was admitted to the facility. The note documented the resident was confused and had dementia. The note documented the resident was dependent on staff for all ADL care and required two person assist for all transfers. The resident's EHR was reviewed. The record documented the baseline care plan was started on 12/07/23 and was still in progress. The admission assessment, dated 12/11/23, documented the resident was severely impaired cognitively. The assessment documented the resident required partial to moderate assist with personal hygiene and substantial to maximal assist with toileting. The assessment documented the resident had a history of falls resulting in a fracture. The care plan, dated 01/02/24, documented the resident was at risk for falls due to a history of a fall with a fracture. The approach was to provide individualized toileting interventions based on needs/pattern and increased staff supervision with intensity based on resident need. On 01/29/24 at 11:30 a.m., the ADON stated the baseline care plan should have been completed in the first 24 hours after the resident's admission.

Based on record review and interview, the facility failed to ensure labs were obtained per physician orders for one (#8) of five sampled residents reviewed for unnecessary medications. The DON identified 44 residents that resided at the facility. Findings: Res #8 was admitted on [DATE] and had diagnoses of multiple sclerosis, overactive bladder, chronic pain, chronic kidney disease, and diabetes mellitus type II. On 07/14/23 the pharmacist recommended to monitor the resident's Hemoglobin A1C and a lipid panel for the month of July 2023 and then every 6 months thereafter. The physician agreed with the recommendation and dated the form 07/19/23. A significant change assessment, dated 12/11/23, documented the resident was moderately impaired with cognition and required extensive assistance with most ADLs. On 01/25/23 at 12:20 p.m., the DON was interviewed and they stated the Hemoglobin A1C and a lipid panel had not been as ordered.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#11) of three residents reviewed for accident hazards. The DON identified 44 residents resides in the facility. Findings: Res #11 was admitted on [DATE] with diagnoses of diabetes mellitus with diabetic nephropathy, idopathic peripheral autonomic neuropathy, acute embolism and thrombosis of unspecified deep veins of right lower extremity, anxiety, and schizoaffective diagnoses. A physicians order, dated 09/27/23, documented the resident may have bed rails for bed mobility. A care plan, dated 11/02/23, documented the resident may use bed rails with help for positioning. The care plan also documented the resident would use bed rails without adverse consequences. A quarterly assessment, dated 11/13/23, documented the resident's cognition was severly impaired. Res #11 required assistance with all ADLs. The assessment did not document the resident utilized a low air mattress with bed rails attached to both sides of the bed. On 01/23/24 at 11:43 a.m., the resident was observed lying supine in the bed sleeping with their head leaning on the U-bar bed rail while on an air mattress. An attempted interview with the resident was unsuccessful due to the resident's cognition. On 01/25/24 at 7:55 a.m., an interview was conducted with the DON and they stated there was a consent and assessment for the bed rails completed on 09/27/23. On 01/29/24 at 9:40 a.m., an interview was conducted with the maintenance man #1 and they stated they had only started checking the bed rails in January 2024, but they thought their supervisor had more bed rail audits from 2023. The maintenance man #1 stated they had contacted their supervisor to ask where the 2023 bed rail assessments would be located. No documentation for 2023 was provided.

Based on observation, record review, and interview, the facility failed to ensure residents' rights to privacy was provided during dining for five of (#1, 2, 3, 4, and #6) of six sampled resident's reviewed for privacy. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included hypertension, dementia, pneumonia, and acute kidney failure. A significant change assessment, dated 09/23/23, documented Res #1 was severely impaired with cognition and required extensive assistance with ADLs. 2. Res. #2 had diagnoses of diabetes mellitus type II, post traumatic stress disorder, insomnia, and schizoaffective disorder. A quarterly assessment, dated 07/29/23, documented Res #2 was cognitively intact and required limited assistance for some ADLs. 3. Res. #3 had diagnoses of congestive heart failure, paroxysmal atrial fibrillation, and Parkinson's disease. A quarterly assessment, dated 08/13/23, documented Res #3 had problems with cognition and required extensive assistance with ADLs. 4. Res. #4 had diagnoses of chronic obstructive pulmonary disease, contact dermatitis, atrial fibrillation, and depression. A quarterly assessment, dated 07/28/23, documented Res #4 required extensive assistance with all ADLs. 6. Res. #6 had diagnoses of diabetes mellitus type II, chronic obstructive pulmonary disease, edema, muscle spasms, and breast cancer. A quarterly assessment, dated 06/07/23, documented Res #6 was cognitively intact and required extensive assistance with some ADLs. 7. An incident report form 283, dated 08/18/23, was faxed to the State of Oklahoma regarding and incident of abuse/mistreatment towards the residents and an investigation was initiated. The report document on 08/18/23 a dietary aide had reported that another dietary aide and a housekeeper/laundry aide had video recordings of the residents. An in-service report, dated 08/19/23, documented the DON had completed an in-service with the staff in the kitchen, housekeeping, and laundry, on privacy and HIPAA violations. On 08/29/23 the investigation was completed and a final report was faxed to the State of Oklahoma on a final 283 form. Monitoring sheets were provided which revealed on 09/02/23 a weekly monitoring system was initiated by the administrator and the DON to ensure that the residents had privacy in the dining area. On 10/10/23 at 8:07 a.m., the DON stated a thorough investigation was initiated on 08/18/23 regarding the incident of the kitchen, housekeeping, and laundry staff, related to video recording residents who resided in the facility. They stated the investigation was completed on 08/29/23 and an in-service for all kitchen, housekeeping, and laundry staff related to privacy was conducted. The DON stated the administration and DON would be monitoring the cameras placed throughout the facility to ensure no staff members were video recording any residents. A form titled Monthly QA/PI Committee Meeting form, dated 10/11/23, documented a QA meeting with the medical director was completed related to the privacy of the residents.

