Every finding on record at Heritage at Brandon Place Health & Rehabilitation

Based on observation and interview, the facility failed to provide sufficient medication aide staffing to ensure residents' medication needs were being met.The regional director of operations identified 52 residents resided in the facility.Findings:On 08/06/26 at 10:44 a.m., CMA #1 was observed completing the morning medication pass. CMA #1 was observed to be one hour late filling the medication they were doing at the time.On 08/06/26 at 3:19 p.m., CMA #1 was observed still completing medication pass.On 08/05/26 at 8:55 p.m., Resident #3 stated they were not getting some of their medications and they had told the CNAs, but the CNAs had not been able to do anything because there was no CMA available.On 08/05/26 at 11:07 p.m., Resident #10 stated they received their medications late and that made them feel bad.On 08/06/26 at 10:58 a.m., CMA #1 stated they started the medication pass at 7:00 a.m. today and did one hall already but still needed to complete the 200 and 600 halls. They stated they were the only CMA on shift.On 08/06/26 at 2:37 p.m., the staffing coordinator stated there were normally two CMA's and two nurses available, but one CMA walked out recently.On 08/06/26 at 3:18 p.m., the administrator stated they had no staffing number policy and they followed state guidelines for staffing ratios that needed to be met.On 08/06/26 at 3:58 p.m., CMA #1 stated the medication pass they were completing at 3:19 p.m. today, was for a medication for a resident that needed to be administered from 6:00 a.m. to 10:00 a.m. CMA #1 stated if a medication was given an hour before or an hour earlier than the scheduled time then it was not given at the right time. CMA #1 stated if they are the only CMA, then it was very hard for them to stay within the time range of the medication pass times. CMA #1 stated if residents were not given medications on time, then it could run into the other dose for the next shift. They stated residents could have adverse health outcomes due to late medications. CMA #1 stated there used to be two CMAs who worked each shift, but not anymore.On 08/07/26 at 12:39 p.m., the administrator stated they were made aware today by the DON of only one resident who had complained of not receiving their medications.On 08/10/26 at 9:36 a.m., CMA #2 stated they did not believe the facility had an adequate number of staff to ensure resident needs were being met.On 08/10/26 at 11:12 a.m., CMA #2 stated the facility did not have enough CMAs and needed at least three per shift. CMA #2 stated it was really hard to pass medications on one hall and then pass medications on another hall on time if only one CMA was doing it. CMA #2 stated it put too much pressure on one person to be a CMA on two halls, let alone three. They stated due to low CMA staffing medications could also be missed. CMA #2 stated that harm could come to residents if medications were missed or given late.

Based on observation, record review, and interview, the facility failed to:a. remove medications of discharged residents from refrigerator #2 for 2 (#13 and #18) of 15 sampled residents reviewed for medication storage; and b. return and/or destroy unused medications in the medication storage room. The regional director of operations identified 52 residents resided in the facility and three refrigerators in the medication storage room.Findings:1. On [DATE] at 8:08 p.m., refrigerator #2 was observed to have Latonoprost 0.005% eye drops for Resident #13, who had expired [DATE].On [DATE] at 8:29 p.m., refrigerator #2 was observed to have Novolog 100 unit/ml flexpen for Resident #18, who had expired [DATE].An undated policy titled Medication Storage, read in part, Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of.On [DATE] at 8:20 p.m., LPN #2 stated medications for residents that had discharged or expired should be removed from the refrigerator.On [DATE] at 11:39 a.m., LPN #1 stated they had only worked at the facility two months and did not know what to do with medications if a resident expired or discharged to another facility.On [DATE] at 12:07 p.m., the regional director of operations stated medications should be removed from the medication storage refrigerators at least 48 hours of discharge.2. On [DATE] at 6:58 p.m., the medication storage room was observed to have four large cardboard boxes and one large green tub with medications of residents that had expired, discharged , or transferred. The medication storage room had nine logs in one large cardboard box that had not been completed. No other cardboard boxes or large green tub had logs.An undated policy titled Medication Storage, read in part, Medications awaiting destruction that cannot be disposed of immediately should be recorded on a log to include the name of the individual(s) storing the medication, resident name, the prescription number if applicable, the quantity of the medication, the strength of the medication and the date of disposition.On [DATE] at 7:02 p.m., LPN #3 stated the boxes of medications were expired and medications of residents who had been discharged or the medication was discontinued. LPN #3 stated they had no clue about the process for destruction or when it occurred.On [DATE] at 8:32 p.m., LPN #2 stated the facility was supposed to destroy medications monthly.On [DATE] at 11:28 a.m., CMA #1 stated they logged medications as they destroyed them. CMA #1 acknowledged they had not destroyed medications for at least a month and was not sure if anyone had.On [DATE] at 12:08 p.m., the regional director of operations stated medications that awaited destruction should be written on the log and destroyed. The regional director of operations stated the pharmacist came to the facility once a month and they did not know if the medications had been destroyed in the last month, but probably not.

Based on observation, record review, and interview, the facility failed to ensure medication error rates were not 5% or greater for 3 (#17, 22, and #23) of 3 sampled residents reviewed for medication administration. The regional director of operations identified 52 residents resided in the facility. Findings: On 08/06/26 from 10:44 a.m. to 11:34 a.m., a morning medication pass was observed with CMA #1. There were 34 opportunities for medication administration observed, of which 19 were either given over an hour late or not given at all. The following medication pass errors were observed for Resident #22 on 08/06/26:a. Omeprazole (proton pump inhibitor) 20 mg tablet given at 10:44 a.m., with an order time of 7:00 a.m.,b. Gabapentin (an anticonvulsant) 100 mg tablet given at 10:46 a.m., with an order time of 8:00 a.m.,c. Eliquis (an anticoagulant) 5 mg tablet given at 10:46 a.m., with an order time of 8:00 a.m.,d. hydrocodone-acetaminophen (pain medication) 7.5-325 mg tablet given at 10:50 a.m., with an order time of 8:00 a.m., ande. calcium citrate (supplement) tablet was not given due to the facility not having the medication. The following medication pass errors were observed for Resident #23 on 08/06/26:a. Stool softener tablet given at 11:02 a.m., with an order time of 8:00 a.m.,b. Eliquis 5 mg tab given at 11:02 a.m., with order time of 8:00 a.m.,c. Gabapentin 400 mg capsule given at 11:02 a.m., with order time of 8:00 a.m.,d. Arginald powder (supplement) given at 11:05 a.m., with order time of 6:00 a.m. to 10:00 a.m., ande. Hydrocodone acetaminophen 5-325 mg tablet given at 11:10 a.m., with order time of 8:00 a.m. The following medication pass errors were observed for Resident #17 on 08/06/26:a. Atorvastatin (for cholesterol) 40 mg tablet given at 11:29 a.m., with order time of 8:00 a.m.,b. Amlodipine (calcium channel blocker) 10 mg tablet given at 11:29 a.m., with order time of 8:00 a.m.,c. Stool softener tablet given at 11:30 a.m., with order time of 8:00 a.m.,d. Furosemide (a diuretic) 20 mg tablets given at 11:30 a.m., with order time of 8:00 a.m.,e. Sevelsamer carbonate (phosphate binder) 800 mg tablet given at 11:31 a.m., with order time of 8:00 a.m.,f. Sodium bicarbonate (an antacid) 650 mg tablet given at 11:31 a.m., with order time of 8:00 a.m.,g. Pantoprazole (proton pump inhibit) 40 mg tablet given at 11:32 a.m., with order time of 6:00 a.m.,h. Enulose (osmotic laxative) 10g/15 mL given at 11:34 a.m., with order time of 6:00 a.m., [NAME]. Sennoside (stimulant laxative) 8.6 mg capsule was not given during medication pass. A facility policy titled Medication Administration, dated 05/01/24, read in part, 10: Ensure that six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right Route e. Right time f. Right documentation .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 08/06/26 at 3:58 p.m., CMA #1 stated if a medication was given an hour before or an hour later than the scheduled time then it was not given at the right time. CMA #1 stated if they were the only CMA on shift, then it was very hard for them to stay within the time range of the medication pass times. CMA #1 stated if medications were not given on time, then it could run into the other dose for the next shift. CMA #1 stated residents could also have adverse health outcomes. On 08/07/26 at 12:14 p.m., the DON stated their expectations for medication administration was to follow the medication administration policy. The DON stated medication pass should be completed an hour before and hour after the order time. The DON stated they could see the CMAs marked off they filled the medications during a time period but not what time they marked it.

Based on observation, record review, and interview, the facility failed to:a. ensure stored medications were monitored at proper temperatures to preserve their integrity for 3 (refrigerator #1, 2, and #3) of 3 refrigerators reviewed in the medication storage room; and b. ensure medications were secure for 1 of 1 treatment carts observed. The regional director of operations identified 52 residents resided in the facility.Findings:1. On 08/05/26 at 6:59 p.m., the refrigerator logs for refrigerator #1 was observed to be missing entries for the entire month of 06/2026 and 07/2026. There was no log for 08/2026.On 08/05/26 at 7:07 p.m., the refrigerator logs for refrigerator #2 was observed to be missing entries for the entire month of 06/2026 and 07/2026. There was no log for 08/2026.On 08/05/26 at 7:08 p.m., the refrigerator logs for refrigerator #3 was observed to be missing entries for the entire month of 06/2026 and 07/2026. There was no log for 08/2026.On 08/05/26 at 7:08 p.m., the following resident medications were observed in refrigerators #1 and #3:Refrigerator #1a. Resident #2 had Ozempic (a glucagon-like peptide -1) (GLP-1) 0.25-0.5 mg/dose pen, and Liragutide (a GLP-1) 3-pak 18mg/3ml pen;b. Resident #4 had Sodium chloride (a parenteral fluid and electrolyte replenisher) 0.9% for irrigation, Liragutide, (a GLP-1) 3-pak 18mg/3ml pen;c. Resident #9 had Insulin Lispro, (an antidiabetic agent) 100 unit/ml (2) pens, Novolog, (an antidiabetic agent) 100 unit/ml (7) flexpens; d. Resident #10 had Trulicitgy (a GLP-1) 3mg/0.5ml pen; e. Resident #11 had Ozempic (a GLP-1) 8mg/3ml, Insulin Glargine Solostar (a long-acting insulin analog) u300 pen; f. Resident #12 had Ozempic (a GLP-1) 4mg/3ml (2) pens, Daptomycin (an antibiotic) 700mg/100ml/normal saline (5) bags; g. Resident #14 had Tezruly (an alpha-1 adrenoceptor antagonist) 1mg/ml solution; h. Resident #15 had Arformoterol Tartrate inhalation (a bronchodilator) (6) solutions; i. Resident #16 had Ozempic (a GLP-1) 0.25-0.5mg/dose pen; j. Resident #17 had Insulin Glargine-YFGN (a long-acting insulin analog) U100 pen; k. Resident #19 had Liraglutide (a GLP-1) 3-pak 18mg/3ml pen; and l. Resident #20 had Insulin Aspart (an antidiabetic agent) 100 unit/ml (2) pens. Refrigerator #3 a. Resident #21 had compounded magic mouthwash, lidocaine, diphenhydramine, antacid 1:1:1 suspension (a mouth and throat product).An undated policy titled Medication Storage, read in part, Medications requiring 'refrigeration' or 'temperatures between 2 C (36 F) and 8 C (46 F)' are kept in a refrigerator with a thermometer to allow temperature monitoring.A temperature log or tracking mechanism is maintained to verify that temperature has remained within acceptable limits.If no vaccines are stored in the refrigerator, document temperature checks at least once daily.On 08/07/26 at 11:26 a.m., CMA #1 acknowledged there were no temperatures documented for June, July, and August 2026 for refrigerators #1, 2, and #3. CMA #1 stated they were supposed to check temperatures of the refrigerators in the medication storage room and write it down on the log.On 08/07/26 at 12:02 p.m., the regional director of operations acknowledged refrigerators #1, 2, and #3 had no temperatures logged for June, July, and August 2026. The regional director of operations stated the temperatures were normally tracked at night, and the charge nurse should verify it on their rounds.2. On 08/10/26 at 10:54 a.m., a treatment cart on hall 200 was observed to be unlocked and unattended with medications stored on top of the cart. Medications observed included Diclofenac Sodium Topical Gel 1% (a nonsteroidal anti-inflammatory drug) and Povidone Iodine prep solution (an antiseptic).An undated policy titled Medication Storage, read in part, The medication supple shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members.medication supplies should remain locked when not in use or attended to by persons with authorized access.On 08/10/26 at 10:56 a.m., LPN #4 stated they should have removed the Diclofenac Sodium Topical Gel 1% and Povidone Iodine prep solution from the top of the cart. LPN #4 stated the cart should have been locked prior to stepping away according to the policy.

