Every finding on record at Ignite Medical Resort Norman, LLC

Based on interview, record review, and facility document review, the facility failed to employ an activity professional with the required educational background and/or certifications for 1 of 1 activity professional reviewed.Findings included: A facility Job Description for the Director of Entertainment, created on 08/01/2023, indicated the qualifications included, To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required.High School Diploma or it's equivalent and satisfactory completion of a training course for Activity Directors2 years minimum experience in a social or recreational programExceptional verbal and written communication skills. A resume for the Hospitality Director (HD), who also served as the facility's Director of Entertainment revealed the HD graduated from high school in 05/2024. The resume revealed certifications for the HD included on the resume did not include completion of a training course for an activity director or two years minimum experience in a social or recreational program. During an interview on 06/30/2026 at 8:46 AM, the HD stated she was in charge of activities for the residents. The HD stated she placed activity calendars in residents' rooms at the end of the month or the beginning of the new month. The HD stated she scheduled the activities she would like to do on the calendars but added she was not always able to have all the activities on the calendar. During an interview on 06/30/2026 at 10:42 AM, the HD stated she had been responsible for the facility activity program since 10/2025 and stated she had no idea what she was doing and had to find her own rhythm to figure things out. The HD stated she started as the HD and had no educational preparation and had learned a lot on her own. The HD stated she had not completed a state approved activity director program. During an interview on 07/01/2026 at 3:06 PM, the Chief Nursing Officer (CNO) stated the person leading the facility activity program should have completed a state activity program. The CNO stated she was unaware of the HD's educational background. The Administrator was interviewed on 07/01/2026 at 9:56 PM. The Administrator stated qualifications for an activity director included passing the activity certification course. No reason was given as to why the HD was hired to lead activities without the proper education.

Based on observation, interview, record review, and review of manufacturer instructions for use, the facility failed to ensure nursing staff administering insulin via a prefilled pen had knowledge of priming an insulin pen before administration for 3 (Licensed Practical Nurse [LPN] #1, #2, and #3) of 3 nurses reviewed for competency.Findings included:A manufacturer's Instructions for Use for insulin lispro, revised 07/2023, revealed the section titled, Priming your Pen, included, Prome before each injection. - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. The Instructions for Use revealed Step 6: - To prime your Pen, turn the Dose Knob to select 2 units. Step 7: - Hold you Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: - Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8.An observation of medication administration on 06/29/2026 at 11:28 AM revealed LPN #1 administered five units of insulin lispro to Resident #18. LPN #1 was not observed to prime the insulin pen prior to administration. An observation of medication administration on 06/29/2026 at 11:42 AM revealed LPN #1 administer five units of insulin lispro to Resident #38. LPN #1 was not observed to prime the insulin pen prior to administration. During an interview on 07/01/2026 at 3:58 PM, LPN #1 stated she had no knowledge of how to prime an insulin pen prior to administration. During an interview on 07/01/2026 at 4:04 PM, LPN #2 stated he had received no training on how to prime an insulin pen prior to administration or the importance of completing that step. During an interview on 07/01/2026 at 4:24 PM, LPN #3 stated she had not been educated on how to prime an insulin pen prior to administration or the importance of completing that step. During an interview on 07/02/2026 at 2:45 PM, the Pharmacist stated the manufacturer recommendations for insulin pens were to prime the insulin pen with two units of insulin prior to administering the ordered dose of insulin to a resident. During an interview on 07/02/2026 at 1:10 PM, the facility's Medical Director stated he was unfamiliar with priming an insulin pen prior to insulin administration or the importance of doing so. He stated if that was a recommendation from the manufacturer, then pharmacy should include the instructions on the packaging for administration. During an interview on 07/01/2026 at 3:03 PM, the Chief Nursing Officer (CNO) stated the facility did not have a policy on priming insulin pens; however, insulin pens should be primed with two units of insulin prior to administering the ordered dose of insulin. She stated she had provided no training to her staff on priming an insulin pen and had expected the nursing staff to have gained the knowledge during nursing school. During a follow-up interview on 07/02/2026 at 1:18 PM, the CNO stated the facility did not have a policy for competency on insulin administration or priming insulin pens and she could not locate competencies for priming an insulin pen for LPN #1, #2, or #3. During an interview on 07/02/2026 at 12:55 PM, the Administrator stated she would defer her expectation of staff competency related to priming an insulin pen for insulin administration to the CNO.

Based on observation, interview, and facility policy review, the facility failed to store medications safely after pharmacy delivery for 1 of 2 pharmacy deliveries observed.Findings included: A facility policy titled, Storage of Medications, dated 01/2026, indicated Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an observation on 07/01/2026 at 8:07 PM, five brown paper bags were observed at the nurses' station. One bag had a sticker that indicated the contents should be refrigerated and another bag had a sticker that indicated the contents were fragile. Six punch cards of medications were laying beside the five brown paper bags along with one box of ipratropium bromide-albuterol inhalation solution, one box of albuterol sulfate inhalation solution, one box of enoxaparin sodium injection 30 milligrams (mg)/0.3 milliliters (ml) and one silver bag. A certified medication aide (CMA) and a licensed practical nurse (LPN) were seen in one hall away from the medication. Another LPN was observed in another hall away from the medications. Two certified nursing assistants (CNAs) that were assigned to work on the unit were not observed. At the time of the observation no residents were observed in the hall near the nurses' station. During an observation on 07/01/2026 at 8:42 PM, LPN #7 approached the nurses' station and opened the brown paper bags. During a concurrent interview, LPN #7 stated one bag contained intravenous (IV) antibiotics, the silver bag contained IV vancomycin, one bag contained IV piperacillin, one bag contained a variety of pills (per the nurse's description), and one bag contained IV normal saline flushes. LPN #7 stated she was unsure at what time the medications had been delivered. LPN #7 removed the brown paper bags of medications at 8:45 PM but left the six punch cards of pills and the three boxes of inhalation medication at the nurses' station. The six cards of medications included Zofran (a medication for nausea, omeprazole (a medication for gastroesophageal reflux disease), citalopram (an antidepressant), Synthroid (a medication to treat hypothyroidism), and Remeron (an antidepressant). During an observation on 07/01/2026 at 8:58 PM, a second pharmacy delivered medication and LPN #12 signed as receiving the medication. LPN #12 took the medications that were delivered and placed the medications in the locked medication room. During an interview on 07/01/2026 at 9:02 PM, LPN #12 stated the medications from the first pharmacy were delivered on his shift (6:00 PM to 6:00 AM) but he was unsure of the time. LPN #12 stated medications should be stored either on the medication cart or in the medication room. He stated that he was unsure why the medications delivered first were left at the nurses' station and had not been stored properly and stated it was staff's responsibility to make sure medications were stored properly. LPN #12 stated that he was not the nurse that signed for the medications that were received from the first pharmacy delivery.During an interview on 07/01/2026 at 10:58 PM, LPN #7 stated she had signed for the medications that were at the desk at 8:07 PM that had been delivered by the first pharmacy. LPN #7 stated she was unsure of the facility policy on storage of medications but guessed the medications should be stored properly. LPN #7 stated she was pulled in all directions and had not stored the medications properly, adding she had not been told it was an issue to keep the medications at the nurses' station until she had time to store them properly.During an interview on 07/01/2026 at 11:01 PM, the Chief Nursing Officer (CNO) stated that when medications were delivered by the pharmacy, she expected the medications to be placed in the medication room behind locked doors. The CNO stated leaving the medications at the nurses' station was unacceptable and she had provided many in-services on medication storage.The Administrator was interviewed on 07/02/2026 at 4:23 PM. The Administrator stated she expected medications delivered from the pharmacy to be immediately secured in the medication cart or the locked medication room.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the interdisciplinary team (IDT) assessed and determined self-administration of medication was appropriate for 1 (Resident #8) of 5 residents reviewed for unnecessary medication. Findings included: A facility policy titled, Medication at Bedside, revised 05/2026, indicated, Policy: 1. Self-Administration of medications and treatment is a decision by the interdisciplinary team with input from the family or patient. 2. Physicians must provide an order for medication to be kept at bedside. Under Procedure the policy indicated, 2. A care plan will be created by the clinical staff for self-administration of medication. 3. If a treatment order is self-administered, the resident must perform a return demonstration of the treatment to be able to do the treatment independently. An admission Record revealed that the facility admitted Resident #8 on 05/19/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute kidney failure, type 2 diabetes mellitus without complications, gastroesophageal reflux disease without esophagitis, and end stage renal disease. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/2026 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which revealed the resident had intact cognition. The MDS indicated Resident #8 was able to understand (had clear comprehension) verbal content, and their vision was adequate. The MDS revealed that Resident #8 rejected care four to six days during the seven-day assessment look-back period. Resident #8's Care Plan Report included a focus area initiated on 05/22/2026, that indicated Resident #8 may need help reading instructions, pamphlets, or other written materials from doctors or pharmacies. The Care Plan Report also included a focus area initiated on 06/01/2026, that indicated Resident #8 had impaired cognitive function and/or impaired thought processes. Interventions directed staff to cue, reorient, and supervise as needed (initiated 06/01/2026). A Nursing Evaluation dated 05/19/2026 indicated Resident #8 did not self-medicate and had no desire to self-medicate. Resident #8's Order Summary Report with active orders for the timeframe ending 07/02/2026, included an order dated 05/19/2026 for ondansetron hydrochloride (Zofran) oral tablet 4 milligrams (mg) to be given every six hours as needed for nausea and vomiting. The Order Summary Report revealed no physician orders to self-administer medication and no orders for saline nasal spray, triple antibiotic ointment, or hydrocortisone cream. Resident #8's June 2026 Medication Administration Record [MAR]' included an entry for ondansetron hydrochloride tablets, 4 mg, to be given every six hours as needed for nausea and vomiting. The MAR revealed staff documented that Resident #8 received the medication on 06/26/2026 at 12:42 PM and the medication was effective. A concurrent observation and interview with Resident #8 in their room on 06/29/2026 at 10:44 AM revealed a bottle of saline nasal spray and two packaged tablets labeled ondansetron on the resident's over bed table. Resident #8 stated a nurse had not given the medication to them; it was their own property, but the nurses were aware the resident had the medication. Resident #8 stated that when they felt sick, they took the medication. Resident #8 stated that sometimes when they felt sick during the night, they called the nurse who would ask whether the resident needed the nurse to bring ondansetron or the resident was taking their own medication. Resident #8 stated all staff who administered medications knew the ondansetron was in their room and had said nothing. During a concurrent observation and interview on 06/30/2026 at 9:53 AM, nasal spray was on Resident #8's over bed table; however, the ondansetron tablets were not on the table. Resident #8 stated one of the tablets had fallen on the floor; however, no medication was observed on the resident's floor. Resident #8 declined to explain what had happened with the other ondansetron tablet. Resident #8 stated staff had assessed them for medication self-administration, and staff only asked the resident to report when they took their own ondansetron, so the nurse could document that the medication had been taken. Certified Medication Aide (CMA) #4 was interviewed on 06/30/2026 at 10:09 AM. CMA #4 stated that there were no residents in the facility that kept medication at the bedside or self-administered their own medications. CMA #4 stated if she found medication at the bedside, whether left by staff or brought in by a resident's family, she would report to the nurse. CMA #8 was interviewed on 07/01/2026 at 11:42 PM. CMA #8 stated he administered medications in the hallway where Resident #8's resided and had not seen medications in any resident's room, including Resident #8's room. CMA #8 stated that if he saw medication at a resident's bedside, he would notify the nurse. Certified Nursing Assistant (CNA) #5 was interviewed on 06/30/2026 at 10:17 PM. CNA #5 stated that she had been caring for Resident #8 and had not seen medication at the resident's bedside. CNA #5 stated that if she observed medication at a resident's bedside, she would report to the nurse. Licensed Practical Nurse (LPN) #6 was interviewed on 06/30/2026 at 2:15 PM. LPN #6 stated that there was one resident on the unit that had orders for self-administration of medication, but that resident was not Resident #8. LPN #6 stated before a resident was allowed to self-administer medications, an assessment was completed to ensure the resident was knowledgeable of the process, and a physician's order was obtained that specifically allowed the resident to keep medication at the bedside. LPN #6 stated that this was the process applied to all medications, including over the counter medications. LPN #6 stated that if medications were found at the bedside, staff were expected to notify the nurse so the nurse could remove the medications. LPN #6 stated she had not received reports from staff that Resident #8 had medications at the bedside. Per LPN #6, there might be interactions between what the resident took and what the facility staff administered. LPN #6 also stated medication should be kept inside the bedside table, not on top of the over bed table because another resident could take medication that was left out. During an observation and concurrent interview on 06/30/2026 at 2:30 PM, LPN #6 went to Resident #8's room and found and removed hydrocortisone cream and triple antibiotic cream. LPN #6 stated that she did not find any ondansetron tablets in the resident's room. LPN #6 revealed that Resident #8 had not been assessed for self-administration of medication and had no physician orders for self-administration of any medication. LPN #6 also revealed that Resident #8 did not have physician orders for saline nasal spray, hydrocortisone cream, or triple antibiotic cream. LPN #7 was interviewed on 07/01/2026 at 10:55 PM. LPN #7 stated that, on occasion, physicians allowed residents to keep medications at their bedside. She stated that if she found medication at a resident's bedside, she would ask the resident what the medication was for and whether they had an order to keep it there. LPN #7 further stated she was unaware that residents had to be assessed for self-administration of medications and stated that she had not seen any medication at Resident #8's bedside. The Chief Nursing Officer (CNO) was interviewed on 07/01/2026 at 3:22 PM. The CNO revealed that Resident #8 was not approved to self-administer medications. The CNO stated she expected the CMAs and the CNAs to report to the nurse when medication was found at a resident's bedside. She further stated that she expected the nurse to remove the medication until an assessment of the resident's ability to self-administer had been completed, and orders were obtained for self-administration. The Administrator was interviewed on 07/01/2026 at 10:14 PM. The Administrator stated that if medications were found at a resident's bedside, she expected staff to explain to the resident that medications were not allowed at bedside without a physician order and then remove the medication. Per the Administrator, if the resident refused to have the medication removed, she expected staff to notify the physician immediately and request an order for self-administration and to complete the necessary evaluation. The Administrator stated that Resident #8 should not have had medications at the bedside without the physician's order for self-administration.

Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care for 1 (Resident #47) of 4 residents reviewed for activities of daily living (ADL) care.Findings included: A facility policy titled, ADL Policy, dated 11/2020, indicated, This facility will provide each resident with care, treatment and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: - Bathing - Dressing - Grooming. An admission Record indicated the facility admitted Resident #47 on 06/01/2026. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the resident's left non-dominant side, need for assistance with personal care, and muscle wasting. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2026, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS further indicated that the resident was dependent on staff for showers/bathing and dressing and required partial to moderate assistance with personal hygiene. Resident #47's Care Plan Report, included a focus area initiated on 06/02/2026, that indicated the resident had ADL self-care performance deficits and limitations in physical mobility. Interventions indicated that the resident was dependent on staff for personal hygiene (initiated 06/02/2026). During a concurrent observation and interview on 06/29/2026 at 10:26 AM, the nails on Resident 47's right hand were long and had a brown substance under the nails. The resident stated the brown substance under their fingernails could be a brownie from a couple of days prior, or it could be blood from scratching their back and legs. During an observation on 06/30/2026 at 2:28 PM, Resident #47 had a brown substance under their fingernails on their right hand. During an interview on 07/02/2026 at 3:51 PM, Resident #47 stated that the staff had never offered to provide nail care during morning care or on days they received a shower. During a concurrent interview and observation on 06/30/2026 at 2:44 PM, Certified Nursing Assistant (CNA) #10 stated she had worked with the resident on 06/29/2026 and she was the resident's CNA on 06/30/2026. She stated the resident was fully dependent on staff and received a shower twice per week. She stated she had not cut the resident's fingernails. CNA #10 observed the resident's fingernails and stated she saw a black substance under the nails. She stated she had not noticed the black substance under the resident's nails until the observation. She stated that Resident #47's fingernails needed to be cut and cleaned. During an interview on 06/30/2026 at 4:06 PM, CNA #11 stated she was the shower aide Monday through Friday. She stated if the resident asked her to cut their fingernails or toenails she would cut them, but that she did not ask the residents if they wanted their nails cut or cleaned. During an interview on 06/30/2026 at 3:13 PM, Licensed Practical Nurse (LPN) #1 stated that she worked with Resident #47 on 06/29/2026 and she was their nurse on 06/30/2026. LPN #1 stated if any staff member noticed a resident's nails were dirty, they should clean them and if they were long, they should cut them or tell the nurse. LPN #1 stated that she provided nail care if the resident requested their nails to be cleaned or trimmed. She stated she was not aware that Resident #47's fingernails were long and dirty. She stated the resident had not asked her to cut or clean their nails, and if they had, she would have provided nail care. During an interview on 07/01/2026 at 3:00 PM, the Chief Nursing Officer (CNO) pro that staff should look at residents' nails daily and should ask the residents if they could cut and clean their fingernails during shower time and ADL care. The CNO stated that residents should not be required to ask for nail care. During an interview on 07/01/2026 at 9:55 PM, the Administrator stated if a resident's nails were visibly soiled or needed to be cut, she expected staff to identify the need and to ask the resident if they would like their nails cleaned and cut. She stated the resident should not have to ask for nail care.