Based on interview and record review, it was determined the facility failed to provide care and services according to the resident's comprehensive plan of care for one (#2) of four residents sampled for quality of care. The facility failed to: a) Follow physician orders [REDACTED]. b) Obtain a response from the physician after an abnormal PT/INR laboratory result. c. Notify the physician after the resident was observed to have a bowel movement with blood. d. Develop and/or implement a plan of care for an anticoagulant medication. The resident was sent to the emergency room and was diagnosed with [REDACTED]. The director of nursing (DON) identified two residents in the facility who were receiving [MEDICATION NAME] (an anticoagulant medication). Findings: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated 08/02/18, documented to administer [MEDICATION NAME] 5 milligrams daily. A physician order, dated 08/02/18, documented to obtain a PT/INR blood test the next morning and report the results to the physician. A care plan, dated 08/02/18, did not document the resident's use of an anticoagulant medication. An admission assessment, dated 08/09/18, documented the resident was cognitively intact and required extensive assistance with most activities of daily living. The assessment documented the resident received an anticoagulant medication seven days of the seven day look back period. A physician order, dated 08/13/18, documented to obtain a PT/INR lab test every week on Wednesday. A laboratory (lab) result, dated 08/13/18, documented the PT was 45.8 and the INR was 3.74. A hand written note on the lab results, signed by licensed practical nurse (LPN) #1 and dated 08/13/18, documented the physician was notified. The lab documented the results were high. The lab results did not document the physician's response. There was not a nurse note documenting the nurse had spoken to the physician. A nurse note, dated 08/19/19, documented the resident had a blood-tinged, runny bowel movement that morning. The note did not document the physician was notified of the blood in the resident's bowel movement. A nurse note, dated 08/20/18, documented the resident had a large amount of black tarry stool with a red tinge. The note documented the physician was notified and orders were obtained to send the resident to the emergency room (ER). A hospital history and physical (H&P), dated 08/20/18, documented the resident had an upper GI bleed and black tarry stools. The H&P documented the resident's INR was over 10. The H&P documented the resident received an anticoagulant antidote in the ER and was admitted to the intensive care unit (ICU) with hypercoagulable state. A hospital discharge summary, dated 08/24/18, documented the resident presented with acute upper gastrointestinal symptoms with nausea, vomiting, blood in stools, and black stools. The summary documented the resident's electrolytes were replaced and the hemoglobin was stabilized. The discharge summary, documented the resident's INR was down to 2.1. The discharge summary documented the resident was to follow up in a week to arrange a colonoscopy. On 11/19/18 at 11:50 a.m., the minimum data set coordinator was interviewed. She stated she did not care plan the resident's anticoagulant medication. On 11/19/18 at 1:30 p.m., registered nurse #1 was interviewed by telephone. She reported she did not remember documenting the resident had blood in his stool because she would have reported bloody stool to the physician. She stated she really did not remember the resident at all. On 11/19/18 at 3:15 p.m., the DON stated the physician was not available and he was going to be out of his office all week. At that time the DON was asked who would be covering for the physician and the DON stated she wasn't sure. On 11/19/18 at 3:20 p.m., LPN #2 called the physician's nurse practitioner and left a message for her to return the phone call. No returned call was received. On 11/19/18 at 4:00 p.m., the DON was asked what were the therapeutic PT/INR levels for the resident. She could not provide any physician documented levels for PT/INR results and was unable to reach the physician. On 11/19/18 at 4:10 p.m., the MDS coordinator stated she had not been able to find the PT/INR lab results dated 08/03/18. She stated she called the laboratory and there were no lab results dated 08/03/18. On 11/19/18 at 6:01 p.m., the DON stated a PT/INR lab result for 08/03/18 was not completed. She stated if the staff could not obtain a lab draw, that should have been documented. She stated she would like the nurses to fax the PT/INR result to the physician and then call and speak with the physician, the physician's assistant, or the nurse practitioner for confirmation and orders. The DON stated the physician should have been notified on 08/19/18 and informed of the blood in resident's stool. On 11/19/18 at 6:07 p.m., LPN #1 was asked if she spoke to the physician when she called regarding the PT/INR results on 08/18/18. She stated she did not. She stated she only spoke to the office receptionist. She stated she gave report to the receptionist and then the receptionist would call back with orders. The LPN stated she would rather have talked to a nurse or the physician, but that was the way the physician did things.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received supervision and/or failed to implement and modify interventions to prevent falls for one (#21) of four sampled residents who were reviewed for falls. The resident sustained [REDACTED]. The director of nursing (DON) identified 39 residents who had fallen during (YEAR). Findings: Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The care plan, dated 06/15/17, documented the resident was at risk for falls related to a [DIAGNOSES REDACTED]. The documented dates the care plan was reviewed were 09/08/17, 12/09/17, and 03/09/18. The care plan documented the following approaches: ~ Assist the resident with one staff member for all transfers. ~ The resident prefers wearing non-skid socks. ~ The resident needs a night light on to help see at night. ~ Remind the resident to ask for assist for all transfers. ~ The resident uses an alarm while in the chair. ~ The resident uses an alarm while in bed. ~ Refer the resident for a physical therapy evaluation. ~ Monitor for changes in the resident's condition which may warrant increased supervision/assistance and notify the physician. ~ Refer the resident to the restorative nursing program. ~ The resident uses a wheelchair for long distance mobility. An interdisciplinary care plan meeting, dated 09/13/17, documented a care plan meeting was held for the resident. The resident's medical record was reviewed and did not document any other care plan meetings. An incident report, dated 10/06/17, documented the resident attempted to transfer herself from her wheelchair to her bed, slid to the floor, and did not sustain any injuries. The report did not document any steps to prevent reoccurrence (STPR). An incident report, dated 11/01/17, documented the resident was sitting in her wheelchair, reached for her snacks, and slid to the floor. The report did not document any injuries. The report documented the STPR were to get a bed and chair alarm and put snacks within the reach of the resident. A quarterly assessment, dated 12/09/17, documented the resident had moderately impaired cognition. The assessment documented the resident required the extensive assistance of one person with bed mobility, transfers, toilet use, locomotion on the unit, and personal hygiene. The assessment documented the resident did not walk and could feed herself. The assessment documented the resident was always incontinent of urine and bowel and did not have any impairment with extremities. The assessment documented the resident did not have any falls since the last assessment and had received scheduled pain medication in the previous five days. The assessment documented the resident was 66 inches in height, weighed 109 pounds, and did not receive physical therapy or restorative services. The care plan, with a review date of 12/09/17, was not updated with the intervention to put the snacks within reach of the resident. An incident report, dated 01/25/18, documented the resident was found on the floor beside her bed. The report documented the resident attempted to transfer herself from the wheelchair to the bed and did not sustain any injuries. The STPR was to place a chair alarm on the chair. The care plan, updated 01/25/18, documented a fall occurred on 01/25/18. The care plan documented to place the bed in low position and perform frequent checks to ensure all the resident's needs and wants were met. An incident report, dated 01/27/18 at 1:45 a.m., documented the resident was found lying on floor next to her bed. The report documented the resident complained of pain to her lower leg and had a three inch bruise to her shin area. The STPR were to encourage the resident to use the call light for assistance and the aides and nurses were to conduct frequent checks on the resident. An x-ray report, dated 01/27/18, documented a spiral [MEDICAL CONDITION] tibia diaphysis and a non-displaced [MEDICAL CONDITION] diametaphysis of the fibula. The report documented osteopenia was present. The care plan, updated 01/27/18, documented a fall occurred on 01/27/18. The care plan documented the resident was sent to the emergency room and was diagnosed with [REDACTED]. A hospital discharge summary, dated 01/30/18, documented the discharge [DIAGNOSES REDACTED]. A nurse note, dated 01/30/18, documented the resident returned to the facility per stretcher. The note documented the resident had a cast to her left leg and had an indwelling urinary catheter. A nurse note, dated 01/31/18, documented the resident was non-weight bearing to her left leg which was in a cast from her hip to her ankle. A prospective payment system (PPS) five day assessment, dated 02/06/18, documented the resident had moderately impaired cognition and required the extensive assistance of two people with bed mobility, transfers, dressing, and toilet use. The assessment documented the resident required the extensive assistance of one person with locomotion on the unit and personal hygiene. The assessment documented the resident did not walk and could feed herself. The assessment documented the resident did not have impairment in her upper extremities but did have impairment with one of her lower extremities. The assessment documented the resident was incontinent of bowel and had an indwelling urinary catheter. The assessment documented the resident had received scheduled and as needed (PRN) pain medication in the previous five days, was 66 inches in height, and weighed 126 pounds. The assessment documented the resident had a fracture in the last month prior to admission related to a fall and did not have a fall since admission or prior assessment. The assessment documented the resident had received physical therapy. A quarterly assessment, dated 03/09/18, documented the resident had moderately impaired cognition. The assessment documented the resident required the extensive assistance of two people with bed mobility; total assistance of one person with transfers and toilet use; and the extensive assistance of one person with locomotion on the unit, dressing, and personal hygiene. The assessment documented the resident did not walk and required the assistance of one person with eating. The assessment documented the resident had an indwelling catheter and was always incontinent of bowel. An incident report, dated 05/06/18, documented the resident's roommate reported the resident had fallen. The report documented the resident said she slid out of her wheelchair when she was trying to go to bed. The report documented no injuries. The report did not document any STPR. On 05/07/18 at 4:23 p.m., the resident was observed lying in bed. The resident was asked what the facility had done to help keep her from falling. She said they help her when she wants up. The resident was asked if she ever used her call light and she said she did not. An orthopedic boot was observed in the resident's room. The resident said she wore the boot when she got out of bed. On 05/09/18 at 5:45 p.m., the assistant director of nursing (ADON) was asked if there was any documentation related to the 01/25/17 intervention of frequent checks for the resident. The ADON stated she had only worked at the facility three weeks and was not aware of any documentation for frequent checks. She said she searched for documentation and said she could not find anything related to frequent checks. She stated she could not say the frequent checks had been done. On 05/09/18 at 6:00 p.m., the surveyor and the DON observed the resident in her room from the hallway. The resident was observed to raise up in bed and was moving her legs toward the side of the bed. The resident was asked what she was doing. The resident said, I was going to get up before ya'll came in.'' The resident then laughed. The call light was not on at that time. The resident's bed did not have a bed alarm on her bed at