Every finding on record at Homestead of Hugo

Based on record review and interview, the facility failed to ensure an RN was in the facility at least eight consecutive hours a day, seven days a week. The administrator identified 55 residents resided in the facility.Findings:The facility RN time summary sheets, dated 11/2025 through 02/2026, showed the facility had an RN in the facility at least eight consecutive hours on 11/01, 11/02, 11/05, 11/06, 11/09, 11/12, 11/13, 11/15, 11/16, 11/19, 11/20, 11/22, 11/23, 11/26, 11/27, 11/29, 11/30, 12/03, 12/04, 12/06, 12/07, 12/10, 12/11, 12/13, 12/14, 12/17, 12/18, 12/20, 12/21, 12/24, 12/25, 12/31, 01/01, 01/03, 01/04, 01/07, 01/08, 01/10, 01/14, 01/15, 01/17, 01/18, 01/21, 01/22, 01/24, 01/25, 01/28, 01/29, 02/01, 02/04, 02/05, 02/07, 02/14, and 02/15. The facility did not show eight hours consecutive RN coverage consistently from 11/2025 through 02/2026. On 02/18/26 at 9:55 a.m., the interim DON/corporate RN stated they had been considered the interim DON for the facility since the end of October 2025 to current date. The interim DON stated they were considered the RN coverage for eight consecutive hours a day Monday through Friday. The interim DON stated they did not complete time summary sheets/document their days and times worked in the facility as the RN coverage. The interim DON stated they should have documented their time. On 02/18/26 at 1:45 p.m., the administrator stated the interim DON/corporate RN was considered their eight hour a day RN coverage for the facility. The administrator stated they could not provide documentation for the eight hour a day RN coverage for the facility.

Based on record review and interview, the facility failed to ensure sufficient staff were provided on a 24-hour basis to meet the needs of the residents in accordance with resident plans of care. The administrator identified 55 residents resided in the facility. Findings:The Quality of Care Monthly Report, dated 11/2025, showed the facility did not meet the required direct care staffing hours 18 of 30 days for the day shift, 12 of 30 days for the evening shift, and six of 30 days for the night shift. The report showed the facility did not meet the required direct care staffing hours on 11/01, 11/02, 11/07 through 11/10, 11/15 through 11/19, 11/22 through 11/24, and 11/27 through 11/30 for day shift. The report showed the facility did not meet the required direct care staffing hours on 11/01 through 11/03, 11/09, 11/10, 11/15, 11/16, 11/22, 11/23, and 11/28 through 11/30 for evening shift. The report showed the facility did not meet the required direct care staffing hours on 11/01, 11/07, 11/09, 11/23, 11/28, and 11/29. The Quality of Care Monthly Report, dated 12/2025, showed the facility did not meet the required direct care staffing hours 22 of 31 days for the day shift, 12 of 31 days for the evening shift, and five of 31 days for the night shift. The report showed the facility did not meet the required direct care staffing hours on 12/01, 12/04, 12/06, 12/07, 12/09 through 12/16, 12/19, 12/29, and 12/30 for the day shift. The report showed the facility did not meet the required direct care staffing hours on 12/06, 12/07, 12/11 through 12/16, 12/24, and 12/26 through 12/28 for the evening shift. The report showed the facility did not meet the required direct care staffing hours on 12/14, 12/26 through 12/28, and 12/31 for night shift. The Quality of Care Monthly Report, dated 01/2026, showed the facility did not meet the required direct care staffing hours for 14 of 31 days for the day shift, 13 of 31 hours for the evening shift, and 17 of 31 days for the night shift. The report showed the facility did not meet the required direct care staffing hours 01/01 through 01/04, 01/06, 01/10, 01/11, 01/17 through 01/19, and 01/24 through 0 1/27, for day shift. The report showed the facility did not meet the required direct care staffing hours on 01/06, 01/10, 01/17, 01/18, 01/24 through 01/17, and 01/30 the facility did not meet the required direct care staffing hours for evening shift. The report showed on 01/01, 01/03, 01/04, 01/07, 01/09 through 01/11, 01/16 through 01/18, 01/23 through 01/26, 01/30, and 01/31 the facility did not meet the required direct care staffing hours for night shift. On 02/18/26 at 10:30 a.m., the administrator stated they were aware of staffing shortages on various shifts for the last three months. The administrator stated they would call current staff for staffing needs but was not always able to find coverage. The administrator stated they did not use agency staff or any other source for staffing needs.

On 11/24/25 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure hazardous chemicals were secured away from wandering residents located in the memory care unit.Upon observation of the memory care unit there were three rooms found to be unlocked/unsecured with hazardous chemicals. A clean linen closet, a soiled linen closet, and a whirlpool/shower room with a cabinet in the unlocked whirlpool/shower room: with three unsecured bottles of cleaner, degreaser, and bleach products, unsecured personal products as shaving cream, disinfectant cleaner, and other personal care items. On 11/24/25 at 4:14 p.m., the OSDH verified the existence of the IJ situation.On 11/24/25 at 4:27 p.m., the administrator was notified of the IJ situation and the IJ template was read in full to the administrator.On 11/25/25 at 12:40 p.m., an acceptable plan of removal was submitted to the OSDH. The plan of removal read in part, Immediate Jeopardy ResponseNovember 25, 2025, Time sent at 12:34 p.m.Homestead Of HugoIJ Plan of Removal for Chemical StorageCompletion Date November 25, 2025, 12:32 p.m.The locks on the clean linen room and dirty room have been locked. The padlock on the shower cabinet has been replaced. The entire facility has been checked for chemicals. The keys to these rooms will be on a separate key chain locked in the Medication Cart. In person and telephone in-services were begun on all employees about chemical storage. Monitoring will be conducted daily for 2 months, weekly for 2 months then move to random checks during compliance rounds.On 11/25/25 at 1:12 p.m., the survey team completed a tour of the facility, and both linen doors were locked and the cabinet in the shower room was locked. The keys to the linen closets were locked up in the med cart.On 11/25/25 at 2:16 p.m., in-service records were reviewed, interviews with staff were conducted, and observation of locked linen doors and cabinet doors were all locked.On 11/25/25 at 2:31 p.m., the administrator was notified that the immediacy had been lifted after all components of the plan of removal were verified effective 11/25/25. The deficient practice remained isolated with no actual harm.Based on observation, record review, and interview, the facility failed to ensure resident environments remained free of hazardous chemicals for 10 of 26 wandering residents in the memory care unit.The administrator identified 12 rooms in the facility that stored hazardous chemicals and 10 residents who wandered on the memory care unit.Findings:On 11/24/25 at 11:38 a.m., an unlocked soiled linen closet was observed with a bottle of Room Sense Disinfectant Cleaner (disinfectant), an unsecured bottle of all-purpose cleaner Fabuloso all-purpose cleaner and degreaser, and an unsecured bleach bottle Novel Wash Bleach labeled keep out of reach of children. On 11/24/25 at 11:45 a.m., an unlocked clean linen closet was observed with bottles of 1/2 gallon of DermaCen Peri Wash (a no rinse spray cleanser), shaving cream, a 4 oz bottle of mouthwash, and two (4 oz) bottles of hand sanitizer labeled keep out of reach of children. Resident #1 was observed wandering and opened the clean linen closet door.A significant change assessment, dated 10/10/25, showed Resident #1 was severely impaired in cognition.A resident face sheet, dated 11/2/5/25, showed Resident #1 had a diagnosis of dementia.On 11/24/25 at 11:45 a.m., LPN #1, assigned to the memory care unit, stated the doors were supposed to be locked, but they had a female resident that would grab the key that was hanging up by the door, and they can't find the keys. LPN#1 stated there were at least four residents that wandered independently.On 11/24/25 at 11:56 a.m., CNA #1 stated the linen doors were usually locked and they did not remember if they were locked overnight. On 11/24/25 at 12:05 p.m., an unlocked whirlpool/shower room was observed with two cans of shaving cream, a plastic bottle of disinfectant cleaner (Room Sense 200) labeled Do not drink and keep out of reach of children in the unlocked cabinet in the shower room.On 11/24/25 at 12:05 p.m., an unlocked whirlpool/shower room on the memory care unit was observed with cans of shaving cream, a plastic bottle of Room Sense 200 (disinfectant cleaner) and other personal care items which read in part, Do not drink and keep out of reach of children. The cabinet in the shower room was observed unlocked with the keys hanging up on the side of the cabinet. The keys observed hanging up on the side of the cabinet were to unlock the cabinet where the unsecured hazardous chemicals were observed.On 11/24/25 at 12:12 p.m., CNA #1 stated the items in the shower room were supposed to be locked up in the cabinet in the shower room. CNA #1 stated the cabinet in the shower room had not been locked in approximately one month.On 11/24/25 at 1:15 p.m., the administrator was notified of the unlocked clean, soiled linen closets, and shower room containing the hazardous chemicals.On 11/24/25 at 1:16 p.m., the administrator stated they did not have a policy. The administrator stated they just thought it was a given the doors should be locked.

Based on record review and interview, the facility failed to ensure an allegation of abuse, neglect, exploitation, or mistreatment was reported immediately to the OSDH, but no later than two hours after the allegation for 1 (#4) of 3 sampled residents reviewed for abuse. The administrator identified five allegations of abuse from 06/01/25 through 12/01/25.Findings:A facility policy titled Abuse-Reportable Events, revised 01/2018, read in part, Abuse- 2 Hour Limit- As defined in 42 CFR 483.5- The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. An undated face-sheet showed Resident #4 had diagnoses which included major depressive disorder, psychotic features, dementia, and behavioral disturbances.A discharge return anticipated assessment, dated 09/18/25, showed Resident #4 was severely impaired for daily decision making and required substantial assistance with activities of daily living.An OSDH incident report, dated 09/17/25, showed an allegation of abuse. The report showed an allegation of financial abuse by a family member. A fax transmittal report showed the allegation of abuse was reported to the OSDH on 09/23/25.On 12/01/25 at 3:35 p.m., the administrator reviewed the incident report regarding the allegation of abuse for Resident #4 on 09/27/25. The administrator stated all allegations of abuse should be reported to the OSDH within two hours. The administrator stated they did not know why the allegation of abuse regarding Resident #4 was not reported within the two hour required time frame.

Based on record review and interview, the facility failed to ensure comprehensive assessments were completed within 14 days of admission for 2 (#3 and #61) of 6 sampled residents reviewed for comprehensive assessments. The administrator identified 51 residents resided in the facility. Findings: 1. An undated Resident Face Sheet, showed Resident #3 was admitted to the facility on [DATE]. Resident #3's electronic health record was reviewed. The health record showed the annual assessment, dated 04/16/25, was still in progress. On 06/04/25 at 1:58 p.m., the MDS coordinator stated the assessment for Resident #3 had not been completed and it was still in progress. On 06/04/25 at 1:59 p.m., the MDS coordinator stated Resident #3's assessment should have been submitted no later than May 9th. 2. An undated Resident Face Sheet, showed Resident #61 was admitted to the facility on [DATE]. Resident #61's assessment was still in progress. On 06/05/25 at 9:02 a.m., the MDS coordinator stated the assessment, dated 05/09/25, for Resident #61 should have been completed by 05/18/25. On 06/05/25 at 9:06 a.m., the MDS coordinator stated the assessment for Resident #61 had not been completed.

Based on record review and interview, the facility failed to transmit MDS assessments data to CMS in the required timeframe for 3 (#9, 49, 52, and #61) of 6 sampled residents reviewed for MDS assessments. The administrator identified 51 residents resided in the facility. Findings: 1. An undated Resident Face Sheet, showed Resident #52 was admitted to the facility on [DATE]. Resident #52's quarterly assessment, dated 04/23/25, was completed, but not submitted. On 06/04 at 2:06 p.m., the MDS coordinator stated Resident #52's assessment should have been submitted by 04/30/25. 2. An udated Resident Face Sheet, showed Resident #9 was admitted to the facility on [DATE]. Resident #9's annual assessment, dated 04/23/25, was completed, but not submitted. 3. An undated Resident Face Sheet, showed Resident #49 was admitted to the facility on [DATE]. Resident #49's quarterly assessment, dated 04/23/25, was completed, but not submitted. A CMS Submission Report, dated 06/02/25, showed Resident #9, 49, and #52's records were submitted late. On 06/04/25 at 2:07 p.m., the MDS coordinator stated Resident #9 and Resident #49's assessments should have been submitted no later than 04/29/25. 4. An undated Resident Face Sheet, showed Resident #61 was admitted to the facility on [DATE]. Resident #61's assessment, dated 05/09/25, was still in progress. On 06/05/25 at 9:02 a.m., the MDS coordinator stated the assessment, dated 05/09/25, for Resident #61 should have been completed by 05/18/25. On 06/05/25 at 9:06 a.m., the MDS coordinator stated the assessment for Resident #61 had not been completed. A CMS Submission Report, dated 06/09/25, showed Resident #61's record was submitted late.