Based on observation, interview, record review, and facility policy review, the facility failed to provide a resident's preferred activities for 1 (Resident #43) of 1 resident reviewed for activities.Findings included: A facility policy titled, Life Enhancement and Activities Programming, revised 11/2025, indicated, Quality of life applies to ALL care and services throughout this organization. It is the responsibility of all staff to create opportunities for each resident to experience pleasures of their choice each day. The policy also indicated, The facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. An admission Record revealed that the facility admitted Resident #43 on 06/19/2026. According to the admission Record, the resident had a medical history that included diagnoses of mild cognitive impairment and periprosthetic fracture around an internal prosthetic right hip joint. An Initial/Baseline Care Plan dated 06/19/2026 revealed a focus area that indicated Resident #43 had difficulty hearing at times and had impaired cognitive function and/or impaired thought processes. The Initial/Baseline Care Plan indicated that Resident #43 required partial to moderate assistance from staff for transfers to a chair from the bed and to ambulate 10 feet and 50 feet. The resident's activity preferences was not addressed on the baseline care plan. An Activity- admission Interview dated 06/23/2026 revealed that Resident #43 answered that keeping up with the news and participation in religious services or practices was very important to them. The assessment was completed by the resident, or family/significant other. A June 2026 activity calendar indicated the following activities:06/29/2026 Puzzle packets at the hydration station next to the nurse's station06/20/2026 Bingo in the dining room at 1:00 PM. Resident #43's Progress Notes for the timeframe from 06/19/2026 through 07/02/2026 revealed no documentation of activity participation. During an interview on 06/29/2026 at 9:32 AM, Resident #43 and Family Member (FM) #9 stated they were unaware of any activities offered by the facility. FM #9 stated they had not seen any activities offered during visits to Resident #43 and as far as they knew, Resident #43 had not been invited to any activities while they had been present. FM #9 stated visits to Resident #43 were made daily. During observations on 06/29/2026 from 8:00 AM until 5:00 PM no activities were observed occurring in the facility. During observations on 06/30/2026 from 7:30 AM to 4:30 PM no activities were observed occurring in the facility. The calendar indicated BINGO at 1:00 PM in the dining room. The activity did not occur. An observation was made on 06/30/2026 at 9:46 AM of the activity calendar posted on the wall to the right of Resident #43's doorway. During a concurrent interview FM #9 asked what the paper was and asked what the activity was for the day. FM #9 was told BINGO at 1:00 PM in the dining room. Resident #43 was watching television and stated they did not want to attend, and FM #9 had to explain the activity was happening in the afternoon. During an observation on 07/01/2026 at 8:09 AM, puzzle packets were observed setting on the hydration table in the hall for residents to pick up as desired. During an interview on 06/30/2026 at 8:46 AM, the Hospitality Director (HD) stated she was in charge of activities for the facility. The HD stated it was hard to get residents out of their rooms and a lot of the residents only wanted to leave their rooms for therapy. The HD stated she provided a surprise and delight cart that has a variety of coloring books and pencils, root beer floats at times, and sometimes fruit. The HD stated during BINGO the previous week eight residents attended and that it was the biggest group of residents that had attended an activity. The HD stated she posted activity calendars at the end of the month or the beginning of the new month. The HD stated she filled the calendars with activities she would like to do but was unable to do the activities listed. During an interview on 06/30/2026 at 10:04 PM, Certified Medication Aide (CMA) #4 stated activities included coloring packets and snacks. She stated that the coloring packets were kept in a common area of the facility and the residents got them as desired. CMA #4 stated she had not seen any arts and crafts or music activities provided for residents and was not sure what was offered on the weekend. CMA #4 stated there were few hands-on activities provided for residents and added the residents did not seem to want to leave their rooms. During an interview on 06/30/2026 at 10:27 AM, Certified Nursing Assistant (CNA) #5 stated she had seen group therapy with multiple residents in attendance, BINGO, and sometimes pets are brought to the facility. CNA #5 stated she had not seen Resident #43 in the group therapy sessions. CNA #5 stated activities were not offered to residents on a daily basis. During an interview on 06/30/2026 at 10:42 AM, the HD stated she had been responsible for the facility's activity program since 10/2025. The HD stated during rounds she spoke with residents to determine what they would like to do and on admission she completed an activity assessment that identifies activities of interest. The HD stated BINGO was the most popular activity and she planned that as a weekly event. The HD stated if only one resident attended BINGO, then she cancels BINGO and offers a boardgame or a puzzle. She stated she assisted therapy with group therapy on Fridays and added once the residents bowled. The HD stated if the resident had said that music or religious events were important she would ask if they wanted to do bible study that she taught, but the residents often said no. The HD stated she had no music or religious services scheduled for residents and stated at the moment she had no volunteers helping to provide activities. The HD stated the person that had provided pet therapy was no longer with the facility and Resident #43 had not been able to enjoy the pets. The HD stated she had asked Resident #43 to attend BINGO, but the resident had not attended. The HD stated she had been to Resident #43's room with her cart of snacks and coloring packets. The HD stated she had not tried to arrange any religious services with the local churches, and she was unsure of how to go about arranging the services. During an interview on 06/30/2026 at 2:09 PM, Licensed Practical Nurse (LPN) #6 stated puzzles and newspapers were found at the front of the facility near the cafe. LPN #6 stated the facility did not have daily group activities, BINGO was offered once a week, and therapy offered a group session on Fridays. LPN #6 stated residents stayed in their rooms, watched television, read, or completed coloring sheets. LPN #6 stated she had not seen any type of religious activities in the facility. LPN #6 stated the activities that were listed on the activity calendar had not occurred due to lack of resident participation. During an interview on 07/01/2026 at 1:55 PM, the HD stated that she had no participation records for residents and that she did not provide one-on-one visits with residents for the purpose of providing activities. The HD stated she went to rooms with her snack cart. The HD stated she passed puzzle packets once or twice a week and there had been instances where she sat with residents to complete the packets. The HD stated she had not completed any activities with Resident #43. The HD stated BINGO had not worked out as scheduled on 06/30/2026 and instead she passed puzzle packets. She stated she had told the facilities' General Manger (GM) that it was difficult to complete all the activity tasks and the hospitality tasks but had not told any administrative staff there were days when she was unable to provide activities because of her hospitality duties. During an interview on 07/01/2026 at 3:05 PM, the Chief Nursing Officer (CNO) stated that she expected monthly activity calendars to be in resident rooms and residents should be asked to attend activities. The CNO stated that activities were not offered to residents daily but was not sure why daily activities were not offered. The CNO stated she thought rehabilitation had been more of a focus in the facility than activities. The CNO added that she expected one-on-one activities to be offered to residents that did not attend group activities. The CNO stated that she was unaware that the HD was unable to provide activities due to the HD's other duties. The CNO stated that she would have expected Resident #43 and FM #9 to be aware of facility offered activities. The Administrator was interviewed on 07/01/2026 at 9:56 PM. The Administrator stated that the calendar for the activities should be posted, and she expected follow-through on the activities listed. The Administrator stated if the activity calendar was changed the residents should be notified. The Administrator stated that if residents chose not to leave their rooms, she expected the HD to complete one-on-one activities and to gauge what the resident wanted to do based on the completion of the activity assessment. The Administrator stated she found out on 06/30/2026 that the HD was not following the activity calendar. The Administrator stated that while the HD had told her that getting the activities done was difficult on some days, the HD had not informed her that on some days she was unable to complete activities at all.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide foot/nail care for 1 resident with diabetes (Resident #45) of 4 residents reviewed for activities of daily living (ADL) care. Findings included:A facility policy titled, Bathing, reviewed/revised 04/2026 revealed 2. Skin condition is monitored at bathing and problems reported to the charge nurse or skin care coordinator. The policy revealed the procedure for a bed bath included, 10. Wash thighs, legs and feet. 14. Care of fingers and toenails is part of the bath. Be certain nails are clean, and if toenails would be difficult to care form [sic] notify the nurse for a podiatry consult. Never cut a resident's toenails. 19. Report any skin issues to the Charge Nurse or Skin Care Coordinator. An admission Record indicated the facility admitted Resident #45 on 05/20/2026. According to the admission Record, the resident had a medical history that included diagnoses of osteomyelitis of the vertebra-lumbar region, diabetes mellitus-type II without complications, generalized muscle weakness, anesthesia (loss of sensation) of the skin, and unspecified fracture of the lower end of the right femur. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2026 indicated that Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident had intact cognition. Per the MDS, the resident rejected care on one to three days during the assessment look-back period. The MDS indicated Resident #45 had functional limitations in range of motion of both lower extremities. The MDS also revealed the resident required set up or clean up assistance from staff for personal hygiene, was dependent on staff putting on/taking off footwear and required substantial/maximal assistance from staff for showering/bathing. Resident #45's Care Plan Report included a focus area initiated 06/02/2026, that indicated that the resident had ADL self-care performance deficits and limitations in physical mobility. Interventions directed staff to provide substantial/maximal assistance with showers/bathing, and that the resident was dependent on staff for putting on/taking off footwear. The Care Plan Report also included a focus area, initiated 06/02/2026, that indicated Resident #45 was resistive to care and at times the resident refused treatments. Interventions directed staff to reassure the resident and to leave and return at a later time to try again if the resident was resistant to assistance with ADLs (initiated 06/02/2026). An Order Summary Report for active orders as of 06/29/2026 revealed an order dated 05/20/2026 for a podiatry consultation as indicated to evaluate, treat, and debride fungal toenails and calluses. An admission Nursing Evaluation dated 05/20/2026 indicated that Resident #45's lower extremities had a normal skin color and were dry. Under the section for skin impairments, a nurse documented toes but did not include a description of the resident's toes/skin impairment. A weekly Skin Observation dated 06/23/2026 revealed Resident #45 had no skin issues with their feet. Resident #45's Progress Notes for the timeframe from 05/20/2026 to 06/28/2026 revealed no documented evidence that a podiatrist had seen the resident or that the resident had refused podiatry care or foot/nail care. An observation on 06/29/2026 at 10:23 AM revealed Resident #45's toenails were long, thick, and some were curling under the toe. The observation revealed that the bottom of Resident #45's feet had a thick buildup of dry skin. Resident #45 stated that staff had not washed their feet since admission to the facility. Certified Medication Aide (CMA) #4 was interviewed on 06/30/2026 at 10:07 AM. The CMA stated if a resident had a diagnosis of diabetes mellitus, the nurses were responsible for providing nail care and the certified nursing assistants (CNAs) would report the need for nail care to the nurses. CNA #5 was interviewed on 06/30/2026 at 10:24 AM and stated that CNAs provided toenail care when a resident was showered. Per CNA #5, staff did not document that nail care was provided. She stated if the resident declined for their toenails to be trimmed, she reported the refusal to the nurse. The CNA stated if a resident's toenails were thick or long, she would ask the nurse for assistance, but that had not previously been an issue. CNA #5 also stated that if a resident had a diagnosis of diabetes, she could not trim the resident's toenails. CNA #11 was interviewed on 06/30/2026 at 4:07 PM. The CNA stated if a resident had diabetes mellitus the nurse was responsible for nail care. She stated that if she found the resident's toenails were long, thick, or curled, she would notify the nurse. CNA #11 stated she had assisted Resident #45 with a shower on one occasion, but the resident was uncomfortable on the shower bed. CNA #11 stated she gave Resident #45 a bed bath to the best of her ability, but Resident #45 rushed her and yelled at her to stop because of pain or that they had other things to do. CNA #11 stated she was unable to remember what Resident #45's toenails looked like on 06/29/2026 or 06/30/2026. Licensed Practical Nurse (LPN) #6 was interviewed on 06/30/2026 at 2:21 PM and stated that the Hospitality Director (HD) arranged podiatry services. According to LPN #6, all residents that had a physician's order and wanted to be seen by the podiatrist were seen. LPN #6 stated that she expected the CNAs to notify her if a resident had toenails that were long, thick, and curling but stated that she had not received any such reports about Resident #45. LPN #6 also stated that residents' feet should be washed daily if they had diabetes mellitus. LPN #6 confirmed that Resident #45 had diabetes mellitus and should be receiving daily foot care. The LPN stated that if a resident refused care, the CNA was expected to report the refusal to the nurse so the nurse could speak with the resident. LPN #6 observed Resident #45's feet and stated with the dry, peeling, thick skin it was obvious the resident had not received foot care. The LPN also revealed that Resident #45's toenails were curling under and stated that no one had reported the condition of the resident's toenails to her. The HD was interviewed on 07/01/2026 at 1:47 PM. The HD stated that the contract podiatrist notified her when they would be visiting the facility and when they arrived, they gave her a list of residents they were going to see. The HD stated she reminded the nursing department of the podiatry visits and reminded them that if anyone needed to be seen they needed to let her know. She stated that the podiatrist did not see all new admissions, they only saw residents that she added to their list. She stated that the last podiatry visit was in May 2026. The HD stated residents had to wait for the podiatrist to visit the facility, and she had not arranged outside appointments for podiatry services. The Chief Nursing Officer (CNO) was interviewed on 07/01/2026 at 3:14 PM and stated she expected residents' feet to be washed, which included washing and drying between the toes. The CNO stated that if a resident had diabetes mellitus, it was important to receive foot care due to the resident's diminished sensation. The CNO stated that while the CNA was unable to trim nails for residents with diabetes, she expected the CNA to report to the nurse if the toenails needed to be trimmed. The CNO stated that the podiatrist was in the building every three months and was last in the building in April 2026. The CNO stated she added all residents with diabetes diagnosis to the list to be seen by the podiatrist and stated if a resident had curled toenails, she expected to be notified so an appointment could be made with another podiatrist. The CNO stated she had received no reports that Resident #45's toenails were curling. The CNO also stated she did not expect Resident #45's feet to have thick, flakey skin and its presence indicated the resident had gone more than one day without their feet being washed. The CNO stated that she had not received any reports that Resident #45 refused to have their feet washed. She stated Resident #45 was alert and able to verbalize their needs or if anything was wrong. The Administrator was interviewed on 07/01/2026 at 10:06 PM and stated she expected the CNAs to report long, curled toenails to the nurse and expected the resident's feet to be washed daily, if the feet were dirty, and if the resident requested. The Administrator stated it was important for residents with diabetes to have good foot care. The Administrator stated she would not have expected Resident #45's feet to have large patches of dry skin or curled toenails.

Based on observation, interview, record review, and review of manufacturer instructions for use, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 2 medication errors out of 28 opportunities, affecting 2 (Resident #18 and Resident #38) of 9 residents reviewed during the medication administration task, resulting in a medication error rate of 7.14%.Findings included:A manufacturer's Instructions for Use for insulin lispro, revised 07/2023, revealed the section titled, Priming your Pen, included, Prome before each injection. - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. The Instructions for Use revealed Step 6: - To prime your Pen, turn the Dose Knob to select 2 units. Step 7: - Hold you Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: - Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8.An admission Record revealed the facility admitted Resident #18 on 06/10/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus without complications. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2026, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin daily during the assessment's seven-day lookback period. An Order Summary Report, dated 07/02/2026, revealed an order dated 06/14/2026 for insulin lispro injection solution with instructions to give five units subcutaneously before meals. An observation on 06/29/2026 at 11:28 AM revealed Licensed Practical Nurse (LPN) #1 administered five units of insulin lispro to Resident #18. LPN #1 was not observed to prime the insulin pen prior to administration. An admission Record revealed the facility admitted Resident #38 on 06/18/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An admission MDS, with ARD of 06/24/2026, revealed Resident #38 had a BIMS score of 13, which indicated the resident had intact cognition. The MDS indicated the resident received insulin five days during the assessment's seven-day lookback period. An Order Summary Report, dated 07/02/2026, revealed an order dated 06/25/2026 for insulin lispro injection solution with instructions to give four units subcutaneously before meals for diabetes. The Order Summary Report revealed an order dated 06/25/2026 for insulin lispro injection solution with instructions to inject as per sliding scale; if the residents blood glucose reading was 150 - 200 (milligrams per deciliter; mg/dL) staff were instructed to administer one unit subcutaneously before meals for diabetes. An observation on 06/29/2026 at 11:44 AM revealed LPN #1 obtained Resident #38's blood glucose level, which measured 200 mg/dL. LPN #1 administered five units of insulin lispro to Resident #38. LPN #1 was not observed to prime the insulin pen prior to administration. During an interview on 07/01/2026 at 3:58 PM, LPN #1 stated she had no knowledge of how to prime an insulin pen prior to administration. During an interview on 07/02/2026 at 2:45 PM, the Pharmacist stated the manufacturer recommendations for insulin pens were to prime the insulin pen with two units of insulin prior to administering the ordered dose of insulin to a resident. During an interview on 07/01/2026 at 3:03 PM, the Chief Nursing Officer (CNO) stated the facility did not have a policy on priming insulin pens; however, insulin pens should be primed with two units of insulin prior to administering the ordered dose of insulin. The CNO also stated she expected the medication error rates to remain less than 5%. During an interview on 07/02/2026 at 12:55 PM, the Administrator stated she would defer the expectation of insulin administration to the CNO; however, she expected the medication error rate to not exceed 5%.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff provided enhanced barrier precautions (EBP) for 1 (Resident #23) of 2 residents observed for wound care. Specifically, staff failed to wear a gown when providing wound care to Resident #23's surgical woundFindings included: A facility policy titled, Enhanced Barrier Precautions, revised 03/2026, revealed, This facility follows recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI). Per the policy, In addition to the above-listed pathogens [which included Methicillin-resistant Staphylococcus Aureus (MRSA)], residents with the following conditions require EBP for all cares and services regardless of MDRO [multidrug-resistant organism] colonization status: Wounds including any skin opening requiring a dressing regardless of MDRO colonization status. The policy revealed, Gowns and gloves are used during high-contact activities with increased risk for MDRO transmission to staff clothing and hands including but not limited to: Wound care: any skin opening requiring a dressing. An admission Record revealed the facility admitted Resident #23 on 05/14/2026. According to the admission Record, the resident had a medical history that included diagnoses of necrotizing fasciitis (flesh eating disease caused by bacteria), encounter for other specified surgical aftercare, cellulitis of the left upper limb, sepsis, laceration of an unspecified blood vessel at the shoulder and upper arm level of the left arm, and the presence of other vascular implants and grafts. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2026, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had a recent major surgery that involved tendons, ligaments, or muscles and had a surgical wound. Resident #23's Care Plan Report, included a focus area initiated 05/14/2026, that indicated the resident was on EBP related to chronic wounds. Interventions directed staff to provide EBP as indicated, specifically gowns and gloves, during high-contact resident care activities (initiated 05/14/2026). The Care Plan Report also included a focus area initiated 05/14/2026, that indicated Resident #23 had a surgical wound to the left forearm. Interventions directed staff to provide a wound vacuum to assist in wound healing per physician orders (initiated 05/18/2026). Resident #23's Order Summary Report, with active orders as of 06/29/2026, contained an order dated 05/14/2026 for EBP. An observation on 06/30/2026 at 10:20 AM revealed a sign on Resident #23's door that indicated the resident was on EBP. The observation revealed the Wound Nurse provided wound care, which included removing the old dressing and wound vacuum, cleaning the wound, and reapplying the wound vacuum and a new dressing for Resident #23's surgical wound to the left upper extremity. During the observation of wound care, the Wound Nurse did not wear a gown. During an interview on 06/30/2026 at 11:07 AM, the Wound Nurse stated he completed wound care for Resident #23, who was recently treated for MRSA in the wound to the left arm. The Wound Nurse stated he overlooked the signage that indicated the resident was on EBP and stated he should have worn a gown when providing wound care. During an interview on 07/02/2026 at 1:33 PM, the Assistant Chief Nursing Officer, who is also the Infection Preventionist Nurse stated that the Wound Nurse should wear a gown when providing wound care to Resident #23. During an interview on 07/01/2026 at 3:03 PM, the Chief Nursing Officer (CNO) stated she expected the Wound Nurse to wear a gown when providing wound care to Resident #23. During an interview on 07/02/2026 at 12:55 PM, the Administrator stated she expected the Wound Nurse to wear a gown when providing wound care to Resident #23.

Based on interview and facility document review, the facility failed to ensure the posted nurse staffing information included the discipline of each staff member and the total number of hours worked for each discipline for 1 day (07/01/2026) during the 4 days of survey. Findings included: During an interview on 07/02/2026 at 1:15 PM, the Chief Nursing Officer (CNO) stated that the facility did not have a policy for the daily posted nurse staffing information. A facility Daily Staffing form dated 07/01/2026 revealed actual hours worked per shift by licensed and unlicensed nursing staff directly responsible for resident care were not documented. Further review revealed nurses were not identified as either registered nurses (RNs) or licensed practical nurses (LPNs). During an interview on 07/02/2026 at 9:02 AM, the CNO stated either the Assistant Chief Nursing Officer (ACNO) or the Human Resources Director were responsible for posting the nurse staffing information at the receptionist desk. The CNO stated that she was unsure of the process for correcting the posted staffing information at the beginning of the shift. The CNO stated she was aware the regulations mandated the staff positions and time work be posted. The CNO reviewed the daily staffing form posted for 07/01/2026 and stated that the posting was not accurate and the posting should include the total number of hours worked from each job position. During an interview on 07/02/2026 at 9:22 AM, the ACNO stated she printed the daily nurse staffing form and placed the form at the receptionist desk. The ACNO stated she had been informed that the form she used had met the regulation for posted nurse staffing and had been told the form only had to meet state regulations and not federal regulations. The Administrator was interviewed on 07/02/2026 at 10:00 AM and stated the overall direct care hours for a 24-hour shift should be included on the posted daily staffing form along with the RN hours. The Administrator reviewed the posted daily staffing form for 07/01/2026 and stated the positions were not identified and the total hours each position worked were not listed. The Administrator stated that RN hours had not been posted on the form. The Administrator stated that the form for the posted staffing should be corrected at the beginning of the shift. She stated the facility had been using the correct form but had quit using the correct form a few months back when there had been a turnover in the staffing coordinator. The Administrator stated that the current form was used because it was printed directly from the staffing portal. She stated that she had looked at the posted staffing form but had not looked at the big picture and had lost focus that the information posted was for the public and stated family members should not have to calculate the total hours worked.

