Every finding on record at Grand Lake Villa

Based on record review and interview, the facility failed to ensure a resident was not sexually abused for 1 (#48) of 2 sampled residents reviewed for sexual abuse.The DON identified 65 residents resided in the facility.On 04/23/26, an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #48 was not sexually assaulted by Res #17 on 03/11/26. This failure caused Res #48 to be fearful living at the facility.On 04/23/26 at 4:30 p.m., the OSDH was notified and verified the existence of the IJ related to the sexual assault of Res #48 by Res #17.On 04/23/26 at 4:33 p.m. the administrator and DON were notified of the IJ situation and provided with the IJ template.On 04/29/26 at 8:27 a.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, Resident #17 and resident #48 were immediately separated upon finding of incident. On 4/24/26 resident [Resident #17] was placed on 1:1 supervision until resident was discharged from facility at approximately 3:30pm on 4/24/2026 per POA's choice. Resident #48 was seen by Geri-psych nurse practitioner on 4/24/26 to address psychosocial needs. Plan of care updated. During the process of investigating the allegation of abuse on resident #17 and resident #48, interviews with residents and staff, record reviews and policy reviews were conducted. [Administrator], Grand Lake Villa Abuse Coordinator/Administrator, has been re-educated on revised/updated Abuse Policy on 4/24/26 by [name withheld], Director of Operations for [company name withheld]. On 4/27/2026, [Administrator] was quizzed on the Abuse and Neglect Policy by [Director of Operations]. On 4/24/26, at our mandatory in-service, [name withheld], Director of Operations for [company name withheld] and [name withheld], Administrator/Coordinator for Grand Lake Villa, reviewed the updated/revised Abuse Policy line by line. Each staff member received a paper copy of the policy and signed acknowledgement of this education. On 4/27/26, Grand Lake Villa staff were given a written quiz regarding the abuse policy to verify understanding and compliance. All residents and family members were provided with a copy of the revised/updated Abuse Policy along with Resident's Rights via in person (resident), and by mail (family) on 4/27/2026. All staff were questioned if they were aware of any current abuse in the facility or if they were aware of any current resident relationships in the facility, any concerns were immediately addressed. On 4/28/26, all residents that are lacking capacity were provided skin assessments to ensure no signs or symptoms of abuse. All residents that have capacity were asked if they were ever abused sexually, mentally, or physically while in the facility on 4/27/2026. Competent residents were asked if they were currently in a relationship with another resident in the facility or if they had plans to begin a relationship with another resident in the facility. On 4/28/26, the facility formally adopted and implemented a capacity to consent assessment and a policy addressing both consensual and non-consensual sexual relations among residents, in accordance with resident rights and safety standards. On 4/29/26 all staff were provided a copy of the consensual and non-consensual resident sexual relations policy and signed an acknowledgement of receipt.The IJ was lifted on 04/29/26 at 2:37 p.m., when all components of the plan of removal had been reviewed and verified:a. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify Res #17 was placed on 1:1 observations and discharged from the facility, Res #48 had been seen by mental health professionals, Res #48's care plan had been updated, and an investigation to determine the validity of the allegation and identify any other possible instances of abuse had occurred,b. documentation and interviews were conducted to verify the administrator had been re-educated and quizzed on the abuse and neglect policies,c. documentation was reviewed and interviews with 19 facility staff were conducted to verify each staff member had been re-educated and tested on the facility's abuse and neglect policies,d. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify staff, residents, and families were provided copies of the updated abuse and neglect policies,e. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify staff and residents were aware of any resident relationships at the facility,f. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify residents had been assessed for signs of possible abuse and if relationships between residents existed, andg. documentation was reviewed and interviews with 19 facility staff members were conducted to verify each staff member had been aware of the new abuse and resident relationship policies.The deficient practice remained at an isolated level with potential for more than minimal harm that is not immediate jeopardy.Findings:A policy titled Abuse - Neglect - Misappropriation - Mistreatment Policy, dated 02/16/24, read in part, It is the policy of Grand Lake Villa that the residents of this facility will be free from abuse, neglect, mistreatment, and misappropriation of property.A quarterly assessment, dated 12/30/25, showed Res #48 had a BIMS score of 14 (BIMS is a cognitive screening tool used to assess memory, orientation, and decision-making skills and a BIMS score of 14 indicated the resident's cognitive abilities were intact).A health status note, authored by RN #1, dated 03/11/26 at 7:53 p.m., showed LPN #3 had found Res #17 touching Res #48 inappropriately through Res #48's clothing. The note showed RN #1 had separated the two residents, RN #1 had asked Res #48 if they were ok with the other resident touching them, and Res #48 had replied, No. The note showed the DON had been contacted about the incident.A health status note, authored by the SSD, dated 03/12/26 at 8:53 a.m., showed the SSD and DON had confronted Res #48 about the resident's previous sexually suggestive actions and speech toward Res #17. The note showed Res #48 was told they had a BIMS score of 14 and was oriented times four (a medical term that suggests cognitive awareness) and they should no longer make advances toward Res #17. The note showed Res #48 denied the accusations and tried to hit the staff members.An initial incident report, dated 04/22/26, showed an incident of alleged abuse where Res #17 had their hand on Res #48's body in their private area on 03/11/26 and the incident was reported to the OSDH and local law enforcement on 04/22/26.On 04/22/26 at 3:18 p.m., RN #1 stated they had been the person that had confronted Res #17 and Res #48 on 03/11/26 after LPN #1 had witnessed what they thought was a sexual act. RN #1 stated they separated the two and reported the incident to the DON.On 04/22/26 at 3:27 p.m., LPN #1 stated RN #1's note, dated 03/11/26 at 7:53 p.m., was accurate to what they had seen. LPN #1 would not state what they had seen during the interview, but referred to RN #1's progress note, dated 03/11/26 at 7:53 p.m., that described the incident.On 04/23/26 at 7:31 a.m., the DON stated they had heard Res #48 refer to Res #17 as their (term of endearment withheld) in the past prior to the incident. The DON stated they had told Res #48 not to say that and did so because of Res #17's limited cognition.On 04/23/26 at 9:38 a.m., the DON stated they had not reported the incident to the OSDH or law enforcement at the time they found out about the incident on 03/11/26. The DON stated they had not interviewed staff or residents to determine if other potential victims existed. The DON stated they had instructed Res #17 and Res #48 to stay away from each other and were not allowed to eat with each other. The DON stated Res #48 was upset with the rules, but followed them. The DON stated after the incident had occurred, they had contacted their corporate headquarters and together they decided it was not necessary to report the incident to the OSDH or law enforcement.A health status note, authored by LPN #1, dated 04/24/26 at 2:44 p.m., showed Res #17 had been discharged from the facility.A psychiatric evaluation note, dated 04/24/26 at 2:53 p.m., showed Res #48 had been evaluated because of the incident on 03/11/26 where the resident had been inappropriately touched by another resident. The note showed Res #48 appeared more agitated than normal and reported fearfulness and not feeling safe. The note showed facility staff had reported the resident had become more isolative since the incident. The note showed Res #48's Zoloft (an antidepressant medication) was increased from 50 mg once daily to 100 mg, once daily because of the resident's increased irritability and anxiety.

Based on record review and interview, the facility failed to ensure the facility's abuse policy had been implemented after an allegation of abuse for 1 (#48) of 2 sampled residents reviewed for abuse.The DON identified 65 residents resided in the facility.On 04/23/26, an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #48 was not sexually assaulted by Res #17 on 03/11/26. This failure caused Res #48 to be fearful living at the facility.On 04/23/26 at 4:30 p.m., the OSDH was notified and verified the existence of the IJ related to the facility not implementing their abuse policy related to sexual assault.On 04/23/26 at 4:33 p.m. the administrator and DON were notified of the IJ situation and provided the IJ template.On 04/29/26 at 8:27 a.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, [name withheld], Grand Lake Villa Abuse Coordinator/Administrator, has been re-educated on revised/updated Abuse Policy on 4/24/26 by [name withheld], Director of Operations for [company name withheld]. On 4/27/2026, [Administrator] was quizzed on the Abuse and Neglect Policy by [Director of Operations]. On 4/24/26, at our mandatory in-service, [name withheld], Director of Operations for [company name withheld] and [name withheld], Administrator/Coordinator for Grand Lake Villa, reviewed the updated/revised Abuse Policy line by line. Each staff member received a paper copy of the policy and signed acknowledgement of this education. On 4/28/26, all residents that are lacking capacity were provided skin assessments to ensure no signs or symptoms of abuse. All residents that have capacity were asked if they were ever abused sexually, mentally, or physically while in the facility on 4/27/2026. Competent residents were asked if they were currently in a relationship with another resident in the facility or if they had plans to begin a relationship with another resident in the facility. On 4/27/26 - MDS Coordinator, [name withheld], examined progress notes for all residents over the last 30 days to determine if there were any additional allegations of abuse. Administrator/DON will ensure Abuse Policy and Procedures are followed and implemented per policy when incidents arise to protect residents during investigations of alleged abuse per CMS regulations. All residents and family members were provided with a copy of the revised/updated Abuse Policy along with Resident's Rights via in person (resident), and by mail (family) on 4/27/2026. On 4/28/26, the facility formally adopted and implemented a capacity to consent assessment and a policy addressing both consensual and non-consensual sexual relations among residents, in accordance with resident rights and safety standards.The IJ was lifted on 04/29/26 at 2:37 p.m., when all components of the plan of removal had been reviewed and verified:a. documentation and interviews were conducted to verify the administrator had been re-educated and quizzed on the abuse and neglect policies,b. documentation was reviewed and interviews with 19 facility staff were conducted to verify each staff member had been re-educated and tested on the facility's abuse and neglect policies,c. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify residents had been assessed for signs of possible abuse and if unknown relationships between residents existed,d. progress notes were reviewed for documentation of possible abuse having occurred and the MDS coordinator was interviewed to determine if they had reviewed the progress notes,e. the administrator and DON were interviewed to determine they understood to implement the abuse policy when allegations of abuse are made,f., documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify staff, residents, and families were provided copies of the updated abuse and neglect policies, andg. documentation was reviewed and interviews with 19 facility staff members were conducted to verify each staff member had been aware of the new abuse and resident relationship policies.The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings:A policy titled Abuse - Neglect - Misappropriation - Mistreatment Policy, dated 02/16/24, read in part, The facility will implement policy and procedures to prevent abuse, neglect or misappropriation of property of our resident. This included but not limited to.The facility will provide protection for resident in the case of any allegations of abuse, neglect, or misappropriation of property.They facility will conduct an investigation in a timely manner.A quarterly assessment, dated 12/30/25, showed Res #48 had a BIMS score of 14 (a BIMS score of 14 indicated the resident's cognitive abilities were intact).A health status note, authored by RN #1, dated 03/11/26 at 7:53 p.m., showed LPN #3 had found Res #17 touching Res #48 inappropriately through Res #48's clothing. The note showed RN #1 had separated the two residents, RN #1 had asked Res #48 if they were ok with the other resident touching them, and Res #48 had replied, No. The note showed the DON had been contacted about the incident.An initial incident report, dated 04/22/26, showed an incident of alleged abuse where Res #17 had their hand on Res #48's body in their private area on 03/11/26 and the incident was reported to the OSDH and local law enforcement on 04/22/26.On 04/23/26 at 9:38 a.m., the DON stated they had not reported the incident to the OSDH or law enforcement at the time they found out about the incident on 03/11/26. The DON stated they had not interviewed staff or residents to determine if other potential victims existed. The DON stated they had instructed Res #17 and Res #48 to stay away from each other and were not allowed to eat with each other. The DON stated Res #48 was upset with the rules but followed them. The DON stated after the incident had occurred, they had contacted their corporate headquarters and together they decided it was not necessary to implement the abuse policy in that situation.

Based on record review an interview, the facility failed to ensure a thorough investigation of an allegation of sexual abuse was conducted for 1 (#48) of 2 sampled residents reviewed for abuse.The DON identified 65 residents resided in the facility.On 04/23/26, an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #48 was not sexually assaulted by Res #17 on 03/11/26. This failure caused Res #48 to be fearful living at the facility.On 04/23/26 at 4:30 p.m., the OSDH was notified and verified the existence of the IJ related to the facility not thoroughly investigating and reporting the sexual assault of Res #48 by Res #17.On 04/23/26 at 4:33 p.m. the administrator and DON were notified of the IJ situation and provided the IJ template.On 04/29/26 at 8:27 a.m., the plan of removal was approved by the OSDH. The plan of removal, read in part, Resident #17 and resident #48 were immediately separated upon finding of incident. On 4/24/26 resident [Resident #17] was placed on 1:1 supervision until resident was discharged from facility at approximately 3:30pm on 4/24/2026 per POA's choice. Resident #48 was seen by Geri-psych nurse practitioner on 4/24/26 to address psychosocial needs. Plan of care updated. During the process of investigating the allegation of abuse on resident #17 and resident #48, interviews with residents and staff, record reviews and policy reviews were conducted. [name withheld], Grand Lake Villa Abuse Coordinator/Administrator, has been re-educated on revised/updated Abuse Policy on 4/24/26 by [name withheld], Director of Operations for [company name withheld]. On 4/27/2026, [Administrator] was quizzed on the Abuse and Neglect Policy by [Director of Operations]. On 4/24/26, at our mandatory in-service, [name withheld], Director of Operations for [company name withheld] and [name withheld], Administrator/Coordinator for Grand Lake Villa, reviewed the updated/revised Abuse Policy line by line. Each staff member received a paper copy of the policy and signed acknowledgement of this education. On 4/27/26, Grand Lake Villa staff were given a written quiz regarding the abuse policy to verify understanding and compliance. All staff were questioned if they were aware of any current abuse in the facility or if they were aware of any current resident relationships in the facility, any concerns were immediately addressed. On 4/28/26, all residents that are lacking capacity were provided skin assessments to ensure no signs or symptoms of abuse. All residents that have capacity were asked if they were ever abused sexually, mentally, or physically while in the facility on 4/27/2026. Competent residents were asked if they were currently in a relationship with another resident in the facility or if they had plans to begin a relationship with another resident in the facility. On 4/27/26 - MDS Coordinator, [name withheld], examined progress notes for all residents over the last 30 days to determine if there were any additional allegations of abuse. Administrator/DON will ensure Abuse Policy and Procedures are followed and implemented per policy when incidents arise to protect residents during investigations of alleged abuse per CMS regulations.The IJ was lifted on 04/29/26 at 2:37 p.m., when all components of the plan of removal had been reviewed and verified:a. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify Res #17 was placed on 1:1 observations and discharged from the facility, Res #48 had been seen by mental health professionals, Res #48's care plan had been updated, and an investigation to determine the validity of the allegation and identify any other possible instances of abuse had occurred,b. documentation and interviews were conducted to verify the administrator had been re-educated and quizzed on the abuse and neglect policies,c. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify staff, residents, and families were provided copies of the updated abuse and neglect policies,d. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify staff and residents were aware of any resident relationships at the facility,e. documentation was reviewed and interviews with 19 facility staff and five residents were conducted to verify residents had been assessed for signs of possible abuse and if relationships between residents existed,f. progress notes were reviewed for documentation of possible abuse having occurred and the MDS Coordinator was interviewed to determine if they had reviewed the progress notes, andg. the administrator and DON were interviewed to determine they understood to implement the abuse policy when allegations of abuse were made.The deficient practice remained at an isolated level with the potential for more than minimal harm that is not immediate jeopardy. Findings:A policy titled Abuse - Neglect - Misappropriation - Mistreatment Policy, dated 02/16/24, read in part, The facility will implement policy and procedures to prevent abuse, neglect or misappropriation of property of our resident. This included bun not limited to.The facility will provide protection for resident in the case of any allegations of abuse, neglect, or misappropriation of property.They facility will conduct an investigation in a timely manner.A health status note, authored by RN #1, dated 03/11/26 at 7:53 p.m., showed LPN #3 had found Res #17 touching Res #48 inappropriately through Res #48's clothing. The note showed RN #1 had separated the two residents, RN #1 had asked Res #48 if they were ok with the other resident touching them, and Res #48 had replied, No. The note showed the DON had been contacted about the incident.An initial incident report, dated 04/22/26, showed an incident of alleged abuse where Res #17 had their hand on Res #48's body in their private area on 03/11/26 and the incident was reported to the OSDH and local law enforcement on 04/22/26.On 04/22/26 at 3:18 p.m., RN #1 stated they had been the person that had confronted Res #17 and Res #48 on 03/11/26 after LPN #1 had witnessed what they thought was a sexual act. RN #1 stated they separated the two and reported the incident to the DON.On 04/23/26 at 9:38 a.m., the DON stated after they became aware of the alleged sexual abuse of Res #48 by Res #17, they had not investigated the incident. The DON stated they had contacted their corporate headquarters and together they decided the incident did not require being reported to OSDH.A psychiatric evaluation note, dated 04/24/26 at 2:53 p.m., showed Res #48 had been evaluated because of the incident on 03/11/26 where the resident had been inappropriately touched by another resident. The note showed Res #48 appeared more agitated than normal and reported fearfulness and not feeling safe. The note showed facility staff had reported the resident had become more isolative since the incident. The note showed Res #48's Zoloft (an antidepressant medication) was increased from 50 mg once daily to 100 mg, once daily because of the resident's increased irritability and anxiety.