Based on record review and interview, the facility failed to ensure the initiation of a comprehensive care plan for 1 (#61) of 6 sampled residents reviewed for care plans. The administrator identified 51 residents resided in the facility. Findings: An undated Resident Face Sheet, showed Resident #61 was admitted to the facility on [DATE]. Resident #61's electronic health record was reviewed. The electronic health record did not show a comprehensive care plan for Resident #61. On 06/05/25 at 9:07 a.m., the MDS coordinator stated Resident #61 did not have a comprehensive care plan yet.

Based on observation, record review, and interview, the facility failed to ensure accurate code status was documented for a resident with a DNR for 1 (#17) of 24 sampled residents whose advance directive were reviewed. The administrator identified 51 residents resided in the facility. Findings: On 06/04/25 at 1:27 p.m., Res #17's doorway was observed with a red dot beside their name plate. On 06/04/25 at 1:47 p.m., Res #17's medical chart was observed with a sticker on the spine which documented the code status as DNR. An undated face sheet showed Res #17 had diagnoses which included acute respiratory failure with hypoxia and peripheral vascular disease. The face sheet showed Res #17 had a DNR advance directive. An Oklahoma DNR consent form, dated 01/03/24, showed Res #17 had consented to DNR status. A care plan, dated 01/03/24, showed Res #17 had chosen DNR status. A physician order, dated 10/12/24, showed Res #17 was full code status. On 06/04/25 at 2:04 p.m., the MDS coordinator stated Res #17 was a DNR. They stated Res #17's face sheet indicated DNR, and Res #17 had a signed DNR advance directive in their medical chart. The MDS coordinator stated they weren't sure why Res #17 had a physician order that showed they were full code. They stated the order must have been entered in error. On 06/04/25 at 2:38 p.m., the ADON stated Res #17 was a DNR. They stated Res #17's nameplate and face sheet indicated DNR status. The ADON stated the full code order must have been entered in error after Res #17 returned from the hospital in October. On 06/09/25 at 3:45 p.m., the DON stated a red dot out beside a resident's name plate indicated the resident was a DNR. They stated the chart would have a DNR sticker and the face sheet would indicate DNR status.

Based on record review and interview, the facility failed to have sufficient direct care staffing levels for May through July which had the potential to affect all residents. The Resident Current Status Report, dated 08/13/24, documented a census of 47 residents. Findings: The Quality of Care Monthly Report documented the following days below the required staffing level: May 2024: Day Shift: 05/08/24 - 3.85 hours short 05/11/24 - 6.22 hours short 05/18/24 - 10.31 hours short 05/19/24 - 7.44 hours short 05/26/24- 11.44 hours short Evening Shift: 05/11/24 - 9.21 hours short 05/18/24 - 7.12 hours short 05/25/24 - 8.33 hours short June 2024: Day Shift: 06/01/24 - 12.55 hours short 06/09/24 - 19.76 hours short 06/22/24- 25.16 hours short 06/23/24- 10.03 hours short 06/28/24 - 6.41 hours short 06/30/24 - 8.93 hours short Evening Shift: 06/01/24 - 11.20 hours short 06/02/24 - 12.22 hours short 06/08/24 - 9.69 hours short 06/09/24 - 8.96 hours short 06/16/24 - 11.81 hours short 06/23/24 - 15.33 hours short 06/29/24 - 7.90 hours short 06/30/24 - 5.89 hours short July 2024: Day Shift: 07/04/24 - 6.37 hours short 07/20/24 - 7.60 hours short 07/21/24 - 12.59 hours short 07/27/24 - 12.78 hours short 07/28/24 - 19.84 hours short Evening Shift: 07/14/24 - 5.22 hours short 07/27/24 - 14.14 hours short 07/28/24 - 13.22 hours short On 08/15/24 at 2:25 p.m., the administrator reported they have had challenges with staffing and continue daily to try to acquire more staff.

Based on record review and interview, the facility failed to develop a diabetes care plan for one (#2) of three residents whose care plans were reivewed. The Resident Current Status Report, dated 08/13/24, documented a census of 47 residents. Findings: Res #2 had diagnoses which included diabetes. Physician's orders, dated 06/14/24 documented in part, Novolin R insulin .sliding scale: If blood sugar 0-200, give 0 units, if blood sugar is 201-250, give 5u, if blood sugar is 251-300, give 7u, if blood sugar is 301-350, give 10u, if blood sugar is 351-400, give 14u, if blood sugar is greater than 400, call MD before meals and at bedtime . Res #2's blood sugar log documented blood sugars above 400 14 times. Res #2's comprehensive care plan did not have a care plan focus for diabetes. On 08/15/24 at approximately 3:30 p.m., the DON reported they were not able to locate a care plan for Res #2's diabetes. The adminisrtator and DON reported Res #2's diabetes should have been care planned and must have been overlooked.

Based on observation and interview, the facility failed to ensure staff washed or sanitized their hands and change gloves as needed during the cleaning of a residents' perineal area to prevent potential infection for one (#1) of three sampled residents reviewed for increased assistance with activities of daily living. The administrator reported 52 residents resided in the facility. A facility policy titled, Infection Control - Prevention and Control Program dated 03/2012, read in part, The intent of the program is to assure the home develops, implements, and maintains an Infection Prevention and Control in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Resident #1 had diagnoses which included Alzheimer's Disease and muscle wasting and atrophy. On 05/30/24 at 9:40 a.m., an observation of Resident #1 receiving perineal care was observed. CNA #3 and Employee #1 were observed transferring Resident #1 from a wheelchair to a bed. The two employees were gloved during the transfer. The two employees were observed to initiate perineal care without changing gloves. The employees removed the resident's pants and dirty briefs. Employee #1 cleaned the resident's vaginal area then with a new wipe the anal area. The staff members then placed a new brief on the resident and touched them at various parts of their body with the dirty gloves. The staff members then rearranged the bedding including the pillow with the dirty gloved hands. Employee #1 was observed touching their face with the gloved hand they had used to wipe the resident's vaginal and anal areas. The two staff members did not change their gloves or clean their hands during the care. There were no spare gloves observed in the room during the care. After the care was completed, the two were asked how they believed the care had gone. CNA #3 stated they had forgotten to bring a trash bag for the dirty items. They were asked how many times they had changed their gloves while they provided the care. They each stated they had forgotten to change gloves after handily potentially soiled items. Employee #1 stated they should have changed their gloves. On 05/30/24 at 10:20 a.m., RN #2 [Regional RN] was informed of the care that had been provided to Resident #1. They stated the two staff members should have cleaned their hands prior to providing care and after handling the dirty items. They stated the two staff members did not follow infection control procedures.

Based on observation, record review, and interview, the facility failed to ensure: a. infection control policy were implemented in the kitchen. b. food was distributed in a sanitary manner. The administrator identified 50 residents who received meals from the kitchen. Findings: An undated facility policy titled Employee Health Policy Agreement, read in part, Reporting: Symptoms of illness I agree to report to the manager when I have: 1. diarrhea 2. Vomiting .If you have any of the symptoms or illness listed above, you may be excluded*or restricted**from work .if an employee is on duty during the onset of symptoms, their immediate supervisor will release them to leave the facility until they are free of symptoms . 1. Times cards were reviewed for 03/16/24 for DA #1 and DA #2. DA #1 worked from 6:00 a.m., to 11:06 a.m. DA #2's time card documented they had clocked in at 10:59 a.m. on 03/16/24 to relieve DA #1. On 04/09/24 at 3:45 p.m., DA #1 stated on 03/16/24 I was sick and came to work sick. DA #1 stated the DM made them stay at work until someone came into relieve them. DA #1 stated they worked passing meals out to the residents. On 04/09/24 at 3:40 p.m., the DM stated when the if kitchen staff came to work they sick they should have been sent home. The DM stated they had not had anyone sick at work who was made to stay and work. On 04/10/24 at 8:43 a.m., Cook #2 stated a staff member had been sick in the kitchen and was throwing up. The cook stated they called the DM. The DM told Cook #2 to send the sick staff member home, so DA#2 was called in to work. Cook #2 stated the sick staff member did not stay at work until the relief staff got to work. 2. On 04/09/24 at 11:36 a.m., during meal service the following things were observed. Cook #2 was touching the rims of the glasses while serving them to the residents. Cook #2 was observed to touch the eating end of the silverware with bare hands. The serving trays were observed to be wet. On 04/09/24 at 11:47 a.m., Cook #1 was observed to leave the serving area, retrieve a can of tomato juice, poured it into a glass, and returned to serving the meals without removing their gloves or washing their hands. On 04/09/24 at 12:02 p.m., the DM stated the kitchen staff should not have been touching eating areas of the silverware or drinking glasses. They stated the staff should not have been touching dirty items and returning to serve the food in the same gloves. The DM stated the trays should have been air dried completely before using them for service.

Based on record review and interview, the facility failed to provide a sufficient number of staff to ensure residents received the needed care and services for two (#2, and #4) of four residents reviewed for staffing. The administrator identified 50 resident residing in the facility. Findings: 1. Res #2 had diagnoses which included psoriasis, skin changes, and moderate protein calorie malnutrition. A physician order, dated 7/13/21, documented the resident required one person assist with bathing. A quarterly assessment, dated 01/15/24, documented the resident required supervision to touch assist with bathing. On 04/09/24 at 11:21 a.m., Res #2 stated they had asked for a bath on Sunday 04/07/24 and did not receive a bath. Res #2 was scheduled to receive a shower or bath on Mondays, Wednesdays, and Fridays of each week. During March 2024 the resident received four showers out of 13 opportunities. One shower was on a scheduled shower day and the other three were not on scheduled days. The documentation on the shower sheets revealed eight refusals on scheduled days, and no documentation was provided for the remaining shower days. The resident's scheduled shower sheets for April 2024 did not document the resident had a shower in April as of the 10th. The resident scheduled days would have been the 1st, 3rd, 5th, 8th, and 10th, of April. The documentation revealed on April 1st the resident refused a shower. There was not a shower sheet for April 3rd. On April fifth there was a shower sheet but did not documented if the resident had a shower or not that day, On April 7th, the date the resident stated they had requested a shower, the resident's name was on a shower sheet but there was no documentation of the resident receiving a shower. 2. Res #4 had diagnoses of hemiplegia and hemiparesis, muscle weakness, and lack of coordination. A quarterly assessment, dated 02/06/24, documented the resident was dependent with bathing. The shower sheets observed for Res #4 documented the resident did not receive a shower on their scheduled shower days for 3/23/24, 3/30/24 for March 2024. On 04/10/24 at 1:38 p.m., CNA #2 stated at times they had to rush to get the showers done. CNA #2 stated if they did not get a shower on the scheduled day they tried to get it on the next day. CNA #2 stated they had to ask the resident three times and then report to the nurse if the resident refused to shower. CNA #2 stated sometimes the shower would be completed but did not get documented. On 04/10/24 at 1:42 p.m., CNA #1 stated they had a shower chart they went by to know what resident was supposed to get a shower. CNA #1 stated they had two CNAs currently so they did three showers today because did not have the time to get all the showers completed. The CNA stated if the shower sheet did not document a bath or refusal the resident probably did not receive a shower that day. 3. Documents titled Homestead of [NAME] Daily Staffing Hours sheets were reviewed for February and March 2024. The facility had one day in February 2024 where they did not meet the staffing requirements. March sheets revealed 11 days the staffing requirements were not met. On 04/10/24 at 2:09 p.m., the DON stated the facility did not have enough CNAs the first part of March. They stated the facility had to let a couple of them go and had some not shown up for work and/or just never came back. The DON stated staffing was challenging but they had some good staff who just needed leadership.