On 07/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a significant medication error by administering the wrong dose of morphine (an opioid) to Resident #3.On 07/11/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 07/11/25 at 2:23 p.m., the administrator and the general manager were notified of the IJ situation and the IJ template was provided.On 07/14/25 at 2:00 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,IJ removal Plan - Ignite Medical Resort [NAME].Ignite Medical Resort [NAME] is committed to ensuring the safety and well-being of all residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Ignite Medical Resort [NAME]'s written credible allegation of compliance for the immediate jeopardy noted. Facility will be in compliance on 7/14/2025.1. On 07/02/25, Resident #3 was transferred to the emergency room for evaluation and treatment of altered mental status related to receiving morphine 15 mg ER instead of prescribed morphine 5 mg IR. The facility immediately:Removed all morphine 15 mg ER from Resident #3's medication supply.Ensured Narcan [opioid antagonist] was obtained and available in the emergency medication supply.Narcan to be available at all times and present on each nurse cart.Conducted medication reconciliation for all of Resident #3's medications.2. On 07/03/25, the facility:Identified 25 additional residents receiving opioid medications; audit completed on 7/11/2025 and all were receiving correct medications as ordered.Verified correct medication strength/formulation for all current residents in house against physician orders.Confirmed Narcan availability for all residents on opioid therapy.Reviewed all medication changes from the past 7 days to ensure proper receipt and reconciliation.3. Effective 07/04/25:Medication manifest will be checked with all delivered medications.Re-educated all medication administration staff on proper medication verification procedures (5 rights). Included but not limited to the policy and procedures on ordering, receiving, reconciliation, administration, and discrepancy process (completed on 7/11/2025).4. The Director of Nursing reported monitoring plan and results to the Quality Assurance and Performance Improvement (QAPI) committee on 7/11/2025.The IJ was lifted, effective 07/14/25, when all components of the plan of removal had been completed. Multiple staff on different shifts were interviewed regarding the in-service they received, availability of Narcan, medication carts, pharmacy manifest, and all audits were reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to have a system in place to ensure medications received were reconciled for accuracy and to ensure medications were available to be administered as ordered for 1 (#3) of 3 sampled residents reviewed for medication administration. The general manager identified 36 residents resided in the facility.Findings:A Medication Ordering and Receiving From Pharmacy Provider policy, revised 01/2025, read in part, Receives medications delivered to the nursing care center from the pharmacy and documents delivery on the medication delivery receipt/manifest. Verifies medications received with the prescriber orders.An admission Record with an admit date of 06/30/25, showed Resident #3 had a diagnosis of other chronic pain.Resident #3 had a physician's order, dated 06/30/25, for morphine tablet soluble, give 5 mg IR by mouth three times a day for pain. A physician's order, dated 06/30/25, showed Narcan nasal liquid 4 mg /0.1 milliliter. Administer one spray in nostril as needed for opioid reversal. Spray contents of one nasal spray as a single dose in one nostril. Administer additional doses if required in alternating nostril.A pharmacy Delivery Manifest Report Details, showed morphine 15 mg tablet was delivered to the facility on [DATE] at 10:24 p.m. for Resident #3.There was no documentation the facility received Resident #3's Narcan from the pharmacy.There was no documentation the pharmacy received the order for morphine 5 mg IR three times a day.A Nursing Evaluation note, dated 06/30/25 at 5:25 p.m., showed Resident #3 was alert, oriented to person, place, and situation. It showed the resident had clear speech.A Medication Error report, dated 07/02/25 at 3:45 p.m., showed CMA #1 administered 15 mg ER instead of 5mg IR. The report showed the Resident #3 was more difficult to arouse than normal. The report showed the resident continued to become more obtunded and less responsive to painful stimuli. EMSA was called to administer Narcan. The report showed family was worried about a possible stroke and wanted the resident taken to the emergency room.A nursing note, dated 07/02/25 at 5:36 p.m., showed Resident #3 was sent to the emergency room for altered mental status. An EMS report, dated 07/02/25, showed Resident #3 was picked up for possible overdose.A hospital record, dated 07/02/25, showed chief complaint of altered mental status. The record showed EMS stated Resident #3 had altered mental status and the facility believed the resident needed Narcan and it was not availableOn 07/10/25 at 12:08 p.m., CMA #2 stated they administered morphine 15 mg ER that was on the cart instead of the 5 mg IR as ordered. They stated they administered the medication twice on 07/01/25 around 8:00 a.m. and 2:00 p.m.On 07/10/25 at 12:12 p.m., CMA #2 stated Resident #3 was on morphine 15 mg ER, but it was changed to morphine 5 mg IR. They stated pharmacy must not have been aware of the order changes that was why they sent the 15 mg ER.On 07/10/25 at 12:31 p.m., Resident #3's physician stated the resident received Narcan after admission at the hospital and their mentation improved a little. On 07/10/25 at 12:36 p.m., CMA #1 stated they gave the morphine 15 mg ER on ce on 07/01/25 around 7:00 p.m. and once on 07/02/25 around 8:00 a.m.On 07/10/25 at 12:39 p.m., CMA #1 stated they noticed the medication discrepancy when they tried to reorder the medication on 07/02/25 around 10:30 a.m.On 07/10/25 at 1:16 p.m., LPN #2 stated upon discovering the medication error incident, they attempted to administer Narcan but there was none available to administer in the facility. On 07/10/25 at 12:48 p.m., the DON stated Resident #3 was initially on morphine 15 mg ER on ce a day. They stated the physician changed the order to morphine 5 mg IR three times a day on 06/30/25 due to availability from pharmacy. On 07/10/25 at 12:58 p.m., the DON stated there was no Narcan in the facility during the incident.On 07/11/25 at 9:39 a.m., the DON stated they could not find documentation to show the pharmacy received the order for morphine 5 mg IR three times a day.On 07/11/25 at 10:06 a.m., CMA #2 stated the process for receiving medications from pharmacy was to look at the medication delivered and verify with the sheet they sent with the medication. On 07/11/25 at 10:07 a.m., CMA #2 stated it was the pharmacy's responsibility to ensure the medication received by the pharmacy matched the resident's physician's orders on the MAR.On 07/11/25 at 10:29 a.m., Resident #'s representative stated the resident was able to converse and make their needs known prior to being over medicated. They stated on the day of the incident the resident was not communicating and was not talking.

On 07/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a significant medication error for Resident #3. On 07/11/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 07/11/25 at 2:23 p.m., the administrator and the general manager were notified of the IJ situation and the IJ template was provided.On 07/14/25 at 2:00 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,IJ removal Plan - Ignite Medical Resort [NAME].Ignite Medical Resort [NAME] is committed to ensuring the safety and well-being of all residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Ignite Medical Resort [NAME]'s written credible allegation of compliance for the immediate jeopardy noted. It is the facility's policy to ensure that residents are free of any significant medication errors. Facility will be in compliance on 7/14/2025.On 07/02/25, the following immediate actions were taken for Resident #3:Emergency medical services were contacted when resident showed signs of altered mental status and decreased responsiveness.Resident was transferred to the emergency department for evaluation and treatment.Narcan (an opioid antagonist) was administered to reverse opioid effects.Physician was notified of the medication error.Morphine (an opioid) 15 mg ER tablets were immediately removed from the medication cart.Correct medication (morphine 5mg IR) was verified and placed on the medication cart.On 07/02/25 and 07/03/25, the facility:Conducted 100% audit of all residents receiving medications to verify correct medication, dose, and formulation.Reviewed all medication carts to identify any other instances where incorrect medications were stocked.Verified all medications match current physician orders.Identified 25 additional residents receiving opioid medications; audit completed on 7/11/2025 and all were receiving correct medications as ordered.Effective 07/03/25, the facility implemented:Mandatory in-service training for all medication administration staff on high-alert medications and proper verification procedures. To include but not limited to policy and procedure on ordering, receiving, reconciliation, administration, and discrepancy process (completed 07/11/25 for all staff).Narcotics placed on nurse cart and to be administered by licensed nurses only.The Director of Nursing reported monitoring plan and results to the Quality Assurance and Performance Improvement (QAPI) committee on 7/11/2025.The IJ was lifted, effective 07/14/25, when all components of the plan of removal had been verified as completed. Multiple staff on different shifts were interviewed regarding the in-service they received, medication carts, and all audits were reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to prevent a significant medication error for 1 (#3) of 3 sampled residents reviewed for medication administration. The general manager identified 36 residents resided in the facility. Findings: An ADMINISTRATION OF MEDICATIONS policy, revised 07/2025, read in part, All medications are administered safely and appropriately to aid residents to and help in overcome illness, relieve and prevent symptoms and help in diagnosis.An admission Record with an admit date of 06/30/25, showed Resident #3 had a diagnosis of other chronic pain.Resident #3 had a physician's order, dated 06/30/25, for morphine tablet soluble, give 5 mg IR by mouth three times a day for pain. A nursing evaluation note, dated 06/30/25 at 5:25 p.m., showed Resident #3 was alert, oriented to person, place, and situation. The note showed the resident had clear speech.A narcotic record, dated 06/30/25, showed morphine 15 mg ER, give one tablet by mouth daily. The record showed Resident #3 received morphine 15 mg ER three times on 07/01/25 and one time on 07/02/25. A July 2025 MAR, showed Resident #3 received the wrong morphine on:a. 07/01/25 at 9:59 a.m.,b. 07/01/25 at 1:04 p.m.,c. 07/01/25 at 7:05 p.m., andd. 07/02/25 at 8:00 a.m.A Medication Error report, dated 07/02/25 at 3:45p.m., showed CMA #1 administered 15 mg ER instead of 5 mg IR. The report showed Resident #3 was more difficult to arouse than normal. The report showed the resident continued to become more obtunded and less responsive to painful stimuli. EMSA was called to administer Narcan. The report showed family was worried about a possible stroke and wanted the resident taken to the emergency room.A nursing note, dated 07/02/25 at 5:36 p.m., showed Resident #3 was sent to the emergency room for altered mental status. An EMS report, dated 07/02/25, showed Resident #3 was picked up for possible overdose.A hospital record, dated 07/02/25, showed chief complaint of altered mental status.On 07/10/25 at 12:08 p.m., CMA #2 stated they administered morphine15mg ER that was on the cart instead of the 5 mg IR as ordered. They stated they administered the medication twice on 07/01/25 around 8:00 a.m. and 2:00 p.m.On 07/10/25 at 12:10 p.m., CMA #2 stated Resident #3 was coherent when they took care of the resident. They stated they were not at the facility on the day the resident was sent to the emergency room.On 07/10/25 at 12:35 p.m., CMA #1 stated they made a medication error on Resident #3's morphine. They stated the process for medication administration was to verify the resident's name, the right room, right medication, and the right dose.On 07/10/25 at 12:36 p.m., CMA #1 stated they gave the morphine 15 mg ER on ce on 07/01/25 around 7:00 p.m. and once on 07/02/25 around 8:00 a.m.On 07/10/25 at 12:39 p.m., CMA #1 stated they noticed the medication discrepancy when they tried to reorder the medication on 07/02/25 around 10:30 a.m.On 07/10/25 at 1:14 p.m., LPN #2 stated they took care of Resident #3 after CMA #1 went home. They stated the resident's representative wanted them to send the resident to the emergency room. They informed the resident's representative there had to be a reason to send the resident to the emergency room. LPN #2 stated the resident's representative stated the resident's cognition had changed. They stated they informed family they could send the resident to the emergency room for altered mental status. LPN #2 stated it was the first time caring for the resident and was not sure what their baseline cognition was.On 07/10/25 at 12:48 p.m., the DON stated Resident #3 was initially on morphine 15 mg ER on ce a day. They stated the physician changed the order to morphine 5mg IR three times a day on 06/30/25 due to availability from pharmacy.

Based on observation, record review, and interview, the facility failed to provide pain medication to a resident as ordered for 1 (#1) of 3 sampled residents reviewed for medication as ordered. The general manager identified 36 residents resided in the facility. Findings:On 07/09/25 at 12:01 p.m., CNA #1 and CNA #2 were providing incontinent care on Resident #1. The resident informed CNA #1 and CNA #2 they were in pain. Resident #1 was groaning holding their left hip. On 07/09/25 at 12:10 p.m., Resident #1 groaned in pain as they were turned to their left side. On 07/9/25 at 12:22 p.m., CNA #2 was observed speaking with CMA #3. A physician's order, dated 04/15/25, showed Tylenol (pain medication) 325 mg give two tablets by mouth every six hours as needed for pain.A Pain Management policy, dated 04/17/25, read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Physician's orders, dated 05/01/25, showed oxycodone HCl (pain medication) 5 mg give one tablet by mouth every six hours as needed for pain level three to six and oxycodone HCl 5 mg give two tablets by mouth every six hours as needed for pain level seven to 10. Resident #1's significant change status resident assessment, dated 05/10/25, showed the resident's cognition was intact with a brief interview for mental status of 14. The assessment showed the resident received pain medication as needed and was frequently in pain. A July 2025 MAR showed oxycodone 5 mg was administered on 07/09/25 at 5:06 a.m.A July 2025 MAR showed oxycodone 5 mg was administered on 07/09/25 at 1:07 p.m.Tylenol 325 mg was not administered on 07/09/25 during the time of investigation. On 07/09/25 at 12:04 p.m., CNA #1 informed Resident #1 they could take a break, but they had to clean them. On 07/09/25 at 12:07 p.m., CNA #1 asked Resident #1 if they received their pain medication this morning. Resident #1 responded, Yes.On 07/09/25 at 12:14 p.m., CNA #1 and CNA #2 completed incontinent care. CNA #1 informed the Resident #1 they would inform the nurse about their pain. On 07/09/25 at 12:36 p.m., CNA #2 stated they informed CMA #3 the res complained of pain. They stated CMA #3 stated Resident #1 had pain medication, but it was not time to administer. On 07/09/25 at 12:37 p.m., CNA #2 stated if a resident complained of pain, they were to inform the CMA. On 07/09/25 at 12:40 p.m., CMA #3 stated they were informed the resident complained of pain around 12:25 p.m. to 12:30 p.m. but it was too early for administration. They stated the Resident #1 already had everything they could for pain.On 07/09/25 at 12:41 p.m., CMA #3 stated the resident took oxycodone 5 mg 2 tablets every six hours as needed, and Tylenol 325 mg two tablets every six hours as needed for pain.On 07/09/25 at 12:42 p.m., CMA #3 stated the last time Resident #1 received their pain medication prior to incontinent care observation was on 07/09/25 at 5:17 a.m. On 07/09/25 at 12:43 p.m., CMA #3 stated they administered the pain medication at 1:07 p.m. on 07/09/25. They stated the Resident #1 rated their pain at 8/10 on a numerical scale.On 07/09/25 at 12:46 p.m., CMA #3 stated the resident should have received their pain medication when they complained of pain. They stated it was a miscalculation on their part. On 07/10/25 at 6:30 a.m., LPN #3 stated CMA #3 had informed them Resident #1 complained of pain, and it was too soon to administer. On 07/10/25 at 8:30 a.m., the DON stated CMA #3 did not follow Resident #1's order for pain.

Based on observation and interview, the facility failed to ensure dirty linens were handled in a manner to prevent cross contamination during:a. incontinent care for 1 (#1) of 3 sampled residents observed for incontinent care; and b. a hall observation. The general manager identified 36 residents resided in the facility. Findings:On 07/09/25 at 12:01 p.m., CNA #1 and CNA #2 was observed to provide incontinent care on Resident #1. Both CNAs had on gloves and provided privacy. On 07/09/25 at 12:05 p.m., Resident #1's brief was observed soiled. CNA #2 wiped the resident's genitalia.On 07/09/25 at 12:10 p.m., Resident #1 was observed rolled to their left side. CNA #1 removed the resident's soiled pad and placed on the floor next to a white sheet. On 07/09/25 at 12:12 p.m., CNA #1 was observed to wipe the Resident #1's buttocks and anal area. CNA #1 changed their gloves and put a new brief on the resident. On 07/09/25 at 12:14 p.m., CNA #1 and CNA #2 completed incontinent care on Resident #1. They adjusted the resident in bed.On 07/09/25 at 12:18 p.m., CNA #2 was observed to remove the resident's pillowcase and place it on the floor next to the pad and white sheet. They retrieved a plastic bag and put the dirty linens in the bag. On 07/09/25 at 12:20 p.m., CNA #1 and CNA #2 were observed to take out the trash and the bag of dirty linens.On 07/10/25 at 4:50 a.m., CNA #3 was observed to pick up linen and a pad from room [ROOM NUMBER]'s floor by the door. The door was open. They had no gloves. CNA #3 held the linen and pad close to their upper body and transported to a room identified as environment. On 07/09/25 at 12:30 p.m., CNA #1 stated dirty linens should be put in a bag. They stated they did not follow the facility's process on handling dirty linens during the incontinent care observation. On 07/09/25 at 12:34 p.m., CNA #2 stated dirty linens should be placed in a plastic and taken to the designated laundry. They stated they did not follow the process during incontinent care observation. On 07/10/25 at 6:07 a.m., CNA #3 stated the linen they transported was a top blanket, flat sheet and a bed pad. They stated the linen was dirty. CNA #3 stated the facility's process was to put dirty linen in a bag and put them in a hamper in the environment room. They stated they did not follow the process. On 07/10/25 at 8:30 a.m., the DON stated staff should put dirty linens in bags during care and transportation.

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed for tube feeding administration and removal of a Foley catheter for one (#4) of three sampled residents reviewed for physician orders. The administrator identified 39 residents resided in the facility. Findings: A facility TUBE FEEDING policy, revised 04/2024, read in part, The physician or nurse practitioner should be notified if tube feeding amount not infused as ordered. Res #4 admitted to the facility on [DATE] with diagnoses which included rectal cancer. A physician order, dated 11/15/24, documented to provide catheter care every shift and PRN. A physician order, dated 11/17/24, documented to administer Jevity 1.5 Cal at 65 ml/hr via g-tube every shift for feeding. An admission MDS, dated [DATE], documented Res #4 was moderately cognitively impaired, had an indwelling catheter, and received greater than half of nutritional intake through a feeding tube. An office visit physician note, dated 11/27/24, read in part, Okay for trial of void with removal of Foley catheter per [their] skilled nursing facility with replacement of the indwelling urinary catheter if [they] are unable to void. A physician order, dated 11/27/24, documented to administer Jevity 1.5 Cal at 65 ml/hr via g-Tube every night shift for feeding. The order documented the feeding was to be on for 12 hours and off for 12 hours. The order was documented to start on 11/28/24. A MAR/TAR for November 2024 documented a blank for the PM administration of the Jevity on 11/27/24. A MAR/TAR for November 2024 documented Res #4 refused the tube feeding on 11/28, 11/29, and 11/30. A MAR/TAR for December 2024 documented Res #4 refused the tube feeding on 12/01. On 12/02/24 at 8:09 a.m., Res #4 was observed in their bed. A full bag of tube feeding formula was observed hanging from a pump pole near the bed. The bag was not labeled or dated. The connection end of the feeding was observed with an accumulation of dried and crusted formula. The resident stated the feeding had been discontinued. The resident was observed with a Foley catheter bag hanging from the bedside with approximately 100 ml of clear yellow urine in the collection bag. The resident denied concerns related to the catheter. On 12/02/24 at 10:10 a.m., Res #4 was again observed in their bed. The tube feeding formula was still at bedside untouched. The resident stated it had been discontinued a few nights ago because they were now eating solids. On 12/02/24 at 11:07 a.m., the ADON stated the physician was aware the resident was refusing their feeding. They stated as long as the resident consumed 80-100% of their meals the physician was okay with the refusal. On 12/02/24 at 12:45 p.m., Res #4 stated the catheter had not been removed for a voiding trial. They stated they were unaware the physician had ordered it. On 12/02/24 at 12:46 p.m., LPN #2 stated the Foley catheter had not been removed for a voiding trial. They stated there should be documentation in the progress notes regarding notification of the physician of refusal of the tube feeding. They stated there was not an order to hold or okay the refusal if Res #4's intake was 80% or greater. On 12/02/24 at 3:00 p.m., the DON stated the blank on the MAR/TAR indicated the tube feeding was not done. They stated there should have been documentation of physician notification in the progress notes related to the refusal of the tube feeding. They stated the Foley catheter should have been discontinued for a voiding trial.

