Every finding on record at Hennessey Nursing & Rehab

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The administrator identified 27 residents resided in the facility. Findings: A Staffing policy, updated 10/2023, read in part, RN must be on duty 8 hours a day 7 days a week. A PBJ Staffing Data Report, dated 10/01/25 through 12/31/25, showed no RN hours on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. An Employee Timecard Report dated 10/01/25 through 12/31/25, did not show the facility had RN hours for 8 consecutive hours on the following dates, 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. On 03/26/26 at 12:45 p.m., the MDS coordinator stated yes those are the only three RN's for the facility. They stated the facility did not have RN coverage on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, or 12/18/25.On 03/26/26 at 1:04 p.m., the Administrator stated they were not aware the facility did not have coverage on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25.They stated if they knew there was not RN coverage on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25, they would have called the Infection Control Preventionist in to cover those shifts.

Based on observation, record review, and interview, the facility failed to post the most recent state survey results in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 27 residents resided in the facility.Findings: On 03/25/26 at 11:27 a.m., the surveyor walked the halls and the lobby of the facility, there was no posting showing were to find the survey results binder. A Survey Results, Examination of policy, revised 04/2007, read in part, A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plan of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. On 03/25/26 at 11:01 a.m., 10 resident council members present for the meeting stated they did not know where to find the state survey results. On 03/25/26 at 11:30 a.m., the Administrator stated there was a little card on the table where the results were located. The survey results binder was located in a wooden cabinet behind closed doors in the lobby near the front door. On 03/25/26 at 11:33 a.m., the Administrator stated, Well I guess you're going to catch me with my pants down because I don't see the card. They stated no at this time there was no posting telling the visitors or residents where to find the survey results.On 03/25/26 at 11:42 a.m., the Administrator stated, The sign showing where to find the survey results was not assessable to the residents and visitors.

Based on record review and interview, the facility failed to ensure the food service supervisor completed certification as a certified dietary manager within three years of beginning employment per State requirement.The administrator identified 27 residents who received meals from the kitchen. Findings:The Food and Nutrition Services Staff policy, revised 10/20, read in part, Nutrition service manager if not already certified will be enrolled in an accredited/approved program within regulatory timeframe.An undated Employee Information Report, showed the dietary supervisor was hired on 02/04/20.There was no documentation the dietary supervisor had completed a certified program.On 03/23/26 at 1:47 p.m., the dietary supervisor stated they have not completed a certification course. On 03/26/26 at 9:35 a.m., the administrator stated they were aware the dietary supervisor was not certified. They stated the dietary supervisor was hired for their role on 02/04/20.

Based on record review and interview, the facility failed to notify a physician of a resident's change in condition for 1 (#24) of 1 sampled resident reviewed for self-administration of medication.The DON identified nine residents who received breathing treatments in the facility.Findings:The Acute Condition Changes-Clinical Protocol policy, revised 03/18, read in part, The nursing staff will contact the physician based on urgency of the situation.Resident #24's quarterly resident assessment, dated 01/27/26, showed the resident had diagnoses which included chronic obstructive pulmonary disease and cough. It showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 02/03/26, showed ipratropium-albuterol (a bronchodilator breathing treatment) inhalation solution 0.5-2.5, 3 mg/3ml. Inhale one vial three times a day for wheezing.The March 2026 Orders Administration notes showed Resident #24 refused ipratropium-albuterol treatment on the;a. 4th at 8:46 p.m. due to, It makes me shake too bad,b. 5th at 9:04 p.m.,c. 9th at 8:48 p.m. due to, It makes me shake too bad,d. 10th at 9:00 p.m.,e. 11th at 9:57 p.m. due to, It makes me shake,f. 12th at 9:35 p.m. due to shakes,g. 15th at 7:37 a.m. due to shaking after using it and at 1:07 p.m. due to feeling shaky and weak,h. 19th at 8:14 p.m. due to shakes,i. 20th at 4:57 p.m and 7:35 p.m., andj. 21st at 1:14 p.m. because they did not like the way it made them feel.There was no documentation the physician was notified of the resident's refusals and shaking with the breathing treatments.On 03/24/26 at 8:43 a.m., Resident #24 stated the physician ordered their breathing treatment three times a day. They stated they got the Shakes, from administering the breathing treatment three times a day. Resident #24 stated they would self-administer the breathing treatment two times a day.On 03/24/26 at 9:24 a.m., LPN #1 stated they were aware of Resident #24 getting shaky with administration of the breathing treatment. LPN #1 stated they personally did not notify the physician. They stated they could not locate documentation the physician was notified.On 03/25/26 at 11:01 a.m., Physician #1 stated the facility should notify them if Resident #24 complained of being shaky with breathing treatments and refused them so they could change the resident's order.On 03/25/26 at 11:02 a.m., Physician #1 stated they were not aware of any notification from the facility regarding the resident being shaky or refusing treatment.On 03/25/26 at 11:55 a.m., the DON stated the facility should notify the physician if a resident complained of being shaky with breathing treatments and refused them.On 03/25/26 at 12:01 p.m., the DON stated they could not locate documentation the provider was notified of the resident's complaint of being shaky and refusal of breathing treatments.