Based on observation, record review, and interview, the facility failed to ensure double portions were provided for one (#2) of four residents who were reviewed for nutrition. The administrator identified 15 residents who had weight loss. Findings: Res #2 had diagnoses which included moderate protein calorie malnutrition. A physician order, dated 08/02/23, documented the resident was to receive a regular diet with double portions. A quarterly assessment, dated 01/15/24 documented the resident's weight was 209 pounds and had not had a loss or gain. The assessment documented the resident required supervision or touch assist with eating. A dietary note, dated 04/08/24, documented the resident weight was 204.5 pounds with a BMI of 26.3, WNL. The note documented no significant weight changes. The resident's diet was documented as a regular diet with double portions and the resident's intake was 76 to 100% of their meal. The note documented to continue care. On 04/09/24 at 11:21 a.m., Res #2 stated the food in the facility sucks and was delivered cold. Res #2 stated they had been hungry for a month. On 04/09/24 at 11:33 a.m., the lunch meal service was observed. At 12:22 p.m., the kitchen ran out of taco meat and a test tray was not provided. Cook #1 stated they served all the residents but were out of taco meat. They were observed to not serve any resident double portions of food. On 04/10/24 at 8:48 a.m., cook #1 stated they did not have any residents who received double portions of food with meals. Res #2's meal card was observed it documented the resident was to receive a regular diet with thin liquids. Double portions was not documented on the meal card. On 04/10/24 at 1:56 p.m., the DON reviewed Res #2's orders and stated they were not aware Res #2 was to receive double portions of food with their meals.

Based on record review and interview, the facility failed to provide bathing to residents as scheduled for two (#2 and #4) of four residents reviewed for bathing. The administrator identified 50 resident residing in the facility. Findings: 1. Res #2 had diagnoses which included psoriasis, skin changes, and moderate protein calorie malnutrition. A physician order, dated 07/13/21, documented the resident required one person assist with bathing. A quarterly assessment, dated 01/15/24, documented the resident required supervision to touch assist with bathing. On 04/09/24 at 11:21 a.m., Res #2 stated they had asked for a bath on Sunday 04/07/24 and did not receive a bath. Res #2 was scheduled to receive a shower or bath on Mondays, Wednesdays, and Fridays of each week. During March 2024 the resident received four showers out of 13 opportunities. One shower was on a scheduled shower day and the other three were not on scheduled days. The documentation on the shower sheets revealed eight refusals on scheduled days, and no documentation was provided for the remaining shower days. The resident's scheduled shower sheets for April 2024 did not document the resident had a shower in April as of the 10th. The resident scheduled days would have been the 1st, 3rd, 5th, 8th, and 10th, of April. The documentation revealed on April 1st the resident refused a shower. There was not a shower sheet for April 3rd. On April fifth there was a shower sheet but did not documented if the resident had a shower or not that day, On April 7th, the date the resident stated they had requested a shower, the resident's name was on a shower sheet but there was no documentation of the resident receiving a shower. 2. Res #4 had diagnoses of hemiplegia and hemiparesis, muscle weakness, and lack of coordination. A quarterly assessment, dated 02/06/24, documented the resident was dependent with bathing. The shower sheets observed for Res #4 documented the resident did not receive a shower on their scheduled shower days for 03/23/24, 03/30/24 for March 2024. On 04/10/24 at 1:38 p.m., CNA #2 stated at times they had to rush to get the showers done. CNA #2 stated if they did not get a shower on the scheduled day they tried to get it on the next day. CNA #2 stated they had to ask the resident three times and then report to the nurse if the resident refused to shower. CNA #2 stated sometimes the shower would be completed but did not get documented. On 04/10/24 at 1:42 p.m., CNA #1 stated they had a shower chart they went by to know what resident was supposed to get a shower. CNA #1 stated they had two CNAs currently so they did three showers today because did not have the time to get all the showers completed. The CNA #1 stated if the shower sheet did not document a bath or refusal the resident probably did not receive a shower that day. On 04/10/24 at 1:49 p.m., the DON stated by looking at the documentation the showers were not completed as scheduled.

On 01/04/24 at 3:00 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility's failure to follow their abuse policy and ensure background screenings were completed for 7 of 46 employees. On 01/04/24 at 3:05 p.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation. On 01/04/24 at 3:10 p.m. the administrator was notified of the IJ situation. On 01/04/24 at 5:31 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Completion Date 01/04/24 at 7:00 p.m. The Administrator will be educated over the telephone by the Regional Director on employee background checks. The Business Office Manager's employment will be terminated immediately. Currently in progress: Reviewing all employee personnel records to verify criminal background checks are completed. Any employee without a criminal background check will not be allowed to return to work until completed. New hires will have criminal background checks performed before starting to work. The names of the employees that were sent home are (names withheld), Housekeeper #1 and Dietary Aide #1. The names of the employees that were not allowed to come to work were (names withheld), Dietary Aide #2, CNA #1, CNA #2, CNA #3, and CNA #4. The IJ was lifted, effective 01/04/24 at 7:00 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 record review and interview, the facility failed to follow their abuse policy and ensure background checks were completed for new hires. The administrator identified 41 residents who resided in the facility. Findings: The Abuse Prevention Program policy, last revised August 2006, read in part, Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Comprehensive policies and procedures have been developed to aide our facility in preventing abuse .Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Protocols for conducting employment background checks . An Abuse - Reportable Events policy, dated 01/2018, read in part, .1. Screening: a. Pre-employment screening will be completed on all employees, to include: Criminal History Check, Background Check . The Homestead of [NAME] Employee Roster provided by the OK-Screen & Detention Programs was compared to the facility employee roster. The following seven of 46 employees did not have background screenings: a. Dietary Aide #2 hired on 10/11/23, b. Housekeeping #1 hired on 12/01/22, c. CNA #1 hired on 07/03/23, d. CNA #2 hired on 06/26/23, e. CNA #3 hired on 09/21/23, f. CNA #4 hired on 05/19/23, and g: Dietary Aide #1 hired on 09/26/23. On 01/04/24 at 2:30 p.m., the business office manager reported they had not gotten to employee background checks. The business office manager reported all background checks should have been completed upon hire. On 01/04/24 at 3:15 p.m., the administrator reported she thought the business office manager was doing her job and following protocol. 01/08/24 at 4:05 p.m., the administrator reported they thought the business office manager was following a check list for new hires. The administrator reported they had not followed up regarding background checks to ensure they were completed.

Based on record review, observation, and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The administrator identified 39 residents who receive their meals from the kitchen. Findings: On 01/02/24 at 9:39 a.m., an initial tour of the kitchen was completed. Observations made in the refrigerators were peaches in cups not dated and labeled, two sandwiches in plastic bags were not dated or labeled, a glass of juice not covered, sliced cheese open to air and not dated or labeled, and hamburger patties wrapped up not labeled or dated. On 01/02/24 at 9:45 a.m., Cook #1 the acting DM stated the items in the refrigerators should be labeled and dated and not open to air. On 01/02/24 at 9:48 a.m., the freezer was observed with ice all over the boxes of food, the ceiling, door, and floor. Cook #1 the acting DM stated they had been working on the freezer but it had been that way a while. On 01/04/23 at 3:38 p.m., DA #1 was observed to touched the trash can lid with her hand and did not wash her hands. On 01/04/23 at 3:39 p.m., observed DA #1 preparing the puree. The lid for the food processor was broken. DA #1 was using both pieces to cover the container while making the puree. On 01/04/23 at 3:40 p.m., DA #1 stated the lid got cracked in August and a few weeks ago the lid got broke. She thought they had ordered a new lid. At this time DA #1 touched her nose by her mask and continued with making the puree. The smaller piece of the lid was observed to fall into the puree, DA #1 retrieved the part of the lid from the puree and served the puree. On 01/04/23 at 3:43 p.m., the small drinking glasses were observed on the storage rack upside down and observed to be wet on the inside of the glasses. The serving trays were observed stacked on a cart and the trays were stacked wet. On 01/04/23 at 3:47 p.m., the freezer door was observed not closed completely. DA #1 stated they would have to knock the ice off the freezer door to get it to shut. On 01/04/23 at 3:48 p.m., the maintenance man and DA #3 were observed to come in the back door or the kitchen. The maintenance man walked through the kitchen and out another door. DA #3 did not wash their hands when they entered the kitchen for work. On 01/04/23 at 3:55 p.m., DA #1 was observed to wash the food processor container in the three compartment sink. DA #1 was asked to check the sanitizer in the sink water and the dish machine. The dish machine did not register any sanitizer nor did the sanitizer in the sink. On 01/04/23 at 4:08 p.m., the bowls DA #1 was going to serve the spinach in were observed to be wet on the inside. DA #1 was asked at that time if the bowls were wet. DA #1 stated the bowls were wet and should be air dried before using them the bowls were not used at this time. On 01/04/23 at 4:14 p.m., DA #3 was washing dishes in the dish machine trying to get the sanitizer to register. DA #3 switched the container of sanitizer to the dish machine and the sanitizer registered at 50 PPM. DA #3 did not wash her hands before going through the clean trays to see which ones were dry and taking the other to place in the rack to air dry. The log for the dish machine sanitizer was observed blank for 01/04/24. On 01/05/24 at 12:48 p.m., Cook #1 stated they the lid for the food processor had been broken for a month or two the administrator had ordered one and they were waiting for it to come in. Cook #1 stated they did not check the sanitizer yesterday morning for the dish machine. Cook #1 stated the staff working 01/04/24 should have been able to check the sanitizer in the three compartment sink and the dish machine. Cook #1 stated the glasses, bowl, and trays should have been air dried before stacking. Cook #1 stated when anyone enters the kitchen they should put on a hair net and wash their hands. The cook stated the staff should wash their hands after touching anything dirty. On 01/08/24 at 2:09 p.m., the administrator stated they were ordering a new door for the freezer. The administrator then stated the company told them they could put a strip around the door. The administrator stated they did not know the date the freezer would be fixed but were on a list. The administrator stated every staff should know how to check the sanitizer. The administrator stated the staff should wash their hands when something dirty was touched and the items should be air dried before use.

Based on record review and interview, the facility failed to ensure resident assessments were transmitted to CMS within the required timeframes. The administrator identified 41 residents who resided in the facility. Findings: An Electronic Transmission of the MDS policy, last revised on October 2010, read in part, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data . The facility was unable to provide QIES transmission reports, but was able to provide transmission records from their EHR system. Transmission records from 09/06/23 though 01/03/24 were reviewed. 69 of 98 MDS/Resident assessments were submitted late. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the MDS coordinator's last day was 11/11/23 and none of the facility staff had login credentials with QIES to obtain reports and transmit resident assessments.

Based on record review and interview, the facility failed to ensure a level ll PASRR referral was made to the Oklahoma Health Care Authority for three (#6, 39, and #41) of 16 residents who were reviewed for PASARR. The administrator identified 41 residents who resided in the facility. Findings: 1. Res #6 was admitted the facility with diagnoses which included moderate intellectual disabilities, depression, and bipolar disorder. A PASRR level l form, dated 01/27/23, documented the resident was admitted to the facility as a skilled resident. The form documented if the resident remained in the facility more than 30 days and as a long term care resident the would need to be updated. On 01/04/24 at 8:42 a.m., the administrator reviewed the resident's clinical record and stated per the PASRR level l completed a referral to the Oklahoma Health Care Authority should have been made when the resident remained in the facility longer than 30 days. The administrator stated a referral was not made to the Oklahoma Health Care Authority for a PASRR level ll when the resident remained in the facility more than 30 days and became a long term care resident with a diagnosis of a serious mental illness. 38495 2. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia. A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors. A PASRR I, dated 08/29/22, documented the resident had a serious mental illness. The PASRR documented a PASRR II was not needed this stay per administrator. A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLS. The assessment documented the resident received an antipsychotic and an antianxiety medication. On 01/04/24 at 8:30 a.m., the administrator stated they did not make medical decisions and that the PASRR was completed by the last DON. The administrator stated according to the documentation of the resident having a serious mental illness OHCA should have been contacted. 3. Res #41 admitted to the facility on [DATE] with the following diagnoses bipolar disorder, depression, and dementia with behavioral disturbance. A PASRR I , dated 07/12/23, documented the resident did not have a serious mental illness. A quarterly assessment, dated 09/30/23, documented the resident was severely impaired with cognition, and requires extensive assistance with ADLs. The assessment documented the resident received an antipsychotic and an antidepressant medication. On 01/04/24 at 8:23 a.m., the administrator stated the resident had the bipolar diagnosis on admission. The administrator stated the PASRR I was not filled out correctly and bipolar should have been listed as a serious mental illness on the PASRR I. The administrator stated the resident primary diagnosis was unspecified dementia.

