Every finding on record at Ignite Medical Resort Okc, LLC

Based on record review and interview, the facility failed to ensure medications were administered according to physicians' orders for 2 (#2 and #69) of 4 sampled residents reviewed or medication administration.The MDS coordinator identified 72 residents resided in the facility.Findings:A Medication Orders policy, dated 01/2023, read in part, If medication is ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication. 1. Resident #32's Order Summary Report, dated 09/2025, showed they had diagnoses which included atherosclerosis of coronary artery bypass graft without angina pectoris, major depressive disorder, and overactive bladder. Resident #32's Order Summary Report, dated 09/2025, showed clopidogrel bisulfate (antiplatelet) 75 mg, lamotrigine (anti-epileptic) 25 mg, oxybutynin (anticholinergic/antimuscarinic) 15 mg. On 09/11/25 a number 9 (other/see nurses note) was documented on the MAR on the following medications:a. clopidogrel bisulfate 75 mgb. lamotrigine 25 mgc. oxybutynin 15 mg2. Resident #69's Order Summary Report, dated 09/2025, showed they had diagnosis which included major depressive disorder. and an order for escitalopram oxalate (antidepressant) 20 mg.On 09/11/25 a number 9 (other/see nurses note) was documented on the MAR on the above medication. There was no other documentation found in the resident's health record for this medication.On 09/11/25 at 1:01 p.m., CMA #1 stated a number 9 on the MAR meant see other/ notes. She stated she had marked them because they were waiting on the pharmacy for the medication. They stated the medication was unavailable.On 09/11/25 at 1:02 p.m., CMA #1 stated the policy for ordering medications was to order before it ran out.On 09/11/25 at 2:11 p.m., the DON stated their expectation for reordering medications was to order when down to about three days' worth and if medications were in within 24 hours they should be notified.On 09/11/25 at 2:14 p.m., the DON stated there should not have been a break in days on those medications. They stated those are important medications.

Based on observation, record review, and interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (#48) of 3 sampled residents reviewed for weight loss. The MDS coordinator identified 72 residents resided in the facility.Findings:On 09/11/25 at 8:57 a.m., Resident #48 was sitting in their wheelchair eating breakfast. The resident was assisted with the meal by the private sitter. An undated face sheet showed Resident #48 had diagnoses which included quadriplegia, muscle weakness, the need for assistance with personal care, gastroesophageal reflux disease, and a body mass index (BMI) 19.9 or less. A care plan, dated 08/16/25, showed Resident #48 had the potential for alterations in nutrition and hydration. Interventions were to evaluate any weight changes and follow facility protocol for weight change. A physician order, dated 08/22/25, showed Resident #48 was to receive a regular diet and Ensure one can with meals for a supplement. A physician order, dated 08/22/25, showed Resident #48 was to be offered assist with every meal. A physician order, dated 08/28/25, showed Resident #48 was to be weighed weekly for four weeks and then monthly.An admission assessment, dated 08/28/25, showed Resident #48 had a BIMS of 10. The assessment showed the resident had not had weight loss.Resident #48's weight record, dated 09/04/25, showed the resident weighed 137.5 pounds and had a 5.4% weight loss from the weight on 08/16/25 of 145.4 pounds.Resident #48's electronic record for the task amount eaten of meals, showed the resident ate 76% to 100% of meals. On 09/10/25 at 1:20 p.m., the private sitter stated they assisted the staff with Resident #48's personal care. On 09/10/25 at 4:17 p.m., the DM stated the dietitian was in the facility twice a week. The DM stated the dietitian was responsible for monitoring resident weights. On 09/11/25 at 8:38 a.m., the physician stated the facility had weekly QA meetings and weight loss was one of the topics. The physician stated they did not have a QA meeting last week. The physician stated the dietician monitored the resident weights and should be aware. On 09/11/25 at 9:21 a.m., the dietician stated they were not in the facility last week and the weekly QA meeting was cancelled. The dietician stated they would have been aware of the resident's weight loss this week.On 09/11/25 at 10:00 a.m., the DON stated the dietician was responsible for monitoring resident weights and notifying the physician. The DON stated the resident's weight loss had flagged in the computer last week. The DON stated no new intervention had been implemented since the identified weight loss on 09/04/25.

