Every finding on record at Hill Nursing Home, Inc.

Based on observation, interview, facility record review, and facility policy review, the facility failed to thoroughly investigate falls to determine the root cause and failed to revise their care plan as needed to reduce the likelihood of another fall, which affected 2 residents (Resident #10 and Resident #41) of 2 residents that were reviewed for falls. The facility also failed to ensure residents were assessed to determine if they were safe to smoke and failed to provide supervision to residents according to their policy agreement, which affected 2 (Resident #18 and Resident #19) of 2 residents reviewed for smoking concerns. Findings included: A facility policy titled, Accidents and Incidents- Investigating and Reporting, dated 2001, indicated, All accidents or incident involving residents, employees, visitors, vendors etc. [et cetera, and so forth], occurring on our premises shall be investigated and reported to the administrator. The policy revealed, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy revealed, 2. The following data, as applicable, shall be included on the Report of Incident/Accident form, which included c. The circumstances surrounding the accident or incident; e. The name(s) of witnesses and their accounts of the accident or incident; g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions. An admission Summary (Standard) revealed the facility admitted Resident #10 on 07/18/2025. According to the admission Summary, Resident #10 had a medical history that included diagnoses of dementia, unspecified depression, unspecified anxiety disorder, type 2 diabetes mellitus, ankylosing spondylitis, and idiopathic gout. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2026, indicated Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had no functional limitation in range of motion and used a walker for ambulation. The MDS indicated Resident #10 required supervision or touching assistance from staff for bed mobility, going from a sitting position to lying, going from a lying position to sitting, going from a sitting position to standing, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers, and ambulation. The MDS indicated Resident #10 was frequently incontinent of urine and continent of bowel. Per the MDS, Resident #10 experienced frequent pain that rarely interfered with day-to-day activities, and the MDS indicated the resident rated the pain as a 5, on a scale of 0-10, with 10 being the worst possible pain. The MDS indicated that since the prior assessment, Resident #10 had experienced one fall with no injury. Resident #10's Temporary Problem Care Plan indicated the resident had a fall on 06/04/2026 that resulted in a knot on the resident's head, on 06/09/2026 the resident fell and hit their head, on 06/12/2026 the resident experienced a fall and had a knot on their head, and on 07/12/2026 the resident had a fall in the bathroom and sustained no injury. The Temporary Problem Care Plan listed a fall on 07/19/2026 in which Resident #10 fell while going to the bathroom without assistance or the use of a call light and had pain to the chest (rib) area. The care plan listed the interventions for the falls as staff providing one to one staff supervision, the use of a baby monitor, and to monitor the resident. The resident's Care Plan, dated 07/28/2025, indicated the resident was a risk for falls. Undated interventions directed staff to assist the resident with the use of one to two staff with activities of daily living (ADLs), assist the resident with ambulation as tolerated, use a baby monitor, encourage the resident to use their call light, keep the call light within reach, have the resident's bed in the lowest position and locked, use a rolling walker or cane for ambulation, allow the resident to sit on the seat of the rolling walker if needed, complete the fall risk assessment on admission and with any occurrence of a fall to re-evaluate needs, coordinate a medication review with a pharmacist, and provide 24/7 sitter when needed. Resident #10's progress notes included a note, dated 01/08/2026 at 5:20 PM, that indicated that the resident was heard calling out from their room and was found on the floor with a fingernail file in their hand. The note indicated that the resident stated their legs had given out while standing. The progress note indicated that the resident had been repeatedly warned that they needed to use their walker with ambulation. The note indicated that Resident #10 was very quick and forgetful. Per the note, the resident was instructed to call for help prior to ambulation. The note indicated that other interventions included a monitor in the room and the call bell within reach. The facility's incident report related to the 01/08/2026 fall indicated the contributing environmental factors included poor lighting, a wet floor, and improperly maintained wheelchair. There was no evidence of witness statements to detail the last time the resident had been seen. The incident report indicated that a baby monitor was listed as an intervention. Resident #10's progress notes included a note, dated 01/11/2026 at 9:35 AM, that indicated Resident #10 had fallen in their room. The resident stated the walker tipped and a fall occurred. At 11:59 AM, a progress note indicated the resident was upset due to continued falls. The note indicated the resident was given non-skid socks and encouraged to wear the socks. The resident was also encouraged to use the call light and request assistance for walking and transfers. The facility's incident report related to the 01/11/2026 fall indicated the resident had fallen in their room while standing. There was other information included on the incident report and no interventions were documented. Resident #10's progress notes included a note, dated 01/13/2026 at 1:25 PM, that indicated the resident had fallen in the bathroom while attempting to get their coffee off their walker. The note indicated that coffee spilled and the resident slipped on the coffee. Per the note, the resident was encouraged to ask for assistance with transfers and ambulation. The facility's documents revealed no evidence of an incident report or an investigation related to the fall on 01/13/2026. Resident #10's progress notes included a note, dated 01/24/2026 at 5:35 AM, that indicated that at 2:45 AM the resident was getting off their knees while in their room and had been incontinent. The facility's documents revealed no evidence of an incident report or an investigation related to the fall on 01/24/2026. Resident #10's progress notes included a note, dated 02/04/2026 at 11:31 AM, that revealed that at 10:58 AM, Resident #10 was on the floor with the wheelchair behind their back. The note indicated that Resident #10 stated they had stumbled. Per the note, the fall had been witnessed by the roommate, who stated Resident #10 had used the walker and got tangled up in another resident's wheelchair and fell. The facility's documents revealed no evidence of an incident report or an investigation related to the fall on 02/04/2026. Resident #10's progress notes included a note, dated 03/13/2026 at 2:33 PM, that indicated that that after hearing a cry, the nurse had found Resident #10 lying on the floor in front of the bed. The note indicated that the resident complained of pain, and staff wanted to send the resident to the hospital for evaluation. Per the note, both Resident #10 and the resident's representative declined. The facility's incident report related to the 03/13/2026 fall revealed the fall occurred in the resident's room. There was no other information or interventions included. Resident #10's progress notes included a note, dated 03/18/2026 at 12:38 PM, that revealed the resident had fallen after getting tripped up with another resident while exiting the dining room. The note revealed Resident #10 had a sitter in place from 12:00 AM to 8:00 AM. The facility's documents revealed no evidence of an incident report or an investigation related to the fall on 03/18/2026. Resident #10's progress notes included a note, dated 05/21/2026 at 7:35 PM, that indicated that after the resident yelled out, the nurse found the resident on the floor in front of their rocking chair where they had been sitting. The facility's incident report related to the 05/21/2026 fall indicated that the fall occurred in the resident's room. There was other information included. The incident report indicated that frequent visualizations were listed as the intervention. Resident #10's progress notes included a note, dated 05/22/2026 at 11:24 PM, that indicated staff heard a loud crash followed by Resident #10 yelling for help. The note indicated that a certified nursing assistant (CNA) had been in the room with Resident #10 and had left the room for a task. The note revealed that as soon as the CNA left the room, she heard a noise, went back to Resident #10's room, and found the resident on the floor in front of the rocking chair. The facility's incident report related to the 05/22/2026 fall indicated that the fall occurred in the resident's room. The incident report included no further information and no intervention documented. Resident #10's progress notes included a note, dated 06/04/2026 at 3:41 PM, that revealed someone was heard calling for help, and Resident #10 was found sitting by the bed, leaned against the bedside chest. The note indicated that a fall mat was under the resident. Per the note, the resident stated they had tripped on the walker and fell forward. The facility's incident report related to the 06/04/2026 fall indicated poor lighting and improper maintenance or the wheelchair were factors. There were no interventions listed. Resident #10's progress notes included a note, dated 06/08/2026 at 3:03 PM, that indicated that Resident #10 was found sitting on the floor by the closet with their back against the wall. The note indicated that the resident had spilled water on the floor. The note did not reveal if the resident had slid down in the water or had lost their balance. The progress noted the resident had an unsteady gait. The facility's documents revealed no evidence of an incident report or an investigation related to the fall on 06/08/2026. Resident #10's progress notes included a note, dated 06/09/2026 at 4:19 PM, that indicated that Resident #10 had fallen in the dining room. The note indicated that the fall had been witnessed by other residents and staff. The facility's incident report related to the 06/09/2026 fall indicated that the resident was sitting at a table and got up, turned, and lost their balance. There was no evidence that indicated that the root cause had been reviewed and determined or that interventions had been implemented. Resident #10's progress notes included a note, dated 06/12/2026 at 3:20 AM, that indicated the resident had fallen two times but gave no indication when the two falls had occurred or what the details of the falls were. Resident #10's progress notes included a note, dated 06/12/2026 at 5:30 PM, that indicated the nurse had received in report that Resident #10 had a fall early in the morning. The facility's documents revealed no evidence of an incident report or an investigation related to a fall on 06/12/2026. Resident #10's progress notes included a note, dated 07/12/2026 at 9:47 PM, that revealed that Resident #10 had fallen and some pain to the left side of the head. The note did not identify when, where, or the circumstances surrounding the fall. The note indicated the resident had slip-proof socks in place and the call light was in place. The note indicated that the resident was reminded to use the walker and increased supervision was given. The facility's documents revealed no evidence of an incident report or an investigation related to a fall on 07/12/2026. Resident #10's progress notes included a note, dated 07/19/2026 at 2:41 PM, that indicated that Resident #10 was status post fall and complained of left sided rib pain. The resident's notes revealed no documentation from 07/18/2026 at 2:34 AM to 07/19/2026 at 2:41 PM that described when and how Resident #10 had fallen or what interventions had been placed. The facility's incident report related to the fall that was indicated in the 07/19/2026 note, completed on 07/19/2026, indicated the resident had been going to the bathroom. There was no further information and no interventions listed. The MDS Coordinator was interviewed on 07/20/2026 at 10:40 AM. The MDS Coordinator stated she had no fall investigations for any falls prior to 07/19/2026 and stated that at some point, the nurses had quit completing the fall investigations. The MDS Coordinator stated that she thought it was in 2024, when a previous Director of Nursing (DON) left. The MDS Coordinator stated that the Quality Assurance/Performance Improvement (QAPI) meeting was held monthly and at that time, the falls were discussed. Licensed Practical Nurse (LPN) #10 was interviewed on 07/21/2026 at 11:55 AM. LPN #10 stated that when a resident fell, she was expected to assess for injury, obtain vital signs, and notify the family, Administrator, and DON. LPN #10 stated that after a fall, residents received a seven-day pain screening and documentation was made for three days after a fall. LPN #10 stated that when a resident fell, the expectation was to complete a progress note, complete an incident report, and place immediate interventions to prevent other falls. LPN #4 was interviewed on 07/22/2026 at 9:14 AM. LPN #4 stated that after a resident fell, he was expected to assess for pain and injury, notify all parties, write a nurse's note, and complete an incident report, a pain screen, and a fall risk assessment. LPN #3 was interviewed on 07/22/2026 at 12:30 PM. LPN #3 stated that when a resident fell, the expectation was for her to assess, notify parties, set up neurological checks if needed, and place interventions to prevent other falls. The LPN stated staff stopped doing the fall investigations more than a year prior because the DON at the time did not continue the fall investigations. The LPN stated questions were still asked to determine the root cause, but the investigation was not documented. LPN #3 stated she questioned the resident and the CNAs to try to determine what happened to make the resident fall. LPN #3 stated that a previous DON had instructed her not to complete a fall investigation worksheet. The MDS Coordinator was interviewed on 07/23/2026 at 10:38 AM and stated she expected incident reports to be completed for all falls. The MDS Coordinator stated the staff were required to notify the DON, Administrator, and physician of falls and stated it would be nice if they notified her. The MDS Coordinated stated nurses' notes were not reviewed, and if the staff did not tell her about residents' falls, she sometimes heard by eavesdropping on shift report. The MDS Coordinator stated that without knowledge of a resident's fall and without the incident reports, the falls could not be adequately or thoroughly investigated. The MDS Coordinator stated she determined if an intervention was effective by monitoring the intervention and making sure the intervention was in place and stated that if the resident continued to fall, then the intervention was not effective. The MDS Coordinator nurse stated the incidents reports stopped being consistently completed when the new DON started and stated the falls were not being investigated. The Nurse Practitioner (NP) was interviewed on 07/24/2026 at 8:44 AM. The NP stated the facility usually reported falls to her and stated that at times, the staff requested input about interventions. She stated she asked what had caused the fall and had previously recommended interventions such as toileting programs and low beds. She stated she expected the facility to investigate the fall to determine the root cause and gather witness statements from observed falls. The NP stated that if the fall was not witnessed, she expected the staff caring for the resident to be interviewed to determine when the resident was last seen and what the resident was doing at the time they were last seen. The NP stated she expected to be notified of any change in condition. In regards to there were only seven incident reports for Resident #10's falls, the NP stated, That is a problem, and stated the value of the incident report was to help track and trend the falls and help to develop plans to help prevent falls. The NP stated she was not sure with Resident #10's drive for independence that any interventions would reduce falls. The DON was interviewed on 07/24/2026 at 2:40 PM. The DON stated the investigation for a fall should include what caused the fall, witness statements, notification of parties, and interventions to prevent falls, a post-fall huddle, and the post-fall investigation. She stated the post-fall investigation was important to determine what could have prevented the fall and any future falls. The DON stated she would like the investigation to determine the root cause of the fall. The DON stated she expected the fall investigation tool to include environmental issues, physical issues, and what the resident was doing, and without including those items, the DON stated the root cause of the fall could not be determined. She stated that without the root cause of the fall identified, the interventions would be based on hypothesis. The DON stated the post-fall huddles were not being done. She stated the nurses brainstormed but there was no documentation, and she had no explanation why the documentation was missing. The DON stated there were no fall risk meetings held for falls. An interview was held with the Administrator and the Assistant Administrator (AA) on 07/24/2026 at 4:07 PM. The AA stated she expected a thorough investigation to be completed in order to determine the root cause of the fall. An admission Summary (Standard) revealed the facility admitted Resident #41 on 03/21/2025. According to the admission Summary (Standard), the resident had a medical history that included diagnoses of chronic pain syndrome, rheumatoid arthritis, and unspecified convulsions. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2025, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision or touching assistance with going from a sitting position to standing, toilet transfers, and walking from 10 feet to 150 feet. The MDS also indicated the resident had impairments of both lower extremities and did not use a mobility device. Resident #41's Care Plan included a problem area dated 03/21/2025, that indicated Resident #41 was at risk for falls. Undated interventions directed staff to encourage compliance with activities of daily living and provide assistance to use the regular commode, provide assistance with incontinence care and transfers, and to keep the call light in reach. An incident report, dated 04/01/2025 at 12:45 PM, indicated that Resident #41 was found on the floor. Environmental factors indicated incorrect bed height, improperly fitted or maintained wheelchairs. The report indicated that Resident #41 was observed sitting up, with their legs out front. The report indicated that the resident went to sit on the side of the bed and missed. Per the report, the resident complained of knee pain, which was present prior to the fall, and pain medications were given. Per the report, Resident #41 was assisted in using the bedside commode then back to bed. The report indicated that no injuries were noted. Resident #41's Care Plan included an intervention, dated 04/01/2025, that indicated that a bedside commode was placed at bedside to assist when the resident was feeling weak, and the resident was reminded to use the call light for assistance. The care plan did not include updated interventions to address the environmental factors. Resident #41's record revealed no documentation of an investigation into the fall to determine the root cause or how the incorrect bed height and improperly fitted or maintained wheelchairs were addressed. An incident report, dated 04/02/2025 at 12:01 AM, indicated that Resident #41 was found on the floor. Environmental factors indicated incorrect bed height. The report indicated that Resident #41 was observed sitting beside their bed. The report indicated the resident slipped off the side of the bed. The report indicated that the resident used the bedside commode and was assisted back to bed. Per the report, there were no injuries reported. Resident #41's Care Plan included an intervention, dated 04/02/2025, that indicated that a toileting program was implemented for every two hours. The care plan did not include updated interventions to address the environmental factors. Resident #41's record revealed no documentation of an investigation into the fall to determine the root cause or how the incorrect bed height was addressed.An incident report, dated 04/06/2025 at 9:12 AM, indicated that Resident #41 was found sitting on the floor, scooting themself around, attempting to get off the floor. The report indicated that the resident was assisted off the floor, visibly agitated. Per the report, Resident #41's heart rate was elevated, and oxygen was 85% and supplemental oxygen was given at 2 liters per minute. The report indicated that Resident #41 refused transfer to the hospital, and the resident's Power of Attorney agreed to not send the resident to the hospital. Per the report, Resident #41 was assisted back to bed and was observed less agitated and without signs or symptoms of discomfort or distress. Resident #41's Care Plan was not updated to reflect the fall from 04/06/2025 or that an intervention had been implemented (the use of supplemental oxygen or that the resident was moved closer to the nurses' station for monitoring). Resident #41's record revealed no documentation of an investigation into the fall to determine the root cause. During an interview on 07/22/2026 at 12:58 PM, Licensed Practical Nurse (LPN) #3 stated that the facility used to do fall investigations and stopped after one of the previous Directors of Nursing (DONs) left. During an interview on 07/22/2026 at 3:44 PM, the MDS Coordinator stated that a fall investigation was not completed for Resident #41's falls and should have been. The MDS Coordinator stated the fall protocol included staff completing an incident report, fall assessment, pain screening, and intervention with every fall and stated that they could not do a root cause analysis without a meeting. She stated that they could have looked at new or old medications and looked at medication reductions, vital signs, and witness statements. The MDS Coordinator stated the fall from 06/06/2025 was not added to the care plan, but the resident was moved closer to the nurses' station. During an interview on 07/24/2026 at 8:29 AM, the Nurse Practitioner (NP) stated that she expected the staff to investigate falls and get witness statements to find the root cause of the fall. During an interview on 07/24/2026 at 3:33 PM, the DON stated staff should be following the policy for falls. During an interview on 07/24/2026 at 4:45 PM, Assistant Administrator (AA) stated staff should be following the policy for falls. 2. A facility policy titled, Facility Smoking Policy & Resident Cigarette/Tobacco Smoking Program, revised 11/2008, revealed, Resident's [sic] will be given a cigarette @ [at] the scheduled smoke break time and supervised by the staff. The policy included a signature line for the residents, Administrator, and a family member and revealed, I have been informed about the potential hazards and complications to my well being on issues of smoking and going outside if weather permitting. It is my wishes to be granted that I go outside to smoke @ Scheduled times with supervision. An admission Summary (Extended) revealed the facility admitted Resident #18 on 04/28/2026. According to the admission Summary (Standard), the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, epilepsy, muscle weakness, and hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2026, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #18's Care Plan dated 05/06/2026, included a problem statement that indicated the resident smoked. Interventions directed staff to take the resident outside to smoke when the resident wanted and supervise the resident when they smoked; and to complete a smoking assessment at the time of admission, quarterly, and annually. Resident #18's record included the facility's Facility Smoking Policy & Resident Cigarette/Tobacco Smoking Program, revised 11/2008, that was signed by the resident that indicated that they would be supervised and dated 04/28/2026. During an observation on 07/22/2026 at 7:44 AM, Resident #18 was observed sitting outside smoking without supervision. During an observation on 07/22/2026 at 7:46 AM, Resident #18 was observed with Licensed Practical Nurse (LPN) #4 being assisted back into the facility from the smoking area and taken to their room. During an interview on 07/22/2026 at 7:48 AM, LPN #4 stated he took Resident #18 outside to smoke and left them to smoke unsupervised since he stated he had watched them smoke when they admitted . LPN #4 stated he was not sure if Resident #18 had a smoking assessment completed or where to find it. LPN #4 checked the electronic record and stated Resident #18 had not been assessed to smoke. He stated he would get with the MDS Coordinator to help him complete the assessment. During an interview on 07/22/2026 at 4:00 PM, the MDS Coordinator stated she had not completed a smoking assessment for Resident #18. An admission Summary (Extended) record revealed the facility admitted Resident #19 on 04/27/2026. According to the admission Summary (Extended), the resident had a medical history that included diagnoses of unspecified convulsions and fibromyalgia. A quarterly MDS, with an ARD of 05/08/2026, revealed Resident #19 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #19's Care Plan, dated 07/09/2026 revealed, Discontinue nicotine patch, refuse to quit smoking. Resident #19's Smoking Safety Evaluation, dated 04/27/2026, indicated that the resident required supervision with smoking, and indicated that the resident was vision impaired. Resident #18's record included the facility's Facility Smoking Policy & Resident Cigarette/Tobacco Smoking Program, revised 11/2008, that was signed by a family member that indicated that the resident would be supervised and dated 04/27/2026. During an observation and interview on 07/19/2026 at 12:19 PM, Resident #19 was observed smoking outside unsupervised. Resident #19 stated they were a safe smoker and could come outside and smoke unsupervised. During an interview on 07/21/2026 at 9:59 AM, LPN #10 stated she has not looked at the smoking assessments to see who was safe to smoke. During an interview on 07/21/2026 at 10:46 AM, LPN #5 stated that Resident #19 was transferred to her unit over the weekend, and she did not think the resident required supervision to smoke. During an interview on 07/23/2026 at 10:16 AM, MDS Coordinator stated staff had not been in-serviced on safe smoking. During an interview on 07/24/2026 at 4:45 PM, Assistant Administrator (AA) stated her expectation would be for the staff to follow the policy.