Based on interview and record review, the facility failed to ensure quarterly resident assessment were completed within the required timeframe for 12 (#5, 6, 23, 26, 30, 31, 35, 36, 37, 39, 42 and #44) of 15 sampled residents whose resident assessments were reviewed. The administrator identified 41 residents who resided in the facility. Findings: A review of resident assessments was conducted with the following results: a. Res #5's annual resident assessment was completed on 07/31/23. A quarterly resident assessment was due on 10/31/23 but was not completed. b. Res #6's annual resident assessment was completed on 08/25/23. A quarterly resident assessment was due on 11/25/23 but was not completed. c. Res #23's annual resident assessment was completed on 08/06/23. A quarterly resident assessment was due on 11/06/23 but was not completed. d. Res #26's annual resident assessment was completed on 08/16/23. A quarterly resident assessment was due on 11/16/23 but was not completed. e. Res #30's quarterly resident assessment was completed on 08/13/23. A quarterly resident assessment was due on 11/13/23 but was not completed. f. Res #31's annual resident assessment was completed on 08/05/23. A quarterly resident assessment was due on 11/05/23 but was not completed. g. Res #35's quarterly resident assessment was completed on 08/25/23. A quarterly resident assessment was due on 11/25/23 but was not completed. h. Res #36's quarterly resident assessment was completed on 08/24/23. A quarterly resident assessment was due on 11/24/23 but was not completed. i. Res #37's quarterly resident assessment was completed on 08/08/23. A quarterly resident assessment was due on 11/08/23 but was not completed. j. Res #39's annual resident assessment was completed on 08/26/23. A quarterly resident assessment was due on 11/26/23 but was not completed. k. Res #42's annual resident assessment was completed on 08/22/23. A quarterly resident assessment was due on 11/22/23 but was not completed. l. Res #44's quarterly resident assessment was completed on 08/28/23. A quarterly resident assessment was due on 11/28/23 but was not completed. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the quarterly resident assessment should have been completed within the required timeframe. The Corporate RN #1 reported the MDS Coordinator's last day was 11/11/23 and there was no one in place initially to do MDS in the interim.

An IJ situation was determined to be in existence related to the facility failing to ensure a resident's respiratory status was assessed, monitored, and interventions were put in place to prevent hospitalization . The staff failed to notify the physician of significant changes in condition and call Emergency Medical Services. On 01/17/23, staff documented Res #1 had an oxygen saturation of 44% and 64%. The staff documented they gave Res #1 a breathing treatment prior to calling EMS. There was no physician notification documented. A physician's order on 01/21/23, read in part, .maintain O2 sat above 90%. On 02/20/23 at 4:49 a.m., staff documented the resident's oxygen saturation was 79%, the staff administered a breathing treatment, the oxygen saturation rose to 88%. There was no physician notification documented. On 02/20/23 at 7:15 a.m., staff documented the resident's oxygen saturation was 91%, the respiratory rate was 36, and lung sounds were diminished. There was no physician notification or call to EMS documented. On 02/21/23 Res #1 was diagnosed with bacterial pneumonia. On 04/29/23 at 1:52 p.m., staff documented Res #1 was very short of breath, a breathing treatment was started, the oxygen saturation was 83%. There was no physician notification or call to EMS documented. On 04/29/23 at 5:40 p.m., staff documented the oxygen saturation was 85%. There was no physician notification or call to EMS documented. On 04/29/23 at 10:35 p.m., staff documented, cpap in place and 02 @ 2 l/m via cpap. Patient resp at 20 with SP02 69%. Patient's granddaughter present and requesting patient be sent to CMH ER. Nurse has been monitoring 02 and trying to determine if cpap is operating properly. Removed cpap and 02 admin via n/c @ 2 l/m . Staff failed to call EMS immediately. On 04/30/23 Res #1 was transferred from the local hospital to a higher level of care with an elevated troponin and myocardial infarction. On 05/01/23 at 4:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/01/23 at 4:55 p.m., the Administrator and DON were notified of the IJ situation. On 05/01/23 at 7:30 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: IJ Plan of Removal for Respiratory Assessment, Monitoring, and Interventions Completion Date 5-1-23 at 8:30 p.m. All staff will be educated with a sign in sheet that are currently working in the facility. Any remaining staff that aren't at the facility will be called and educated over the telephone. Employee name and time of call will be documented. Any staff we are unable to contact for educational training will not be allowed to clock in until education is completed. Resident Change of Condition-Physician Notification Clinical Staff Education will be completed on the following items: Respiratory Assessment Pulse Oximeter CPAP/BIPAP Support COPD Clinical Protocol Currently in progress: Reviewing all residents with respiratory diagnosis, oxygen therapy, CPAP/BIPAP to ensure appropriate physician orders and interventions are in place. SBARS will be completed on any residents with a change of condition. The change of condition will be documented, physician will be notified, and time of notification will be documented. Care plans will be updated with any changes made to current orders. On 05/01/23 at 7:30 p.m., the Administrator and DON were notified the immediacy was lifted effective 05/01/23 at 7:30 p.m. and the deficiency remained at a harm level. On 05/03/23, facility staff were interviewed and were able to state they had been educated on respiratory assessment, pulse oximetry, CPAP/BIPAP support, COPD Clinical Protocol, Resident Change in Condition, and physician notification. Care plans had been updated to reflect identified residents' need for oxygen therapy, CPAP/BIPAP, and monitoring of respiratory status. The Resident Census and Conditions of Residents, dated 05/01/23 the DON identified four residents with oxygen therapy. Findings: 1. Res #1 was admitted with diagnoses which included COPD, chronic dyspnea, and C02 retention. A care plan, last reviewed/revised on 01/12/23, documented in part, .resident has episodes of shortness of breath and is at risk for respiratory distress/failure .assess respiratory status ie: breath sounds, respiratory rate, skin color, etc. notify MD of abnormal .monitor for sob .report to MD .notify MD of any changes in condition . A progress noted, dated 01/17/23 at 6:04 a.m., documented, sob o2 sat keep going down 44 and 64 alert with confusion weak gave albuterol breathing treatment o2 sat kept going down called 911 was here in few minutes left enroute to [hospital, name omitted] for eval daughter (name omitted) called and notified of sending to ER don notified. A physician's order, dated 01/21/23, documented, obtain 02 sat q shift. Maintain above 90%. A quarterly assessment, dated 02/08/23, documented Res #1 required oxygen therapy. A progress note, dated 02/20/23 at 4:49 a.m., documented, o2 sat went down to 79 breathing treatment given up to 88-90 down head of bed up 02 at 2 liters via nc . o2 sat 88 will continue to monitor. A progress note, dated 02/20/23 at 7:15 a.m., documented, Vs: 91% 2l/m n/c, 36 resp, 88hr neb treatment given with rate to 24 post. Diominished [sic] breath sounds bilaterally. A physician's order, dated 02/23/23, documented, 0xygen at 2 liters via mask continuously. A Clinical Report, dated 04/12/23 at 4:48 p.m., documented Res #1 was taken to the hospital by family. A progress note, dated 04/12/23 at 11:54 p.m., documented, hospital called said they were going to admit her to hospital for hypoxia. A hospital discharge summary, dated 04/13/23, documented Res #1 was admitted on [DATE] and discharged on [DATE] with diagnoses which included hypoxia and acute exacerbation of COPD. The summary documented to notify the physician of shortness of breath. A progress note, dated 04/29/23 at 1:52 p.m., documented in parts, .CNA .ASKED ME TO . CHECK ON THIS RESIDENT D/T HER BECOMING VERY SOB . STARTED BREATHING TX, .TRIED TO TRANSFER RESIDENT SHE BECAME VERY WEAK,02 WAS 83% WITH 02 3LITER . WILL CONT TO MONITOR . A progress note, dated 04/29/23 at 5:40 p.m., documented in parts, .O2 85% with O2 @ 2L . A progress note, dated 04/29/23 at 11:35 p.m. [late entry] documented in parts, . 02 @ 2 l/m via cpap. Patient resp at 20 with SP02 69% . Nurse has been monitoring 02 and trying to determine if cpap is operating properly. Removed cpap and 02 admin via n/c @ 2 l/m . transported patient to . ER. A Medical Necessity for Ambulance Services, dated 04/29/23 (no time), documented Res #1 was transferred to higher level of care for the services of a cardiologist and admission to an Intensive Care Unit due to an elevated troponin, hypoxia, and hypercapnia. A hospital document, with no title, dated 04/30/23 at 1:59 a.m., documented the resident's admitting diagnoses as COPD, Hypoxia, and NSTEMI. On 05/01/23 at 3:45 p.m., Corp RN #1 reported the staff should have notified the physician on 01/17/23 when the resident's sat was 44% and 64%, on 02/20/23 when the resident's sat was 79% and 88%, and the respiratory rate was 36, on 04/29/23 when the resident's sat was 85%, and on 04/29/23 when the resident's sat was 69%. On 05/01/23 at 3:55 p.m., the ADON reported the staff should have notified the physician on 01/17/23 when the resident's sat was 44% and 64%, on 02/20/23 when the resident's sat was 79% and 88%, and the respiratory rate was 36, on 04/29/23 when the resident's sat was 85%, and on 04/29/23 when the resident's sat was 69%.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #51's physician was notified for a change in condition. On [DATE] at 2:00 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 2:20 p.m., the Administrator was notified of the IJ situation. On [DATE] at 5:23 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated [DATE] at 5:23 p.m., read in parts, .All staff will be educated with a sign in sheet that are currently working in the facility. Any remaining staff that aren't at the facility will be called and educated over the telephone. Employee name and time of call will be documented. Resident Change of Condition-Physician Notification Policy. Clinical Staff Education will be completed with everyone that is currently working in the facility. Staff that aren't at the facility will be called and educated over telephone. Time of call will be documented. Resident Assessments, SBAR, Physician Notification. Currently in progress: Nurse Assessments are being completed on all residents for change of condition, decline in function, and appropriate interventions. A SBAR will be completed on any residents with a change of condition. The change of condition will be documented, physician will be notified, and time of notification will be documented. The IJ was lifted, effective [DATE] at 7:00 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with a potential for harm. Based on record review and interview, the facility failed to ensure: a. the physician was notified of a change in condition for one (#51) of one resident reviewed for a change in condition; b. a diabetic protocol was followed for two (#1 and #16) of five residents reviewed for diabetic care; and c. a physician's order was obtained for a DNR for one (#39) of one resident whose code status was reviewed. The Resident Census and Conditions of Residents, dated [DATE], documented a census of 53. Findings: 1. Res #51 was admitted with diagnoses which included diabetes and hypertension. A Condition Change, Of the Resident (Observing, recording and Reporting), policy undated, documented in parts, .observe, record and report any condition change to the attending physician so proper treatment will be implemented . [Recorded as Late Entry on [DATE] at 1:11 p.m.] A progress note, dated [DATE] at 8:00 a.m., read in parts, Resident had vomited scant amount of greenish clear emesis . There was no documentation of physician notification for Res #51's change in condition. A progress note, dated [DATE] at 11:34 a.m., read in parts, Went into room to check resident FSBS (finger stick blood sugar), he was acting strange with covers over his face, noted that his BS registered HI, he was waving his hands around up in the air, his skin was cool and clammy and eyes rolling, also drenched in sweat, not making any sense .got charge nurse (name withheld), EMS was called, moved resident to floor to cont to CPR .they intubated .continued CPR, no pulse, EMS called and spoke to ER Dr. and was called at 11:59 . A progress note, dated [DATE] at 11:36 a.m., read in parts, upon being called to the resident's room EMS notified of need for transfer with a noted change in mental status. skin pale, diaphoretic, temp 96.6. fsbs HI, ems notified of change in status. upon ems arrival resident became unresponsive agonal, pulse thready with no bp palpable, sat will not pick up. connected to aed per ems and intubated with oral tube per ems. vital signs cease . A progress note, dated [DATE] at 12:11 p.m., documented the physician was notified of Res #51's death. On [DATE] at 12:32 p.m., RN #2, stated they had observed the resident on [DATE] at 8:00 a.m., RN #2 stated Res #51 had vomited a small amount of greenish fluid and they did not think it was important. RN #2 stated they did not notify the physician. 2. Res #1 was admitted with diagnoses which included diabetes. A Sliding Scale For Regular Insulin protocol for the patients of Dr. (name withheld), read in parts, .Blood Sugar >350 Call Doctor Res #1 had a blood sugar over 350 nine times between [DATE] and [DATE]. There was no documentation Res #1's physician was notified of the blood sugar results over 350. On [DATE] at 12:30 p.m., RN #2 reported the sliding scale protocol for Res #1 should have been followed and the physician notified of blood sugar results over 350. Res #16 was admitted with diagnoses which included diabetes. An Obtaining a Fingerstick Glucose Level policy, dated ,d+[DATE], read in parts, .The blood sugar results .Report results promptly to the .Attending Physician . A physician's order, dated [DATE], read in parts, .if blood sugar is greater than 400, call MD. On [DATE] at 11:12 a.m., Res #16's blood sugar registered as 441 and 12 units of Regular insulin was given. On [DATE] at 11:14 a.m., RN #1 stated the blood sugar registered as 441 and the physician was to be notified and the blood sugar to be rechecked in two hours. On [DATE] at 3:30 p.m., Res #16 reported the nurse had not rechecked their blood sugar. On [DATE] at 3:35 p.m., there was no documentation the physician was notified or the blood sugar was rechecked. On [DATE] at 3:42 p.m., RN #1 reported they had not rechecked the blood sugar or notified the physician and had reported the blood sugar to LPN #1 to follow up. On [DATE] at 3:44 p.m., LPN #1 reported they were aware of Res #16's blood sugar of 441 and they had not notified the physician or rechecked the blood sugar. On [DATE] at 3:49 p.m., the ADON reviewed the health record and reported the blood sugar had not been rechecked and the physician had not been notified as ordered. On [DATE] at 4:14 p.m., the corporate administrator reported the blood sugar should have been rechecked and the physician notified. 45913 3. Res #39 was admitted with diagnoses which included vascular dementia and cardiac pacemaker. A physician's order, dated [DATE], documented in part, .Full code. A physician's order, dated [DATE], documented in part, Admit to homestead of [NAME] hospice services . The Hospice Admission Consent was signed on [DATE]. A Physician Order Report, dated [DATE] to [DATE], documented in parts, .start date [DATE] . Full code . A Hospice Care Plan Conference Summary dated [DATE], documented Res #39 was a DNR. A care plan, last revised on [DATE], documented in parts, . I choose to be a FULL CODE .My wishes will be honored through the next review date . If my heart should stop beating or I should stop breathing, I want all life support measures to be taken A physician's order, dated [DATE], and signed by the physician on [DATE], documented in parts . Code Status: DNR . On [DATE] at 2:00 p.m., the Corporate Administrator reported the lack of a physician's order for the DNR status was discovered on [DATE] during chart reviews. The Corporate Administrator reported the physician's order for the DNR status should have been obtained and documented on [DATE].