that time. The resident was wearing socks but they were not non-skid socks. A chair alarm was not observed in the resident's chair. On 05/09/18 at 6:02 p.m., certified nurse aide (CNA) #1 was asked about the resident's bed alarm. He stated when the resident got up, he would take the alarm off her bed and would place it on her chair. The CNA reported he did not know the alarm was missing from the bed. On 05/10/18 at 9:27 a.m., licensed practical nurse (LPN) #1 was asked what she was doing to prevent the resident from falling. She said they used a bed alarm. The LPN was asked if staff members were doing frequent checks the two days before the resident's fall which resulted in a broken leg. She said staff were up and down the hall all the time and could see her in her bed. She said nothing was documented about checking her frequently. On 05/10/18 at 9:40 a.m., CNA #7 was asked what she did to prevent the resident from falling. The CNA said if she saw the resident moving, she would help her up into the wheelchair. The CNA said the resident did not try to get up during the day shift. She said she had not heard the resident's alarm go off. The CNA was asked what frequent checks meant. She said she would look in on the resident when she went up and down the hall, but was not sure how often frequent checks were meant to be done. On 05/10/18 at 9:43 a.m., CNA #8 was asked what she did to keep the resident from falling. She said they kept the resident's door open and if she was moving in bed, they would get her up. On 05/14/18 at 2:04 p.m., the DON was asked how the facility determined what interventions to use to prevent the resident from falling. She said, We go by what is on the care plan and we talk about falls in the stand up meetings. She was asked how she ensured the fall interventions were implemented. She said she monitored by being out on the floor and making observations. She was asked about the frequent check intervention on the care plan, dated 01/25/18, and how was it documented as being implemented. She said she had only worked there since (MONTH) (YEAR) and did not know. She said the intervention of frequent checks should have been more specific. The DON reviewed the care plan and noted the interventions on the incident reports were already listed on the care plan at the time the resident was admitted . On 05/15/18 at 2:53 p.m., the minimum data set (MDS) coordinator was asked about the care plans not being updated with a fall intervention and change of care needs after the resident experienced a fracture. She said the care plan should have been updated with the intervention about the snacks being kept close to the resident. She stated she had started as the MDS coordinator on 03/22/18. On 05/14/18 at 3:34 p.m., the social services director (SSD) said she was the coordinator for the care plan meetings. The SSD was asked if the resident had a care plan meeting around the time of the (MONTH) (YEAR) assessment. She said the care plan meeting was not held. The SSD was asked about the meeting for the (MONTH) assessment. She said she could not remember if a meeting was held during that time. On 05/15/18 at 3:31 p.m., the MDS coordinator was asked how she knew when residents had falls. The MDS coordinator said she found out in the stand-up meeting at the beginning of the shift. She said she did not visualize the incident reports unless they were in the chart or documented on the fall log.

On [DATE] a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide cardiopulmonary resuscitation (CPR) for resident #1 who was a full resuscitation code. The facility failed to initiate cardiopulmonary resuscitation for resident #1 who did not have vital signs and had a full code status. Resident #1's clinical record documented the resident passed away. On [DATE] at 3:15 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the past noncompliance IJ related to the facility's failure to initiate cardiopulmonary resuscitation for resident #1 who did not have vital signs and had a full code status. On [DATE] at 3:30 p.m., the administrator and the director of nursing were informed of the past noncompliance IJ related to the facility's failure to initiate cardiopulmonary resuscitation for resident #1 who was absent of vital signs and had a full code status. On [DATE], the facility implemented measures to prevent a recurrence of the incident. The facility in-serviced staff in regard to appropriate measures to be taken when a resident was found absent of vital signs. One staff member was terminated related to the failure to to initiate CPR when the resident was absent of vital signs. A performance improvement plan, dated [DATE], was initiated by the director of nursing (DON). The performance improvement (PI) plan documented the goal was to ensure nursing team members were educated on CPR policy and procedure. The PI plan documented the initiative was failure to initiate CPR per policy and procedure. The PI action plan documented to send the incident report to the OSDH as appropriate, get statements from staff, and suspend the charge nurse who cared for the resident. The PI action plan documented to get statements from the certified nurse aides (CNAs) responsible for the care of the resident, as well as statements from other staff working at the time of the event. The PI action plan documented social services was to audit 100% of resident charts to ensure CPRs and DNRs were identified on the chart. The plan documented any resident missing a code status would be reviewed with the MD/RP/POA contacted and medical records updated as appropriate, by close of business on [DATE] and completion on [DATE]. The PI action plan documented education of 100% of nursing staff by the Regional Nurse or assistant director of nursing (ADON) regarding the CPR policy. The plan documented no nursing staff member, regardless of title, would be allowed to work on the floor until they were educated. The plan documented a staff roster was used to ensure 100% completion with completion on [DATE]. The PI action plan documented a 100% audit of nursing staff personnel files by the human resources (HR) coordinator to ensure documentation of staff training in CPR was present with completion on [DATE]. The DON reported the CPR in-service training began on [DATE] at 4:00 a.m. and ended at 11:00 p.m. Based on interview and record review, it was determined the facility failed to initiate cardiopulmonary resuscitation for one (resident #1) of three residents reviewed for CPR status and provision. Resident #1 had a full resuscitation code status, but was not provided with CPR when the resident was discovered without vital signs. Resident #1's clinical record documented the resident passed away. The facility identified 50 residents who had a full resuscitation code status. Findings: A cardiopulmonary resuscitation policy documented cardiopulmonary resuscitation (CPR)/basic life support (BLS) would be initiated if a resident experienced sudden [MEDICAL CONDITION], unless the resident had a current do not resuscitate (DNR) order. The policy documented if a resident was found unresponsive and not breathing normally, a licensed staff member who was trained in CPR would initiate CPR. The policy documented a second staff member would immediately call [DATE]. The policy documented CPR/BLS would continue until the resident regained consciousness or emergency medical services arrived. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A code status form, dated [DATE], documented the resident wanted CPR in the event his heart stopped beating and he stopped breathing. The form was signed by the resident. A physician order, dated [DATE], documented the resident was a full code. A care plan, dated [DATE], documented the resident required limited assistance with activities of daily living and was a high risk for falls. A readmission assessment, dated [DATE], documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident received oxygen therapy. The assessment documented the resident received occupational and physical therapy services. A nurse note, dated [DATE] at 12:00 p.m., documented resident #1 was in his room resting in his recliner. The note documented the resident's oxygen was on, his respirations were unlabored, the resident was free from distress, his feet were elevated, and his call light was within reach. On [DATE] at 1:00 p.m., certified nurse aide (CNA) #4 reported in a written statement she had found the resident in bed and nonresponsive. The CNA documented she immediately notified the nurse. A nurse note, dated [DATE] at 1:29 p.m., documented a CNA had called the nurse to the resident's room. The note documented the resident was found to be cyanotic with no pulse. The note documented the resident was stiff and cold to touch. The note documented an RN reassessed the resident and no pulse was found. A nurse note, dated [DATE] at 1:30 p.m., documented the LPN notified the RN and immediately checked for pulse via stethoscope after no pulse was detected. The note documented the physician was notified of the resident's condition, there were no vital signs, and an order to resuscitate was not given. The note described the resident's condition as supine in bed, head of bed slightly elevated, face and hands cyanotic, skin pale, cool to touch, hands curled, and stiffening had already began. The note documented the oxygen concentrator in the room had been in use. The note documented the resident was covered with a blanket over his legs. The note documented the resident appeared to have been resting in bed. The note documented the CNA was instructed to remain in the room until further notice. The note documented the DON was contacted at approximately 1:45 p.m. The note documented the DON instructed the facility to call for the funeral home to pick up the resident. The note documented the funeral home and family were notified. The note documented the funeral home received the body at 2:55 p.m. and the family received the resident's belongings. An initial incident report form, dated [DATE], documented an allegation of neglect. The form documented the resident was observed in his room with the absence of vital signs. The form documented the nurse failed to initiate CPR on the resident who was a full code. The form documented the nurse had been in-serviced on the policy for initiation of CPR and was suspended pending investigation. The form documented the resident was an [AGE] year-old male. The form documented the resident had [DIAGNOSES REDACTED]. The form documented the resident required oxygen at 4 (four) liters per nasal cannula with frequent breathing treatments. The form documented the resident was alert and oriented times three. The form documented the physician had discussed with him the possibility of hospice services. The initial incident report form documented it had been faxed to OSDH on [DATE] at 8:51 p.m. A final incident report form, dated [DATE], documented an allegation of neglect. The form documented the resident was observed in his room with the absence of vital signs. The form documented the nurse failed to initiate CPR for the resident who was a full code. The form documented the nurse had been in-serviced on the policy for initiation of CPR. The form documented the nurse had been suspended pending investigation. The form documented the resident was an [AGE] year-old male. The form documented the resident had [DIAGNOSES REDACTED]. The form documented the resident required oxygen at 4 (four) liters per nasal cannula with frequent breathing treatments. The form documented the resident was alert and oriented times three. The form documented the physician had discussed with the resident the possibility of hospice services. The form documented the investigation was initiated with witness statements obtained from staff on duty at the time of the incident. The form documented an interview was conducted with the nurse responsible for the resident's care. The form documented the nurse verified she did not start CPR. The form documented the nurse had been terminated. The form documented nursing staff had been in-serviced on the CPR policy of initiating CPR on all residents with full code status if found unresponsive. The final incident form was documented as faxed to the OSDH on [DATE] at 10:59 a.m. On [DATE] at 3:00 p.m., the director of nursing (DON) was interviewed related to alleged neglect related to failing to initiate CPR for resident #1. The DON reported she became aware of the incident on [DATE] at 1:30 p.m. The DON reported she began in-services on [DATE] and reported staff were in-serviced prior to beginning their shift. The DON reported the last signature for in-serviced staff was obtained at 11:00 p.m. on [DATE]. On [DATE] and [DATE], interviews and record reviews were conducted to verify the completion of staff in-services. Documentation was provided to indicate all staff had been in-serviced regarding initiation of CPR for any resident with a full resuscitation code status. Staff reported knowledge of the facility's policy for initiation of CPR on residents with a full resuscitation code status.