Based on interview, facility document review, and facility policy review, the facility failed to provide staff-initiated activities in the evenings and on the weekends. This deficient practice affected 7 of 7 residents who attended the Resident Council meeting and had the potential to affect other residents residing in the facility who desired activity programming outside of regular weekday hours.Findings included: An undated facility policy titled, Activity Program, indicated, 6. Individualized and group activities are provided that - a. reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends. A facility activities calendar for the month of July 2026 revealed there were no activities scheduled after 3:00 PM and there were no staff-initiated activities scheduled on the weekends. The calendar revealed that activities scheduled on the weekends were resident-initiated games, crafts, and watching TV Land. During a Resident Council meeting on 07/21/2026 at 2:02 PM, residents in attendance stated they did not have any weekend activities, and the residents who depended on the staff to provide activities were not provided with any activities. The residents in attendance stated they wished the facility provided better activities during the week and the weekends. During an interview on 07/20/2026 at 8:46 AM, the Social Services Director (SSD), who was also the Activities Director, stated she worked weekly Monday through Friday. The SSD stated there were no scheduled activities on the weekends and that the activities on the weekends were resident-initiated because she did not work on weekends. The SSD stated she did not know if the residents who were bed-bound got any activities on the weekends. During an interview on 07/21/2026 at 10:42 AM, Certified Nursing Assistant (CNA) #11 stated there were no organized activities provided to the residents on the weekends or the evenings. CNA #11 stated no activities were provided to the bed-bound residents. During an interview on 07/22/2026 at 10:21 AM, CNA #12 stated she worked the evening shift at the facility and did not see any activities staff and only saw resident-initiated activities. During an interview on 07/22/2026 at 10:54 AM, CNA #6 stated no activities were provided for residents on the weekends. During an interview on 07/22/2026 at 12:23 PM, Licensed Practical Nurse (LPN) #3 stated activities were not provided for residents in the evenings or on the weekends. During an interview on 07/22/2026 at 3:42 PM, the Minimum Data Set (MDS) Coordinator stated they had no activities for residents in the evenings or on the weekends. The MDS Coordinator stated that the bed-bound residents were not provided with activities. During an interview on 07/23/2026 at 8:59 AM, the SSD stated she did not always get to do one-on-one with the bed-bound residents because she stayed so busy with other job duties. During an interview on 07/23/2026 at 10:44 AM, LPN #13 stated she worked the evening shift at the facility and had not seen any activities provided for the residents. During an interview on 07/24/2026 at 9:02 AM, CNA/Certified Medication Aide (CMA) #1 stated she worked weekends, no activities staff worked on the weekends, and the only activities were resident-initiated. CNA/CMA #1 stated she did not see any activities for the bed-bound residents on the weekends. During an interview on 07/24/2026 at 12:06 PM, the Director of Nursing (DON) stated she expected the residents to be provided with activities. The DON stated no activities staff worked on the weekends. During an interview on 07/24/2026 at 12:40 PM, the Assistant Administrator (AA) stated there were no activities staff that worked the weekends. The AA stated the activities on the weekends were resident-initiated.

Based on facility policy review, record review, and interview, the facility failed to develop a comprehensive person-centered care plan for 4 (Residents #3, #5, #7, and #10) of 12 sampled residents. Specifically, the facility failed to develop a comprehensive care plan related to the use of psychotropic medication for Residents #3, #5, #7, and #10, failed to develop a care plan related to a diagnosis of post-traumatic stress disorder (PTSD) for Resident #3, and failed to develop a care plan related to suicidal ideations for Resident #7.Findings included: A facility policy titled, Care Planning-Interdisciplinary Team, revised 03/2022, indicated, The interdisciplinary team is responsible for the development of resident care plans. The policy revealed, 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 1. An admission Summary (Standard) indicated the facility admitted Resident #3 on 11/17/2025. According to the admission Summary (Standard), Resident #3 had a medical history that included a diagnosis of PTSD. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2026, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #3 did not exhibit any hallucinations or delusions during the assessment timeframe. The MDS indicated that the resident had active diagnoses of anxiety disorder and PTSD. Resident #3's State of Oklahoma, Oklahoma Health Care Authority, Nursing Facility Level of Care Assessment, submitted to the state survey agency on 11/26/2026, indicated that PTSD was listed as a secondary diagnosis. Resident #3's August 2026 Doctor's Orders included an order, dated 11/28/2025 for risperidone (an antipsychotic medication) 0.5 milligrams (mg) daily at bedtime for delusions, and listed the diagnosis of unspecified PTSD as the indication for use. Resident #3's Care Plan indicated that the resident was at risk for decline due to using psychotropic medications but did not specify a goal or objective that addressed target behaviors related to the diagnosis that the psychotropic medications were used to treat or other interventions used to treat the resident's symptoms of PTSD.Resident #3's Care Plan, dated 11/26/2025, revealed that it did not include a problem area for the resident's diagnoses of anxiety or PTSD. The MDS Coordinator was interviewed on 07/21/2026 at 10:27 AM. The MDS Coordinator stated that she was unsure why Resident #3 had been placed on an antipsychotic medication. Licensed Practical Nurse (LPN) #3 was interviewed on 07/22/2026 at 4:14 PM and stated Resident #3's antipsychotic medication had been ordered on 11/28/2025 for delusions. LPN #3 stated Resident #3 had delusions of grandeur and would say they knew the governor and did drugs with the governor. The LPN stated Resident #3 focused on talking about other people, doing drugs, and had even accused a staff member's spouse of running drugs. The Nurse Practitioner (NP) was interviewed on 07/24/2026 at 9:38 AM. The NP stated Resident #3 had been admitted with a diagnosis of PTSD associated with family trauma when they were young. The NP stated Resident #3 had lived in a truck for years to avoid the family situation. The NP stated Resident #3 had not been comfortable enough to confide details of the trauma and stated that Resident #3's diagnosis of PTSD should have been care planned. The Director of Nursing (DON) was interviewed on 07/24/2026 at 2:59 PM. The DON stated that PTSD was considered a mental health diagnosis and should have been care planned. The DON stated that target behaviors should be included on the care plan with interventions to negate the triggers. The DON stated that while staff were able to make suggestions about care plans, the MDS Coordinator was responsible for initiating and developing the care plans. 2. An admission Summary (Extended) indicated the facility admitted Resident #5 on 03/09/2026. According to the admission Summary (Extended), Resident #5 had a medical history that included diagnoses of psychotic disorder with delusions, major depressive disorder, conversion disorder, paranoid personality disorder, and a nightmare disorder. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2026, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #3 had intact cognition. The MDS indicated that Resident #3 did not exhibit any hallucinations or delusions during the assessment timeframe. The MDS revealed that the resident received antipsychotic medication and antidepressant medication. Resident #5's August 2026 Physician's Orders contained the following orders:- Paroxetine hydrochloride (an antidepressant) 20 milligrams (mg) daily for a diagnosis of paranoid personality disorder, dated 03/09/2026.- Quetiapine fumarate (an antipsychotic) 100 mg at bedtime for vascular dementia without behavioral disturbance, dated 05/08/2026.- Olanzapine (an antipsychotic) 5 mg at bedtime for a diagnosis of psychotic disorder with delusions, dated 05/08/2026.- Lorazepam (a benzodiazepine) 0.5 mg every four hours as needed for anxiety, dated 07/16/2026. Resident #5's Temporary Problem Care Plan, dated 07/14/2026, indicated that Resident #5 had quetiapine discontinued, and olanzapine was started. The Temporary Problem Care Plan indicated Resident #5 had a psychotic disorder with delusions and nightmares but did not specify a goal or objective that addressed target behaviors related to the diagnoses that the psychotropic medications were used to treat or other interventions used to treat the resident's symptoms. Resident #5's Care Plan indicated that the resident was at risk for adverse reactions from psychotropic medication use but did not specify not specify a goal or objective that addressed target behaviors related to the diagnoses that the psychotropic medications were used to treat or other interventions used to treat the resident's symptoms. Licensed Practical Nurse (LPN) #3 was interviewed on 07/22/2026 at 4:14 PM and stated the medications were started for Resident #5 by the psychiatric nurse practitioner for nightmares and PTSD. 3. An admission Summary (Standard) revealed the facility admitted Resident #10 on 07/18/2025. According to the admission Summary (Standard), Resident #10 had a medical history that included diagnoses of dementia, unspecified depression, and unspecified anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2026, indicated Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident did not exhibit any behavioral symptoms and indicated that the resident had an active diagnosis of anxiety. The MDS revealed Resident #10 had received antipsychotic medications, antianxiety medication, and antidepressant medication. Resident #10's August 2026 Physician's Orders included the following orders:- Lamotrigine (an anticonvulsant) 25 milligrams (mg), two tablets to be taken daily for dementia in other diseases with behavioral disturbances, dated 07/18/2025.- Trazadone (an antidepressant) 100 mg at bedtime for insomnia, dated 07/08/2025.- Lorazepam (a benzodiazepine) 2 mg/milliliter (ml) at 7:00 PM for anxiety and additionally every four hours as needed, dated 04/17/2026.- Duloxetine (a serotonin-nonrepinephrine reuptake inhibitor) 60 mg daily for depression, dated 06/23/2026. - Risperidone 0.25 mg at noon and 0.5 mg at 7:00 PM for dementia with behaviors, dated 07/06/2026. Resident #10's Temporary Problem Care Plan, dated 06/19/2026, indicated that an order for risperidone was changed to 0.25 mg twice a day with orders to resume 0.5 mg at bedtime if behaviors increased. The Temporary Problem Care Plan revealed that it did not specify a goal or objective that addressed target behaviors related to the diagnoses that the psychotropic medications were used to treat or other interventions used to treat the resident's symptoms. Resident #10's Care Plan, dated 07/28/2025, indicated the resident was at risk for a decline due to the use of psychotropic medications and the side effects. The Care Plan revealed a list of side effects along with the names of the medications: lorazepam, duloxetine, lamotrigine, and risperidone. The Care Plan revealed that it did not specify a goal or objective that addressed target behaviors related to the diagnoses that the psychotropic medications were used to treat or other interventions used to treat the resident's symptoms. 4. An admission Summary (Standard) indicated the facility admitted Resident #7 on 03/04/2026. According to the admission Summary (Standard), Resident #7 had a medical history that included diagnoses of schizoaffective disorder, suicidal ideations, major depressive disorder, and bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2026, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated that the resident exhibited no behavioral symptoms during the assessment timeframe. The MDS indicated that the resident had active psychiatric diagnoses that included anxiety disorder, bipolar disorder, and schizophrenia. The MDS revealed Resident #7 had received antipsychotic medications. Resident #7's Care Plan, dated 10/15/2025, indicated Resident #7 had been sent to the hospital for an evaluation of suicidal ideations. Interventions directed staff to administer medications as ordered by the physician, and that the nurses were to monitor for continued suicidal thoughts. There was no information that indicated target behaviors following the return from the hospital or other interventions on how to keep the resident safe. The Care Plan also indicated that the resident was at risk for adverse reactions from psychotropic medication use but did not specify not specify a goal or objective that addressed target behaviors related to the diagnoses that the psychotropic medications were used to treat or other interventions used to treat the resident's symptoms. Resident #7's Temporary Problem Care Plan included a problem statement dated 07/14/2026, that revealed that a psychiatric nurse had made medication changes and indicated that the resident's olanzapine (an antipsychotic) was decreased to 15 milligrams (mg) at bedtime for bipolar disorder. The Temporary Problem Care Plan included a problem statement dated 07/15/2026, that revealed, Behaviors and indicated the resident was cursing staff, and staff were to discourage the behavior and monitor the resident. The Temporary Problem Care Plan revealed that it did not specify a measurable goal or objective that addressed target behaviors or other interventions used to treat the resident's behaviors. The Nurse Practitioner (NP) was interviewed on 07/24/2026 at 9:07 AM and stated she expected residents on psychoactive medications to have a care plan that included nonpharmacological interventions and expected target behaviors to be identified. The NP stated she expected Resident #7's suicidal ideations to be care planned. The MDS Coordinator was interviewed on 07/23/2026 at 10:02 AM. The MDS Coordinator stated that any nurse could initiate or revise a care plan but none of the other staff would initiate or revise care plans. The MDS Coordinator stated that she was not familiar with the term target behavior and stated that she was unaware the target behaviors should be included on the care plan. She stated that she typically care planned antipsychotic medications. The Director of Nursing (DON) was interviewed on 07/24/2026 at 3:04 PM. The DON stated that target behaviors for antipsychotic medications and other psychoactive medications should be included on the care plan with interventions to negate the triggers. The DON stated that while staff were able to make suggestions about care plans, the MDS Coordinator was responsible for initiating and developing the care plans. The Director of Nursing was interviewed on 07/24/2026 at 3:12 PM and stated she expected Resident #7's suicidal ideations to be care planned, so staff knew what set the resident off and how to keep the resident safe. The Administrator and Assistant Administrator were interviewed on 07/24/2026 at 4:14 PM. They both stated that they expected the resident's suicidal ideations to be care planned and that they expected the use of antipsychotic medications and target behaviors to be care planned along with nonpharmacological interventions.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff cleaned and stored respiratory equipment after each use for 1 (Resident #18) of 2 residents reviewed for respiratory care. Findings included: A facility policy titled, Administering Medication through a Small Volume (handheld) Nebulizer revised 10/2010, revealed, 27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; d. rinse all pieces with sterile water (NOT tap, bottled, or distilled); and e. allow to air dry on a paper towel. 28. Wash and dry hands. 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. An admission Record (Extended) revealed the facility admitted Resident #18 on 04/28/2026. According to the admission Record (Extended), the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2026, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #18's Doctor's Orders for 07/2026 revealed an order dated 07/08/2026 for ipratropium bromide/albuterol sulfate 0.5-2.5 milligrams (mg) per 3 milliliters (ml) with instructions to give one vial handheld nebulizer every six hours routine for exacerbation of COPD and pneumonia. During an observation on 07/21/2026 at 11:44 AM, Resident #18's nebulizer mask was not stored in a bag or clean and dry. During an interview on 07/21/2026 at 11:53 AM, Resident #18 stated they had not seen anyone clean or empty the liquid in the nebulizer and was not sure when they changed the tubing. During a concurrent interview and observation on 07/21/2026 at 11:58 AM, LPN #5 stated that Resident #18 received a nebulizer treatment four times a day and did not keep it bagged. LPN #5 stated she did not clean the nebulizer mask or cannister, and the nebulizer mask stayed wet for the week. LPN #5 confirmed that liquid was present in the nebulizer, and it had not been cleaned, dried, or bagged. During an interview on 07/22/2026 at 9:40 AM, LPN #4 stated he made sure the solution was out of Resident #18's nebulizer and if just a little was left, he would empty the solution and leave the nebulizer mask on the machine. During an interview on 07/24/2026 at 3:33 PM, the Director of Nursing (DON) stated that she expected the nebulizer to have been cleaned and placed in a bag after use. During an interview on 07/24/2026 at 4:45 PM, the Assistant Administrator stated she expected the nurse to clean the nebulizer after use and place it in a bag.