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received supervision to prevent falls for one (#2) of three residents who were reviewed for accidents. The facility failed to ensure two staff members were present to prevent a fall while transferring the resident. A hospital inpatient examination summary documented the resident had a left proximal femur fracture related to a fall. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, updated 11/22/18, documented the resident required two person assistance during transfers. An annual assessment, dated 11/22/18, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident was frequently incontinent of bowel and bladder. An incident report, dated 09/09/19, documented the resident was standing and holding onto a grab bar during changing of her clothes and the resident's leg gave away causing the resident to fall. A witness statement, dated 09/09/19, documented a staff member was in the shower room with the resident and when the staff member attempted to get a chair the resident fell . Three other witness statements, dated 09/09/19, documented the resident was already in the floor when entering the shower room. A hospital inpatient examination summary, dated 09/11/19, documented the resident had a left proximal femur fracture related to a fall. A quarterly assessment, dated 09/20/19, documented the resident was cognitively intact. The assessment documented the resident was totally dependent on staff with activities of daily living. The assessment documented the resident was incontinent of bowel and bladder. On 10/21/19 at 9:30 AM, the resident was observed sitting in a wheelchair. The resident reported she and one certified nurse aide (CNA) was in the bathroom. The CNA was alone. The resident stood up and the CNA went to get a chair to slide under the resident and the resident reported falling during the time the CNA went for the chair. The resident reported two staff members were supposed to be with her when transferring. On 10/21/19 at 2:12 PM, the director of nursing (DON) reported only one staff member was present when the resident fell in the shower room. The DON reported there should have been two staff members transferring the resident in the shower room.