Based on record review and interview, the facility failed to ensure the care plan was revised to show a new skin alteration for 1 (#28) of 3 residents reviewed for care plans.The administrator reported 27 residents resided in the facility.Findings:A Care Plans, Comprehensive Person-Centered policy, revised 12/2016, read in part, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions of change. Resident #28's care plan, initiated on 03/06/25, showed resident had diagnoses which included cerebral palsy and major depressive disorder. An Incident Note, dated 12/04/25 at 12:01 p.m., read in part, During a transfer utilizing the mechanical lift [name withheld], the res stated, The chair pinched me.A review of Resident #28's care plan did not show documentation of a laceration. Upon transfer back to bed 3 superficial lacerations were noted to the gluteal area regions. An Incident Note, dated 12/04/25 at 4:00 p.m., read in part, New order received; Cleanse lacerations with wound cleaner and pat dry daily and as needed until resolved. Resident #28's care plan did not show documentation of the lacerations. On 03/26/26 at 10:16 a.m., the MDS coordinator stated care plans were to be updated with falls or other changes the same day or the next day. On 03/26/26 at 10:19 a.m., the MDS coordinator stated yes, the care plan should have been updated with the lacerations and no I don't have the lacerations on the care plan.

Based on observation, record review, and interview, the facility failed to ensure a resident's breathing treatment was accurately documented for 1 (#24) of 1 sampled resident reviewed for self-administration of medication.The DON identified nine residents who received breathing treatments in the facility.Findings:On 03/24/26 at 8:42 a.m., there were two vials of ipratropium bromide/ albuterol sulfate 0.5-3 mg in 3 ml sitting on the Resident #24's bedside table.The Charting and Documentation policy, revised 07/17, read in part, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.Resident #24's quarterly resident assessment, dated 01/27/26, showed the resident had diagnoses which included chronic obstructive pulmonary disease and cough. It showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 02/03/26, showed ipratropium-albuterol (a bronchodilator breathing treatment) inhalation solution 0.5-2.5, 3 mg/3ml. Inhale one vial three times a day for wheezing.The March 2026 treatment administration record, showed the ipratropium-albuterol was initialed as given for the 8:00 a.m. dose on the 24th.On 03/24/26 at 8:43 a.m., Resident #24 stated the nurse gave them the breathing treatment vials that morning. They stated the last time they self-administered the breathing treatment was on 03/23/26 around 4:00 p.m.On 03/24/26 at 9:16 a.m., LPN #1 stated Resident #24 self-administered their breathing treatments.On 03/24/26 at 9:20 a.m., LPN #1 stated they documented in Resident #24's treatment administration record as given for the 8:00 a.m. dose on 03/24/26. They stated they assumed the resident self-administered the breathing treatment. They stated Resident #24 usually inform them when they self-administer the breathing treatment but they did not inform the nurse this morning.On 03/24/26 at 9:21 a.m., LPN #1 stated the documentation was not accurate on the treatment administration record.On 03/24/26 at 9:29 a.m., LPN #1 stated they did not observe Resident #24 administering their breathing treatment.On 03/25/26 at 11:52 a.m., the DON stated the breathing treatment should be documented as refused unless witnessed as given.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order and an assessment to self-administer medications for 1 (#24) of 1 sampled resident reviewed for self-administration of medication.The DON identified nine residents who received breathing treatments in the facility.Findings:On 03/24/26 at 8:42 a.m., there were two vials of ipratropium bromide/albuterol sulfate 0.5-3 mg in 3 ml sitting on the Resident #24's bedside table.Resident #24's quarterly resident assessment, dated 01/27/26, showed the resident had diagnoses which included chronic obstructive pulmonary disease and cough. It showed the resident's cognition was intact with a BIMS of 15.A physician's order, dated 02/03/26, showed ipratropium-albuterol (a bronchodilator breathing treatment) inhalation solution 0.5-2.5, 3 mg/3ml. Inhale one vial three times a day for wheezing.There was no documentation the Resident #24 had an assessment and a physician's order for self-medication administration.On 03/24/26 at 8:43 a.m., Resident #24 stated the nurse gave them the breathing treatment vials this morning. They stated the last time they self-administered the breathing treatment was on 03/23/26 around 4:00 p.m.On 03/24/26 at 9:16 a.m., LPN #1 stated Resident #24 administered their own breathing treatment. They stated the resident does not have an order to leave the breathing treatment medication at bedside.On 03/24/26 at 9:17 a.m., LPN #1 stated the process for medication left at bedside was to obtain a physician's order.On 03/24/26 at 9:18 a.m., LPN #1 stated Resident #24 does not have an assessment for self-administration of medications.On 03/24/26 at 9:29 a.m., LPN #1 stated the breathing medications should not be left at bedside.On 03/24/26 at 2:56 p.m., the DON stated Resident #24 does not have an assessment and a physician's order for self-medication administration.On 03/24/26 at 3:13 p.m., the DON stated the facility does not allow residents to self-administer medications.

Based on observation, record review, and interview, the facility failed to complete bed rail safety assessments, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to installation of bed rails for three (#13, #15, and #82) of three sampled residents with bed rails in use. The DON identified 33 residents resided in the facility. Findings: A Bed Safety and Bed Rails' policy, revised August 2022, read in parts, .3. The use of bed rails or side rails .is prohibited unless the criteria for use of bed rails have been met, including .interdisciplinary evaluation, resident assessment, and informed consent . 1. On 08/04/24 at 12:25 p.m., Resident #13 was observed in bed with two upper bed rails raised. 2. On 08/04/24 at 2:05 p.m., Resident #15 was observed in bed with two upper bed rails raised. 3. On 08/05/24 at 12:58 p.m., Resident #82 was observed in bed with two upper bed rails raised. There was no documentation in the clinical records of Resident #13, #15, nor #82 that bed rail safety assessments had been completed, risks and benefits of bed rails had been reviewed with the resident or resident representative, nor that informed consent had been obtained. On 08/06/24 at 10:10 a.m., the DON acknowledged the necessary paperwork that needed to be completed before bed rails were used had not been completed according to facility policy for the Residents listed above.