Based on observation, record review, and interview, the facility failed to:a. perform hand hygiene during incontinent care for 1 (#5) of 4 sampled residents observed for incontinent care; andb. perform hand hygiene during medication administration.The regional director of operations identified 52 residents resided in the facility. The administrator identified 36 residents with incontinence. Findings: 1. On 08/05/26 at 9:41 p.m., CNA #1 and LPN #3 were observed to perform incontinent care for Resident #5. CNA #1 and LPN #3 were not observed to perform hand hygiene after removing their gloves and exiting Resident #5's room. A policy titled Perineal Care, updated 05/01/24, read in part, 13. Remove gloves and discard. Perform hand hygiene. On 08/05/26 at 9:50 p.m., CNA #1 stated they should have performed hand hygiene prior to exiting Resident #5's room after performing incontinent care. LPN #3 stated they should have performed hand hygiene prior to exiting Resident #5's room after performing incontinent care. On 08/06/26 at 11:43 a.m., CNA #2 stated staff should perform hand hygiene after incontinent care. On 08/07/26 at 12:13 p.m., the regional director of operations stated their expectation was that staff performed hand hygiene after completing incontinent care for residents. 2. On 08/06/26 from 10:44 a.m. to 11:34 a.m., CMA #1 was observed to perform a medication pass. During the medication pass observation, CMA #1 was not observed to use hand hygiene in between each medication administration. A facility policy titled Medication Administration, dated 05/01/24, read in part, wash hands prior to administering medication per facility protocol and product. On 08/06/26 at 3:58 p.m., CMA #1 stated staff should use hand sanitizer in between medication passes, but after the third medication pass, they should wash their hands. CMA #1 stated they forgot to do that earlier during medication pass. CMA #1 stated hand hygiene was required so that germs were not spread.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The regional director of operations identified 52 residents resided in the facility. Findings:A DON/RN attestation and hours, dated 07/23/26 through 08/06/26, did not show RN coverage for eight consecutive hours on 08/01/26 and 08/02/26.On 08/07/26 at 12:14 p.m., the DON stated there was no RN on 08/01/26 and 08/02/26. The DON stated they thought the facility would call in an RN from an agency if an RN was unable to come in.On 08/07/26 at 12:39 p.m., the administrator stated they believed there were days without an RN because the facility probably tried to schedule an RN through an agency service but could not get anyone.

Based on observation, record review, and interview, the facility failed to follow enhanced barrier precautions and perform hand hygiene to prevent the development of infections for 1 (#1) of 3 sampled residents reviewed for infection control.The DON identified 55 residents resided in the facility and 13 residents with enhanced barrier precautions. Findings:On 05/05/26 at 12:40 p.m., CNA #1 and CNA #2 were observed providing incontinent care for Resident #1. A sign posted at Resident #1's door read, enhanced barrier precautions, staff must wear gown and gloves for bathing, changing linen, and providing hygiene for the resident. CNA #1 and CNA #2 did not wear a gown when providing care. CNA #1 did not wash or sanitize their hands when changing their gloves and moving from a dirty area to a clean area. On 05/05/26 at 2:25 p.m., LPN #1 was observed to change the wound vac dressing for Resident #1. LPN #1 was not wearing a gown. LPN #1 stated they did not know the resident was on enhanced barrier precautions. LPN #1 placed a new wound vac dressing, removed their gloves, and did not wash or sanitize their hands after removing their gloves. On 05/06/26 at 10:27 a.m., the ADON was observed to complete wound care for Resident #1. The ADON cleaned the pressure ulcer wounds to the gluteal folds and wearing the same pair of gloves applied a clean dressing. A facility policy titled Enhanced Barrier Precautions, dated 04/01/24, read in part, An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices .Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room.A facility policy titled Hand Hygiene, dated 06/13/24, read in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.On 05/05/26 at 12:42 p.m., CNA #2 stated they did not wear a gown when incontinent care was provided for Resident #1. CNA #2 stated they should have worn a gown to provide care. On 05/05/26 at 12:43 p.m., CNA #1 stated they were in a hurry and forgot the put a gown on to provide care for Resident #1. CNA #1 stated they should have worn a gown when care was provided for Resident #1.On 05/06/26 at 10:29 a.m., the DON stated the ADON should have changed their gloves and washed their hands between dirty and clean surfaces. The DON stated staff was to wear a gown and gloves per enhanced barrier precautions when providing contact resident care for Resident #1.

Based on observation, record review, and interview, the facility failed to provide treatment and care for a resident with a wound vac for 1 (#1) of 1 sampled resident reviewed for a wound vac. The DON identified one resident with a wound vac. Findings:On 05/05/26 at 12:00 p.m., Resident #1 was observed lying in a bariatric bed with an air mattress in place watching television. Resident #1 had a wound vac to the abdomen, the dressing was not dated, and the wound vac machine was turned off.An undated admission record showed Resident #1 had diagnoses which included local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus, pressure ulcer of contiguous site of back, buttock, and hip stage 2.An undated facility policy titled Negative Pressure Wound Therapy, read in part, Whenever therapy cannot be resumed within two hours, remove the dressing and apply a moist wound dressing. Notify physician for specific orders.A treatment administration record, dated 04/21/26, showed a treatment for a midline abdomen surgical wound. The order showed the staff was to cleanse the wound with full strength Dakins solution, pat dry, apply barrier wipes to peri wound skin, allow to dry, apply cut strips of hydrocolloid (a wound care dressing) along peri wound edges, lightly pack undermining from 10 to11 o'clock with half inch cut strip of white vac foam then fill in the wound bed with black foam, secure with vac drape followed by track pad then set negative pressure wound therapy every Tuesday and Friday morning. A physician order, dated 05/05/26, showed an as needed order for wound care to the midline abdomen surgical wound. The order showed if wound vac was leaking, blocked or off more than two hours, the entire vac dressing must be removed, cleanse with full strength Dakins solution, pat dry, dampen Kerlix (a wound dressing) with Dakins solution, them lightly pack wound bed, cover with dry gauze, secure with tape, and change dressing as needed daily.On 05/05/26 at 12:30 p.m., LPN #1 stated the wound vac was turned off this morning when they started their shift around 7:15 a.m. LPN #1 stated they turned the wound vac on, but the wound vac was not working correctly. LPN #1 stated they did not know how long the wound vac had been turned off or if infection had built up under the dressing. LPN #1 stated they informed the DON the wound vac was not working correctly and the DON stated they would take care of it.On 05/05/26 at 2:25 p.m., LPN #1 stated they changed the wound vac for Resident #1. LPN #1 stated the wound vac was still not working correctly. On 05/05/26 at 2:45 p.m., LPN #1 stated per the physician orders the wound vac should have been removed and a dressing applied after the wound vac had not worked for two hours. LPN #1 stated they should have followed the physician order. On 05/06/26 at 1:00 p.m., the DON stated LPN #1 should have followed the physician order and notify the physician about the wound vac not working correctly. The DON stated LPN #1 did not follow the physician order for the wound vac care.

Based on observation, record review, and interview, the facility failed to provide pressure ulcer treatments to promote healing and prevent infection for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The DON identified three residents with pressure ulcers. Findings:On 05/05/26 at 12:42 p.m., CNA #1 and CNA #2 were observed to enter Resident #1's room to provide incontinent care. CNA #2 positioned Resident #1 on their side and CNA #1 washed Resident #1's buttock. There was packing in the pressure ulcer, but no dressing covering the wound. Bowel was on the edges and inside edges of the pressure ulcer. When CNA #1 was rolling the soiled linen to discard CNA #1 also caught the packing that was in the pressure ulcer wound bed. CNA #1 removed the packing part of the dressing with the soiled linen. CNA #1 did not tell the nurse about the resident's dressing (packing) being removed.On 5/06/26 at 10:17 a.m., the ADON was observed to complete wound care to the bilateral gluteal folds for Resident #1. There was no dressing covering the pressure ulcer wounds. An undated admission record showed Resident #1 had diagnoses which included local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus, obesity, pressure ulcer of contiguous site of back, buttock, and hip stage 2, depression, and anxiety disorder.An on-site wound visit report, dated 04/29/26, showed Resident #1 had a stage 4 pressure ulcer to the right gluteal fold that measured 6.6cm length x 12cm width x 3cm depth. The report showed Resident #1 had a stage 4 pressure ulcer to the left gluteal fold that measured 8cm in length x 12.5cm in width x 3.7cm in depth. The report showed Resident #1 had a stage 3 pressure ulcer to the right buttock that measured 2cm in length x 2cm in width x 0.1cm in depth.A physician order, dated 04/30/26, showed staff was to clean the right gluteal fold wound with Dakins quarter strength solution, pat dry, soak 4x4 gauze in wound solution and apply to wound, cover with a dressing, and secure with tape for a stage 4 wound. A physician order, dated 04/30/26, showed staff was to clean the left gluteal fold wound with Dakins quarter strength solution, pat dry, soak 4x4 gauze in wound solution and apply to wound, cover with a dressing, and secure with tape for a stage 4 wound. On 05/05/26 at 12:30 p.m., LPN #1 stated they were not to use tape on Resident #1. LPN #1 was unsure why they were not to use tape on Resident #1.On 05/05/26 at 2:45 p.m., LPN #1 stated the physician orders to use tape to secure the dressings to the gluteal folds, must be new orders. LPN #1 stated per the physician order they should have used tape to secure the dressing and cover the pressure ulcer to the gluteal fold.