Based on record review and interview, the facility failed to ensure facility staff had been trained in the Quality Assurance and Performance Improvement program for 103 of 103 employees of the facility.The assistant director of nursing identified 103 employees worked in the facility.Findings:An undated Quality Assurance / Assessment and Performance Improvement Plan, read in part, All staff, including contracted staff, are educated on the principles of QAPI. QAPI is included in the orientation of new employees and in the annual education that all staff are required to attend.An undated Inservice Schedule, was reviewed. The schedule did not included training on the subject of QAPI.On 04/28/26 at 11:43 a.m., the DON stated the facility had not conducted any training with all their staff on QAPI. The DON stated they had reviewed their records and found no documentation of the facility staff being trained in QAPI. The DON stated they had looked at their annual training list and did not find QAPI listed as one of the subjects.

Based on record review and interview, the facility failed to ensure residents understood binding arbitration agreements before signing them for 2 (#55 and #56) of 2 sampled residents reviewed for binding arbitration agreements.The DON identified 65 residents resided in the facility.Findings:1. An Arbitration of Disputes document in the assessment agreement, dated 09/29/25, read in part, Any and all claims, controversies, disputes, disagreements or demands of any kind .arising out of or in any relating to the Agreement, including the interpretation of this Agreement, or the Residents stay at, or the care of services provided by, the Facility shall be resolved exclusively by binding arbitration. The document showed Res #56's name printed in the resident representative's section of the signature page of the admission agreement. The SSD signed in the facility's representative area of the signature page.An admission assessment, dated 10/05/25, showed Res #56 had a BIMS score of 15 (a BIMS score of 15 indicated the resident's cognition was intact and was able to make decisions of daily living).On 04/22/26 at 8:06 a.m., Res #56 stated they did not recall giving anyone permission to sign an arbitration agreement for them. Res #56 stated because of their condition when they were admitted to the facility, they were not in their right mind to sign any documents.2. An Arbitration of Disputes document in the assessment agreement, dated 04/08/26, read in part, Any and all claims, controversies, disputes, disagreements or demands of any kind .arising out of or in any relating to the Agreement, including the interpretation of this Agreement, or the Residents stay at, or the care of services provided by, the Facility shall be resolved exclusively by binding arbitration. The document showed Res #55's name printed in the resident representative's section of the signature page of the admission agreement. The resident's signature was not on the signature page. The SSD signed in the facility's representative area of the signature page.An admission assessment, dated 04/15/26, showed Res #55 had a BIMS score of 14 (a BIMS score of 14 indicated the resident's cognition was intact and was able to make decisions of daily living).On 04/22/26 at 8:33 a.m., Res #55 stated they did not recall signing an arbitration agreement and did not get an explanation of what they had signed when they admitted . They stated they just signed where they were told to sign.On 04/22/26 at 8:37 a.m., the SSD stated they had not received any training on arbitration agreements, and they were the one who oversaw them because they were part of the admission packet. They stated each resident had the opportunity to read the documents in the admission packet, but they did not recall any resident reading the entire document. The social services director stated regarding Res #56 they had read the admission documents to them and signed for them because the resident was too shaky at the time.

Based on record review and interview, the facility failed to ensure binding arbitration agreements did not pre-determine the arbitrator for arbitration proceedings for 2 (#55 and #56) of 2 sampled residents binding arbitration agreements reviewed for binding arbitration agreements.The DON identified 65 residents resided in the facility.Findings:1.An Arbitration of Disputes document in the assessment agreement, dated 09/29/25, read in part, The parties' intend that the Arbitration Services shall be Judicial Arbitration and Mediation Services, Inc (JAMS) or its successor. If JAMS is unable or unwilling to service as the Arbitration Service, the parties' intent [sic] that the National Arbitration Forum ('NAF') or its successor shall serve as the Arbitration Service. The document showed Res #56's name printed in the resident representative's section of the signature page of the admission agreement. The SSD signed in the facility's representative area of the signature page.2.An Arbitration of Disputes document in the assessment agreement, dated 04/08/26, read in part, The parties' intend that the Arbitration Services shall be Judicial Arbitration and Mediation Services, Inc (JAMS) or its successor. If JAMS is unable or unwilling to service as the Arbitration Service, the parties' intent [sic] that the National Arbitration Forum ('NAF') or its successor shall serve as the Arbitration Service. The document showed Res #55's name printed in the resident representative's section of the signature page of the admission agreement. The SSD signed in the facility's representative area of the signature page.On 04/22/26 at 8:37 a.m., the SSD stated they had not received training in arbitration agreements and oversaw them because it was a part of the admission paperwork they go over with the new residents. They stated they were unaware of the particulars of the regulations that covered the arbitration agreements.

Based on record review and interview, the facility failed to include the estimated cost of services on a SNF ABN form CMS-10055 for 1 (#69) of 3 sampled residents reviewed for beneficiary notices.The DON identified 29 residents had been discharged from skilled services within the last six months. Findings:A document titled Form Instruction Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018), dated 2018, read in part, Estimated Cost Section. In this section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate.A CMS-10055 form for Res #69, dated 03/25/26, showed the resident's representative had indicated on the form they wanted to continue the skilled services mentioned on the form and they may be responsible for the costs if Medicare denied the claim. The form showed physical therapy, occupational therapy, daily skilled nursing care, and speech therapy as the services that may not be covered by Medicare after 04/14/26. The area on the form to show the resident or their representative the estimated cost of those services was blank.On 04/21/26 at 11:18 a.m., the SSD stated they had known Res #69's ABN did not have an estimated cost because corporate did not know what to put because they did not know how much the insurance would pay. The SSD stated they used to put in a set dollar amount, but now just left that portion of the form blank.

Based on record review and interview, the facility failed to report an alleged incident of sexual abuse to the OSDH within the required two-hour time frame for 1 (#48) of 1 sampled resident reviewed for abuse.The DON identified 65 residents resided in the facility.Findings:An abuse policy titled Abuse - Neglect - Misappropriation - Mistreatment Policy, dated 02/16/24, read in part, The facility will send a report to all reporting agencies as required by OSDH guidelines. The facility will send a report to the ODSH on form 283 within 2 hours of being notified of any allegation.A health status note authored by RN #1, dated 03/11/26 at 7:53 p.m., showed LPN #3 had found Res #17 touching Res #48 inappropriately through Res #48's clothing. The note showed RN #1 had separated the two residents, RN #1 had asked Res #48 if they were ok with the other resident touching them, and Res #48 had replied, No. The note showed the DON had been contacted about the incident.An initial incident report, dated 04/22/26, showed an incident of alleged abuse had occurred on 03/11/26 and was reported to the OSDH and the local law enforcement on 04/22/26.On 04/23/26 at 9:38 a.m., the DON stated they had not reported the incident to the OSDH or law enforcement at the time they found out about the incident on 03/11/26. The DON stated after the incident had occurred, they had contacted their corporate headquarters and together they decided it was not necessary to report the incident to the OSDH or the law enforcement.

Based on record review and interview, the facility failed to ensure a quarterly assessment accurately reflected a resident's fall history for 1 (#2) of 17 sampled residents reviewed for MDS assessment accuracy.The DON identified 65 residents resided in the facility.Findings:A quarterly assessment, dated 01/08/26, showed Res #2 had not had any falls. A health status note, dated 01/19/26 at 7:51 p.m., showed Res #2 had been found lying on the floor. The note showed no injuries were found on the resident.An incident note, dated 02/22/26 at 1:58 p.m., showed Res #2 had been found on the floor of their room. The note showed no injuries were found on the resident.An incident note, dated 03/05/26, showed Res #2 had been found on the floor of their room. The note showed no injuries were found to the resident.An incident note, dated 03/24/26, showed Res #2 was found on the floor of the locked unit's television room and the resident had a small hematoma on their head.A health status note, dated 04/09/26, showed Res #2 had been found lying on the floor after they were hit by a door someone had opened. The note showed the resident did not sustain any injuries.A quarterly assessment, dated 04/10/26, showed Res #2 had one no-injury fall since the last quarterly assessment, dated 01/08/26. The assessment showed the resident had not had any falls with minor injuries.A care plan, revised date 04/15/26, showed Res #2 had falls on 01/29/26, 02/22/26, 03/05/26, 03/24/26, and 04/10/26. On 04/21/26 at 1:09 p.m. certified medication aide #2 stated Res #2 had three for four falls in the last couple of months and one of those caused a bump on their head.On 04/21/26 at 1:44 p.m., MDS coordinator #1 observed Res #2's quarterly assessment, dated 04/10/26 and stated they saw one non-injury fall had been documented on the assessment. MDS Coordinator #1 reviewed Res #2's medical records and stated the care plan showed the resident had multiple falls that had not been recorded on the quarterly assessment, dated 04/10/26. MDS Coordinator #1 stated the assessment was not accurate.On 04/21/26 at 3:12 p.m., the DON stated the facility did not have a policy for MDS assessment accuracy but used the Resident Assessment Instrument Manual for the requirements they expected their staff to follow.

Based on record review and interview, the facility failed to ensure APS was notified of an allegation of abuse for 1 (#3) of 3 sampled residents reviewed for abuse. The DON reported the facility census was 59. Findings: An admission record, dated 05/12/22, showed Res #1 had diagnoses which included Alzheimer's disease and anxiety. A facility document titled Abuse-Neglect-Misappropriation-Mistreatment Policy, dated 02/16/24, read in part, The facility will send a report to all reporting agencies as required by OSDH guidelines .The facility will send copies of the report to the OSDH/Adult Protective Services at the same time the report is sent to the OSDH. A quarterly assessment, dated 05/15/25, showed Res #3 had a brief interview for mental status score (a test for cognitive function) of 3, which was indicative of severe cognitive impairment. The assessment also showed Res #3 was dependent on staff for care. A nurse's note, dated 06/09/25 at 8:28 a.m., showed an allegation of abuse was reported to facility staff involving Res #3. The note also showed the OSDH, police department, power of attorney, administrator, and the physician were notified. The note did not show APS was notified. An incident report form, dated 06/09/25, showed an allegation of abuse was reported involving Res #3. The report also showed the physician, family, resident's legal representative, and local law enforcement were notified. The report did not show APS was notified. On 06/13/25 at 1:10 p.m., the DON stated APS should be contacted with any allegation of abuse. The DON also stated they could not find any documentation APS was notified of the allegation of abuse involving Res #3.

Based on record review and interview, the facility failed to ensure an alleged incident of physical and verbal abuse was reported to the facility administrator and Oklahoma State Department of Health within two hours of the allegation for one (#1) of four sampled resident reviewed for abuse. A facility census report, dated 07/08/24, documented 56 residents resided in the facility. Findings: An Abuse Investigating and Reporting policy, dated 2017, read in part, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR (sic) resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND (sic) has not resulted in serious bodily injury. An ODH 283 form (incident report form) documented an allegation of physical and verbal abuse occurred on 06/08/24. The form documented the allegation was reported to the DON on 06/10/24. A facility employee counseling form, dated 06/10/24, documented RN #1 had been disciplined for not reporting and allegation of abuse to the DON and not following the facility abuse policy regarding reporting. The form further documented RN #1's statement that they had been informed of the allegation by CNA #2 and instructed an LPN to assess the resident. The statement said RN #1 did not inform the DON of the allegation. On 07/08/24 at 10:10 a.m., CNA #2 stated they had witnessed CNA #1 curse at Resident #1 and grab the wrist of the resident and forcibly pull the resident's hands from their grip on the table. They stated about 45 minutes later they reported the incident to RN #1. They stated on the morning of 06/10/24 they also reported the incident to the DON. On 07/08/24 at 10:25 a.m., DON stated they had been told of the allegation that involved CNA #1 and Resident #1 on 06/10/24 by CNA #2. They stated that was the first time they heard about the allegation. They stated RN #1 reported they had been informed of the allegation on 06/08/24 but had not contacted the administration. They stated RN #1 had not followed policy regarding reporting and was counseled and reeducated on reporting allegation of abuse.

Based on observation and interview, the facility failed to maintain the ice machine in a sanitary manner for one of one ice machines observed. The DON identified 63 residents who received nourishment from the kitchen. Findings: On 05/02/23 at 10:40 a.m., the maintenance supervisor was asked who was responsible for cleaning the ice machine. The maintenance supervisor stated the machine was leased and the leasing company performed all cleanings. The maintenance supervisor stated the machine was last cleaned in March 2023. The ice machine was observed with the maintenance supervisor. They removed the panel covering the mechanical components used to make the ice. An opaque tube, which appeared to run from the water reservoir, located at the base of the machine, to the top of the evaporator, was observed to have a shadowy, transitioning to a solid black, substance caked to the interior of the tube. The maintenance supervisor was asked what the substance was in the interior of the tube. The maintenance supervisor stated it was nasty and they would contact the supplier to clean the machine.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for one (#36) of 15 residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 05/02/23, documented 60 residents resided at the facility. Findings: Resident #36 had diagnoses which included congestive heart failure. A Physician's Order, dated 02/15/23, documented to administer lorazepam 0.5 mg every eight hours as needed for anxiety. This order was discontinued on 03/04/23. Review of the Care Plan, dated 02/23/23, did not reveal a problem, goal, or interventions for anxiety. A Physician's Order, dated 03/04/23, documented to administer lorazepam 0.5 mg every eight hours as needed for anxiety. On 05/05/23 at 3:15 p.m., the MDS/Care Plan nurse was asked why the care plan for Resident #36 had not been revised to include a care plan for anxiety. They stated they must have overlooked it.

Based on record review and interview, the facility failed to ensure as needed psychotropic medications were not ordered past 14 days without a documented physician's clinical rationale for two (#24 and #36) of five residents reviewed for unnecessary medications. The DON identified 12 residents who received as needed psychotropic medications. Findings: An Antipsychotic Medication Use policy, dated December 2016, read in part, .The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . 1. Resident #36 had diagnoses which included congestive heart failure. A physician's order, dated 02/15/23, documented to administer one tablet of lorazepam 0.5 mg every eight hours as needed for anxiety. A physician's order, dated 03/04/23, documented to administer one tablet of lorazepam 0.5 mg every eight hours as needed for anxiety for 60 days. Review of the April 2023 medication administration records revealed the resident had the order for lorazepam as an active order and had received the as needed medication 25 times. 2. Resident #24 had diagnoses which included anxiety. The Care Plan, dated 02/08/23, documented the resident was at risk for side effects and complications due to psychotropic drug use related to anxiety. A physician's order, dated 03/26/23, documented lorazepam 1mg every six hours PRN for anxiety/agitation. The electronic record documented Indefinite for the end date. Review of the April 2023 medication administration records revealed the resident had the order for lorazepam as an active order and had received the as needed medication six times. Review of the clinical record did not reveal a clinical rationale for continuation past 14 days or a specified duration of the PRN lorazepam. On 05/05/23 at 12:12 p.m., the consultant pharmacist was asked what the protocol was for PRN psychotropic medications. They stated PRN psychotropic medications were to be ordered for 14 days or the medication could extend past 14 days with a documented rationale from the physician. The consulting pharmacist was asked what the clinical indication for the PRN lorazepam was for Resident #36. They stated their records documented it was for anxiety. They stated in February 2023 they had requested the med be reviewed or reordered. They stated the physician addressed the recommendation on 03/02/23. The consulting pharmacist was asked what the physician's rationale was for continuing the as needed psychotropic medication for 60 days. They stated the physician had not provided a clinical rationale. They were asked what the clinical rationale was for the PRN lorazepam for Resident #24. The consultant pharmacist stated they reviewed the resident's medication in April 2023 but did not see any requests to the physician regarding the PRN lorazepam. They stated they did not recommend a duration or a rationale on every resident, every month. They stated they spread them out over the course of several months as to not overwhelm the facility. On 05/05/23 at 12:37 p.m., the DON was asked what the facility's protocol was for as needed psychotropic medications. They stated they would need to check. On 05/05/23 at 12:48 p.m., the DON stated the physician ordered as needed psychotropic medications for a duration of 14, 30, or 60 days, then re-evaluated the residents' need for the medication. The DON was asked what the duration was for the as needed lorazepam for Resident #24. They reviewed the electronic clinical record and stated they did not see a duration documented by the physician. They were asked where the physician had documented a clinical rationale for continuing the as needed psychotropic medication past 14 days. The DON reviewed the clinical record and stated there was not a clinical rationale documented by the physician. On 05/05/23 at 2:21 p.m., the DON was asked where the physician documented a clinical rationale to extend the as needed psychotropic medication past 14 days for Resident #36. They stated the physician did not document a rationale to continue past 14 days.