Based on record review and interview, the facility failed to ensure influenza and pneumococcal vaccinations were offered for four (#15, 18, 22, and #82) of five residents reviewed for immunizations. The DON identified 33 residents resided in the facility. Findings: Immunization records for Residents #15, #18, #22, and #82 were reviewed. There was no documentation in their record the residents, nor their representatives had been offered or received an influenza or pneumonia immunization. On 08/07/24 at 9:41 a.m., the DON was asked if residents were offered influenza and pneumonia vaccines. They stated immunizations should be offered during admission process and annually. The DON acknowledged neither Resident #15, #18, #22, nor #82 or their representative had documentation in their clinical record showing they were offered nor received the influenza or pneumococcal vaccines.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered by the physician and oxygen tubing was changed for one (#27) of one sampled resident reviewed for respiratory care. The DON identified two residents who received continuous oxygen therapy in the facility. Findings: The Oxygen Administration policy, revised 10/10, read in part, Review the physician's orders or facility protocol for oxygen administration. Resident #27 had diagnoses which included COPD and acute and chronic respiratory failure with hypoxia. A physician's order, dated 02/05/24, documented oxygen at 3 liters per nasal cannula to keep oxygen saturation at 90% or above. On 08/04/24 at 1:29 p.m., Resident #27 was observed receiving oxygen. The concentrator was set at 3.5 LPM. The oxygen tubing was dated 07/22. On 08/04/24 at 1:42 p.m., RN #1 stated Resident #27's oxygen order was 3 liters via nasal cannula. On 08/04/24 at 1:43 p.m., RN #1 stated oxygen tubing were to be changed weekly on Sundays. On 08/04/24 at 1:46 p.m., RN #1 observed the Resident's concentrator. They stated the oxygen delivery was set at 3.5 LPM. RN #1 stated the physician's order was not followed. On 08/04/24 at 1:47 p.m., RN #1 stated the date on the Resident's oxygen tubing was 07/22. They stated the oxygen tubing should have been changed per facility policy.

Based on record review and interview, the facility failed to have a process in place to identify a resident's code status for one (#131) of three sampled residents reviewed for advanced directives. Findings: Resident #131 was admitted on [DATE]. A physician's order, dated 07/23/24, documented DNR. A care plan, dated 07/27/24, documented Resident #131 preferred to be a DNR. There was no documentation of a completed Oklahoma DNR consent form in Resident #131's record. On 08/05/24 at 10:47 a.m., the DON stated Resident #131 did not have a DNR consent form in their health record. They stated residents should have a physician's order and a DNR form in their chart upon admission or remain a full code until a DNR consent form was obtained. On 08/05/24 at 11:36 a.m., LPN #1 stated residents code status were found in their health record and resident roster at the nurse's station.

Based on observation, record review, and interview, the facility failed to implement a comprehensive care plan for one (#132) of one sampled resident reviewed for the use of a urinary catheter. The DON identified 33 residents resided in the facility. Three residents had urinary catheters in the facility. Findings: Resident #132 was admitted on [DATE] with diagnoses which included neuromuscular dysfunction of bladder and hydronephrosis. A physician order, dated 07/05/24, documented to change foley catheter every 30 days on the 1st of the month on night shift. Resident #132's admission resident assessment, dated 07/11/24, documented the Resident had an indwelling catheter. On 08/04/24 at 10:31 a.m., Resident #132 was observed to have an indwelling urinary catheter. Review of Resident #132's baseline care plan did not document the use of an indwelling urinary catheter. There was no record of the completion of a comprehensive care plan for Resident #132. On 08/07/24 at 9:18 a.m., Nurse Consult. #1 stated Resident #132 did not have a comprehensive care plan. They stated they were working on completing one.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed in a timely manner for one (#131) of 12 sampled residents reviewed for baseline care plans. The DON identified 33 residents resided in the facility. Findings: Resident #131 was admitted on [DATE]. Resident #131's baseline care plan documented a completion date of 07/27/24. On 08/06/24 at 8:16 a.m., Nurse Consult. #1 stated Resident #131's baseline care plan was not completed in a timely manner. They stated a baseline care plan was to be completed within 48 hours of admission.

Based on record review and interview, the facility failed to provide notice of a facility initiated discharged for one (#30) of three sampled discharged residents. The DON identified 33 residents resided in the facility. Findings: Resident #30 was admitted on [DATE] with diagnoses that included anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. A nurse's note, dated 06/25/24 at 8:10 p.m., documented Resident #30 was transferred to the VA hosp ER D/T behaviors. A Discharge Summary, dated 06/26/24, documented Resident #30 had been discharged from the facility on 06/25/24. There was no documentation in the clinical record that the facility notified, or attempted to notify, Resident #30 or their family of their discharge from the facility. On 08/06/24 at 9:33 a.m., the DON acknowledged neither Resident #30 nor their family had been notified of their discharge from the facility.