On 03/12/15 at 3:00 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to have a system to ensure assessments were timely and accurate; interventions were implemented, monitored, and revised; and changes in a resident's condition were recognized, evaluated, and reported to the physician. The facility failed to consult with the physician regarding a pressure ulcer with dark drainage and an odor. The resident was hospitalized with multiple [MEDICAL CONDITION], fever, cough, and headache following a visit from a physician assistant on 03/04/15. An operative report from the hospital documented the resident had multiple stage III pressure ulcers, a stage V pressure ulcer with malodorous necrosis and gangrene, and a wet gangrene ulcer. On 03/12/15 the OSDH verified an immediate jeopardy situation existed related to the facility's failure to have a system to ensure skin/pressure ulcer assessments were timely and appropriate; interventions were implemented, monitored, and revised; and changes in a resident's skin/pressure ulcer condition were recognized, evaluated, and reported to the physician. On 03/12/15 the administrator and director of nursing (DON) were informed of the IJ situation related to not having a system to ensure assessments were timely and appropriate; interventions were implemented, monitored, and revised; and changes in a resident's condition were recognized, evaluated and reported to the physician. The administrator and the DON were informed the immediate jeopardy situation constituted substandard quality of care. The administrator and DON verbalized understanding. On 03/12/15 at 8:00 p.m., the 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: "Homestead of Hugo Subject: plan of removal Date: 03/12/2015 The physician was notified on 03/12/15 regarding the drainage present to the wound for (Resident's name deleted) on 03/12/2015. The resident was hosptalized on [DATE] and currently remains hospitalized . Plan of Correction for Failure of Wound Assessment and Monitoring of Wounds and Failure to notify the physician. Wound Assessment and Monitoring of wounds Will place daily wound sheet in treatment book. Monitor by the DON/designee 3 x week for 2 months, the weekly for 2 months, then bi-weekly. Will place Weekly wound documentation sheets in treatment book for completion. Monitor by the DON/designee 3 x week for 2 months, then weekly for 2 months, then bi-weekly Will place Weekly skin assessment with nurse assignments in skin book at each nurse station for completion. Monitored by the DON/designee 3 x week for 2 months, then weekly for 2 months, then bi-weekly. Will have Monthly summary completed in Matrix to include skin and printed off and place in chart. Monitored by the DON/designee 3 x week for 2 months, then weekly for 2 months, then bi-weekly. Will educate all nursing staff on daily, weekly, and monthly wound and skin assessments and proper completion by 8AM on 03/13/2015. If staff is out of town, or on medical leave or vacation, they will not be allowed to return to work until in serviced by the DON/designee on wound assessments, monitoring of wounds and physicians notification. In-services sheets will be signed and dated for acknowledgement. Will educate all staff (CNA's, CMA's, and general staff) to notify charge nurse of any new skin issue to be addressed for evaluation and treatment by 8 AM on 03/13/2015. If staff is out of town or on medical leave or vacation, they will not be allowed to return to work until in-serviced by the DON/designee. In-service sheets will be signed and dated for acknowledgement. Homestead of Hugo Wound care policy and procedures will be reviewed/revised and implemented to reflect the ongoing assessments of wounds for drainage, odor, measurements, and physician notifications. Will have monitor forms for completion each AM by MDS coordinator on daily basis on Monday-Friday and will be monitored by weekend RN on Saturday and Sunday for completion and will notify DON/or designee for further orders and or physician notification. DON/MDS Coordinator or designee will assess and re-measure all wounds in the facility for correct and accurate measurements, drainage/odor and will notify physician and get new orders if needed. New employees will be educated on the wound care policy and procedures at time of hire by the DON/designee. Care plans will be updated with new or changed wound conditions/treatments. Each AM at the morning stand up meeting Monday-Friday the DON/designee will bring and skin issue, treatment orders, and wound measurement, on changes in wound for QA." Surveyors interviewed staff on all shifts to verify their knowledge of the facility's policy related to assessments, implementing interventions, monitoring and revision, recognizing, and evaluating changes in a resident's condition, and reporting to the physician. The staff verbalized an understanding of the facility's policy related to assessments, implementing interventions, monitoring and revision, recognizing and evaluating changes in a resident's condition, and reporting to the physician. On 03/13/15 at 11:00 a.m., the facility was informed the IJ was removed, effective 03/12/15 at 10:30 p.m., when all components of the plan of removal had been implemented and staff verbalized an understanding of inservices related to assessments, implementing interventions, monitoring and revision, recognizing and evaluating changes in a resident's condition, and reporting to the physician. The deficiency remained at the level of actual harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to provide care to prevent the development and/or promote healing of pressure ulcers for two (#2 and #7) of three residents sampled for pressure ulcers. The facility failed to have a system to ensure assessments were timely and accurate; interventions were implemented, monitored, and revised; and changes in the resident's condition were recognized, evaluate, and reported to the physician. The resident was hospitalized with multiple [MEDICAL CONDITION], fever, cough, and headache. An operative report from the hospital documented the resident had multiple stage III pressure ulcers, a stage V pressure ulcer with malodorous necrosis and gangrene, and a wet gangrene ulcer. The facility identified six residents with pressure ulcers. Findings: The facility policy on pressure ulcers documented the facility nursing staff was to assess residents' skin and document physician notification if appropriate. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The closed record of the resident was reviewed. A quarterly assessment, dated 12/28/14, documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with activity of daily living needs and ambulation. The assessment documented the resident's skin was intact. A nurse note, dated 01/06/15 at 9:15 p.m., documented arrived at the facility via ems carrier. The note documented four surgical sites with a total of 33 staples and three sites with a total of 27 staples. A pressure ulcer documentation form, dated 01/07/15 at 11:06 a.m., documented an assessment of a wound to the right buttock that was hospital acquired. The form documented a stage II pressure ulcer. The form documented the size of the pressure ulcer was 1 x 3 x 0.1. The form documented new orders were obtained from the physician. A pressure ulcer documentation form, dated 01/07/15 at 11:09 a.m., documented a stage I pressure ulcer to the right lower leg. The form documented the size of the pressure ulcer was 3 x 5 x UTD (unable to determine). A nurse note, dated 01/07/15 at 8:07 p.m., documented orders received to cleanse the right sacrum with DWC, apply [MEDICATION NAME], cover with [MEDICATION NAME], and secure with 4 x 4 border. The note documented a foam dressing change was to be done every three days and as needed until healed or a 14 day evaluation. The note documented to cleanse the right lower leg with DWC, apply [MEDICATION NAME], cover with 6 x 6 non border dressing, secure with [MEDICATION NAME], and change every three days. A nurse note, dated 01/13/15 at 12:08 a.m., documented a wound care assessment was performed with a stage I to the right back of the calf and a stage II with two small openings. The note documented the wound was expected to open related to fragile tissue from pressure. The note documented new orders from the physician. A long term care pressure ulcer documentation form, dated 01/13/14 at 8:54 a.m., documented a stage II pressure ulcer to the right lower leg on the right outer side opened up a small sore with new orders noted. The form documented to offload the legs. A long term care pressure ulcer documentation form, dated 01/13/15 at 8:58 a.m., documented the resident had a new stage II pressure ulcer to the right lower calf on back. The form documented the size of the pressure ulcer was 0.8 x 9.4 x 0.1. The form documented a wound assessment to right lower leg with a smooshy, reddened area. The form documented a new order was obtained from the physician. The care plan, dated 01/19/15, documented the resident had pressure ulcers of various sites per skin ulcer documentation. The care plan was not updated for changes in the resident's condition or changes in the treatments of the pressure ulcers. An admission assessment, dated 01/19/15, documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with activity of daily living needs. The assessment documented ambulation did not occur. The assessment documented the resident had one stage I and three stage III pressure ulcers. A nurse note, dated 01/28/15, documented the resident had multiple wounds with wound care performed and [MEDICATION NAME] applied. A nurse note, dated 01/29/15, documented the resident had some breakdown on her back and buttocks. The note documented the application of [MEDICATION NAME] every two hours with turning and repositioning. The note documented the resident had wound care to the back of both calves and that dark drainage and odor were present. A nurse note, dated 02/03/15 at 3:50 p.m., documented the resident had some breakdown on her back and buttock and the application of [MEDICATION NAME] every two hours with turning and repositioning for comfort. The note documented bilateral lower extremities with [MEDICAL CONDITION]. The note documented wound care to the back of both calves and that dark drainage with odor to the right calf was present. The note documented, "Cleansed and redressed wounds." The note documented, "Will call Dr about wound." A nurse note, dated 02/05/15 at 9:27 a.m., documented the resident had some breakdown on her back and buttock and the application of [MEDICATION NAME] every two hours with turning and repositioning every two hours for comfort measures. The note documented bilateral lower extremities with [MEDICAL CONDITION]. The note documented wound care to back of both calves with dark drainage and strong odor to right calf and left calf healing. The note documented the wounds were cleansed and redressed. The note documented a message was left with the physician (name deleted). The note documented the facility was waiting to hear back from the physician. A nurse note, dated 02/05/15 at 12:09 p.m., documented the physician ordered Keflex 500 milligrams (mg) four times daily for 10 days and [MEDICATION NAME] to the wound daily. According to nurse note documentation, the pressure ulcers were not measured from 01/13/15 to 02/13/15. According to nurse note documentation, the physician was not notified for one week following the first documentation of odor and dark drainage and for two days following the documentation of "Will call Dr about wound." A weekly pressure ulcer record, dated 02/13/15, documented a pressure ulcer to the right ankle with the stage scribbled out. The record documented the size was 5.9 x 4.7 x 0.3 with serous sanguineous exudate. The record documented a foul odor with a white/red wound bed and red surrounding skin color. The record documented a [MEDICATION NAME] treatment to the right and left buttocks. A weekly pressure ulcer record, dated 02/13/15, documented a pressure ulcer to the right calf. The ulcer was not staged. The record documented the size was 2.2 x 1.5 x .5 with no odor. The record documented a pink wound bed with surrounding skin color pink/red with surrounding tissue intact. The record documented to cleanse the right back side of the calf with DWC, apply silver alginate, and cover with border foam dressing and an ABD pad. A weekly pressure ulcer record, dated 02/13/15, documented stage II pressure ulcer to the left ankle. The record contained no documentation of the size, exudate, odor, or color of the wound. The record documented an order to cleanse the left ankle with DWC, apply Silver Alginate, then apply oil [MEDICATION NAME] dressing and border foam dressing daily until healed, and re-evaluate in 14 days. A weekly pressure ulcer record, dated 02/13/15, documented a stage II pressure ulcer to the buttocks. The record contained no documentation of the size, exudate, odor, or color of the wound. The record documented to cleanse the right upper and lower and left upper and lower buttocks with DWC, apply oil [MEDICATION NAME] gauze and border foam dressing daily and as needed until healed, and re-evaluate in 14 days. A nurse note, dated 02/13/15 at 5:07 p.m., documented wound care on the bilateral lower extremities and bilateral buttocks. The note documented [MEDICATION NAME] applied to buttock. A focused assessment, dated 02/14/15 at 9:03 p.m., documented a stage IV decubitus to the left calf. A focused assessment, dated 02/15/15 at 10:00 a.m., documented a stage IV decubitus to the left calf. A nurse note, dated 02/15/15 at 7:41 p.m., documented wound care was performed per order to the stage IV ulcer to the right calf. A nurse note, dated 02/16/15 at 4:38 p.m., documented wound care was performed per order to stage IV ulcer to the right calf. A nurse note, dated 02/17/15 at 2:15 p.m., documented wound care was performed per order to stage IV ulcer to the right calf. A weekly pressure ulcer record, dated 02/18/15, documented no stage, the size was documented as right 3 x 1.5 and left was 2 x 1. The record documented serous sanguineous exudate with no odor and a pink/red wound bed. The record documented the surrounding skin color was red on the right and within normal limits on the left. The record documented the treatment was the same. A weekly pressure ulcer record, dated 02/20/15, documented the wound to the right ankle/calf was 5.9 x 4.6 x 0.3 with serous sanguineous exudate. The record documented a foul odor, a white/red wound bed, red surrounding skin color. The record documented over [MEDICATION NAME]. The record documented the pressure ulcer was non-healing. A weekly pressure ulcer record, dated 02/20/15, documented the stage II pressure to the left ankle was healed. An undated weekly pressure ulcer record, documented a stage II pressure ulcer to the right buttock. The size was documented as 3.9 x 1.4. The record documented serous sanguineous exudate, no odor, with a red/pink wound bed. The record documented the pressure ulcer was healing. An undated weekly pressure ulcer record, documented a stage II pressure ulcer to the left buttock. The size was documented as 1.8 x 0.7. The record documented serous sanguineous exudate, no odor, with a red/pink wound bed. The record documented the pressure ulcer was healing. A nurse note, dated 02/21/15 at 3:19 a.m., documented wound care performed per order to stage IV ulcer to the right calf. A nurse note, dated 02/22/15 at 10:28 a.m., documented wound care performed per order to stage IV ulcer to the right calf. A nurse note, dated 02/25/15 at 9:54 p.m., documented [MEDICAL CONDITION] noted to bilateral lower extremities. The note documented the wound to the left lower extremity was weeping heavily. The note documented the dressing was replaced with the assistance of the wound care nurse. The note documented treatment orders were reviewed and clarified. A physician order, dated 02/25/15, documented an order for [REDACTED]. A weekly pressure ulcer record, dated 02/27/15, documented the pressure ulcer to the right ankle was 5.9 x 4.5 x 0.3 with serous sanguineous exudate. The record documented a foul odor, a red wound bed, and red surrounding skin color. The record documented over [MEDICATION NAME]. The record documented the pressure ulcer was healing. A weekly pressure ulcer record, dated 02/27/15, documented the stage II pressure ulcer to the right buttock was 2.5 x 1.2 with serous sanguineous exudate, a red odor, and a red wound bed. The record documented the surrounding skin color and tissue edges were within normal limits. The record documented the pressure ulcer was healing. A weekly pressure ulcer record, dated 02/27/15, documented the stage II pressure ulcer on the left buttock. The size was documented as 1.8 x 0.8 with serous sanguineous exudate no odor, a red/pink wound bed and surrounding skin color and tissue were within normal limits. The record documented the pressure ulcer was healing. A nurse note, dated 02/27/15 at 3:55 p.m., documented the dressing to the right lower extremity had an odor. The note documented performed daily and prn (as needed) with breakdown to left lower extremity with weeping. A nurse note, dated 02/28/15 at 2:52 p.m., documented the residents right lower extremity had odor and 2+ [MEDICAL CONDITION]. The note documented the dressing was changed twice that day. A nurse note, dated 03/02/15 at 10:16 a.m., documented the right lower extremity with odor and 2+ [MEDICAL CONDITION]. The note documented changed wound care to oil [MEDICATION NAME] first then calcium Alginate then cover with border foam gauze. The note documented wound care daily and as needed with breakdown to left lower extremity with weeping. A nurse note, dated 03/03/15 at 3:45 p.m., documented the right lower extremity with odor and 2+ [MEDICAL CONDITION]. The note documented changed wound care to oil [MEDICATION NAME] first then calcium Alginate then cover with border foam gauze. The note documented wound care daily and prn with breakdown to left lower extremity with weeping. A nurse note, dated 03/04/15 at 3:30 a.m., documented the dressings to the lower extremities were changed. The resident's medical records did not contain documentation of the resident's admission to the hospital or the circumstances leading up to the hospital admission on 03/04/15. The pressure ulcers were not thoroughly or consistently assessed from the time the resident was readmitted from the hospital till discharged back to the hospital. A history and physical (H&P) from the hospital, dated 03/04/15, documented the chief complaint on admission was a lesion/sore. The H&P documented, "Presents with [MEDICAL CONDITION]. There are multiple [MEDICAL CONDITION] of concern. The rash/lesion is a new problem that the patient has not encountered before. It is located over the right leg. She describes this area is oozing, red, fluid filled, and skin tear. Other symptoms noted include cough, fever and headache." A hospital report, dated 03/05/15, documented the patient received an ultrasound exam. The findings on the report documented the common femoral veins down to the posterior tibial veins showed no identifiable [MEDICATION NAME] filling defect. The report documented normal venous blood flow, compression and augmentation demonstrated. The report documented subcutaneous [MEDICAL CONDITION] to both lower extremities. The report documented the impression was no evidence of [MEDICAL CONDITION]. A surgical consult form from the hospital, dated 03/07/15, documented the patient had five pressure ulcers on her right leg and one on her left leg with gangrene and necrosis. The consult form documented the pressure ulcer on the right Achilles was into the Achilles tendon and was malodorous. The form documented the pressure ulcer on the left showed a dark, black eschar-like covering of the wound that was a stage III. An operative report from the hospital, dated 03/06/15, documented, "Gross findings: that of a 1 x 2 and 1 x 3 and 2 x 3, 1.5 x 2 and 1 x 1 cm (centimeter) stage III ulcer right lateral leg. There is also a stage V ulcer with malodorous necrosis and gangrene in the right Achilles/ankle area and also a 2.5 x 3 cm wet gangrene ulcer left posterior lower leg...." A wound culture report from the hospital, dated 03/08/15, documented a large amount of gram negative rods. A nurse note, dated 03/09/15 at 5:54 p.m., documented a nurse from the hospital called and reported the resident would be admitted to a speciality care facility due to the wounds. On 03/12/15 at 11:21 a.m., the assistant director of nursing (ADON) was interviewed and reported skin assessments had not been done from 01/13/15 to 02/13/15. On 03/12/15 at 12:00 p.m., the director of nursing (DON) was interviewed regarding gaps in documentation of assessments of the resident's wounds. The DON reported the last assistant director of nursing did the wound assessments and after she left the nurses did not know they were to do the skin assessments. The DON reported the residents were not assigned to a specific nurse so the skin assessments were missed. The DON was asked when the physician should have been notified regarding documentation of dark drainage and odor documented in a nurse note on 01/29/15. The DON reported the physician should have been notified when the dark drainage and odor were first noticed. The DON reported the charge nurse should have contacted the DON and the physician for any change in a resident's condition. On 03/12/13 at 7:30 p.m., the minimum data set (MDS) coordinator was interviewed and was asked about the gaps in documentation of the resident's wounds. The MDS coordinator reported, "We need to be more accurate in our documentation." The MDS coordinator reported there should have been documentation the PA made rounds and the resident was a direct admit to the hospital. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan updated, on 01/15/14, documented the resident had a stage II pressure ulcer to the right ischium present on admission. Pressure ulcer documentation in the resident's medical records were reviewed. The medical record contained no documentation the pressure ulcer was measured from 12/31/14 to 01/29/15. A quarterly assessment, dated 01/13/15, documented the resident's cognition was intact. The assessment documented the resident had a stage III pressure ulcer that was present on admission. On 03/12/15 at 9:40 a.m., the resident was observed in bed in his room. Facility staff was observed providing wound care for the resident per physician orders. On 03/12/15 at 12:00 p.m., the director of nursing (DON) was interviewed regarding gaps in documentation of assessments of the wound. The DON reported the last assistant director of nursing did the wound assessments and after she left the nurses did not know they were to do the skin assessments. The DON reported the residents were not assigned to a specific nurse so the skin assessments were missed.