Based on record review and interview, the facility failed to ensure assessments were accurate for one (#2) of one resident who was reviewed for hospice services. The Resident Census and Conditions of Residents report, dated 05/02/23, documented 12 residents received hospice services. Findings: Resident #2 had diagnoses which included congestive heart failure. A Physician's Order, dated 08/30/22, documented to admit the resident to hospice services. A Hospice Certification of Terminal Illness form, dated 09/01/22 through 11/29/22, read in part, .Verbal Certification .Medical Director .I certify that this patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course . The Certification was electronically signed by the physician. The significant change assessment, dated 09/09/22, documented the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. A Hospice Certification of Terminal Illness form, dated 11/30/22 through 02/27/23, read in part, .Verbal Certification .Medical Director .I certify that this patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course . The Certification was electronically signed by the physician. The quarterly assessment, dated 12/10/22, documented the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. A Hospice Certification of Terminal Illness form, dated 02/28/23 through 04/28/23, read in part, .Verbal Certification .Medical Director .I certify that this patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course . The Certification was electronically signed by the physician. The significant change assessment, dated 03/12/23, documented the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. On 05/05/23 at 1:33 p.m., the MDS coordinator was asked when assessments were to be coded the resident had a condition or chronic disease that may result in a life expectancy of less than six months. They stated if the physician documented the resident had a life expectancy of less than six months they would code the question as yes. They were asked where they obtained the physician's documentation. The MDS coordinator stated the hospice physician provided that information. The MDS coordinator was asked why the assessments dated 09/09/22, 12/10/22, and 03/12/23, for Resident #2, were not coded as having a life expectancy of less than six months. They stated they had not reviewed the physician's documentation on the hospice certification forms.

Based on record review and interview, the facility failed to ensure resident representatives were notified of room changes for two (#1 and #2) of three sampled residents who were reviewed for notification related to room changes. The Resident Census and Conditions of Residents form identified 58 residents who resided in the facility. Findings: A facility policy, dated December 2016, titled Transfer, Room to Room, read in part, .his or her family and visitors will be informed of the room change . 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly assessment, dated 05/12/22, documented the resident was severely impaired in cognition for daily decision making. The electronic face sheet documented the resident's spouse was the power of attorney. Review of the resident's electronic record, revealed the resident had changed rooms on 05/27/22, 05/28/22, 06/15/22, 06/16/22, 06/18/22, and 06/27/22. The record did not reveal documentation the resident's power of attorney had been notified of the room changes. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 05/13/22, documented the resident was severely impaired in cognition for daily decision making. The electronic face sheet documented the resident's family member was the emergency contact. Review of the electronic clinical record, revealed the resident had changed rooms on 05/13/22, 05/27/22, 07/02/22, and 07/03/22. The record did not reveal the resident's representative had been notified of the room changes. On 07/05/22 at 2:43 p.m., the social services director was asked who was responsible to notify resident representatives of room changes. They stated they were responsible to notify resident representatives of room changes or the the nurses made the notifications. On 07/05/22 at 4:16 p.m., the ADON was asked what the facility protocol was for resident room changes. They stated they were to notify the resident representative and had a form for the representative to sign. The ADON was asked who was responsible to notify resident representatives of room changes. They stated the social services director or the nurses. On 07/05/22 at 4:16 p.m., the ADON was asked why resident #1 had changed rooms. They stated they had treated and follow-up treated the resident's room for possible bed bugs, the resident had moved from the memory care unit to another hall, one room change was per the family member's request, and once was due to a roommate change. The ADON was asked why resident #1's power of attorney had not been notified of the room changes. They stated they did not know. They stated they had reviewed the clinical record and had not found documentation the power of attorney had been notified of the above room changes. On 07/05/22 at 4:16 p.m., the ADON was asked why resident #2 had changed rooms. They stated they had treated and follow-up treated the resident's room for possible bed bugs, one move was due to condensing the hall to make an open room, and one move was due to a disagreement with another resident. The ADON was asked why resident #2's representative had not been notified of the room changes. They stated they did not know and they had not found any documentation which indicated the resident's representative had been notified. On 07/05/22 at 4:42 p.m., the DON was asked who was responsible to notify resident representatives of room changes. They stated the nurses or the social services director. The DON was asked why the resident representative for resident #1 and resident #2 had not been notified of the room changes. They stated they should have notified the representatives and documented the notification.

Based on record review and interview, the facility failed to notify the resident representative of change for one (#1) of three sampled residents who were reviewed for notification of change. The Resident Census and Conditions of Residents form identified 58 residents who resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly assessment, dated 05/12/22, documented the resident was severely impaired in cognition for daily decision making. The electronic face sheet documented the resident's spouse was the power of attorney. A nurse note, dated 06/18/22, read in part, .Resident up in chair in dining with family at side assisting with meal and noted a red raised rash area approx 5cm x3cm to right anterior shoulder . The note was signed by the DON and did not document the resident's power of attorney had been notified of the rash. On 07/05/22 at 4:16 p.m., the ADON stated there had been two bed bugs found in the resident's room on 05/13/22. The ADON was asked who had notified the resident's representative of the two bed bugs on 05/13/22. They stated another family member had been notified but could not find documentation the facility had notified the power of attorney. On 07/05/22 at 4:42 p.m., the DON was asked who the family member was who they referenced in the progress note dated 06/18/22. They stated the family member who was present was not the power of attorney.The DON was asked why the power of attorney had not been notified of the resident's change in skin condition and when two bed bugs were found on 05/13/22. They stated the other family member was present at the facility but they should have notified the power of attorney.

Based on observation, record review and interviews, the facility failed to ensure residents were allowed to have visitors of their choice. The Director of Nursing identified 62 residents residents resided in the facility. Findings: On 10/19/21 at 9:30 a.m., a sign stating No Visitors Allowed was observed posted on the front door of the facility. Residents were asked if they were able to have visitors. They replied they just recently were able to have visitors again and only outside visits were allowed. On 10/19/21 at 2:00 p.m., two residents and their visitors were observed outside the front door of the facility. No indoor visitation was observed of any residents and visitors during the survey. On 10/19/21 at 3:15 p.m., the Director of Nursing was asked how visitation guidelines were set. She stated Corporate makes the policy based on CMS guidelines. She stated visitation was currently all outside unless the resident was unable to leave their room and/or required compassionate visits. On 10/19/21 at 3:50 p.m., the Ward Clerk was ask how visitation was done. She stated outdoor visitation was now allowed. She stated she was not scheduling any indoor visitations. Record review of the facility County positivity rate and resident vaccination percentage rate documented indoor visitation was acceptable per current CMS guidelines.

Based on observation, recored review and interviews, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences to one (#5) of four sampled residents who were identified as receiving pain medications. The Director of Nursing (DON) identifed 39 residents in the facility receiving pain medications. Findings: Resident #5 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/02/21 at 16:45 (4:45 p.m.), a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Health Status Note, dated 09/02/21 at 20:05 [8:05 p.m.], read in part, Resident arrived to the facility .Resident demanding pain medication as soon as she got inside the building .states the only thing that helps her pain is the pain pills. A Baseline Care Plan intervention, dated 09/02/21 at 20:21 [8:21 p.m.], read in part, the resident was alert, cognitively intact, and being administed opiod medications. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain level 9. On 10/19/21 at 2:30 p.m., Res #5 stated her pain was a 10 on a 1-10 pain scale on her arrival to the facility the evening of 09/02/21 at 20:05 (8:05 p.m.) On 10/19/21 at 3:20 p.m., the DON was asked how medications were obtained for new resdients. She stated the pharmacy should have the prescribed medications for a new resident within four hours. She was asked when the resident should have been given the pain medication prescribed. She stated as soon as possible, and should have also be reassessed for pain and pain medication effectiveness after given. She stated she was not aware this was not done for the resident.

Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent the potential spread of infection. The facility failed to: ~ Ensure staff wore appropriate PPE and properly disposed of PPE during provision of care for two (#5 and #6) residents who were positive for COVID-19 of four sampled residents who resided in the facility and were reviewed for infection control; ~ Ensure staff wore face masks appropriately; and ~ Ensure residents were thoroughly monitored for all possible COVID-19 symptoms that were documented on the CDC website. Findings: The CDC guidance titled, Preparing for COVID-19 in Nursing Homes, documented: .Implement Source Control Measures .HCP should wear a facemask at all times while they are in the facility .Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . The CDC guidance titled, Using Personal Protective Equipment, documented: .Remove gown .Dispose in trash receptacle . The CDC guidance titled, Symptoms of Coronavirus, documented: .People with these symptoms may have COVID-19: Fever or chills .Cough .Shortness of breath or difficulty breathing .Fatigue .Muscle or body aches .Headache .New loss of taste or smell .Sore throat .Congestion or runny nose .Nausea or vomiting .Diarrhea . 1. On 10/21/20 at 12:09 p.m., RN #1 was observed to perform blood glucose monitoring on resident #5. Resident #5 was identified as a COVID-19 positive resident. RN #1 was observed to don PPE but had not worn eye protection. When he exited the room he doffed his gown, rolled it up, and placed it on top of the treatment cart by the computer. He touched the gown with bare hands twice, touched the computer, the treatment cart, and then placed the gown in the trash bin on the side of the treatment cart. He obtained the gown from the trash bin and placed it in the biohazard box in the resident's room. At 12:19 p.m., RN #1 was observed to perform blood glucose monitoring on resident #6. Resident #6 was identified by the facility as a COVID-19 positive resident. RN #1 was observed to don PPE but had not worn eye protection. He exited the resident's room, doffed PPE, and tossed it from the doorway into the biohazard box in the resident's room. At 1:11 p.m., RN #1 was asked what PPE was utilized for residents who were positive for COVID-19. He stated full PPE. He stated gown, gloves, shoe covers, and N-95 mask. He was asked why he had not worn eye protection when he provided care to resident #5 and resident #6. He stated he wore reading glasses at times but did not wear goggles or a face shield. He was asked why he doffed PPE outside the residents' doors and then tossed it back into the room into the biohazard bin. He stated he did not realize he had taken it off in the hall. He was asked why he had doffed his gown and placed it on top of the treatment cart. He stated he should have placed it in the biohazard bin as per standard protocol. On 10/21/20 at 2:24 p.m., the infection preventionist/ADON was asked what PPE was to be worn by staff when providing care to residents who were positive for COVID-19. She stated full PPE. She was informed of observations of staff not wearing eye protection while caring for COVID-19 positive residents and placing the gown on top of the treatment cart. She stated eye protection was to be worn throughout the entire facility, used PPE was to be placed in the biohazard. 2. On 10/21/20 at 3:33 p.m., CMA #1 and CMA #2 were observed in the medication room with the door open on a hall with COVID-19 positive residents. CMA #1 was not observed to wear a face mask or eye protection. She was observed to have the medication cart open and medication cards on the top of the cart. At 3:42 p.m., CMA #1 was asked why she did not have a face mask on. She stated, I'm eating. She was asked why she was eating at the medication cart. She stated she did not know. On 10/22/20 at 1:22 p.m., the infection preventionist was informed of the observation. She stated the staff were to have a mask on at all times and were to eat in the break room. 3. Review of the clinical record for resident #1, #2, #3, and #4 revealed they were not monitored for congestion, runny nose, nausea, vomiting, or diarrhea. On 10/21/20 at 4:06 p.m., the infection preventionist was asked why residents were not monitored for all possible symptoms of COVID-19. She stated they had updated the list of symptoms at the end of August but must had not added all of the symptoms.

Based on interview and record review, it was determined the facility failed to ensure residents were free of significant medication errors for one (#1) of six residents whose pain medication regimens were reviewed. This resulted in the resident being intubated, placed on a ventilator, and admitted to the intensive care unit of a hospital. The facility identified 11 residents who received narcotic pain medications. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 06/28/19, documented the resident was moderately impaired in cognition and required assistance with most activities of daily living. The assessment documented the resident was in frequent moderate pain. The monthly physician's orders [REDACTED]. The care plan, dated 07/03/19, documented, .Focus .I am at risk for pain .Goal .My goal is to be free from pain with use of pain medication and comfort measues (sic) over the next 90 days .Interventions .Administer routine pain medication as prescribed and monitor effectiveness .Administer, monitor effectiveness, and monitor for adverse side effects of routine pain management medication . The medication administration record, dated 07/07/19, documented the resident received a new [MEDICATION NAME] 25mcg/hr patch and a new [MEDICATION NAME] 12mcg/hr patch applied to their skin. The record documented the previous [MEDICATION NAME]es were removed. The nurse's note, dated 07/07/19 at 11:10 a.m., documented, .Resident requested this Nurse by staff to room stating that 'it was hard to get her breath'. (sic) Upon entering Residents room this Nurse observed resident lying in bed with H.O.B (sic) up. Resident stated 'I'm having trouble breathing.' Resident noted to be using external rib muscles in breathing. Attempt made to obtain O2 sats. Unable to obtain due to hand tremors. This Nurse had staff obtain O2 concentrator to apply O2 for comfort. Resident cont. to be display s/s of Anxiety et S.O.B. Resident states, 'I'm going to die.' This Nurse attempted to reassure Resident that Dr. was going to be contacted. Nurse had staff remain with Resident while Dr. (PCP Name Withheld) was contacted about condition. Order received from Dr. (PCP) to; (sic) Send to (ER Name Withheld) via EMS for s/s of up anxiety et S.O.B. EMS contacted at 11:20 am of order for transport. Resident remained awake et responsive et verbal to staff et EMS. Resident stated to this Nurse, 'Make sure you call my family.' This Nurse reassured her family would be contacted. EMS then transferred Resident to ER . The emergency room Provider Note, dated 07/07/19 at 3:33 p.m., documented, .Emergency Department Decision .Disposition: Transfer To Another Facility .Disposition Condition: Critical .Chief Complaint: Patient presents with Respiratory Distress. Patient sent from nursing home with respiratory difficulty, found [MEDICATION NAME]es x4 on patient (74mg total) .Patient present to ER with chief complaint of altered mental status per EMS she is somnolent GCS of 5 minimal change with [MEDICATION NAME] patient's urgently intubated for airway protection and she is found to have for (sic) [MEDICATION NAME]es on her she has a history of a new [DIAGNOSES REDACTED].patient was taken to room placed on a monitor urgently intubated a broad differential for altered mental status was considered given the urgent nature in minimal response to [MEDICATION NAME] a broader workup was performed .discussed the case with Dr (1st physician name withheld) there is a concern that this may be a simple overdose compounded by [DIAGNOSES REDACTED] crisis Dr. (2nd physician name withheld) feels that the patient be better served with neurology available patient is transferred to (hospital name withheld) . A facility inservice, dated 07/09/19, documented, .CMA's - Any time a [MEDICATION NAME] Patch is placed, a witness needs to be present for the destruction of the old [MEDICATION NAME]. Also, ensure to document on the MAR where the new patch is placed . The inservice did not address what side effects to monitor or what were the signs and symptoms of a narcotic overdose. The inservice did not address the role of the certified nurse aide in assisting with the monitoring of residents receiving narcotic pain management. The sign in sheet for the inservice documented all of the certified medication aides were present for the inservice. The sign in sheet for the inservice documented not all of the licensed nurses, who also administer medications, were present for the inservice. A facility incident report, dated 07/10/19, documented the resident was sent to the hospital for complaint of shortness of breath and increased anxiety. While at the hospital it was noted the resident had four [MEDICATION NAME]es on her. The hospital did not state the placement of patches or dates on patches. The report documented the medication aide which had last administered the [MEDICATION NAME]es to resident #1 had a witness who watched her remove the two patches before placing the new ones. The CMA who administered the previous dose did not have a witness to her removing the two patches before placing the new ones. The report documented the medication aides were in-serviced on 07/09/19 for proper [MEDICATION NAME] placement and removal. The report documented the in-service instructed to document not only the patches were removed and then reapplied, but also placement of the new patches and the destruction of the previous patches which were removed. The report documented the witness must sign the medication administration record indicating that they witnessed the removal and destruction of the [MEDICATION NAME]es. The report documented the facility was unable to determine which medication aide caused the medication error but all medication aides were in-serviced. The discharge summary from the hospital, dated 07/15/19, documented, .Discharge Diagnoses: [REDACTED]. Continue supportive management. Suspected that this was related to medication particularly narcotics .Unintentional opiate overdose - found 4 [MEDICATION NAME]es on patient. Removed, resolved .Aspiration right lower lobe pneumonia - finished antibiotics . Hospital Course .was admitted for respitatory failure and distress leading to intubation at outlying facility .She was found to have 4 [MEDICATION NAME]es on her body. Removed, but did not respond quickly to the [MEDICATION NAME] and was intubated. She was treated for [REDACTED]. Pulmonology and Neurology consulted with her history of [DIAGNOSES REDACTED] . On 07/30/19 at 11:30 a.m., the DON was asked what was the facility policy on the administration of narcotic patches. She stated the person administering the new patch was to remove the old patch and discard with a witness. The person was then to apply the new patch and document on the medication administration record the removal of the old patch with witness initials, and where the new patch was applied. She was asked if licensed staff administered medications. She stated yes. She was asked if all the licensed staff had received the in-service. She stated no. She was asked what nursing position spent the most amount of time in contact with residents and was most likely to notice a change in condition. She stated the certified nurse aides were most likely. She was asked if all the certified nurse aides had received an inservice on the potential side effects of narcotic medications. She stated no. She was asked why was resident #1 transferred to the hospital on [DATE]. She stated the resident felt she was having difficulty breathing so she was sent to the emergency room . She stated when the nurse called to check on the resident, the facility was informed the resident had four [MEDICATION NAME]es on her when she arrived at the emergency room and inserviced the medication aides because of it. 07/30/19 at 1:00 p.m., the administrator was asked if there was any other facility training performed due to the four patches of [MEDICATION NAME] found on resident #1. She stated no. She was asked if the licensed nurses passed medications. She stated yes. She was asked if the certified nurse aides assisted in monitoring residents for changes in condition. She stated yes. She was asked if either group received inservices regarding [MEDICATION NAME]es and/or the potential side effects of narcotic medications. She stated she had questioned if the facility inservice had been enough or not. She was asked what happened with resident #1. She stated the resident had been sent to the emergency room and was found with four [MEDICATION NAME]es on her person. She stated the facility investigation was unable to determine which CMA had neglected to remove the patches prior to administering the new set.