Based on observation and interview, the facility failed to post notice of the availability of past State survey results in areas of the facility that were prominent and accessible to residents, representatives, and the public.The DON identified 48 residents resided in the facility. Findings:On 01/12/26 at 11:34 a.m., a tour of the facility was conducted. There was no notice informing the public where the past State survey results were posted.On 01/12/26 at 11:40 a.m., the past State survey results were observed in a binder on the administrator's door in a file holder.On 01/12/26 at 11:44 a.m., the administrator stated the there was no notice posted about where to locate the past State survey results. They stated it should have been posted on the bulletin board.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 3 (#1, 3, and #7) of 4 sampled residents reviewed for assistance with ADLs.The DON identified 38 residents required assistance with bathing. Findings: An Activities of Daily Living (ADLs) policy, revised 01/26/25, read in part, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, and grooming .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. A facility Bath List schedule, dated 11/07/25, showed Resident #7 was to receive showers three times a week on Tuesday, Thursday, and Saturday. Resident #7's quarterly resident assessment, dated 11/14/25, showed the resident had moderate cognitive impairment with a BIMS of 12. The assessment showed Resident #7 required partial to moderate assistance from staff for showers. A facility Documentation Survey Report v2 for December 2025, showed Resident #7 was not bathed, six out of 13 opportunities. The report showed: a. blanks on 12/02/25, 12/06/25, 12/13/25, 12/27/25, and b. activity itself did not occur, or family and/or non-facility staff provided care 100 percent of the time on 12/25/25 and 12/30/25. The facility Documentation Survey Report v2 for January 2026, showed Resident #7 was not bathed, two out of five opportunities. The report showed blanks on 01/01/26 and 01/03/26. On 01/12/26 at 9:14 a.m., Resident #7 stated their shower days were Saturday and Tuesday. They stated, I just don't get them. On 01/12/26 at 1:27 p.m., CNA #2 stated they reviewed the shower list to determine when a resident was scheduled for a shower. On 01/12/26 at 2:46 p.m., CNA #1 stated the process for giving Resident #7 a shower was to gather the bathing supplies, assist the resident with bathing, and allow the resident to participate as much as they could. CNA #1 stated Resident #7 did not refuse showers. On 01/12/26 at 3:12 p.m., the DON reviewed the facility Documentation Survey Report for December 2025 and January 2026. They stated Resident #7 received showers seven days in December and four days in January. The DON stated they were not sure if they were reading the document correctly. 2. An undated diagnosis report for Resident #3 showed they were admitted on [DATE] with diagnoses which included chronic embolism and thrombosis of unspecified deep veins of left lower extremity and morbid (severe) obesity due to excess calories. Resident #3's annual assessment, dated 02/27/25, showed Resident #3 had a BIMS of 14, indicating their cognition was intact, and they were dependent on staff for bathing. Resident #3's quarterly assessment, dated 11/21/25, showed Resident #3 had a BIMS of 14, indicating their cognition was intact, and they were dependent on staff for bathing. An ADL documentation record for November 2025 showed Resident #3 was not bathed on 11/04/25, 11/06/25, 11/08/25, 11/11/25, 11/13/25, 11/15/25, 11/18/25, 11/20/25, 11/22/25, 11/25/25, 11/27/25, and 11/28/25. An ADL documentation record for December 2025 showed Resident #3 was not bathed on 12/02/25, 12/04/25, 12/06/25, 12/09/25, 12/11/25, 12/13/25, 12/16/25, 12/20/25, 12/25/25, and 12/30/25. On 01/12/25 at 9:30 a.m., Resident #3 stated they had not had a shower in a month. On 01/12/26 at 3:35 p.m., CNA #3 stated Resident #3's bath schedule was on Tuesday, Thursday, Saturday on the 3:00 p.m. to 11:00 p.m. shift. On 01/12/26 at 3:49 P.M., the DON stated the documentation showed Resident #3 had not received baths as scheduled for the months of November or December. 3. A facility Bath List schedule, dated 11/07/25, did not show Resident #1 on the document. Resident #1's care plan for ADL intervention, initiated 12/16/25, showed the resident had diagnoses which included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing. The care plan showed the resident was totally dependent on staff to provide showers two times per week and as necessary. A facility Documentation Survey Report for December 2025 showed Resident #1 received showers on the 10th and 30th out of eight opportunities in the month for showers. On 01/14/26 at 9:16 a.m., the DON stated Resident #1 was admitted to the facility on [DATE] and discharged on 01/08/26. On 1/14/26 at 9:20 a.m., the DON stated they did not see what Resident #1's shower days were from the facility electronic health record or shower book. On 1/14/26 at 9:21 a.m., the DON reviewed the facility Documentation Survey Report for December 2025 for Resident #1. They stated the document showed Resident #1 had two showers in December. On 1/14/26 at 9:23 a.m., the DON reviewed the care plan for Resident #1. They stated the resident was totally dependent on staff to provide showers two times per week and as necessary. On 1/14/26 at 9:25 a.m., the DON stated based on the care plan, Resident #1 did not receive two showers per week. On 1/14/26 at 9:27 a.m., the DON stated the importance of resident's receiving showers as scheduled and as needed included skin care, infection control, and quality of care.

Based on record review and interview, the facility failed to ensure a resident who experienced pain received treatment for pain for one (#2) of three sampled residents reviewed for pain management. The VP of clinical services identified 46 residents had orders for pain management in the facility. Findings: The Administering Pain Medications policy, revised 10/10, read in part, The pain management program is based on a facility-wide commitment to resident comfort. The policy also read, .Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained .Administer pain medication as ordered .document the following in the resident's medical record: results of the pain assessment; medication; dose; route of administration; and results of the medication. Resident #2 was admitted on [DATE] and had diagnoses which included pain, dementia, and displaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing. A baseline care plan, dated 10/03/24 at 4:56 p.m., documented Resident #2 was cognitively impaired and their pain level was a five with the PAINAD scale. A physician's order, dated 10/03/24, documented Oxycodone HCL (analgesic opioid medication) 5 mg give one tablet by mouth every six hours as needed for pain. A physician's order, dated 10/03/24 at 8:00 p.m., documented morphine sulfate solution (analgesic opioid medication) 20 mg per ml give 0.5 ml sublingual every four hours as needed for pain and air hunger. A pain assessment, dated 10/03/24 at 10:35 p.m., documented Resident #2's pain was at a 10 on a numerical scale. Resident #2 did not receive pain medication with the assessment above. There was no documented follow up pain assessment per facility policy with the assessment above. A narcotic count sheet, documented morphine 100 mg per ml was available at the facility on 10/04/24 at 12:05 a.m. A nursing note, dated 10/04/24 at 4:11 a.m., documented Resident #2 was in bed awake, calm, and denied any needs. A physician's order, dated 10/04/24 at 5:15 a.m., documented morphine sulfate solution 100 mg per 5 ml give 0.5 ml orally every two hours as needed for pain and shortness of breath. A pain assessment, dated 10/04/24 at 5:41 a.m., documented Resident #2's pain was at a 10 on a numerical scale. The October 2024 MAR documented the morphine was initialed as given at 5:41 a.m. An Initial State Reportable Incident form, dated 10/27/24, documented an allegation of abuse/mistreatment. It documented an investigation was started based on a (social media name withheld) post. A Final State Reportable Incident form, dated 11/05/24, documented an allegation of abuse/mistreatment with an incident date of 10/04/24. It documented the family alleged the facility did not treat the resident's pain. The deficiency was determined to be a past noncompliance. The record review and interview below support a past noncompliance. An In-Service Training Form, dated 10/27/24, documented the facility provided ongoing training to staff over pain management, new resident admission process, and abuse. The facility conducted pain and new admit audits on residents for the month of November 2024. A QA summary form, dated 11/21/24, documented pain management was reviewed. On 12/04/24 at 1:16 p.m., ACMA #1 stated the process for pain management was to report to the nurse a residents complaint of pain and to administer pain medication if available. They stated if the resident did not have ordered pain medication they would let the nurse know so an order can be received from the provider. They stated they would stay with the resident until the resident received pain medication and offer non-pharmacological interventions. On 12/04/24 at 1:21 p.m., ACMA #1 stated it was unacceptable for a resident not to be offered pain medication if their pain rating was a 10 on a numerical scale. They stated a rating of 10 meant the resident was in a lot of pain. On 12/04/24 at 2:22 p.m., the VP of clinical services stated the staff should have notified hospice for a STAT order of pain medication for the resident with a rating of 10 on a numerical scale. They stated they could not locate a follow up pain assessment for the assessment conducted on 10/03/24 at 10:35 p.m. On 12/04/24 at 2:43 p.m., the VP of clinical services stated they conducted pain audits on all residents and new admits. They stated the facility did a staff in-service on pain and addressed the pain management in QAPI. The staff interviewed stated they had pain training in the month of November 2024.

Based on record review and interview, the facility failed to ensure residents' property was not misappropriated for three (#3, 4, and #7) of three sampled residents reviewed for misappropriation. The administrator identified 74 residents resided in the facility. Findings: An undated ABUSE, NEGLECT, EXPLOITATION AND MISAPPROPRIATION OF PROPERTY PROHIBITION policy, read in part, The Facility will ensure a safe environment for residents by prohibiting abuse, neglect, exploitation and misappropriation of resident property with mechanisms for reporting, investigating, and protecting residents from actual or potential harm. 1. Resident #7 had diagnoses which included hypertensive heart disease with heart failure. A nursing note, dated 08/03/24 at 1:50 p.m., documented the resident reported someone had moved their card in their wallet. They looked at their online banking and noticed that on 08/01/24 there were two withdrawals. One withdrawal was for $440 and one was for $500. An Initial State Reportable Incident form, dated 08/03/24, documented an allegation of misappropriation of resident property. It documented Resident #7 reported their bank card had been compromised and two different transactions were withdrawn for the sum of $900. It documented further information to follow. Resident #7's discharge assessment return anticipated, dated 11/07/24, documented the resident had memory problems. A Final State Reportable Incident form, dated 08/16/24, documented the resident was advised not to give cards or cash to staff at anytime to purchase outside items. It documented the staff member remained on suspension. 2. Resident #4 had diagnoses which included combined systolic and diastolic heart failure. Resident #4's quarterly resident assessment, dated 09/19/24, documented the resident's cognition was intact. A concern form, dated 10/25/24, documented Resident #4 asked for their bank card. The resident stated there was a charge on their bank account that was not theirs. A nursing note, dated 10/28/24 at 4:53 a.m., read in part, Resident came to the Administrator with concerns about their bank statement and money being taken through the use of their debit card over the past two years. Upon investigation, it was determined large amounts were taken by current and previous employees. This was reported to the State, APS, and Oklahoma police for investigation. An Initial and final State Reportable Incident form, dated 11/6/24, documented an allegation of misappropriation of resident property. It documented Resident #4's bank statement showed fraudulent activity. It documented two staff members were identified. 3. Resident #3 had diagnoses which included cerebral infarction. Resident #3's quarterly resident assessment, dated 09/27/24, documented the resident had moderate cognitive impairment. An Initial State Reportable Incident form, dated 11/5/24, documented an allegation of misappropriation of resident property. It documented the resident inquired about their debit card. The resident stated a staff member had their card in the safe. There was no card to be found in the safe. It documented the staff member was terminated for previous reportable of misappropriation. On 12/05/24 at 2:28 p.m., the administrator and VP of clinical services stated residents' cards were locked up in the social services office or business manger's office per preference. They stated residents could keep cards at bedside and a lock could be added to their nightstand. On 12/05/24 at 2:28 p.m., the VP of clinical services stated to protect residents from future misappropriation of funds, all cards were now locked in the business manager's office. They stated all purchase receipts from social services would be verified and kept by the business office manager.

Based on observation, record review, and interview, the facility failed to ensure a call light was within reach of a resident for one (#1) of three sampled residents observed for call lights in reach. The administrator identified 74 residents resided in the facility. Findings: A Call Lights: Accessibility and Timely Response policy, dated 05/2024, read in part, The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance. The policy also read, All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. The policy also read, Each resident will be evaluated for unique needs and performances to determine any special accommodations that may be needed in order for the resident to utilize the call system. The policy also read, Staff will ensure the call light is within reach of resident and secured, as needed. Resident #1 had diagnoses which included weakness and congestive heart failure. Resident #1's care plan for activities of daily living performance/deficits, revised 09/20/23, documented encourage to use call bell for assistance. Resident #1's quarterly resident assessment, dated 08/28/24, documented the resident had severe cognitive impairment. On 11/27/24 at 9:16 a.m., Resident #1 was observed in bed and the call light button was observed to have been tucked under the foot of the bed. The call light was not within reach of the resident. On 11/27/24 at 9:27 a.m., CNA #2 stated the policy for call lights was to have them close to the resident at all times. CNA #2 stated Resident #1 was able to use the call light and that morning the resident used it and they had tended to them. On 11/27/24 at 9:30 a.m., CNA #2 went into Resident #1's room for the call light and reached towards the foot of the resident's bed where the call light button was clipped to the bottom of the blanket. CNA #2 stated, They turned it upside down. CNA #2 removed the call light and clipped it near Resident #1's right hand. CNA #2 stated the resident could not have reached the call light and repeated that someone put the blanket on upside down. On 11/27/24 at 9:32 a.m., CNA #2 was asked how the resident would reach the call light with it upside down on the cover at the foot of the bed. They had no verbal response. 48344

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of misappropriation of resident property for one (#7) of three sampled residents reviewed for misappropriation of resident property. The administrator identified 74 residents resided in the facility. Findings: An undated ABUSE, NEGLECT, EXPLOITATION AND MISAPPROPRIATION OF PROPERTY PROHIBITION policy, read in part, The Facility will ensure a safe environment for residents by prohibiting abuse, neglect, exploitation and misappropriation of resident property with mechanisms for reporting, investigating, and protecting residents from actual or potential harm. Resident #7 had diagnoses which included hypertensive heart disease with heart failure. A nursing note, dated 08/03/24 at 1:50 p.m., documented the resident reported someone had moved their card in their wallet. They looked at their online banking and noticed that on 08/01/24 there were two withdrawals. One withdrawal was for $440 and one was for $500. An Initial State Reportable Incident form, dated 08/03/24, documented an allegation of misappropriation of resident property. It documented Resident #7 reported their bank card had been compromised and two different transactions were withdrawn for the sum of $900. It documented further information to follow. A Final State Reportable Incident form, dated 08/16/24, documented the resident was advised not to give cards or cash to staff at anytime to purchase outside items. It documented the staff member remained on suspension. The facility investigation did not identify the staff member who was suspended. The report to OSDH did not include supplemental documentation regarding the investigation. Resident #7's discharge assessment return anticipated, dated 11/07/24, documented the resident had memory problems. On 12/09/24 at 11:13 a.m., the VP of clinical services stated they could not determine all the steps that were taken to investigate the misappropriation or who was the suspended staff in the state reportable. They stated the investigation should include safe surveys and staff in-services. On 12/09/24 at 12:09 p.m., the VP of Clinical Services stated they do not believe a thorough investigation was completed.