Based on record review and interview, the facility failed to ensure residents were not involuntarily discharged for one (#30) of three sampled discharged residents. The DON identified 33 residents resided in the facility. Findings: Resident #30 was admitted on [DATE] with diagnoses that included anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. A physician's order, dated 06/25/24 at 7:48 p.m., read in parts, .Transfer to VA hosp ER D/T behaviors . There was no documentation in the clinical record that the facility followed-up on Resident #30's status after he was transferred to the VA hospital ER and no documentation stating the resident had been discharged . On 08/06/24 at 9:33 a.m., the DON stated Resident #30 did not return to the facility because they were a danger to self and others due to their behaviors. They stated they could not meet Resident #30's needs at the facility. On 08/06/24 at 11:50 a.m., Nurse Consult. #1, who completed the transfer MDS for Resident #30, was asked how they determined Resident #30's return was not anticipated. Nurse Consult. #1 stated, Probably by the time I put the MDS in on 06/28/24 we must have known we weren't taking him back. There was no documentation in Resident #30's clinical record indicating the facility would not be able to meet the needs of the resident upon their return from the VA hospital and there was no physician's order in the clinical record to discharge resident #30.

Based on record review and interview, the facility failed to ensure a discharge summary and discharge instructions were completed upon discharge for one (#11) of three sampled residents whose discharge paperwork was reviewed. The DON identified 33 residents resided in the facility. Findings: Resident #11 was admitted to the facility on [DATE] and discharged at the end of their skilled days on 04/12/24. A 'Discharge Summary' form for Resident #11, dated 02/28/24, was located in their clinical record, but it had not been completed. A Discharge Instructions form for Resident #11, was located in their clinical record undated and not completed. On 08/06/24 at 9:27 a.m., the DON acknowledged the discharge summary and discharge instructions for Resident #11 had not been completed.

Based on record review and interview, the facility failed to: a. implement a physician order for a gradual dose reduction for one (#26); b. have a physician response to a gradual dose reduction recommendation for one (#6) of five sampled residents reviewed for unnecessary medications. The DON identified 33 residents resided in the facility. 18 residents received psychotropic's in the facility. Findings: 1. Resident #26 had diagnoses which included insomnia and anxiety. An MRR, dated 05/28/24, documented a GDR recommendation for 150 mg trazodone (an antidepressant) reduction to 100 mg at bedtime. A physician's response, dated 06/11/24, documented agreement to the trazodone reduction. A nurse's acknowledgement, dated 06/14/24, was documented on the MRR. There was no physician's order corresponding to the nurse's acknowledgement on 06/14/24 for Resident #26. A nurse's acknowledgement, dated 06/21/24, was documented on the MRR. A physician's telephone order, dated 06/21/24, documented 100 mg trazodone one tablet by mouth at bedtime per pharmacy recommendation. The June 2024 MAR documented 150 mg trazodone was given till 06/21/24. The June 2024 MAR documented 100 mg trazodone was first given on 06/22/24. On 08/06/24 at 1:54 p.m., the DON reviewed Resident #27's June 2024 MAR, MRR, and physician orders. They stated the physician's response to the GDR was implemented on 06/21/24. They stated the Resident received the first dose of the 100 mg trazodone on 06/22/24. 2. Resident #26 had diagnoses which included schizophrenia, anxiety, insomnia, and depression. A physician's order, dated 05/30/23, documented 10 mg Abilify (an antipsychotic) give one tablet by mouth once daily at bedtime for schizophrenia. A physician's order, dated 07/13/23, documented 5 mg buspirone (an antianxiety) give one tablet by mouth twice daily for anxiety. A physician's order, dated 07/27/23, documented HCL 60 mg duloxetine (an antidepressant) give one capsule by mouth twice daily for depressive disorder. A physician's order, dated 04/02/24, documented 50 mg trazodone (an antidepressant) give two tablets by mouth every evening for insomnia. An MRR, dated 02/13/24, documented a GDR recommendation for buspirone 5mg to half tablet twice daily. An MRR dated 03/19/24, documented a GDR recommendation for Abilify from 10 mg to 7.5 mg at bedtime. An MRR, dated 04/15/24, documented a GDR recommendation for duloxetine from 60 mg twice daily to 30 mg in the morning and 60 mg at bedtime. There was no documentation of a physician's response to the above three GDRs. On 08/07/24 at 9:27 a.m., the DON reviewed the above MRRs with the GDR recommendations. They stated there was no physician response to the above GDRs.

Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were followed during the administration of medication for one (#13) of seven sampled residents observed during medication administration. The DON identified 33 residents resided in the facility. Findings: An 'Administration Set/Tubing Changes' policy, revised February 2023, read in parts, General Guidelines .4. Label tubing with date, time, and initials .5. Any tubing that is found not labeled must be changed and then labeled accordingly .6. Any tubing that is suspected to have been contaminated or compromised is changed immediately . Resident #13 was receiving intravenous antibiotic therapy via a PICC line in place to left upper arm. On 08/05/24 at 8:45 a.m., this surveyor observed LPN #1 during IV medication administration for Resident #13. Upon entering the resident's room, I observed there was no date on the tubing that was hanging in the previously used IV bag. LPN #1 used the hanging IV tubing to spike the new IV bag, primed the line and laid the end of the IV tubing on the resident's pillow. During the process of flushing the 3 PICC line lumens, the end of the IV tubing that you connect to the lumen slid to the floor. After flushing the lumens, LPN #1 picked the tubing up from the floor, removed the cap, connected it to the PICC line lumen, and started the IV. LPN #1 was asked if a new IV tubing should have been used. They stated the night nurse probably changed it. When asked if the IV tubing should have been placed on the resident's pillow or used after it had fallen to the floor, LPN #1 stated it had a cap on it. On 08/06/24 at 10:49 a.m., the DON reported facility policy dictated IV tubing should be changed every 24 hours and labeled with the date, time, and initials. The DON was informed of the above observations and acknowledged that proper infection control practices were not observed and facility policy had not been followed.