Based on record reviews, observations and staff interviews, it was determined the facility failed to ensure: a) A resident's swollen and reddened (R) arm had been assessed and monitored for one (#6) of one sampled resident sent to the hospital with a worsening condition. This had caused harm to the resident. This had the potential to affect four residents with a change in condition in the past 60 days per the DON. b) A resident complaining of pain with a pain scale score of 3 - 4 with 10 being the highest, for six straight days, had been offered Tylenol 325 mg 2 tablets per G/T q 6 hours PRN for pain 5 or less for one (#6) of four sampled residents sampled for pain control. This had the potential to affect 20 residents residing in the facility on a pain management program per the DON. c) A resident was assessed and had been provided the necessary care and treatment of [REDACTED]. This had the potential to affect 77 of 77 residents residing in the facility per the DON. d) A resident was receiving the correct [DEVICE] formula as ordered by the physician for one (#2) of four sampled residents identified with a [DEVICE]. This had the potential to affect six residents with [DEVICE]s residing in the facility per the DON. e) A resident with a rash had been assessed and monitored for one (#2) of one sampled resident identified with a rash. This had the potential to affect 77 of 77 residents residing in the facility per the DON. f) A physician had been contacted for a resident's high PT/INR result, in a timely manner, for one (#10) of one sampled resident. This had the potential to affect nine residents residing in the facility on anticoagulant therapy per the DON. g) A resident identified at admission with a [DIAGNOSES REDACTED].#11) of two sampled residents diagnosed with [REDACTED]. This had the potential to affect 39 residents residing in the facility with psychiatric [DIAGNOSES REDACTED]. Findings: 1. The [DIAGNOSES REDACTED]. An annual admission assessment, dated 03/13/13, identified the resident had been readmitted to the facility from an acute care hospital. The resident had severly impaired cognition with short and long term memory loss, had a problem with sleeping, had been feeling tired daily and had a problem with concentration. The resident had no behaviors and was on an antidepressant medication. Extensive assistance of two + staff were required for all ADL's. A care plan dated 03/23/2011, documented the resident was at risk for pain R/T [MEDICAL CONDITION]. The goal was for the resident to not experience rated pain at a 3 or more on a scale of 1 - 10 by next review. Approaches included, "Tylenol as ordered, [MEDICATION NAME] as ordered. Evaluate location, frequency, duration and intensity of pain. Document evaluation. Report increased pain trend to physician. Have (resident's Name deleted) to rate his pain on a scale of 0-10...Give pain medications as ordered and monitor effects of pain medication..." Another care plan dated 03/23/11, documented the resident was at risk for skin breakdown. Approaches included to monitor skin on bath days and prn for any skin disturbances...color changes, warmth and firmness... The April 2013, physician's orders [REDACTED].= 650mg) via [DEVICE] q 6 hours PRN temp/pain 5 or < ..." A form dated April 2013, documented, "Monitor numeric pain scale q shift." This form also documented the resident had complained of pain on the 3-11 shift daily for six days straight at a pain scale of 3-4. On the 1st, 2nd, 4th and 5th the resident complained of pain as a '4' on a scale of 0-10, 10 being the worst. A 'Pain Assessment Form', dated 04/02/13, documented the resident had not experienced pain in the last 7 days. Complained of pain less than daily. Denied pain at that time. Stated pain is increased with transfers and was relieved with PRN pain medication. The PRN pain medication: [MEDICATION NAME] 50mg 1 tab per G/T q 6 hours prn for pain 6 or >; and Tylenol 325mg 2 tabs per G/T q 6 hours prn for pain 5 or < than 5. The April 2013, 'PRN Pain Medication' form, was reviewed to verify if the prn Tylenol had been administered for the resident's complaint of pain. The form documented, "Tylenol 325mg 2 tabs (to + 650mg) via [DEVICE] q 6 hours PRN Temp/pain 5 or < ...start date 2/27/13." There were no initials the Tylenol had been administered to the resident for his verbal complaint of pain. The back side of the form had areas to document the following: "Location of Pain; Current Intensity; Precipitating/Aggravating Factors; Non-Med Intervention; Medication/Dose; Follow-up Monitoring of effective intervention; Arousal Scale; Initials." Non-Med interventions documented, "Heat, ice, massage, relaxation, 1:1 activities, positioning, music, medication and gentle ROM." The backside of the form was blank. On 04/08/13 at 11:35 a.m., the resident was observed lying in bed scratching his (R) arm. The arm appeared swollen and had a reddish color from the area just above the wrist to above the elbow. When the resident was asked what was wrong with his arm the resident replied it was itching. The resident was then asked if he had told the nurse. He stated, "No, it wouldn't do any good." He went on to say they wouldn't do anything for him anyway. The resident stated, "I can't even lift my arm up." He proceeded to try to lift his arm and could not do so. He was asked about his (L) arm and he said that arm itched too. At 11:40 a.m., the surveyor left the resident's room to find a nurse. RN #1 was asked to come into the resident's room to look at the resident's arm. The nurse went into the room and asked the resident what had happened to his arm. He told her he didn't know, but told her it itched. RN #1 then told the surveyor the resident had been diagnosed with [REDACTED]. At 11:45 a.m., LPN #1, who was the charge nurse, was asked if she knew about the resident's arm being red, itching and swollen. She said she did not know anything about his arm. The LPN then went to look at the resident's arm. On 04/08/13, the LPN filled out an 'SBAR' report at 11:50 a.m., which documented, "Noted redness [MEDICAL CONDITION] & a 3 x 2 cm purple bruise to Rt forearm ^ warmth c/o itching noted resident scratching arm...Giving resident PRN [MEDICATION NAME], obtained order for ABT..." At 12:00 p.m., LPN #1 reported she had called the physician and the resident's son regarding the resident's arm. On 04/08/13, a physician's telephone order documented, "(1) [MEDICATION NAME] 100mg 1 per gtube daily x 7 days [MEDICAL CONDITION] (2) DC [MEDICATION NAME] .25mg/10ml q 6 hours prn pegtube (3) [MEDICATION NAME] 25mg 1 tab per gtube q 6 hours for itching." On 04/09/13 at 1:05 a.m., the facility's charge nurse filled out an 'SBAR' report which documented, "Distended abdomen, 3+ [MEDICAL CONDITION] (R) arm & generalized [MEDICAL CONDITION], SOB. This started 4-8-13...Mental changes confusion, A & O x 1 Confused & disoriented @ x's...Orders to send res to (Name deleted hospital) via ambulance for eval..." The following are hospital reports obtained by the surveyor from the hospital: At 1:39 a.m., a hospital nurse's note, documented, "...Pain currently is 5 out of 10 on a pain scale....Quality of pain is described as aching. Pain began 2-3 days ago is continuous...Abdomen is distended..." At 3:31 a.m., a physician's hospital note, documented, "...02:13...complaints of abdominal swelling...He states right arm hurts..Onset: The symptoms/episode began/occurred 3 days ago...02:15...MS/extremity: Positive for [DIAGNOSES REDACTED], pain, swelling, tenderness, warmth, of the RUE...noted in the right arm distal, elbow, and proximal forearm red with increased temperature plus mild swelling..." Another hospital's physician's report, dated 04/09/13, documented, "...looks quite weak and in moderate distress due to pain and discomfort in his right upper extremity...Right upper extremity with significant [DIAGNOSES REDACTED]tous changes with localized tenderness and fluctuant type lesion on the medial side...Impressions: 1. Right upper extremity redness, tenderness and swelling. 2. Low-grade fever, chills, probably from underlying infection, [MEDICAL CONDITION] process..." On 04/08/13 at 11:45 a.m., LPN #1 who was the charge nurse was interviewed. She was asked if she had known about the resident's (R) arm being swollen, red and itching. The LPN said she had not been aware and had not been told about the arm. On 04/11/13 at 9:15 a.m., the DON was shown the prn medication form for April 2013, where the Tylenol had not been administered the six days the resident had complained of pain. The DON said she had talked with a 7-3 shift CMA and the CMA had told her she had not learned in school to document pain medication not given if the resident refused the pain medication. The pain had been documented on the 3-11 shift. 2. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 11/14/12, documented the resident was receiving anticoagulant therapy. A physician's telephone order, dated 12/07/12, documented PT/INR weekly on Monday and Friday. The resident's care plan, updated 02/07/13, documented, "(Name deleted) at risk for bleeding due to anticoagulant therapy R/T CAD. The interventions included: Administer anticoagulant as ordered by physician, coordinate lab work as ordered, [MEDICATION NAME] as ordered, Aspirin as ordered, PT/INR as ordered." The March and April's 2013, physician's orders [REDACTED].PT/INR weekly on Monday and Friday." The laboratory result for the PT/INR dated 04/05/13, was reviewed. The PT laboratory result was 47.5 and the INR laboratory result was 3.9. Normal ranges for PT were 12.2 - 15.6 and normal ranges for INR were 2.0 - 3.5. The abnormal laboratory results were faxed by LPN #2 to the physician's office on 04/05/13, which was a Friday. The nurse never attempted to contact the physician by telephone and the physician had not responded to the faxed abnormal PT/INR results. The next ordered PT/INR was to be drawn on 04/08/13, a Monday. The 04/08/13, PT/INR laboratory results could not be located in the resident's medical records. On 04/08/13 at 9:30 a.m., LPN #2 was interviewed. She reported she had faxed the PT/INR results to the physician on 04/05/13 (Friday). She further reported she had not yet received an answer from the physician, but would notify the physician by phone when the results of the PT/INR were available for the draw that day (04/08/13). LPN #2 was asked if she had been inserviced on when to notify or renotify a physician with abnormal lab results. She reported she had not been inserviced and did not know the facility's policy. On 04/09/13 at 10:15 a.m., the DON was asked if she could locate the PT/INR results for 04/08/13. The DON looked through the medical record and was unable to find the results. The DON said the PA was in the facility and she would go visit with him. At 11:15 a.m., the PA had been informed by the staff the resident's PT/INR had not been drawn on 04/08/13, as previously ordered. At 11:30 a.m., the PA wrote the following orders: "1. DC routine lab orders for PT/INR 2. Redraw PT/INR Monday 04/14/13, report lab to Dr. (Name deleted) for further lab orders." On 04/09/13 at 11:45 a.m., LPN #2 was interviewed again. She reported she had received new physician orders [REDACTED]. She further reported the physician was changing orders since the lab was not drawn yesterday and the facility did not know why. 3. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/11/13, documented the resident was severely impaired in cognition, required total assistance with activity of daily living needs, had impairment of lower and upper extremities, had a rash and had a feeding tube. The resident's care plan, updated on 02/20/13, documented the resident had a feeding tube and had an alteration in nutrition. The care plan documented the resident had potential for skin breakdown and the goal documented the skin would remain intact. A physician's orders [REDACTED]. On 04/09/13 at 8:50 a.m. the resident's [DEVICE] formula was observed. The Glucerna formula hanging and infusing was observed as Glucerna 1. The wrong formula was observed hanging and infusing to the resident. On 04/09/13 at 9:10 a.m., the DON observed the [DEVICE] Glucerna formula. The DON stated the staff had hung the wrong formula. The DON stated the resident should have Glucerna 1.2 infusing. At 9:55 a.m., the resident was observed receiving personal care. Upon entering the resident's room, an odor of urine was noted. CNA #3 removed the resident's top sheet and a strong odor of urine was noted. CNA #3 stated the resident's brief was dry but the resident's bottom sheet and bed were wet. CNA #3 stated the staff who applied the resident's brief had not attached it correctly. CNA #3 was asked what time did the resident have incontinent care last. CNA #3 stated the resident had incontinent care before the night shift left at 7:00 a.m. The resident was observed with a rash scattered over her body. The resident's eyes were observed inflamed and matted together. CNA #3 stated the nurse aides wiped the resident's eyes every day. CNA #3 stated the resident had the rash over her body for sometime. On 04/09/13 at 11:30 a.m., LPN #1 was interviewed regarding the rash on the resident's body and the resident's inflamed eyes. LPN #1 stated she thought the resident's rash was from [MEDICAL CONDITION]. LPN #1 stated she did not know of anything the facility had done for the resident's matted and inflamed eyes. At 11:45 a.m., the DON was interviewed regarding the resident's inflamed and matted eyes. The DON stated she would have to review the chart to see if anything had been done. At 5:40 p.m., the DON and RN #1 observed the resident. RN #1 stated the physician should be contacted for an order for [REDACTED]. 4. Resident #11 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A 'Level I PASRR' screen, dated 11/23/12, three days after the resident had been admitted , documented the resident had: "Evidence of serious mental illness including possible disturbances in orientation or mood (dementia or other organic mental disorders are not considered a serious mental illness). [DIAGNOSES REDACTED]. Recent history of mental illness or been prescribed a [MEDICAL CONDITION] medication for a possibly undiagnosed mental illness in the absence of a justifiable neurological disorder within the last two years." A nurse's note, dated 11/20/12 at 1:00 p.m., documented, "Spoke c res D/T fingernails long and growing under end of fingers. Res refused- will try tomorrow." A nurse's note, dated 11/20/12 at 3:00 p.m., documented, "To res room to do TB skin test. Res states, 'I'm not taking because I've been in & out of pen & been exposed to TB before.'" A care plan, dated 11/20/12, documented: "Problem: Resident receives anti-psychotic medication, R/T dx: [MEDICAL CONDITION] Approach:...Monitor resident behavior and document prn. Report any negative observations to physician. Refer to Social Services if needed for psych follow-up." Another care plan, dated 11/20/12, documented: "Problem: (Name deleted resident #11) is unable to dress independently, however he only requires supervision with set up for rest of ADLs... Approaches:...Refused bath @ Xs constantly smells of BM." A nurse's note, dated 01/12/13 at 10:00 a.m., documented, "This nurse requested resident allow her to cut his fingernails resident stated, '...no...', educated res on risk for infection 2 nails being dirty and unkept cont to refuse and walked away." A nurse's note, dated 02/12/13 at 9:25 a.m., documented, "This nurse asked resident if he would let her cut nails replies 'no' and walked away...CMA/CNA asked the resident 2 different times if he would like a shave & nails trimmed. Resident stated 'No'." A quarterly assessment, dated 02/27/13, documented the resident had adequate short and long term memory, was cognitively intact, resisted care and required supervision with ADL care. The March 2013, physician's orders [REDACTED]. [MEDICATION NAME] 15 mg daily for arthritis. [MEDICATION NAME] per nebulizer as needed for shortness of breath. [MEDICATION NAME] 50 mg as needed for pain. The March 2013, ADL sheet documented the resident was independent with ambulation, bed mobility, dressing and transfers. The ADL sheet documented the resident had not showered from the 1st through the 8th. Had showered on the 9th and the 11th, then 12 days later on the 23rd and 24th. A nurse's progress note, dated 03/09/13, documented, "Res was outside in smoking area heard outside alarm go off, this nurse & 2 CNAs went out back to smoke shack, where we found res on floor. Res stated he lost his balance & fell , stated he hurts all over. Asked res if he wanted to go to ER resi stated yes...ambulance arrived at facility at 3:30 a.m.... At 5:43 a.m., resi returned to the facility...EMT stated he refused to let the Dr at hospital eval..." A physician's progress note, dated 03/26/13, documented, "Resident became very angry and agitated when I attempted to trim nails and flat out refused to let me shorten them and we will re-attempt when he agree's." A telephone physician's orders [REDACTED]. A 'Psychiatric Evaluation and Management' form, dated 04/10/13, documented, "Chief complaint: chronic pain, [MEDICAL CONDITION]. Symptoms:...hx: [MEDICAL CONDITION] Adjustments: [MEDICATION NAME] 100 mg q pm x 1 wk then 200 mg q pm. [MEDICATION NAME] 300 mg tid (pain) hold if sedated..." On 04/07/13 at 6:00 p.m., the resident was observed sitting on a sofa in the television area at the end of the dining room. On 04/08/13 at 4:00 p.m., a group meeting was held with 13 alert and oriented residents attending the meeting. During the meeting, residents complained of resident #11 being incontinent with BM and not allowing anyone to clean him. He would sit on the public furniture in the common area with BM on his clothes. They were tired of the foul odor and were afraid to sit on the same furniture for fear of getting BM on themselves. On 04/10/13 at 2:00 p.m., the resident was interviewed in his room. The resident talked very loudly. The room had a bad odor and the resident appeared unkempt. On 04/10/13 at 2:05 p.m., LPN #3 was interviewed. The LPN reported the resident refused to allow anyone to assist to clean him. The LPN said at times the resident would allow him to clean him up when offered cigarettes. The LPN said the resident was incontinent of bowel. On 04/11/13 at 10:30 a.m., RN #1 and RN #2 were interviewed regarding the resident having a [DIAGNOSES REDACTED]. They said they had a problem with getting a physician to do a psych-eval.