Based on record review and interview, the facility failed to ensure labs were not collected without a physician order for one (#6) of three sampled residents reviewed for lab services. The administrator identified 74 residents resided in the facility. Findings: The Lab and Diagnostic Test Results-Clinical Protocol policy, revised 09/2012, read in part, The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. Resident #6 had diagnoses which included chronic peripheral venous insufficiency and nonrheumatic mitral valve insufficiency. A lab report, dated 10/13/24, documented a CBC, CMP, HbA1c and prothrombin time with INR were collected. There was no physician order to collect the labs. On 12/05/24 at 12:43 p.m., the VP of clinical services stated they could not locate a lab order for the labs collected on 10/13/24 for Resident #6. On 12/05/24 at 12:46 p.m., the VP of clinical services stated the facility's process for laboratory services was to receive an order from the provider, contact the lab, verify completion, retrieve results, notify the physician, and follow up on new orders if indicated.

Based on record review and interview, the facility failed to ensure resident identifiable records were not released to the public. The administrator identified 74 residents resided in the facility. Findings: A Resident Rights Guidelines for All Nursing Procedures policy, dated 10/2010, read in part, Staff must have appropriate in-service training on resident rights, including; Confidentiality of protected health information; A HIPAA Training Program policy, dated 04/2007, read in part, All facility personnel, including business associates, are required to attend our facility's HIPAA compliance training program. On 11/27/24 at 3:24 p.m., the previous administrator stated the process for releasing medical records was that once the request form was signed it would go to the corporate office. They stated the corporate office then would decide if there would be a charge and then would send out the records themselves. They stated records were not sent out unless the corporate office stated to do so. They stated the corporate office gave direction to send the records for Resident #1 by email to their daughter per their request. On 11/27/24 at 3:30 p.m., the previous administrator stated there were a couple of other resident records mixed in with Resident #1's records. They previous administrator stated they sent the records to corporate for their review and when they approved to send it, the previous administrator did not review before they sent the records to the family. The previous administrator stated they should have reviewed the record before sending and that it went against the policy. The exposed residents names were not provided. 48344

On 08/16/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2, who had a known history of unsafe smoking did not smoke in their room and catch themselves on fire. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident #2 was admitted to the hospital on 08/11/24 with second and third degree burns. On 08/16/24 at 11:45 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to for Res #2 smoking in their room and catching themselves on fire. On 08/16/24 at 11:47 a.m., the administrator was notified of the IJ situation. On 08/19/24 at 9:10 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan of Removal (Accident Hazards Related to Smoking Without Supervision) Tag Cited: F-689 (Accident Hazards Related to Smoking Without Supervision) Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. The facility asserts that the likelihood of serious harm no longer exists as of August 16, 20247 at 4:30 p.m. Issue Cited: The facility failed to supervise Resident #2, who had a known history of unsafe smoking, to ensure they did not have access to smoking materials or were supervised while smoking. As a result, Resident #2 caught on fire while smoking a lit cigarette in their room. The resident's daughter reported that Resident #2 is currently being treated at hospital for second and third degree burns to the abdomen and back. Identification of Residents Affected or Likely to be Affected: ( Completion Date 08/12/2024) a. Resident #2 was not in the building at the time of this survey b. [Resident #3] c. [Resident #1] d. [Resident #4] e. [Resident #5] f. [Resident #6] g. [Resident #7] Actions to Prevent Occurrence Recurrence: 1. Social Services conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status. 8-12-24 2. Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status. 8-12-24 3. Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status. 8-12-24 4. The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision. 8-12-24 5. The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers. 8-12-24 6. The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status. 8-12-24 7. The Administrator attended the Resident Council to review the smoking policy with the residents. 8-13-24 8. The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials. 8-12-24 9. The DON and the Administrator conducted a smoking in-service for all employees, which was completed on August 16, 2024, at 4:30 PM. Ongoing education will be provided to new staff and as needed. 10. The Administrator conducted QAPI to discuss the smoking policy and procedure, completed on August 15, 2024. 11. Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers, 8-12-24 12. The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions. 8-12-24 13. Admissions and Social Service will review the smoking times and policy with each new admission. 8-12-24. The immediacy was lifted, effective 08/16/24 at 4:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm. Based on record review, and interview, the facility failed to ensure a resident at risk for unsafe smoking did not have access to smoking materials and was supervised during smoking for one (#2) of three sampled residents reviewed for safe smoking. The administrator identified six residents who required supervision with smoking and 17 residents who smoked independently. Findings: The facility's undated, Resident Smoking policy, documented it was the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, included safety as related to smoking, and safety protections applied to smoking and non-smoking residents. The policy documented all residents and family member would be notified of the policy during the admission process and as needed, any resident who was deemed safe to smoke, with or without supervision, would be allowed to smoke in designated smoking areas in accordance with their care plan, all safe smoking measures would be documented on the resident's care plan, supervision would be provided as indicated on each resident's care plan, smoking materials of residents requiring supervision with smoking would be maintained by nursing staff or designee. Resident #2 had diagnoses which included unspecified dementia, psychotic disturbance, mood disturbance, and acquired absence of right leg below the knee. Resident #2's baseline care plan, dated 07/18/24, documented they required one person physical assistance with transfers, was alert, cognitively impaired, had a diagnosis of dementia, resident smoked supervised. The care plan also documented the resident's family provided cigarettes for Resident #2 but would like them locked up for the nurse to ration out or the resident would smoke them all. Resident #2's Smoking care plan, dated 07/19/24, read in part, [Resident #2] is a smoker. [Resident #2] has a history of being non compliant with facility smoking policies. The resident will not suffer injury from unsafe smoking practices through the review date. Interventions Instruct resident about smoking risks and hazards and about smoking cessation aids available. Date Initiated on 07/19/2024 Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 07/19/2024 Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 07/19/2024 The resident requires a smoking apron while smoking. Date Initiated: 07/19/24 The resident requires SUPERVISION while smoking. Date Initiated: 07/19/2024 The resident's smoking supplies are stored Hall 200 nurse cart. Date Initiated 07/19/2024 Revision 08/12/2024. A nurse's progress note, dated 07/23/24 at 5:26 p.m., documented the nurse observed Resident #2 in the smoking area holding their cigarette resident stopped looking at where the cigarette was and almost burned their leg, witnessed it again and placed a smoking apron on the resident, the resident refused the apron shortly after it was placed on the resident and stated, I can't wear this, it swallows me. The note documented the nurse notified the activities director that the resident did not use the big aprons and they stated they would follow up on it in the morning. An admission assessment, dated 07/24/24, documented Resident #2's cognition was intact, had no behaviors of rejection of care, wandering, physical or verbal aggression, had limited range of motion lower extremity and utilized a wheelchair for ambulation, needed supervision or touching assistance for transfers to and from bed to chair. A nurse's progress note, dated 07/29/24 at 4:36 p.m., documented Resident #2 had fallen outside in smoking area, nurse assessed the resident and no new injuries were noted, upon questioning Resident #2, they stated that they were bending over to pick up a cigarette butt off of the ground to smoke and fell over, two residents who were outside witnessed the incident and stated the resident did not hit their head. A nurse's progress note, dated 07/30/24 at 3:54 p.m., documented Resident #2 continued to go outside and smoke without staff supervision, nursing staff giving frequent reminders on safety and requesting assistance as needed. A nurse's progress note, dated 07/31/24 at 5:02 p.m., documented Resident #2 continued to propel self in wheelchair to go out and smoke without supervision, Resident #2 was verbally aggressive, demanding cigarettes from other residents and remains non-compliant with safe smoking protocols, nursing staff giving frequent reminders on safety and requesting assistance as needed. A nurse's progress note, dated 07/31/24 at 6:16 p.m., documented Resident #2 was self propelling themselves outside to try to smoke unsupervised and resisted all attempts to redirect. A nurse's progress note, dated 08/01/24 at 3:53 p.m., documented Resident #2 was seen by staff and other residents this morning falling asleep while in the smoking area with a lit cigarette in their hand, staff stated they picked up the cigarette out of Resident #2's lap but the resident's clothing was singed, the nurses assessed the resident and saw no new concerns to skin at the time. The progress note also documented the DON stated Resident #2 should go with staff and resident was notified that they would need to begin smoking with staff and the only time they could go smoke was with staff and they asked Resident #2 if they could have their lighter, Resident #2 handed over their lighter to the staff. A document titled, Incident Report Form, dated 08/11/24, read in part, Initial .Certain Injuries .investigation initiated .Resident was seen headed out to the smoking area by on duty nurse. Nurse went to another hall, upon return [they] heard resident yelling out for help. Resident was found in room with a lit cigarette and clothing on fire. Nurse used blanket to put fire out. Resident had burns and was sent out to ER . An ambulance report, dated 08/11/24, documented upon arrival Resident #2 was found sitting in their wheelchair with burns. Nurse had advised that she had been passing dinner trays and heard the resident yelling help me, the nurse went to the room and found Resident #2's torso to be on fire, the resident's shirt was noted to be on the floor and burned. The report also documented the wheelchair had areas where it had melted, the resident's brief and pants were also melted on the left side waist band. The nurse reported they did not know how the resident had gotten a lighter into their room. A document titled, ED to Hospital Admission-Burn ICU, dated 08/11/24, read in part, impression: Acute pain .Burn involving 10-19 % of body surface, third degree burn less than 10% .14% [total body surface area] flame burn Third degree burn chest .Left upper extremity .Plan for debridement and grafting on 8/13 . The admission assessment also read, .Full thickness burn of chest wall .Full thickness burn of multiple sites of left upper extremity .17% [total body surface area] flame burn . A document titled History and Physical, dated 08/11/24, documented Patient initially sustained burn injuries on 08/11/24 after being found by nursing facility staff at 6:14 p.m., the nursing staff heard the patient crying out in their room and found them on fire sitting in their wheelchair. The patient sustained burn injuries to the left flank, torso, and left upper extremities. The fire was put out by the nursing staff and EMS was notified. Patient was brought to the emergency department and admitted with a diagnosis of 17% total body surface area flame burn. Due to the patient's dementia, it is unclear the event leading up to the incident, but patient reportedly states they were attempting to light a cigarette. A document titled, ED Provider Note, dated 08/11/24, read in part, Left side of the patient's head has burn marks to the hair without burns to the face itself .Left upper inner arm noted to have a PICC in place .PICC tubing does have evidence of melting noted . On 08/15/24 at 4:02 p.m., Resident #11 stated they kept their cigarettes and lighter with them. Resident #11 stated they were told by staff another resident tried to burn themselves up by smoking in their room. On 08/16/24 at 6:41 a.m., Resident #10 was observed in the smoking area. Resident #10 was asked if other residents had requested cigarettes or a lighter from them. They stated yes, a couple of times. Resident #10 stated the staff had told them not give other residents cigarettes or lighter. On 08/16/24 at 6:45 a.m., Resident #9 was observed in the smoking area. Resident #9 stated other residents had asked them for cigarettes and they had given them a cigarette. On 08/16/24 at 7:11 a.m., Resident #8 was observed in the smoking area. Resident #8 stated they were allowed to smoke when they wanted and had their smoking material on them. Resident #8 stated the staff brought some residents out and assisted them with putting on an apron and stayed with them while they had a cigarette. Resident #8 stated at times the staff would leave the residents who needed assistance and go in and get something but the resident would not have a lit cigarette and they would come right back out. Resident #8 was asked if any residents had asked them for cigarettes and/or lighter. They stated yes, and they would tell them no. Resident #8 stated a CNA had told them a resident had burned themselves smoking in their room. On 08/16/24 at 7:44 a.m., CNA #5 stated they had been working the day Resident #2 caught on fire. They stated it had happened during shift change and they were not aware how it had happened and they had not taken Resident #2 out to smoke. On 08/16/24 at 8:06 a.m., CNA #4 stated Resident #2 had tried to smoke in the building before 08/11/24. CNA #4 stated the facility did not have interventions in place to ensure the resident did not have a cigarette or lighter when they came back in from the smoking area. They stated the nurses kept Resident #2's cigarettes and lighter on the nurse's cart. CNA #4 stated on one occasion when they smelled smoke they had checked Resident #2's room and notified the charge nurse, they stated they did not find anything and kept a close eye on the resident that day. CNA #4 was asked if they had an in-service related to the smoking incident since it had happened. They stated, No. CNA #4 was asked what interventions had been put in place to prevent the resident from going out to smoke unsupervised or smoking in the building. They stated they would put him up by the nurses' station. On 08/16/24 at 8:17 a.m., LPN #3 stated they went in Resident #2's room after the fire had been put out and the resident had a cigarette in their hand. LPN #3 stated Resident #2's shirt was burnt, their abdomen, left side flank/back area, and upper forearm was burned and the resident's hair and eyebrows were singed. LPN #3 was asked how the resident had gotten the cigarette and lighter. They stated the cigarette was short and they did not know how the resident had gotten it. LPN #3 stated Resident #2 would sit by the nurses' station and ask for cigarettes. LPN #3 stated Resident #2 required supervision when they smoked. On 08/16/24 at 8:30 a.m., CNA #2 stated they had just gotten to work on 08/11/24 when the incident had happened with Resident #2 setting themselves on fire. They stated they did not know how the resident got the cigarette or lighter. CNA #2 stated LPN #1 had found a lighter in Resident #2's room but did not say how the resident got the lighter. On 08/16/24 at 8:42 a.m., LPN #4 stated they had smelled smoke and found a cigarette butt in Resident #2's pocket. LPN #4 was what interventions were in place to prevent Resident #2 from smoking in the building. They stated they would take the resident out to smoke extra times because the resident became fixated on smoking and was hard to redirect. LPN #4 stated Resident #2 would follow them down the hall and ask to smoke. LPN #4 stated when the resident was admitted all of their clothes had what looked like cigarette burn holes in them. LPN #4 stated Resident #2 was not safe to smoke unsupervised. LPN #4 stated they had found a cigarette on Resident #2 twice in one day. On 08/16/24 at 9:31 a.m., Resident #2's family member stated they were not there when the resident caught themselves on fire and did not know how the resident got the cigarette or lighter. They stated Resident #2 required supervision while smoking. Resident #2's family member stated they thought the resident knew the smoking rules but the resident had dementia and had to be reminded they were at the facility because of their foot. Resident #2's family member stated the resident was in the burn unit with third degree burns to their back, second degree burns to the chest. Resident #2's family member stated they had not given the resident the cigarettes or lighter. They stated they had given the cigarette and lighter to the nurses. On 08/16/24 at 9:51 a.m., the administrator was asked what occurred when Resident #2 caught themselves on fire. The administrator stated based on interviews and phone calls the nurse reported Resident #2 was injured in a fire. The resident was outside being supervised, came back to their room and the nurse heard the resident yelling for help, the nurse saw the resident on fire, and put the fire out with a blanket. The administrator stated they did not know who had been supervising Resident #2 while they had been smoking. The administrator stated they had not interviewed all the staff who had worked that day. The administrator stated the staff they had talked to did not say who had supervised Resident #2 while they were smoking. The administrator stated the staff reported the resident was non-compliant with the smoking policy. The administrator was asked what interventions had been put in place for the resident to prevent smoking accidents. They stated they had told the other residents not to give out cigarettes or lighters to other residents, staff was to monitor Resident #2 while smoking, attempted care plan meeting with family and resident, and smoking cessation medication. The administrator stated Resident #2 had smoked approximately an hour before they had caught themselves on fire but did not know who had supervised the resident. An email statement from the former DON, dated 08/16/24 at 10:06 a.m., read in part,[Resident #2] was determined to be a supervised smoker upon admission. [Resident #2] was non-compliant with care and with smoking policy. Many educational conversations were had with the resident [related to] following the smoking policy, allowing staff to assist to smoke, and wearing smoking apron. Resident refused to wear smoking apron, continuously demanded cigarettes from other residents, and would go outside without alerting staff or asking for help. Staff educated all other residents not give cigarettes to resident. Staff obtained orders for medication to assist with smoking cessation. Facility attempted to set up a care plan meeting with [family] and resident but both declined to come to meeting. [Family] was informed of all incidents with resident and stated that these were not new behaviors . On 08/16/24 at 10:48 a.m., the administrator stated they would have to look in the computer to see when the resident required smoking supervision. The administrator stated the DON usually answered these questions however the current DON was new and was not here when the incident occurred. The administrator was asked if anyone had followed up to get Resident #2 a smaller smoking apron as stated in progress note on 07/23/24. They stated they would have to check. The administrator was asked how the resident had fallen in the smoking area trying to pick up a cigarette butt if they were being supervised. They stated the staff may not have gotten to the resident in time to prevent them from falling. The administrator was asked what interventions were put in place to prevent Resident #2 from going out to smoke unsupervised besides redirecting. They stated they would have to check. The administrator was asked if there had been any new interventions put in place on 07/31/24 when the resident was asking other residents for cigarettes. They stated they would have to look. The administrator was asked how Resident #2's clothes became singed on 08/01/24 if the resident was being supervised. The administrator stated they would have to check. On 08/16/24 at 1:12 p.m., CNA #6 stated they had received an in-service today 08/16/24 right before lunch related to residents smoking. The CNA stated this was the first in-service they had received this week related to residents smoking. On 08/16/24 at 1:13 p.m., CNA #4 stated they had received an in-service related to smoking around 12:30 p.m. CNA #4 was asked if they had received any other in-services this week related to residents smoking prior to today. They stated, No. On 08/16/24 at 1:28 p.m., housekeeper #1 stated they had received an in-service related to residents smoking today 08/16/24. They stated this was the first in-service related to resident smoking they had received this week. On 08/16/24 at 1:40 p.m., CMA #1 stated they had not received an in-service this week. They stated they had last worked on Sunday 08/11/24.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive care plan for two (#47 and #73) of 18 residents reviewed for care plans. The administrator identified 76 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised 2016, read in part, the comprehensive care plan will describe, at a minimum .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, the comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. 1. Resident #47 admitted on [DATE], had diagnoses that included sepsis, atrial fibrillation, and congestive heart failure. Resident #47's admission assessment documented resident #47 was on hospice services and required moderate to maximal assist with toileting, dressing, bathing, bed mobility, and was unable to walk. On 05/29/24 at 10:50 a.m., MDS #1 stated a 48-hour baseline care plan was initiated on 03/27/24, but no comprehensive care plan had been initiated. 2. Resident #73 admitted on [DATE], had diagnoses that included infection due to left knee prosthesis, acute osteomyelitis of left femur, and heart disease. Resident #73's admission assessment documented they required moderate assistance with toileting, bathing, dressing, transfers and were unable to walk. The Comprehensive care plan documented only that the resident was a fall risk and was admitted on antibiotic therapy. On 05/30/24 at 11:05 a.m., MDS Coordinator #1 stated the care plan was not fully developed.