Based on record review and interview, the facility failed to ensure dependent residents were showered for one (#3) of three sampled residents reviewed for ADLs. The administrator identified 39 residents resided in the facility. Findings: Res #3 admitted to the facility on [DATE] with diagnoses which included spinal stenosis, back pain, and dementia. Record review documented Res #3 did not receive a shower from 09/12/24 to 09/17/24. An admission MDS, dated [DATE], documented Res #3 was cognitively intact and required moderate assistance with hygiene/bathing. On 12/02/24 at 11:30 a.m., the DON stated Res #3 was to receive their showers on Tuesdays, Thursdays, and Saturdays. On 12/02/24 at 2:02 p.m., the DON stated they were unable to locate documentation Res #3 received a shower on 09/14/24. On 12/02/24 at 3:07 p.m., the DON stated Res #3 should have received their shower on 09/14/24.

Based on record review and interview, the facility failed to provide baths/showers as scheduled for one (#36) of three sampled residents reviewed for activities of daily living. The DON identified 47 residents who resided in the facility. Findings: A Bathing policy, dated 05/24, read in part, .All residents are given a bath or shower in accordance with their preferences. If no preferences on a bath is voiced, a bath or shower will be offered twice per week . Res #36 was admitted [DATE] with diagnoses which included chronic kidney disease, pleural effusion, and fluid overload. The resident was discharged [DATE]. A facility shower schedule documented Res #36 was to receive a shower every Tuesday and Friday. An admission assessment, dated 06/14/24, documented Res #36 was cognitively intact and required substantial to maximal assistance with bathing. A Resident Grievance form, dated 07/07/24, documented the resident had requested a shower for days. Res #36's medical record had no documentation the resident received a shower/bath from admission until discharge. On 08/13/24 at 10:54 a.m., the DON stated Res #36's completed baths should have shower sheets scanned into the EHR or should have been documented as completed under tasks in the resident's medical record. The DON stated if no documentation could be found, then there was no way to prove Res #36 had a shower while in the facility. On 08/15/24 at 8:52 a.m. the administrator in training stated all residents should receive baths twice weekly and as needed. They stated the facility was unable to locate any documentation of completed baths for Res #36.

Based on observation, record review, and interview, the facility failed to prevent an injury to a resident during transfers for one (#29) of two residents sampled for accidents and hazards. The Administrator identified 47 residents resided in the facility. Findings: The facility's Incident and-Accidents policy, dated 11/2018, read in part, If an accident occurs, a full investigation will be initiated, including staff, interviews, equipment, checks, and follow through on policy and procedures. The policy also read, Facility will monitor the effectiveness of the interventions, including adequate supervision consistent with the residents needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. The policy also read, The facility shall maintain a file of all written reports of each incident and accident affecting the resident that is not a expected outcome of a residence condition or disease process. Resident #29 was admitted on [DATE] with diagnoses which included fracture of the right femur and dysphasia. A comprehensive assessment dated [DATE] documented Resident #29's cognition was mildly impaired, had range of motion impairments in the lower extremities on both sides, and was dependent for transfers. A care-plan, dated 07/11/24, read in part, Chair/bed-to-chair transfer: Substantial/maximal assistance. On 08/11/24 at 9:58 a.m., Resident #29 was observed with a laceration on left leg below knee with a bandage not affixed and open with a scab. Resident #29 was asked about the injury. The Resident stated they were injured during a transfer from the bed to the wheel chair. They stated it was hurt three weeks ago and then happened again last week. They stated the facility bandaged it and does not think they care planned anything to keep the injury from occuring again. On 08/14/24 at 11:20 a.m., Resident #29 was observed with a new bandage on left knee. Resident #29 stated the injury hurt and was caused during a transfer from aides from the bed to the wheel chair. The resident stated a nurse named LPN #1 dressed the bandage and was told how the injury occurred. The resident stated that the injury has occurred three times during transfers from aides while transferring from the bed to a wheel chair. On 08/14/24 11:25 a.m., Resident #29's health records were reviewed. The EHR did not document the following: a. the left knee wound, b. interventions to prevent injuries during transfers, and c. incidents involving an injury during a transfer. On 08/14/24 at 11:32 a.m., LPN #2 was asked about Resident #29's skin conditions. LPN#2 stated, they observed the resident had a dressed abrasion on the left knee where the skin was broken on 08/13/24. LPN #2 stated they asked the resident what happened and the resident reported that the abrasion happened during a transfer from the bed to the wheel chair. LPN #2 stated they cleaned the wound with cleanser and dressed it on 08/14/24 after the resident requested a new dressing. LPN #2 stated there was documentation of the wound or incident in the health record and they did not document an incident or the wound care in the residents health records. On 08/14/24 at 12:59 p.m., LPN #1 was asked to discuss the injury on Resident #29's left knee. LPN #1 stated, on 08/13/24 around 4:00 p.m., CNA #1 stated the Resident had an abrasion and needed to be assessed. They stated CNA #1 reported the w/c had caught the residents leg during a transfer. LPN #1 stated they dressed the wound after assessing it and the Resident stated that they were transferring and their leg got caught. LPN #1 was asked if they documented anything in the health record or an incident report. They stated ,No, I forgot to do that. LPN #1 was asked what was the facility's policy when a resident gets injured. LPN #1 stated they should of documented the wound care and completed an incident report but they forgot because they got busy. On 08/15/24 at 8:25 a.m., the Administrator was asked for the facility's wound care policy. The Corporate Administrator stated they did an investigation and was able to determine on 08/8/24 that CNA #2 who was working on their first day reported to RN#1 that the resident had an injury during transfer and RN#1 dressed the wound under standing orders. They were asked if RN#1 did an IR and document the incident and wound care. The Corporate Administrator stated, No, I really think its a documentation problem. On 08/15/24 at 9:14 a.m., the DON was asked about the Resident #29's abrasions on their left knee. The DON stated the Resident told them the incident occurred on 8/8/24. The DON stated that LPN #2 and Transport #1 were transferring the Resident and the skin was raised. Next, on 8/10/24, CNA #2 scraped residents leg during a transfer. The CNA told RN #1 and RN #1 put a bandage on the residents left knee abrasion under the standing orders. RN #1 stated she did not put a note in the chart or document. The DON was asked what they thought the deficient practice was. The DON stated they should of been documenting to prevent further injury to the resident. Again, On 8/13/24, CNA #1 reported to LPN #1 that the resident was injured during a transfer on the left knee. LPN #1 evaluated and put a bandage on the abrasion. The DON was asked where they thought the deficient practice was. They stated, it should of been documented. LPN #1 did not document anything.

Based on observation and interview, the facility failed to ensure oxygen tubing was labeled and dated, per professional standards of care for three (#4,26, and #93) of three resident sampled for respiratory care. The DON identified 5 residents had orders for oxygen therapy. Findings: 1. Resident #4 was admitted on [DATE] with diagnoses which included acute kidney failure and systolic heart failure. Resident #4's physician orders, dated 8/04/24, read in part, May administer supplemental Oxygen as needed. On 08/11/24 at 9:05 a.m., Resident #4 was observed wearing oxygen via a nasal cannula. The tubing was attached to an oxygen saturator. There was no date observed on the humidifier or oxygen tubing indicating when the tubing was last changed. On 08/11/24 at 9:06 a.m., CNA #3 was asked what the date was on the oxygen tubing and/or humidifier. They stated there was not a date on the oxygen tubing or humidifier. On 08/11/24 at 9:11 a.m., RN #1 was taken to resident #4's room and asked if the oxygen tubing and humidifier was dated. RN #1 stated the tubing was not labeled with the date and it should be changed every 7 days and dated. 2. Resident #26 was admitted on [DATE] with diagnoses which included Atherosclerotic heart disease and and spondylosis without myelopathy. Resident #26's physician orders, dated 07/18/24, read in part, May administer supplemental Oxygen as needed. On 08/11/24 at 8:57 a.m., Resident #26 was observed in bed with head of bed elevated elevated wearing oxygen via a nasal cannula attached to an oxygen saturator. The oxygen tubing or humidifier was not observed to be labeled with the date indicating when it was last changed. On 08/11/24 at 8:59 a.m., RN #1 was shown the oxygen saturator and tubing. They were asked where the date was on the O2 tubing and saturator indicating when it was last changed. RN #1 stated there was not a date and it should be labeled and changed every 7 days. 3. Resident #93 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease and lower respiratory infection. Resident #93's physician orders, dated 7/01/24, read in part, Continuous O2 Via (NC/MASK). The order also read, Change O2 tubing every day shift every Sun and as needed. On 08/11/24 at 9:16 a.m., Resident #93 was observed wearing oxygen via a nasal cannula attached to an oxygen saturator. There was no date observed on the oxygen tubing or humidifier indicating the last time it was changed. On 08/11/24 at 9:17 a.m., CNA #3 was taken to resident #93's room and asked asked what the date was on the oxygen tubing and humidifier. CNA #3 stated they did not see a date. On 08/11/24 at 9:19 a.m., the ADON was asked to look at Resident #93's oxygen tubing and humidifier. The ADON stated there was not date labeled on the tubing or humidifier indicating when it was last changed. The ADON stated it was a nursing standard and should be changed weekly and labeled with the date.

Based on observation, record review, and interview, the facility failed to perform an entrapment risk assessment prior to installing bed or side rails for two (#2 and #86) of two residents and failed to obtain a physician order for the medical rationale and use of bed rails prior to installation for one (#86) of two sample residents reviewed for accident hazards. The DON identified 44 residents whose beds were equipped with a bed rail of any type. Findings: An Admission Packet excerpt, undated, read in part, .The grab bars/side rails are/will be implemented for positioning only after a licensed nursing assessment. FULL SIDE RAILS WILL NOT BE UTILIZED. Responsible Party and/or Guest have been advised that bed/side rails may be installed. The risks and alternatives to using bed/side rails, as they apply to Guest's particular condition and circumstances have been clearly explained. A written order from the Guest's attending physician, specifying the medical rational and circumstances for use will be obtained prior to the installation of this medical treatment device. Facility will periodically review and re-evaluate the Guest's need for bed/side rails and Guest Responsible Party and attending physician will be consulted in this matter . 1. Res #2 had diagnoses which included epilepsy, muscle wasting, and morbid obesity. A physician order, dated 03/04/20, documented quarter bed rails for turning and positioning. A care plan, dated 07/09/20, documented Res #2 had an ADL self-performance deficit related to chronic weakness. The care plan documented use of a quarter side rail or enabler/assist bar to improve mobility. An annual assessment, dated 07/11/24, documented the resident was cognitively intact, dependent with most ADLs, and dependent with bed mobility. There was no documentation of an entrapment risk assessment found in the medical record. On 08/11/24 at 9:16 a.m., Res #2 was observed sitting in a recliner beside their bed. The bed was observed to have bilateral upper quarter bed rails. The resident stated they used the rails for turning and positioning. On 08/13/24 at 12:10 p.m., the administrator stated a completed entrapment risk assessment could not be located for Res #2. They stated the assessment should have been completed prior to installation of the bed rails and quarterly thereafter. 2. Res #86 was admitted with diagnoses which included muscle weakness, difficulty in walking, and peripheral vascular disease. An admission assessment, dated 06/19/24, documented the resident was cognitively intact, required partial to moderate assistance with most ADLs, and required supervision to touch assistance with bed mobility. A care plan, dated 06/26/24, documented Res #86 had an ADL self-care performance deficit related to limitation in physical mobility. The care plan documented use of enabler/grab rails for safety during care provision to assist with bed mobility. The care plan documented to observe for injury or entrapment related to side rail use and reposition as necessary to avoid injury. There was no documentation of a physician order for bed rails or an entrapment risk assessment found in the medical record. On 08/11/24 at 9:37 a.m., Res #86 was observed lying in bed. Bilateral upper quarter bed rails were observed in the up position. The resident stated the rails were used to assist in turning. On 08/13/24 at 12:03 p.m. the administrator stated a completed entrapment risk assessment and physician order could not be located for Res #86. They stated a physician order should have been obtained and the assessment should have been completed prior to installation of the bed rails.

Based on observation, record review and interviews, it was determined the facility failed to manage a resident's pain by providing pain medication timely for one (#20) of two sampled residents reviewed for pain management. The resident had complained of pain to a certified nurse aide who reported this to a charge nurse. The resident was in excruciating pain at a level of nine on a scale of 0-10 and did not received her pain medication for over forty minutes. The Resident Census and Conditions of Residents form, dated 04/30/18, documented 26 residents were on a pain management program. Findings: The facility policy titled, Pain Management Policy documented, .It is the policy .to utilize an interdisciplinary approach to the management of pain to assure that each resident is provided with effective interventions for the relief of unwanted pain and suffering .medications will be administered as ordered by RN's (registered nurses) . A second facility policy titled, Pain Management Policy documented, .Resident's rights .health professional who respond quickly to reports of pain . Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 02/12/18, documented the resident's cognition was intact, was able to make self understood, could understand others, had a fracture and frequent pain. The assessment further documented the resident's pain was a 10 on a scale of 0-10, limited her daily function over the previous five days and received opiods seven out seven days. A care plan, dated 02/22/18, documented, Problems (Resident #20) is at risk for further impaired comfort r/t (related to) healing fracture to her R (right) ankle RA (right ankle) general muscle weakness . Goal pain will be minimized or controlled . Interventions if restless, assess for pain/discomfort or other physical needs .observe for physical signs of distress .observe for non-verbal indicators of pain (rubbing, moaning, crying, guarding, etc.) report to nurse .evaluate location, nature, intensity and duration of pain .[MEDICATION NAME] ER (extended release) [MEDICATION NAME] per physicians orders. Monitor for effectiveness, side or adverse effects . The current physician's orders [REDACTED]. [MEDICATION NAME] 40 milligram (mg) tablet extended release every 12 hours, Tylenol 325 mg as needed (PRN) every four hours, and [MEDICATION NAME] 30 mg PRN every six hours. A care plan update, dated 04/09/18, documented, Tylenol 325 mg PO (by mouth) q 6 (every six hours) prn. A significant change assessment, dated 04/11/18, documented the resident's cognition was intact, had a [DIAGNOSES REDACTED]. The assessment also documented the resident had frequent pain at a level of nine over the previous five days of the assessment. A care plan update, dated 04/19/18, documented, OT (occupational therapist) clarification order to provide pain management modalities such as .tens, ultrasound, soft tissue mobility . On 04/30/18 at 9:53 am., the resident was interviewed. During the interview the resident grabbed her leg and shoulder and cried out in pain. She stated the pain is really bad since she had broken her ankle. She was asked if pain medication was provided and effective. She stated it help some, but at times it takes a while to get her medication. On 05/02/18 at 2:57 p.m., certified nurse aide (CNA) #1, was observed at the nurses station and reporting to licensed practical nurse (LPN) #2 the resident was having pain and needed some pain medication. The nurse stated she would be right with the resident. From 2:57 p.m. through 3:25 p.m., the room was observed. No staff was observed entering the room to provide the resident her pain medication. At 3:25 p.m., the resident was observed in her room grimacing and had a distressed look on her face. She was asked if she had received her pain medication she requested. She stated they had not provided her the medication. Resident #20 was asked to rate her pain on a scale of 0 to 10. She stated, It's a nine. She was asked what medications she had ordered for her pain. She stated she had a routine order every twelve hours and an order for [REDACTED]. At 3:28 p.m., CNA #1 came into the residents room to check on her. The CNA asked the resident if she had received her pain medication. The resident stated she had not received her pain medication yet and that she was in a lot of pain. The CNA stated she was going to check with the nurse to see why the pain medication had not been provided and immediately left the room. From 3:28 p.m. through 3:40 p.m., the surveyor sat with the resident in her room waiting for the pain medication to be provided. At 3:43 p.m., LPN #2 was approached at the nurses station. She was asked if she had been informed of Resident #20 needing pain medication. She stated, The aide just came to me about five to ten minutes ago stating the resident needed pain medication. She then held up a medicine cup and stated she was getting ready to administer the medication and stated, This was the first time someone had told me about it. At 3:45 p.m., CNA #2 was asked when she first informed someone the resident needed pain medication. She stated it was before 3:00 p.m. She was asked who she had reported it to. She stated, (Name deleted LPN #2). She was asked who she had reported to the second time. She stated, The charge nurse (Name deleted LPN #2) because I wanted to know why she hadn't received the pain medication because she is definitely in a lot of pain. The Medication Administration Record, [REDACTED]. The resident had waited over forty minutes before she received her pain medication. On 05/03/18 at 11:00 a.m., the administrator and the minimum data set (MDS) coordinator was asked how long a resident with a pain level of nine should have to wait to receive medication. The administrator stated, As soon as we are made aware of it. They were made aware of the observation where the resident waited in excess of 40 minutes to receive pain medication. The administrator stated, That is not okay to wait that long to get the medication. The MDS coordinator nodded her head in agreement. They were asked if the care plan had been followed for pain management. The MDS coordinator stated, No.