On 12/12/12, an immediate jeopardy (IJ) situation was determined to exist regarding the facility's failure to ensure residents who smoked had been supervised and monitored for safety while smoking. The facility failed to ensure effective steps were put into place to prevent repeated incidents of a resident smoking in his room. On 12/12/12 at 1:25 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the immediate jeopardy situation, related to the facility's failure to supervise and monitor smoking residents for safety and to put effective steps into place to prevent residents from smoking in their rooms. On 12/12/12 at 1:35 p.m., the corporate RN, DON and the administrator were informed of the IJ situation which constituted substandard quality of care. On 12/12/12 at 5:15 p.m., the corporate RN provided the survey team with an acceptable plan of removal which documented: "1. The resident was placed on one on one, continuous, staff member to resident supervision, at 1:00 pm which will continue until a wander guard bracelet can be obtained to help alert staff to the resident existed from the facility to an area he could possibly obtain smoking paraphernalia. Resident's room checked for any smoking items and any found were removed. Personal items checked for burn holes. Care plan updated. The resident was also moved to another room so that he could be re-directed away from exiting out of hall 2 exit. Smoking alarms were purchased and installed in resident's room and bathroom. 26 Smokers will be re-assessed by midnight for the ability to be a safe smoker. Any smoker that is considered unsafe will have their smoking materials removed from their possession and their room checked for any other items. Care plans will be updated. 2. This has the potential to affect all residents and those that smoke. All residents who smoke will be informed of their updated evaluation and also informed that any resident found to be smoking in a non designated smoking area i.e. resident room will automatically become a supervised smoker with their smoking items kept at the nurse's station. A new smoker's evaluation will be done to reflect this with care plan updated. All other unsupervised smokers will be educated on not sharing any smoking materials with other residents. 3. Licensed nurse's, CMA's and CNA's will be re-educated by MIDNIGHT by the DON/Designee on the resident smoking policy including the supervision of residents, reporting and completing an occurrence report for any resident found to be smoking in a non-designated smoking area, updating the care plan and completing a new smoking evaluation. Staff in all other departments will be educated by Administrator/Designee for notifying nursing if a resident is observed in a non designated smoking area. In addition the resident's will be educated by Administrator/Social Services/DON/Designee on not sharing of smoking materials as this will result in them becoming supervised smokers. 4. The Administrator/DON/Designee will randomly audit observe residents who smoke for appropriate supervision and safety and will intervene when necessary. Effectiveness of the smoking policy, based upon the audit will be discussed through the QA process with changes made as needed. Random audits will be done weekly X4, monthly X3 and quarterly with results reported to the QA committee." On 12/13/12 at 9:30 a.m., the facility was informed the IJ was removed, effective 12/13/12 at 9:30 a.m., when the last staff member had been inserviced and the staff verbalized an understanding of the inservices. The deficiency remained at the level of no actual harm with potential for more than minimal harm with more than a very limited number of residents affected. The facility had inserviced their staff on "Smoking Policy, Smoking Regulations, Reporting smoking on occurrence report, updating completing care plan & completing a new smoking eval, notification of a nurse if a resident is observed in a non smoking area" The facility's revised 'Smoking Regulations', put into place on 12/12/12, documented: "In the best interest of our residents, employees and the Four Seasons Rehab Center there will be no smoking in the designated non-smoking areas. The following policies have been adopted: 1. Smoking is prohibited in the building. 2. Residents will be classified as 'at risk' or 'supervision' with smoking. 3. Resident's classified as 'at risk' will have cigaretts and smoking materials held at the nurses station/designated area. Will be giving enough cigarettes for one smoking session only. Staff will assist in lighting cigarettes. Lighters/matches will not be left with resident. They will be allowed to finish their cigarette unsupervised. 4. Resident's classified as 'supervision' will require a staff person or family member to light the cigarette and remain in attendance while the cigarette is burning. Cigarettes and smoking equipment will be kept at the nurses' station/designated area. They will be considered an unsafe smoker. 5. Smokers which are determined 'supervision' will be allowed to smoke every two hours with staff supervision 7am to 7pm. A staff member will be designed to supervise smoking on two hour intervals. 6. The IDT will determined which resident's are 'at risk' or 'supervision'. 7. The following area is designated for resident's smoking area: Hall 2 patio. Any violation of the above regulations should be reported to the Administrator IMMEDIATELY! The resident will be deemed as 'supervised' smoker with their smoking items kept at the nurse's station. A new smoker's evaluation will be done to reflect this with the care plan updated." Based on observation, record review and interview, it was determined the facility failed to: a) Assess, supervise and monitor residents who smoked for safety, for one (#7) of three sampled residents who smoked. This had the potential to affect 26 residents identified by the corporate RN, as being smokers. b) Ensure effective steps were put into place to prevent recurrences when a resident repeatedly smoked in non-designated areas for one (#7) of three sampled residents who smoked. This had the potential to affect all 80 residents. Findings: The facility's policy and procedure documented" "Smoking Policy- Residents: Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extend to which the facility can accommodate their smoking or non-smoking preferences; for example, in making room assignments. Non-smoking signs shall be prominently displayed throughout the facility when smoking is prohibited. Smoking restrictions shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas... Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be altered to these issues. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services and the Attending Physician. Smoking articles for residents with independent smoking privileges: Residents who have independent smoking privileges shall be permitted to keep cigarettes, pipes, tobacco or smoking articles in their possession. Residents may only keep disposable safety lighters. All other forms of lighters, including matches, shall be prohibited... Residents with independent smoking privileges may not give smoking articles to other resident with restricted smoking privileges. (Note: Anyone who observes this happening shall report it to the On-Duty Charge Nurse immediately.) Smoking shall not be permitted in bed, at any time, except under direct supervision. Smoking articles for residents without independent smoking privileges: Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Smoking shall not be permitted in bed without direct supervision. Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking... This facility may check periodically to determine if residents have any smoking articles in violation of our smoking policies. Staff shall confiscate any such articles, and shall notify the Charge Nurse/ Unit Manager that they have done so." Resident #7 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A smoking safety assessment, dated 08/29/12, documented the resident was aware of smoking safety and safe to smoke independently. An admission assessment dated [DATE], documented the resident had adequate short and long term memory, was cognitively intact, was independent with bed mobility, transfers, ambulation and required supervision with bathing. On 09/07/12 at 9:30 a.m., a nurse's note documented, "Smelled smoke in resident's room, resident admits to smoking educated on smoking policy states, 'okay', fax sent to (Name deleted physician)." On 09/07/12 at 9:30 a.m., a fax had been sent to the resident's physician and documented, "Resident has been smoking in room. Instructed him smoking is only permitted outside in smoking area." A care plan, dated 09/12/12, documented: "Problem: Resident is currently a smoker... Approach: Resident will smoke in designated area outside with staff asst. Resident cigarettes and all smoking materials to be kept at nursing station d/t pt smoking in room. Will educate pt on safety of smoking in designated areas and harmful side effects of smoking in room or building d/t other residents safety and O2 supplies." On 10/01/12 at 8:00 a.m., a nurse's note documented, "Reported by (Name deleted CNA #3) resident smoking in room. Instructed resident not to smoke, his lighter would be removed, he had burned his pants that were on bed on fire..." On 10/01/12 at 8:00 a.m., an incident/accident report documented, "Smoking in room. reported by (Name deleted CNA #3) resident smoking in room. Instructed resident not to smoke in room, explained danger of smoking in room. Noted burn hole in bottom of blue jeans... STPR: No cigarettes or lighter in room." A 'Safe Smoking Assessment', dated 10/01/12 at 3:03 p.m., documented, "Resident Observation: the resident can light and smoke a cigarette or other smoking devise while demonstrating safe disposal of ashes. The resident is able to physically hold the smoking device while smoking. The resident remains alert during the course of smoking. Resident interview: The resident is able to verbalize that they understand smoking materials are for their own personal use. The resident is able to verbalize that they understand smoking materials are for use only in the designated smoking area. Interdisciplinary Team Determination: Smoking Comment 1: Smoking in room x2. Smoking Comment 2: Dropped lit cigarette on pants on floor. Smoking Comment 3: Smoking materials to be kept by nursing..." A letter was issued to the resident and dated 11/29/12, which documented the resident would be issued a 30 day notice to discharge from the facility if he violated the smoking policy again. One of the infractions listed in the letter documented "...10/02/12, "Found resident smoking in room, smelled smoke in air and hallway smelled of smoke." The nurses' notes did not contain documentation related to the incident. An incident report had not been completed nor had steps to prevent recurrence been addressed. On 10/03/12 at 10:50 p.m., an incident/accident report documented, "Smoking in room. Found pt smoking inside the room, pt denies but smoke was in the air, also the hallway smell smoke cigarette. STPR: Teaching resident the dangerous of smoking inside the room R/T oxygen use in the facility, also encourage to go outside for smoke and turn in cigarette package to the CMA for control." On 10/03/12 at 11:30 p.m., an incident/accident report documented, "Activity @ time: Smoke in room... STPR: Smelled cig in hall entered residents room & very smoky. Resident denies smoking in room...Had resident to let staff hold a carton of cig & pkg of lighters @ nurse station. Refused to let staff have 1 pk of cig. Advised resident dangers of smoking in room. Verbally stated he understood." An ICP meeting form, dated 10/03/12, documented, "...Resident smoking in room. Adm spoke c resident along c social services. Instructed on no smoking in building policy. Pt verbalizes understanding. All smoking materials & cigarettes taken to NS to be locked in med cart for pt. Can smoke in designated areas c assist..." On 10/04/12, a social services note, documented, "...has been smoking in his room. Nursing has his cigarettes in the med cart. Temporary Administrator (Name deleted) and I spoke with (Name deleted) and explained to him that it is against policy and unsafe to smoke in his room or the building. (Name deleted resident #7) understood and agreed to smoke in the smoke areas. We will also try to have a C/P meeting to issue a 30 day discharge letter that can be retracted if he follows the rules." On 10/08/12 at 11:30 p.m., a nurse's note documented, "Found pt smoke in the room, pt denies, but smoke still in the air and also in hallway, encouraged to go to smoke in the designated area for smoking..." An incident report had not been completed nor had steps to prevent recurrence been addressed. On 10/18/12 at 8:41 a.m., a nurse's note documented, "(Name deleted CNA #3) brought small glass c 4 cigarette butts to desk. Room examined for more cigarette butts, cigarette lighter, burns in clothing or linens 0 found." An incident report had not been completed nor had steps to prevent recurrence been addressed. A smoking safety assessment, dated 10/19/12, documented the resident was an independent smoker and his smoking supplies were kept in the medication cart. On 10/29/12 at 9:10 a.m., an incident/accident report documented, "Activity @ time: noted cigarette ashes & smoke in room...(Name deleted CNA #3) reports there was cigarette smoke & cigarette butt in room. did not observed burn holes in cloths. STPR: Instructed & educated resident about smoking room the danger, 0 burn holes in cloths observed. Dr. (Name deleted) notified order written resident not to go out s asst. R/T smoking in room." A statement dated 10/29/12, and written by CNA #3 regarding the incident documented: "Upon doing 7 am rounds, I entered (Name deleted resident #7) smoke filled room and found ashes on the floor, a cup of water filled with ashes and a once lit cigarette butt sitting on bedside table burnt as if it were left standing on end with filter left burning to go out...Witnessed cloud of smoke as I opened the door. This is an ongoing occurrence. The hall is always stagnant with smoke and other residents rooms as well. There are many resident on the hall that do not smoke who are at risk of becoming sick, or increasing illnesses due to ongoing issue. I have never actually caught him in the act or found unsmoked cigarettes in his room. But I have seen plenty of evidence of his smoking." A care plan note dated 10/29/12, documented, "Nurse aides report strong odor smoke in room ashes in water in Styrofoam cup. Social services will counsel resident r/t not being able to go out unattended d/t getting smoking materials & keeping in room & smoking. Dr notified." An ICP meeting form, dated 10/29/12, documented, "(Name deleted resident #7) resident FSRC nurse aides reported found ashes in water Styrofoam cup. Strong smoke odor in room...Notified Social Services will talk c resident in regard to not being able to leave facility, unattended r/t not following rules of smoking policy." On 11/03/12 at 1:00 p.m., an incident/accident report documented, "Smoking in rm. Resident observed smoking in room. STPR: Took lighter & cig in rm, place in CMA cabinet when he goes out to smoke aide needs to go c to light cig q 30 min check to room." A care plan note dated 11/03/12, documented, "Smoking in rm. Cigs/lighter placed in CMA cabinet. Aids to go c to smoke, 30 min room checks." On 11/05/12, a visual check sheet documented the resident had been observed every 30 minutes starting at 11:30 a.m., and continued through 11/08/12. On 11/08/12 at 12:00 p.m., a fax had been sent to the resident's physician and documented, "Requests to DC to Tulsa, OK to home requests a discharge order to go home to Tulsa Oklahoma. Awaiting return response." On 11/08/12 at 5:00 p.m., a nurse's note documented, the resident had 'refused' to discharge home on 11/09/12 and a fax had been sent to the resident's physician. On 11/10/12 at 9:15 a.m., an incident/accident report documented, "Smoking in rm, sitting on side of bed. Found pt smoking inside his room. Had resident extinguish cigarette, took butt & lighter from resident. Educated to dangers of smoking in room. STPR: Educated to hazards of smoking in rm. when other residents have O2 in place. Encouraged resident to go out to smoke. Also supervised smoking sessions. 