Based on interview, record review, and facility policy review, the facility failed to ensure a new Level I Preadmission Screening and Resident Review (PASARR) was submitted after an antipsychotic medication was added for post-traumatic stress disorder (PTSD) for 1 (Resident #3) of 1 resident reviewed for PASARR.Findings included: A facility policy titled, Behavioral Assessment, Intervention and Monitoring revised 02/2025, indicated, a. All residents receive a Level I PASARR screen prior to admission. b. If the level I screen indicates the individual may meet the criteria for a mental disorder, intellectual disability, or related condition he or she will be referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 6. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or related disorder are referred for a PASARR Level II evaluation. An admission Summary (Standard) indicated the facility admitted Resident #3 on 11/17/2025. According to the admission Summary (Standard), Resident #3 had a medical history that included a diagnosis of PTSD. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2026, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #3 had no hallucinations or delusions during the assessment's lookback period. The MDS revealed the resident had diagnoses of anxiety disorder and PTSD. Resident #3's Care Plan dated 11/26/2025 did not include a problem area for the resident's anxiety or PTSD. A State of Oklahoma, Oklahoma Health Care Authority, Nursing Facility Level of Care Assessment, submitted to the State Agency on 11/26/2025, indicated PTSD was a secondary diagnosis. The form indicated that for the Level I PASARR Resident #3 had no serious mental illness and had not been recently prescribed a psychotropic medication for a possibly undiagnosed mental illness within the past two years. Resident #3's Doctor's Orders for August 2026 contained an order, dated 11/28/2025, for risperidone (an antipsychotic medication) 0.5 milligrams (mg) daily at bedtime for delusions related to unspecified PTSD. There was no evidence in Resident #3's medical record that a new nursing facility level of care assessment (Level I PASARR) had been submitted that included the diagnosis of delusions or the addition of the risperidone. During an interview on 07/21/2026 at 10:27 AM, the MDS Coordinator who was responsible for facility PASARRs stated she completed a Level I PASARR on all residents and that on admission Resident #3 had no mental health issues or a mental health diagnosis. The MDS Coordinator stated she was unaware that if a resident received a psychiatric diagnosis or psychoactive medication, a new PASARR was submitted to the State Agency for review. The MDS Coordinator stated she was unsure why Resident #3 had been placed on an antipsychotic medication. The MDS Coordinator stated the facility had no policy for the completion of the PASARR. The Director of Nursing (DON) was interviewed on 07/24/2026 at 2:59 PM. The DON stated the MDS Coordinator was responsible for reviewing PASARRs on admission for accuracy. The DON stated PTSD was considered a mental health diagnosis and since Resident #3 had received an antipsychotic medication after admission, a new Level I PASARR should have been completed and submitted to the State Agency for review. The Administrator and the Assistant Administrator (AA) were interviewed on 07/24/2026 at 4:14 PM. They stated if a resident received a new diagnosis or new antipsychotic medication, they would have expected staff to resubmit the PASARR for a Level II review.

Based on facility policy review, record review, and interview, the facility failed to provide laboratory services according to orders for 1 (Resident #41) of 12 sampled residents.Findings included: A facility policy titled, Charting and Documentation, revised 07/2017, revealed, The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. An admission Summary (Standard) revealed the facility admitted Resident #41 on 03/21/2025. According to the admission Summary (Standard), the resident had a medical history that included diagnoses of chronic pain syndrome, rheumatoid arthritis, and unspecified convulsions. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2025, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Resident #41's Care Plan included a problem area dated 03/21/2025, that indicated Resident #41 had a seizure disorder. Interventions directed staff to obtain laboratory tests as ordered and to report abnormal results to their physician as needed. Resident #41's History and Physical, dated 03/28/2025 revealed that the Nurse Practitioner (NP) ordered laboratory tests after seeing Resident #41, which included complete blood count (CBC), comprehensive metabolic panel (CMP), lipids (measures fat in the blood), A1C (amount of sugar in blood over past three months), pre-albumin (protein), and valproic acid levels. Resident #41's progress notes included a Doctor Visit note, dated 03/28/2025 at 2:29 PM, that revealed the NP saw Resident #41 and ordered laboratory tests, including CBC, CMP, lipids, A1C, pre-albumin, and valproic acid levels. Resident #41's Nursing Home Visits record, dated 04/04/2025, revealed the NP ordered laboratory tests after seeing Resident #41, which included CBC, CMP, lipids, A1C, and pre-albumin. Resident #41's medical record revealed no evidence of any laboratory test results that were ordered on 03/28/2025 or 04/04/2025. During an interview on 07/24/2026 at 8:29 AM, NP stated that she ordered laboratory tests on 03/28/2025 and reordered tests again on 04/04/2025. The NP stated that she had not received the results on her electronic system and stated that once she ordered them, she expected them to be drawn within a week. During an interview on 07/24/2026 at 3:26 PM, Licensed Practical Nurse (LPN) #3 stated that Resident #41's name was on the laboratory list. She stated that the resident's name was circled then re-written and crossed out as if the tests were completed, but she could not find the results. She stated that the facility staff called the laboratory to obtain the results from 03/28/2025 and 04/04/2025, and the lab did not have any results from those dates. During an interview on 07/24/2026 at 3:28 PM, the Director of Nursing (DON) stated that laboratory tests should be drawn there, and if the nurses could not get them, then the resident would go to the hospital to get drawn. She further stated that when the results came in, the provider was notified. During an interview on 07/24/26 at 4:45 PM, the Assistant Administrator (AA) stated she expected the nurses to follow doctors' orders for laboratory tests and follow up on results appropriately.

Based on interview, record review, and facility document review, the facility failed to ensure an as needed (PRN) order for an antianxiety medication did not extend beyond 14 days without a documented rationale and specific duration for 1 resident (Resident #10) of 5 residents whose medications were reviewed.Findings included: An admission Summary (Standard) revealed the facility admitted Resident #10 on 07/18/2025. According to the admission Summary (Standard), Resident #10 had a medical history that included diagnoses of dementia, unspecified depression, and unspecified anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2026, indicated Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had no behaviors with anxiety identified as a diagnosis. The MDS revealed Resident #10 had received antipsychotic medications, antianxiety medications, and antidepressant medications during the assessment period. Resident #10's Care Plan dated 07/28/2025 indicated the resident was at risk for decline due to the use of psychotropic medications and the side effects. A list of side effects was included in the care plan along with the names of the medications: lorazepam, duloxetine, lamotrigine, and risperidone. An Expanded DRR [Drug Regimen Review] Report dated 03/05/2026 indicated the Consultant Pharmacist (CP) had notified the facility that Resident #10 had an as-needed (pro re nata, PRN) lorazepam order that was over 14 days old. A progress note dated 05/22/2026 at 4:11 PM indicated that Resident #10's PRN lorazepam had been accidentally discontinued on 04/17/2026. The note indicated that both the hospice staff and the Nurse Practitioner (NP) were aware. Resident #10's Physician's Orders for August 2026 contained an order, dated 05/22/2026, for lorazepam 2 milligram (mg) per milliliter (ml) to be given every four hours PRN for anxiety and agitation. Resident #10's 06/2026 medication administration record (MAR) revealed staff documented that the resident had received PRN lorazepam on 06/06/2026 at 3:35 PM and 9:48 PM, 06/07/2026 at 10:25 AM and 8:50 PM, 06/09/2026 at 9:16 PM, 06/14/2026 at 9:37 AM, and 06/20/2026 at 2:03 PM. Further review revealed the administration of the medication was listed as effective. Resident #10's progress notes indicated no behaviors, or non-pharmacological interventions had been documented for 06/06/2026, 06/07/2026, 06/09/2026, 06/14/2026, or 06/20/2026. Resident #10's 07/2026 MAR indicated PRN lorazepam had not been administered to Resident #10. An Expanded DRR Report dated 07/08/2026 indicated that Resident #10 had a PRN lorazepam order that was over 14 days old. During an interview on 07/22/2026 at 4:14 PM, Licensed Practical Nurse (LPN) #3 stated behavior monitoring was documented in the progress notes. LPN #3 stated if there were no progress notes about behaviors, that meant the resident had not exhibited behaviors. LPN #3 stated the PRN lorazepam for Resident #10 had been ordered by hospice as part of their comfort pack, and the PRN lorazepam was used during the medication readjustment for the resident. LPN #3 stated she was aware that the PRN lorazepam should only be ordered for 14 days and then the resident should be reassessed. During an interview on 07/23/2026 at 10:02 AM, the MDS Coordinator stated residents' behaviors were documented in progress notes if behaviors occurred. The MDS Coordinator stated behavior monitoring was not included on the MAR, and the facility did not utilize a separate behavior monitoring sheet. The MDS Coordinator stated that PRN psychoactive medications could be written for 14 days and then the resident must be reassessed before the order was extended. The MDS Coordinator stated hospice staff had been educated about the regulation for PRN psychoactive medications. The MDS Coordinator was unaware that prior to the use of PRN psychoactive medication, nonpharmacological interventions must be attempted, the intervention documented, and the effectiveness of the nonpharmacological interventions should be recorded. During a telephone interview on 07/23/2026 at 1:56 PM, the Consultant Pharmacist stated he expected the facility to do as the regulation directed, which was to be seen by the physician before extending the PRN lorazepam order for an additional 14 days. The Consultant Pharmacist stated he directed the previous Director of Nursing (DON) to place an automatic stop date on the PRN lorazepam and then the physician would have to come in and assess the resident to see if the lorazepam was still needed. The Consultant Pharmacist stated facility staff had not mentioned the lorazepam order was written by hospice, but he had assumed the order came from hospice. The Consultant Pharmacist stated he expected the facility to use non-pharmacological interventions before using the PRN lorazepam. During a telephone interview on 07/23/2026 at 2:35 PM, Hospice Registered Nurse (RN) #17 stated that PRN lorazepam had been ordered by the hospice physician as part of the hospice medication package for comfort to make sure the resident had the medication if needed. Hospice RN #17 stated at the time the medication was ordered the resident had declined physically and had increased anxiety. Hospice RN #17 stated the facility had not educated her that PRN psychoactive medications could not be ordered for more than 14 days. The NP was interviewed on 07/24/2026 at 9:07 AM. The NP stated she was aware the resident received PRN lorazepam per hospice and she was unable to overrule the hospice orders. The NP stated she assumed the hospice physician knew long-term care regulations concerning PRN lorazepam and she had not spoken to the hospice physician. The NP stated for psychoactive medications she expected behavior monitoring and a care plan to include nonpharmacological interventions and expected target behaviors to be identified. The DON was interviewed on 07/24/2026 at 3:04 PM. The DON stated that the PRN lorazepam should not last more than 14 days. The DON stated PRN lorazepam should be a last resort, and non-pharmacological interventions should be included in Resident #10's care plan. The Administrator and Assistant Administrator (AA) were interviewed on 07/24/2026 at 4:14 PM. They stated they expected antipsychotic medications and behaviors to be care planned along with nonpharmacological interventions. The AA stated PRN psychoactive medications should not be ordered for more than 14 days at a time. The AA stated she expected the facility staff to educate hospice staff about the 14-day rule for PRN psychoactive medication.

Based on observation, interview, record review, and facility policy review, the facility failed to promote a resident's dignity by covering the resident's urinary catheter drainage bag for 1 (Resident #27) of 3 residents reviewed for dignity.Findings included: An undated facility policy titled, Resident Rights Policy indicated that each resident had the right To receive care and treatment in a manner and in an environment that promotes maintenance enhancement of each resident's quality of life, dignity and highest practicable mental, physical, and psychosocial well being. An admission Summary (Extended) indicated the facility admitted Resident #27 on 07/08/2026. According to the admission Summary (Extended), Resident #27 had a medical history that included a diagnosis of unspecified retention of urine. Resident #27's Baseline Care Plan dated 07/09/2026 indicated that Resident #27 was alert, oriented, and confused. The Baseline Care Plan revealed that Resident #27 had an indwelling urinary catheter. Resident #27's Doctor's Orders for July 2026 revealed the resident received tamsulosin hydrochloride (a medication used to improve urine flow) 0.4 milligrams (mg) every night at bedtime for unspecified retention of urine. An observation on 07/19/2026 at 11:59 AM revealed Resident #27 was lying in bed with their indwelling urinary catheter observed with no privacy covering the drainage bag. During an observation on 07/19/2026 at 2:45 PM, Resident #27 was sitting in their wheelchair by the bed. The urinary catheter drainage bag was able to be seen from the hallway, and there was no privacy bag covering the drainage bag. During an observation on 07/20/2026 at 3:40 PM, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) #1 completed catheter care on Resident #27. The urinary catheter drainage bag remained uncovered and visible from the hall when the door was opened. During a concurrent interview CNA/CMA #1 stated she usually placed a pillowcase over the drainage bag to provide privacy but had not worked the weekend, and someone had not placed anything over the bag to maintain privacy. CNA/CMA #1 stated she had no reason she had not replaced the pillowcase to provide privacy earlier in the shift. An observation on 07/20/2026 at 5:23 PM revealed there was no privacy bag on Resident #27's urinary catheter drainage bag. During an interview on 07/21/2026 at 8:51 AM, CNA/CMA #1 stated that she had not provided privacy for Resident #27's urinary catheter drainage bag. CNA/CMA #1 stated she had given report to the oncoming CNA about completing catheter care but had not told the oncoming CNA that the resident's urinary catheter drainage bag required covering. During an interview on 07/21/2026 at 11:36 AM, CNA/CMA #2 stated that the facility policy indicated that the urinary drainage bag was to be covered for dignity. CNA/CMA #2 stated the facility used to have bag covers, but she had not seen any in a while and was not sure what was being used now. CNA/CMA #2 stated it was the responsibility of the charge nurse to make sure the urinary catheter drainage bag had privacy covers and added that not having a privacy cover was a dignity issue. CNA/CMA #2 stated she was aware Resident #27 had a catheter but had not noticed if the privacy bag was covering the drainage bag. During an interview on 07/22/2026 at 12:30 PM, Licensed Practical Nurse (LPN) #3 stated it was important to keep the resident's urinary catheter drainage bag covered to maintain dignity. During an interview on 07/22/2026 at 3:18 PM, the MDS Coordinator stated she expected staff to keep the urinary catheter drainage bag inside something to protect Resident #27's dignity. The MDS Coordinator stated there had been multiple educational sessions covering urinary drainage bags. An observation on 07/23/2026 at 8:35 AM revealed Resident #27 was asleep in bed with their urinary catheter drainage bag hanging on the side of the bed, with no privacy cover, and was able to be seen from the hallway. During an interview on 07/23/2026 at 8:35 AM, LPN #4 stated there should have been a privacy bag covering Resident #27's urinary catheter drainage bag. LPN #4 stated that when he arrived at work at 12:00 AM and when he saw Resident #27 at 4:30 AM, the drainage bag had been covered. LPN #4 stated that the privacy bag had been removed between 4:30 AM and 8:30 AM. The Director of Nursing (DON) was interviewed on 07/24/2026 at 2:56 PM. The DON stated she expected the urinary catheter drainage bag to be covered to provide Resident #27 with dignity and for cleanliness. The Administrator and Assistant Administrator (AA) were interviewed on 07/24/2026 at 4:14 PM. They stated they expected urinary catheter drainage bags to be covered at all times for dignity purposes.