Based on observation, record review, and interview, the facility failed to ensure proper hand hygiene was performed during medication administration observation for 4 (#32, 53, 69, and #69) of 6 sampled residents reviewed for medication administration.The MDS coordinator identified 72 residents resided in the facility.Findings:On 09/11/25 at 8:32 a.m., CMA #1 was observed to prepare and administer Resident #81's medications without proper hand hygiene performed. CMA #1 was not observed to wash their hands before, during, and throughout the medication administration process.On 09/11/25 at 8:40 a.m., CMA #1 was observed to prepare and administer Resident #53's medications without proper hand hygiene, CMA #1 was not observed to wash their hands before, during, and throughout the medication administration process.On 09/11/25 at 9:25 a.m., CMA #1 was observed to prepare and administer Resident #32's medications without proper hand hygiene, CMA #1 was not observed to wash their hands before, during, and throughout the medication administration process.On 09/11/25 at 9:40 a.m., CMA #1 was observed to prepare and administer Resident #69's medications without proper hand hygiene, CMA #1 was not observed to wash their hands before, during, and throughout the medication administration process.A Hand Hygiene policy, revised 04/2025, read in part, All staff members will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare-associated infections (HAIs) .Indications for Hand-washing .Before and after medication administration .If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands in the following clinical situation .before and after medication administration.On 09/11/25 at 9:53 a.m., CMA #1 stated the policy for hand hygiene during medication administration was to either wash or sanitize their hands before and after each resident. They stated they had not sanitized during the observed medication administration observation at all.

Based on observation and interview, the facility failed to ensure a homelike environment for 1 (#16) of 5 sampled resident rooms reviewed for cleanliness.The MDS coordinator identified 72 residents resided in the facility.Findings: On 09/09/25 at 9:50 a.m., Resident #16's floor of their room was observed to have a substance throughout the room. The substance was clear to white in appearance and there were footprints in the substance in several different places. There were small pieces of paper and white tape scattered on the floor. There were two large pieces of black cardboard on the floor by Resident #16's bed. On 09/09/25 at 10:59 a.m., Resident #16's floor was observed to still have the sticky substance, pieces of paper, tape, and black cardboard on the floor of their room. On 09/10/25 at 5:22 p.m., Resident #16's floor was observed to still have the sticky substance, pieces of paper, tape, and black cardboard on the floor of their room. An undated policy Room Cleaning for Residents, read in part, The resident's room daily cleaning steps daily cleaning steps and recommended procedures are as follows: Pick up all paper, trash, etc. Dust the floor thoroughly. After mopping the floor, place a wet floor sign. On 09/09/25 at 9:51 a.m., Resident #16 was asked how comfortable their room was for them. They stated, It's dirty. My [family member] told them to clean it and they still haven't. On 09/09/25 at 11:00 a.m., Resident #16's family member stated they had asked multiple staff members to have Resident #16's room cleaned since their admission, but it still had not been done. On 09/11/25 at 8:56 a.m., housekeeper #1 was asked how often they cleaned resident rooms. They stated, Every day. They were asked if Resident #16's room was cleaned on 09/10/25. Housekeeper #1 stated, Yeah, every day. They were asked if the floor had been swept and mopped. They stated, Yeah. On 09/11/25 at 9:00 a.m., housekeeper #1 was shown Resident #16's floor and asked when the last time the floor was mopped. They stated, Yesterday. Housekeeper #1 was advised the floor had been sticky with footprints on it and the paper, tape, and black cardboard had been present since at least 09/09/25. They stated, Oh. Housekeeper #1 was asked if Resident #16's floor was dirty. They stated, Yes. On 09/11/25 at 10:37 a.m., the maintenance director was asked how often the housekeepers were supposed to mop the resident rooms. They stated, Every day. The maintenance director was asked what their expectation of the housekeepers was for mopping resident rooms. They stated, A quick sweep or dust mop first, then mop every day.