Based on interview and record review, it was determined the facility failed to assess, monitor, and intervene in a timely manner for a resident with constipation for one (#1) of six sampled residents whose records were reviewed. The resident required digital removal of impacted stool at the rectum and admission to the ICU. The facility identified 74 residents residing in the facility. Findings: A facility policy, dated (MONTH) 2013 and titled Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, documented, .As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symtoms. This should include a review of gastrointestinal problems during any recent hospitalization s, results of previous [MEDICATION NAME] studies, endoscopies, etc. Examples of lower gastrointestinal tract conditions and symptoms include: fecal incontinence; pain with defecation; passing blood rectally; alteration in bowel movement; residents taking antidiarrheal medications or medications related to bowel motility . In addition, the nurse shall assess and document/report the following: presence of fecal impaction; abdominal assessment; digital rectal examination; onset, duration, frequency, severity of signs and symptoms; all current medications; all active diagnoses; and recent labs . The physician will identify and order pertinent cause-specific and symptomatic interventions; for example, modify tube feedings, address underlying emotional or mood disorder, stop medication causing ileus, adjust foods related to malabsorption, institute a regimen to prevent constipation, etc . The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort of distress, ifrequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc. The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors . Resident #1 had [DIAGNOSES REDACTED]. The care plan, dated 08/30/18, documented, .Focus .(Resident) is at risk for constipation . Goal: remain free from s/sx of constipation . Interventions: If no BM for 3 days follow facility protocol to include: Milk of Magnesia, [MEDICATION NAME] Suppository, and Fleets enema .Offer frequent small amounts of fluids daily .Provide medication as ordered and PRN .Document each bowel movement . .Focus .(Resident) uses antidepressant medication r/t Depression . Goal: will be free from discomfort or adverse reactions related to antidepressant therapy through the review date . Interventions: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT .Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of [MEDICATION NAME] .Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: constipation, fecal impaction, diarrhea . The (MONTH) 2019 monthly physician's orders [REDACTED]. ~ [MEDICATION NAME] tablet 500mg daily for constipation. ~ [MEDICATION NAME] capsule 100mg twice daily for constipation. ~ [MEDICATION NAME] solution 30ml twice daily for constipation. ~ Senna-S tablet 8.6mg / 50mg two tablets twice daily for constipation. The orders also documented the resident was to receive the following medications as needed for constipation: ~ [MEDICATION NAME] suppository rectally as needed for constipation. ~ Fleet enema 7-19gm/118ml rectally as needed for constipation. ~ [MEDICATION NAME] tablet 5mg two tablets as needed for constipation every third day without a bowel movement. ~ Milk of Magnesia 30ml every morning and evening of the fourth day without a bowel movement. ~ Mag [MEDICATION NAME] one bottle to be administered on the fifth day without a bowel movement. A physician's progress note, dated 05/07/19, documented, .Chief Complaint: abnormal loss of weight .10% wt loss since 11-6-18 despite [MEDICATION NAME].Review of Systems: weight loss, weakness, confusion .Physical Exam: ill appearing, not well nourished, not using accessory muscles to breath, no jugular venous distension, no abdominal distension .Diagnosis: [REDACTED].Plan: D/C [MEDICATION NAME], begin [MEDICATION NAME] 40mg BID . A progress note, dated 05/07/19 at 4:05 p.m., documented, .Dr (PCP) here for rounds in private room. Weight loss noted. N.O. to DC [MEDICATION NAME] and change to [MEDICATION NAME] 40mg twice daily for gastritis. Noted and applied to MAR . A progress note, dated 05/09/19 at 6:06 p.m., documented, .Resident has been initial dosed with her [MEDICATION NAME] 40mg bid. Will monitor for adverse reactions . A progress note, dated 05/13/19 at 6:06 a.m., documented, .Resident cont on [MEDICATION NAME] 40mg BID dx gastritis, resident is having no s/sx of any adverse reactions . A physician's progress note, dated 05/22/19, documented, .Chief Complaint: anorexia .Present Illness: anorexia .appetite/eating better, no headache .Review of Systems: weight loss, heartburn, depression, no headache .Physical Exam: not well nourished, ill appearing, not using accessory muscles to breath, no jugular venous distension, abdomen non distended, sad .Diagnosis: [REDACTED].Mindful can cause headache . The quarterly assessment, dated 05/24/19, documented the resident was modified independent in cognitive skills for daily decision making, required the assistance of two for toileting, was frequently incontinent of bowel, and was not on any bowel toileting program. A progress note, dated 05/28/19 at 2:13 p.m., documented, .Dr (PCP) here for rounds in private room. No new orders noted at this time . The (MONTH) 2019 record of bowel movements was reviewed. The record documented the following BM output: ~ 05/04/19 - small loose stool. ~ 05/13/19 - small formed stool and medium loose stool. ~ 05/21/19 - small loose stool. ~ 05/31/19 - medium formed stool. There was no documentation the facility provided as needed medications to aide the resident in having more frequent bowel movements. There was no documentation the facility informed the physician of the resident's infrequent bowel movements. The (MONTH) 2019 monthly physician's orders [REDACTED]. ~ [MEDICATION NAME] tablet 500mg daily for constipation. ~ [MEDICATION NAME] capsule 100mg twice daily for constipation. ~ [MEDICATION NAME] solution 30ml twice daily for constipation. ~ Senna-S tablet 8.6mg / 50mg two tablets twice daily for constipation. The orders also documented the resident was to receive the following medications as needed for constipation: ~ [MEDICATION NAME] suppository rectally as needed for constipation. ~ Fleet enema 7-19gm/118ml rectally as needed for constipation. ~ [MEDICATION NAME] tablet 5mg two tablets as needed for constipation every third day without a bowel movement. ~ Milk of Magnesia 30ml every morning and evening of the fourth day without a bowel movement. ~ Mag [MEDICATION NAME] one bottle to be administered on the fifth day without a bowel movement. The Medication Administration Record, [REDACTED]. A progress note, dated 06/04/19 at 2:24 a.m., documented, .bowel protocol started on 6/3 at this time, no results reported, no C/O pain/discomfort voiced or noted, active BS x4 quads, abd soft non tender resting in bed with eyes closed, call light in hand and fluids offered and taken as needed .will continue bowel protocol in the a.m . The Medication Administration Record, [REDACTED]. A progress note, dated 06/05/19 at 11:02 a.m., documented, .Dr (PCP) here for rounds in private room. No new orders noted at this time . The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. A progress note, dated 06/11/19 at 1:12 p.m., documented, .Dr. (PCP) here for rounds in private room. No new orders noted at this time . A progress note, dated 06/11/19 at 1:36 p.m., documented, .resident vomitted (sic) x1, denies any pain, or upset stomach, bowel sounds active x4 abd soft non tender .N/O received for [MEDICATION NAME] 4mg PO/SL tab give 1 tab q 4 hours PRN. med (sic) given per orders . The Medication Administration Record, [REDACTED]. A progress note, dated 06/12/19 at 1:12 p.m., documented, .no more c/o nausea or vomiting by resident, cont on bowel protocol milk of mag given waiting (sic) . There was no documentation the physician was informed the bowel program was initiated for the resident nor that the resident was administered Milk of Magnesia for six of the first 12 days of June. The (MONTH) 2019 record of bowel movements was reviewed. The record documented the following BM output: ~ 06/04/19 - large loose stool. ~ 06/12/19 - large formed stool. ~ 06/13/19 - medium formed stool and a medium putty like stool. ~ 06/14/19 - medium putty like stool and a large formed stool. ~ 06/15/19 - medium formed stool. There was no documentation the resident received the Fleets enema, [MEDICATION NAME] tabs, or [MEDICATION NAME] suppository ordered as needed for constipation. A progress note, dated 06/16/19 at 3:16 a.m., documented, .Called to patients (sic) room by staff. Noted copious amount bright red blood draining rectally. (PCP) notified. EMS called .EMS arrived and transported resident out .Report called to .ER. Residents (sic) brother called and informed of situation . A progress note, dated 06/16/19 at 3:19 a.m., documented the resident's vital signs included a heart rate of 123 beats per minute. A progress note, dated 06/16/19 at 10:12 a.m., documented, .Call to .Hospital, to enquire on residents (sic) status. resident (sic) noted to be admitted to the ICU for Fecal Impaction . The emergency room physician's physical exam, dated 06/16/19, documented, .Digital rectal exam there is a large amount clay consistency stool impacted in the rectal vault. The patient also has blood clots and red blood noted. After evacuating the rectal vault the patient does not have ongoing or persistent bleeding . The patient is complaining of pain and points towards her lower abdomen and rectum. The patient did have a softball size bolus of stool in her diaper. After removing the large stool bolus in the digital rectal exam revealed a large amount of clay consistency stool in the rectal vault . Her heart rate has improved after fluids and pain medication. CT of the abdomen is obtained and shows a large amount of stool in the colon. No free air is noted. The patient also has a decreased caliber possible stricture at the junction of the descending and sigmoid colon with mucosal thickening below this and [MEDICAL CONDITION] changes. The may represent inflammation versus infection versus malignancy. There is also a linear high density within the rectal region that may represent prominent vascularity or hemorrhage .I discussed this case with .hospitalist service who has accepted this patient for admission to the ICU . The radiology/CT results, dated 06/16/19, documented, .There is severe diffuse colonic stool noted. There is severe wall thickening of the colon in the region of the distal sigmoid colon and rectum. There are mild pericolonic [MEDICAL CONDITION] changes in these regions .No free fluid or air within the abdomen or pelvis . Impression: Wall thickening and [MEDICAL CONDITION] changes in the region of the distal sigmoid colon and rectum. Correlate for focal [MEDICAL CONDITION]/protitis versus other etiologies (malignancy is not completely excluded.) 2. Severe diffuse colonic stool without definite obstruction. 3. Additional chronic changes as detailed above . The hospital course summary, dated 06/16/19, documented, .is found to have red blood clots and clots per rectum this morning. EMS was notified and patient was initially found to be hypotensive. She was given IV fluids and evaluated in the emergency department. She had a large stool bolus and large red blood clots on evaluation in the emergency department. Has long history of constipation and fecal impaction . CT scan of the abdomen and pelvis showed large amount of stool consistent with [MEDICAL CONDITION], decreased caliber and possible stricture at the junction of the descending and sigmoid colon, and mucosal thickening and adjacent [MEDICAL CONDITION] changes present. Patient was admitted and evaluated by me in her intensive care unit room . The hospital course summary, dated 06/17/19, documented, .Had large bowel movement this morning. No significant blood loss but hemoglobin continues to fall. Patient's pain is improved .General surgery not planning surgical intervention at this time (and) continue to recommend enemas (and) monitoring . The hospital course summary, dated 06/18/19, documented, .Patient has had several large, formed BMs since admission but x-ray shows continued stool burden in colon. She denied pain on exam but was crying in pain trying to have BM later in the morning . The hospital course summary, dated 06/19/19, documented, .RN reports she had 3 large BMs yesterday. Patient feels that she has evacuated her colon but DRE (digital rectal exam) revealed continued soft stool in the rectal vault. [MEDICATION NAME] to be added to regimen today . The x-ray report, dated 06/20/19, documented, .Indication: Abdominal pain and distention; constipation. Findings: Severe stool is seen throughout the colon, however there is no evidence of large or small bowel obstruction. There is no free intra-abdominal air. There are no pathologic intra-abdominal masses or calcifications. The osseous structures are intact .Impression: Severe, diffuse colonic without definite obstruction . The physician's physical exam, dated 06/20/19, documented, .Abdomen lumpy (most likely from stool) but improved from yesterday . The hospital course summary, dated 06/20/19, documented, .4 BMS since yesterday. No further abdominal pain .Constipation may take quite some time to resolve and we will continue her on a bowel regimen at discharge. She may need further surgical evaluation for [MEDICAL CONDITION] or if constipation continues . The physician's discharge summary, dated 06/20/19, documented, .Constipation / Severe / Much improved since admission / Still quite a it of stool burden in colon on x-ray / Continue daily [MEDICATION NAME] and [MEDICATION NAME] along with [MEDICATION NAME] and [MEDICATION NAME] at nursing home / PRN enemas / High fiber diet / Consider sitz marker study if constipation continues . [MEDICAL CONDITION] / H&H stable low / No active blood loss .Poor candidate for iron therapy currently due to severe constipation . On 07/03/19 at 12:40 p.m., RN #1 was asked how the facility monitored the resident's bowel movements. He stated the nurse aides kept up with the resident's bowel movements. He stated he also would ask the alert and oriented residents if they had recently had a bowel movement. He was asked what did he do when a resident had not had a bowel movement recently. He stated the facility had a bowel program the facility followed. He stated the bowel program consisted of administering Milk of Magnesia every morning and evening of the third and fourth day without a bowel movement. He stated if the resident still had not had a bowel movement, they would administer Mag [MEDICATION NAME] on the fifth day. If there were no results from the administration of Mag [MEDICATION NAME], they would contact the physician who may order enemas, suppositories, or have the resident sent to the ER. He was shown the bowel record for resident #1 for (MONTH) and (MONTH) of 2019. He was asked if the resident should have received as needed medications for constipation. He pointed to each of the four days a bowel movement was documented and stated the resident should have received medications every third day without a bowel movement. He stated they should have continued with interventions until the resident had a bowel movement or the interventions were exhausted and the physician notified. On 07/03/19 at 12:50 p.m., CMA #1 was asked how did she know when the bowel program was initiated and she knew to provide Milk of Magnesia to a resident. She stated she was given a bowel protocol sheet from the night nurse which listed residents who were to be administered Milk of Magnesia on the morning of the third day without a bowel movement and again on the morning and evening of the fourth day without a bowel movement. She was asked how the evening medication aide knew to administer the evening dose of Milk of Magnesia. She stated she passed on in report that she had administered Milk of Magnesia to a resident and the evening medication aide should be reviewing the Medication Administration Record [REDACTED] On 07/03/19 at 1:00 p.m., LPN #1 was asked if she had provided care to resident #1. She stated yes. She was asked if the resident had a history of [REDACTED]. She stated yes. She stated the resident was on multiple routine medications to aide the resident with constipation. She was asked if a resident with a history of trouble evacuating her bowels would need to have their bowel movements monitored. She stated yes. She was asked how the facility staff monitored bowel movements for such residents. She stated they recently transferred from paper charting to an electronic medical record and now had to go into another area of the program to individually view the each resident's documented bowel movements. She was asked what did she do when she saw a resident had gone days without a bowel movement. She stated the facility had a bowel program which she would initiate. She stated the bowel program consisted of administering Milk of Magnesia twice daily on the third and fourth days without a bowel movement. She stated on the fifth day without a bowel movement, they would administer Mag [MEDICATION NAME]. She was asked if she would notify anyone the resident had not had a bowel movement. She stated she would notify the physician on the sixth day. She was shown the bowel record for resident #1 for (MONTH) and (MONTH) of 2019. She was asked if the resident should have received as needed medications for constipation. She stated yes. She was asked if there is concern for a resident with a known history of constipation and documented infrequent bowel movements who complains of nausea and vomiting. She stated yes. She was asked if the physician should have been notified of the resident's bowel record. She stated yes. On 07/03/19 at 1:10 p.m., the DON was asked how the medication aide knew when to give Milk of Magnesia. She stated the night nurse would go into the computer and print off a list of residents the medication aide was to provide Milk of Magnesia to. She was asked if she kept a copy of each list provided. She stated she was not provided a copy. She was asked how the facility monitored resident's bowel movements. She stated the nurse aides documented the bowel movements in the electronic medical record and were reviewed by the night nurse. She was asked if the facility had a bowel program to aide residents with constipation. She stated the bowel program was currently under review to be rewritten. She stated she now reviewed the resident's bowel record every morning. She was asked if she was familiar with resident #1's bowel elimination record for (MONTH) and (MONTH) 2019. She stated yes. She was asked why the facility had not intervened and provided the resident with an as needed medication to aide in the evacuation of her bowels in the month of May. She stated she did not know. She was asked if there was any documentation the facility notified the resident's physician regarding the resident's infrequent bowel movements. She stated no. She was asked if the physician should have been informed of the resident's infrequent bowel movements in (MONTH) and June. She stated yes.

Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ A resident was supervised to prevent a fall which resulted in a fracture for one (#27) of six sampled residents reviewed for falls. The DON identified there had been four residents who had experienced a fall with a fracture in the last six months, and: ~ Residents were safe from hot water for nine (#57, #27, #32, #48, #52, #53, #59, #56, and #110) of nine sampled residents who were observed to have hot water on two hallways (#200 and #500) of four facility hallways. The facility census and condition identified 60 residents resided in the facility. Findings: 1. Resident #27 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/12/17, documented the resident was cognitively intact, required extensive assistance with most activities of daily living, was continent of bowel and bladder, had no pain, had no falls, had no pressure ulcer, and received an antidepressant seven days out of the seven day look back period. A health status note, dated 01/27/18 at 7:40 p.m., documented, .CNA (certified nurse aid) came to this nurse and LPN (licensed practical nurse) on shift stating she needed help because this resident had fallen and was laying on the floor. Resident laying on floor, supine. Resident states having trouble breathing and having back pain. Resident is diaphoretic and abdominal area and back have purple discoloration. Vital signs as followed, T (temperature) 98.6, BP (blood pressure) 93/45, Oxygen saturation 90%, pulse 55. Resident assisted to bed with X2 assistance, resident still diaphoretic and oxygen saturation from 84% to 92% blood glucose 134. ADON notified and asked for advise. ADON advice to send to ER for further evaluation. POA (power of attorney) notified, thankful for call and states will go to the hospital. An investigation report, dated 01/29/18, documented, .TIMELINE OF EVENTS: Resident fell @1920, charge nurse notified ADON (assistance director of nursing) and DON (director of nursing). CNA (certified nurse aid) was suspended until investigation can be complete. Resident transferred to (un-named hospital). Upon return, all staff was inserviced by therapy about how to properly use a gait belt. Initial report sent into state. DON and ADON are also watching CNAs complete transfers with gait belts. Final report to be completed. SUMMARY OF CRITICAL INFORMATION OBTAINED DURING INVESTIGATION: CNA did not have gait belt around resident, resident's legs gave out while CNA was moving w/c. ACTION TAKEN DURING INVESTIGATION: CNA was suspended. All CNA staff re-educated in inservice. That CNA was brought back into work, into a full time position, working side by side with other aides for more education & training. CNA also did one on one training with PT (physical therapist). CONCLUSION: CNA was just fresh out of CNA classes. She requires continuing education on proper use of gait belt and transferring. She is also receiving more one on one education with another aide with nurse supervision . The investigation report was signed by the DON. A mandatory inservice attendance roster, dated 01/29/18, documented an inservice was conducted regarding gait belt use and proper transfer methods. The mandatory inservice roster documented the PTA and the facility corporate nurse conducted the training. The mandatory inservice roster documented 20 CNAs were in attendance, one LPN was in attendance, and one RN was in attendance when the training was conducted. A significant change assessment, dated 02/07/18, documented the resident was cognitively intact, required total assistance with most activities of daily living, was continent of bowel and bladder, had one fall with a major injury, had no pressure ulcer, had received an antidepressant seven days out of the seven day look back period, and had received an opioid four days out of the seven day look back period. A care plan, dated 02/08/18, documented: Focus The resident was at risk for falls related to a history of falls and required assistance with transfers and mobility. Goal The resident would be free of falls through the review date. Interventions 1. Anticipate and meet the resident's needs. 2. Be sure the call light was within reach and encourage the resident to use it for assistance as needed. Respond promptly to all requests for assistance. 3. The resident was on the Star identification plan 4. Follow facility fall protocol. 5. PT/OT to evaluate and treat as ordered 6. Two person assistance with transfers using a gait belt. Focus The resident had [MEDICAL CONDITION] with risk for fracture. Goal The resident would remain free of injuries or complications related to [MEDICAL CONDITION] through the review date Interventions 1. Give [MEDICATION NAME] as needed for pain. The resident may complain of pain, stiffness or weakness. Document complaints. 2. Give medications as ordered. Monitor/document for side effects and effectiveness. 3. Monitor/document for risk of falls. Educate the family and the resident on safety measures that need to be taken in order to reduce risk of falls. 4. Monitor/document/report as needed signs/symptoms of complications related to [MEDICAL CONDITION]: acute fracture, compression fractures, loss of height, kyphosis, pain, especially back pain. 5. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. 6. Provide with pillows, etc. to help maintain comfortable position. 7. PT evaluation and treatment as ordered. Focus The resident had a fractured T10 related to a fall. Goal The resident would not develop complications or permanent loss of mobility related to fracture through review date. Interventions 1. Give pain, anti-[MEDICAL CONDITION] medications as ordered. Monitor/document side effects and effectiveness. 2. Handle gently when moving or positioning. Maintain body alignment. 3. Monitor/document/report as needed: [MEDICAL CONDITION], bruising/discoloration of skin, skin temperature changes. 4. Support injured area with abdominal binder as ordered. Focus The resident had chronic pain related to [MEDICAL CONDITION]. Goal The resident would not have an interruption in normal activities due to pain through the review date. Interventions 1. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. 2. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and the resident's satisfaction with results, impact on functional ability and impact on cognition. 3. Identify, record and treat existing conditions which may increase pain and or discomfort such as [MEDICAL CONDITION], fractures. 4. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician. 5. The resident's pain was aggravated by increased activity and weather changes. 6. The resident's pain was alleviated/relieved by as needed pain medication. 7. Notify the physician if interventions were unsuccessful or if current complaint was a significant change from the resident's past experience of pain. On 02/12/18 at 8:25 a.m., the resident was observed in bed with a fall mat next to the bed. The resident stated she was doing well. Juice and coffee were on the bedside table. On 02/12/18 at 10:04 a.m., the resident was observed in bed with the head of the bed up. A fall mat was on the floor next to the bed. On 02/12/18 at 11:12 a.m., the resident was observed in bed with the head of the bed up. The television was on and a fall mat was next to the bed. On 02/12/18 at 2:54 p.m., the resident was asked what happened when she had fallen. She stated she was helped to stand up by two staff members and they had left her standing by herself and she fell . The resident was asked if the staff members had used a gait belt. She stated she was not sure if they had a gait belt. She stated she was sent to the hospital for x-rays and they found out she had a fracture in her back. She stated she had pain with the fracture but the facility had been giving her pain medication and it had helped. The resident was asked how staff transferred her now. She stated there were always two staff members and they always used a gait belt. On 02/13/18 at 8:35 a.m., the resident was observed in the dining room feeding herself oatmeal and toast. On 02/13/18 at 9:49 a.m., the resident was observed lying supine in bed with the head of the bed up and a fall mat next to bed. On 02/13/18 at 11:00 a.m., the resident was observed sitting in her wheelchair in her room watching TV. On 02/13/18 at 3:30 p.m., the resident was observed lying in bed supine with the head of the bed up and a fall mat in place. On 02/13/18 at 5:38 p.m., the resident was observed lying in bed with the head of the bed up watching television. A fall mat was next to the bed. On 02/14/18 at 5:08 a.m., the resident was observed lying in bed with her eyes closed and a fall mat next to the bed. On 02/14/18 at 7:38 a.m., the resident was observed lying in bed with her eyes closed and a fall mat next to the bed. On 02/14/18 at 8:56 a.m., the resident was observed in the restorative dining room being assisted to eat by a CN[NAME] On 02/15/18 at 8:31 a.m., LPN #4 was asked what happened when the resident had fallen and fractured her back. The LPN stated a CNA was assisting the resident to get up and the CNA did not use a gait belt and the resident lost her balance and fell . She stated the CNA called for help and staff came to the resident's room. The LPN stated the resident was assessed and emergency medical services were called as well as the family. The LPN stated the CNA was interviewed at that time and was suspended at that time for five days during the investigation. The LPN stated that evening she had done an inservice with the evening and night shift CNAs regarding how to properly transfer residents. She stated the next day the DON and ADON did an all staff inservice regarding properly transferring residents. On 02/15/18 at 9:12 a.m., the resident was observed dressed and sitting on the bedside. CNA #1 was observed to put a gait belt around the resident. Then she and CNA #2 put their arms around the resident and used the gait belt to stand the resident up and the resident pivoted a couple of steps to her chair. On 02/15/18 at 10:38 a.m., CNA #3, the CNA who was transferring the resident when she fell , was asked what happened when the resident had fallen. She stated she assisted the resident to stand up and had asked her if she had her balance. She stated the resident said yes. She stated she stepped away from the resident for one minute to move the wheelchair and the resident fell . The CNA was asked if she had used a gait belt to transfer the resident. She stated no. The CNA was asked what happened after the incident. She stated she was suspended for a week and then was retrained on the day shift for four days on how to safely transfer residents. She was asked if the resident had been a one or two person transfer. She stated at that time the resident was a one person transfer. On 02/21/18 at 9:45 a.m., the resident was observed sitting in a wheelchair in her room watching television. On 02/21/18 at 11:34 a.m., the DON was asked what interventions were currently in place for the resident to prevent falls. She stated they had done all staff inservices regarding properly transferring residents. The DON stated the CNA who had transferred the resident was a brand new CNA at the time of the resident's fall. The DON stated the CNA had asked the resident if she was stable after she had assisted the resident to stand and the resident had responded that she was stable and then the resident had fallen. She stated after the inservice each staff member was visually checked off after being observed to transfer someone. She stated now they had increased new hire orientation to one week. The DON stated each new employee was given a gait belt and were given a demonstration of proper transfer techniques. She stated then the new hire was observed transferring a resident to ensure they did it properly. The DON stated she did spot checks to ensure the CNAs were using a gait belt with each resident transfer. A facility water temperature policy and procedure, undated, documented it was the policy of the facility to check and record daily water temperatures in resident rooms. The policy documented resident rooms were to be alternated daily to assure all room water temperatures are at state and federal compliance. The policy documented the water temperatures should not be above 115 degrees and the temperatures would be recorded daily by maintenance. If maintenance was not available then the water temperatures would be recorded by the housekeeping supervisor. 1. Resident #57 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 01/24/18, documented the resident was severely cognitively impaired, and required limited assistance with transfers and toileting. On 02/02/18 at 10:00 a.m., the hot water temperature in the resident's bathroom sink was 124 degrees Fahrenheit (F). The resident was observed lying in bed with her eyes closed. The resident required staff assistance to toilet and used a wheel chair for ambulation. There were no other resident's who resided in the room. 2. Resident #27 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A significant change assessment, dated 02/07/18, documented the resident was cognitively intact and required total assistance with ADLs including toileting. 02/12/18 at 10:04 a.m., the hot water temperature in the resident's bathroom sink was 125 degrees F. The resident was observed in bed with the head of the bed up and a fall mat on the floor next to the bed. There were no other resident's who resided in the room. 3. Resident #32 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/15/17, documented the resident was severely cognitively impaired and required extensive assistance with most ADLs including transfers and toileting. On 02/12/18 at 10:10 a.m. the hot water temperature in the resident's bathroom sink was 124 degrees F. The resident was observed in her room in a recliner with her feet elevated. The resident was unable to answer questions appropriately. There were no other resident's who resided in the room. 4. Resident #48 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 01/27/18, documented the resident was cognitively intact and required set up only for transfers and toileting. On 02/12/18 at 10:18 a.m., the hot water in the resident's bathroom sink was 123 degrees F. The resident was observed sitting on the side of her bed watching television. The resident was asked if the water in her bathroom was ever too hot. She stated if the water would get too hot she would turn on the cold water. She stated she had never been burned by the hot water. There were no other resident's who resided in the room. On 02/12/18 at 10:28 a.m., LPN #3 was asked if there were any wanderers on the 200 hall. She stated no. 5. Resident #52 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 01/18/18, documented the resident was cognitively intact and required extensive assistance for transfers and limited assistance for toileting. On 02/12/18 at 10:40 a.m., the water temperature in the resident's bathroom sink was 124 degrees F. The resident was out of the building for [MEDICAL TREATMENT]. There were no other resident's who resided in the room. 6. Resident #53 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 01/11/18, documented the resident was moderately impaired cognitively and required extensive assistance for transfers and total assistance for toileting. On 02/12/18 at 10:45 a.m., the water temperature in the resident's bathroom sink was 124 degrees F. The resident was out of the room at therapy. When the resident returned to his room he was asked if the water in his bathroom sink was ever too hot. He stated no. He was asked if he had ever been burned from hot water. He stated no. There were no other resident's who resided in the room. 7. Resident #59 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 01/22/18, documented the resident was cognitively intact and required extensive assistance with transfers and toileting. On 02/12/18 at 10:47 a.m., the hot water in the resident's bathroom sink was 125 degrees F. The resident was out of the room. There were no other resident's who resided in the room. 8. Resident #56 in room [ROOM NUMBER] was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/03/18, documented the resident was cognitively intact and required limited assistance for transfers and extensive assistance for toileting. On 02/12/18 at 10:36 a.m., the hot water in the resident's bathroom sink was 122 degrees F. The resident was asked if the water ever got too hot. She stated yes the water will get hot but it was easy to turn on the cold water. The resident was asked if she had ever been burned by the hot water. She stated no. There were no other resident's who resided in the room. 9. Resident #110 in room [ROOM NUMBER] was admitted to the facility on [DATE]. There was no assessment due for the resident. A care plan, dated 02/13/18, documented the resident required extensive assistance for transfers and toileting. On 02/12/18 at 10:50 a.m., the hot water in the resident's bathroom sink was 122 degrees F. The resident was asked if the water was ever too hot. She stated no. She was asked if she had ever been burned from hot water in her sink. She stated no. There were no other resident's who resided in the room. On 02/12/18 at 10:51 a.m., CNA #4 was asked if there were any wandering residents on the 500 hall. She stated no. She stated the residents who wandered were all in the locked memory unit. She was asked if she was aware of any residents being burned by hot water in their bathroom sinks. She state no. On 02/12/18 at 11:04 a.m., the administrator was informed of the hot water temperatures on #200 and #500 halls. She stated she would take care of the hot water right now. She was asked if there were any residents who wandered on those hallways. She stated no. She was asked if there had been any reports of residents being burned by hot water. She stated no. The administrator was asked for the water temperature logs for the last six months. At 12:07 p.m., the administrator stated the maintenance man had turned down the temperatures on the hot water tanks and would recheck the water temperatures in one hour. The administrator was again asked for the water temperature logs. At 12:15 p.m., the administrator came to this surveyor and stated the housekeeping supervisor had been checking the hot water temperatures in the resident rooms and she had left in (MONTH) (YEAR). She stated the housekeeping supervisor had taken all the logs. She stated no one had been checking the water temperatures since that time. She stated there were no water temperature logs. At 2:10 p.m., hot water temperatures were rechecked. The first room checked on #200 hall was room [ROOM NUMBER]. The water temperature was 123 degrees F. The first room checked on #500 hall was room [ROOM NUMBER]. The water temperature was 123 degrees F. The administrator was informed of the continued high water temperatures. She informed the maintenance man who again adjusted the temperatures on the hot water tanks and drained some of the water out of the tanks. Beginning at 3:15 p.m., all of the rooms with hot water were rechecked and found to be at safe temperatures. The temperatures ranged from 101 degrees F. to 105 degrees F.