Based on interview and record review, it was determined the facility failed to consult with a resident's physician for a change in condition for one (#2) of seven sampled residents who were reviewed for physician consultation/notification. The facility failed to consult with the physician regarding a pressure ulcer with dark drainage and an odor. The resident was hospitalized with multiple [MEDICAL CONDITION], fever, cough, and headache. An operative report from the hospital documented the resident had multiple stage III pressure ulcers, a stage V pressure ulcer with malodorous necrosis and gangrene, and a wet gangrene ulcer. The facility identified 38 residents with a change in condition in the last 90 days. Findings: The facility policy on change of condition documented it was the policy of the facility to inform the resident's physician of a significant change in the resident's physical, mental or psychosocial status such as a deterioration in health or clinical complications. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The closed record of the resident was reviewed. A quarterly assessment, dated 12/28/14, documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with activity of daily living needs and ambulation. The assessment documented the resident's skin was intact. A nurse note, dated 01/06/15 at 9:15 p.m., documented the resident arrived at the facility via ems carrier. The note documented four surgical sites with a total of 33 staples and three sites with a total of 27 staples. A pressure ulcer documentation form, dated 01/07/15 at 11:06 a.m., documented an assessment of a wound to the right buttock that was hospital acquired. The form documented a stage II pressure ulcer. The form documented the size of the pressure ulcer was 1 x 3 x 0.1. The form documented new orders were obtained from the physician. A pressure ulcer documentation form, dated 01/07/15 at 11:09 a.m., documented a stage I pressure ulcer to the right lower leg. The form documented the size of the pressure ulcer was 3 x 5 x UTD (unable to determine). A nurse note, dated 01/07/15 at 8:07 p.m., documented orders received to cleanse the right sacrum with DWC, apply [MEDICATION NAME], cover with [MEDICATION NAME], and secure with 4 x 4 border. The note documented a foam dressing change was to be done every three days and as needed until healed or a 14 day evaluation. The note documented to cleanse the right lower leg with DWC, apply [MEDICATION NAME], cover with 6 x 6 non border dressing, secure with [MEDICATION NAME], and change every three days. A nurse note, dated 01/13/15 at 12:08 a.m., documented a wound care assessment was performed with a stage I to the right back of the calf and a stage II with two small openings. The note documented the wound was expected to open related to fragile tissue from pressure. The note documented new orders from the physician. A long term care pressure ulcer documentation form, dated 01/13/14 at 8:54 a.m., documented a stage II pressure ulcer to the right lower leg on the right outer side opened up a small sore with new orders noted. The form documented to offload the legs. A long term care pressure ulcer documentation form, dated 01/13/15 at 8:58 a.m., documented the resident had a new stage II pressure ulcer to the right lower calf on back. The form documented the size of the pressure ulcer was 0.8 x 9.4 x 0.1. The form documented a wound assessment to right lower leg with a smooshy, reddened area. The form documented a new order was obtained from the physician. The care plan, dated 01/19/15, documented the resident had pressure ulcers of various sites per skin ulcer documentation. The care plan was not updated for changes in the resident's condition or changes in the treatments of the pressure ulcers. An admission assessment, dated 01/19/15, documented the resident was moderately impaired in cognition. The assessment documented the resident required extensive assistance with activity of daily living needs. The assessment documented ambulation did not occur. The assessment documented the resident had one stage I and three stage III pressure ulcers. A nurse note, dated 01/28/15, documented the resident had multiple wounds with wound care performed and [MEDICATION NAME] applied. A nurse note, dated 01/29/15, documented the resident had some breakdown on her back and buttocks. The note documented the application of [MEDICATION NAME] every two hours with turning and repositioning. The note documented the resident had wound care to the back of both calves and that dark drainage and odor were present. A nurse note, dated 02/03/15 at 3:50 p.m., documented the resident had some breakdown on her back and buttock and the application of [MEDICATION NAME] every two hours with turning and repositioning for comfort. The note documented bilateral lower extremities with [MEDICAL CONDITION]. The note documented wound care to the back of both calves and that dark drainage with odor to the right calf was present. The note documented, "Cleansed and redressed wounds." The note documented, "Will call Dr about wound." A nurse note, dated 02/05/15 at 9:27 a.m., documented the resident had some breakdown on her back and buttock and the application of [MEDICATION NAME] every two hours with turning and repositioning every two hours for comfort measures. The note documented bilateral lower extremities with [MEDICAL CONDITION]. The note documented wound care to back of both calves with dark drainage and strong odor to right calf and left calf healing. The note documented the wounds were cleansed and redressed. The note documented a message was left with the physician (name deleted). The note documented the facility was waiting to hear back from the physician. A nurse note, dated 02/05/15 at 12:09 p.m., documented the physician ordered Keflex 500 milligrams (mg) four times daily for 10 days and [MEDICATION NAME] to the wound daily. According to nurse note documentation, the pressure ulcers were not measured from 01/13/15 to 02/13/15. According to nurse note documentation, the physician was not notified for one week following the first documentation of odor and dark drainage and for two days following the documentation of "Will call Dr about wound." A weekly pressure ulcer record, dated 02/13/15, documented a pressure ulcer to the right ankle with the stage scribbled out. The record documented the size was 5.9 x 4.7 x 0.3 with serous sanguineous exudate. The record documented a foul odor with a white/red wound bed and red surrounding skin color. The record documented a [MEDICATION NAME] treatment to the right and left buttocks. A weekly pressure ulcer record, dated 02/13/15, documented a pressure ulcer to the right calf. The ulcer was not staged. The record documented the size was 2.2 x 1.5 x .5 with no odor. The record documented a pink wound bed with surrounding skin color pink/red with surrounding tissue intact. The record documented to cleanse the right back side of the calf with DWC, apply silver alginate, and cover with border foam dressing and an ABD pad. A weekly pressure ulcer record, dated 02/13/15, documented stage II pressure ulcer to the left ankle. The record contained no documentation of the size, exudate, odor, or color of the wound. The record documented an order to cleanse the left ankle with DWC, apply Silver Alginate, then apply oil [MEDICATION NAME] dressing and border foam dressing daily until healed, and re-evaluate in 14 days. A weekly pressure ulcer record, dated 02/13/15, documented a stage II pressure ulcer to the buttocks. The record contained no documentation of the size, exudate, odor, or color of the wound. The record documented to cleanse the right upper and lower and left upper and lower buttocks with DWC, apply oil [MEDICATION NAME] gauze and border foam dressing daily and as needed until healed, and re-evaluate in 14 days. A nurse note, dated 02/13/15 at 5:07 p.m., documented wound care on the bilateral lower extremities and bilateral buttocks. The note documented [MEDICATION NAME] applied to buttock. A focused assessment, dated 02/14/15 at 9:03 p.m., documented a stage IV decubitus to the left calf. A focused assessment, dated 02/15/15 at 10:00 a.m., documented a stage IV decubitus to the left calf. A nurse note, dated 02/15/15 at 7:41 p.m., documented wound care was performed per order to the stage IV ulcer to the right calf. A nurse note, dated 02/16/15 at 4:38 p.m., documented wound care was performed per order to stage IV ulcer to the right calf. A nurse note, dated 02/17/15 at 2:15 p.m., documented wound care was performed per order to stage IV ulcer to the right calf. A weekly pressure ulcer record, dated 02/18/15, documented no stage, the size was documented as right 3 x 1.5 and left was 2 x 1. The record documented serous sanguineous exudate with no odor and a pink/red wound bed. The record documented the surrounding skin color was red on the right and within normal limits on the left. The record documented the treatment was the same. A weekly pressure ulcer record, dated 02/20/15, documented the wound to the right ankle/calf was 5.9 x 4.6 x 0.3 with serous sanguineous exudate. The record documented a foul odor, a white/red wound bed, red surrounding skin color. The record documented over [MEDICATION NAME]. The record documented the pressure ulcer was non-healing. A weekly pressure ulcer record, dated 02/20/15, documented the stage II pressure to the left ankle was healed. An undated weekly pressure ulcer record, documented a stage II pressure ulcer to the right buttock. The size was documented as 3.9 x 1.4. The record documented serous sanguineous exudate, no odor, with a red/pink wound bed. The record documented the pressure ulcer was healing. An undated weekly pressure ulcer record, documented a stage II pressure ulcer to the left buttock. The size was documented as 1.8 x 0.7. The record documented serous sanguineous exudate, no odor, with a red/pink wound bed. The record documented the pressure ulcer was healing. A nurse note, dated 02/21/15 at 3:19 a.m., documented wound care performed per order to stage IV ulcer to the right calf. A nurse note, dated 02/22/15 at 10:28 a.m., documented wound care performed per order to stage IV ulcer to the right calf. A nurse note, dated 02/25/15 at 9:54 p.m., documented [MEDICAL CONDITION] noted to bilateral lower extremities. The note documented the wound to the left lower extremity was weeping heavily. The note documented the dressing was replaced with the assistance of the wound care nurse. The note documented treatment orders were reviewed and clarified. A physician order, dated 02/25/15, documented an order for [REDACTED]. A weekly pressure ulcer record, dated 02/27/15, documented the pressure ulcer to the right ankle was 5.9 x 4.5 x 0.3 with serous sanguineous exudate. The record documented a foul odor, a red wound bed, and red surrounding skin color. The record documented over [MEDICATION NAME]. The record documented the pressure ulcer was healing. A weekly pressure ulcer record, dated 02/27/15, documented the stage II pressure ulcer to the right buttock was 2.5 x 1.2 with serous sanguineous exudate, a red odor, and a red wound bed. The record documented the surrounding skin color and tissue edges were within normal limits. The record documented the pressure ulcer was healing. A weekly pressure ulcer record, dated 02/27/15, documented the stage II pressure ulcer on the left buttock. The size was documented as 1.8 x 0.8 with serous sanguineous exudate no odor, a red/pink wound bed and surrounding skin color and tissue were within normal limits. The record documented the pressure ulcer was healing. A nurse note, dated 02/27/15 at 3:55 p.m., documented the dressing to the right lower extremity had an odor. The note documented performed daily and prn (as needed) with breakdown to left lower extremity with weeping. A nurse note, dated 02/28/15 at 2:52 p.m., documented the residents right lower extremity had odor and 2+ [MEDICAL CONDITION]. The note documented the dressing was changed twice that day. A nurse note, dated 03/02/15 at 10:16 a.m., documented the right lower extremity with odor and 2+ [MEDICAL CONDITION]. The note documented changed wound care to oil [MEDICATION NAME] first then calcium Alginate then cover with border foam gauze. The note documented wound care daily and as needed with breakdown to left lower extremity with weeping. A nurse note, dated 03/03/15 at 3:45 p.m., documented the right lower extremity with odor and 2+ [MEDICAL CONDITION]. The note documented changed wound care to oil [MEDICATION NAME] first then calcium Alginate then cover with border foam gauze. The note documented wound care daily and prn with breakdown to left lower extremity with weeping. A nurse note, dated 03/04/15 at 3:30 a.m., documented the dressings to the lower extremities were changed. The resident's medical records did not contain documentation of the resident's admission to the hospital or the circumstances leading up to the hospital admission on 03/04/15. The pressure ulcers were not thoroughly or consistently assessed from the time the resident was readmitted from the hospital till discharged back to the hospital. A history and physical (H&P) from the hospital, dated 03/04/15, documented the chief complaint on admission was a lesion/sore. The H&P documented, "Presents with [MEDICAL CONDITION]. There are multiple [MEDICAL CONDITION] of concern. The rash/lesion is a new problem that the patient has not encountered before. It is located over the right leg. She describes this area is oozing, red, fluid filled, and skin tear. Other symptoms noted include cough, fever and headache." A hospital report, dated 03/05/15, documented the patient received an ultrasound exam. The findings on the report documented the common femoral veins down to the posterior tibial veins showed no identifiable [MEDICATION NAME] filling defect. The report documented normal venous blood flow, compression and augmentation demonstrated. The report documented subcutaneous [MEDICAL CONDITION] to both lower extremities. The report documented the impression was no evidence of [MEDICAL CONDITION]. A surgical consult form from the hospital, dated 03/07/15, documented the patient had five pressure ulcers on her right leg and one on her left leg with gangrene and necrosis. The consult form documented the pressure ulcer on the right Achilles was into the Achilles tendon and was malodorous. The form documented the pressure ulcer on the left showed a dark, black eschar-like covering of the wound that was a stage III. An operative report from the hospital, dated 03/06/15, documented, "Gross findings: that of a 1 x 2 and 1 x 3 and 2 x 3, 1.5 x 2 and 1 x 1 cm (centimeter) stage III ulcer right lateral leg. There is also a stage V ulcer with malodorous necrosis and gangrene in the right Achilles/ankle area and also a 2.5 x 3 cm wet gangrene ulcer left posterior lower leg...." A wound culture report from the hospital, dated 03/08/15, documented a large amount of gram negative rods. A nurse note, dated 03/09/15 at 5:54 p.m., documented a nurse from the hospital called and reported the resident would be admitted to a speciality care facility due to the wounds. On 03/12/15 at 11:21 a.m., the assistant director of nursing (ADON) was interviewed and reported skin assessments had not been done from 01/13/15 to 02/13/15. On 03/12/15 at 12:00 p.m., the director of nursing (DON) was interviewed regarding gaps in documentation of assessments of the resident's wounds. The DON reported the last assistant director of nursing did the wound assessments and after she left the nurses did not know they were to do the skin assessments. The DON reported the residents were not assigned to a specific nurse so the skin assessments were missed. The DON was asked when the physician should have been notified regarding documentation of dark drainage and odor documented in a nurse note on 01/29/15. The DON reported the physician should have been notified when the dark drainage and odor were first noticed. The DON reported the charge nurse should have contacted the DON and the physician for any change in a resident's condition. On 03/12/13 at 7:30 p.m., the minimum data set (MDS) coordinator was interviewed and was asked about the gaps in documentation of the resident's wounds. The MDS coordinator reported, "We need to be more accurate in our documentation." The MDS coordinator reported there should have been documentation the PA made rounds and the resident was a direct admit to the hospital.