30 min visual checks ADM spoke c resident over smoking." A care plan note, dated 11/10/12, documented, "Smoking in rm. Educated about smoking in rm & hazard supervised smoking sessions 30 minute visual checks, Dr notified." On 11/10/12, a visual check sheet documented the resident had been observed every 30 minutes starting at 7:00 a.m., and continued through 11/11/12. There were no visual checks documented every 30 minutes from 11/12/12 through 11/18/12. On 11/19/12 at 10:00 a.m., an incident/accident report documented, "Cigarette butt/ashes found in glass in room. Smoking in room. (Name deleted housekeeper #1) brought a glass 1/2 full of cigarette butts & ashes to nurses station denies smoking in room. STPR: Cigarette lighter removed, educated on dangers of smoking in room, visual every 30 min check, supervised while smoking." A care plan note dated 11/19/12, documented, "1/2 glass full of cigarette butts & ashes found in room. Denies smoking in rm. Cig lighter removed educated resident visual q 30 DON notified doctor notified, staff supervised smoker." On 11/19/12, a visual check sheet documented the resident had been observed every 30 minutes starting at 10:00 a.m., and continued through 11/20/12. The visual checks had been restarted on 11/21/12 at 7:00 a.m., and continued until 11/22/12 at 8:30 a.m. One hour and 15 minutes later the resident is observed smoking in his room again. On 11/22/12 at 9:45 a.m., an incident/accident report documented, "Smoking in room... (Name deleted CNA #4) report resident smoking in his room, he put cigarette out 0 burn holes noted in clothing or lines. STPR: Cigarettes & lighter removed from resident's room. Educated resident on hazard of smoking in room...Were there any witnesses: yes (Name deleted) roommate." On 11/22/12 at 9:55 a.m., a physician communication and progress note documented, "...resident smoking in his room he put cigarette out. 0 burn holes in clothing or linens cigarette & lighter removed from resident's room. Visual q 30 min check initiated." A care plan note, dated 11/22/12, documented, "Smoking in rm, lighter & cigarettes removed; Resident educated on hazard ADON notified." On 11/22/12 at 10:00 a.m., a 'Visual Check Sheet' had been initiated and documented the resident was checked every 30 minutes, through 11/25/12. There were no other visual checks documented every 30 minutes. On 11/28/12 at 5:00 p.m., an incident/accident report documented, "Smoking in room. (Name deleted assistance administrator #1) came up to desk stated (Name deleted resident #7) smoking in his room on his bed. STPR: 1+1 given, could not smoke in rm, taken out to smoking area to smoke c supervision..." A care plan note, dated 11/28/12, documented, "Smoking in rm. Res. may leave facility only c assist R/T smoking. 1:1 given taken out to smoke c supervision, doctor notified." On 11/29/12 at 11:00 p.m., a physician communication progress note documented, "Resident came to nurse station wanting a cig advised resident that he could smoke c supervision only became upset & demanding 'all' his cigarettes and states. 'I'm leaving here anyway.'..." On 11/30/12 at 3:00 a.m., a nurse's note documented, "Resident has been to nurse station x2 for cigarette. Staff has supervised resident both times 0 smoking in room @ this X." On 12/01/12 at 8:00 a.m., a nurse's note documented, "...supervision c staff @ smoke area..." On 12/01/12 at 8:00 p.m., a nurse's note documented, "...up to NSG station or CMAs to request cigarettes and supervision of staff to go out to smoking area. No episodes of smoking in facility..." On 12/03/12 at 7:30 p.m., a nurse's note documented, "...Dr. (Name deleted) here- may leave tomorrow but AMA." A quarterly care plan note, dated 12/06/12, documented, "(Name deleted resident #7) is independent c walking. He is a smoker, encouraged to smoke outside in smoking area. He is alert & oriented 0 c/o pain." On 12/07/12 at 5:00 a.m., a nurse's note documented, "Resident sitting on bed in room c tv on, odor of cigarettes & smoke haze noted. Resident denies smoking in room, becomes loud and states, 'I'll smoke if I want to' advised resident again on smoking policy..." On 12/09/12 at 10:45 p.m., a nurse's note documented, "Resident reported to be smoking in room. When I entered room resident had already gone outside. Resident was then encouraged to ask for supervision along c his cigarettes. Resident states, 'I'll do what I want, I'm leaving anyway.'..." On 12/09/12 at 10:45 p.m., an incident/accident report documented, "Resident smoking in room. (Name deleted CNA #5) reported that (Name deleted resident #7) was smoking in his room. Upon entering his room he was already outside. 0 injuries noted. STPR: Resident encouraged to ask for supervision before smoking. Administrator states must find placement- 30 day notice can be served. SW to start looking for placement..." A statement from CNA #5 documented, "(Name deleted CNA #6) told me to go to check on him. (Name deleted resident #7) and he was smoking and I told him to put it out and not to smoke in the building again." On 12/10/12 at 7:00 a.m., a nurse's note documented, "Cigarette butts found in residents room, denies any smoking in room." A care plan note, dated 12/11/12, documented, "Start Nicoderm CQ as ordered x 24 hrs X 1 month & DC. No smoking while patch is on." The MAR for December 2012, did not contain documentation of the Nicoderm CQ as being administered. On 12/11/12 at 4:00 p.m., a nurse's note documented, "Request to have medication to aide in smoking cessation. Call to (Dr. Name deleted) c no. received noted...Nicoderm CQ states, yes to topical patch works great." On 12/12/12 at 10:30 a.m., a group meeting was conducted with nine alert and oriented residents. During the meeting a resident not identified for privacy stated, "We don't understand why management here allows some residents to smoke in their room. Why is it okay? We are scared about this." Another of the residents stated, "We have heard some resident has been told to stop smoking in their room but they have not stopped yet. Can't something be done to stop this?" On 12/12/12 at 12:00 p.m., the room of resident #7 was observed to contain a clear drinking cup. The cup was sitting beside the resident's bed. In the bottom of the cup were three cigarette butts, a pack of cigarettes and a couple of small pieces of paper. The overbed table sitting next to the resident's bed was observed to have a dusting of cigarette ashes. The resident was outside in the smoke area at the time of the observation. Housekeeper #1 was with the surveyors and reported they found smoking material in the resident's room frequently. In the resident's closet were three shirts. A red t-shirt was observed to have burn holes in the abdominal area. The resident's roommate was present during the observations. The roommate was asked if he had been aware of any residents smoking in their rooms. He stated, "Yes, him." The roommate was pointing to resident #7's side of the room. The roommate then stated, "I told him twice last night he needed to quit smoking in here, but he won't listen. " At 12:20 p.m., a resident that resided in the room close to resident #7's room was interviewed. The resident was asked if they had been aware of any resident smoking in their room. The resident stated, "Yes, about 1 or 2:00 yesterday morning the smoke was so strong I am surprised the smoke alarms did not go off. The smoke comes from that direction." The resident was pointing toward resident #7's room. The resident then stated, "If this place catches on fire I won't be able to get out in time." On 12/12/12 at 12:25 p.m., LPN #1 was interviewed. The LPN was asked if she had had any incidents with residents smoking in non-designated areas. The LPN reported she did, (Name deleted resident #7). The LPN reported the resident had been placed on every 30 minute checks this morning (Tuesday), due to a report of the resident smoking in his room over the weekend. She was asked why the visual checks had just been initiated today. The LPN stated, "Because I did not hear about it till this morning." On 12/12/12 at 6:42 p.m., the resident had been reassessed for smoking safety. The 'safe smoking assessment' documented, 'Supervised smoker/wear apron. The resident is able to verbalize that they understand smoking materials are for use in the designated smoking area..."