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#62) of 18 sampled residents were reviewed for baseline care plans.The MDS coordinator identified 72 residents resided in the facility.Findings:Resident #62's Care Plan Report, dated 08/28/25, showed Resident #62 admitted on [DATE].Review of the electronic health record did not show a baseline care plan had been completed for Resident #62.A Care Plan policy, revised 04/2025, read in part, A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission to the facility. The care plan includes minimum health care information necessarily to properly care for the resident.On 09/10/25 at 3:03 p.m., the MDS coordinator stated the facility had 48 hours to complete a baseline care plan. They stated it was to be completed by the admitting nurse. The MDS coordinator stated the baseline care plan had been started but not completed within the required 48 hours.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was completed for 1 (#62) of 18 sampled residents reviewed for care plans.The MDS coordinator identified 72 residents resided in the facility.Findings:Resident #62's Care Plan Report, dated 08/28/25, showed Resident #62 admitted on [DATE].Review of the electronic health record showed 1 activity entry in the care plan; no other entries had been documented.A Care Plan policy, revised 04/2025, read in part, The comprehensive care plan is developed within 7 days of CAA completion . The care plans are developed by the members of the interdisciplinary team based on their assessments and interaction with the resident and/or resident's significant others.On 09/10/25 at 3:04 p.m., the MDS coordinator stated the comprehensive care plan had not been completed by all departments and should have been completed on 09/03/25.

Based on observation, record review, and interview, the facility failed to assess, monitor, and intervene for no bowel elimination from 09/02/25 to 09/07/25 for 1 (#48) of 3 sampled residents reviewed for bowel elimination.The MDS coordinator identified 72 residents resided in the facility.Findings:On 09/10/25 at 1:20 p.m., Resident #48 was lying in bed watching television. The resident was clean and without foul odor. The resident was pleasant and denied pain or discomfort at the time. A private sitter was in the room at the time of the observation.A facility policy titled Bowel Monitoring, revised/reviewed 07/2025, read in part, Licensed nursing staff will complete a review daily to ensure there are no abdominal abnormalities present. Abnormal findings may include but aren't limited to:.Infrequent bowel patterns and/or consistency of stool.An undated face sheet showed the Resident #48 had disease of spinal cord, quadriplegia C5-C7 incomplete, cognitive communication deficit, and need for assistance with personal care.A care plan, dated 08/16/25, did not show a care plan for constipation. A physician order, dated 08/22/25, showed Resident #48 was to have bowel and bladder training every two hours. The order showed the resident was to be offered the bedpan and urinal every two hours. A physician order, dated 08/22/25, showed Resident #48 was to receive Colace (a stool softener) 100mg two times a day for constipation.A physician order, dated 08/23/25, showed Resident #48 was to receive MiraLAX (an osmotic laxative) 17 GM every 24 hours as needed for constipation. An admission assessment, dated 08/28/25, showed Resident #48 had a BIMS of 10 which indicated they were moderately impaired for daily decision making. The assessment showed Resident #48 was incontinent of bowel. The task area of Resident #48's medical record showed the history of bowel elimination. The record showed Resident #48 had not had a bowel movement from 09/02/25 to 09/07/25.On 09/11/25 at 12:43 p.m., RN #1 stated if a resident had not had a bowel movement within two days, they would notify the physician and see if the resident had a physician order for as needed medication for constipation available. On 09/11/25 at 1:03 p.m., the DON stated if a resident had not had a bowel movement within three days, they would expect the nurse to notify the physician.