Based on observation, clinical record review, staff and resident interviews, hospital record review and review of facility policy and procedure, it was determined the facility failed to ensure a family member, interested party and/or physician were notified of the development of a pressure ulcer, changes to a pressure ulcer, or administration of incorrect wound care treatments, in a timely manner for one (#2) of two sampled residents reviewed for pressure ulcers. Resident #2 developed a pressure ulcer while admitted to the facility. The resident's wound progressed from a stage II to an unstageable wound with necrotic tissue. This had the potential to affect nine residents identified by the facility who were at high risk for the development of pressure ulcers. Two residents were identified by the facility with pressure ulcers. Findings: A facility policy, titled Pressure Ulcer, Care and Prevention Of, documented: "...Purpose: To prevent and treat further breakdown of pressure sores... General Guidelines for assessment may include, but are not limited to: Skin at risk General condition of skin Any pain; report to physician... Incontinence of bowel and bladder... Procedure 1. Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk for a pressure ulcer to begin... treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers..." A facility policy, titled Change of Condition Notification, documented: "Notification of change of condition include. Resident Physician Family Member/responsible party/POA/Guardian The DONC, Administrator and MDS Coordinator are notified. Means of notification include telephone, in person, written communication. A family meeting may be arranged." A facility policy, titled Change in Condition, documented: "A change in condition requires increased attention from staff to provide adequate care for residents. Some changes are temporary and require only a temporary change in the intensity of care required until the resident recovers adequately enough to allow for the resumption of the care prior to the change in condition... Assessments: Whether the change is permanent or temporary, the resident requires an assessment to determine the need for additional care. Through the assessments a plan or approach will determine the intensity and duration of care required. Documenation of the assessment of symptoms and conditions must be part of the resident record, conveyed to care staff across all shifts and followed until the change in condition has been resolved or determined to need further assessments..." An emergency department report, dated 02/01/15, for resident #2 documented, "...Stated complaint: Fall... History of Present Illness: She has been living and caring for herself. Patient's friend has noticed that since last fall patient has become more withdrawn. She has not wanted to get out of the house...The friend call nearly every day but the patient did not answer the phone on Friday which was 2 days ago. She went over to her house to check on her and see seemed to be 'doing ok'. She tried calling her several times today and the patient did not answer the phone. When she went to her house she found the patient lying in the floor in the bathroom. She thinks the patient couldn't (sic) been there for at least 2 days. Patient does not remember falling or lying on the floor...She does admit to feeling depressed... Skin: No rashes... General Appearance: ...She is disheveled and unkempt... ED Course/Procedures ...Patient is very withdrawn and depressed. She is unable to care for herself and does not need to be living alone. She is in rhabdomylosis... Impression: Primary Impression: Volume depletion Additional Impression: Rhabdomylosis, Urinary Tract Infection..." A hospital pain assessment, dated 02/04/15, documented, "...Presence of Pain Yes Pain assessment label Posterior Coccyx Pain behavior description Moaning Pain comment c/o tailbone with bed mob and bed transfers..." Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment, dated 02/06/15, documented, "...Skin...Does this resident have a [MEDICAL CONDITION] or an open wound...Specify location: (blank)... Does this resident have a pressure ulcer...Specify location: (blank)... Did the resident have a skin ulcer that was resolved or cured in last 90 days...Specify location: (blank)..." An admission assessment, dated 02/13/15, documented the resident was cognitively alert in skills for daily decision making. She required extensive assistance from staff with transfers, ambulation, dressing, hygiene and bathing. She was frequently incontinent of bowel and bladder. She had an unhealed stage two pressure ulcer present prior to admission. A skilled nurse assessment, dated 02/14/15, documented, "...Skin Condition. Pressure Ulcer..." There were no notes of family, interested party or physician notification found in the clinical record. A skilled nurse note, dated 02/15/15 at 4:08 a.m., documented, "...Had incontinent bowel episode x 1 in briefs. W/C replaced at wound at intergluteal cleft..." A skilled nurse note, dated 02/16/15 at 4:20 a.m., documented, "...Allowed staff to place her in bed to sleep due to wound. W/C remains at wound at intergluteal cleft..." There was no documentation of family, interested party or physician notification of the wound. A wound assessment, dated 02/16/15, documented, "...Wound origination...(checked box) Facility... Wound Type Pressure Ulcer Wound Location Buttocks Crease Wound Stage Stage 2 Where Acquired Facility Wound Depth Superficial Wound Length 7.0 Wound Width 3.0 Drainage Absent Drainage Color (blank) Odor Absent Wound Bed Color (checked box) pink Wound Tissue Granulation Surrounding Tissue (checked box) clear Date Family Notified (blank) Date Physician Notified (blank)..." A skilled nurse note, dated 02/17/15 at 12:34 a.m., documented, "...dressing still intact to sacral area, report rec'd from prev shift that res has open area to buttocks and dressing was applied..." An unsigned physician's orders [REDACTED]. Pat dry, apply hydrogel (and) cover c padded dressing Q day and PRN. Critical care give 30 ml po Q day for wound healing." There was no notification of family, interested party or physician notification for the development of the wound and ordered treatment. A treatment administration record, dated February 2015, documented, "...Hydrogel (1)...Gram topical...starting 2/17/15...Notes: Clean buttocks wound with wound cleanser, pat dry and apply Hydrogel and cover with padded dressing..." The Hydrogel wound treatment was documented as administered 02/18/15 through 02/23/15. There was no documentation in the clinical record the physician had been notified a wound treatment was implemented for the pressure ulcer. A physician progress notes [REDACTED]. Skin...sacral wound 4 x 7 cm c eschar, no odor... Unstageable wound, sacrum. Santyl/[MEDICATION NAME]" A physician's orders [REDACTED]. A treatment administration record,dated February 2015, documented, "...Santyl 250 unit/gram (Layer) ointment (Gram) topical every one day starting 02/20/15...Discontinued (02/24/15)...Pressure ulcer, Unstageble (sic). Notes: Clean area apply Santyl and [MEDICATION NAME] cover with sacral patch daily (and) PRN..." The Santyl and [MEDICATION NAME] wound treatment was documented as administered 02/20/15 through 02/23/15. A weekly skin assessment, dated 02/20/15, documented, "...Wound Origination...(checked box) hospital... Location of Wound Gluteal Crease Wound Length 7.0 CM Wound Width 3.0 CM Drainage (checked box) absent Drainage Color (checked box) No drainage Wound Drainage Odor (checked box) Absent Wound Bed Color (Checked box) Black (Checked box) Brown (Checked box) Gray Wound Tissue (checked box) Necrotic Wound Bed Wound Margins (checked box) Intact Surrounding Tissue (checked box) red... Current Interventions. (checked box) Air mattress (checked box) Dietary interventions (checked box) Frequent position changes (checked box) Keep clean and dry (checked box) Wheelchair cushion Date Family Notified (blank) Date Physician Notified (blank) Comments Clean apply Santyl/[MEDICATION NAME] and cover with sacral patch/foam daily (and) PRN... Wound Update Change in Measurement..." There was no documentation the physician, family or interested party was notified of changes to the resident's pressure ulcer. A standing order for (named physician #1), dated 02/22/15 at 11:00 p.m., documented, "...Wounds...Stage I pressure ulcer- Apply skin barrier cream, and ensure resident is being turned and changed approx q 2 h...Friction- Apply transparent film, and change q 3-5 days and prn loosening/soiling. DC when healed... Stage II a. Blister- Apply skin prep/[MEDICATION NAME] to wound edges and apply transparent film. Change q 3-5 days and prn soiled. D/C when healed. b. Abrasion/Crater- Clean wound with DWC or saline, dry with 4x4 guaze, apply [MEDICATION NAME] or skin prep, apply foam dressing, and secure with tape. Change q 3 days and prn loosening or soiling. D/C when healed. c. Pressure- Apply [MEDICATION NAME] to affected area (please specify) twice daily and prn soiling... Attention Pharmacy: Please send the medications circled above..." The section identified as wounds, on the standing orders document, had no orders circled for initiation and/or pharmacy ordering. A skilled nurse note, dated 02/23/15 at 4:11 a.m., documented, "...Resident c/o pain to lower back/sacral area and neck d/t air mattress deflated...dressing changed, drainaged (sic) noted on dressing with very foul odor, wound bed area black in color at top of sacral area, and red opened area to rest of wound, cleaned area, dried, hydrogel then (sic) dressing applied. Tol well." There was no documentation of family, interested party or physician notification in the clinical record related to wound changes. A weekly skin assessment, dated 02/24/15, documented, "...Wound Origination...(checked box) hospital... Location of Wound Gluteal Crease Wound Length 9.2 CM Wound Width 9.2 CM Drainage (checked box) scant Drainage Color (checked box) clear Wound Drainage Odor (checked box) Absent Wound Bed Color (Checked box) Black (Checked box) Brown (Checked box) Gray (Checked box) Red (Checked box) Yellow Wound Tissue (checked box) Eschar (checked box) Necrotic Wound Bed Wound Margins (checked box) Intact Surrounding Tissue (checked box) pink... Current Interventions. (checked box) Air mattress (checked box) Dietary interventions (checked box) Frequent position changes (checked box) Keep clean and dry (checked box) Wheelchair cushion Date Family Notified (blank) Date Physician Notified (blank) Comments ...Counseled PT on eating better. P.T. in to assess. Discussed with Dr. Pt's status... Wound Update Change in Measurement..." There was no documentation the family or interested party was notified of changes to the resident's pressure ulcer. A physician's orders [REDACTED]. A treatment administration record, dated February 2015, documented, "...Santyl 250 unit/gram (Layer) ointment (Gram) topical every one day starting 02/24/15...Pressure Ulcer, Unstageble (sic). Notes: Clean wound apply Santyl (and) [MEDICATION NAME] cover with sacral patch daily..." The Santyl and [MEDICATION NAME] wound treatment was not documented as administered. On 02/24/15 at 4:25 p.m., the DON was asked when the resident acquired the intergluteal pressure ulcer. He stated the wound was acquired at the facility. He further stated the wound was first observed on 2/15/15, which was a Sunday. He then stated he was notified on 02/16/15 and performed an assessment of the wound. He was then asked to review the resident's treatment administration records and physician orders. He was asked if he could explain why an order for [REDACTED]. He further stated the order for Santyl and [MEDICATION NAME] was not implemented. He was then asked to review the resident's treatment administration record for Hydrogel on 02/17/15 and Santyl and [MEDICATION NAME] ointment on 02/19/15. He was asked why both treatments were documented as administered each day from 02/20/15 through 02/23/15. He stated, "I'm not sure why that's documented." On 02/24/15 at 4:45 p.m., LPN #1 was asked if she could explain the discrepancies identified on the resident's treatment administration record. She stated she wrote the order for Santyl and [MEDICATION NAME] in error. She was then asked if Santyl and [MEDICATION NAME] was utilized or Santyl and [MEDICATION NAME]. She stated, "I was doing Santyl and [MEDICATION NAME]." She was asked if the Hydrogel wound treatment, which was documented as administered, was documented in error. She stated, "Yeah." At 9:30 a.m., the resident was asked how long she had the wound on her buttocks. She stated, "I had it before I came." She further stated, "I had it at home too." She was asked if the hospital had done any wound treatments prior to her admission to the facility. She stated, "I don't know if they did any treatments there at the hospital." She was asked if she had notified anyone at the hospital or facility of the wound on her buttocks. She stated, "I don't think so." She was then asked if the facility examined her buttocks when she was admitted . She stated, "I don't remember if they looked at it when I first got here. Don't know when they first noticed it." She further stated the wound had been on her buttocks for a long time. She was asked if she had seen a physician for her wound. She stated, "No. Not really." On 02/25/15 at 9:35 a.m., RN #1 was asked if she assessed the resident's buttocks on admission. She stated, "Yes. I did." She then stated, "I can't remember if I noticed any wounds though." At 9:50 a.m., the resident was asked if she was treating her wound at home prior to her hospital admission. She stated she noticed it was there quite awhile before she was admitted to the hospital. She further stated, "I didn't see a doctor for it though." On 02/25/15 at 10:25 a.m., the DON was asked to review a nursing assessment from 02/14/15, which documented the resident had a pressure ulcer. He was then asked when he was first notified of the pressure ulcer. He stated he was notified on 02/16/15. He was then asked when was the physician, family or interested party notified the resident had developed a pressure ulcer. He stated the resident's family was at the facility on 02/16/15 and made aware of the wound then. He was asked if notification of the family was documented. He stated it was not. He further stated the physician was first made aware of the resident's pressure ulcer on 02/17/15. He was asked if the physician notification of the resident's pressure ulcer was documented. He reviewed the resident's chart and was unable to find documentation of physician notification. He was then asked if the resident's physician, family or interested party was notified of changes to the resident's wound after the wound assessment on 02/20/15. He stated, "I know (named physician #1) saw it. Should be in the note he wrote." He reviewed the resident's assessment and the physician's progress notes. He then stated he could not see where the physician, family or interested party were notified of changes to the resident's pressure ulcer. He was asked to review a nurse's note from 02/23/15 which documented the resident's pressure ulcer had drainage with a foul odor. He was asked if he could determine if the resident's family, interested party or physician was notified of the changes to the resident's pressure ulcer. He stated, "No." He was then asked if the resident's physician was notified the wrong treatment had been administered to the resident's pressure ulcer from 02/19/15 through 02/23/15. He stated, "No. Cause we just noticed that yesterday." On 02/25/15 at 10 30 a.m., CNA #1, 2 and #3 were observed while they provided incontinent care for the resident. A wound was observed on the resident's buttocks. The wound was at the level of the resident's coccyx and extended down the crease of the buttocks. The wound bed was black, brown and grey. The wound was approximately 9 cm by 9 cm. CNA #2 and #3 were asked how long the wound had been present. Both staff stated, "Since admit." CNA #2 and #3 were asked if the wound bed had always been dark in color. CNA #2 stated she was not sure how long it had looked dark in color. She further stated the wound had looked "bad" for awhile. CNA #3 stated the wound looked worse compared to what it use to look like. At 10:40 a.m., RN #1 was observed as she provided wound care for the resident. Physical therapist #1 was at bedside during the care. Physical therapist #1 was asked how long the wound the had been present. She stated, "Since admit." She was then asked how long the wound had been black in color. She stated she had first observed the resident's wound yesterday. She then stated she was not sure. She further stated she was just asked yesterday to evaluate the wound. On 02/25/15 at 2:22 p.m., physician #1 was asked if the resident's wound was considered a pressure ulcer or a wound. He stated the wound was a pressure ulcer. He was then asked when he first examined the resident's buttocks. He stated he noticed her skin the first time her saw her on 02/10/15. He stated her buttocks was a little pink. He stated he did not document his assessment of the resident's buttocks. He further stated he did not consider the pink area or her buttocks to be "even a stage one". He was then asked when he was first notified of the resident's pressure ulcer. He stated he was notified the day before he saw the wound on the 02/18/15. He then stated he observed the resident the morning of 02/19/15. He then stated, "I was out of town the 13th through the 18th. I didn't talk to anyone out there. Maybe they called my partner but I didn't hear anything." He was asked if the facility staff notified him of the resident's pressure ulcer draining a foul smelling discharge on 02/23/15. He stated he talked to a staff member on 02/24/15. He then stated he asked the staff member to have physical therapy evaluate the pressure ulcer and for sharp debridement. He was then asked if he was aware the facility had an order for [REDACTED]. He was asked if administration of the wrong ordered treatment could negatively impact the progress of the resident's pressure ulcer. He stated, "Possibly if they weren't using Santyl and only Hydrogel." He was then notified the pressure ulcer was first documented on 02/14/15. He was asked if a delay in treatment from 02/14/15 to 02/18/15 could negatively impact the progress of the resident's pressure ulcer. He said it is possible. On 02/25/15 at 2:34 p.m., the DON was asked if he administered the resident's pressure ulcer treatment on 02/21/15. He stated he had administered the treatment. He was then asked which treatment he had administered since then treatment record listed both Hydrogel and Santly and [MEDICATION NAME] were administered. He stated he administered the Santly and [MEDICATION NAME] treatment. At 2:37 p.m., RN #1 was asked if she administered the resident's pressure ulcer treatment on 02/20/15. She stated she had administered the treatment. She was then asked which treatment she had administered since the treatment record listed both Hydrogel and Santly and [MEDICATION NAME] were administered. She stated, "The Hydrogel." She was then asked why were both treatments documented as administered. She stated, "I don't know." She was then asked why she chose Hydrogel over the Santyl and [MEDICATION NAME]. She stated, "That's what I was told. I don't remember who told me." On 02/26/15 at 3:30 p.m., the DON was asked why he wrote an order for [REDACTED]. He was then asked if the facility had standing order for wound treatments. He stated, "Yeah." He then reviewed the physician standing orders for stage two pressure ulcers. He was notified the standing orders did not include Hydrogel. He was also informed the order sheet was initiated on 02/22/15 and no treatments were identified to be initiated for the resident's pressure ulcer. He was then asked if it is a routine practice to write an order for [REDACTED].