Based on observation, interview, and record review, it was determined the facility failed to ensure an appliance to heat water was not an accident hazard in order to prevent a burn for one (#11) of one sampled resident observed for accident hazards. ~ The resident sustained [REDACTED]. ~ The resident was never assessed for the safe use of a water heating device. The administrator identified 2 residents who resided in the facility and had a water heating device. Findings: A Center for Disease Control document regarding burn classification, undated, documented, .Second-Degree Burns: Second-degree burns involve the first two layers of skin. Signs: * Deep reddening of the skin * Pain *Blisters . Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 08/24/16, documented the resident was cognitively intact, required supervision only with eating, bed mobility and ambulation off the unit, required limited assistance with dressing, required extensive assistance with hygiene and bathing, was totally dependent on staff for transfer and toileting, and was continent of bowel and bladder. A nurse's note, dated 10/04/16 at 3:30 a.m., documented, Res was pouring hot water in room from tea pot and spilled some on her L inner thigh, nonstick pad placed c dry dressing - Dr notified awaiting orders. A physician's telephone order, dated 10/04/16, documented to cleanse left thigh with normal saline and gently pat dry. Apply Silvadene 1 gram and cover with non stick pad then cover with gauze and secure with tape once daily. Diagnoses: [REDACTED]. A treatment sheet, dated October 2016, documented, .Cleanse L thigh with NS and gently pat dry. Apply Silvadene 1 gram and cover with non stick pad then cover with gauze and secure with tape once daily . The treatment sheet documented the treatment began on 10/05/16. A care plan update, dated 10/04/16, documented the resident had a burn to her left thigh. The care plan goal was to resolve the burn. The interventions included; cleanse left thigh with normal saline and gently pat dry, apply Silvadene 1 gram and cover with non stick pad, cover with gauze, and secure with tape once a day. A treatment sheet, dated November 2016, documented, .CLEANSE LEFT THIGH WITH NORMAL SALINE, PAT DRY, APPLY SILVADENE AND COVER WITH NON STICK PAD, THEN COVER WITH GAUZE AND SECURE WITH TAPE DAILY . The treatment sheet documented the treatment was discontinued on 11/03/16. A nurse's note, dated 11/03/16 untimed, documented a new order had been received to discontinue the treatment to the resident's left thigh. A quarterly assessment, dated 11/24/16, documented the resident was cognitively intact, required supervision only with eating and ambulation off the unit, required extensive assistance with bed mobility, dressing, hygiene, bathing, and toileting, was totally dependent on staff for transfer, and was continent of bowel and bladder. On 12/15/16 at 8:20 a.m., resident #11 was observed lying cross wise in bed with her head elevated on pillows and her feet on the floor. Bilateral wraps were observed on the resident's lower legs. The resident's eyes were closed. A water heating device was observed sitting on the bedside table. At 9:50 a.m., the ADON was asked if she was aware resident #11 had a water heating device or if she knew the resident had gotten burned. The ADON stated she did not know the resident had been burned or that she had a water heating device. She stated it should not have been in her room. She stated it was dangerous. At 10:25 a.m., the DON was asked if she was aware resident #11 had a water heating device or if she knew the resident had gotten burned. The DON stated she was not aware the incident had occurred or that the resident had a hot water pot in her room. The DON stated there had been no incident report turned in. The DON was asked if there had been an assessment of the burn. The DON stated she had been unable to find any assessment. At 11:44 a.m., LPN #4 was asked about resident #11's burn. The LPN stated the resident had burned herself with hot water from the electric hot water pot she had in her room. The LPN was asked what she had done to protect the resident after the burn had occurred. The LPN stated she had educated the resident to call for help if she wanted to heat water up in the pot. The LPN was asked if she had removed the water heating device from the resident's room. She stated no. The LPN stated she had completed an incident report however, she had not notified the DON or ADON about the incident. At 12:30 p.m., the resident's water heating device was no longer observed to be in the resident's room. Resident #11 was asked about the incident. The resident stated she had tried to move the pot while it was still plugged in and it caught and caused water to spill from the pot onto her left thigh. She stated the burn was a blister about the size of a half dollar. The resident stated the facility had treated the burn. The resident was asked what the facility had done to try to prevent the accident from happening again. She stated the nurse told her she should take the cup to the pot instead of trying to move the pot. She stated she had the hot water pot since she was admitted to the facility. The resident stated she had left the pot unplugged unless she wanted to heat a cup of hot water. She stated she was in her room almost all of the time.

On 06-16-14 at 11:30 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to have an adequate system in place to monitor laboratory tests for residents who received anticoagulant therapy. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. On 06-16-14 at 11:55 a.m., the director of nursing (DON) and administrator were notified of the IJ situation. On 06-16-14 at 1:25 p.m., an acceptable plan of removal was presented to the survey team. The plan of correction documented: "...Nurse Aide Training regarding residents with anticoagulants, signs & symptoms of bleeding, what to look for and reporting to charge nurses...All nursing staff in the facility at the time of the survey have been in-serviced regarding residents with anticoagulants...All licensed nurses have been in-serviced in the facility or by phone regarding residents with anticoagulants by 3:00 p.m. 6.16.14...All licensed nurses have been in-serviced in the facility or by phone investigation of bruising of "unknown origin"...Remaining nurse aides and medication aides will be in-serviced by Friday 6/20/14 regarding residents with anticoagulants...The attached Policy & Procedure has been given to charge nurses or will be given to charge nurses as a guide for implementation...The Director of Nursing and/or her designee will monitor for compliance by verifying physician's orders [REDACTED]. All new admission charts will be brought to the morning standup meeting for review. Physicians orders will be verified by (2) licensed nurses. Monitoring will be accomplished weekly times four, then monthly times two and quarterly times three and reviewed during our weekly QAPI (Quality Assessment and Performance Improvement) meeting..." On 06-16-14 at 5:45 p.m., the IJ was removed when all components of the plan had been completed. The deficient practice remained at a level of actual harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to provide care and/or services to ensure residents maintained their highest levels of well-being for 4 (#1, #2, #4 and #5) of six sampled residents reviewed for well-being and who were on anticoagulant therapy. The facility failed to: a) thoroughly assess and monitor resident #1 after discovering bruising on the resident. b) obtain the necessary laboratory tests per the physician orders [REDACTED].#2, #4, and #5 who were on anticoagulant therapy. The DON identified 5 residents in the facility who received anticoagulant therapy. Findings: A facility policy, revised on 02/2013, documented, "...All residents requiring [MEDICATION NAME] or [MEDICATION NAME] administration will have a PT/PTT ([MEDICATION NAME] time/partial [MEDICATION NAME] time) drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Licensed nurses will monitor the required lab work completion and administration of the anticoagulant..." 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission/start-up physician order, dated 10-30-13, documented, "[MEDICATION NAME] 5mg (milligrams) PO (by mouth) daily @ 1700 (5:00 p.m.)[MEDICATION NAME] 40mg SQ (subcutaneous) daily till INR (international normalized ratio) is therapeutic...Aspirin 81mg PO QID (four times) daily...PT/INR daily..." A 5-day PPS (prospective payment system) assessment, dated 11-06-13, documented resident #1 was severely impaired cognitively, was dependent on staff for activities of daily living, was incontinent of bladder, continent of bowel and had been on an anticoagulant medication for seven of seven days during the look back period. Skilled nurses' notes, dated 10-30-13 through 11-05-13, contained no documentation of monitoring and/or other issues related to the resident's anticoagulant therapy. A nurse's note, dated 11-06-13 at 8:30 a.m., documented, "...Reported to nurse that resident had some bruises to R. (right) arm and R. thigh. Assessed resident R. arm. Resident has bruise to R. inner arm that is purple in color. Resident has bruise to R. in (sic) thigh that (sic) purple to center and light purple to edges. Resident is unable to make needs known. CNA (certified nurse assistant) state that she did no (sic) see it..." A PT/INR result, drawn on 11-07-13 at 12:32 a.m. and reported to the charge nurse on 11-07-13 at 3:30 p.m., documented, "...PT 77.1 critical (range 10.2 -13.4)...INR 6.7 critical (range 2.0-3.5)...Hgb (hemoglobin) 6.4 critical (range 12.0-15.6)...Hct (hematocrit) 19.2 critical (range 35.0-46.0)..." A nurse's note, dated 11-07-13 at 1:00 a.m., documented, "...Upon rounds-found pt (patient) cool to touch, diaphoretic, a & o (alert and oriented) x2, able to answer questions,.. bp (blood pressure) 50/34 manual, denies pain or discomfort. SaO2 (saturated oxygen) 61%-O2 placed at 2L (liters) per NC (nasal cannula)...color pale-called (physician name deleted)-new "O" (order) send to ER (emergency room ) for eval (evaluation) & treat..." A hospital physician progress notes [REDACTED]. Hypovolemic shock, resolved. 2. Blood-loss [MEDICAL CONDITION], improving. Coagulopathy better now that aspirin, [MEDICATION NAME], and [MEDICATION NAME] have been stopped..." A nurse's note, dated 11-11-13, documented, "...Review of residents chart. Found order for daily PT/INR that were not ordered or put in the computer to be obtained on start-up orders..." On 06-16-14 at 11:00 a.m., licensed practical nurse (LPN) #1 was asked about the admission orders [REDACTED]. LPN #1 was asked how he informed the ADON that the admit labs needed to be done. LPN #1 stated he placed a sticky note on the ADON's computer alerting her to the need to input the lab orders. LPN #1 was asked how the order was followed up on. LPN #1 stated he did not follow-up to see if it was done. On 06-16-14 at 11:17 a.m., the ADON was asked about resident #1. The ADON stated she was the only person at that time with access to the lab computer. The ADON was asked if she remembered putting the admission laboratory orders into the computer. The ADON stated no, she did not remember putting the admission laboratory orders into the computer. The ADON was asked to review the laboratory order history on resident #1. The ADON stated she did not add daily PT/INRs until 11-07-13. On 06-16-14 at 11:18 a.m., the DON was asked how orders were processed when a resident was admitted on anticoagulant therapy. The DON stated since March 2014, all nurses now have access codes to the laboratory computer and should enter any labs ordered by the physician directly into the computer. When asked if this was being done. The DON stated she had only been employed as the DON since April 2014 and was in the process of correcting problems that have occurred. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 05-28-14, documented resident #2 was cognitively aware, required extensive assistance with activities of daily living, did not ambulate, was continent of bowel and bladder, and had not taken an anticoagulant medication in the last seven out of seven days during the look back period. An admission/start-up pharmacy order, dated 06-02-14, documented, "[MEDICATION NAME] 2 mg 1/1 (one tablet) PO q (every) day...PT/INR in 2 days..." A review of the clinical record showed no documentation a PT/INR was obtained on 06-04-14 per the physician's orders [REDACTED]. On 06-16-14 at 9:20 a.m., resident #2 was observed sitting in her wheelchair eating breakfast. Resident #2 was asked if she was on an anticoagulant medication. She stated yes. Resident #2 stated she was experiencing nausea however, she had no other complaints and felt the nurses were following the physician's orders [REDACTED].#2 was observed to have no obvious bruising. On 06-16-14 at 11:05 a.m., LPN #2 was asked about the missing PT/INR for resident #2. LPN #2 stated the admission nurse must have overlooked the order and the labs were not done. LPN #2 stated a stat order for PT/INR would be obtained that day. 3. Resident #4 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 04-11-14, documented resident #4 was severely impaired cognitively, was dependent on staff for activities of daily living, did not ambulate, was incontinent of bowel and bladder, and had been on anticoagulant therapy for seven out of seven days during the look back period. A physician's telephone order, dated 04-16-14 at 7:00 a.m., documented, "... [MEDICATION NAME] 2mg po 1 daily...INR 2 weeks..." The clinical record did not show documentation an INR was obtained on 04-30-14 per the physician's orders [REDACTED]. A pharmacy consultation report, dated May 2014, documented, "...Please consider monitoring an INR on the next convenient lab day and at least monthly thereafter..." A laboratory result, dated 05-23-14, documented PT was 38.6 high (range 10.2-13.4) and an INR of 3.3 (range 2.0-3.5). A physician's telephone order, dated 05-27-14, documented, "...draw INR in AM (morning) then monthly thereafter..." The clinical record showed no documentation an INR was obtained on 05-28-14 per the physician's orders [REDACTED]. A fax to physician, dated 05-29-14, documented, "...PT 38.6. Had nosebleed last night and this morning. Please advise..." There was no documentation the facility followed up with the physician after sending the fax on 05-29-14 until the physician responded on 06-03-14. A fax from the physician, dated 06-03-14, documented the physician requested the resident's vital signs. A fax to physician, dated 06-03-14, documented, "...as per your request from fax from 05/29/14 regarding 2 nosebleeds-Res (resident) VS (vital signs) 102/51, P (pulse) 91, R (respirations) 16, T (temperature) 98.3-Res has had no more reports of nose bleed since 5/29/14..." A physician's telephone order, dated 06-11-14, documented [MEDICATION NAME] was discontinued. 4. Resident #5 was admitted to the facilty on 04-28-14 and had [DIAGNOSES REDACTED]. An admission/start-up physician order, dated 04-28-14, documented, "[MEDICATION NAME] 5mg PO q HS (bedtime)...PT/INR q week..." An admission assessment, dated 05-05-14, documented resident #5 was severely impaired cognitively, required supervision for activities of daily living, was continent of bowel and bladder, and had been on an anticoagulant medication for seven out of seven days during the look back period. A physician's telephone order, dated 05-08-14, documented, "...INR in 10 days..." The clinical record showed no documentation the required lab was obtained after 05-13-14 per the physician's orders [REDACTED]. On 06-16-14 at 11:35 a.m., resident #5 was observed sitting in her wheelchair in her room. Resident #5 stated she was aware she was on a blood thinner medication. She stated she thought she was getting lab work done at the facility however, did not understand the question. Resident #5 was observed to have no obvious bruising. On 06-16-14 at 1:30 p.m., the ADON was asked about the weekly PT/INRs for resident #5. The ADON reviewed the physician's orders [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to notify the physician of a resident's continuing rash and itching for 1 (#1) of 5 sampled residents who had been treated for [REDACTED]. Resident #1 had red raised bumps on her face, neck, arms, and abdomen. Resident #1's arms had several scratch marks and scabbed areas, with one scabbed area that was bleeding. The resident's fingernails were long, uneven, and several of the fingernails had a dark colored substance under them. The director of nursing (DON) identified 4 residents had been treated for [REDACTED]. Findings: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's admission assessment, dated 05-13-13, documented the resident was severely cognitively impaired, had short and long term memory loss, required assistance with activities of daily living, and was always incontinent of bowel and bladder. A care plan, dated 05-14-13, documented, "...Weekly skin monitoring by nurse..." A facility change in condition report, titled "SBAR" and dated 07-24-13, documented, "...res. (resident) has rash. Small areas of light pink rash R (right) upper arm et (and) R upper chest. Dr (doctor) sent update..." A physician's telephone order, dated 07-25-13, documented an order for [REDACTED]. A care plan, dated 07-25-13, documented, "...I have a rash to my upper chest (and) [MEDICATION NAME] 0.1% cream BID (twice a day) x (times) 10 d (days)..." A treatment administration record (TAR), dated July 2013 and August 2013, documented [MEDICATION NAME] cream had been applied to resident #1's rash twice a day from 07-26-13 through 08-04-13. A facility 24 hour report/change of condition report was reviewed for resident #1 from 07-29-13 through 08-23-13. The report documented resident #1 continued to have a rash and/or itching on 07-29-13, 07-31-13, 08-01-13, 08-11-13, 08-12-13, 08-13-13, and 08-14-13. A quarterly assessment, dated 08-13-13, documented the resident was severely cognitively impaired, had short and long term memory loss, required total assistance with activities of daily living, and was always incontinent of bowel and bladder. On 08-28-13 at 10:15 a.m., resident #1 was observed lying in bed awake. Resident #1 had several red bumps, sores and scabbed areas on her forearms, face, and neck. Resident #1 was observed scratching herself. Resident #1 was unable to answer questions. On 08-28-13 at 11:35 a.m., licensed practical nurse (LPN) #1 was asked if any residents were being treated for [REDACTED]. LPN #1 was asked if resident #1 was being treated for [REDACTED]. He stated he thought the resident just had dry skin now, and the physician had said to treat the dry skin with lotion. LPN #1 was asked if there was a physician's orders [REDACTED]. He stated no. On 08-28-13 at 11:40 a.m., resident #1 was observed sitting at the dining room table in her wheelchair. She was rubbing her forearms with her hands. Her fingernails were long, uneven, and had a dark substance underneath them. Resident #1's forearms had several scabbed and bruised areas. The skin on both forearms was dry. On 08-28-13 at 2:40 p.m., certified nursing assistant (CNA) #3 was asked if resident #1 had a rash and if she had been scratching herself. She stated yes. CNA #3 was asked if she had reported it to anyone. She stated yes, she had reported it to LPN #1 a couple of days ago. On 08-28-13 at 2:50 p.m., resident #1 was observed lying in bed with her eyes closed. Her abdomen was partially exposed. Resident #1's abdomen was observed to have several red bumps on it. A facility change in condition report, titled "SBAR" and dated 08-28-13 at 4:00 p.m., documented, "...Report to nurse that resident has rash to upper torso. Assessed resident, Noted rash to upper torso. Skin WDI (warm dry intact) c (with) raised red areas to arms chest (and) abdomen. Notified Dr (doctor) (and) family..." A physician's telephone order, dated 08-28-13, documented to apply Trimcinolone cream to affected areas twice a day for seven days for a rash. On 08-28-13 at 4:30 p.m., CNA #1 was asked if resident #1 had a rash. She stated yes, the resident had a rash with itching since she had been there. CNA #1 was asked how long she had worked at the facility. She stated three weeks. CNA #1 was asked if she had reported resident #1's rash to anyone. She stated she had been told the rash had already been reported to nursing. On 08-28-13 at 5:20 p.m., the DON was asked if she had observed resident #1's skin. She stated no. The DON was asked if she was aware resident #1 had a skin rash. She stated no. On 08-29-13 at 10:00 a.m., resident #1 was observed lying in bed on her left side scratching her back. Resident #1's fingernails were long and uneven. There was a dark colored substance underneath several of her fingernails. Resident #1's pillow case had several areas of a red colored substance on it. This surveyor asked LPN #1 to come into the room and assess resident #1. LPN #1 looked at resident #1's skin and found an old scabbed area on her right forearm was bleeding. LPN #1 was asked why resident #1 had several scabbed areas on her arms. He stated from scratching. LPN #1 was asked if resident #1 had been assessed for her rash and itching. He stated no, not until yesterday. On 08-29-13 at 10:18 a.m., the DON was asked if she thought resident #1 had been assessed, monitored, and treated appropriately in regards to her rash/itching. She stated she did not think resident #1 had been adequately assessed.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to ensure residents maintained their highest levels of well-being for 1 (#1) of 5 sampled residents who were reviewed for a skin rash. The facility failed to: a. assess, monitor, and provide interventions to treat a skin rash for resident #1. b. evaluate the effectiveness of a treatment for [REDACTED]. c. notify the physician of resident #1's continuing rash and itching. Resident #1 had red raised bumps on her face, neck, arms, and abdomen. Resident #1's arms had several scratch marks and scabbed areas, with one scabbed area that was bleeding. The resident's fingernails were long, uneven, and several of the fingernails had a dark colored substance under them. The director of nursing (DON) identified four residents who resided in the facility who had been treated for [REDACTED]. Findings: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's admission assessment, dated 05-13-13, documented the resident was severely cognitively impaired, had short and long term memory loss, required assistance with activities of daily living, and was always incontinent of bowel and bladder. A care plan, dated 05-14-13, documented, "...Weekly skin monitoring by nurse..." A facility change in condition report, titled "SBAR" and dated 07-24-13, documented, "...res. (resident) has rash. Small areas of light pink rash R (right) upper arm et (and) R upper chest. Dr (doctor) sent update..." A physician's telephone order, dated 07-25-13, documented an order for [REDACTED]. A care plan, dated 07-25-13, documented, "...I have a rash to my upper chest (and) [MEDICATION NAME] 0.1% cream BID (twice a day) x (times) 10 d (days)..." A facility weekly skin integrity sheet, dated 07-26-13, documented, "...New...change of condition noted..." A treatment administration record (TAR), dated July 2013 and August 2013, documented [MEDICATION NAME] cream had been applied to resident #1's rash twice a day from 07-26-13 through 08-04-13. A facility 24 hour report/change of condition report was reviewed for resident #1 from 07-29-13 through 08-23-13. The report documented resident #1 continued to have a rash and/or itching on 07-29-13, 07-31-13, 08-01-13, 08-11-13, 08-12-13, 08-13-13, and 08-14-13. A quarterly assessment, dated 08-13-13, documented the resident was severely cognitively impaired, had short and long term memory loss, required total assistance with activities of daily living, and was always incontinent of bowel and bladder. A facility weekly skin integrity check, dated 08-27-13, documented, "...Skin clear, no change of condition assessed..." There were no other weekly skin integrity checks documented for the month of August 2013. On 08-28-13 at 10:15 a.m., resident #1 was observed lying in bed awake. Resident #1 had several red bumps, sores and scabbed areas on her forearms, face, and neck. Resident #1 was observed scratching herself. Resident #1 was unable to answer questions. On 08-28-13 at 11:35 a.m., licensed practical nurse (LPN) #1 was asked if any residents were being treated for [REDACTED]. LPN #1 was asked if resident #1 was being treated for [REDACTED]. He stated he thought the resident now just had dry skin and the physician had said to treat the dry skin with lotion. LPN #1 was asked if there was a physician's orders [REDACTED]. He stated no. On 08-28-13 at 11:38 a.m., the DON was asked when staff applied lotion to the resident's skin. She stated the aides applied lotion after giving a resident a bath. On 08-28-13 at 11:40 a.m., resident #1 was observed sitting at the dining room table in her wheelchair. She was rubbing her forearms with her hands. Her fingernails were long, uneven, and had a dark substance underneath them. Resident #1's forearms had several scabbed and bruised areas. The skin on both forearms was dry. On 08-28-13 at 2:40 p.m., certified nursing assistant (CNA) #3 was asked if resident #1 had a rash and if she had been scratching herself. She stated yes. CNA #3 was asked if she had reported it to anyone. She stated yes, she had reported it to LPN #1 a couple of days ago. CNA #3 was asked if she had ever applied lotion to resident #3's skin. She stated yes, one time when she saw her scratching. CNA #3 was not taking care of resident #1 that day. On 08-28-13 at 2:50 p.m., resident #1 was observed lying in bed with her eyes closed. Her abdomen was partially exposed. Resident #1's abdomen was observed to have several red bumps on it. A facility change in condition report, titled "SBAR" and dated 08-28-13 at 4:00 p.m., documented, "...Report to nurse that resident has rash to upper torso. Assessed resident, Noted rash to upper torso. Skin WDI (warm dry intact) c (with) raised red areas to arms chest (and) abdomen. Notified Dr (doctor) (and) family..." A physician's telephone order, dated 08-28-13, documented to apply Trimcinolone cream to affected areas twice a day for seven days for a rash. On 08-28-13 at 4:25 p.m., CNA #4 was asked if resident #1 had a rash. She stated yes and she had just assisted the resident to get up. CNA #4 was asked if she had reported resident #3's rash to anyone. She stated no, another aide had told her the nurses already knew about it. CNA #4 was asked when she would put lotion on a resident. She stated if their skin looked dry. CNA #4 was asked if she had applied lotion to resident #3's skin when she got her up. She stated no. On 08-28-13 at 4:30 p.m., CNA #1 was asked if resident #1 had a rash. She stated yes, the resident had a rash with itching since she had been there. CNA #1 was asked how long she had worked at the facility. She stated three weeks. CNA #1 was asked if she had reported resident #1's rash to anyone. She stated she had been told the rash had already been reported to nursing. CNA #1 was asked if she had applied lotion to resident #1's skin. She stated no, the resident did not have any lotion. On 08-28-13 at 5:20 p.m., the DON was asked if she had observed resident #1's skin. She stated no. The DON was asked if she was aware resident #1 had a skin rash. She stated no. On 08-29-13 at 10:00 a.m., resident #1 was observed lying in bed on her left side scratching her back. Resident #1's fingernails were long and uneven. There was a dark colored substance underneath several of her fingernails. Resident #1's pillow case had several areas of a red colored substance on it. This surveyor asked LPN #1 to come into the room and assess resident #1. LPN #1 looked at resident #1's skin and found an old scabbed area on her right forearm was bleeding. LPN #1 was asked why resident #1 had several scabbed areas on her arms. He stated from scratching. LPN #1 was asked how often resident nail care was done. He stated weekly by the CNAs unless the resident was a diabetic then a nurse would provide nail care. LPN #1 was asked if resident #1 was a diabetic, he stated no. LPN #1 was asked if resident #1 had received nail care. He stated not that week. LPN #1 was asked if resident #1 had been assessed for her rash and itching. He stated no, not until the previous day. On 08-29-13 at 10:18 a.m., the DON was asked if she thought resident #1 had been assessed, monitored, and treated appropriately in regards to her rash/itching. She stated she did not think resident #1 had been adequately assessed. The DON was asked if she thought the inadequate assessment and lack of treatment had caused harm to resident #1. She stated she thought it had caused the resident to be uncomfortable. The DON was asked about the scabbed/bleeding areas on the resident's arms. She stated the areas were a result of the resident itching and scratching and would therefore be harm to the resident. She further stated it had not been intentional harm.