Based on record review and interview, the facility failed to complete a nurse aide performance review once every 12 months for two (CNA #1 and CNA #2) of five employee files reviewed. The DON identified 33 residents resided in the facility. Findings: The Competency of Nursing Staff policy, revised 10/17, read in part, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. CNA #2 had a hire date of 04/28/22. There was no CNA annual competency review located in the employee's file. CNA #1 had a hire date of 05/12/23. There was no CNA annual competency review located in the employee's file. On 08/06/24 at 7:59 a.m., the BOM stated there was no CNA annual competency review for CNA #1 and CNA #2.

Based on record review and interview, the facility failed to ensure a discharge MDS assessment was completed within the required timeframe for one (#11) of three sampled residents whose discharge assessments were reviewed. The DON identified 33 residents resided in the facility. Findings: Resident #11 was admitted to the facility on [DATE] and discharged at the end of their skilled days on 04/12/24. The EHR did not document a discharge MDS assessment had been completed. On 08/06/24 at 11:40 a.m., Nurse Consult. #1 acknowledged the discharge MDS assessment for Resident #11 had not been completed.

On 04/11/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a resident experiencing a significant change in condition and ensure a resident received prescribed antibiotic therapy to treat pneumonia. 03/08/24 Resident #1 had acute change of condition, very weak, unable to stand/sit, 3-4 person assist to transfer, irregular HR, O2 sats 80%, incontinent B&B, and decline in mental status. MD notified. Not sent to ER. 03/19/24 Resident #1's condition deteriorates and they requested to be sent to ER. Returned from ER same day with DX: pneumonia and orders for Augmentin 875mg-125mg tab- 1 tab oral q12hrs x7days. Their physician was not notified of new order, the medication order was not submitted to the pharmacy, and the medication was not placed on the MAR. There was no documentation that Augmentin was ever ordered, received from the pharmacy, or given to the resident between 03/19/24 and 04/08/24. 03/26/24 Nursing staff documented further decline in residents condition including cannot sit or stand without support, cannot bear weight, requires full body lift, brown urine, poor food/fluid intake, and decreased mental status. 04/08/24 Resident #1 was sent to ER with low B/P, labored breathing, erratic pulse, and altered mental status. Resident was admitted and is currently in the hospital. On 04/11/24 at 10:40 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/11/24 at 4:15 p.m., the administrator was notified of the IJ situation. On 04/15/24 at 2:38 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan of Removal On 04/11/2024, All Licensed RN/LPN staff educated on how to recognize acute changes in resident baseline condition\ orientation and\or change in vital signs with documentation of notification to the physician and family. 1. All newly hired Licensed RN/LPN staff will be educated on how to recognize change in resident baseline condition\ orientation and\or change in vital signs with documentation of notification to the physician and family. 2. All direct care nursing staff educated on how to recognize acute changes in resident baseline condition/orientation and/or change in vital signs and report to charge nurse immediately. 3. DON/Designee will review all new hire packets to ensure all training is completed. 4. DON/Designee will report any negative findings monthly to the QAPI team. Completed by 8:00 p.m. 04/11/2024. On 04/11/2024, all licensed RN/LPN In-serviced on Facility Policy and Procedure properly assessing, monitoring, and intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed. 1. All licensed new hires will be educated on Facility Policy and Procedure on properly assessing, monitoring, intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed. 2. DON/designee will review all new hire packets to ensure all training is completed. 3. DON/designee will report any negative findings quarterly to QAPI Completed by 8 p.m. 04/11/2024. 1. DON/Designee will compare physician orders on all new admissions to MAR and verify all medications are on hand. 2. Any staff that are on leave will be educated prior to being placed on the schedule. 3. DON/ADON in-serviced on reviewing all physicians' orders to include hospital discharges/doctor's appointment daily during clinical meeting to ensure orders are not missed. 4. DON/ADON will review all physicians' orders to include hospital discharges/doctor's appointment daily during clinical meeting to ensure orders are not missed. Any negative findings will be corrected immediately. Completed by 1030 a.m. 04/12/2024. 1. All Licensed nurses educated on comparing new orders/hospital discharge orders with the MAR and updating MAR to reflect any new orders. Completed by 3:00 p.m. 04/15/2024. The immediacy was lifted, effective 04/15/24 at 3:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the residents. Based on record review and interview, the facility failed to: a. assess, monitor, and intervene for a resident experiencing a significant change in condition for one (#1) of two sampled residents reviewed for change in condition, and b. ensure a resident received prescribed antibiotic therapy to treat pneumonia for one (#1) of two sampled residents reviewed for receiving medications as ordered. The Administrator identified 31 residents resided in the facility. Findings: a. Resident #1 had diagnoses that included s/p amputation of left toes and PICC line in upper right arm. A 'Skilled Daily Nurses Note', written 03/8/24 at 7:50 p.m., documented Resident #1 experienced episode of being very weak, unable to stand or sit up, unable to follow direction, irregular pulse, and low O2 saturation. MD was notified and advised staff to monitor resident. A 'Skilled Daily Nurses Note', written 03/8/24 at 9:00 p.m., documented Resident #1 required the assistance of three staff to transfer them from bed to wheelchair and the assistance of four staff to transfer them back to bed. 'Skilled Daily Nurses Notes', written 03/9/24 through 03/15/24, document Resident #1's persistent weakness, inability to stand/sit, need for assistance to transfer, incontinence of B&B, and decline in mental status. No MD notification was documented throughout this time period. A 'Skilled Daily Nurses Note', written 03/19/24 at 6:30 p.m., documented Resident #1 was transported to the emergency room per their request. On 04/10/24 at 10:05 a.m., CNA #1 reported, on admission, Resident #1 was able to get out of bed and use the walker with minimal assistance to go to the bathroom. When asked if they had noticed a change in Resident #1's condition, CNA #1 stated, Yes, [they] were a lot weaker. After a while, we had to use a full body lift to get [them] up. [They] were still verbal but not all there. On 04/10/24 at 4:50 p.m., the DON was asked to review the 'Skilled Daily Nurse Notes' for Resident #1 from 03/8/24 through 03/19/24. When asked if Resident #1 had experienced an acute change of condition, the DON stated yes. The DON acknowledged Resident #1 had not been assessed, monitored, nor received necessary interventions according to facility policy, after they experienced a significant change of condition. b. Resident #1 returned to facility from the emergency roiagnom on [DATE]. emergency room diagnoses included pleural effusion with evidence of possible pneumonia. An 'ED Physician Record' for Resident #1, dated 03/20/24, read in parts, .Impression and Plan .we will plan to treat for possible early pneumonia including use of antibiotics .Augmentin 875 mg-125 mg oral tablet (Prescribe): 1 Tabs, Oral, q12H, for 7 Days . A 'Skilled Daily Nurses Note', written 03/20/24 at 1:30 a.m., documented Resident #1 had returned from the emergency room with no new orders. There was no documentation in Resident #1's clinical record their physician was notified of the ER diagnoses nor the order for Augmentin stated in the 'ED Physician Record'. Resident #1's March 2024 and April 2024 MAR's did not include documentation that Augmentin had been given to the resident between 03/19/24 and 04/08/24. On 04/10/24 at 4:45 p.m., the DON was asked to review the above records. After reviewing the records, the DON acknowledged Resident #1 had not received the prescribed antibiotic therapy to treat pneumonia.