Based on observation, clinical record review, staff and resident interviews, hospital record review and review of facility policy and procedure, it was determined the facility failed to: ~ complete a thorough skin assessment on admission; ~ notify the physician promptly of skin breakdown; ~ ensure physician's orders were obtained for treatment; ~ ensure treatments were not provided without physician's orders; ~ ensure the correct treatments were provided; and ~ notify the physician promptly of changes in the wound, including increases in wound size, the development of eschar and/or necrotic tissue, and the development of a foul odor for one (#2) of two sampled residents reviewed for pressure ulcers. The resident's wound progressed from a stage II to an unstageable wound with necrotic tissue. This had the potential to affect nine residents identified by the facility who were at high risk for the development of pressure ulcers. Two residents were identified by the facility with pressure ulcers. Findings: A facility policy, titled Pressure Ulcer, Care and Prevention Of, documented: "...Purpose: To prevent and treat further breakdown of pressure sores... General Guidelines for assessment may include, but are not limited to: Skin at risk General condition of skin Any pain; report to physician... Incontinence of bowel and bladder... Procedure 1. Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk for a pressure ulcer to begin... treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers..." A facility policy, titled Change of Condition Notification, documented: "Notification of change of condition include. Resident Physician Family Member/responsible party/POA/Guardian The DONC, Administrator and MDS Coordinator are notified. Means of notification include telephone, in person, written communication. A family meeting may be arranged." A facility policy, titled Change in Condition, documented: "A change in condition requires increased attention from staff to provide adequate care for residents. Some changes are temporary and require only a temporary change in the intensity of care required until the resident recovers adequately enough to allow for the resumption of the care prior to the change in condition... Assessments: Whether the change is permanent or temporary, the resident requires an assessment to determine the need for additional care. Through the assessments a plan or approach will determine the intensity and duration of care required. Documenation of the assessment of symptoms and conditions must be part of the resident record, conveyed to care staff across all shifts and followed until the change in condition has been resolved or determined to need further assessments..." An emergency department report, dated 02/01/15, for resident #2 documented, "...Stated complaint: Fall... History of Present Illness: She has been living and caring for herself. Patient's friend has noticed that since last fall patient has become more withdrawn. She has not wanted to get out of the house...The friend called nearly every day but the patient did not answer the phone on Friday which was 2 days ago. She went over to her house to check on her and she seemed to be 'doing ok'. She tried calling her several times today and the patient did not answer the phone. When she went to her house she found the patient lying in the floor in the bathroom. She thinks the patient couldn't (sic) been there for at least 2 days. Patient does not remember falling or lying on the floor...She does admit to feeling depressed... Skin: No rashes... General Appearance: ...She is disheveled and unkempt... ED Course/Procedures ...Patient is very withdrawn and depressed. She is unable to care for herself and does not need to be living alone. She is in rhabdomylosis... Impression: Primary Impression: Volume depletion Additional Impression: Rhabdomylosis, Urinary Tract Infection..." A Behavioral Medicine Consult, dated 02/02/15, documented, "...Reason for consultation: Evaluation for severe depression... History of presenting illness: The patient was brought to the ER after she was found by her friend on the floor and it was reported that the patient was found on the floor in the bathroom...Patient's friend usually checks on her and for the last 2 days, she was calling the patient and the patient was not responding. The friend also reported the patient has been very depressed...and for the last 2 to 3 weeks, the patient was isolating herself and not coming out of the house...when she could not find her for 2 days, she was (sic) eventually got into the house and found her passed out on the bathroom floor. The patient had evidence of a urinary tract infection, severe rhabdomylosis, generalized weakness, volume depletion and dehydration..." A hospital pain assessment, dated 02/04/15, documented, "...Presence of Pain Yes Pain assessment label Posterior Coccyx Pain behavior description Moaning Pain comment c/o tailbone with bed mob and bed transfers..." Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment, dated 02/06/15, documented, "...Skin...Does this resident have a [MEDICAL CONDITION] or an open wound...Specify location: (blank)... Does this resident have a pressure ulcer...Specify location: (blank)... Did the resident have a skin ulcer that was resolved or cured in last 90 days...Specify location: (blank)..." An admission assessment, dated 02/13/15, documented the resident was cognitively alert in skills for daily decision making. She required extensive assistance from staff with transfers, ambulation, dressing, hygiene and bathing. She was frequently incontinent of bowel and bladder. She had an unhealed stage two pressure ulcer present prior to admission. A skilled nurse assessment, dated 02/14/15, documented, "...Skin Condition. Pressure Ulcer..." A skilled nurse note, dated 02/15/15 at 4:08 a.m., documented, "...Had incontinent bowel episode x 1 in briefs. W/C replaced at wound at intergluteal cleft..." A skilled nurse note, dated 02/16/15 at 4:20 a.m., documented, "...Allowed staff to place her in bed to sleep due to wound. W/C remains at wound at intergluteal cleft..." A wound assessment, dated 02/16/15, documented, "...Wound origination...(checked box) Facility... Wound Type Pressure Ulcer Wound Location Buttocks Crease Wound Stage Stage 2 Where Acquired Facility Wound Depth Superficial Wound Length 7.0 Wound Width 3.0 Drainage Absent Drainage Color (blank) Odor Absent Wound Bed Color (checked box) pink Wound Tissue Granulation Surrounding Tissue (checked box) clear Date Family Notified (blank) Date Physician Notified (blank)..." A skilled nurse note, dated 02/17/15 at 12:34 a.m., documented, "...dressing still intact to sacral area, report rec'd from prev shift that res has open area to buttocks and dressing was applied..." There was no physician order for [REDACTED]. A care plan, dated 02/17/15 and last updated 02/19/15, documented, "Problems: (named resident) is at risk of pressure ulcer and impaired skin integrity r/t stage II pressure ulce (sic) to coccyx and debility... Interventions: Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown... Perform nutritional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown... Use pillows, pads, or wedges to reduce pressure on heals (sic) and pressure points. Turn/reposition... Nursing to perform wound care as ordered and document..." A care plan, dated 02/17/15, documented, "Problems: (named resident) is at risk for infection r/t debility; stage II pressure ulcer to coccyx. Interventions: Assess, document and report signs of systemic or localized infection such as change in energy level, change in vital signs, erythemia, indurations, discharge, foul odor..." An unsigned physician's order, dated 02/17/15, documented, "...Clean buttock c wound cleanser. Pat dry, apply hydrogel (and) cover c padded dressing Q day and PRN. Critical care give 30 ml po Q day for wound healing." A treatment administration record, dated February 2015, documented, "...Hydrogel (1)...Gram topical...starting 2/17/15...Notes: Clean buttocks wound with wound cleanser, pat dry and apply hydrogel and cover with padded dressing..." The Hydrogel wound treatment was documented as administered 02/18/15 through 02/23/15. A physician progress notes [REDACTED]. Skin...sacral wound 4 x 7 cm c eschar, no odor... Unstageable wound, sacrum. Santyl/[MEDICATION NAME]" A physician's order, dated 02/19/15, documented, "...Critical care 30 cc po BID...Change sacral wound dressing to Santyl and [MEDICATION NAME] q day..." A treatment administration record,dated February 2015, documented, "...Santyl 250 unit/gram (Layer) ointment (Gram) topical every one day starting 02/20/15...Discontinued (02/24/15)...Pressure ulcer, Unstageble (sic). Notes: Clean area apply Santyl and [MEDICATION NAME] cover with sacral patch daily (and) PRN..." The Santyl and [MEDICATION NAME] wound treatment was documented as administered 02/20/15 through 02/23/15. A weekly skin assessment, dated 02/20/15, documented, "...Wound Origination...(checked box) hospital... Location of Wound Gluteal Crease Wound Length 7.0 CM Wound Width 3.0 CM Drainage (checked box) absent Drainage Color (checked box) No drainage Wound Drainage Odor (checked box) Absent Wound Bed Color (Checked box) Black (Checked box) Brown (Checked box) Gray Wound Tissue (checked box) Necrotic Wound Bed Wound Margins (checked box) Intact Surrounding Tissue (checked box) red... Current Interventions. (checked box) Air mattress (checked box) Dietary interventions (checked box) Frequent position changes (checked box) Keep clean and dry (checked box) Wheelchair cushion Date Family Notified (blank) Date Physician Notified (blank) Comments Clean apply Santyl/[MEDICATION NAME] and cover with sacral patch/foam daily (and) PRN... Wound Update Change in Measurement..." A skilled nurse note, dated 02/22/15 at 5:43 a.m., documented, "...As of 2/19 res has new orders for her sacral area wound, critical care liquid and Santyl ointment daily and prn..." A standing order for (named physician #1), dated 02/22/15 at 11:00 p.m., documented, "...Wounds...Stage I pressure ulcer- Apply skin barrier cream, and ensure resident is being turned and changed approx q 2 h...Friction- Apply transparent film, and change q 3-5 days and prn loosening/soiling. DC when healed... Stage II a. Blister- Apply skin prep/[MEDICATION NAME] to wound edges and apply transparent film. Change q 3-5 days and prn soiled. D/C when healed. b. Abrasion/Crater- Clean wound with DWC or saline, dry with 4x4 guaze, apply [MEDICATION NAME] or skin prep, apply foam dressing, and secure with tape. Change q 3 days and prn loosening or soiling. D/C when healed. c. Pressure- Apply [MEDICATION NAME] to affected area (please specify) twice daily and prn soiling... Attention Pharmacy: Please send the medications circled above..." The section identified as wounds, on the standing orders document, had no orders circled for initiation and/or pharmacy ordering. A skilled nurse note, dated 02/23/15 at 4:11 a.m., documented, "...Resident c/o pain to lower back/sacral area and neck d/t air mattress deflated...dressing changed, drainaged (sic) noted on dressing with very foul odor, wound bed area black in color at top of sacral area, and red opened area to rest of wound, cleaned area, dried, hydrogel then (sic) dressing applied. Tol well." A weekly skin assessment, dated 02/24/15, documented, "...Wound Origination...(checked box) hospital... Location of Wound Gluteal Crease Wound Length 9.2 CM Wound Width 9.2 CM Drainage (checked box) scant Drainage Color (checked box) clear Wound Drainage Odor (checked box) Absent Wound Bed Color (Checked box) Black (Checked box) Brown (Checked box) Gray (Checked box) Red (Checked box) Yellow Wound Tissue (checked box) Eschar (checked box) Necrotic Wound Bed Wound Margins (checked box) Intact Surrounding Tissue (checked box) pink... Current Interventions. (checked box) Air mattress (checked box) Dietary interventions (checked box) Frequent position changes (checked box) Keep clean and dry (checked box) Wheelchair cushion Date Family Notified (blank) Date Physician Notified (blank) Comments ...Counseled PT on eating better. P.T. in to assess. Discussed with Dr. Pt's status... Wound Update Change in Measurement..." A physician's order, dated 02/24/15, documented, "...PT eval for sharp debridement of sacral wound..." A treatment administration record, dated February 2015, documented, "...Santyl 250 unit/gram (Layer) ointment (Gram) topical every one day starting 02/24/15...Pressure Ulcer, Unstageble (sic). Notes: Clean wound apply Santyl (and) [MEDICATION NAME] cover with sacral patch daily..." The Santyl and [MEDICATION NAME] wound treatment was not documented as administered. On 02/24/15 at 4:25 p.m., the DON was asked when the resident acquired the intergluteal pressure ulcer. He stated the wound was acquired at the facility. He further stated the wound was first observed on 2/15/15, which was a Sunday. He then stated he was notified on 02/16/15 and performed an assessment of the wound. He was then asked to review the resident's treatment administration records and physician orders. He was asked if he could explain why an order for [REDACTED]. He further stated the order for Santyl and [MEDICATION NAME] was not implemented. He was then asked to review the resident's treatment administration record for Hydrogel on 02/17/15 and Santyl and [MEDICATION NAME] ointment on 02/19/15. He was asked why both treatments were documented as administered each day from 02/20/15 through 02/23/15. He stated, "I'm not sure why that's documented." On 02/24/15 at 4:45 p.m., LPN #1 was asked if she could explain the discrepancies identified on the resident's treatment administration record. She stated she wrote the order for Santyl and [MEDICATION NAME] in error. She was then asked if Santyl and [MEDICATION NAME] was utilized or Santyl and [MEDICATION NAME]. She stated, "I was doing Santyl and [MEDICATION NAME]." She was asked if the Hydrogel wound treatment, which was documented as administered, was documented in error. She stated, "Yeah." On 02/25/15 at 9:15 a.m., the MDS/Care plan coordinator #2 was asked if she completed the resident's admission MDS assessment for skin issues. She stated she complete the portion of the assessment. She was then asked if the resident had a pressure ulcer prior to admission as documented in her assessment. She stated, "I saw in her hospital H and P (history and physical) she had a wound." She then said she thought the wound was found a few days after admission to the facility. She then stated, "Maybe or probably was there on admit." At 9:30 a.m., the resident was asked how long she had the wound on her buttocks. She stated, "I had it before I came." She further stated, "I had it at home too." She was asked if the hospital had done any wound treatments prior to her admission to the facility. She stated, "I don't know if they did any treatments there at the hospital." She was asked if she had notified anyone at the hospital or facility of the wound on her buttocks. She stated, "I don't think so." She was then asked if the facility examined her buttocks when she was admitted . She stated, "I don't remember if they looked at it when I first got here. Don't know when they first noticed it." She further stated the wound had been on her buttocks for a long time. She was asked if she had seen a physician for her wound. She stated, "No. Not really." On 02/25/15 at 9:35 a.m., RN #1 was asked if she assessed the resident's buttocks on admission. She stated, "Yes. I did." She then stated, "I can't remember if I noticed any wounds though." At 9:48 a.m., MDS/care plan coordinator #2 stated she received notification of the resident's pressure ulcer on 02/16/15. She then stated the resident's assessment was submitted on 02/16/15. She further stated she entered the information related to when the resident's pressure ulcer started in error. At 9:50 a.m., the resident was asked if she was treating her wound at home prior to her hospital admission. She stated she noticed it was there quite awhile before she was admitted to the hospital. She further stated, "I didn't see a doctor for it though." On 02/25/15 at 10:25 a.m., the DON was asked to review the nursing admission assessment from 02/14/15, which documented the resident had a pressure ulcer. He was then asked when he was first notified of the pressure ulcer. He stated he was notified on 02/16/15. He was then asked when was the physician, family or interested party notified the resident had developed a pressure ulcer. He stated the resident's family was at the facility on 02/16/15 and made aware of the wound then. He was asked if notification of the family was documented. He stated it was not. He further stated the physician was first made aware of the resident's pressure ulcer on 02/17/15. He was asked if the physician notification of the resident's pressure ulcer was documented. He reviewed the resident's chart and was unable to find documentation of physician notification. He was then asked if the resident's physician, family or interested party was notified of changes to the resident's wound after the wound assessment on 02/20/15. He stated, "I know (named physician #1) saw it. Should be in the note he wrote." He reviewed the resident's assessment and the physician's progress notes. He then stated he could not see where the physician, family or interested party were notified of changes to the resident's pressure ulcer. He was asked to review a nurse's note from 02/23/15 which documented the resident's pressure ulcer had drainage with a foul odor. He was asked if he could determine if the resident's family, interested party or physician was notified of the changes to the resident's pressure ulcer. He stated, "No." He was then asked if the resident's physician was notified the wrong treatment had been administered to the resident's pressure ulcer from 02/19/15 through 02/23/15. He stated, "No. Cause we just noticed that yesterday." On 02/25/15 at 10:30 a.m., CNA #1, 2 and #3 were observed while they provided incontinent care for the resident. A wound was observed on the resident's buttocks. The wound was at the level of the resident's coccyx and extended down the crease of the buttocks. The wound bed was black, brown and grey. The wound was approximately 9 cm by 9 cm. CNA #2 and #3 were asked how long the wound had been present. Both staff stated, "Since admit." CNA #2 and #3 were asked if the wound bed had always been dark in color. CNA #2 stated she was not sure how long it had looked dark in color. She further stated the wound had looked "bad" for awhile. CNA #3 stated the wound looked worse compared to what it use to look like. At 10:40 a.m., RN #1 was observed as she provided wound care for the resident. Physical therapist #1 was at bedside during the care. Physical therapist #1 was asked how long the wound the had been present. She stated, "Since admit." She was then asked how long the wound had been black in color. She stated she had first observed the resident's wound yesterday. She then stated she was not sure. She further stated she was just asked yesterday to evaluate the wound. On 02/25/15 at 12:30 p.m., MDS/care plan coordinator #1 was asked if a resident's pressure ulcer care plan is updated and revised when new orders are received. She stated, "When we get new orders we write the new ones on the care plan." At 12:31 p.m., MDS/care plan coordinator #2 was asked to review the resident's care plan for a stage two pressure ulcer. She was asked if the care plan had been updated with the new wound treatments, interventions and changes in pressure ulcer staging. She stated each time a new order is written the date of the order is written on the care plan. She then stated the resident's care plan is not updated with any specifics from the order. She then stated if a new intervention is started only a date of the assessment is entered on the care plan. She further stated there are no specifics listed to outline new interventions. She then stated, "I have to tell you we are new and learning." On 02/25/15 at 2:22 p.m., physician #1 was asked if the resident's wound was considered a pressure ulcer or a wound. He stated the wound was a pressure ulcer. He was then asked when he first examined the resident's buttocks. He stated he noticed her skin the first time he saw her on 02/10/15. He stated her buttocks was a little pink. He stated he did not document his assessment of the resident's buttocks. He further stated he did not consider the pink area on her buttocks to be "even a stage one". He was then asked when he was first notified of the resident's pressure ulcer. He stated he was notified the day before he saw the wound on the 02/18/15. He then stated he observed the resident the morning of 02/19/15. He then stated, "I was out of town the 13th through the 18th. I didn't talk to anyone out there. Maybe they called my partner but I didn't hear anything." He was asked if the facility staff notified him of the resident's pressure ulcer draining a foul smelling discharge on 02/23/15. He stated he talked to a staff member on 02/24/15. He then stated he asked the staff member to have physical therapy evaluate the pressure ulcer for possible sharp debridment. He was then asked if he was aware the facility had an order for [REDACTED]. He was asked if administration of the wrong ordered treatment could negatively impact the progress of the resident's pressure ulcer. He stated, "Possibly if they weren't using Santyl and only Hydrogel." He was then notified the pressure ulcer was first documented on 02/14/15. He was asked if a delay in treatment from 02/14/15 to 02/18/15 could negatively impact the progress of the resident's pressure ulcer. He said it is possible. On 02/25/15 at 2:34 p.m., the DON was asked if he administered the resident's pressure ulcer treatment on 02/21/15. He stated he had administered the treatment. He was then asked which treatment he had administered since the treatment record listed both Hydrogel and Santly and [MEDICATION NAME] were administered. He stated he administered the Santyl and [MEDICATION NAME] treatment. At 2:37 p.m., RN #1 was asked if she administered the resident's pressure ulcer treatment on 02/20/15. She stated she had administered the treatment. She was then asked which treatment she had administered since the treatment record listed both Hydrogel and Santyl and [MEDICATION NAME] were administered. She stated, "The Hydrogel." She was then asked why were both treatments documented as administered. She stated, "I don't know." She was then asked why she chose Hydrogel over the Santyl and [MEDICATION NAME]. She stated, "That's what I was told. I don't remember who told me." On 02/26/15 at 3:30 p.m., the DON was asked why he wrote an order for [REDACTED]. He was then asked if the facility had a standing order for wound treatments. He stated, "Yeah." He then reviewed the physician standing orders for stage two pressure ulcers. He was notified the standing orders did not include Hydrogel. He was also informed the order sheet was initiated on 02/22/15 and no treatments were identified to be initiated for the resident's pressure ulcer. He was then asked if it is a routine practice to write an order for [REDACTED].