Based on observation, interview, and facility policy review, the facility failed to ensure staff stored medications in a locked medication cart for 1 (Medication Cart for Halls 3 and 4) of 2 medication carts observed. Additionally, the facility failed to secure the keys for a locked medication cart and failed to count controlled substances between shifts for 1 (Medication Cart for Halls 1 and 2) of 2 medication carts observed.Findings included: 1. A facility policy titled, Administering Medications dated 04/2019, indicated, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. An observation was made on 07/20/2026 at 10:45 AM of medication cards with medications in the cards tucked inside the narcotic count book on top of the medication cart for Halls 3 and 4. No staff were seen near the cart. Residents were walking in the hallway and were in close proximity to the medication cart. During an interview on 07/20/2026 at 10:50 AM, Licensed Practical Nurse (LPN) #3 stated it was not common practice to leave medications unattended on top of the medication cart. LPN #3 identified Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) #2 as responsible for the medication cart. During an interview on 07/20/2026 at 10:55 AM, CNA/CMA #2 stated it was not her practice to leave medications unattended on top of the medication cart. CNA/CMA #2 stated the medications she had placed on top of the cart were ready to expire, and the plan was to take them to the medication room when a resident called out for their neck pillow. CNA/CMA #2 stated usually she placed medications in the bottom drawer of the medication cart until she could get to the medication room, but she needed to get the resident their neck pillow so they would stop yelling and disturbing other residents. CNA/CMA #2 stated the danger of leaving the medications unattended was that other residents could pick the medications up. The medications left on top of the medication cart were reviewed with CNA/CMA #2 and included Magnesium Oxide 400 milligrams (mg) 10 tablets, Sinemet 25-250 mg five tablets, Promethazine 25 mg 22 tablets, and Baclofen 10 mg 33 tablets. During an interview on 07/21/2026 at 9:10 AM, LPN #5 stated medications were not supposed to be left on top of the medication cart and the medication cart was not to be left unlocked. The Director of Nursing (DON) was interviewed on 07/24/2026 at 3:16 PM. The DON stated she expected medications to be stored in the medication cart or in the medication room and not on top of the cart. The DON stated that the medication carts should be kept locked when not attended. The Administrator and the Assistant Administrator (AA) were interviewed on 07/24/2026 at 4:14 PM. They stated they expected medications to be locked in the medication cart or the medication room. They stated they expected the medication cart to be locked when staff were not nearby. 2. An undated facility policy titled, Storage and Documentation of Controlled Medications, indicated, All controlled medications shall be checked for accountability at each change of shift. The medication nurse going off duty and the medication nurse coming on duty shall perform the audit. Documentation of the audit will be completed on the appropriate form and will manually or electronically sign the 8-hour verification sheet. An undated facility policy titled, Procedure of Transfer of Keys for Controlled Substances, indicated, All controlled substances are to be counted when keys are to be transferred from one nurse to another. Each time keys change hands this process must be followed. An observation was made of Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) #8 arriving for work on 07/20/2026 at 4:05 PM. During a concurrent interview, CNA/CMA #8 stated she had not received report from the morning CMA. During an interview on 07/20/2026 at 4:32 PM, CNA/CMA #8 stated she had not completed a narcotic count with any other staff member but had the keys to the medication cart and had left the medication cart unlocked. CNA/CMA #8 stated the off-going CMA had counted with the nurse prior to leaving the facility prior to her arrival in the facility.During an interview on 07/20/2026 at 4:17 PM, Licensed Practical Nurse (LPN) #4 stated he was the evening charge nurse and that the day shift nurse had counted narcotics with the dayshift CMA that left at 3:00 PM. LPN #4 stated the nurses and CMAs counted narcotics with each other and should document the count of narcotics, but that did not always occur.During an interview on 07/20/2026 at 5:05 PM, CNA/CMA #8 stated she received the keys to the mediation cart by going into the drawer inside the nurse's station where CMA #9, the day shift CMA, had placed the keys when she left. CNA/CMA #8 stated she realized if any controlled medications were missing, it would have fallen back on her because she had taken possession of the keys. CNA/CMA #8 stated that when CMA #9 or other staff left early, they placed the keys to the medication cart in a drawer. CNA/CMA #8 stated that practice occurred one to two times per week. CNA/CMA #8 stated she was not sure if the Director of Nursing (DON) was aware staff were taking possession of the medication keys without counting controlled substances but admitted she had not informed the DON. CNA/CMA #8 identified LPN #5 as the nurse that had counted narcotics with CMA #9 before CMA #9 had left the facility. CNA/CMA #8 stated she received report from LPN #5, but she and LPN #5 had not counted the controlled medications During an interview on 07/21/2026 at 9:10 AM, LPN #5 stated that on 07/20/2026, CMA #9 had left the facility around 2:30 PM. LPN #5 stated she had counted narcotics with CMA #9 and then had placed the keys to the medication cart inside a drawer in the nurse's station. She stated the keys to the medication cart should be kept on a person and not placed in a drawer, but she had placed them in the drawer because the keys would have been bulky when she sat down and heavy in her pants. LPN #5 stated she had given CNA/CMA #8 the keys before without counting, and yesterday CNA/CMA #8 had removed the keys from the drawer. LPN #5 stated that the facility policy indicated controlled substances should be counted before the keys were passed. LPN #5 stated the danger in taking the medication keys without counting would be possible theft of medication. LPN #5 stated confirmation of counting controlled substances was documented on an 8-hour narcotic verification sheet and if a signature was missing, it meant the narcotics were not counted or the nurse had not signed. LPN #5 reviewed the 8-hour narcotic verification sheet for 07/20/2026 and stated the form was not accurate, nurses had signed in the wrong spot, and some nurses had not signed at all. LPN #5 stated she had not signed the sheet to verify the count on 07/20/2026 when she counted narcotics with CMA #9. She stated that CMA #9 had started counting the narcotics on 07/20/2026 before she was able to get to the medication cart to count, and when she arrived at the medication cart, CMA #9 had only four more cards of controlled medications before finishing. During an interview on 07/21/2026 at 9:53 AM, CMA #9 stated she had requested LPN #5 count narcotics with her, but the LPN got tied up. CMA #9 stated she knew it was not right or legal to count by herself, but she had started by herself. CMA #9 stated the other CMA was busy, and she had not asked the DON to count narcotics with her. CMA #9 stated the Graveyard shift refused to count narcotics and refused to sign the 8-hour narcotic verification form. CMA #9 stated she had not reported the staff's refusal to count narcotics to the DON. During an interview on 07/21/2026 at 12:12 PM, LPN #10 stated that at the end of the shift the oncoming nurse counted narcotics with the off-going nurse and then the keys to the medication cart were given to the oncoming nurse. LPN #10 stated she was aware there were staff members that refused to count narcotics, and she was aware the medication keys were kept in a drawer at the nurse's station but had not reported the practice to anyone.During an observation and interview on 07/22/2026 at 7:46 AM, LPN #4 stated he did not have his keys to the medication cart and left them at the nurse's station. LPN #4 was observed reaching through an open window at the nurse's station and retrieving the keys. He stated he usually kept one set of keys on his person and locked the other set in the medication room.During an interview on 07/22/2026 at 8:51 AM, LPN #4 stated that it was not appropriate to take the medication keys before the narcotics were counted. LPN #4 stated it was not appropriate to leave the medication keys in a drawer in the nurse's station or on the counter in the nurse's station. LPN #4 stated that morning he had been in the middle of a conversation, saw the CMA was near, and got sidetracked. LPN #4 stated he knew if he stuck his hand through the window to get the medication keys, then anyone else would be able to do the same. LPN #4 stated that he was unaware that nurses refused to count narcotics. LPN #4 stated that if a signature was missing from the 8-hour verification narcotic form, it meant the medication was counted and the staff forgot to sign. He stated that he had experienced counting narcotics by himself because staff on the 4:00 PM to 12:00 AM shift would not wait at the facility for him to get there to count.During an interview on 07/22/2026 at 12:30 PM, LPN #3 stated staff were expected to count narcotics at the end of a shift. LPN #3 stated she had been guilty of not counting narcotics at the end of the shift when she worked nights because it was hard to count two medication carts and get report from two CMAs or nurses. LPN #3 stated it was not appropriate to throw the keys to the medication cart in a drawer at the nurse's station since that would give anyone that got the keys access to the medication cart, the narcotic box, and the medication room. LPN #3 stated the previous DON had knowledge that staff were not keeping possession of the medication keys and were not always counting narcotics. LPN #3 stated if the 8-hour narcotic verification sheet was not signed, it could mean the nurse did not count, or the nurse forgot to sign the sheet. During an interview on 07/22/2026 at 2:47 PM, the Minimum Data Set (MDS) Coordinator stated she expected the oncoming CMA or nurse and the off-going nurse or CMA to count narcotics to make sure the medication count was accurate. The MDS Coordinator stated if one nurse refused to count the narcotics, she expected the nurse or CMA to report the refusal to the DON or ask another nurse that was present to count medications. The MDS Coordinator stated the nurses that completed the medication count were expected to sign the 8-hour verification narcotic count shift log in the spot that was either off-going or oncoming and if the narcotic verification form was not signed, she would assume the staff were too lazy to sign the sheet or the medication had not been counted. During a telephone interview on 07/23/2026 at 1:56 PM, the Consultant Pharmacist stated he expected the nurses to keep the medication carts locked. The Consultant Pharmacist stated he expected narcotics to be counted between shifts. The Nurse Practitioner (NP) was interviewed on 07/24/2026 at 9:20 AM. The NP stated she expected the medication cart to be locked when unattended and expected controlled medications to be counted between shifts to check for any discrepancies. The NP stated that the keys to the medication cart should be kept on the person and not thrown in a drawer at the nurse's station, and the nurse should not accept the keys to the cart before counting the narcotics. The NP stated that the nurses were expected to sign the 8-hour narcotic verification sheet. The DON was interviewed on 07/24/2026 at 3:16 PM. The DON stated she expected staff to count narcotics at the end of the shift and both nurses, the oncoming and off going nurse or CMA, should be involved in the count to assure the accuracy. The DON stated it was not proper for one person to count. The DON stated that the medication carts should be kept locked when not attended, and the keys to the medication cart should be kept with the nurse and should not be kept in a drawer at the nurse's station. The DON stated she knew some nurses kept the medication keys in the drawer, but she had done nothing about the practice. The Administrator and Assistant Administrator (AA) were interviewed on 07/24/2026 at 4:14 PM. They stated they expected medications to be locked in the medication cart or the medication room and expected the medication cart to be kept locked. The Administrator and AA stated narcotics should be counted between shifts with the ongoing and off-going nurses to make sure the count was correct. They stated nursing staff should keep the medication cart keys on their person.

Based on interview, facility document review, and facility policy review, the facility failed to include the mandated information on the daily posted nurse staffing forms for 6 (07/19/2026 through 07/24/2026) of 6 days reviewed.Findings included: A facility policy titled, Posted Direct Care Daily Staffing Numbers dated 08/2022, indicated, 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs [registered nurses], LPNs [licensed practical nurses], LVNs [licensed vocational nurses]) and the number of unlicensed nursing personnel (CNAs [certified nursing assistants] and Nas [nursing assistants]) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including but not limited to: assisting with activities of daily living (ADLs), administering medications, supervising care provided by CNAs, and performing nursing assessments. Medication aides, feeding assistants, hospice staff, private duty aides, and administrative staff are not calculated in direct care staffing numbers. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working that shift who are paid by the facility (including contract staff); g. The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non-licensed nursing staff working for the posted shift. Posted nurse staffing forms for the timeframe from 07/19/2026 through 07/24/2026 revealed that the forms did not include the census of the facility, the total hours worked for each discipline, or the total number of staff for licensed and non-licensed staff. Further review revealed that the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator were listed as staff providing direct care to residents. During an interview on 07/22/2026 at 2:58 PM, the MDS Coordinator stated she was responsible for the posted nurse staffing forms. The MDS Coordinator stated that she was unaware of what information was included on the form, but she used the form the facility had always used. The mandated information from the regulation was reviewed with the MDS Coordinator, who confirmed she had been unaware of the information that needed to be included. The DON was interviewed on 07/24/2026 at 3:22 PM. The DON stated she was unaware of the information that was needed on the posted nurse staffing form. The Administrator and the Assistant Administrator (AA) were interviewed on 07/24/2026 at 4:14 PM. The Administrator and the AA stated that they were unaware of the mandated information that should be included in the posted nurse staffing form.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#1) of three sampled residents reviewed for abuse. The deficient practice resulted in skin tears to the resident's wrists. The administrator identified five allegations of abuse in the last six months. Findings: A policy title Abuse, Neglect and Exploitation, dated 08/07/24, read in part, The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or occur .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but not limited to: D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; .The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made. A policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 08/07/24, read in part, When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee. d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. A policy titled QAPI Coordination in Situations of Abuse, Neglect and Exploitation, dated 08/07/24, read in part, All reports of abuse, neglect, misappropriation of resident property and exploitation, whether by staff or residents, will be communicated to the QAA committee for tracking and corrective action .The QAA committee will determine through a coordinated effort: a. If a thorough investigation is conducted; b. Whether the resident is protected; . e. Whether there is further need for systemic actions such as: . ii. Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about; . iv. Measures to verify the implementation of corrective actions and timeframes, and v. Tracking patterns of similar occurrences. Resident #1 had diagnoses which included dementia with behavioral disturbances, anxiety disorder, delusional disorders, and major depressive disorder. The care plan, dated 02/13/24, documented the resident had dementia with impaired cognition with frequent verbal and physical behaviors. The care plan documented staff were to leave the resident alone and retry later or get a different caregiver to provide care. A quarterly assessment, dated 07/08/24, documented the resident was severely impaired for daily decision making and required substantial/maximal assistance with most activities of daily living. A witness statement for incident reports, dated 07/28/24 at 12:00 p.m., documented an employee witnessed CMA #1 attempting to give medicine to the resident. The witness statement documented the resident did not want to take the medicine and threw the spoon at CMA #1. The witness statement documented the resident started hitting the CMA and the CMA took the cup of water they were holding and threw the water in the resident's face. The witness statement documented the resident started hitting CMA #1 again and the CMA stated, If your going to hit me then I'm going to make you hit yourself. The witness statement documented CMA #1 grabbed the resident by both wrists and hit them against the resident's face. It was documented the resident became more combative. The witness statement documented the CMA grabbed the resident again and stated, [Verbiage withheld] you better stop playing with me. The witness statement doucmented the CMA grabbed the resident by the wrists slamming the resident further back in the bed causing the resident to hit their head on the bed rails. An incident report, dated 07/28/24, documented an allegation of abuse for Resident #1 and CMA #1. The report documented the administrator was made aware of the incident on 07/29/24 at 1:00 p.m. by the resident's family. The report documented an investigation revealed Resident #1 became combative with CMA #1 and CMA #1 grabbed Resident #1's wrists causing skin tears. The report documented the primary care physician, family, administrator, and DON were notified and safety precautions maintained. A time card report, dated 07/28/24, documented CMA #1 worked from 7:51 a.m. to 12:38 a.m totaling 16.30 hours. A disciplinary report form, dated 07/28/24, documented on 07/29/24 LPN #2 was placed on suspension pending the investigation. The report documented LPN #2 was terminated for failure to notify the administrator, DON, and remove CMA #1 after the incident on 07/28/24. A disciplinary report form, dated 07/28/24, documented on 07/29/24 at 4:00 p.m. CMA #1 was placed on suspension pending an investigation. The report documented on 08/05/24 after the investigation was completed the staff member was terminated. A police department incident report, dated 07/29/24 at 8:50 p.m., documented the police was dispatched to the facility to take an information report. A fax transmission verification report, dated 07/29/24 at 8:51 p.m., documented the allegation of abuse was reported to the Oklahoma State Department of Health. A documented interview with Resident #1's family, dated 07/29/24, documented at 1:15 p.m. the family visited the resident and noticed the resident's right and left hands were bleeding. It was documented the family inquired about the injury and was told by CMA #1 the resident became combative and We weren't going to let [them] hit us. A class attendance record, dated 08/01/24, documented an in-service regarding elderly abuse and neglect was provided to staff. On 11/13/24 at 2:45 p.m., the APRN stated they were notified of the allegation of abuse regarding Resident #1 a few days after the incident occurred. On 11/14/24 at 9:43 a.m., the administrator stated LPN #2 did not report the allegation of abuse regarding Resident #1 to them or protect the resident from the identified staff member. The administrator stated they did not report the allegation of abuse to the Oklahoma State Department of Health within the two hour required time frame. The administrator stated the QAPI committee had not had a meeting since sometime in April 2024. The administrator stated the incident regarding the allegation of abuse had not been presented in a QAPI meeting. The administrator stated their abuse policy was not followed.

Based on record review and interview, the facility failed to implement their written abuse policies and procedures for one (#1) of two sampled residents reviewed for abuse. The administrator identified five allegations of abuse in the last six months. Findings: A policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 08/07/24, read in part, When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect [them] from further incident. b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee. d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. Resident #1 had diagnoses which included dementia with behavioral disturbances, anxiety disorder, delusional disorders, and major depressive disorder. The care plan, dated 02/13/24, documented the resident had dementia with impaired cognition with frequent verbal and physical behaviors. The care plan documented the staff were to leave the resident alone and retry later or get a different caregiver to provide care. A quarterly assessment, dated 07/08/24, documented the resident was severely impaired for daily decision making and required substantial/maximal assistance with most activities of daily living. On 11/14/24 at 9:43 a.m., the administrator stated LPN #2 did not report the allegation of abuse regarding Resident #1 to them or protect the resident from the identified staff member. The administrator stated they did not report the allegation of abuse to the Oklahoma State Department of Health within the two hour required timeframe.

Based on record review and interview, the facility failed to report an allegation of abuse within the two hour required timeframe to the Oklahoma State Department of Health for one (#1) of three sampled residents reviewed for abuse. The administrator identified five allegations of abuse in the last six months. Findings: A policy titled Abuse, Neglect and Exploitation, dated 08/07/24, read in part, The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made. Resident #1 had diagnoses which included dementia with behavioral disturbances, anxiety disorder, delusional disorders, and major depressive disorder. The care plan, dated 02/13/24, documented the resident had dementia with impaired cognition with frequent verbal and physical behaviors. The care plan documented the staff were to leave the resident alone and retry later or get a different caregiver to provide care. A quarterly assessment, dated 07/08/24, documented the resident was severely impaired for daily decision making and required substantial/maximal assistance with most activities of daily living. An incident report, dated 07/28/24, documented an allegation of abuse for Resident #1 and CMA #1. The report documented the administrator was made aware of the incident on 07/29/24 at 1:00 p.m. by the resident's family. The report documented an investigation revealed Resident #1 became combative with CMA #1 and CMA #1 grabbed Resident #1's wrists causing skin tears. The report documented the primary care physician, family, administrator, and DON was notified and safety precautions maintained. A fax transmission verification report, dated 07/29/24 at 8:51 p.m., documented the allegation of abuse was reported to the Oklahoma State Department of Health. On 11/14/24 at 9:43 a.m., the administrator stated LPN #2 did not report the allegation of abuse regarding resident #1 to them or protect the resident from the identified staff member. The administrator stated they did not report the allegation of abuse to the Oklahoma State Department of Health within the two hour required timeframe.

Based on observation, record review, and interview, the facility failed to ensure menus were: a. prepared in advance, b. followed, and c. reviewed by the facility's dietitian or other qualified nutrition professional for the residents. The administrator identified 38 residents who ate meals prepared by the kitchen and two resident who received nutrition via feeding tube. Findings: The Facility Assessment Tool HNHINC, last updated 06/26/24, read in parts .OUR FACILITY IS CURRENTLY TRANSITIONING TO LIBERAL DIETS WITH DIET MODIFICATIONS AS REQUIRED TO MEET RESIDENTS' NEEDS. MENUS WILL BE CREATED BY OUR DSM AND STAFF AND APPROVED BY OUR REGISTERED DIETITIAN WITH CONSIDERATION OF SPECIALIZED DIETS AS ORDERED BY THE PCP. OUR CONSULTANT DIETITIAN VISITS THE FACILITY MONTHLY AND SUBMITS RECOMMENDATIONS TO THE FACILITY TO PRIVIDE [sick] TO THE PCP'S FOR APPROVAL. QUARTERY IN-SERVICE TRAINING CLASSES ARE CONDUCTED BY THE RD . The facility menu provided did not document therapeutic diets or portions sizes. On 07/01/24 at 7:32 a.m. the DM was asked for a copy of the therapeutic menus. The DM pointed to a hand written menu with no portion sizes or therapeutic diets documented. The DM stated this was the menu provided for meals. On 07/02/24 at 11:57 a.m., the assistant administrator stated currently a part time cook, who was the previous dietary manager, made the facility menus and has for over a year. The assistant administrator stated the previous dietary manager was not certified and the dietitian does not sign off for the menus. On 07/02/24 at 12:15 p.m., the part time cook/ previous dietary manager stated they watched the residents eat and based on their likes and dislikes determined the menus. The cook stated the staff just know what portion sizes to give for the meals. The cook stated the kitchen staff should know portion sizes based on the education given at weekly meeting. On 07/02/24 at 1:43 p.m., the dietary aide stated they would know what to prepare and serve for the day when they arrive that morning. Stated the dinner meal was oven baked hot dogs with chili, tator tots, salad, and desert. The dietary aide did not know what the desert was for the dinner meal. The dietary aide stated they prepare what the DM tells them to prepare. On 07/02/24 at 2:05 p.m., the facility dietitian was contacted by phone. The dietitian stated they had not documented or signed off on menus in a year. The dietitian stated menus were prepared and signed off by the facility's food provider to their knowledge. On 07/03/24 at 10:05 a.m., the assistant administrator provided menus for a month. The assistant administrator stated the dietary did not follow the menus provided, but followed the menus prepared by the part time cook/previous dietary manager. On 07/03/24 at 12:10 p.m., the DM prepared the pureed diet for the residents. The DM stated the facility has beans every Wednesday and fish every Friday. The DM stated beans was not on the menu for every Wednesday, but that was what the kitchen served. On 07/03/24 at 5:38 p.m., the assistant administrator stated the kitchen had stopped serving beans every Wednesday, but guess they stated back. The assistant administrator stated the DM decided what the meal would be each day just like you would if you were home.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner for the residents. The administrator identified 38 residents who ate meals prepared by the kitchen and two resident who received nutrition via feeding tube. Findings: On 07/01/24 at 7:28 a.m., the refrigerator contained dozens of unpasteurized eggs. No pasteurized eggs were observed. The dietary aide was serving scrambled eggs for breakfast. The dietary aide stated the unpasteurized eggs were served and prepared as scrambled eggs, hard eggs, and sometimes over medium eggs. On 07/01/24 at 7:32 a.m., the DM stated they had not had pasteurized eggs for two weeks. The DM stated there were some residents who request hard eggs and one resident who requests over medium eggs. The DM stated they should be using pasteurized eggs. On 07/01/24 at 7:34 a.m., the refrigerator in the kitchen contained a bag of shredded cheese open to air and three containers containing a liquid cheese, gravy, and some type of meat not dated. On 07/01/24 at 7:35 a.m., the DM stated meat was from yesterdays meal and should be thrown out. The DM did not respond regarding the other undated items in the refrigerator. On 07/01/24 at 7:38 a.m., the refrigerator in the storage room contained thawed meat in a container with bloody juice and was uncovered. On 07/01/24 at 7:39 a.m., the DM stated the meat was thawed last Friday and was used for the alternate menu. The DM stated the meat should not be served if thawed more than two days.