Based on record review and interview, the facility failed to accurately assess residents' risk for and initiate dietary measures to aide in the prevention of avoidable pressure ulcers for one (#1) of two sampled residents reviewed for pressure ulcers. The Administrator identified 31 residents resided in the facility. Findings: Resident #1 had diagnoses that included s/p amputation of left toes and PICC line in upper right arm. Resident #1's Care Plan documents, on 03/15/24, resident was at risk of nutritional decline and had lost 12 lbs. in a month. The RD completed a 'Nutrition Risk Assessment' for Resident #1, dated 03/18/24, with a risk score of NO/LOW RISK, and no interventions for prevention of pressure ulcers were put into place. Discrepancies in the RD assessment included: 1. RD documented no weight loss/gain- weight record documented a weight loss of <5% since admission. Resident #1's documented weights include 176 lbs. on 02/28/24, 172 lbs. on 03/11/24, 168 lbs. on 03/22/24, 164 lbs. on 03/27/24, and 160.5 lbs. on 04/05/24. 2. RD documented oral/nutrition intake meets 76-100% of estimated needs- 'Skilled Daily Nurses Notes' documented appetite poor-to-very poor with significant change in condition after 03/08/24 3. RD documented resident was ambulatory and able to feed self- 'Skilled Daily Nurses Notes' document decreased activity and need for extensive assistance with mobility and transfers and some assist with eating after significant change in condition on 03/08/24 4. RD documented lab values were WNL- Chem Profile done 03/13/24 documented Albumin less than 3.0 g/dL (2.5g/dL) and 3 other nutrition-related labs were abnormal (Potassium 3.4 mEq/L, Calcium 8.0 mg/dL, Protein 5.7 g/dL) 5. RD documented skin was intact- resident had become incontinent of bowel after change in condition on 03/08/24. Physicians' orders on Resident #1's April 2024 MAR, read in parts, .04/03/24 .Clean coccyx open areas with NS, pat dry apply Triad cream and cover with foam drg q3 days . A 'Skilled Daily Nurse Note', written 04/04/24, read in parts, .Skin (cont'd.) .Pressure Injury(ies) .Coccyx . No date of development, measurements, nor description of the pressure injury to the coccyx was documented anywhere in Resident #1's clinical record. There were no assessments for risks of skin breakdown documented in Resident #1's clinical record following their change in mobility and continence status that occurred on 03/08/24 through 04/08/24. No updates were made to Resident #1's Care Plan addressing interventions to prevent skin breakdown following their change of condition on 03/08/24. On 04/10/24 at 4:20 p.m., the DON was asked to review the RD's 'Nutrition Risk Assessment', the Care Plan, the Physician's Orders, and the Skilled Daily Nurse Notes for Resident #1 referenced above. After reviewing the documents, the DON acknowledged the RD's assessment was not accurate, dietary measures should have been initiated, and interventions should have been care planned to aid in preventing Resident #1's development of pressure ulcers.