Based on observation and interview, the facility failed to ensure incontinence care was provided in a timely manner for one (#24) of four dependent residents observed for timely overnight incontinence care. The administrator identified 48 residents were dependent for incontinence care. Findings: The Urinary Incontinence-Clinical Protocol policy, revised 2012, read in part, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Resident #24 was admitted [DATE] with diagnoses that included aphasia following cerebral infarction. Resident #24's quarterly assessment dated [DATE] documented they are unable to speak, can only sometimes understand, has severe cognitive impairments, functional impairments to all four extremities, requires tube feedings, and is dependent for all care. On 05/31/24 at 5:05 a.m., CNA #1 stated the policy is to check and change every 2 hours, but the staff is not supposed to use briefs at night unless the resident requests it. On 05/31/24 at 5:31 a.m., Resident #24 was changed, the gown and all the padding beneath them were wet. There was a dark yellow ring visible on the blue pad beneath them. LPN #1 states the resident was last changed at 2:00 a.m. On 05/31/24 at 5:49 a.m., CNA #3 stated that Resident #24 was unable to use the call light and staff were supposed to check on them every couple of hours. On 05/31/24 at 5:57 a.m., CNA #2 stated the policy was to turn and provide incontinent care if needed every 2 hours, they were not to use briefs if there was a wound. CNA #2 stated that Resident #24 was last changed at 2:00 am.