Based on observation, interview, and record review, it was determined the facility failed to promote healing of a pressure wound for 1 (#9) of 3 sampled residents with a wound. The facility failed to: a. thoroughly assess and monitor resident #9's pressure wounds, including measuring the pressure wounds. b. ensure physician treatment orders included treatment for [REDACTED]. c. update resident #9's care plan to include the pressure wounds on the buttocks. d. ensure activity of daily living (ADL) sheets were completed by certified nursing assistants to document resident #9 was turned every two hours according to the resident's physician orders. The ADON identified 17 residents resided in the facility with an order to turn and reposition every two hours. The assistant director of nursing identified 3 residents with a wound who resided in the facility. Findings: Resident #9 was admitted on [DATE] and had [DIAGNOSES REDACTED]. An admission/start up order, dated 08-20-12, documented, "...Barrier cream BID (twice a day) to coccyx for redness..." An admission/start-up order, dated 08-20-12, documented, "...Turn q (every) 2 (hours)..." A facility admission-data collection form, dated 08-20-12, documented the resident was a moderate risk for pressure ulcers. An initial assessment, dated 08-27-12, documented the resident was severely impaired cognitively, had short and long term memory loss, required total assistance with activities of daily living, was incontinent of bowel and bladder, and had no skin problems. A nurse's note, dated 08-27-12, documented, "...small open area on coccyx from sling - applied Baza cream to area will monitor..." An ADL sheet, dated September 2012, documented, "...TURN EVERY 2 HOURS..." The ADL sheet did not contain any documentation the resident had been turned every two hours. A nurse's note, dated 09-12-12, documented, "...reddened area to coccyx - applied thera cream..." A weekly skin assessment, dated 09-27-12, documented a 3x2 (undocumented method of measure) stage II pressure ulcer on resident #9's left buttock, a 2x2 stage II pressure ulcer and a 2x1 stage II pressure ulcer on the resident's right buttock. An ADL sheet, dated October 2012, documented, "...TURN EVERY 2 HOURS..." For the 6-2 shift there were twenty-two blanks out of thirty-one opportunities. For the 2-10 shift there were twenty-five blanks out of thirty-one opportunities. All blanks were filled in on the 10-6 shift. A care plan, dated 10-03-12, documented, "...I am at risk for skin breakdown and pressure ulcers r/t (related to) Decreased Mobility, incontinence and involuntary movements of sliding down...My skin will remain in tact (sic) through next review...Assess and record changes in skin status. Report pertinent changes to physician...Provide/monitor effectiveness of pressure relieving or reduction device(s): ...Weekly skin monitoring by nurse..." An undated hand written note on the care plan documented, "...Pressure ulcer to coccyx..." Another hand written note on the care plan, dated 10-5-12, documented, "...Low air loss mattress..." There was no care plan to reflect resident #9's skin integrity prior to the care plan, dated 10-03-12. A weekly skin assessment, dated 10-04-12, documented a 2x2 (undocumented method of measure) stage II pressure ulcer on resident #9's left buttock, a 2x1.5 stage II pressure ulcer and a 2x1 stage II pressure ulcer on the resident's right buttock. A physician's telephone order, dated 10-10-12, documented, "...Low air loss mattress...decub coccyx..." A weekly skin assessment, dated 10-10-12, documented a 2x1 (undocumented method of measure) stage II pressure ulcer on resident #9's left buttock, a 1x1 stage II pressure ulcer on the resident's right buttock. A weekly skin assessment, dated 10-19-12, documented a 3x2 (undocumented method of measure) stage II pressure ulcer on resident #9's left buttock, a 2x2 stage II pressure ulcer on the resident's right buttock. There was no care plan update to reflect the wounds on resident #9's buttocks. Resident #9's clinical record did not document any treatment for [REDACTED]. Resident #9's nurses' notes documented the nursing staff had been applying Baza cream to the resident's coccyx area until 9-12-12. After that date thera cream had been applied to the resident's coccyx. A physician's telephone order, dated 10-27-12, documented to give a multivitamin per gastrostomy tube ([DEVICE]) once a day, Zinc 220 milligrams (mg) per [DEVICE] once a day, vitamin AC 500 mg per [DEVICE] twice a day, and Arginade one packet in 8 ounces of water per [DEVICE] twice a day. Resident #9's clinical record did not contain any further documentation related to wound measurement/status or documentation after 10-19-12. Resident #9 was discharged from the facility to the hospital on 11-02-12 and did not return to the facility. A hospital skin assessment record, dated 11-02-12, documented, "...reddened OPEN AREAS ON COCCYX..." On 01-16-13 at 2:35 p.m., the ADON was asked about the blanks in documentation. The ADON stated, "If they didn't document it wasn't done." On 01-16-13 at 4:20 p.m., the DON was asked who was responsible for identifying and assessing wounds. The DON stated the nurses do weekly skin assessments. She stated if there was an open area, weekly wound measurements would be started. On 01-17-13 at 8:50 a.m., licensed practical nurse (LPN) #2 was asked if resident #9's skin status had been care planned prior to the care plan dated 10-03-12. She stated no. On 01-17-13 at 8:50 a.m., licensed practical nurse (LPN) #2 was asked about the missing documentation related to wound measurements/status after 10-19-12. She stated she had been the acting wound nurse up until that time and management changed her status to floor nurse. LPN #2 was asked who was responsible for measuring and documenting wound status weekly. She stated the previous director of nursing (DON) was responsible for wound measurements at that time. She further stated she did not know who was responsible for wound measurements now that the DON was gone. On 01-17-13 at 8:56 a.m., LPN #2 was asked if the physician had been notified about resident #9's wounds. She stated the physician was made aware of any resident skin/wound issues when he was in the facility doing rounds. LPN #2 was asked if there was any documentation the physician had been made aware of resident #9's wounds. She stated no.