Based on record review and interview, it was determined the facility failed to assess, monitor, and intervene for one (#7) of two sampled residents reviewed for falls. Resident #7 sustained a fracture due to a fall and had complaints of increased pain. The facility failed to throughly assess the resident after the fall, failed to monitor her for increased complaints of pain, and failed to obtain X-rays of the injured site in a timely manner. This resulted in actual harm to the resident. The facility identified four residents who had sustained falls within the last 30 days. The facility Census and Conditions report, dated 12/16/14, documented 36 residents resided in the facility. Findings: Resident #7 had a new [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/25/14, documented the resident was cognitively intact, made herself understood, understood others and was independent with all activities of daily living (ADLs). An incident report, dated 12/11/14 (no time given), documented the resident told a nurse she had fallen earlier in the day and had hit her left shoulder. The report also documented no injury was noted upon assessment and the physician had been notified. The report was signed by the director of nursing (DON). A nurse's note, dated 12/11/14 (no time given), documented the resident stated she had fallen that morning while in her bathroom and hit her left shoulder on a waste basket. The note also documented the resident complained of left shoulder and side pain and no apparent injuries were documented. A nurse's note, dated 12/11/14 at 2:00 p.m., documented the resident complained of left side pain and was given [MEDICATION NAME] 10/325 (a pain medication) milligram (mg) with little relief. This note was signed by licensed practical nurse (LPN) #1. A nurse's note, dated 12/12/14 at 10:45 a.m., documented the resident complained of left rib pain and requested pain medication. The resident was administered [MEDICATION NAME]. A nurse's note, dated 12/13/14 at 4:00 p.m., documented the resident had been crying and complained of severe left sided rib pain. The report documented the resident requested her physician be notified. The resident was administered [MEDICATION NAME] and the physician was notified. A new order was issued by the physician to obtain a mobile x-ray or send the resident to the emergency room for evaluation. The note further documented a mobile x-ray was obtained (no time was given). A nurse's note, dated 12/14/14 at 3:00 p.m., documented the resident continued to complain of pain to her left side ribs. The note further documented no x-ray results had been received at this time. The clinical record contained no additional information regarding assessments or monitoring for the fall/pain. On 12/17/14 at 3:00 p.m., the resident was interviewed. She stated she fell last Thursday in the bathroom and hit her left shoulder and ribs on a metal waste basket. The resident was asked if she told anyone that she had fallen. She stated she had reported the fall. The resident was asked if the pain kept her from attending activities or kept her from doing her normal activities. She stated, "Yes, it had because every time I moved the pain would grab me." The resident added sometimes she would "screech" because of the pain. The resident stated, "I just stayed in bed a lot, because it hurt to move." On 12/17/14 at 3:08 p.m., the resident's primary care physician's office was contacted. The physician wasn't in the office, so the office nurse was interviewed. She reviewed the resident's chart and stated she couldn't find any documentation to indicate the physician had been notified regarding the fall on either 12/11/14 or 12/13/14. On 12/17/14 at 4:34 p.m., the director of nursing (DON) was asked for additional documentation regarding the fall. She stated she didn't see any additional reports in the chart, but would look. On 12/18/14 at 8:28 a.m., the DON provided the x-ray report, dated 12/13/14, and stated it had been faxed to the facility on [DATE]. The report documented the resident had a 6th, left, lateral rib fracture. The assistant director of nursing (ADON) stated the facility had received the x-ray report between 6:00 p.m. and 6:30 p.m. on 12/14/14. She added the physician had been notified at 6:30 p.m. On 12/18/14 at 9:41 a.m., the DON was asked if there was documentation of an assessment having been conducted for the resident on the morning of 12/11/14. She stated there was no documentation, but licensed practical nurse (LPN) #1 had assessed the resident at the nursing station. The DON added the LPN did not tell her the resident was complaining of pain. The DON was asked if there was documentation of any additional assessments having been conducted due to the resident's continued complaints of rib pain. She stated there was no documentation, "We could have been better." The DON then stated, "We should have assessed and followed up on the fall/pain." The DON was asked if she had been made aware of the resident's continued complaints of pain for the two days following the fall. She stated no one had informed her. The DON stated they should have done something prior to the resident crying and having to request her physician be called. The DON was asked for documentation the physician had been notified on 12/11/14. She stated there wasn't any, but he had been notified. She was asked if the physician had been informed the resident had complained of shoulder and rib pain. The DON stated since she wasn't informed of the complaints of pain, she wasn't aware if LPN #1 had informed the physician. On 12/18/14 at 11:33 a.m., LPN #1 and the DON were interviewed about the resident's fall on 12/11/14. The LPN was asked if she remembered if she had done an assessment on resident #7 on the morning of 12/11/14. The LPN stated she had assessed the resident in the resident's room. She added she had inspected the injury site and performed range of motion. She stated she didn't remember if she documented it or not. The LPN was asked if she thought the resident might require further assessment due to the continued complaints of pain. She stated the resident had frequently complained of pain, so she didn't think anything about it. The resident's narcotic sign out sheet, dated December 2014, was reviewed. The sheet documented the resident had only requested PRN (as needed) pain medication two times between 12/01/14 and 12/11/14. Between 12/11/14 and 12/18/14, the narcotic sign out sheet documented the resident requested and was administered PRN pain medication nine times. On 12/18/14 at 12:02 p.m., the physician was asked what information the facility had provided him on 12/11/14. He stated he had not been notified about the resident's fall/pain on 12/11/14. He added if he had been informed of the fall and increased complaints of pain on 12/11/14, he would have ordered an x-ray. He stated he was notified for the first time about the fall and increased complaints of pain, late in the day on 12/13/14. He further stated he was notified of the Xray results late Sunday on 12/14/14. The physician stated he instructed the facility to monitor the resident and treat her pain. He was asked how the facility normally notified him of a resident's change in condition. He stated the facility staff usually called or faxed him. He stated he had gone through all of his paper work, but didn't find a fax notification for 12/11/14. On 12/18/14 at 1:54 p.m., the DON, administrator, and corporate nurse were notified of the actual harm for resident #7. The DON stated they had problems faxing the physician in the past, but the physician had been notified. "There just wasn't any documentation."