Based on observation, record review, and interview, the facility failed to ensure a resident with limited mobility was provided with the appropriate padding for a cervical collar for 1 (#48) of 1 sampled resident reviewed for the use of a cervical collar. The MDS coordinator identified 72 residents resided in the facility.Findings:On 09/10/25 at 1:20 p.m., Resident #48 was lying in bed watching television. The resident was wearing a Miami J cervical collar. On 09/11/25 at 8:57 a.m., Resident #48 was sitting in their wheelchair eating breakfast with assistance from the private sitter. The resident's cervical collar was lying on the bed and the padding was soiled. An undated face sheet showed Resident #48 had diagnoses which included disease of the spinal cord, quadriplegia C5- C7 incomplete, and falls. The care plan, dated 08/16/25, showed Resident #48 had an ADL self-care performance deficit and limitations in physical mobility. A physician order, dated 08/25/25, showed Resident #48 was to always wear the Miami J cervical collar except during meals and showers until follow up in six weeks.An admission assessment, dated 08/28/25, showed Resident #48 had a BIMS of 10, which indicated the resident was moderately impaired for daily decision making. The assessment showed Resident #48 was dependent with bathing and required assistance with eating. On 09/10/25 at 1:34 p.m., LPN #1 stated the Resident #48 had a Miami J cervical collar and the facility only had padding to fit an Aspen cervical collar. On 09/10/25 at 2:40 p.m., the DON stated the padding the facility had was not for a Miami J cervical collar. The DON stated the facility did not have padding for the cervical collar. On 09/10/25 at 2:57 p.m., the DON stated the facility did not have the correct padding for Resident #48's cervical collar. The DON stated there was a miscommunication regarding the availability of the correct cervical collar padding. The DON stated the padding should be changed when soiled, at least after showers, or maybe daily with sweating.

Based on record review and interview, the facility failed to ensure: a. medication allergy adherence; b. a medication was accurately transcribed; and c. medications were administered as ordered for 1 (#2) of 3 sampled residents reviewed for medication administration. The director of MDS identified 69 residents resided in the facility. Findings: An Administration of Medication policy, dated 04/2024, read in part, All medications are administered safely and appropriately to aid residents to and help in overcome [sic] illness, relieve and prevent symptoms and help in diagnosis. Resident #2 had diagnoses which included polyosteoarthritis, essential hypertension, and venous insufficiency. Resident #2's admission record showed they admitted to the facility on [DATE] and had allergies which included acetaminophen. A physician order, dated 01/04/25, showed Tylenol/acetaminophen (a pain reliever and fever reducer) eight hour oral tablet 650 mg, give one tablet every six hours as needed for pain not to exceed 3000 mg in 24 hours. The medication was discontinued on 01/06/25. Resident #2's medication administration record did not document the Tylenol was ever administered. A provider visit note, dated 01/06/25, showed the assessment and plan for Resident #2's bilateral leg edema included adding metolazone daily for a few days. The note was signed by physician #1. A physician order, dated 01/06/25, showed metaxalone (a muscle relaxant) oral tablet give 5 mg orally one time a day for edema for five days. A discontinue order for the above metaxalone was dated 01/08/25. The reason for the discontinue showed entered wrongly. Resident #2's medication administration record did not document the metaxalone was ever administered. A physician order, dated 01/08/25, showed metolazone (a diuretic) oral tablet 5 mg, give one tablet by mouth one time a day for fluid retention for five days. Resident #2's medication administration record did not document the metolazone was ever administered. On 03/11/25 at 9:24 a.m. family member #1 stated they were concerned with medical negligence. They stated while at the facility, Resident #2 had an order for Tylenol. They stated the resident was allergic to the medication and regardless of the outcome, should not have been ordered when the resident was allergic to it. They stated Resident #2 had experienced swelling in their legs and the physician had ordered medication for it that was not started for two days. On 03/12/25 at 9:25 a.m., CMA #1 stated if a medication was not available to be administered, staff would call the pharmacy and check on the status. They stated they would ensure a resident was not allergic to the medication before administering it. They stated if the resident had an allergy to the medication, they would notify the nurse who would notify the physician. They stated the medication would be held until