Based on observation, record review and interviews, it was determined the facility failed to ensure residents who had a reoccurrence of falls with injuries were assessed and had interventions in place to aid in the prevention of falls with injuries for two (#4 and #7) of eight sampled residents. This deficient practice resulted in an actual harm. The DON identified 24 residents who had sustained falls from 07/01/12 through 09/26/12. Findings: The "Falls Management Program" policy documented, "...Goals of Falls Management Program will be to promote a safe environment of all residents and limit the risk for falls/injuries as much as possible. The DON/ADONOC (ADONOC? quoted from policy book-staff not able to state what this abbreviation stands for.) will complete the Tracking Record for Improving Patient Safety (TRIPS) to identify any new safety concerns; any new changes for the resident's Plan of Care will be reported to the Falls Management Team. The DON/ADONOC or MDS Coordinator will enter the changes in the Plan of Care as indicated. Any orders received from the physician in reference to the faxed fall report will be implemented by the Charge Nurse. Possible interventions include but are not limited to fall assistive devices i.e. bed alarms, personal alarms, low bed/concave mattress and/or individualized timed frequency checks, and other interventions as identified." 1. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An undated fall risk assessment documented the resident was a high risk for falls with a score of 15. A score of ten or greater indicated a risk. The assessment was signed by the charge nurse working at the time of admission. An initial care plan dated 06/12/12, documented, "Fall/Safety Risk: Goal: no injury/falls; interventions: assess for contributors: BPs standing, sitting, pains, need to void, meds, gait. Encourage to use call light. PT referral. Instruct on safety measures...ADL decline...assist with ambulation/transfers prn, assist with toileting..." A "Fall interventions Plan" dated 06/12/12, documented, "Risk factor: mobility: selected interventions: increase staff assistance to and from toilet, during ambulation, during all transfers, with ADLS...correct height of bed, toilet or chair: keep bed at correct height...increase bathroom safety: use adequate handrails support...promote wheel chair safety: use same wheel chair consistently, check brakes and instruct pt on use...therapy skilled... Risk factor: unsafe behavior; selected interventions: increase assistance and surveillance: personal or chair alarm, answer call lights promptly, increase activities involvement...reduce risk for injury: non skid socks/shoes...increase comfort: pain management, frequent rest periods, exercise..." An admission assessment dated [DATE], documented the resident's cognition was intact, required extensive assistance with transfers, locomotion off the unit, and toileting. The resident also was continent of bowel and bladder and had falls within the previous month prior to admission. The assessment also documented the resident was able to stabilize self with staff assistance during the following: moving from a seated to a standing position, walking, turning around, moving on and off the toilet and surface to surface transfers. The CAA summary dated 06/18/12, documented the resident triggered for falls and that it would be developed on the care plan. "Fall Interventions Monitor" forms dated 06/12/12, 06/19/12, 06/25/12 and 07/03/12, documented, "Are interventions effective: yes. Changes: none comments no falls since admit..." A care plan dated 06/22/12, documented, "Routine treatment: Fall precautions...Diagnoses: [REDACTED]. Problem: Resident has a history of falls and is at risk for increased falls and fractures as evidenced by antidepressant & anxiolytic meds narcotic analgesic... Goal: dignity will be maintained incidence of falls will be reduced an no occurrence of injury will occur... Approach: encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, therapy to eval and treat per orders, anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encourage socialization and activity attendance as tolerates, bed or chair alarm... Problem: ADL function...Goal: will maintain a sense of dignity...ADL needs will be met /c staff assistance...Approach...assist with ADLs as needed...assist with transfers as needed..." A second care plan dated 06/22/12, documented, "Problem: Fall precautions...Goal: Client will be free from injurious falls X next review... Approaches: Encourage to ask for assistance with transfers and ambulation attempts...call light within reach...eliminate potential hazards...repeated reminders of safety hazards...assist with all transfers and ambulations...instruct to request assist from staff...discourage from transferring/ambulation without assistance...provide with w/c...observe for changes in gait or ambulation abilities...clean all spills promptly...assit (sic) as necessary to prevent falls/injuries..." An incident report dated 07/08/12 at 9:30 p.m., documented, "Resident self transferring from toilet to wc 1 brake wasn't locked. Resident lost balance & went to floor. ST to RLE & LUE obtained. Did not hit head...was first aid (sic) administered? yes ST dressings..." No intervention or step to prevent a recurrence of falls was documented on the incident report. There was no documentation in the nurse's note dated 07/08/12, regarding the resident's fall or interventions to prevent further occurrences of falls. A review of the "Brookhaven Extensive Care" daily schedule dated 07/08/12, for the evening shift, documented three CNAs were working at the time of the fall. One CNA was assigned to hall 100, one to hall 200 and one floated between both halls. A "TRIPS" dated 07/09/12, documented the resident had a fall with minor injuries. There was no documentation on the form to verify the facility assessed the resident's continual falls and/or implemented interventions to aide in the prevention of further falls with injury. A "Fall Interventions Monitor" form dated 07/10/12, documented, "Are interventions effective: yes. Changes: alarms, comments last fall 7-8-12. CPOC." An incident report dated 07/22/12 at 11:30 a.m., documented, "Resident stood up/s assist, fell on bed. Did not hit head denies pain...type of injury other: S/T...was first aid administered? yes s/t on (L) knee..." No intervention or step to prevent a recurrence of falls was documented on the incident report. There was no documentation in the nurse's note dated 07/22/12, regarding the resident's fall and/or interventions to prevent further occurrences of falls. A nurse's note dated 07/23/12 at 5:00 a.m., documented, "Resident c/o SOB again & called a friend to take her to ER...attempted to page Dr. (Name deleted) number disconnected..." A DX report from the hospital dated 07/23/12, documented, "Left wrist, 3 views with navicular for fall. Findings...a non displaced fracture at the distal radius..." A hospital physician order [REDACTED].@ 2:10 p.m./c Dr (Name deleted) ortho..." A nurse's note entry on 07/23/12 at 10:15 a.m., documented, "Resident returned from hospital follow up appointments scheduled..." A report sent to the Oklahoma State Department of Health, documented, "On 07/23/12, (Resident) was having difficulty breathing, before charge nurse could make arrangements (Resident) called a friend to transport her to the hospital. Upon return from the hospital, she had an x-ray showing a fracture to right wrist. She had an appointment 07/24/12 with an ortho, who casted (sp) it...it was discovered that on 07/22/12 at 1130, (Resident) had gotten up in her room without assistance and fell ...catching herself on her arms on her bed...at 0230 (2:30 a.m.) on 07/23/12, (Resident) reported to the charge nurse that she had pain in her right wrist. A mobile x-ray was ordered for first thing in the morning...Alarms had been placed in her chair and on her bed, and she was reminded to use her call light for any transfers...her most recent fall risk assessment was 15, indicating risk for falls...interventions include: increase staff assistance during all transfers, with ADLs, to and from toilet, and during ambulation; keep bed at correct height, increase bathroom safety by using adequate handrails support; promote wheel chair safety by using the same wheelchair consistently and checking brakes and instructing the patient on use; skilled therapy, increase assistance and surveillance with pressure change alarm, personal alarm, answering call lights promptly, and increasing activities involvement, reduce risk of injury with non-skid socks and shoes; increase comfort with pain management, frequent rest periods, and exercise...continually refuses to use her call light and continually gets up from her bed and from her chair by herself. Staff checks her frequently for safety and reminds her frequently of safety interventions..." There was no documentation in the nurse's note the resident had a displaced fracture. There was no documentation in the clinical record the facility assessed the resident's fall and implemented different interventions to prevent further occurrences of falls with injuries. The resident's care plan did not reflect any changes in interventions to prevent a recurrence of falls with injuries. An incident report dated 07/25/12 at 1:30 a.m., documented, "Resident was walking self from bathroom & fell on bottom. Did not hit head, denies pain...type of injury: other skin tear...was first aid (sic) administered? no..." There were no documented interventions or steps to prevent a recurrence of falls on the incident report. A nurse's note dated 07/25/12 at 7:30 a.m., documented, "Notified by staff that resident had fallen. Found resident sitting in floor. Stated she was coming out of bathroom and fell ...Sm s/t to (L) upper arm. Explained to resident that due to several falls lately she needs to use call light and ask for help anytime she needs to get up. Resident stated she wouldn't do that because it takes too long. Tried to reassure staff would assist as soon as possible...talked to therapy about reiterating safety issues. Will monitor for changes." A review of the "Brookhaven Extensive Care" daily schedule dated 07/24/12, for the evening shift, documented four CNAs were working at the time of the fall. Two CNAs were assigned on hall 200, where the fall occurred on 07/25/12 at 1:30 a.m. (The facility did 12 hour shifts, beginning on 07/24/12 and ending on 07/25/12, for the evening shift.) A physician's progress note dated 07/26/12, documented, "...She was sent to the...hospital emergency room because of abnormal blood pressures and frequent falling...her skin is very fragile and she sustained multiple skin tears...assessment: cast on (L) arm and hand..." A "TRIPS" dated 08/01/12, documented the resident had a fall with minor and major injuries on 07/22/12. The major injury was identified as a fracture. A second "TRIPS" dated 08/01/12,documented the resident had a fall with minor injuries on 07/25/12. There was no documentation on the forms to indicate the facility assessed the resident's continual falls and implemented interventions to aide in the prevention of further falls with injuries. A "Fall Interventions Monitor" form dated 08/06/12, documented, "Are interventions effective: no, changes: none; comments: continually refuses to use call light gets up to ambulate & transfers/s assist. States she doesn't need help. Last fall 7-25-12 CPOC." An incident report dated 08/07/12 at 4:15 a.m., documented, "Resident was walking back from bathroom slipped and fell on to floor lg skin tear on inside left arm and on left shoulder...type of injury other S/T..." A second incident report dated 08/07/12 at 4:15 a.m., documented, "Res assisted self to bathroom and she stated she slipped and fell in bathroom. Skin tears noted on (L) arm and shoulder...type of injury other skin tear..." No intervention or step to prevent a recurrence of falls was documented on either incident report. A daily skilled nurse's note dated 08/07/12 at 4:15 a.m., documented, "Resident pulled emergency cord and CNA found her sitting in her chair with skin tear...she stated she slipped in B/R floor and fell backwards not hitting her head...she had a 12 cm S/T on her inside (L) arm above cast and a 10 cm S/T on her (L) shoulder...S/T covered with nonstick bandage and arm was wrapped in gauze and back covered with op site (sic)...resident c/o pain and was given PRN pain med at 0430 (4:30 a.m.)..." A "TRIPS" dated 08/07/12, documented the resident had a fall with minor injuries on 08/07/12. There was no documentation to verify the facility assessed the resident's continued falls and/or implemented interventions to aide in the prevention of further falls. A review of the "Brookhaven Extensive Care" daily schedule dated 08/06/12, for the evening shift, documented four CNAs were working at the time of the fall. Two CNAs were assigned on hall 200 where the fall occurred on 08/07/12 at 4:15 a.m. (The facility did 12 hour shifts, beginning on 08/06/12 and ending on 08/07/12, for the evening shift.) A physician's progress note dated 08/09/12, documented, "...assessment: skin tears..." A "Fall Interventions Monitor" form dated 08/13/12, documented, "Are interventions effective: yes; changes: none; comments: Last fall 8-7-12 CPOC..." A 30 day assessment dated [DATE], documented the resident had one fall with with an injury such as abrasions and skin tears. The assessment did not document the resident had a major injury of a bone fracture. There were no updates to the resident's care plan after the 30 day assessment. The resident had four falls from 07/08/12 through 08/07/12, resulting in injuries of skin tears, abrasions and a displaced fracture. The current monthly physician's orders [REDACTED]." The fall precautions were first started on 06/11/12. "Fall" was listed as the principal [DIAGNOSES REDACTED]. During the initial tour of the facility on 09/24/12 at 9:30 a.m., LPN #3 indicated the resident was a high risk for falls and had a fractured wrist. On 09/24/12 at 12:35 p.m., the resident's room was observed. An aide was observed at the opening of the door to the bathroom conversing with the resident. The resident's oxygen concentrator was located in the corner by the bed, approximately 20 feet from the bathroom. The tubing was observed entering the bathroom and was bunched up on the floor. An interview was conducted on 09/25/12 at 9:45 a.m., with LPN #2 regarding the resident's falls. She was asked about the resident's falls with injuries and if anyone assessed the falls to determine the cause of them. She stated, "She gets tangled up in her oxygen cord and looses her balance." She was asked what interventions the facility had in place to prevent recurring falls. She stated, "Try to keep a closer eye on her; watching her more often; keep pathways clear and go by and remind her to ask for help." She then stated, "Can't always keep a close enough eye on her because there is not enough staff all the time." The LPN was asked if the interventions were appropriate to prevent recurring falls with injuries. She stated, "The pathways are clear except for the oxygen tubing." An interview was conducted on 09/25/12 at 9:52 a.m., with the ADON regarding the resident's continual falls and injuries. He was asked what the resident's fall precautions were. He stated, "Encourage to use call light, check and assist to bathroom." He then stated each resident's precautions are based on the individual. He was asked what interventions had been put in place to prevent the recurrence of falls. He stated, "Toileting after meals, therapy for strength, and body alarm." He was asked when the interventions had been implemented. He stated, "06/22/12." He was asked if the resident's falls had been assessed and interventions changed and updated to aide in the prevention of further falls with injuries. He stated, "No. They were not changed and had been the same since 06/22/12." An interview was conducted on 09/25/12 at 10:20 a.m., with the resident. She was asked how her falls had occurred. She stated, "It's hard to get around with thirty feet of tubing tangled up in my legs." She was asked if she had a chair and bed alarm in place. She stated, "No. I never had a bed or chair alarm." She was asked how often staff came by and checked on her. She stated, 'Every two hours." On 09/25/12 at 11:45 a.m., LPN #2 was asked to observe the resident in her room. She was asked if the resident had a chair and bed alarm. She stated, "There are no alarms on the chair and bed." She was asked about the oxygen tubing length. She pulled out the oxygen tubing and stated, "It's a hazard with the long oxygen tubing." An interview was conducted on 09/26/12 at 11:30 a.m., with the DON and ADON regarding the resident's falls with injuries. She was asked if there was any documentation in the clinical record regarding the fractured wrist. She stated, "I have not found anything new. there is nothing in the record about the fractured wrist." She was asked if the nurses' notes should address the resident's falls. She stated all falls should be documented on the incident report and in the nurses' notes. She also indicated all incident reports should have documentation regarding interventions. The DON and ADON acknowledged the lack of documentation and interventions. The DON was asked where the x-ray report was found. She stated the hospital had to fax the report. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE], documented the resident was a high risk for falls with a score of 14. A score of ten or greater indicated the resident was a high risk for falls. An initial care plan dated 08/01/12, documented, "Fall/safety risk: assess for contributors: BPs, standing, sitting, pain, need to void, meds, gait; encourage to use call light, PT referral; instruct on safety measures; adaptive devices..." A "Fall interventions Plan" dated 08/02/12, documented, "Risk factor: mobility: selected interventions: increase staff assistance to and from toilet, during ambulation, during all transfers, with ADLS...correct height of bed, toilet or chair: keep bed at correct height...increase bathroom safety: use adequate handrails support...promote wheel chair safety: use same wheel chair consistently, check brakes and instruct pt on use...therapy skilled... Risk factor: unsafe behavior; selected interventions: increase assistance and surveillance: personal or chair alarm, locate patient near station, answer call lights promptly, increase activities involvement...reduce risk for injury: non skid socks/shoes...increase comfort: pain management, frequent rest periods, exercise..." An admission assessment dated [DATE], documented the resident was moderately impaired with cognitive skills for daily decision making, required extensive assistance with transfers, walking in the room, dressing and toilet use. The assessment also documented the resident stabilized self with staff assistance while moving on and off the toilet, walking, turning around, surface to surface transfers and moving from a seated to a standing position. The assessment documented the resident fell in the past month prior to admission. A care plan dated 08/10/12, documented, "Routine treatment: fall precautions.... Problem: Fall precautions. Goal: will be free of falls by the next review date... Approaches: PT and OT to evaluate and treat...eliminate potential environmental hazards...assist with turning and positioning in bed and for transfers...keep call light in reach, remind/encourage her to call for assistance...keep pathways clean and clear of clutter...observe for changes in sitting balance and transfer abilities...clean all spills promptly..." An incident report dated 08/11/12 at 12:00 p.m., documented, "Resident tried transferring self & fell on bottom...type of injury: none apparent." There was no documented intervention or step to prevent a recurrence of falls on the incident report. A "Notification of Fall Fax Alert" dated 08/11/12, documented, "Tried transferring self in bathroom & fell . Did not hit head." An incident report dated 08/20/12 at 4:00 a.m., documented, "Resident found sitting on bottom on floor. (No) injuries noted stated she was trying to get up to go to BR and misjudged bed..." No interventions were addressed. A "Notification of Fall Fax Alert" dated 08/20/12, documented, resident tried to go to bathroom unassisted & slid off bed onto bottom on floor. Did not hit head..." A nurse's note dated 08/20/12, documented, "0400 (4:00 a.m.): Resident trying to get out of bed to go to bathroom & sat on floor on bottom...no injuries..." There was no documentation in the clinical record the facility assessed the fall and changed interventions to prevent a recurrence of falls. A review of the "Brookhaven Extensive Care" daily schedule dated 08/19/12, for the evening shift, documented two CNAs were working at the time of the fall. One CNA was assigned on each hall at the time of the fall on 08/20/12 at 4:00 a.m. (The facility did 12 hour shifts, beginning on 08/19/12 and ending on 08/20/12, for the evening shift.) An incident report dated 08/21/12 at 1:05 a.m., documented, "Resident was found sitting on the floor beside bed with back leaning against frame of bed. States she sat up on side of bed and slid to floor...type of injury: abrasion to left knee and arm..." There was no documentation on the incident report to indicate the facility notified the family of the resident's fall with an injury. There was no documented intervention and/or step to prevent a recurrence of falls on the incident report. A nurse's note dated 08/21/12, documented, "0105 (1:05 a.m.): Resident was found sitting on the floor... Bed in lowest position top rails up...two sore...1 on (L) knee and 1 on (L) arm. Cleaned left open to air..." There was no documentation in the clinical record the facility notified the family of the fall. There was no documentation in the clinical record the facility had assessed the falls and/or implemented interventions to prevent a recurrence of falls. A review of the "Brookhaven Extensive Care" daily schedule dated 08/20/12, for the evening shift, documented three CNAs were working in the facility at the time of the fall. One CNA was assigned on hall 200, one on hall 100 and one floated between both hallways at the time of the fall on 08/21/12 at 1:30 a.m. (The facility did 12 hour shifts, beginning on 08/20/12 and ending on 08/21/12, for the evening shift.) An undated incident report at 2:30 a.m., documented, "She was found on her bottom beside the bed, roommate pressed her call light for help. States she is not hurt..." The facility failed to document an intervention and/or steps to prevent a recurrence of falls. A "Notification of Fall Fax Alert" dated 09/01/12, documented, "Pt. found on bottom next to bed..." A 30 day assessment dated [DATE], documented the resident had falls since the last assessment. The assessment did not indicate how many falls the resident had. A review of the "Brookhaven Extensive Care" daily schedule dated 08/30/12, for the evening shift, documented three certified nurse aide were working in the facility at the time of the fall. One certified nurse aide was assigned on hall 200 one on hall 100 and one floated between both hallways at the time of the fall on 09/01/12 at 2:30 a.m. (The facility did 12 hour shifts, beginning on 08/30/12 and ending on 09/01/12, for the evening shift.) A "Notification of Fall Fax Alert" dated 09/23/12, documented, "Pt. found in floor bathroom & fell . Pt c/o pain on bottom. Informed family members (son) no open wounds or immediate bruising noted on bottom." There was no incident report for the resident's fall on 09/23/12. No additional documentation was available in the clinical record to verify the facility assessed the fall and implemented interventions to prevent a further recurrence of falls. The current monthly physician's orders [REDACTED]." The physician's orders [REDACTED]. An interview was conducted on 09/26/12 at 8:50 a.m., with CNA #1 regarding the resident's high risk for falls and continual falls. He was asked if the resident had falls and was a risk for falls. He stated, "I'm not sure if she is a fall risk." He was asked how often he worked hall 200, where the resident resided. He stated that was his usual assignment. An interview was conducted on 09/26/12 at 9:05 a.m., with CNA #2. She was asked about the resident's falls. She stated the resident was a fall risk and had several falls. She was asked what interventions were in place to aid in the prevention of the resident falling. She stated, "She is confused and doesn't understand." She then stated the resident was checked every 30 minutes to ensure her safety and to check on her frequently. She stated, "Not all the time, we are short staffed at times." An interview was conducted on 09/26/12 at 9:35 a.m., with the DON regarding the resident's continual falls. Present during the interview was the ADON. She was asked what interventions were in place and when they were implemented. She stated "All interventions had been added to the care plan on 08/10/12." She was asked where the facility's heavy level of care was located. She stated, "Hall 200." She was asked what interventions the resident had to prevent the recurring falls. She stated, "Bed alarm, chair alarm, low bed and matt next to bed." She was asked if the resident had a low bed and a matt available to her in the room. The ADON left and came back into the office and stated, "She doesn't have a low bed or a matt." He then stated, "I'll make sure it gets ordered." She was asked if the facility had a care plan that had been updated to reflect changes in interventions to prevent the recurrence of falls. She stated, "No."