Based on observation, record review, and interview, it was determined the facility failed to prevent the re-occurrence of a pressure ulcer for one (#2) of 1 sampled resident with a pressure ulcer. The facility resident and census report identified one resident with a pressure ulcer. Findings: Resident #2 had [DIAGNOSES REDACTED]. The assessment, dated 08/24/10, documented the resident ambulated independently, had an unsteady gait, understood others, and made herself understood. The nurses notes dated 08/11/10, documented the resident required assistance with ambulation, often refused to use a walker, and was incontinent. The resident was admitted on [DATE], from another nursing facility. Clinical records documented the resident was admitted with a stage 2 pressure ulcer to the right lateral foot, stage 1 pressure ulcers to the boney areas of both great toes, and pressure ulcers to both buttocks. There was no description of the pressure ulcers to the right buttock or the left buttock. The facilities pressure ulcer risk assessment, dated 08/11/10, documented the resident was given a score of 10. The assessment, dated 11/04/10, documented the resident was given a score of 12. A score of 8 or above represented a high risk for developing pressure ulcers. The care plan, dated 08/31/10, documented open areas to bilateral feet and buttocks. Interventions included: a. provide treatments as ordered by physician, b. toilet every 2 hours, c. provide good peri-care after any incontinent episode, and d. provide [MEDICATION NAME] to bottom to prevent further breakdown. On 08/31/10, the registered dietitian's progress notes documented a regular diet with no added salt and documented the resident's current needs were: 1788 calories, 68 grams of protein, and 2032 cubic centimeters of fluid. When the resident was admitted she was placed on a regular diet. She was to be given health shakes two times a day. On 09/16/10, the clinical records documented the residents skin was intact and free from breakdown. On 10/14/10, the clinical records documented the resident had a stage 2 pressure ulcer to the right buttock. On 10/14/10, the physician's progress note documented the resident had a 2 centimeter (cm) x 2 cm, stage 2 pressure ulcer to the left buttock. The facilities skin condition progress report documented the resident was treated with [MEDICATION NAME] every shift and as necessary. On 10/22/10, a physician's orders [REDACTED]. On 10/22/10, the skin condition report documented the resident's pressure ulcer was treated with [MEDICATION NAME], foam, and [MEDICATION NAME]. On 10/28/10, the registered dietitian (RD's) progress notes documented, "A stage 2 decubitus ulcer was now present. The resident needs for wound healing: 1820 calories, protein 89 grams, and 1773 ccs of water. Record alb.([MEDICATION NAME]) labs (laboratory results)." The clinical records did not document the RD's recommendations had been reviewed or implemented. The resident's diet card from the kitchen documented the resident was on a regular diet. On 11/08/10, there was no documentation the care plan had been revised or updated to provide the resident with necessary interventions to prevent new pressure ulcers from developing. On 11/08/10 at 12:00 p.m., the resident was observed eating the noon meal in the dining room. She was seated in her wheel chair, there was no pressure reduction cushion. On 11/08/10, the laboratory results were reviewed. On 11/02/10 an [MEDICATION NAME] test documented the level was 3.3. The reference range was 3.4 - 4.8. On 11/09/10 at 11:15 a.m., the resident was observed sleeping in bed. The bed did not have a pressure reduction device. On 11/10/10 at 10:00 a.m., wound care for the pressure ulcer was observed. One ulcer had been documented in the clinical records as one stage 2, but there were 2 ulcers on her right buttock. Each ulcer had thick dark red/blackish eschar. At 10:10 a.m., licensed practical nurse #1 stated the ulcers had more necrotic tissue than 2 days ago, and if they weren't better in a week she would call a wound specialist. On 11/10/10 at 2:00 p.m., the director of nurses (DON) was shown the RD's recommendations dated 10/28/10. She stated she was unaware of the recommendations and did not know if the resident's diet needed to be changed or if it had been changed. She stated she had not notified anyone of the recommendations. The DON was asked if the care plan had been updated since the appearance of new pressure ulcers. She stated it had not been updated. The facilities protocol for stage two pressure ulcers documented: " 1. Evaluate the need for pressure reduction surface for bed, heel/elbow protectors, and pressure reduction cushion for chair... 4. Dietary consultation to determine nutritional status." On 11/10/10/ at 2:00 p.m., the DON was asked if the facility protocol for stage 2 pressure ulcers had been followed. She stated she had evaluated the pressure ulcers and discussed it. She stated it had been decided the resident did not need pressure reduction devices or a change in care since she was ambulatory. She stated we only recently started requiring the resident to use the wheelchair, so the wheelchair wasn't the cause. When asked if she had evaluated how the resident had acquired the pressure ulcers. She stated she did not know how the resident had acquired them. She was asked if there was documentation of an evaluation regarding the need of pressure reducing devices. She stated there was not. The DON was asked who was responsible for notifying the physician of abnormal lab results. She stated the lab sent the results to his office as well as to the facility. She stated she did not phone his office to discuss the abnormal [MEDICATION NAME] results.