On 07/23/13, an immediate jeopardy was determined to exist in regard to the facility's failure to protect residents with compromised skin integrity and sensory depravation from being burned with second and third degree burns over 4% to 5% of their body while being assisted in the shower. On 07/23/13 at 1:15 p.m., the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy. At 1:30 p.m., the administrator was informed of the existence of the immediate jeopardy. On 07/23/13 at 3:30 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Immediate action taken 1- Hot water to all resident care areas turned off at approximately 1:40 p.m. 2- Plumber notification for evaluation of anti-scald valves at approximately 1:45 pm and is in the facility at approximately 2:40 pm. 3- Staff that provides baths to facility residents will be reeducated of water temperature safety during bathing (Reeducation beginning at approximately 2:00 pm) to be concluded by five pm 7-24-13. Staff will monitor water temperatures prior to bathing as well as throughout bathing. 4-Skin evaluations in progress on resident with similar sensation deficits. (Complete at 2:15 pm) 5- Medical director assessment of resident identified to have been affected. (Complete at 2:15 pm) 6- C.N.A. that bathed identified Resident will be re-educated of bathing process (approximately 1:45 pm) 7- Residents that have been identified to have similar sensation deficits will be assisted in choice in bathing water temperatures. (Temperatures will be set at acceptable degree for resident) 8-Maintenance will check water temperatures in shower areas every hour from seven am through seven pm. 9- Hospice staff that bathed facility residents will be educated to facility policy by five pm 7-24-13." On 07/25/13 at 12:35 p.m., after interviews with staff, review of inservices, observations of water temperatures in the shower rooms, the administrator was informed the immediacy had been lifted on 07/24/13 at 5:00 p.m., and the deficient practice remained at a level of actual harm. Based on observation, record review and interviews, it was determined the facility failed to ensure a resident with sensory depravation was not scolded while being assisted in the shower for one (#1) of three sampled residents who had little or no feeling in their extremities. The temperature reading ranged from 113.5 degrees Fahrenheit to 125.9 degrees Fahrenheit in the shower room on hall 200 and between 98.7 degrees Fahrenheit to 123.5 degrees Fahrenheit in the shower room on hall 300. This resulted in an immediate jeopardy and actual harm. This had the potential to affect four residents who had compromised sensory feeling, compromised skin integrity and was dependent on staff for showering. Findings: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident made himself understood, usually understands others and his cognition was intact. The resident required extensive assistance with transfers, hygiene, bathing and had impairment on both sides of the upper and lower extremities. The assessment also documented the resident was at risk for developing pressure sores and had one stage four pressure ulcer on admission. A care plan dated 04/25/13, documented, "Problem: communication deficit: hearing impaired as evidenced by minimal difficulty when not in quiet setting...understands usually.... Problem: Residents ADL (assistance of daily living)...transfers, bathing, dressing and personnel hygiene ext (extensive) assist...Goal: will maintain a sense of dignity by being clean, dry, odor free and well groomed....approach: set up assist, give shower, shave, oral, hair, nail care....assist with ADls as needed, assist with repositioning as appropriate...". A laboratory draw dated 05/01/13, documented the resident Prealbumin was 15.1. The reference range was 18.0 - 45.0 mg/dl. The Prealbumin level was low. A care plan dated 06/06/13, documented, "Problem: admitted with multiple wounds..." A ninety day medicare assessment dated [DATE], documented the resident condition remained the same and had no declines or improvements. A review of the "Water Temperature Log" for June and July 2013, documented the maintenance director took water temperatures three times a week in one room on each hall the kitchen and laundry. There was no documentation of water temperatures being taken in the resident shower room. An incident report dated 07/10/13, documented, "Dated of incident: 07/10/13...other injury: reddened blistered like areas on (L) thigh and (L) side of his body..." The incident report was signed by the director of nursing. A "Daily Skilled Nurse's Note" dated 07/10/13, documented, "(1100) called to BR (bathroom) per CNA(certified nurse aide) showed me redness and blister like areas on elders (L) thigh and (L) side of his body. Elder didn't know how it happened and he denies pain or discomfort at site....(Physician #1) notified and new orders for silvadene..." A physician's telephone order dated 07/10/13, documented, "Apply Silvadene to reddened blister like areas on (L) side and posterior thigh BID (twice a day) and PRN (as needed) X (times) 5 days cover /c (with) non adherent dressing..." The telephone order was written by the director of nursing and signed by the physician on 07/12/13. The report did not indicate where the resident was located when the area was first identified and who identified and reported the skin problem to the director of nursing. A care plan dated 07/10/13, documented, "Problem: Resident has current skin concerns: large reddened blister like area of unknown origin to left side posterior.. Goal: areas will heal without complications over next 90 days... Interventions...perform treatments per order if no improvement X 2 weeks report to M.D. (medical doctor)...observe areas for increase skin breakdown, s/s (signs and symptoms) of infection....observe for pain, give med per order, monitor for relief...encourage p.o (by mouth) and fluid intake with dietary limits...Silvadene dsg (dressing) per current orders...07/12/13 D/C (discontinue) pervious wound care orders...apply meplex ag ...07/15/13 appt (appointment) @ (at) wd (wound) clinic....07/18/13 & 07/22/13 leave dsg intact to (L) thigh..." An undated "Investigation Report" documented, "Summary of alleged incident: Burn caused by the hot water in the shower room to res (resident) (L) leg...." A progress note dated 07/12/13, from the burn clinic documented, "...(Resident) is a quadriplegic gentlemen who resides in a nursing home. We have been following him for a rotational flap closure of a previous sacral pressure sore...He reports that at his nursing home this week he was receiving a bath. He did not feel the water running next to his left thigh was hot and he was inadvertently burned during this shower. He states that the nursing home has been applying daily dressing to this area...physical examination...on his left lateral thigh, he has approximately 3% total body surface area open wound. The dermis is blistered and peeled away...assessment...A 3% total body surface area superficial and deep partial-thickness scald burns to his left thigh....plan...he may need some skin grafting of this thigh wound..." A physician's telephone order from the wound clinic dated 07/12/13, documented, "DC (discontinue) pervious wound care orders. Apply Mepilex AG to (L) thigh buttock and sacrum....leave dressing intact until appt (appointment) on 07/15/13 at 1300 (1:00 p.m.)." A report to the Oklahoma State Department of Health dated 07/12/13 documented, "Description of incident: Resident states the wound clinic told him he has a burn on his L thigh. Skin eval (evaluation) complete, resident has multiple wounds and fragile skin. Red blistered area noted to left thigh. Doctor aware of all skin issues and treatment in place. Resident stated he noticed in the shower room when a CNA was giving him a shower...Resident stated he had felt the water temperature and it did not feel hot. Resident stated the water was barely warm... relevant history: Alert and oriented. Able to make needs known, wounds, malnutrition..." The report was signed and submitted by the assistant director of nursing. A follow up report to the Oklahoma State Department of Health documented, "...Wound nurse evaluated wound and noted that new area is in the same place as a past skin graft. This area of skin much more sensitive. Facility currently attempting to obtain notes from the doctor at the wound clinic... Medical director of facility evaluated wound unable to determine cause at this time... It was found that CNA who gave the resident a shower on the date resident specified was (certified nurse aide #1). CNA stated he had given the shower on that day. He stated he had trouble getting the water warm enough to give the shower so he let the resident feel the water and the resident told the CNA that it was not that warm but he could work with it... When the CNA was drying resident off he noted the red blistered area and notified the nurse assigned to resident who came and evaluated the area. Nurse was (director of nursing) stated he was unsure of what the area was from..." A progress note dated 07/15/13, from the burn clinic documented, "History...He returns today for a follow up. The patient came to clinic last week and was identified with having a significant burn on his left thigh...adult protective services has been informed...His burn was being treated with Mepilex Ag...physical examination...The patient has a burn involving the lateral aspect of the left thigh that covers his left hip and then goes down to the buttock...the burn on the lateral proximal thigh is deep. He has an area on the lateral aspect of the left thigh going up toward the hip that is deep and it is white....impression and plan: Second and third degree burns to the left hip region approximately 4% to 5% total body surface area. The patient is going to need these areas excised and grafted..." A physician's telephone order from the wound clinic dated 07/15/13, documented, "Appt at wound clinic 07/18/13 and 07/22/13 at 1330 p.m. (1:30 p.m.)...leave drsgs intact to...(L) thigh...until appointment...." A progress note dated 07/16/13, by physician #1, documented, "...Recently I received a phone call from one of his nurses who reported that they had identified [DIAGNOSES REDACTED] on his left thigh and possibly lower back area. The area was noted to be from a possible burn.." A physician's telephone order from the wound clinic dated 07/22/13, documented, "...(L) thigh leave intact to be (changed) @ clinic return to clinic Thursday 07/25/13 at 1:00 p.m." An interview was conducted on 07/23/13 at 8:35 a.m., with resident #1, regarding the care he received at the facility. He was asked if there had been any problems with the water temperatures while taking a shower. He stated, "The water scalded me. The water was cold then got hot." He was asked how he knew the water was hot. He stated, "I saw the steam coming from the water." He then stated, "I don't have feelings in my hands and legs because I'm a quadriplegic." He was asked who was in the shower room with him when he sustained the burns. He stated, "The aide was there and went to the other side of the curtain to get the shaver." He was asked if the facility did anything about the burn. He stated, "(Director of nursing) came and looked at me." The resident then showed the surveyor his left hip and thigh with the burns. On 07/23/13 at 8:35 a.m., the hospice aide walked into the shower room located on hall 200 while the temperatures were being taken. The aide saw the surveyor and stated, "I guess they will fix it. It gets so hot it can scald people." An interview was conducted on 07/23/13 at 10:00 a.m., with the hospice aide. She was asked about the statement she had made earlier. She stated, "This morning it was very hot and could scald someone." She was asked if there had been problems with the water in the shower rooms. She stated, "It can scald. It could give a second or third degree burn. It is cold then turns hot without knowing." She was asked if she told someone at the facility about the problem. She stated, "I first told them about it two Fridays ago." An interview was conducted on 07/23/13 at 10:25 a.m., with certified nurse aide #1. He was asked if he provided resident #1 with the shower on 07/10/13. He indicated he did. He was asked if he looked at the resident's skin condition prior to providing the shower. He stated, "I didn't notice any blisters or skin problems prior to the shower." He was asked when the resident had developed the blisters and skin problem on his left hip and thigh. He stated, "I noticed the redness after the shower was done." He then stated the skin had started to peel off when he was drying the resident. He was asked if he notified anyone about the skin problem he identified at the end of the shower. He stated, "I told (director of nursing) who looked at the skin and called the doctor." He was asked if there had been any problems with the water temperatures in the shower room prior to 07/10/13. He stated he hadn't told anyone about it and it was two weeks prior that he knew about the problem. He was asked how he would determine if the water was an appropriate temperature for a resident. He stated, "I'll ask the resident." He was asked to describe resident #1's ability to feel temperatures. He stated, "He has some feeling in his hands. It's just a bit." He then added, "It's not full feeling." He was asked what caused the burn on the resident. He stated, "The water probably." An interview was conducted on 07/23/13 at 11:50 a.m., with the director of nursing. He was asked to describe resident #1's ability to accurately feel. He stated, "He doesn't feel anything." He was asked if he looked at the resident's skin after the resident had a shower on 07/10/13. He stated, "Red area with blisters on left side." He was asked what caused the blisters and red area. He stated, "An accident from the water." He was asked what the physician said about the condition of the resident's skin. He stated, "It was diagnosed as a burn." He then stated physician #1 provided a telephone order for silvidene for the resident's skin. An interview was conducted on 07/23/13 at 12:15 p.m., with the maintenance director. He was asked how often he took water temperatures. He stated, "Three times a week." He was asked were he took the water temperatures. He stated, "One random room on each hall, kitchen and laundry." He was then asked about the shower rooms. He stated, "I take them but don't document them." He was asked what the last temperature was in the shower room. He indicated he did not know. He was asked how long he would let the run while taking the temperatures. He stated, "Two minutes." An interview was conducted on 07/23/13 at 12:25 p.m., with the assistant director of nursing. She was asked who investigated how the resident received the blisters on the left hip and thigh. She stated, 'She did not investigate or talk with anyone when she received the report." She was asked if it was unusual for a resident to have blisters on his left leg and thigh. She stated, "I knew a person might get blisters if they have a bad case of MRSA (Methicillin resistant staph Aureus." She was asked if the resident had MRSA. She stated, "No, but I didn't know it wasn't until I investigated it." She was asked if she spoke with the director of nursing or the certified nurse aide who identified the resident's skin problem after a shower. She indicated she did not. She was asked what caused the second and third degree burns on the resident's left hip and thigh. She stated, "I found out two days later it was a burn." On 07/23/13 at 12:35 a.m., the left hip and thigh burn was again observed. The skin was observed with reddish brown skin without drainage. The area was approximately seven inches long and extended from mid chest down the resident's left side to approximately one inch above the knee. A licensed practical nurse asked the resident if he was in pain. The resident stated, "I can't feel it. That's why it got burned." On 07/23/13, from 11:07 a.m. through 11:17 a.m. the temperature in the hall 200 shower room was taken and the following results were observed: 11:07 a.m. 113.5 degrees Fahrenheit 11:11 a.m. 125.6 degrees Fahrenheit 11:13 a.m. 125.9 degrees Fahrenheit 11:15 a.m. 125.9 degrees Fahrenheit 11:17 a.m. 113.5 degrees Fahrenheit On 07/23/13, from 11:37 a.m. through 11:47 a.m., the temperature in the hall 300 shower room was taken and the following results were observed: 11:37 a.m. 98.9 degrees Fahrenheit 11:41 a.m. 119.9 degrees Fahrenheit 11:45 a.m. 119.9 degrees Fahrenheit 11:47 a.m. 123.6 degrees Fahrenheit An interview was conducted on 07/23/13 at 1:50 p.m., with physician #1, who was the medical director and the attending physician for the resident. He was asked about the incident on 07/10/13. He was asked if he assessed the resident's left hip and thigh. He stated, "I saw it the next visit." He was asked when he was notified by the facility of the resident's left hip and thigh. He stated, "(Director of nursing) called and said he thought it was caused by the water." He indicated he knew about the same day the incident occurred. He was asked what caused the blisters and redness on the resident's skin. He stated, "It's first degree and some second degree burns." He was asked what had caused the burns. He again stated the director of nursing said water.