On 09-01-10 at 11:50 a.m., an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to provide adequate supervision for 1 (#9) of 1 sampled resident who used a merry walker for ambulation. The facility failed to assess the resident to see if the merry walker was the appropriate and safest assistive device for the resident. This had the likelihood to affect the 8 residents the facility identified as using assistive devices for ambulation. On 09-01-10 at 1:05 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ. On 09-01-10 at 1:18 p.m., the administrator and director of nursing (DON) were notified of the IJ and the facility was in an extended survey. On 09-01-10 at 5:05 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal documented: "Plan of Correction 1. For this resident, the Merry Walker has been discontinued per her physician's orders [REDACTED]. There are currently no other residents in the facility with an order for [REDACTED]. 2. The Physical Therapist (PT) evaluated at 1340 (1:40 p.m.) on 9/1/2010. His recommendation was for the resident to continue to use the Merry Walker as the safest and least restrictive device. PT will provide balance, transfer, and gait training beginning 9/1/10. They will provide periodic updates on residents strengths and mobility needs(.) 3. Dr. (name deleted) contacted and new orders obtained for wheelchair with seatbelt, PT treatment per physical therapy plan of care, and Restorative to ambulate resident to meals effective 9/1/10 at 1430 (2:30 p.m.). 4. Resident's daughter contacted x2 and message left on answering machine to call facility as soon as possible to obtain consent for seatbelt(.) 5. Pre-restraint assessment completed by DON for this resident per facility policy(.) 6. Facility will follow restraint protocol while resident is in wheelchair with seatbelt. Systemic Changes: 1. All staff will be inserviced by the Director of Nursing, ADON (assistant director of nursing), or designee regarding assessment, monitoring, observation and documentation related to use of assistive devices, restraints and Merry Walkers as a safety hazard. This will be completed during shift change over the next 3 shifts, starting with the evening shift on 9/1/2010. All staff will receive this inservice training prior to being allowed to work as a nursing staff member providing direct care. All training will be documented on the Inservice Attendance (sic) Form and will be completed before 11:59 pm on 9/1/2010. 2. Residents will have a completed Fall Risk Assessment on Admission and at least quarterly. Residents will be referred to PT for evaluation and treatment as indicated when a high fall risk is identified. 3. The use of special mobility devices, i.e. Merry Walkers, Canes, Wheelchairs, wheeled walkers, etc., will be determined by assessment utilizing the MDS (minimum data set) and Raps (resident assessment protocol summary) in conjunction with the interdisciplinary team to determine the least restrictive and safest device necessary to allow the resident to move about the facility as independently as possible. 4. The residents care plan will be updated at least quarterly to reflect the appropriate mobility device being used for that individual. Monitoring: 1. The Director of Nursing or designee will complete Fall Risk Assessments per facility protocol. 2. All residents falls will be reviewed by the Director of Nursing or designee to determine if any equipment was involved and the safety of the device for that resident by reviewing the Fall Event documentation. 3. This resident will be monitored visually per facility guidelines for use of wheelchair with a seatbelt. She will be released every 2 hours for 30 minutes for toileting and personal care. She will be visualized by staff every 30 minutes while in the wheelchair with a seatbelt, with documentation of visual check noted on the residents treatment sheet by the charge nurses. 4. Review at QA (quality assurance) quarterly and PRN (as necessary)." On 09-02-10 beginning at 11:07 a.m., nursing staff were interviewed regarding inservice training on safety devices. The nursing staff members interviewed had been inserviced as the plan of removal had documented. The IJ was removed on 09-02-10 at 3:05 p.m., effective to 09-02-10 at 8:00 a.m. when the last staff member had been inserviced. The deficient practice remained at the level of actual harm that was not immediate jeopardy of one or very limited number of residents affected. Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision for 1 (#9) of 1 sampled resident who used a merry walker for ambulation. The facility failed to assess the resident to see if the merry walker was the appropriate and the safest assistive device for the resident. This had the likelihood to affect the 8 residents the facility identified as using assistive devices for ambulation. Findings: The facility's policy and procedure related to physical restraints documented, "Physical restraints will be used when the restraint: a) enables and promotes greater functional independence for the resident, b) enables and promotes treatment of [REDACTED]. . . Physical restraints are ordered by a physician only after non-restraint alternatives have been attempted and have been unsuccessful. Physical restraints must be necessary to treat a specific condition or medical symptom. . . . Procedure 1. Non-emergency situation: Assess the resident's status and response to therapeutic, behavioral interventions using the Restraint Alternative Assessment(.) Notify the physician of specific behaviors exhibited by the resident and therapeutic interventions that have been attempted(.) Discuss the range of less-restrictive alternatives with the physician and the Interdisciplinary Team(.) If a physical restraint is ordered, the order must identify the least-restrictive specific restraint to be used, the reason for the restraint and the duration of use(.) The resident's interdisciplinary care plan should address approaches that will enable progressive removal of restraints or use of less restrictive restraints(.) . . . 3. Monitor the resident at thirty minute intervals." The facility's policy and procedure related to Merry Walker Ambulation Device, documented, "The Merry Walker Ambulation Device must always be used under the observation of professionally trained medical staff and when the resident wishes to exit the device, assistance must be given to release the resident from the device, if necessary. The Merry Walker is restraint free when the user is able to open and close the front gate independently. It must be considered an enabler or justified restraint if the end user is unable to open and close the front gate and must be charted as such. It may require a physician's orders [REDACTED]." 1. Resident #9 had a [DIAGNOSES REDACTED]. A care plan, dated 07-22-09, documented the resident had a potential for injuries related to falls. A fall risk assessment, dated 04-03-10, documented the resident was a high risk for falls. A quarterly assessment, dated 04-08-10, documented the resident was severely impaired related to decision-making skills, had short and long term memory problems, wandered daily and required limited assistance for walking and transfers, required limited to extensive assistance with activities of daily of living, and was frequently incontinent of bowel and bladder. The assessment did not have a restraint documented. A nurse's note, dated 04-20-10 at 3:30 p.m., documented the resident had been up in the merry walker with good mobility. A care plan update, dated "04/20," documented the resident had been placed in a merry walker. A nurse's note, dated 04-21-10 at 1:45 p.m., documented the resident had been up in the merry walker. A nurse's note, dated 04-22-10 at 6:00 p.m., documented the resident continued to do well in the merry walker. A nurse's note, dated 04-23-10 at 10:00 p.m., documented the resident had been up in the merry walker daily to ambulate. A nurse's note, dated 04-25-10 at 6:30 a.m., documented, "Found on Floor facing Merry Walker (with) foot resting against (the) strap. Head up(.) ROM (range of motion) done(.) No c/o (complaints of) pain(.) No facial expression of pain." A fax to the doctor, dated 04-25-10, documented the resident was found on the floor with "no apparent injuries." An incident/accident report, dated 04-25-10 at 6:30 a.m., documented the resident had been found on the floor facing the merry walker with her foot resting against the strap of the merry walker in a lying position. The report documented range of motion was done to the extremities and the resident had no complaints of pain. The report documented the steps to prevent recurrence were "personal alarm placed on pt., to be on at all times." A nurse's note, dated 04-25-10 at 10:00 a.m., documented, "up & around per merry walker." A physician's orders [REDACTED]." A physical restraint informed consent, dated 04-26-10, documented the use of a merry walker to increase mobility, to decrease anxiety, and to increase safety. A nurse's note, dated 05-07-10 at 2:10 p.m., documented the resident had been found in the corridor between 200 and 500 hall lying under the merry walker. The note documented, "(No) injuries noted, (no) redness noted at this time." An incident/accident report, dated 05-07-10 at 2:10 p.m., documented the resident had been found in the corridor between 200 and 500 hall. The report documented the resident "lying under merry walker. (No) injuries noted at this time. (No) redness noted at this time." The documented steps to prevent recurrence were to "observe pt. while in merry walker for whereabouts, maintain alarm." A fall risk assessment, dated 07-03-10, documented the resident was a high risk for falls. An annual assessment, dated 07-08-10, documented the resident was severely impaired related to decision-making skills, had short and long term memory problems, wandered daily, required limited assistance of one person for walking and transfers, used a wheelchair most of the time, required limited to extensive assistance with activities of daily of living, and was frequently incontinent of bowel and bladder. A care plan for wandering, dated 07-08-10, documented, "I wander in facility hallways in merry walker....I will be allowed to wander in facility hallways in merry walker to maintain safety and allow independence for next 92 days." A care plan for falls, dated 07-08-10, documented, "I have a history of falls and potential for self injury....I am currently on psychotropic medications....I will not have a life threatening injury from a fall during the next 92 days....I will be monitored for side effects from these medications and I will remain free from injury for the next 92 days." A nurse's note, dated 08-29-10 at 12:05 p.m., documented the resident had been found, in the doorway of room 206, on the floor. The note documented the merry walker was on top of the resident's lower extremities, there was blood on the floor, and the resident was rolled to her back by the registered nurse and the licensed practical nurse. The note documented the resident had a 1 1/2 cm centimeter (cm) to 2 cm laceration over her right eye, and the resident was awake and moaning. A fax to the doctor, dated 08-29-10, documented the resident fell over her merry walker, received a laceration over her right eye, was sent to the emergency room for evaluation, and returned with an order to keep the site dry for 72 hours. The fax documented that neuro checks were started. An incident/accident report, dated 08-29-10 at 12:05 p.m., documented the resident had been found on the floor in the doorway of room 206, the merry walker was on top of the resident, there was blood on the floor, and the resident was rolled over by two nurses. The report documented the resident had a 1 1/2 cm to 2 cm laceration above her right eye. The report documented the "steps taken to prevent recurrence" of falls was, "returned to facility with steri-strips." An incident report form faxed to the Oklahoma State Department of Health, dated 08-30-10 at 4:48 a.m., documented, "On August 29, 2010 at 1205 (12:05 p.m.) (name deleted, resident #9) was in the doorway of another resident's room in her merriwalker that is used for mobility. She also has an attendant alarm to alert staff if she is standing or leaning too far forward. (Name deleted, resident #9) fell in the doorway and hit her head on the floor. Her alarm was in place. She was noted to have a 4 cm laceration above her right eyebrow. EMT's (Emergency medical technicians) were notified and she was transported to (name deleted, hospital). She was returned to facility with 2 steri-strips in place and orders to keep wound dry for 72 hours. No other orders received. Upon return to facility neuro checks started. No change in mental status during HS (hour of sleep). (Name deleted, resident #9) has a [DIAGNOSES REDACTED]. Attendant alarm in place at all times." On 08-31-10 at 4:55 p.m., resident #9 was observed sitting in the hallway in a merry walker with a personal alarm in place. There was a large amount of purplish/blue discoloration around the resident's right eye and right cheek. The resident was holding onto the strap between her legs that was attached to the merry walker. The resident was moving her feet and legs and speaking unintelligible words. The resident sat down on the strap of the merry walker that was between her legs, then pushed herself back up onto the seat of the merry walker while the merry walker was backed up against the wall. The resident then stood up in the merry walker and attempted to walk through the service hall between 300 and 400 halls. There were several rolling carts observed along the hallway and the resident became stuck in her merry walker between the wall and the rolling carts. The resident began to push against the carts with her merry walker and a staff member came out of an office and straightened her merry walker so she could continue down the service hall. When the resident reached the end of the hall she became stuck again. She began to push forward in her merry walker leaning forward and her personal alarm began to sound. After one minute a maintenance man arrived and saw the resident at about the same time another staff member arrived to assist the resident to get unstuck. The resident continued down the hallway in her merry walker. On 09-01-10 at 8:25 a.m., the resident was observed in her merry walker on 400 hall. She was wandering aimlessly down the hall and no staff was present. The resident wandered into room 404 where the residents were not present at that time. The resident moved between the beds in her merry walker and as she leaned over, her personal alarm began to sound. Staff was observed to respond after one minute and removed the resident from the room. On 09-01-10 at 9:05 a.m., the resident was observed in her merry walker wandering on 500 hall. She wandered up to and around the nursing station. She was observed bumping her merry walker into the legs of another resident who was sitting by the nurses' station. The resident was unaware that she had bumped into the legs of another resident and continued down hallway 300. A staff member redirected her back toward the nursing station area. The resident then sat down in her merry walker beside the nursing station. On 09-01-10 at 9:50 a.m., the DON was asked if there was a schedule to check and change the batteries in the personal alarms. She stated as often as resident #9's alarm goes off they would know if the battery needed changed. The DON stated there was not a policy and there was no documentation but they change them every 30-60 days. On 09-01-10 at 10:00 a.m., the ADON was asked where the care plan had been updated regarding the resident's falls. She stated, "Nowhere, it was not done." On 09-01-10 at 10:10 a.m., the DON was asked for documentation regarding the resident's safety device use and how she (the DON) determined that the merry walker was the least restrictive and safest device of choice. The DON showed the surveyor a signed, one page physical restraint informed consent for a merry walker dated 04-26-10. The DON stated after the resident fell and after talking with the resident's daughter, they decided to try the merry walker. The DON was asked if this was the safest device of choice for the resident. The DON stated she was not saying anything was safe but the merry walker was the safest device of choice. The DON stated the resident had thrived after being put in the merry walker. The DON stated the resident had previously stopped talking and now she was talking in her own way. The DON was asked if she still considered the merry walker the safest device of choice for the resident since the resident had experienced three falls which involved the merry walker. The DON stated, "Yes, the resident would be a vegetable if she were in a wheelchair. She cannot comprehend how to use her feet to move in the wheelchair and she would try to stand and walk. This is not safe." On 09-01-10 at 10:30 a.m., the ADON was asked about an annual assessment, dated 07-18-10, that did not document falls for this resident. She stated well, ok. On 09-01-10 at 10:55 a.m., the resident was observed sitting in her merry walker in the lobby in front of the nurse's station. She was sitting quietly with her eyes closed. On 09-01-10 at 11:00 a.m., the DON was asked for any assessment documentation which would indicate the merry walker was appropriate for the resident. The DON stated she did not have documentation, "I guess I could create something." The DON was asked how the resident's wandering was monitored. The DON stated by the resident's personal alarm. On 09-01-10 at 11:25 a.m., the resident was sitting in her merry walker in the front lobby with her back against the front windows. She was awake and sitting quietly. On 09-01-10 at 11:50 a.m., the resident was sitting in her merry walker beside the nursing station, speaking unintelligible words. On 09-01-10 at 12:25 p.m., the activity director was asked about the resident's decreased use of her right arm and if that was new. She stated she just used the left arm more than the right arm. The activity director stated the resident could use her right arm and could even pick up her merry walker. On 09-01-10 at 12:50 p.m., the DON was asked about a care plan intervention "monitor residents whereabouts when up in merry walker," and how do you monitor her whereabouts. She stated the resident was everywhere, all the staff watch her, sometimes she would follow the staff. On 09-01-10 at 12:50 p.m., the administrator added a comment about monitoring the resident's whereabouts. She stated when she was in her office, she could see out and keep an eye on the resident. On 09-01-10 at 12:50 p.m., RN #1 added a comment about monitoring the resident's whereabouts. She stated the staff could watch the resident from the nursing station and could see her down the halls. The RN stated all the staff and even some residents watched the resident. The RN stated if the resident went into a resident's room they would let them know. The RN stated a lot of the time the resident would go into the dining room and back up against the Coke machine and just sit there. On 09-01-10 at 1:35 p.m., the resident was observed sitting in her merry walker in the doorway of room 301. No staff was present. On 09-01-10 at 1:44 p.m., RN #1 stated the physical therapist (PT) was at the facility and had taken the resident to the therapy room to evaluate her for the least restrictive and safest mobility device. On 09-01-10 at 1:55 p.m., the physical therapist reported his evaluation to the surveyors. He recommended standing/dynamic balance exercises to help her gain more balance. He stated the resident was pretty steady. On 09-01-10 at 2:00 p.m., the resident was observed sitting in her merry walker on the Main Street hallway in view from the nursing station. The resident was sitting with her eyes closed and her personal alarm on. There were several staff members in and around the nursing station. On 09-01-10 at 2:14 p.m., the resident continued to sit in her merry walker on the Main Street hallway. The resident was quiet with her eyes open. On 09-01-10 at 2:30 p.m., the resident continued to sit in her merry walker on Main Street hallway. She was observed by LPN #1 to have her beaded necklace in her mouth. The LPN asked the resident if she was hungry or thirsty. The LPN got the resident a snack and drink and assisted the resident to eat and drink it. The nurse placed the beaded necklace underneath the resident's top. A physician's orders [REDACTED]. W/C (wheel chair) with seatbelt when up - obtain consent from family with in 24 hours-emergency order. RA (restorative aide) to ambulate to meals." On 09-01-10 at 2:40 p.m., the resident was taken to her room in her merry walker by the DON and the ADON. The ADON stated to the resident, "let's go to your room for a minute and take a walk." On 09-01-10 at 2:46 p.m., the resident came out of her room in a wheelchair, accompanied by the DON and ADON. The resident began rolling backward and forward in the hallway using her legs. The resident had a personal alarm on and a self release seat belt. The DON walked away, the resident was in the hallway outside the administrator's office and was in view of the administrator and other staff. On 09-01-10 at 3:00 p.m., a nurse's note documented, "PT eval and treat for mobility and least restrictive mobility devices and safety. Wheelchair with seat belt when up. Obtain consent from family with emergency order. RA to ambulate to meals. Pt. (patient) in wheelchair at this time with seat belt." On 09-02-10 at 8:35 a.m., the resident was observed sitting in a wheelchair with a self release belt on, a personal alarm, and a helmet. The resident was sitting outside the nursing station. On 09-02-10 at 11:05 a.m., the resident was observed sitting in a wheelchair at the nursing station, asleep. She was sitting on a non skid pad, had a self release seat belt, and a personal alarm. She did not have on a helmet.