Based on record review and interview, the facilty failed to provide documentation regarding offering or given the pneumococcal vaccine for three (#5, 8, and #24) of five residents reviewed for immunizations. The administrator identified 40 residents who resided in the facility. Findings: A policy titled Pneumococcal Vaccine documented .Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal accine series, and when indiciated, are offered the vaccine series within thirty (30) days of admission to the facility . 1. Resident #5 was admitted to the facility on [DATE]. The immunization record for the resident did not document the pneumococcal vaccine was offered or given. 2. Resident #8 was admitted to the facility on [DATE]. The immunization record for the resident did not document the pneumococcal vaccine was offered or given. 3. Resident #24 was admitted to the facility on [DATE]. The immunization record for the resident did not document the pneumococcal vaccine was offered or given. On 07/03/24 at 10:16 a.m., the facility IP stated two of five residents reviewed for immunizations had received the pneumococcal vaccine. The IP stated they could not find documentation regarding the pneumococcal vaccine given or offered for the remaining three residents. The IP stated the facility pharmacy had not filled the prescription for the pneumococcal vaccine since 2019.

Based on record review and interview, the facilty failed to impliment their policy regarding monitoring and measures to prevent the growth of Legionella bacteria for the facility. The administrator identified 40 residents who resided in the facility. Findings: A policy titled Legionella Water Management Program documented .our facility has a water management program, which is overseen by the water management team .The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance .The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, .d. The identification of situations that can lead to Legionella growth, .h. A system to monitor control limits and effectiveness of control measures; .j. Documentation of the program . On 07/03/24 at 9:00 a.m., the maintenance director stated they were not familiar with a Legionella program. The staff stated no monitoring documentation has been completed regarding Legionella.

Based on record review and interview, the facility failed to ensure the medical record was accurate for one (#31) of one sampled resident who was reviewed for an injury of unknown origin. The administrator identified 40 residents who resided in the facility. Findings: Res #31 had diagnoses which included cerebral infarction, aphasia, right sided flaccid hemiplegia and osteoporosis. A physician's order, dated 03/10/23, documented Tylenol 325mg 1-2 every six hours as needed for pain. A progress note on 02/22/24 at 6:36 p.m., documented Res #31 had seizure like activity and was transferred to the local hospital emergency room . The resident returned the same day and staff noted Res #31 was unable to bear weight or tolerate range of motion and was holding their right hip hollering in pain. An order to obtain a right hip xray was obtained STAT. A progress note on 02/24/24 at 3:51 p.m. documented the right hip xray was obtained and at 6:08 p.m., the resident was transferred to the local hospital emergency room for a left hip fracture. A hospital xray report on 02/24/24 documented the resident had a comminuted fracture (fracture causing multiple bone splinters) of the left acetabulum (hip socket) with extension into the ischium (pelvis area). The report also documents a fracture of the right sacrum (lower part of the spine). The February medication administration record, documented Res #31 was not medicated for pain on 02/22/24, was given 650mg of Tylenol on 02/23/24 at 10:11 a.m., and 650mg of Tylenol on 02/24/24 at 2:35 p.m. On 07/03/24 at 12:45 p.m., LPN #1 reported Res #31 was in pain with positioning and could not tolerate sitting up in a chair. LPN #1 reported Tylenol helped some but the resident still had pain. LPN #1 reported not documenting the resident's pain and limitations with mobility in the nursing notes and stated, I probably didn't document about their pain because the resident wasn't in pain if they weren't being moved. On 07/03/24 at 1:15 p.m., RN #1 reported the resident had pain with movement and positioning but felt the resident's pain wasn't excruciating and probably didn't document about the pain because the resident had no pain when they weren't being repositioned. The progress notes between 02/22/24 at 6:36 p.m. and 02/24/24 at 6:08 p.m., did not document the resident being in pain. On 07/03/24 at 2:00 p.m., the DON reported the nurses should have documented the resident's pain with mobility in the progress notes.

Based on record review and interview, the facility failed to ensure a resident received proper pain management for one (#31) of one sampled resident who was reviewed for an injury of unknown origin. The administrator identified 40 residents who resided in the facility. Findings: A Pain - Clinical Protocol policy, revised on March 2018, read in part, The physician and staff will identify individuals who have pain or who are at risk for having pain. The nursing staff will assess each individual for pain .when there is onset of new pain .The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, .repositioning. Res #31 had diagnoses which included cerebral infarction, aphasia, right sided flaccid hemiplegia and osteoporosis. A physician's order, dated 03/10/23, documented Tylenol 325mg 1-2 every six hours as needed for pain. A progress note on 02/22/24 at 6:36 p.m., documented Res #31 had seizure like activity and was transferred to the local hospital emergency room . The resident returned the same day and staff noted Res #31 was unable to bear weight or tolerate range of motion and was holding their right hip hollering in pain. An order to obtain a right hip xray was obtained STAT. A progress note on 02/24/24 at 3:51 p.m. documented the right hip xray was obtained and at 6:08 p.m., the resident was transferred to the local hospital emergency room for a left hip fracture. A hospital xray report on 02/24/24 documented the resident had a comminuted fracture (fracture causing multiple bone splinters) of the left acetabulum (hip socket) with extension into the ischium (pelvis area). The report also documents a fracture of the right sacrum (lower part of the spine). The February medication administration record, documented Res #31 was not medicated for pain on 02/22/24, was given 650mg of Tylenol on 02/23/24 at 10:11 a.m., and 650mg of Tylenol on 02/24/24 at 2:35 p.m. 07/03/24 at 11:25 p.m., CMA #1 reported they did not feel the resident's Tylenol was effective for pain and stated, sometimes the Tylenol didn't touch their pain. CMA #1 reported they didn't know why they only gave the resident one dose of Tylenol. On 07/03/24 at 12:45 p.m., LPN #1 reported Res #31 was in pain with positioning and could not tolerate sitting up in a chair. LPN #1 reported calling the xray company to ask why the xray hadn't been done, but reports not calling the physician with an update. LPN #1 reported Tylenol helped some but the resident still had pain. LPN #1 reported they were sure the resident received more Tylenol than what was documented. LPN #1 reported not documenting the resident's pain and limitations with mobility in the nursing notes and stated, I probably didn't document about their pain because the resident wasn't in pain if they weren't being moved. On 07/03/24 at 1:05 p.m, the APRN reported there was no communication from the facility between giving the order for a STAT xray and getting the xray results. APRN reported they would have given an order to send the resident to the hospital had the facility called and reported no xray had been obtained and the resident's level of pain. On 07/03/24 at 2:00 p.m., the DON reported the physician should have been notified of the resident's continued pain and being unable to obtain the xray as ordered. The DON reported the nurses should have documented the resident's pain with mobility.

On 05/12/23 at 3:30 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure background screenings were completed for 45 of 66 employees. On 05/12/23 at 3:50 p.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation. On 05/12/23 at 4:00 p.m., the administrator was notified of the IJ situation. On 05/12/23 at 6:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Preparation and/or completion of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed 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. 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citations for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. All residents have the potential to be affected by this deficient practice. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. 1. Completed 100% audit on all missing employee background checks 2. Nurse consultant in-serviced Administrator, Asst. Admin, DON on background checks. 3. Asst. Administrator and Administrator will in-service department manager on facility's background check policy. 4. All current employees will have a background check completed. 5. All future employees will have a background check completed within 2 days of an offer of employment or contractual agreement. 6. Administrator and Assistant Administrator will monitor for the submission of background checks within 2 days after hiring. Administrator and/or Asst. Administrator will continue monitoring the submission of background checks and results as part of their job description. QA Nurse will review background checks monthly for 6 months or longer until compliance is achieved. Review/modify current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm. Person Assigned, [name omitted], Adm., [name omitted], Asst. Admin, Date Completed, 05/12/23 New policies written/implemented when applicable to insure additional serious harm will be prevented. Person Assigned, [name omitted], Adm., [name omitted], Asst. Admin, Date Completed, 05/12/23 Checklists and monitoring tolls used to verify compliance. Person Assigned, [name omitted], Adm., [name omitted], Asst. Admin, Date Completed, 05/12/23 Educate necessary staff on facility procedures with return demonstration where applicable. Person Assigned, [name omitted], Adm., [name omitted], Asst. Admin, Date Completed 05/12/23. Addendum to Removal of IJ for failure to complete background checks and fingerprint test. Actions to Prevent Occurrence/Recurrence: All fingerprinting will be completed by 4 p.m., Friday, 5/19/23. Results are expected within 5-7 business days after the completion of the test, via email, according to IdentoGo's policies and procedures 05/26/23 at 5 p.m. All future fingerprinting will be initiated within 2 days of an offer of employment and completed prior to employment. Fingerprint testing will be scheduled by the DON and/or MDS Coordinator. The DON and MDS Coordinator have been in-serviced on this upgrade by the Admin. The Administrator and/or Assistant Administrator will monitor for accuracy and completeness to ensure compliance. The Administrator and/or Assistant Administrator will monitor the systemic change weekly for 6 months. The QA nurse will monitor this systemic change for 6 mos. The IJ was lifted, effective 05/12/23 at 6:07 p.m., when all components of the plan of removal had been completed. The deficiency remained at a widespread level with potential for harm. Based on interview and record review, the facility failed to implement the facility's policy to ensure background screenings were completed prior to employment for 45 of 66 employees reviewed for background screening. The administrator reported there were 66 employees. Findings: A Background Screening Investigation policy, revised 03/19, read in parts, .Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment . On 05/11/23 at 4:00 p.m., the assistant administrator was asked to provide background checks for five (CNA #3, CNA #4, RN #1, LPN#2, and LPN #3) staff members. The Assistant Administrator provided one, (RN #1) of the five background checks requested. On 05/12/23 at 9:30 a.m., the DON reported no one currently in the building had access to run background checks. On 05/12/23 at 9:45 a.m., the administrator reported they didn't know if background checks had been done on all staff. The administrator also reported the office had been cleaned out and they were unable to locate background checks previously stored in the office. The administrator was asked to provide documentation of background checks for all staff currently on duty. On 05/12/23 at 10:25 a.m., the administrator reported the background checks requested were unavailable. The administrator reported the staff member responsible for the background checks was unavailable. She reported, We are looking for them. The administrator was asked to provide the background checks for all staff on duty. The administrator identified 21 staff currently on duty. On 05/12/23 at 11:00 a.m., the administrator provided background screenings for seven of the 21 staff currently on duty. Documentation provided by the administrator showed the number of employees hired with no background screening per year as: 1992 - 1 1998 - 1 1999 - 1 2000 - 2 2006 - 1 2009 - 2 2011 - 1 2013 - 1 2015 - 3 2016 - 1 2017 - 3 2018 - 1 2019 - 1 2020 - 2 2021 - 4 2022 - 10 2023 - 10 Total - 45 The Hill Nursing Home Employee Roster, dated 05/12/23, provided by the ONBC (OK-Screen) & Detention Programs, documented the facility had requested screening for 39 employees. On 05/12/23 at 11:15 a.m., the administrator reported they didn't know why the Hill Nursing Home Employee Roster did not document all 66 employees. The administrator and assistant administrator reported they did not have access to the ONBC (OK-Screen) & Detention Programs and were not familiar with the system or the process of submitting employee information for background screenings. On 05/12/23 at 11:17 a.m., the assistant administrator reported they were unable to log into the system to submit employee background screenings and requested assistance from the surveyor. On 05/12/23 at 11:20 a.m., the administrator reported employees should have had background screenings conducted as per the facility's policy. The administrator reported, Due to the pandemic we have had to let other things go and we need to get back on track.

On 05/10/23 at 11:45 a.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure residents were served hot liquids at a safe temperature to prevent injury or harm. On 05/10/23 at 11:55 a.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation. On 05/10/23 at 12:00 p.m., the Administrator was notified of the IJ situation. On 05/10/23 at 4:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Preparation and/or completion of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed 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. 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citations for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. (Completion Date: 05-10-23 @ 1600) List of all residents that drink hot liquids. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. (Completion Date: 05/10/23) 1. Hot liquid safety evaluation on residents that drink hot liquids upon adm and quarterly 2. Individual temperature log on residents identified 2 a. Each identified resident will have a temp log for staff to record temp of hot liquid before serving 3. Inservice all employees on hot coffee temps (115 degrees), hot liquid eval; no coffee pots except one in kitchen; weekly hot liquid log 4. New coffee pot with temp regulation 5. Hot liquid policy update 6. Res #10 has non spill cup Res #22 (name omitted) 7. Employees not in-serviced will not be allowed to work until notified 8. C.P. updated 9. Hot liquid assess/eval completed on all current residents that drink hot liquids Review/modify current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm. Person Assigned, staff, [name omitted], Date Completed, 05/10/23 New policies written/implemented when applicable to insure additional serious harm will be prevented. Person Assigned, staff [name omitted], Date Completed, 05/10/23. Checklists and monitoring tools used to verify compliance. Person Assigned, [name omitted] RN, Date Completed, 05/10/23. Educate necessary staff on facility procedures with return demonstration where applicable. Person Assigned, [name omitted] RN, [name omitted] DON, [name omitted] LPN, Date Completed 05/10/23. The IJ was lifted, effective 05/10/23 at 4:45 p.m., when all components of the plan of removal had been completed. The deficiency remains at a pattern with actual harm. Based on observation, record review, and interview, the facility failed to ensure hot liquids were served at a safe temperature to prevent burns for two (#10 and #22) of two residents sampled with burns from hot coffee. The administrator identified 32 residents who drank hot liquids. 1. Res #10 was admitted with diagnoses which included left-sided hemiplegia (a severe loss of strength) and unspecified convulsions. A progress note, dated 07/20/22, read in part, .1015 called to residents room .noted reddened areas to abdomen, Silvadene applied to areas . An Incident Report Form, dated 07/20/22, read in part, .upon investigation, it is determined that resident frequently refuses coffe cup with lid. New cups have been ordered for use . A progress noted, dated 10/11/22, read in part, .up in wheelchair, in dining room, drinking coffee . A dietary note, dated 11/02/22, read in part, .only drinks coffee for fluids . A progress note, dated 11/21/22 at 9:01 p.m., documented the resident stated they spilled coffee on theirself that morning. The note documented a red area to the right inner thigh measuring 14.0 cm by 0.3 cm and an open blister measuring 4.0 cm by 0.6 cm. The note documented an order from the physician was obtained. On 11/21/22, a diagnosis of second degree burn of lower limb was documented. An Incident Report Form, dated 11/21/22, read in part, .upon investigation of incident, cup was dropped and the lid spilled coffee, resulting in a burn. Additional types of spill proof cups are being ordered to potentially prevent further incidents . A progress note, dated 11/22/22, read in parts, . left side weakness, assist x 1 for all adls .set up assist with meals . A progress note, dated 11/25/22 at 7:49 p.m., read in part, . pcp contacted at this time . coffee burn to (r) inner thigh has erythema (redness) noted to surrounding skin from approx. 0.5 cm to 4.0 cm in varying areas, very warm to touch; wound bed yellow, scant exudate (drainage) noted, surface of wound is sticky with exudate; order clarification received to continue silvadine bid . new order to start cephalexin (an antibiotic) 500 mg po tid x 10 days for dx: wound infection to (r) inner thigh .contact office Wednesday to bring resident in for eval and possible debridement of wound. resident c/o pain to area, very painful to touch . A progress note, dated 12/06/22 at 12:21 p.m., read in parts, .doctor visit n: 1030 am out of facility . appointment .for debridement of wound . 1220 pm retuned [sic] .wound to thigh debrided with dressing in place . A progress note, dated 01/05/23, read in parts, .continues with burn wound to posterior right thigh measuring 2.0 x 0.4 cm . 2. Res #22 was admitted with diagnoses which included cerebral infarction. A care plan, dated 09/18/22, documented Res #22 required setup assistance with meals. A progress note, dated 12/28/22 at 7:15 a.m., read in parts, .cna reports that as i was putting a throw blanket around resident shoulders, in the dining room, i spilled coffee on her lap .7.5 cm x 4.5 cm red area noted to l anterior thigh, 6 cm x 2.5 cm red area noted to l inner thigh, 3 cm x 3 cm red area noted to r anterior inner thigh, skin intact to all areas, no blistering noted @ this time, notified pcp, received order to cleanse areas with ns, pat dry and apply silvadene every day . An untitled document, dated 12/28/22, read in parts, .DON ordered small red cups for drinking coffee with a lid. CNA will place blanket before bringing to dine. Resident has treatment with Silvadene until healed. Resident only drinks coffee on occasion not every day drinker. Resident will have 1 on 1 during meals. The document was signed by the DON. A physician's order, dated 12/28/22, documented to cleanse red area to bilateral thighs with NS, pat dry, and apply silvadine every day for coffee burn. A progress note, dated 12/30/22, documented to continue with Silvadene treatment to thighs for coffee burn. On 05/10/23, at 7:30 a.m., multiple staff members were observed serving coffee in cups without lids or added ice to multiple residents in the dining room. On 05/10/23 at 8:30 a.m., Res #10 was observed in the dining room drinking coffee. On 05/10/23 at 10:15 a.m., a sample cup of coffee was requested, served in the same manner as to residents. The DM served the cup of coffee, upon receipt of the cup of coffee, the DM was requested to check the temperature of the coffee. The DM placed the thermometer into the cup, the temperature of the coffee was 180 degrees Fahrenheit. The DM asked if the 180 degree coffee was a safe temperature, the DM reported it was too hot. The DM also reported they had made the Administrator aware of the coffee being too hot in November 2022. On 05/10/23 at 10:25 a.m., the Assistant Administrator and Nurse Consultant were informed by the surveyor of the 180 degree coffee. The surveyor asked the Assistant Administrator if the coffee temperature was a safe temperature and the Assistant Administrator reported they were not aware of safe temperatures for hot liquids. The Assistant Administrator reported Res #10 was served coffee in a cup with a lid on it and other residents were served coffee with ice. The Assistant Administrator reported they were not aware of the amount of ice or the temperature of the coffee before it was served to residents. On 05/10/23 at 10:45 a.m., the Assistant Administrator provided a Resident Census/Roster, the roster documented 21 residents drank coffee and 16 of the 21 residents were served coffee without ice. The roster did not document residents who drank coffee from cups with lids.