On [DATE], an immediate jeopardy situation was determined to exist in regards to the facility's failure: ~ to immediately notify the physician of a resident who had become severely hypoglycemic after given a total of 28 units of Novalog insulin earlier, within a period of 5 hours; ~ to assess the resident after the blood glucose did not register when measured, the blood glucose had registered as "lo"; ~ to monitor the resident's blood glucose at regular intervals after the [MEDICATION NAME] had been administered; ~ provide the appropriate emergency outside services for this resident; who had a decreased level of consciousness. The resident was found to have no pulse and blood pressure one hour and 25 minutes after the initial FSBS (finger stick blood sugar) reading of "lo" had been obtained. Only one additional FSBS had been obtained, 40 minutes after the initial reading of "lo"; and ~ failed to administer correct doses of sliding scale insulin as ordered by the physician for two sampled diabetic residents and failed to notify the physician of blood sugars outside of defined parameters for one of these residents. At 8:30 a.m., the Oklahoma State Department of Health was notified of and verified an immediate jeopardy situation. At 8:40 a.m., the administrator and the director of nurses were notified of the IJ situation, which constituted substandard quality of care. At 12:10 p.m., the following plan of removal was submitted to the surveyors and accepted: "Plan of Removal For Quail Creek Nursing Center February 14, 2011 1. All residents with a [DIAGNOSES REDACTED]. This was completed at 10:00 a.m. on Monday, February 14, 2011. The residents' physician have been notified if any resident is outside those acceptable limits (for that particular individual/resident). 2. The facility shall immediately in-service all L.P.N.'s and R.N.'s in the facility, then all other's before the start of their next shift. This in-service will ensure awareness of the signs and symptoms of hyper and [DIAGNOSES REDACTED]. In addition, the in-service will include (1) the ability to be able to read a sliding scale order and correctly administer a sliding scale insulin dose as ordered, and (2) the administration of [MEDICATION NAME] as ordered, re-check the finger-stick within 10 minutes, (3) immediately notify the physician and (4) immediately begin transfer procedures to the emergency room for further treatment. (5) Accurate documentation of the insulin administration per the sliding-scale. (6) If the finger-stick remains low, the finger-sticks will continued (sic) to be Monitored every 30 minutes until they are within acceptable limits established by the residents' physician. 3. The facility has implemented an addendum to the policy and procedure for routine and PRN finger-sticks and insulin administration. Guidelines have been established for the administration of insulin, the documentation of that administration, and physician notification of abnormal readings. All insulin administered in the facility will require verification by two signatures. 4. The facility QA/CQI (sic) will monitor finger-sticks and insulin administration for accuracy daily for the one week, then weekly for 4 weeks for continued compliance." At 12:10 p.m., the following addendum was presented with the plan of removal: "Addendum to the Policy and Procedure for the obtaining of a Fingerstick Glucose Level for Diabetic Care Date: February 14, 2011 Steps in the procedure: Page 6 20. All insulin to be administered shall have the verification of two (2) nurses, who will both initial the MAR. The A.M. finger-stick will be completed by the day shift nurse. All sliding-scale insulin will also be completed by the day shift nurse. All sliding-scale insulin will also be verified and documented by two (2) nurses. 21. If [MEDICATION NAME] is to be administered, the finger-stick will be repeated within 10 minutes of administration, the residents (sic) physician will immediately be notified, and transportation arrangements to the ER for further treatment will immediately be initiated. Documentation of the residents' condition, nursing interventions, physician notification, transportation arrangements to the ER, and patient outcomes will be reflected in the nurses notes, MAR's, etc. 22. Finger-sticks outside any residents' sliding-scale parameters will immediately be called to the physician for further orders. Documentation of the residents' condition, nursing interventions, physician notification, transportation arrangements to the ER, and patient outcomes will be reflected in the nurses notes, MAR's, etc. 23. If the finger-stick remains low, the finger-sticks will continued (sic) to be monitored every 30 minutes until they are within acceptable limits established by the residents' physician." At 9:30 a.m., the administrator and the DON announced they had started to in-service all nurses. At 4:00 p.m., the administrator and DON stated all licensed staff had been in-serviced by 2:30 p.m., with the exception of one RN and one LPN. They stated the facility had suspended the employment of that RN and LPN pending their attendance of the in-service provided to all licensed staff. The IJ was removed at 2:30 p.m., after all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on record review and interview, it was determined the facility failed to: a. Provide the following services for a resident with a decreased level of consciousness and a blood glucose that did not register when measured: - Immediately contact the physician for guidance in an emergency situation, - Monitor the resident's blood glucose after the [MEDICATION NAME] had been administered at regular intervals, and - Provide outside emergency medical services to maintain the life of the resident for 1 (#14) of 8 sampled residents who received insulin via the sliding scale. The resident was found without pulse and blood pressure one hour and 25 minutes after the initial FSBS reading of "lo". This had the potential to affect 21 residents identified by the facility who received insulin via the sliding scale. b. Ensure two (#2 and #10) of eight sampled residents who received sliding scale insulin received it as ordered by the physician, and failed to notify the physician of blood sugars outside of defined parameters for one (#2) of these eight sampled residents. This had the potential to affect 21 residents identified by the facility who received sliding scale insulin. c. Ensure an enteral feeding was given per physician's order for one (#15) of two sampled residents who received nutrition through a feeding tube. This had the potential to affect three residents identified by the facility who received enteral feedings. Findings: 1. Resident #14 was admitted on [DATE], from a local hospital where her discharge summary listed [DIAGNOSES REDACTED]. The summary did not identify diabetes as a diagnosis. Hospital records documented the resident was started on total [MEDICATION NAME] nutrition on [DATE]. Insulin, [MEDICATION NAME] 50% and [MEDICATION NAME] were ordered to be given as needed on [DATE]. (Glucose management is often needed for patient's with or without a [DIAGNOSES REDACTED].(www.caribhealthnetwork.com/pCareTPNNutritionalRequirement.aspx)) The total [MEDICATION NAME] nutrition was discontinued prior to discharge. The hospital discharge summary included a list of medications to start for the resident. Included in this list was Novalog insulin. There were no instructions regarding dosage or frequency. Admission/start-up orders, dated [DATE], documented, FSBS AC & HS (bedtime), sliding scale insulin: ,[DATE] = 3 units ,[DATE] = 5 units ,[DATE] = 8 units ,[DATE] = 12 units ,[DATE] = 16 units >320 = 20 units The initial care plan, dated [DATE], identified [DIAGNOSES REDACTED]. The care plan did not identify a [DIAGNOSES REDACTED]. A Glycohemoglobin A1C lab test performed on [DATE], documented a result of 4.6 with a reference range of 4XXX,[DATE].1 as normal. The lab report documented, "The level of glycohemoglobin is an approximate index of the average blood glucose during the preceding ,[DATE] months. The table shows the predicted relationship between glycohemoglobin and average plasma glucose." The report documented 4% Glycohemoglobin A1C would equal an average glucose level of 60 and 5% Glycohemoglobin A1C would equal an average glucose level of 90. The five day medicare assessment, dated [DATE], documented the resident required extensive assistance with ADLs, had anxiety and depression. The wheelchair was the resident's primary source of mobility. The assessment documented the resident had Diabetes and had received insulin injections five times in the previous seven days. A physician's progress note, dated [DATE] at 7:00 a.m., documented the resident had non insulin dependent diabetes mellitus and "Await lab results and follow fingerstick blood sugars." Skilled daily nurses' notes, dated [DATE], documented: "1600 (4:00 p.m.) Res c (with) eyes open & appears to focus c (with) verbal stim (stimuli). Appears to be oriented to person, but does not answer questions approp (appropriately). Daughter @ bedside. VS checked: BP=,[DATE] - ,[DATE] (blood pressure ,[DATE], pulse 76 and respirations 16). SPO2 96% on RA (room air). FSBS (checked) c result of 'lo'. [MEDICATION NAME] kit reconstituted & given SQ immediately- cont to monitor. 1615 (4:15 p.m.) Res appears to be more alert but still does not answer questions approp. Daughter remains @ bedside. 1640 (4:40 p.m.) FSBS rechecked. Result = 39. 1645 (4:45 p.m.) Dr. (name deleted) paged. Attempted to give sugar sublingually but daughter stated res 'won't be able to take that.' Attempted to explain giving some sugar SL, but daughter stated she didn't want res to aspirate. 1655 (4:55 p.m.) Res remains unchanged. Still responds to verbal & tactile stim (stimulation) but does not answer questions approp or follow simple commands. VS- BP ,[DATE]-,[DATE] SPO2 ,[DATE]%. Dr. (name deleted) paged again. 1710 (5:10 p.m.) Dr. (name deleted) returned page (voice mail) c orders to transport to (hosp name deleted) ER. 1718 (5:18 p.m.) (Ambulance name deleted) notified- while giving dispatcher res info, this nurse was called to bedside- Res was found apneic & s (without) pulse. CPR initiated immediately c ambu-bag ventilation. 1725 (5:25 p.m.) Res breathing spontaneously, but very shallow, unable to obtain BP, (no) pulse palp (palpitated)- CPR continued. 1730 (5:30 p.m.) (Ambulance name deleted) & fire dept @ bedside to take over resuscitation efforts. 1830 (6:30 p.m.) (Ambulance name deleted) notified (hospital name deleted) ER Doctor (name deleted) & rec'd order to stop CPR- Daughter remains in facility, in agreeance c order." The resident was found to have no pulse and blood pressure one hour and 25 minutes after the initial FSBS with a reading of "lo". Only one additional FSBS had been obtained, 40 minutes after the initial reading of "lo". The resident expired at the facility two and one half hours after the FSBS had been performed and the resident's blood glucose had registered as "lo". On [DATE] at 4:10 p.m., a family member stated they had reported to staff that something was wrong with the resident. The family member stated they had requested the facility check the resident's blood sugar. The family member reported a staff member informed her the resident had been given 20 units of insulin. The family member reported they had asked why, because the resident was not a diabetic. The family member stated the resident had received insulin while in the hospital because she had been receiving total [MEDICATION NAME] nutrition. The family member reported when the blood sugar was tested it would not register and one amp of [MEDICATION NAME] was administered. The family reported the next reading was 39. The family member reported the facility had stated they did not have another amp of [MEDICATION NAME] in the facility. On [DATE] at 7:45 p.m., during an interview with the DON and LPN #3, the LPN was asked where he had obtained the order and [DIAGNOSES REDACTED]. He stated he had received the report from the nurse at the hospital prior to admitting the resident. He stated the nurse had reported the resident had DM and had received [MEDICATION NAME] per sliding scale. He stated he had called the physician to clarify the orders. On [DATE] at 12:40 p.m., the DON was asked why RN #4 had waited so long to contact the physician and/or why RN #4 had not immediately transported the resident to the ER for emergency care. The DON stated RN #4 had reported to her the physician had ordered her to administer another vial of [MEDICATION NAME] or send the resident out. RN #4 stated she had looked for more [MEDICATION NAME] as the resident had none because there was no order for [MEDICATION NAME]. The DON stated she did not know the reason RN #4 did not immediately send the resident out, as they had usually called the ambulance first; then called the physician. She stated RN #4 had stated her initial intention was to get the resident's blood glucose up ASAP. RN #4 was not available for interview. 2. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The February 2011 monthly physician orders documented the following: "..XXX[DATE]...FSBS QID. Chart result... [DATE][MEDICATION NAME] R insulin sliding scale as follows: If FSBS ,[DATE] give 2 unit (sic) of [MEDICATION NAME] R insulin SQ... If FSBS ,[DATE] give 4 units of [MEDICATION NAME] R insulin SQ... If FSBS ,[DATE] give 6 units of [MEDICATION NAME] R insulin SQ... If FSBS ,[DATE] give 8 units of [MEDICATION NAME] R insulin SQ... If FSBS ,[DATE] give 10 units of [MEDICATION NAME] R insulin SQ... If FSBS above 400 give 12 units of [MEDICATION NAME] R insulin SQ and notify Dr..." The [DATE] Diabetic Testing/Insulin record documented the following: On [DATE] at 4:00 p.m., the FSBS was 431. Twelve units of insulin was given as ordered. There was no documentation to show the physician was notified of the result over 400. On [DATE] at 8:00 p.m., the FSBS was 384. No sliding scale insulin was documented as given. Ten units of insulin should have been given. The following morning,on [DATE] at 6:00 a.m., the FSBS was 318. On [DATE] at 11:00 a.m., the FSBS was 303. No sliding scale insulin was documented as given. Eight units of insulin should have been given. On [DATE] at 4:00 p.m., there were no FSBS results or sliding scale insulin documented. On [DATE] at 8:00 p.m., the FSBS was 364. No sliding scale insulin was documented as given. Ten units of insulin should have been given. The following morning, on [DATE] at 6:00 a.m., the FSBS was 255. On [DATE] at 8:00 p.m., the FSBS was 157. No sliding scale insulin was documented as given. Two units of insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 346. No sliding scale insulin was documented as given. Eight units of insulin should have been given. On [DATE] at 4:00 p.m., the FSBS was 134. Documentation showed four units of [MEDICATION NAME] R insulin was given. No sliding scale insulin should have been given. On [DATE] at 4:00 p.m., the FSBS was 272. Documentation showed both six and eight units of [MEDICATION NAME] R insulin was given. Six units of insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 333. No sliding scale insulin was documented as given. Eight units of insulin should have been given. On [DATE] at 4:00 p.m., the FSBS was 517. Twelve units of insulin was given as ordered. There was no documentation to show the physician was notified of the FSBS over 400. On [DATE] at 8:00 p.m., the FSBS was 481. Twelve units of insulin was given as ordered. There was no documentation to show the physician was notified of the FSBS over 400. On [DATE] at 4:00 p.m., the FSBS was 258. Documentation showed four units of [MEDICATION NAME] R insulin was given. Six units of insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 394. No sliding scale insulin was documented as given. Ten units of insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 256. No sliding scale insulin was documented as given. Six units should have been given. On [DATE] at 8:00 p.m., the FSBS was 345. No sliding scale insulin was documented as given. Eight units of insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 306. No sliding scale insulin was documented as given. Eight units of insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 187. No sliding scale insulin was documented as given. Two units of insulin should have been given. On [DATE] at 4:00 p.m., the FSBS was 440. Twelve units of insulin was given as ordered. There was no documentation to show the physician was notified of the FSBS over 400. On [DATE] at 4:00 p.m., the FSBS was 364. No sliding scale insulin was documented as given. Ten units of insulin should have been given. On [DATE] at 4:00 p.m., the FSBS was 467. Twelve units of insulin was given as ordered. There was no documentation to show the physician was notified of the FSBS over 400. On [DATE] at 8:00 p.m., the FSBS was 457. Twelve units of insulin was given as ordered. There was no documentation to show the physician was notified of the result as ordered. On [DATE] at 8:00 p.m., the FSBS was 298. No sliding scale insulin was documented as given. Six units of insulin should have been given. On [DATE] at 11:00 a.m., the FSBS was 200. Documentation showed four units of [MEDICATION NAME] R insulin was given. Two units of insulin should have been given. At 4:00 p.m., when the next FSBS was performed, the result was 68. On [DATE] at 4:00 p.m., the FSBS was 363. No sliding scale insulin was documented as given. Ten units of insulin should have been given. The resident received the incorrect amount of insulin and/or the physician was not notified of the FSBS results as ordered for 25 of 93 opportunities for [DATE]. The February 2011 Diabetic Testing/Insulin record documented that on [DATE] at 4:00 p.m., the FSBS was 186 and no sliding scale insulin was documented as given. Two units of insulin should have been given. On [DATE] at 8:40 a.m., the DON was informed of the above findings. No further documentation was provided. 3. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The [DATE] monthly physician orders documented the following: "..XXX[DATE]...FSBS BID @ 0600 (6:00 a.m.) & 2000 (8:00 p.m.). Chart result... [DATE]...Regular insulin sliding scale as follows: If FSBS ,[DATE] give 3 units of regular insulin SQ... If FSBS ,[DATE] give 6 units of Regular insulin SQ... If FSBS ,[DATE] give 9 units of Regular insulin SQ... If FSBS ,[DATE] give 12 units of regular insulin SQ... If FSBS >350 give 15 units of Regular insulin SQ and call MD..." The [DATE] Diabetic Testing/Insulin record documented that on [DATE] at 8:00 p.m., the FSBS was 174 and no sliding scale insulin was documented as given. Three units of insulin should have been given. The February 2011 monthly physician orders documented the following: "..XXX[DATE]...FSBS BID @ 0600 & 2000. Chart result... [DATE]...If FSBS ,[DATE] give 6 units of regular insulin SQ... If FSBS >350 give 15 units of regular insulin SQ and call MD... If FSBS ,[DATE] give 9 units of regular insulin SQ... If FSBS ,[DATE] give 12 units of regular insulin SQ... Regular insulin sliding scale as follows: If FSBS ,[DATE] give 3 units of regular insulin SQ..." The February 2011 Diabetic Testing/Insulin record documented the following: On [DATE] at 8:00 p.m., the FSBS was 120. Documentation showed three units of regular insulin was given. No sliding scale insulin should have been given. On [DATE] at 8:00 p.m., the FSBS was 198. No sliding scale insulin was documented as given. Three units of insulin should have been given. The resident received the incorrect amount of insulin as ordered for 2 of 46 opportunities for February 2011. 4. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Admission/Start-up order dated [DATE], documented, "[MEDICATION NAME] (liquid nutrition) 1.2 cal liquid give (one) can + 35 cc PT (per tube) to equal 320 cc 5x daily at 0730 (7:30 a.m.), 1100, 1430 (2:30 p.m.), 1800 (6:00 p.m.), 2200 (10:00 p.m.)..." A physician's telephone order, dated [DATE], documented, "Clarification: [MEDICATION NAME] 1.2 cal (one) can + 42 cc of additional extra can @ 0730 - 1100 - 1430 - 1600 (4:00 p.m.) - 2000 - 2200..." A nurse's note, dated [DATE] for the 3:00 p.m. to 11:00 p.m. shift, documented, "...One TF (2000) [MEDICATION NAME] 1.5 given. Sequoia Pharmacy out of [MEDICATION NAME] 1.2. Approval given by DON to substitute until [MEDICATION NAME] 1.2 avail as res req (required) nutrition..." There was no physician's order for substituting [MEDICATION NAME] 1.2 for [MEDICATION NAME] 1.5. On [DATE] at 9:30 a.m., the DON was asked if she would expect staff to get a physician's order when changing enteral feedings. She stated, "Yes, we should have gotten an order."