Based on observation, record review and interview, it was determined the facility failed to ensure there was sufficient staff on hall 200 to prevent recurring falls with injuries for two (#4 and #7) of two sampled residents on hall 200. This deficient practice resulted in an actual harm. The DON identified 20 residents who resided on hall 200 where the falls occurred. Findings: The "Falls Management Program" policy documented, "...Goals of Falls Management Program will be to promote a safe environment of all residents and limit the risk for falls/injuries as much as possible. The DON/ADONOC (ADONOC? quoted from policy book-staff not able to state what this abbreviation stands for.) will complete the Tracking Record for Improving Patient Safety (TRIPS) to identify any new safety concerns; any new changes for the resident's Plan of Care...the DON/ADONOC or MDS Coordinator will enter the changes...Possible interventions include but are not limited to... individualized timed frequency checks, and other interventions as identified." The facility operates two twelve hour shifts 6:00 a.m. to 6:00 p.m. for the day and 6:00 p.m. to 6:00 a.m. for the evening shift. The evening shift overlaps two separate days. 1. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An undated fall risk assessment documented the resident was a high risk for falls with a score of 15. A score of ten or greater indicated a risk. The assessment was signed by the charge nurse working at the time of admission. An admission assessment dated [DATE], documented the resident's cognition was intact, required extensive assistance with transfers, dressing and toileting. An initial care plan dated 06/12/12, documented, "Fall/Safety Risk: Goal: no injury/falls; interventions: assess for contributors: BPs standing, sitting, pains, need to void, meds, gait. Encourage to use call light. PT referral. Instruct on safety measures...ADL decline...assist with ambulation/transfers prn, assist with toileting..." A "Fall interventions Plan" dated 06/12/12, documented, "Risk factor: mobility: selected interventions: increase staff assistance to and from toilet, during ambulation, during all transfers, with ADLS...correct height of bed, toilet or chair: keep bed at correct height...increase bathroom safety: use adequate handrails support...promote wheel chair safety: use same wheel chair consistently, check brakes and instruct pt on use...therapy skilled... Risk factor: unsafe behavior; selected interventions: increase assistance and surveillance: personal or chair alarm, answer call lights promptly, increase activities involvement...reduce risk for injury: non skid socks/shoes...increase comfort: pain management, frequent rest periods, exercise..." An admission assessment dated [DATE], documented the resident's cognition was intact, required extensive assistance with transfers, locomotion off the unit, and toileting. The resident also was continent of bowel and bladder and had falls within the previous month prior to admission. The assessment also documented the resident was able to stabilize self with staff assistance during the following: moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. The CAA summary dated 06/18/12, documented the resident triggered for falls and that it would be developed on the care plan. A care plan dated 06/22/12, documented, "Problem: Fall precautions...Goal: Client will be free from injurious falls X next review... Approaches: Encourage to ask for assistance with transfers and ambulation attempts...call light within reach...eliminate potential hazards...repeated reminders of safety hazards...assist with all transfers and ambulations...instruct to request assist from staff...discourage from transferring/ambulation without assistance...provide with w/c...observe for changes in gait or ambulation abilities...clean all spills promptly...assit (sic) as necessary to prevent falls/injuries..." An incident report dated 07/08/12 at 9:30 p.m., documented, "Resident self transferring from toilet to wc 1 brake wasn't locked. Resident lost balance & went to floor. ST to RLE & LUE obtained. Did not hit head...was first aid (sic) administered? yes ST dressings..." A review of the "Brookhaven Extensive Care" daily schedule dated 07/08/12, for the evening shift, documented three CNAs were working at the time of the fall. One CNA was assigned to hall 100, one to hall 200 and one floated between both halls. A nurse's note dated 07/23/12 at 5:00 a.m., documented, "Resident c/o SOB again & called a friend to take her to ER...attempted to page Dr. (name deleted) number disconnected..." A DX report from the hospital dated 07/23/12, documented, "Left wrist, 3 views with navicular for fall. Findings...a non displaced fracture at the distal radius..." A report sent to the Oklahoma State Department of Health, documented, "On 07/23/12, (Resident) was having difficulty breathing, before charge nurse could make arrangements (Resident) called a friend to transport her to the hospital. Upon return from the hospital, she had an x-ray showing a fracture to right wrist. She had an appointment 07/24/12 with an ortho, who casted it...it was discovered that on 07/22/12 at 1130, (Resident) had gotten up in her room without assistance and fell ...catching herself on her arms on her bed...at 0230 (2:30 a.m.) on 07/23/12, (Resident) reported to the charge nurse that she had pain in her right wrist. A mobile x-ray was ordered for first thing in the morning...Alarms had been placed in her chair and on her bed, and she was reminded to use her call light for any transfers...her most recent fall risk assessment was 15, indicating risk for falls...interventions include: increase staff assistance during all transfers, with ADLs, to and from toilet, and during ambulation; keep bed at correct height, increase bathroom safety by using adequate handrails support; promote wheel chair safety by using the same wheelchair consistently and checking brakes and instructing the patient on use; skilled therapy, increase assistance and surveillance with pressure change alarm, personal alarm, answering call lights promptly, and increasing activities involvement, reduce risk of injury with non-skid socks and shoes; increase comfort with pain management, frequent rest periods, and exercise...continually refuses to use her call light and continually gets up from her bed and from her chair by herself. Staff checks her frequently for safety and reminds her frequently of safety interventions..." An incident report dated 07/25/12 at 1:30 a.m., documented, "Resident was walking self from bathroom & fell on bottom. Did not hit head, denies pain...type of injury: other skin tear...was first aid (sic) administered? no..." A nurse's note dated 07/25/12 at 7:30 a.m., documented, "Notified by staff that resident had fallen. Found resident sitting in floor. Stated she was coming out of bathroom and fell ...Sm s/t to (L) upper arm. Explained to resident that due to several falls lately she needs to use call light and ask for help anytime she needs to get up. Resident stated she wouldn't do that because it takes too long. Tried to reassure staff would assist as soon as possible...talked to therapy about reiterating safety issues. Will monitor for changes." A review of the "Brookhaven Extensive Care" daily schedule dated 07/24/12, for the evening shift, documented four CNAs were working at the time of the fall. Two CNAs were assigned on hall 200, where the fall occurred on 07/25/12 at 1:30 a.m. (The facility did 12 hour shifts, beginning on 07/24/12 and ending on 07/25/12, for the evening shift.) A "TRIPS" dated 08/01/12, documented the resident had a fall with minor and major injuries on 07/22/12. The major injury was identified as a fracture. A second "TRIPS" dated 08/01/12,documented the resident had a fall with minor injuries on 07/25/12. A "Fall Interventions Monitor" form dated 08/06/12, documented, "Are interventions effective: no, changes: none; comments: continually refuses to use call light gets up to ambulate & transfers /s assist. States she doesn't need help. Last fall 7-25-12 CPOC." An incident report dated 08/07/12 at 4:15 a.m., documented, "Resident was walking back from bathroom slipped and fell on to floor lg skin tear on inside left arm and on left shoulder...type of injury other S/T..." A second incident report dated 08/07/12 at 4:15 a.m., documented, "Res assisted self to bathroom and she stated she slipped and fell in bathroom. Skin tears noted on (L) arm and shoulder...type of injury other skin..." A daily skilled nurse's note dated 08/07/12 at 4:15 a.m., documented, "Resident pulled emergency cord and CNA found her sitting in her chair with skin tear...she stated she slipped in B/R floor and fell backwards not hitting her head...she had a 12 cm S/T on her inside (L) arm above cast and a 10 cm S/T on her (L) shoulder...S/T covered with nonstick bandage and arm was wrapped in gauze and back covered with op site (sic)...resident c/o pain and was given PRN pain med at 0430 (4:30 a.m.)..." A review of the "Brookhaven Extensive Care" daily schedule dated 08/06/12, for the evening shift, documented four CNAs were working at the time of the fall. Two CNAs were assigned on hall 200 where the fall occurred on 08/07/12 at 4:15 a.m. (The facility did 12 hour shifts, beginning on 08/06/12 and ending on 08/07/12, for the evening shift.) The current monthly physician's orders [REDACTED]." The fall precautions was first started on 06/11/12. During the initial tour of the facility on 09/24/12 at 9:30 a.m., LPN #3 indicated the resident was a high risk for falls and had a fractured wrist. She also indicated the resident required frequent checks due to the falls. An interview was conducted on 09/25/12 at 9:45 a.m., with LPN #2 regarding the resident's falls. She was asked about the resident's falls with injuries and if anyone assessed the falls to determine the cause of them. She stated, "She gets tangled up in her oxygen cord and looses her balance." She was asked what interventions the facility had in place to prevent recurring falls. She stated, "Try to keep a closer eye on her watching her more often, keep pathways clear, and go by and remind her to ask for help." She was asked if the interventions were appropriate to prevent recurring falls with injuries. She stated, "Can't always keep a close enough eye on her because there is not enough staff all the time." An interview was conducted on 09/25/12 at 9:52 a.m., with the ADON regarding the resident's continual falls with injuries. He was asked what the resident's fall precautions were. He stated, "Encourage to use call light, check and assist to bathroom." He then stated each resident's precautions are based on the individual. An interview was conducted on 09/25/12 at 10:20 a.m., with the resident. She was asked how her falls had occurred. She stated, "It's hard to get around with 30 feet of tubing tangled up in my legs." She was asked how often staff come by and checked on her. She stated, "Every two hours." 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE], documented the resident was a high risk for falls with a score of 14. A score of ten or greater indicated the resident was a high risk for falls. An initial care plan dated 08/01/12, documented, "Fall/safety risk: assess for contributors: BPs, standing, sitting, pain, need to void, meds, gait; encourage to use call light, PT referral; instruct on safety measures; adaptive devices..." A "Fall interventions Plan" dated 08/02/12, documented, "Risk factor: mobility: selected interventions: increase staff assistance to and from toilet, during ambulation, during all transfers, with ADLS...correct height of bed, toilet or chair: keep bed at correct height...increase bathroom safety: use adequate handrails support...promote wheel chair safety: use same wheel chair consistently, check brakes and instruct pt on use...therapy skilled... Risk factor: unsafe behavior; selected interventions: increase assistance and surveillance: personal or chair alarm, locate patient near station, answer call lights promptly, increase activities involvement...reduce risk for injury: non skid socks/shoes...increase comfort: pain management, frequent rest periods, exercise..." An admission assessment dated [DATE], documented the resident was moderately impaired with cognitive skills for daily decision making, required extensive assistance with transfers, walking in the room, dressing and toilet use. The assessment also documented the resident stabilized self with staff assistance while moving on and off the toilet, walking, turning around, surface to surface transfers and moving from a seated to a standing position. The assessment documented the resident fell in the past month prior to admission. A care plan dated 08/10/12, documented, "Routine treatment: fall precautions.... Problem: Fall precautions. Goal: will be free of falls by the next review date... Approaches: PT and OT to evaluate and treat...eliminate potential environmental hazards...assist with turning and positioning in bed and for transfers...keep call light in reach, remind/encourage her to call for assistance...keep pathways clean and clear of clutter...observe for changes in sitting balance and transfer abilities...clean all spills promptly..." An incident report dated 08/11/12 at 12:00 p.m., documented, "Resident tried transferring self & fell on bottom...type of injury: none apparent." An incident report dated 08/20/12 at 4:00 a.m., documented, "Resident found sitting on bottom on floor. (No) injuries noted stated she was trying to get up to go to BR and misjudged bed..." A "Notification of Fall Fax Alert" dated 08/20/12, documented, resident tried yo go to bathroom unassisted & slid off bed onto bottom on floor. Did not hit head..." A review of the "Brookhaven Extensive Care" daily schedule dated 08/19/12, for the evening shift, documented two CNAs were working at the time of the fall. One CNA was assigned on each hall at the time of the fall on 08/20/12 at 4:00 a.m. (The facility did 12 hour shifts, beginning on 08/19/12 and ending on 08/20/12, for the evening shift.) An incident report dated 08/21/12 at 1:05 a.m., documented, "Resident was found sitting on the floor beside bed with back leaning against frame of bed. States she sat up on side of bed and slid to floor...type of injury: abrasion to left knee and arm..." A review of the "Brookhaven Extensive Care" daily schedule dated 08/20/12, for the evening shift, documented three CNAs were working in the facility at the time of the fall. One CNA was assigned on hall 200, one on hall 100 and one floated between both hallways at the time of the fall on 08/21/12 at 1:30 a.m. (The facility did 12 hour shifts, beginning on 08/20/12 and ending on 08/21/12, for the evening shift.) An undated incident report at 2:30 a.m., documented, "She was found on her bottom beside the bed, roommate pressed her call light for help. States she is not hurt..." A "Notification of Fall Fax Alert" dated 09/01/12, documented, "Pt. found on bottom next to bed..." A review of the "Brookhaven Extensive Care" daily schedule dated 08/30/12, for the evening shift, documented three CNAs were working in the facility at the time of the fall. One CNA was assigned on hall 200, one on hall 100 and one floated between both hallways at the time of the fall on 09/01/12 at 2:30 a.m. (The facility did 12 hour shifts, beginning on 08/30/12 and ending on 09/01/12, for the evening shift.) A "Notification of Fall Fax Alert" dated 09/23/12, documented, "Pt. found in floor bathroom & fell . Pt c/o pain on bottom. Informed family members (son) no open wounds or immediate bruising note on bottom." The current monthly physician's orders [REDACTED]." The physician's orders [REDACTED]. An interview was conducted on 09/26/12 at 8:50 a.m., with CNA #1 regarding the resident's high risk for falls and continual falls. He was asked if the resident had falls and was a risk for falls. He stated "I'm not sure if she is a fall risk." He was asked how often he worked hall 200 where the resident resided. He stated hall 200 was his usual assignment. An interview was conducted on 09/26/12 at 9:05 a.m., with CNA #2. She was asked about the resident's falls. She stated the resident was a fall risk and had several falls. She was asked what interventions were in place to aide in the prevention of the resident falling. She stated, "She is confused and doesn't understand." She then stated the resident was checked every thirty minutes to ensure her safety. She was asked if there was enough staff to ensure she was checked on frequently. She stated, "Not all the time, we are short staffed at times." An interview was conducted on 09/26/12 at 9:35 a.m., with the DON and ADON regarding the resident's continual falls. She was asked where the facility's heavy level of care was located. She stated, "Hall 200." She was asked if residents #4 and #7 had a trend with their falls. She stated, "Yes, it's the night shift." She was asked how many aides work the halls during the night shift. She stated, "Two on each hall." She was asked about nights when there was not enough staff to provide two on a hall. She stated, "We have not increased staff." The ADON stated, "We meet the state ratios." She was made aware of the staffing for the nights of the falls and the DON stated, "That's not enough with one or two."

Based on observation, clinical record review, and staff and resident interviews, it was determined the facility failed to: a. provide pain medication for two (#8 and #11) of two sampled residents who required pain medication. This resulted in actual harm for resident #11. This had the potential to affect ten residents identified by the facility to require pain management; b. assess, monitor, and intervene for one (#5) of eight sampled residents with an altered mental status. This had the potential to affect 11 residents identified by the facility as having altered mental status; c. assess, monitor and intervene for one (#1) of one sampled resident who had an episode of [MEDICAL CONDITION] activity. This had the potential to affect one resident identified by the facility with [MEDICAL CONDITION] activity; and d. failed to monitor a blood pressure as ordered by the physician for one (#5) of seven sampled residents with a [DIAGNOSES REDACTED]. Findings: 1. Resident #11 was admitted to the facility with diagnoses which included HTN, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. A physician's telephone order, dated 10/27/08, documented, "[MEDICATION NAME] 75 mg. give one tab po daily at 1800 (6:00 p.m.)." A review of the controlled medication count sheets for April, May and June 2010 documented the resident was not given [MEDICATION NAME] on 13 occasions. There was no documentation as to why the doses of [MEDICATION NAME] were not given. On 06/09/10 at 9:15 a.m., the resident stated, "I was miserable last night. I couldn't sleep I was so miserable. I didn't get my [MEDICATION NAME]. They said the pharmacy didn't send it. I didn't realize how much [MEDICATION NAME] worked to help me." At 4:30 p.m., CMA #1 was asked if the resident had [MEDICATION NAME] available. The CMA produced the medication card containing [MEDICATION NAME] and labeled for the resident. The CMA was asked to review the documentation for [MEDICATION NAME] on the June 2010 medication administration sheet and the June 2010 controlled medication sheet. She stated the [MEDICATION NAME] was not given on 06/07/10 and 06/08/10 but she could not determine why. On 06/10/10 at 3:30 p.m., the ADON was asked why [MEDICATION NAME] was not given to resident #11 on 13 occasions in April, May and June 2010. She stated, "We had a problem with a CMA not giving meds. That person was fired. We didn't know we still had a problem." 2. Resident #1 was admitted to the facility with diagnoses which included pneumonia, pleural effusion, [MEDICAL CONDITIONS] infarction, hypertension, dementia, anxiety disorder and PEG tube placement. An admission comprehensive assessment, completed on 01/04/10, documented the resident was moderately impaired in cognitive skills for daily decision making and required extensive assistance with care. The care plan, dated 03/12/10, had no documentation to show the resident had [MEDICAL CONDITION] activity. A nurse's note, dated 05/30/10 at 4:30 p.m., documented, "Pt (up) c this nurse getting ready to go to dining rm (room). Transferring pt from chair to w/c pt started having [MEDICAL CONDITION] activity. Pt placed on side, activity [MEDICATION NAME] 40-60 sec (seconds). VS 195/92 - 105 O2 sat (saturation) RA (room air) 96%. Husband notified. Hospice notified." A nurse's note, dated 05/30/10 at 4:45 p.m., documented, "BP (rechecked) et 179/74 - 90..." There was no documentation in the resident's record to show the resident was thoroughly assessed during and after the [MEDICAL CONDITION] or was monitored afterwards. There was no documentation in the nurse's notes to show the physician had been notified. The resident had no [DIAGNOSES REDACTED]. Hospice records were reviewed. There was no documentation that a visit had been conducted on the day of the [MEDICAL CONDITION] activity. On 06/09/10 at 9:40 a.m., the resident was observed as she received her medications through her PEG tube. The resident was awake, alert and confused. No [MEDICAL CONDITION] activity was noted at the time of the observation. At 11:00 a.m., the ADON was asked if a resident who received Hospice services had [MEDICAL CONDITION] activity, should the physician be contacted. She stated, "Well yes. Any [MEDICAL CONDITION] the physician should be notified." She was asked if the physician was notified. She stated she did not know whether or not the physician had been called. She was asked if a resident should be monitored for a period of time after a [MEDICAL CONDITION]. She stated, "Yes, they should be." At 11:10 a.m., the resident's Hospice nurse was asked if the physician had been notified by Hospice. She stated she did not know. She stated there was nothing in the hospice record which would indicate the physician had been called. She stated she would check with the triage nurse. No further information was provided. 3. Resident # 8 was admitted to the facility with diagnoses which included a history of falls, fractures of the coccyx/sacrum, HTN, [MEDICAL CONDITION], dehydration, debility and [MEDICAL CONDITION]. An admission care plan, dated 05/28/10, documented there was no history of wounds, no daily wound treatments, no pain management, and no prn pain medications. A physician's telephone order, dated 06/03/10, documented, "[MEDICATION NAME] 400 mg. po 30 min. before therapy Monday - Friday." A June 2010 MAR indicated [REDACTED]. There was no documentation as to why the [MEDICATION NAME] was not given. On 06/10/10 at 3:30 p.m., the ADON was asked why the [MEDICATION NAME] was not given as ordered. She stated,"I can't explain that. I don't know if it wasn't given or if it is a documentation problem." At 3:50 p.m., the resident was asked if she had received [MEDICATION NAME] before her therapy sessions. She stated, "I wasn't getting it for a while, but now when I ask for it, I get it." She stated, "I had to ask for the [MEDICATION NAME] before therapy. It makes it easier, less painful." 4a. Resident #5 was admitted to the facility with diagnoses which included HTN, [MEDICAL CONDITION], UTI, and altered mental status. The June 2010 monthly physician's orders [REDACTED]. An admission care plan, undated, did not address hypertension or [MEDICAL CONDITION]. A form titled, Vital Sign and Weight Flow Sheet, documented one blood pressure and pulse recording on 05/28/10 "B/P 151/84 T 98.2 P 48 R 20 Weight 163.0." There were no other blood pressures or pulse entries on the form. Daily skilled nurses' notes from 05/28/10 through 06/07/10 (the entire facility stay for the resident), documented only one recorded blood pressure and pulse each day. The daily skilled nurses' notes for 06/06/10 had no record of a blood pressure or pulse for the entire day. On 06/08/10 at 2:30 p.m., the ADON was asked if she could determine whether or not this resident's blood pressure and pulse were monitored twice a day as ordered. She stated she could not. 4b. An admission nursing assessment, dated 05/28/10, documented resident #5 was alert, cooperative, readily answered questions, was slow to comprehend questions, and disoriented to time. A daily skilled nurse's note, dated 05/28/10, documented on the day shift, the resident had periods of confusion and was disoriented to person. There was no documentation of interventions for confusion and disorientation. There was no documentation of assessment and monitoring of the resident's mental status for the night shift. An undated admission care plan did not address the altered mental status. Nurses' notes, dated 05/29/10, 05/30/10 and 05/31/10, documented the resident was alert and oriented to person, place and time and was confused at times on the night shifts. There was no documentation of interventions for confusion. There was no documentation of assessment and monitoring of the resident's mental status on the day shifts. Nurses' notes, dated 06/01/10 and 06/02/10, documented the resident was alert and confused at times on the night shift. There was no documentation of interventions for confusion. There was no documentation of assessment and monitoring of the resident's mental status on the day shifts. A nurse's note, dated 06/03/10, documented for the day shift the resident was alert and disoriented to place and time. There was no documentation of intervention for disorientation to place and time. There was no documentation of assessment and monitoring of the resident's mental status for the night shift. A nurse's note, dated 06/04/10, documented for the day shift the resident was alert and confused. There was no documentation of assessment and intervention for confusion. A nurse's note, dated 06/04/10 at 11:00 a.m., documented, "...attempted to escape the building via back and side door...occurred x 2. Also attempted to escape building via front door, was redirected by staff and assisted from the area. Family notified." There was no assessment of the resident's mental status before, during or after the attempt to leave the building. There was no documentation of additional monitoring or other interventions. There was no other documentation on mental status or behavior for this resident for the remainder of the day, evening or night on 06/04/10. A nurse's note, dated 06/05/10, documented for the day shift the resident was alert, forgetful and confused, was ambulating throughout the facility, and the family was at the bedside due to "exit seeking". There was no other documentation of monitoring the resident's mental status or further interventions. There was no other documentation of assessment and monitoring of the resident's mental status for the night shift. A nurse's note, dated 06/06/10, documented the resident was alert and forgetful/confused on the day shift. There was no assessment of the forgetfulness and confusion. There were no documented interventions. There was no documentation of assessment and monitoring of mental status on the night shift. A nurse's note, dated 06/07/10, had no documentation for the entire day shift. The night shift documented the resident was alert, oriented to person, place and time, and confused at times. There was no documentation of interventions for the resident's confusion or further monitoring. On 06/08/10 at 11:00 a.m., the resident's family members stated they had been called by social services staff at 8:45 a.m. on 06/04/10. The family said they were told the resident had been up all night wandering, trying to get out and messing himself. The family stated this was unusual behavior for the resident. The family also stated they were told the facility believed the resident's behavior demonstrated he could no longer be cared for in the facility. There was no documentation of the above behavior in the clinical record. At 12:00 noon, the ADON was asked what special care resident #5 required. She stated the resident needed a wheelchair, and assistance with meals and toileting. When asked if there were any other problems identified, or special interventions necessary, she stated, "No. I was on call this past weekend and I didn't get any calls about any problems." When asked if there were any staff available for interview who cared for the resident at the end of the prior week, or over the weekend, she stated there were not any available.