Based on record review and interview, it was determined the facility failed to securely/safely transport one (#15) resident of one sampled resident to a physician's orders [REDACTED]. Findings: The facility transportation policy documented the facility would be responsible for arranging normal transportation for each resident of the facility to medical services outside the facility when the attending physician had ordered treatments. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 12/03/2012, documented a problem for the resident requiring extensive assistance for bed mobility, transfers, toileting, dressing, and bathing. An approach to the problem was the facility staff would anticipate and assist with needs to properly care for the resident. A quarterly assessment, dated 01/02/13, documented the resident was moderately impaired with cognition. The assessment documented the resident required moderate assistance from the staff with hygiene, bathing, and toileting. The assessment documented the resident was frequently incontinent of urine. An incident report, dated 04/01/2013, documented the resident was strapped in a wheelchair and secured in the facility van for transport to a doctor's appointment. The incident report documented during transport the resident fell out of the wheelchair on her face in the floor of the facility van. A dietary note, dated 04/02/2013, documented the resident weighed 134 pounds and was 5' 3'' tall. A discharge summary from a local hospital, dated 04/05/2013, documented the resident leaned forward in her wheelchair and the van hit a bump and her wheelchair went forward striking her face on the floor of the van. The discharge summary documented the resident's [DIAGNOSES REDACTED]. On 05/17/2013 at 10:15 a.m., LPN #9, the charge nurse on duty the day of the incident was interviewed regarding the incident during transport to the physician's appointment. LPN #9 stated the resident's wheelchair never turned over and the straps were locked. LPN #9 stated the resident possibly went under the chest/shoulder strap. LPN #9 stated there was no waist belt across the resident's abdomen/waist. On 05/17/13 at 10:30 a.m., CNA #6 was interviewed regarding the incident during transport of the resident to the physician's office. CNA #6 stated when she stopped the van for the railroad crossing the resident slid from the wheelchair to the floor. CNA #6 stated the wheelchair was still locked in position. CNA #6 stated herself and the resident were just down the street from the nursing home and she called the nursing home. CNA #6 stated she returned to the nursing home and the staff was waiting on her and had called emergency medical systems (EMS). CNA #6 stated the resident was transported to the hospital. On 05/17/13 at 11:30 a.m., LPN #3 stated there was no seat belt or securement around the resident's waist. LPN #3 stated since the incident all residents are transported with two staff members. LPN #3 stated one staff drives the van and the other staff sits with the resident. LPN #3 stated the resident was in the hospital at the present time but it was unrelated to the incident on the van.

Based on observation, interview, and record review, it was determined the facility failed: a) to ensure the residents remained free from accident hazards and were provided supervision and/or interventions to prevent reoccurrence of falls for two (#5 and #9) of five sampled residents reviewed for falls. Resident #9 had a fall which resulted in an emergency room visit and a fractured nose. The facility identified 26 residents who had experienced falls in the last 60 days. b) to secure hazardous chemical agents in a secure area on hall 300 and on the memory care unit. This had the potential to affect three wandering residents on the memory care unit. Findings: The facility's policy for falls documented any resident who experienced a pattern of falls (2 or more during a thirty day period) or an injury from a fall would be referred for a falls assessment by the nurse or therapist. The facility resident rights documented the facility would provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services would be provided to maintain a sanitary, orderly, and comfortable interior. 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/29/12, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required supervision with bed mobility, transfers, and activities of daily living. The assessment documented the resident had a history of [REDACTED]. A current care plan was not provided by the facility. A nurse's note, dated 02/14/12 at 2:00 a.m., documented the nurse heard a noise and went into the resident's room. The nurse's note documented the resident was at the foot of her bed on her knees trying to get up. The nurse's note documented the resident had her walking cane at her side. The nurse's note documented the resident reported she did not hit her head. There was no incident report for the fall observed in the resident's medical record. The nurse's note did not document interventions to prevent recurrence. An incident report, dated 03/13/12 at 5:15 p.m., documented the resident was attempting to go to the bathroom. The incident report documented the resident tripped and hit her nose on the door frame. The incident report documented the resident was observed to have a 2 cm (centimeter) by 2.5 cm bruise to her upper lip on the right side with a deviation of her nose to the left with approximately 250 cubic centimeter (cc) of blood on the floor. The report documented the resident was sent to the emergency room . The report documented the resident was at moderate risk for falls. The report documented the resident was a fall risk. The report documented the staff redirected the resident to call for assistance with transfers. A nurse's note, dated 03/13/12 at 9:15 p.m., documented the resident had a fracture to her nose and sinus. An incident report, dated 03/24/12 at 6:00 a.m., documented the staff heard a call for help and went into the resident's room. The report documented the resident was getting up and nearly fell again. The report documented the resident sustained [REDACTED]. The incident report documented steps to prevent reoccurrence were to call for assist when getting up, make sure the floor was kept clear of clutter, and assist the resident to the bathroom every two hours. A nurse's note, dated 03/24/12 at 6:00 a.m., documented the resident still had bruising on her face from the previous fall. The nurse's note documented the resident's face was still sore and tender to touch. A nurse's note, dated 03/24/12 at 6:10 a.m., documented the emergency room physician was called and staff were instructed to observe the resident. On 04/03/12 at 7:40 a.m., the resident was observed in the dining room. The resident was observed to have a large amount of bruising, purple in color, on the left side of her face. The area of bruising affected her left eye, her left cheek and her left jawline. On 04/03/12 at 8:35 a.m., the resident was interviewed regarding the bruising on her face. The resident stated "I think I fell ." On 04/06/12 at 10:45 a.m., the assistant director of nursing (ADON) was interviewed regarding interventions put in place to prevent falls. The ADON reported the staff were to frequently observe the resident. The ADON reported the resident was moved closer to the nurse's station. The ADON reported the therapy department evaluated the resident for the use of a quad cane and a walker. On 04/06/12 at 12:55 p.m., the physical therapy aide (PTA) was interviewed regarding therapy for the resident. The PTA reported the resident could benefit from therapy, but she didn't know if the resident would comply. The PTA reported there were no physical therapy evaluations. She reported the facility was not able to provide Part B physical therapy. On 04/06/12 at 1:00 p.m., the PTA was interviewed regarding restorative services for the resident. The PTA reported the resident was not on the restorative program. On 04/06/12 at 1:15 p.m., the DON was asked what interventions had been put in place for the resident due to the falls with injury. The DON stated the facility had given the resident a walker, a cane, and education with use of call lights for her needs. The DON reported the resident didn't qualify for therapy. The DON was asked if she thought re-education was an appropriate intervention for the resident. The DON stated, "No. Not at this point." On 04/06/12 at 4:10 p.m., the DON (director of nursing) was interviewed regarding how the facility tracked falls. The DON reported she kept them in the incident report book. The DON was asked if the facility monitored tracking and trending of falls. The DON stated, "No." 2. On 04/04/12 at 5:20 p.m., a bottle of cleaning agent was observed in a spray bottle in the housekeeper's office on hall 300. The label on the cleaning agent was reviewed. The label documented the contents were hazardous. The label documented to call poison control if swallowed and to irrigate the eyes if the contents splashed in the eyes. The housekeeper's office door was unlocked. On 04/04/12 at 5:35 p.m., the assistant director of nurses was interviewed regarding wandering residents on hall 300. The assistant director of nurses stated there were no wandering residents on hall 300. The assistant director stated no residents resided on the hall where the housekeeper's office was located. On 04/04/12 at 5:50 p.m., a bottle of cleaning agent in a spray bottle was observed on the memory care unit in the medical records office. The label on the cleaning agent was reviewed. The label documented the contents were hazardous. The label documented to call poison control if swallowed and to irrigate the eyes if the contents splashed in the eyes. The door to the medical records was open. The door was observed to be a self locking door when the door was closed. The facility incident reports were reviewed for any occurrences involving chemical or unusual incidents. No incident reports were identified. On 04/04/12 at 6:25 p.m., the administrator and director of nurses were interviewed regarding the cleaning agents in an unsecured area. The administrator stated automatic door locks would be installed. The administrator stated the staff were looking in all areas of the facility for any chemicals that might be unsecured. On 04/12/12 at 6:45 p.m., the residents identified as wanderers were given a Styrofoam cup to observe if they were physically able to squeeze the cups. The residents were not able to follow directions to squeeze the Styrofoam cups. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/29/12, documented the resident had short term and long term memory problems and was moderately impaired in cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers and extensive assistance with ambulation, dressing, hygiene and bathing. The care plan, updated on 08/29/11, documented the resident had fallen two times in the last 180 days. The care plan documented the goal was to prevent/manage the future likelihood of falls. The care plan documented nursing, physical therapy, and occupational therapy were to promote the proper use of hand rails, hand grips in the bathroom, siderails, parallel bars, etc. The care plan documented the facility was to evaluate the cause of falls and implement a plan to decrease the risk. The facility documented nursing was to assess the cause/pattern of previous falls and act upon resolvable factors. The care plan did not address the use of a lap buddy. An incident report, dated 11/13/11, documented the resident was sitting in the dining room in his wheelchair, took his lap buddy off and fell . Interventions documented on the incident report included to encourage the resident not to take the lap buddy off. An incident report, dated 11/18/11, documented the resident was observed in the floor in his room, was assessed and helped back to his wheelchair. Interventions documented on the incident report included to educate the resident on requesting assistance before ambulating. An incident report, dated 11/28/11, documented the resident was in the dining room and fell backwards in his wheelchair. Interventions documented on the incident report included to monitor the resident closely and instruction given to the resident to not push his feet on objects that would cause him to fall back in his wheelchair. An incident report, dated 01/05/12, documented the resident turned his wheelchair over and obtained a skin tear. The intervention documented on the incident report was to educate the resident on the importance of asking for assistance for ambulation. An incident report, dated 01/18/12, documented the resident fell and sustained no injury. There were no interventions documented on the incident report. There were no updates on the resident's care plan related to the falls. On 04/03/12 at 8:35 a.m., the resident was observed in the dining room with a lap buddy in place. On 04/03/12 at 5:25 p.m., the resident was observed in the dining room waiting for the evening meal. On 04/04/12 at 9:30 a.m., the resident was observed in the lobby in the wheelchair with a lap buddy in place. The surveyor accompanied a staff member who asked the resident to remove the lap buddy. The resident removed the lap buddy on request without difficulty. On 04/06/12 at 4:10 p.m., the DON (director of nursing) was interviewed regarding how the facility tracked falls. The DON reported she kept them in the incident report book. The DON was asked if the facility monitored tracking and trending of falls. The DON stated, "No."