§ 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. §483.25(l) [MEDICAL TREATMENT]. The facility must ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This requirement is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide care and/or services to ensure residents maintained their highest level of well-being for one (#1) of four residents reviewed for assessments and monitoring of skin conditions. The facility failed to: a. Assess, monitor, and provide care for resident #1's wound and or/skin condition. b. Provide pain management for resident #1. The facility failed to assess, monitor, and/or intervene for signs and symptoms of the resident's pain including the resident's pain during wound treatment. Resident #1's clinical record documented the resident voiced pain at the wound site. During an interview a nurse stated when the resident was transferred to the hospital, the resident was crying with pain. Resident #1's clinical record documented the resident was hospitalized for [REDACTED]. The facility identified three residents who required skin and/or wound treatments. Findings: The facility policy on pressure ulcers/skin breakdown - clinical protocol documented the facility nurse would describe and document the resident's skin treatments. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 09/04/16, documented the resident was at risk for pressure ulcers related to impaired cognition, mobility, and incontinence. The care plan documented to keep the resident clean and dry. The care plan documented to monitor the resident's skin on a weekly basis and report to the charge nurse. An annual assessment, dated 09/05/16, documented the resident was severely impaired with cognition. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident required assistance of two staff members with transfers and bed mobility. The assessment documented the resident received applications of skin ointments and/or medications. A nurse note, dated 11/14/16, documented the resident's family had made a request to a certified medication aide (CMA) for the nurse to assess the resident's buttocks due to the resident's complaints of pain. The nurse documented a crescent shaped opening to the right gluteal fold which measured 0.2 centimeters (cm) x 0.7 cm. The note documented the physician was notified and [MEDICATION NAME] 0.275% cream was ordered to apply topically to the affected area every shift and as needed. The resident's medical record was reviewed for skin assessments for November 2016, December 2016, and January 2017, and contained no documentation related to the right buttock after the initial assessment on 11/14/16. A quarterly assessment, dated 12/05/16, documented the resident was severely impaired with cognition. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident required the assistance of two staff members with transfers and bed mobility. The assessment documented the resident received applications of skin ointments and/or medications. A nurse note, dated 01/27/17 at 10:01 p.m., documented the resident was given one 500 milligram (mg) Tylenol for complaint of pain to his buttocks. The note documented the resident was assisted to bed after his meal and had no further complaint of pain. A nurse note, dated 01/31/17 at 8:23 p.m., documented the resident's family requested the nurse to assess the resident's buttocks. The note documented the nurse assessed the resident and found an 18 cm diameter, reddened, swollen area, noted to the right lower buttock. The note documented the resident was crying with pain and complained of tenderness to touch. The note documented the physician was notified and the resident was sent to the emergency room . The note documented the resident was admitted to the hospital for right hip abscess. A radiology report, dated 01/31/17, documented results of a computed tomography (CT) scan of the resident's abdomen and pelvis. The radiologist documented cystic fluid collection which measured 11.2 cm x 4.3 cm. A hospital operative report, dated 02/01/17, documented a procedure of incision and drainage of complex abscess right buttocks. The postoperative [DIAGNOSES REDACTED]. A nurse note, dated 02/06/17 at 1:53 p.m., documented the resident returned to the facility from the hospital. An admission skin assessment note documented an area 0.7 cm in length x 0.5 cm in width as an old sore to the left lower buttock. The skin assessment documented the resident had four incisions noted to the right gluteal area, two areas which measured 2 cm in length x 0.5 cm in width and two areas which measured 1.5 cm in length x 0.5 cm in width. The areas were pink in color. All areas had drains. A physician order, dated 02/06/17, documented to give [MEDICATION NAME] 300 milligrams (mg) one by mouth three times a day for 14 days. A physician order, dated 02/06/17, documented an order for [REDACTED]. A nurse note, dated 02/20/17 at 7:56 p.m., documented incision closest to anus is open more than other three, taking longer to heal. The note documented the physician was notified. A nurse note, dated 02/23/17 at 11:25 p.m., documented Dressing to right gluteal as ordered. No drainage noted. Redness noted to incision sites and hard knot noted to distal incision. 4 sites total. The note documented the resident's surgeon was aware of concerns related to the hardened area. A nurse note, dated 02/24/17 at 5:06 p.m., documented the area continued with a hardened/endured area to the surgical site. A nurse note, dated 02/24/17 at 10:26 p.m., documented the resident's wound treatment was given prior to the evening meal. The note documented there was decreased redness to the incisions. The note documented continues with raised area to distal incision. A physician order, dated 02/27/17, documented to discontinue the wet to dry dressings. The order documented to apply warm moist packs to the right gluteus for 20 minutes, cover the wound with a pad, then secure the dressing with tape every morning until healed. Medication Administration Records (MARs) for February 2017 and March 2017 were reviewed and documented daily wound care treatments as ordered. Nursing staff initialed the MAR's during a particular time frame to indicate the treatments were given. On 03/05/17 at 7:04 p.m., licensed practical nurse LPN #4 reported she had performed the resident's wound care earlier that day. The LPN reported wound care was provided twice a day and it would be done again the following morning. On 03/05/17 at 7:22 p.m., certified nurse aides (CNA) #6 and #7 were observed to provide incontinent care for the resident. The resident was observed to have a clean and dry dressing in place to the right buttock. On 03/06/17 at 10:52 a.m., the director of nursing (DON) was interviewed regarding the facility's policy on skin care assessments. The DON provided a two-week schedule for which nurses were assigned specific rooms. The DON explained the nurses were expected to perform skin assessments on the residents in the assigned rooms sometime during that time period. The DON reported the facility had previously had a skin nurse but she was no longer there. The DON reported they had previously tried to divide the skin assessments between nurses but that had not worked out due to nursing schedules and fairness of the workload. The DON reported she was aware skin assessments were not being done on a weekly basis and had not been performed weekly for at least a couple of months. On 03/06/17 at 11:25 a.m., LPN #2 was observed to provide wound care/treatment for [REDACTED]. On 03/06/17 at 3:35 p.m., the assistant director of nursing (ADON) was interviewed regarding documentation of skin assessments and wound care. The ADON reported skin assessments would be found under the skin tab in the nursing notes. The ADON reported skin assessments might also be included with regular nursing notes. The ADON reported wound care and treatments would be documented on the treatment/medication administration record. The ADON was asked if there was a specific place nurses could look to compare skin assessments and/or wound notes. The ADON reported this information would normally be found somewhere in the nursing notes. On 03/07/17 at 9:04 a.m., LPN #2 was interviewed regarding the resident's wounds. The LPN reported the resident had previously had an area to his left gluteal fold that would come and go. The LPN reported the resident had never had any skin issues on the right buttock. The LPN reported the day she sent the resident to the emergency room , he was crying with pain from his buttock. When asked if the resident was capable of expressing his needs, the LPN stated he would say his butt was hurting. The LPN reported the resident had Tylenol ordered for pain. The LPN reported she assessed the resident after the resident's family came to her and asked that she look at his buttocks. The LPN reported the resident had a large, red, warm area to the right buttock. The LPN reported after she assessed the resident, the physician was called and the resident was sent to the emergency room and admitted to the hospital. On 03/07/17 at 9:55 a.m., the resident's physician was interviewed by telephone. The physician reported the resident had the abscess to the right buttock approximately two months prior to being hospitalized . The physician reported the abscess was encased and could not have healed without eventually being incised and drained.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent an elopement for one (#6) of three residents sampled for elopement. The resident eloped from the facility on the evening of 04/04/17. The facility was unaware of the resident's elopement until notified by the local hospital the resident had fallen and was in the emergency room . The resident sustained [REDACTED]. Findings: The facility's policy on signing a resident out of the facility documented each resident leaving the premises must be signed out. The policy documented a sign-out register was located at each nurses' station. The facility's policy on safety and supervision documented the interdisciplinary care team would analyze information obtained from the assessments and observations to identify any specific accident hazards or risks for residents. The policy documented resident supervision was a core component of the systems approach to safety. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An elopement risk assessment, no date was documented, documented the resident was a new admit. The elopement risk assessment documented the resident was not impaired with cognition. The elopement risk assessment documented the resident was on a secured unit and required frequent monitoring. A smoking safety evaluation, dated 12/09/16, documented the resident's memory was problematic. The smoking safety evaluation documented the resident's judgement was alert. The smoking safety evaluation documented the resident had diminished responses. The smoking safety evaluation documented the resident was to be supervised when smoking. A mental status questionnaire, dated 12/09/16, documented the resident scored five points out of eleven. The mental status questionnaire documented the resident was moderately impaired. An admission assessment, dated 12/22/16, documented the resident was severely impaired with cognition. The assessment documented no behaviors. The assessment documented the resident required limited assistance with bed mobility and transfers. The assessment documented the resident required extensive assistance with ambulation, dressing, and bathing. The assessment documented the resident sustained [REDACTED]. A care plan, dated 01/06/17, documented the resident had impaired daily decision making skills. The care plan documented the resident required assistance with activities of daily living related to impaired balance, impaired mobility, and being a fall risk. The care plan documented the resident often refused care, medications, and treatments. The care plan documented the resident was at risk for falls due to impaired cognition, impaired mobility, and a recent fall. The care plan did not document the resident was a smoker. An elopement risk assessment, dated 03/06/17, documented the resident had shown improvement with cognition. The elopement risk assessment documented the resident was no longer at risk for elopement. A smoking safety evaluation, dated 03/06/17, documented the resident's memory was intact. The smoking safety evaluation documented the resident did not smoke in the designated smoking area. The smoking safety evaluation documented the resident did not follow the smoking guidelines per the facility's policy. The smoking evaluation documented the resident could smoke unsupervised. A mental status questionnaire, dated 03/06/17, documented the resident had a score of ten points out of eleven. The mental status questionnaire documented the resident had no or mild impairment. A quarterly assessment, dated 03/22/17, documented the resident was severely impaired with cognition. The assessment documented the resident rejected care one to three days in the past seven days. The assessment documented the resident required supervision with bed mobility, transfers, and locomotion. The assessment documented the resident required supervision to limited assistance with activities of daily living. The assessment documented no impairments with range of motion. The assessment documented the resident sustained [REDACTED]. An incident report, dated 04/04/17, documented the facility had received a phone call from (name deleted) emergency department stating the resident had been brought to their emergency room . The emergency room staff reported the resident had been found after falling in a ditch on the side of the road. The incident report documented the resident would be evaluated and the emergency room staff would call the facility later. The incident report documented the facility called the hospital approximately three hours later to check on the resident. The incident report documented the resident was being transferred to another hospital due to a fractured hip. The incident report documented the resident's family and primary care physician was notified. A hospital discharge summary, dated 04/05/17, documented the resident had a [DIAGNOSES REDACTED]. A nurse note, dated 04/10/17, documented the resident returned to the facility with his family. The nurse note documented the resident was admitted with a fracture to his right hip. A care plan, dated 04/10/17, documented the resident had a history of [REDACTED]. The care plan documented the resident wore a care system bracelet for safety. The care plan documented the resident had impaired daily decision making skills. The care plan documented the resident had a recent elopement resulting in a fracture to his right hip. The care plan documented the resident would not smoke unsupervised. A smoking safety evaluation, dated 04/10/17, documented the resident's memory was problematic. The smoking safety evaluation documented the resident's judgement was altered. The smoking safety evaluation documented the resident was a supervised smoker. On 04/13/17 at 11:20 a.m., the assistant director of nursing (ADON) was interviewed regarding the resident's safety. The ADON reported the resident was assessed for elopement on admission due to the fact he was confused. The ADON reported the resident was reassessed in March for an elopement risk because he wanted to go out to smoke. The ADON reported the resident's cognition was improved. The ADON reported two weeks after the resident was admitted to the facility he was a safe smoker. The ADON reported the resident went in and out of the facility at will. The ADON reported the resident would use the door code to get outside. The ADON reported the resident never said he would leave the facility. The ADON reported the elopement was a total surprise. The ADON reported the resident never left the facility grounds before. The ADON reported on the night the resident eloped, the facility received a call from the hospital inquiring if the patient in the emergency room was a resident at this facility. The ADON reported the resident had stepped off in the ditch and fallen. The ADON reported approximately three hours later the facility called the hospital to check on the resident and was told the resident was being sent to another hospital due to the [DIAGNOSES REDACTED]. The ADON reported after reviewing the security camera it was determined the resident had last been seen outside smoking at 7:30 p.m. on the evening of 04/04/17. The ADON reported the doors of the facility locked at 7:00 p.m. The ADON reported the resident knew the code to the door. The ADON reported the resident had since been readmitted to the facility. The ADON reported the resident had been reassessed and was considered an elopement risk. The ADON reported the resident was a supervised smoker and wore an ankle monitor. On 04/13/17 at 3:30 p.m., the resident was interviewed in his room. The resident was asked if he remembered how his hip was fractured. The resident stated he was walking to the store to get cigarettes. The resident reported he stepped off the sidewalk and fell . The resident was asked how he got out of the facility. The resident reported he walked out the back door. The resident was asked if he had told anyone at the facility he was leaving. The resident stated, No. The resident was asked if was told he needed to sign out before leaving the facility. The resident stated, No. I just go out the back door. The resident was observed with an ankle monitor. On 04/17/17 at 12:15 p.m, the ADON was interviewed regarding the resident's smoking assessment. The ADON reported the resident did not follow the rules for smoking. The ADON reported she had caught the resident smoking by the back door. The ADON reported in March the resident was able to light and extinguish the cigarette. The ADON reported the resident was now a supervised smoker due to the fact he was an elopement risk.