Based on review of clinical records, review of facility policy and procedure, observations and interviews, it was determined the facility failed to: ~ provide adequate supervision and assistance when using a lift to transfer a resident from bed to wheel chair. This resulted in a fall with injury for one (#15) of five sampled residents who required the use of a lift for transfer. This had the potential to affect ten residents identified by the facility who required the use of a lift for transfers. ~ ensure one (#11) of three sampled residents with personal alarms ordered, was utilizing the alarm as ordered to prevent falls. This had the potential to affect 14 residents identified by the facility with orders for personal alarms to be placed on their beds and/or wheelchairs. Findings: 1. A facility form titled, Hoyer Lift Check-Off Sheet, dated 10/19/10, documented, "...I have successfully completed the procedures for operating the Hoyer Lift. I have demonstrated the tasks and understand that the Hoyer Lift is to be used in a safe appropriate manner...4. Have a CNA on each side of the Hoyer lift..." This form was signed and dated on 10/19/10, by CNA #1 and checked off by LPN #1. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurse's note, dated 12/24/10 at 11:00 a.m., documented, "Res lying on R side beside w/c of (sic) floor, blood note coming from head c sm laceration noted to middle of nose notified Dr. rec'd Rx to send to (hospital name deleted)..." A nurse's note, dated 12/24/10 at 4:35 p.m., documented, "Res return @ this time via (ambulance name deleted) on stretcher...Abrasion noted to bridge of nose, back of R hand, eyelid (L). Bruising noted to L arm @ elbow & just above bruising & some swelling L inner canthus area. Laceration to forehead c sutures x 11..." A facility form titled, Disciplinary/Counseling Form, dated 12/29/10, documented, "(CNA name deleted) failed to obtain assist c the hoyer lift resulting in a fall out of w/c. (CNA name deleted) knows & has been trained to always use 2 people c the hoyer lifts. Corrective Plan of Action: terminate employment..." A form titled, Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property, dated 01/03/11, documented the Nurse Aide Registry was notified regarding the incident involving CNA #1. An incident report form, dated 01/03/11, documented, "Res found on floor in his room in front of his w/c. Res sustained laceration to mid-forehead requiring 11 sutures (ambulance name deleted) transferred res from floor to carrier. Res to ER...Res requires using hoyer lift for transfers...Upon investigation, it was discovered that CNA who transferred res to w/c did not do so according to QC policy. It is believed that improper positioning was probably the cause of fall out of w/c. In-service all CNA's & CMA's on policy. done 12/30/10." A facility policy and procedure titled, Use of Lifts - Hoyer, revised on 01/13/10 (sic), documented: "1. Always think of the resident's safety foremost!!!! 2. Using the Hoyer Lift ALWAYS requires 2 people. One person cannot, under any circumstances, safely use the Hoyer Lift alone...WARNING I understand that if I go against policy and use the lift by myself or any other unsafe method, I will be immediately terminated and risk being reported to my certification/licensing board..." On 02/14/11 at 8:05 a.m., CNA #2 and CNA #3 were observed as they transferred resident #13 from bed to wheel chair using a mechanical lift. The CNAs used proper technique and followed facility policy while transferring the resident. At 9:45 a.m., CNA #4 and CNA #5 were observed as they transferred resident #12 from bed to wheel chair using a mechanical lift. The CNAs used proper technique and followed facility policy while transferring the resident. On 02/16/11 at 10:05 a.m., CNA #4 was asked how the mechanical lift should be used safely. She stated, "Always have two people. Hook it up correctly. Hold the resident as you lower them so they are positioned correctly." At 10:12 a.m., CNA #6 was asked how the mechanical lift should be used safely. She stated, "You should have two people. Hook up to the lift. Have the wheel chair near and slowly lower them to the chair and unhook." At 10:17 a.m., Lpn #2 was asked how the mechanical lift should be used safely. She stated, "Always have two people. Put the sling under the resident and hook it up, lift. When you are putting them in the chair you need to guide them in safely." At 4:30 p.m., Resident #13 was asked if she was transferred safely when staff used the mechanical lift. She stated, "They do ok with the lift. The ones working now are very good." 2. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A telephone order, dated 02/02/11, documented, "Personal alarm while in W/C. Nurses to check for placement q shift and PRN..." An incident report, dated 02/09/11 at 8:15 p.m., documented, "...Resident was wheeling her W/C requesting for the cordless phone to be taken away from her and fell out of her W/C. She fell face down to the floor...Focused assessment done s any injury noted...Additional Comments And/Or Steps Taken To Prevent Recurrence Chair alarm while in W/C. Nurses to check for placement q shift..." The February 2011 treatment reocrd documented, "Personal alarm while in W/C. Nurses to check for placement q shift & PRN..." The treatment record for 02/09/11, documented the nurse's initials on the 3:00 to 11:00 p.m. shift had been circled. There was no explanation documented on the back of the sheet explaining why the initials were circled. An Oklahoma State Department of Health Incident Report Form, completed on 02/10/11, documented, "...Incident Date 2/9/2011... Incident Type...Certain Injuries...Description of Incident...Res up in w/c at nurses desk attempting to reach for resident phone & fell out of w/chair (wheel chair) on her face...relevant resident hisotry...Res is a high fall risk d/t confusion, poor safety awareness & anti-anxiety medication...She fell at home fracturing her (L) radius before admisssion...exhibits anxiety & agitation frequently... summary of the investigation (include investigative actions, findings and causative factors) and corrective measures implemented to prevent recurrence...(1.) Res to have personal alarm while in w/c. Update CNA assignment sheet & care plan. (2.) Nursing to start restraint evaluation and submit to therapy..." On 02/16/11 at 3:30 p.m., the DON was asked if the resident had the personal alarm on her wheel chair at the time of the fall, on 02/09/11, as ordered by the physician. The DON read the incident report and stated it looked like it was ordered after the fall. The DON was informed the order for the alarm was written to be placed on the wheel chair on 02/02/11, following another fall. The DON called LPN #3, who was on duty at the time of the fall, and asked him. After talking to him, she stated the alarm was not on the resident's wheel chair at the time of the fall. She then stated, the LPN had placed one on her W/C immediately following the fall.