On 07/22/15 at 4:40 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to provide supervision to ensure a resident's safety. The facility failed to ensure supervision was provided during a transfer resulting in a fall. Two CNAs failed to report the incident to the charge nurse. The resident was evaluated in the emergency room regarding a change in condition and was diagnosed with [REDACTED]. On 07/22/15 the OSDH verified an immediate jeopardy situation existed related to the facility's failure to ensure supervision was provided during a transfer resulting in a fall, the CNAs' failure to report the incident to the charge nurse, and the CNAs' failure to report the incident to the charge nurse. The resident was evaluated in the emergency room regarding a change in condition and was diagnosed with [REDACTED]. On 07/22/15 at 5:05 p.m., the administrator, the assistant administrator, and the director of nursing (DON) were informed of the IJ situation related to the facility's failure to provide supervision to prevent a fall and the CNAs' failure to report the incident to the charge nurse. The administrator and the DON were informed the immediate jeopardy situation constituted substandard quality of care. The administrator and the DON verbalized understanding. On 07/22/15 at 7:30 p.m., the administrator, the assistant administrator, and the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: 7/22/15 7:30 p.m. Investigation will be the responsibility of DON. Written statements will obtained from all staff. All parties involved will be on suspension until further notice upon completion of investigation. A written summary will then be completed and submitted to OKSHD. One on one supervised instruction was given to immediate staff. Staff was instructed on the definition of a fall i.e., even if a resident is lowered to the floor, this is considered a fall and will need to be reported to charge nurse before resident is moved. Charge nurse will assess residents needs and injury @ this time. New Hire A definition of fall and reporting will be placed in new hire packet upon hire. A leaf or star will be posted @ head of each residents bed. A 'star' is designated to represent a resident to be @ risk for fall. A 'leaf' is designated to represent a resident is a 1 or 2 person assist or transfer. All residents using a mechanical lift is a 2 person assist. All resident are considered as fall risk @ this time. All staff will be supervised one-on-one before starting their shift on 7/23/15. * All residents will be reassessed for fall risk and ADL's. Careplans and MDS will be updated to reflect current status by 7/23/15. A 'fall risk' assessment will be performed on all residents upon admission, quarterly and change of condition i.e. functional. Inservices will be conducted with on coming and on going staff regarding, definition of a fall, when to report, when to assess and what 'star' and 'leaf' is designated to represent by 7/23/15. Monitoring: DON and charge nurses will monitor during daily rounds to ensure that FLFS symbols are @ head of bed. Staff will be quizzed on definition and meaning of leaf and star @ random until full compliance and verbalizes understanding. MDS and Careplans will be updated to reflect whether a person is @ risk for fall and or 1-2 per assist with ADL's and transfers 7/23/15. Staff on vacation will not be allowed to return to work until they have been inserviced on above components and verbalize understanding. All staff will be inserviced and verbalize understanding before starting their shifts for 12-8 and 8-4 on 7/23/15. On 07/24/15 surveyors interviewed staff on all shifts to verify their knowledge of the facility's policy related to supervision of residents and prevention of falls. The staff verbalized understanding of the facility's policy for supervision of residents and prevention of falls. On 07/24/15 the facility was informed the IJ was removed, effective 07/23/15 at 4:00 p.m., when all the components of the plan of correction had been implemented and staff verbalized understanding of the facility's policy for supervision of residents and prevention of falls. The deficiency remained at the level of actual harm that was not an immediate jeopardy at a pattern level. Based on record review and interview, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (#1) of three residents reviewed for supervision and accidents. The facility failed to ensure supervision was provided during a transfer resulting in a fall. Two CNAs failed to report the incident to the charge nurse. The resident was evaluated in the emergency room regarding a change in condition and was diagnosed with [REDACTED]. Findings: The facility policy on accident and incident reports documented when an accident or incident involving a resident occurred any witnessing staff would offer immediate assistance. The policy documented an accident/incident report and the appropriate documentation would be completed by the end of the shift. The policy documented the purpose of the policy was to ensure appropriate follow-through on all accidents and incidents and to give guidance for corrective/preventative action. The policy documented staff was not to move the resident until a nurse evaluated the resident's condition and to notify the nurse in charge. The policy documented to administer any necessary first aid, assess the resident, notify the physician and family, and complete an incident report. The facility policy on the falling leaf and falling star fall prevention program documented a falling star represented a resident was at risk for falls. The policy documented a falling leaf symbolized a two person/mechanical lift was needed. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 06/12/15 at 2:00 p.m., documented the resident was alert and oriented to time and person. The assessment documented the resident required extensive assistance with bed mobility, transfers, and personal hygiene. The temporary care plan, dated 06/12/15, documented the resident was at risk for falls. The care plan did not address how the resident was to be transferred. A hospice skilled nurse note, dated 06/15/15, documented the resident was bed/wheelchair/chair bound and was non-ambulatory. The note documented the resident had left sided paralysis and could stand and pivot with one person assistance. A hospice skilled nurse note, dated 06/25/15 at 2:00 p.m., documented the resident requested to be transported to the emergency room but would not or was unable to express why he wanted to go. A hospice skilled nurse note, dated 06/25/15 at 3:00 p.m., documented the resident was transported to the emergency room for evaluation for positive occult blood in emesis and in stool. An incident report, dated 06/25/15, documented the resident was transferred to the hospital for further evaluation after having coffee ground emesis on 06/24/15 and poor eating habits. The incident report documented during triage at the hospital it was noted the resident had a fracture to the left femur. The resident's hospital records, dated 06/25/15, contained a history and physical documenting it was not known whether the resident had a fall or trauma to his left leg. The record documented imaging studies showed a left femoral fracture. A undated statement by CNA #1 documented an occurrence on 06/25/15 where the CNA stated she was transferring the resident to his wheelchair by herself. The statement documented the resident was unable to move or turn his legs during the transfer. The statement documented the CNA eased the resident to the floor. The statement documented CNA #1 and CNA #2 put the resident into his wheelchair. The employee file of certified nurse aide (CNA) #2 contained a one on one supervision, dated 06/26/15, documenting the employee was counseled regarding what was considered as an incident/fall. The document stated all incidents would be reported to the charge nurse before moving a resident. A written statement by CNA #2, dated 06/26/15, documented on 06/25/15 she was called into the room of resident #1 by CNA#1. The statement documented the resident was lying on the floor. The CNA documented CNA #2 helped CNA #1 put the resident into a wheelchair. On 07/13/15 at 1:30 p.m., CNA #2 was interviewed. The CNA reported at approximately 6:30 a.m. on 06/25/15, CNA #1 had called out to her as she passed the resident's door. She stated the resident was on the floor and CNA #1 was crying and distraught. CNA #2 stated she helped CNA #1 transfer the resident from the floor to the wheelchair. The CNA reported when she came back to work on 06/26/15 she heard the resident had been hospitalized and had a broken leg. The CNA reported she asked if the broken leg had occurred when the resident fell and no one knew about the fall. The CNA reported she then gave a report to the DON regarding the fall on 06/25/15. A schedule for CNA #1 documented the CNA worked on 06/27/15 from 11:45 p.m. to 8:30 a.m. The employee file of CNA #1 contained an employee warning notice documenting the employee was terminated on 07/02/15 because her work was deemed unsatisfactory within her 1st two weeks. On 07/17/15 at 10:55 a.m., the DON was interviewed regarding investigation of the incident. The DON reported she had conflicting reports from different staff members. The DON reported she did a verbal one-on-one with all staff about calling a nurse before getting someone up following an incident. The DON stated she did not document the one-on-one consultations. On 07/17/15 at 3:28 p.m., CNA #3 was interviewed regarding how staff knew how a resident was to be transferred. The CNA reported staff looked at the activities of daily living in the resident's chart. The CNA stated if a resident was new staff would ask the charge nurse how the resident was to be transferred. The CNA reported even if a resident was eased to the floor it was a fall and should have been reported. On 07/17/15 at 3:49 p.m., the DON was interviewed. The DON reported the fall should have been reported to the charge nurse immediately and was not. The DON reported she did not know about the incident until 06/26/15. The DON reviewed the employee schedule. The DON reported CNA #1 had not been scheduled to work on 06/27/15 but the schedule showed she had worked. The DON stated the CNA must have been called in but she didn't know who had called her. The DON was asked if she had told CNA #1 not to come back to work during the investigation after she found out about the fall. The DON stated No. On 07/17/15 at 4:40 p.m., the consulting physician was interviewed. The physician reported the femur fracture had occurred the day the resident was admitted to the hospital up to 72 hours before admission. On 07/17/15 at 5:17 p.m., CNA #4 was interviewed regarding how staff know how residents needed assist with transfers. The CNA reported she thought a leaf on a resident's bed meant a two person physical assist with transfers and a star meant a one person physical assist. On 07/17/15 at 5:38 p.m., the DON was interviewed regarding falls. The DON reported the residents at risk for falls had star on their bed. The DON reported one leaf on the resident's bed indicated the person was a one person physical assist with transfers. The DON reported two leaves indicated a person was a two person physical assist with transfers. The DON reported resident #1 was a two person assist with transfers. On 07/22/15 at 12:23 p.m., LPN #1 was interviewed and was asked how staff knew how a resident was to be transferred. The LPN stated the facility had a falling star program. The LPN reported she did not remember all the components of the program.

On 08/09/11 the Oklahoma State Department of Health (OSDH) was notified of a potential immediate jeopardy (IJ) situation related to the facility's failure to provide supervision to ensure residents' safety. The facility failed to ensure supervision was provided: a. related to the facility's failure to secure dangerous chemicals from two (#11 and #17) of two sampled wandering residents. The facility identified three residents that wandered in the facility. b. while smoking for three (#6, #8, and #13) of three sampled residents who required supervision while smoking. Resident #8 had two cigarette burns on his left thigh related to unsupervised smoking. Resident #6 was observed to have multiple cigarette burns in several articles of clothing related to unsupervised smoking. On 08/09/11 at 1:10 p.m., OSDH verified an immediate jeopardy situation existed related to chemical storage. 1. On 08/09/11 at 1:45 p.m., the administrator and the director of nurses (DON) were informed of the IJ situation related to the dangerous chemicals in the resident care areas. On 08/09/11 at 9:00 p.m., the administrator and the director of nurses (DON) provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: "1) Door lock to Hall 4 whirlpool room changed so that it locks immediately and will only unlock with a key. Auto door closer also installed on whirlpool door. 2) Door lock to cabinet in whirlpool room repaired so that cabinet locks with a key for immediate temporary safety for residents who could be endangered. Keys for each CNA, LPN, and housekeeper have been made are being distributed at this time. 3) A Spring latch lock has been ordered for the whirlpool room cabinet so that cabinet door will automatically lock when shut without a key & can only unlock with a key. A metal brace will be secured to cabinet doors for added security to minimize forced entry. 4) All off-going and oncoming staff of Hill Nursing Home informed regarding identified dangers and inserviced regarding keeping doors locked at all times and removing hazardous materials from throughout the facility. A more detailed inservice will be conducted to cover areas: 1) The possible dangers of Hazardous materials and chemicals. 2) Review health department requirements for the storage of such materials. 3) Review the materials safety data sheet and known possible hazards to residents. 4) Review facility policy and procedures in ensuring that all unsafe chemicals are kept locked and available to staff only. 5) The facility will add to the employee policy manual, 'Failure to keep and return all hazardous chemicals to locked area' as a reason for possible termination." On 08/09/11 at 2:30 p.m., the facility staff that was working and the staff reporting to work for the evening shift were observed attending an inservice provided by the administrator and DON. The facility provided documentation the additional staff were inserviced by telephone concerning the storage of dangerous chemicals. On 08/10/11 at 10:35 a.m., the linen closet on hall 400 was observed. The linen closet door was unlocked. Inside the linen closet were 4 bottles of hand sanitizer, lotion, and a tube of barrier cream. On 08/10/11 at 10:45 a.m., the administrator observed the closet and stated, "It has only been open a minute. The aides store their stuff in there instead of leaving it in the residents' rooms." The administrator was informed the immediate jeopardy situation remained in effect due to the facility's failure to ensure all staff had been effectively educated regarding the components of the plan of removal. On 08/10/11 at 4:30 p.m., an acceptable amended plan of removal was submitted to the survey team by the administrator and the director of nurses. On 08/10/11 4:35 p.m., an additional inservice was observed being provided for the staff working in the facility, by the administrator, regarding the storage and securing of chemicals. Documentation was provided by the facility the remaining staff were inserviced later that evening or contacted by telephone concerning the storage of dangerous chemicals. Surveyors interviewed staff on all shifts, including week-end staff, to verify their knowledge on the storage of dangerous chemicals. The staff verbalized an understanding of the importance of the storage of chemicals being locked. On 08/13/11 at 12:00 p.m., the facility was informed the IJ was removed, effective 08/10/11 at 11:00 p.m., when the last staff member had been in-serviced and the staff verbalized an understanding of the inservices. On 08/10/11, 08/11/11, 08/12/11, and 08/13/11 random observations were conducted throughout the facility to assure chemicals were stored properly. No problems were identified during the random observations. 2. On 08/09/11 the Oklahoma State Department of Health (OSDH) was notified of a potential immediate jeopardy (IJ) situation related to the facility's failure to provide supervision to ensure residents' safety while smoking for three (#6, #8, and #13) of three sampled residents who required supervision while smoking. On 08/09/11 at 3:00 p.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide supervision to ensure residents' safety while smoking. On 08/09/11 at 3:50 p.m., the administrator and the director of nurses (DON) were informed of the IJ situation related to the facility's failure to provide supervision to ensure residents' safety while smoking. On 08/09/11 at 7:40 p.m., the administrator and the DON were informed the immediate jeopardy situation also constituted substandard quality of care. The administrator and the DON verbalized understanding. On 08/09/11 at 11:30 p.m., the administrator and the director of nurses (DON) provided the survey team with an acceptable plan of removal. "Plan of correction for safety to monitor residents with seizures. Immediate action: A seizure assessment form will be performed on all residents upon admission with seizure diagnosis. A log will be kept of description of seizure activity before and after. This form will be done quarterly and at the time of a seizure by DON or designee. PCP (primary care physician) will be notified of all seizures, abnormal assessment, and labs. Safety measures will be put in place for residents with seizure disorders. ie fall mat and low bed. Any resident with seizure disorder that smokes will be under supervision at all times while smoking. The DON or designee will monitor resident/staff daily for compliancy. An in-service was held with oncoming staff and ongoing staff regarding monitoring and assessments of residents with seizure diagnosis. All direct care staff has been contacted and made aware of residents with seizure precautions. All staff will be in-serviced regarding safety issues with residents with [DIAGNOSES REDACTED]. Resident on hall #4 has been admitted into hospital for evaluation. Resident on hall #2 will be closely monitored at all times. Seizure assessments will be done quarterly, annually, and at significant change for resident #2. Resident on hall #2 has not had any seizures in past 3 months. Plan of correction to ensure safety and proper supervision for smoking residents. Immediate actions: A smoking assessment form upon admission will be performed on all residents that smoke to ensure safety. This assessment will be performed on admission, quarterly, annually, and at significant change by DON or designee. DON will monitor staff daily to ensure that proper supervision is in place for residents who smoke that have history of falls and seizures. These residents will be given cigarettes at designated smoke times and supervised by staff until they have finished smoking. All smoking materials must be kept at nurses station. Smoking will not be permitted inside building at any time or under any circumstances. Goal is to prevent injury to unsafe residents while in smoking area. Resident will also be supervised smoking during extreme hot or cold weather. Careplans will specifically state whether resident is to be supervised while smoking and will be updated as needed by MDS (minimum data set) coordinator. Inservice was held on 8/9/2011 with incoming and off going shift/staff regarding smoking safety. This included supervision by staff when a resident goes out to smoke at ALL TIMES. Staff informed to report to DON or designee of any observed incident of unsafe practice during smoking i.e. burns to resident clothing, resident smoking in building, smoking near oxygen. If reported of unsafe practices Don/designee will reassess, notify family, physician and make changes to care plan accordingly. Safe smoking evaluation has been performed on ALL smokers on 8/9/2011 and will be performed quarterly, annually, and at significant changes. All direct care staff was informed of residents that are safe to smoke independently. APS (adult protective services) has evaluated resident on hall #4 due to potential to harm himself and others. Resident agreed to be evaluated by behavioral team. On call physician was notified of residents choice to go to the hospital. Resident on hall #4 has been admitted to behavioral hospital on [DATE]. DON or designee will meet with hospital staff to discuss needs/stipulations at the time of discharge from hospital for resident on hall #4. DON or designee will monitor and track falls quarterly to evaluate reasoning for falls. Goals: Residents will be free from fall and injury." On 08/09/11 at 4:00 p.m., the facility staff that was working and the staff reporting to work for the evening shift were observed to attend an inservice. The facility provided documentation of additional staff that were inserviced by telephone regarding safety and supervision for residents that smoked. On 08/10/11 at 12:35 p.m., resident #20 was observed to ask dietary staff #1 for a cigarette. Dietary staff #1 gave the resident a cigarette and the resident walked outside. The resident was observed to smoke outside without supervision. Resident #13 was observed smoking outside. There were no staff or family members outside with the residents. On 08/10/11 at 1:05 p.m., resident #13 was observed outside on the patio smoking. The resident had a cigarette that was lit and he was holding the cigarette between his fingers. The cigarette was burned down to the filter. LPN #3 told the resident he needed to put his cigarette out. The LPN told the resident he was going to burn his finger. The resident stated, "It's all right." On 08/10/11 at 1:20 p.m., the administrator and the DON were informed the immediate jeopardy situation remained in effect due to the facility's failure to ensure all staff had been effectively educated regarding the components of the plan of removal. On 08/10/11 at 7:05 p.m., an amended plan of correction was submitted by the administrator and the director of nurses. On 08/10/11 at 7:00 p.m., a second inservice regarding resident safety and proper supervision of residents was presented by the administrator and the DON with staff working in the facility. The facility provided documentation the remaining staff were inserviced later that evening or contacted by telephone concerning the supervision of residents while smoking. Surveyors interviewed staff on all shifts, including week-end staff, to verify their knowledge on safety related to residents who required supervision while smoking. The staff verbalized an understanding of the importance of safety related to the supervision of residents while smoking. On 08/13/11 at 12:00 p.m., the facility was informed the IJ was removed, effective 08/10/11 at 11:00 p.m., when the last staff member had been in-serviced and the staff verbalized an understanding of the inservices. The deficiency remained at the level of actual harm that was not an immediate jeopardy with more than a very limited number of residents affected. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to ensure safety for five (#6, #8, #11, #13, and #17) of 20 sampled residents. The facility failed to: a. to ensure supervision was provided related to the facility's failure to secure dangerous chemicals from two (#11 and #17) of two sampled wandering residents. The facility identified three residents that wandered in the facility. b. ensure supervision was provided for safety while smoking for three (#6, #8, and #13) of three sampled residents who required supervision while smoking. c. ensure hot water temperatures were at a safe temperature to prevent a possible injury for two (#11 and #17) of two sampled wandering residents. The facility identified three residents that wandered in the facility. Findings: The facility hazardous materials and waste storage policy documented the policy was to ensure hazardous materials and waste could be stored in a safe manner to prevent injury to residents. Storage areas for hazardous chemicals were kept locked until they were needed. The facility smoking policy, dated November 2008, documented residents were allowed to smoke in a designated area only. The policy documented a supervised smoking program was implemented at scheduled times, in designated areas only, to prevent self injury while smoking. The policy documented no smoking was allowed in the facility. The policy documented all smoking materials must be kept at the nurses' station in a secure area. The policy documented residents would be given a cigarette at the scheduled smoke break time and supervised by the staff. 1. Resident #11 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 05/17/11, documented the resident was severely impaired related to cognitive skills for daily decision-making. It documented the resident experienced wandering behavior. 2. Resident #17 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 07/05/11, documented the resident experienced problems with cognitive skills for daily. The resident's careplan, dated 03/30/11, documented the resident had short-term and long-term memory problems and was wheelchair dependent, but could wheel herself in a straight line. On 08/09/11 at 10:40 a.m., the metal closet was observed in the whirlpool room on hall 300. The metal closet was unlocked. Hair color, conditioner, prescription skin barrier with a label and the resident's name, lotion, shaving cream, Lantiseptic, germicidal, and disinfectant were inside the unlocked metal closet. The label on the "Clinging Disinfectant Cleaner" documented, "Danger, causes irreversible eye damage and skin burns. Harmful if absorbed through the skin. Harmful if swallowed, do not get in eyes, on skin or clothing. Must wear protective clothing, protective eyewear, and rubber gloves. Wash thoroughly with soap and water after handling and before eating, drinking, smoking tobacco, chewing gum and using the toilet. Remove contaminated clothing." On 08/09/11 at 10:50 a.m., the DON observed the metal closet. The DON stated the closet should be locked. On 08/10/11 at 10:35 a.m., the linen closet on hall 400 was observed. The linen closet door was unlocked. Four bottles of hand sanitizer, lotion, and a tube of barrier cream, were in the unlocked closet. On 08/10/11 at 10:45 a.m., the administrator observed the closet and stated it had only been open a minute. The administrator reported the CNAs stored their stuff in the closet instead of leaving it in the residents rooms. The administrator was informed the immediate jeopardy situation remained in effect due to the facility's failure to ensure all staff had been effectively educated regarding the components of the plan of removal. On 08/10/11 at 10:45 a.m., the administrator observed the closet and stated, "It has only been open a minute. The aides store their stuff in there instead of leaving it in the residents' rooms." The administrator was informed the immediate jeopardy situation remained in effect due to the facility's failure to ensure all staff had been effectively educated regarding the components of the plan of removal. On 08/10/11 at 4:30 p.m., an amended plan of correction was submitted by the administrator and the director of nurses. On 08/10/11 a second inservice regarding the storage of chemicals was conducted by the administrator with staff working in the facility. Other staff were inserviced later that evening or contacted by telephone concerning the storage of dangerous chemicals. Surveyors interviewed staff on all shifts and the week-end staff to verify their knowledge on the storage of dangerous chemicals. The staff verbalized an understanding of the importance of the storage of chemicals being locked. On 08/10/11 at 11:00 p.m., the plan of correction was accepted from the administrator after the inservices were verified and random observations of the stored chemicals was completed. On 08/10/11, 08/11/11, 08/12/11, and 08/13/11 random observations were conducted throughout the facility to assure chemicals were stored properly. No problems were identified during the random observations. 3. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The facility was to give 2 -100 milligram caps to equal 200 mg twice a day. A quarterly assessment, dated 05/10/11, documented the resident usually understood and was usually understood by others. The assessment documented the resident was moderately impaired with cognition skills and had short and long term memory problems. The assessment documented the resident had a behavior of inattention and disorganized thinking that fluctuated. The assessment documented the resident was not steady but able to stabilize without human assistance for when moving from a seated to a standing position, walking, turning around, and moving on and off the toilet. The assessment documented the resident required supervision with set up help for all activities of daily living. A nurse's note, dated 06/10/11 at 2:00 p.m., documented the resident had been outside smoking, had a seizure, and fell to his right side. The nurse's note documented the seizure was witnessed by two staff members. The nurse's note documented the resident had bumped his head on the smoking disposal can. The nurse's note documented the resident was nonresponsive and respirations were labored. The nurse's note documented the resident had a small abrasion to his right forehead. The care plan temporary problem list, dated 06/10/11, documented the resident had a fall with a cut on his head. Approaches documented neuro checks were done x 72 hours. A laboratory report, dated 06/15/11, documented a Phenytoin level of 7.8. The report documented the reference range was 10.0 to 20. A nurse's note, dated 06/21/11 at 11:30 a.m., documented the resident was sitting in a chair on the patio. The nurse's note documented the chair fell with the resident and he struck the left side of his forehead on concrete. The nurse's note documented there was blood noted on the concrete. The nurse's note documented the resident was transferred by ambulance to the emergency room for evaluation. The care plan temporary problem list, dated 06/21/11, documented the resident had a fall with a cut on his head. Approaches documented the resident was on the patio, fell out of his chair, and had a laceration to the left side of his forehead. Pressure was applied and emergency medical services was notified. The approaches documented, "Resident non-compliant with any suggestions etc." A nurse's note, dated 06/22/11 at 8:30 p.m., documented the resident returned from the hospital. The nurse's note documented the resident had four staples just above his left eye. The care plan temporary problem list, dated 06/23/11, documented the resident had returned to the facility. Approaches documented wound care was to be provided and the facility was to remove the staples in 7-10 days. Approaches included to notify the physician for redness, swelling, or foul drainage from the wound. Approaches included to, "continue to enc (encourage) resident to stay inside out of hot temps, monitor while smoking for seizure activity/drowsiness etc." A care plan, updated 07/09/11 documented the resident had an unsteady gait and had to be monitored for safety. There were no interventions documented for the safety problem. The care plan also documented the resident had promised to smoke only three packs of cigarettes per week but seemed to have trouble remembering that. The care plan documented the resident wandered inside and outside. The goal documented was to be safe. There were no interventions documented. A nurse's note, dated 07/15/11 at 10:00 a.m., documented the resident was found non responsive with seizure activity outside on the patio. The nurse's note documented the resident had abrasions to the right temporal area. The nurse's note documented the resident was transported to bed, emergency medical service was called, and the resident was transported to the emergency room . The care plan temporary problem list, dated 07/15/11, documented the resident had a fall with a laceration to his right temporal. Approaches documented nursing home protocol was used. The physician was call and the resident was transferred to the emergency room via ambulance. There were no interventions documented to prevent recurrence. A nurse's note, dated 07/21/11 at 11:00 a.m., documented the resident was found face down outside, was not alert, and the emergency medical services was notified. The nurse's note documented the resident was still not awake but was breathing nine minutes later. The nurse's note documented the resident was assisted into the facility via a wheelchair. The nurse's note documented the resident was transferred to the hospital at 11:15 a.m. The care plan temporary problem list, dated 07/21/11, documented the resident had a fall. Approaches documented the physician was notified and neurochecks were to be done for 72 hours. The problem list documented the resident refused to wear an anklet, go to (name deleted) psych unit, stay out of the heat, and was non compliant with any suggestions. A laboratory report, dated 07/27/11, documented a Phenytoin level of 7.7. The report documented the reference range was 10.0 to 20.0 There was no documentation in the nurse's notes the facility had consulted with the physician regarding the abnormal Phenytoin levels on 06/15/11 or 07/27/11. A care plan conference summary, dated 07/22/11, documented the resident had several falls and had low Dilantin levels. The summary documented the resident continued to sit outside in hazardous weather and was non compliant with the smoking policy. The summary documented the resident was to stay out of extreme heat. A nurse's note, dated 08/05/11 at 3:00 p.m., documented, "Lying in bed asleep cigarette in rt (right) hand c (with) ashes woke resi (resident) up instructed him he could not smoke in room. DON notified." A nurse's note, dated 08/05/11 at 4:25 p.m., documented, "called to residents room by housekeeper. He was having a seizure. Reported he had been shaking a lot while lying on bed. Not shaking at this time..." On 08/09/11 at 9:45 a.m., during the initial tour the resident was observed in his room. At that time the MDS coordinator provided information regarding the resident. The MDS coordinator stated the resident was usually outside even if it was cold or 110 degrees. The MDS coordinator reported an incident of the resident smoking in bed when he had fallen asleep. The MDS coordinator reported this had occurred previously but it was the first time the resident had fallen asleep with a cigarette in a long time. The MDS coordinator reported the cigarette was still lit when the resident was found. The MDS coordinator reported the resident across the hall had smelled smoke and notified the facility. The MDS coordinator reported the ombudsman had been at the facility on one occasion when the resident fell asleep outside. The MDS coordinator reported the ombudsman suggested the facility should have the resident sign him self in and out. The MDS coordinator reported that wouldn't work because the resident knew the code. The MDS coordinator was asked if an attempt had been made to change the code. The MDS coordinator reported no attempts had been made to change the code. She stated it had been the same code for over a year. The MDS director reported the facility had tried to send the resident to (Name deleted) psych unit, but the resident wouldn't agree to go. The MDS coordinator reported the resident had passed out outside and thought it was probably due to seizures. The MDS coordinator reported the resident had passed out three times in the past two weeks. The MDS coordinator reported the resident had fallen outside on three occasions. She reported one of the falls had occurred at midnight and the others had been when it was extremely hot. The MDS coordinator reported she wasn't sure how long the resident had been out any of those times because he went in and out of the facility. She stated the resident received Dilantin. The MDS coordinator stated the facility had to control dehydration related to the heat outside. She stated the resident had been at the facility a couple of years. The MDS coordinator reported the facility had tried to have the resident get cigarettes from the medication nurse, but then the facility had to control the other residents' cigarettes so resident #6 couldn't get their cigarettes. On 08/09/11 at 11:15 a.m., the DON was interviewed regarding the resident's falls and smoking. The DON reported the resident was a compulsive smoker. The DON reported the administrator had placed the resident on a program to give him 10 cigarettes a day so the staff could watch him when he went out to smoke. The DON reported the facility had attempted to place the resident on a smoking schedule, but he knew the code and would get cigarettes from whoever came in the building. The resident was observed to have two small holes in the front of his pants. The DON observed the resident's clothes and stated the resident had brought the clothes with him. The DON observed a pair of pants with a cigarette hole in the left leg and a jacket with six holes in the front of the jacket. The DON stated he had brought the clothes in with him. On 08/09/11 at 11:35 a.m., the resident was observed to have a package that contained six cigarettes. A second package that contained 10 cigarettes was observed in the resident's room. The resident stated he bought them to have when he ran out of the 10 cigarettes. On 08/09/11 at 1:55 p.m. the DON was asked if the facility completed smoking assessments on the residents that smoked. The DON stated they did not use a form but they looked at the residents' cognition for safety when residents smoked. The DON stated they did not document that information anywhere. On 08/11/11 at 11:40 a.m., the DON reported she had observed the resident had more than 10 cigarettes in his room. The DON stated, "Like he said he bought them." The DON reported the resident went out with different people. On 08/11/11 at 11:45 a.m., the DON was interviewed regarding the resident smoking outside. The DON reported there was usually someone outside with the resident, either staff or a resident, but there was no way of knowing when he went out. On 08/12/11 at 10:15 the MDS director was interviewed regarding notification of the physician for the abnormal Dilantin levels. The MDS coordinator reported she noted the lab results and faxed them to the doctor. She reported she had told the nurse to notify the doctor. The MDS coordinator reviewed the medical record and reported there was no documentation in the chart that the physician had been notified of the abnormal lab results. On 08/12/11 at 11:20 a.m., the director of nurses (DON) was interviewed regarding notification of the physician for abnormal laboratory results. The DON reported as soon as the facility received a critical lab they faxed it to the physician. The DON reported if the physician didn't call in a little bit the facility would call him. The DON reported the facility did not document when the physician was called. The DON reported the facility needed a policy and a way to track abnormal labs. 4. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 02/12/11, documented the resident was on the smoking program and could only go out with supervision. A nurse's note, dated 04/01/11 at 3:30 p.m., documented, "CNA reported resi (resident) had cigarette burns on lt (left) thigh, 1 cm & 1.8 cm x 1.5 cm open area notes..." The nurse's note documented the nurse spoke with the resident about going out with staff at smoke breaks to be monitored. A nurse's note, dated 04/05/11 at 10 a.m., documented, "Spoke with resident on him smoking c (with) supervision, while speaking to resident on subject, 8 cigarette burns all over jacket, pointed these out to him on possibility of catching hisself on fire. Resi (resident) verbalized understanding of being supervised while smoking." The quarterly assessment, dated 08/02/11, documented the resident was usually understood by others and usually understood others. The assessment documented the resident was severely impaired with cognition skills. The assessment documented the resident had limited range of motion of upper and lower extremities. On 08/09/11 at 2:20 p.m., the DON was asked to assist the surveyor with observation of the resident's clothing. The DON and surveyor observed a pair of nylon pants with five holes, a pair of sweat pants with five holes, and a nylon jacket with multiple holes on the sleeves and front of the jacket. On 08/09/11 at 2:50 p.m., the DON was asked if there was an incident report regarding the resident burning himself with a cigarette. The DON stated, "The time he burned himself there was not an incident report filled out." On 08/10/11 at 3:55 p.m., the resident was observed in his room during incontinent care. The resident was observed to have two circular scars on his left thigh. LPN #5 reported the areas were from the cigarette burns. The resident's cushion in his wheelchair was observed to have two burn holes. On 08/12/11 at 11:35 a.m., the DON was asked asked if she had investigated the cause of the burn. The DON reported she had not investigated the burn or implemented other interventions. The DON reported the nurse that reported to her said it was a cigarette burn. The DON stated she notified the doctor, got an order for [REDACTED]. The DON reported the family brought cigarettes to the nurses' station. 5. Resident #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A laboratory report, dated 01/19/11, documented a Dilantin level of 7.4. The report documented the reference range was 10.0 to 20. A physicians's order, dated 01/20/11, documented to obtain a Dilantin level on 01/26/11 and every six months. A laboratory report, dated 01/26/11, documented a Dilantin level of 7.0. The report documented the reference range was 10.0 to 20. The quarterly assessment, dated 07/05/11, documented the resident was usually understood and was understood by others. The assessment documented the resident was moderately impaired with cognition skills. The assessment documented the resident had short and long term memory problems. The care plan, dated 07/07/11, documented the resident was at risk for falls and was unsteady on his feet. The care plan documented the resident did not realize how weak he was. The care plan documented the resident smoked and was upset

Based on observation, interview, and record review, it was determined the facility failed to consult with the physician regarding abnormal lab values related to [MEDICATION NAME] medication for two (#6 and #13) of three sampled residents reviewed who received [MEDICATION NAME] medication for a history of [MEDICAL CONDITION]. Resident #6 had experienced multiple incidents involving [MEDICAL CONDITION] and falls with injuries. The facility identified four residents with a history of [MEDICAL CONDITION]. Findings: 1. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The facility was to give 2 -100 milligram caps to equal 200 mg twice a day. A quarterly assessment, dated 05/10/11, documented the resident usually understood and was usually understood by others. The assessment documented the resident was moderately impaired with cognition skills and had short and long term memory problems. The assessment documented the resident had a behavior of inattention and disorganized thinking that fluctuated. A nurse's note, dated 06/10/11 at 2:00 p.m., documented the resident had been outside smoking, had a [MEDICAL CONDITION], and fell to his right side. The nurse's note documented the [MEDICAL CONDITION] was witnessed by two staff members. The nurse's note documented the resident had bumped his head on the smoking disposal can. The nurse's note documented the resident was nonresponsive and respirations were labored. The nurse's note documented the resident had a small abrasion to his right forehead. A laboratory report, dated 06/15/11, documented a [MEDICATION NAME] level of 7.8. The report documented the reference range was 10.0 to 20.0 A nurse's note, dated 06/21/11 at 11:30 a.m., documented the resident was sitting in a chair on the patio. The nurse's note documented the chair fell with the resident and he struck the left side of his forehead on concrete. The nurse's note documented there was blood noted on the concrete. The nurse's note documented the resident was transferred by ambulance to the emergency room for evaluation. A nurse's note, dated 06/22/11 at 8:30 p.m., documented the resident returned from the hospital. The nurse's note documented the resident had four staples just above his left eye. The care plan temporary problem list, dated 06/23/11, documented the resident had returned to the facility. Approaches documented wound care was to be provided and the facility was to remove the staples in 7-10 days. Approaches included to notify the physician for redness, swelling, or foul drainage from the wound. Approaches included to, "continue to enc (encourage) resident to stay inside out of hot temps, monitor while smoking for [MEDICAL CONDITION] activity/drowsiness etc." A nurse's note, dated 07/15/11 at 10:00 a.m., documented the resident was found non responsive with [MEDICAL CONDITION] activity outside on the patio. The nurse's note documented the resident had abrasions to the right temporal area. The nurse's note documented the resident was transported to bed, emergency medical service was called, and the resident was transported to the emergency room . A nurse's note, dated 07/21/11 at 11:00 a.m., documented the resident was found face down outside, was not alert, and the emergency medical services was notified. The nurse's note documented the resident was still not awake but was breathing nine minutes later. The nurse's note documented the resident was assisted into the facility via a wheelchair. The nurse's note documented the resident was transferred to the hospital at 11:15 a.m. The care plan temporary problem list, dated 07/21/11, documented the resident had a fall. Approaches documented the physician was notified and neurochecks were to be done for 72 hours. The problem list documented the resident refused to wear an anklet, go to (name deleted) psych unit, stay out of the heat, and was non compliant with any suggestions. A care plan conference summary, dated 07/22/11, documented the resident had several falls and had low [MEDICATION NAME] levels. The summary documented the resident continued to sit outside in hazardous weather and was non compliant with the smoking policy. The summary documented the resident was to stay out of extreme heat. A laboratory report, dated 07/27/11, documented a [MEDICATION NAME] level of 7.7. The report documented the reference range was 10.0 to 20.0. There was no documentation in the nurse's notes the facility had consulted with the physician regarding the abnormal [MEDICATION NAME] levels on 06/15/11 or 07/27/11. A nurse's note, dated 07/28/11 at 1:30 a.m., documented a CNA reported the resident was having a [MEDICAL CONDITION], lying in bed. The nurse's note documented the CNA reported the resident had no verbal response. The nurse's note documented the CNA reported the resident was seizing but it didn't last long. A nurse's note, dated 07/28/11 at 8:00 a.m., documented, "Dayshift LPN notified of [MEDICAL CONDITION]. [MEDICATION NAME] level was low on 7/27 faxed to Dr. states she will call & talk to Dr." There was no documentation the facility had called the physician to discuss the low [MEDICATION NAME] level or the [MEDICAL CONDITION] that occurred on 07/28/11. On 08/09/11 at 9:45 a.m., the resident was observed in his room. On 08/12/11 at 10:15 a.m., the minimum data set (MDS) director was interviewed regarding notification of the physician for the abnormal [MEDICATION NAME] levels. The MDS coordinator reported she noted the lab results and faxed them to the doctor. She reported she had told the nurse to notify the doctor. The MDS coordinator reviewed the medical record and reported there was no documentation in the chart the physician had been notified of the abnormal lab results. On 08/12/11 at 11:20 a.m., the director of nurses (DON) was interviewed regarding notification of the physician for abnormal laboratory results. The DON reported as soon as the facility received a critical lab they faxed it to the physician. The DON reported if the physician didn't call in a little bit the facility would call him. The DON reported the facility did not document when the physician was called. The DON reported the facility needed a policy and a way to track abnormal labs. 2. Resident #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A laboratory report, dated 01/19/11, documented a [MEDICATION NAME] level of 7.4. The report documented the reference range was 10.0 to 20. A physicians's order, dated 01/20/11, documented to obtain a [MEDICATION NAME] level on 01/26/11 and every six months. A laboratory report, dated 01/26/11, documented a [MEDICATION NAME] level of 7.0. The report documented the reference range was 10.0 to 20. The quarterly assessment, dated 07/05/11, documented the resident was usually understood and was understood by others. The assessment documented the resident was moderately impaired with cognition skills. The assessment documented the resident had short and long term memory problems. The care plan, dated 07/07/11, documented the resident was at risk for falls and was unsteady on his feet. The care plan documented the resident did not realize how weak he was. The care plan documented the goal was to be safe and comfortable and free from falls. The care plan did not address the resident's [MEDICATION NAME] medication and laboratory orders or results. On 08/10/11 at 1:05 p.m., the resident was observed outside on the patio smoking. On 08/12/11 at 11:45 a.m., the pharmacy consultant was interviewed regarding abnormal lab values. The pharmacy consultant reported if he saw an abnormal lab and the doctor had written an order to change the medication he would know the physician had seen the laboratory results. The pharmacy consultant reported if the facility had faxed the lab results, it wouldn't count. The pharmacy consultant reported he would ask the facility to find documentation they had spoken with the doctor. On 08/12/11 at 4:55 p.m., the DON was interviewed regarding the [MEDICATION NAME] levels. The DON reported the resident should have [MEDICATION NAME] levels drawn every six months. The DON reviewed the current monthly physician's orders [REDACTED]. The DON reported she would call the lab to see if there had been any lab levels drawn. The DON was asked if the low [MEDICATION NAME] levels should have been followed up on. The DON reviewed the lab results and stated it looked like she had notified the doctor on 01/09/11 of a low lab result. The DON stated the resident had another lab drawn on 01/26/11, a week later. The DON reported that lab result was also low. The DON did not find documentation the physician had been consulted regarding the abnormal lab on 01/26/11. On 08/13/11 at 9:30 a.m., the DON reviewed the care plan and reported the care plan did not address the resident's [MEDICATION NAME] orders, laboratory orders, or lab results.