clarification was obtained. On 03/12/25 at 9:26 a.m., CMA #1 stated the charge nurse was responsible for handling new medication orders from the provider. They stated they would fax new orders over to the pharmacy. They stated new medications that were not ordered stat (urgently) should be received within four hours of ordering. On 03/12/25 at 9:28 a.m., CMA #1 stated Resident #2 had allergies which included Tylenol. They stated they did not know the resident's reaction to the medication. On 03/12/25 at 9:30 a.m., CMA #1 stated Resident #2 had an order for Tylenol eight hour as needed that was dated 01/04/25. They stated they did not know who put the order in. They stated Resident #2 had an order for metolazone dated 01/08/25 and metaxalone 5 mg one time daily for edema which was ordered on 01/06/25. They stated they were unable to view previous administration records and were unable to determine if the resident received either of these medications. On 03/12/25 at 9:44 a.m., LPN #4 stated they would confirm pharmacy received the medication orders to ensure they were available for administration in the facility. They stated they would put new orders into the system and ensure the order was faxed to the pharmacy and the family was aware of the new order. They stated they would check with pharmacy to see how soon the medication would be filled. On 03/12/25 at 10:13 a.m. a.m., LPN #4 stated when staff received new medication orders, if they had any questions, they would send a message to the provider to confirm the medication, dosage, and time. They stated sometimes the handwriting was not the best. They stated staff needed to have a clear understanding of the order before putting it in the system. On 03/12/25 at 10:15 a.m., LPN #4 stated new medications were usually received within four to six hours. They stated if a resident was allergic to the medication, they would determine the reaction, and let the provider know. They stated sometimes the need for the medication outweighs the risk and the provider would still want it given. On 03/12/25 at 10:16 a.m., LPN #4 stated Resident #2 had allergies which included acetaminophen. On 03/12/25 at 10:18 a.m., LPN #4 stated they did not know the resident's reaction to the medication. They stated Resident #2 did have a Tylenol order that was discontinued. They stated they did not know the reason it was prescribed with their allergy. On 03/12/25 at 10:23 a.m., LPN #4 stated they did not see a note the medication was ever administered. On 03/12/25 at 10:28 a.m., LPN #4 stated Resident #2's metolazone was ordered 01/08/25. They stated the metaxalone 5 mg one time a day was ordered on 01/06/25. They stated they were not sure who put the order in. On 03/12/25 at 10:30 a.m., LPN #4 stated metaxalone was a muscle relaxer. They stated metolazone was a diuretic. They stated the provider visit note dated 01/06/25 documented they were adding metolazone to treat Resident #2's edema. They stated they could not see where metaxalone was given, just that it was discontinued. They stated they were unable to see if either one was given. On 03/12/25 at 10:44 a.m., the DON stated anytime medications ran out, the CMA would push reorder in the computer. They stated the facility also had an emergency kit for ensuring medications were available to administer. They stated staff ordered three days in advance before running out. On 03/12/25 at 10:45 a.m., the DON stated for new orders, staff let the resident know, entered it in the electronic record, and notified family. On 03/12/25 at 10:46 a.m., the DON stated both the DON and assistant director of nursing ran an audit of orders on Mondays to ensure orders were put in correctly. They stated pharmacy usually got new medications to the facility within six hours. On 03/12/25 at 10:48 a.m., the DON stated if a resident was allergic to a medication ordered, staff would notify the doctor and make sure they okayed the medication. They stated the resident would be informed as well. On 03/12/25 at 10:52 a.m., the DON stated Resident #2 had allergies which included acetaminophen. They stated they were unsure of the resident's reaction to the medication. They DON stated they were the person who put in the Tylenol order. They stated the resident's orders were reviewed by physician #1 on admit and they placed a check next to Tylenol. They stated it was difficult to remember the reason. On 03/12/25 at 11:00 a.m., the DON stated Resident #2 did not receive the Tylenol before it was discontinued. On 03/12/25 at 11:01 a.m., the DON stated the metolazone was ordered for Resident #2 on 01/09/25 and the medication was used to treat fluid retention. They stated Resident #2 had an order for metaxolone 5 mg give one time a day for edema for five days ordered 01/07/25. They stated the order was put in wrong. They stated metaxolone was used for a muscle relaxant. The DON reviewed the provider visit note dated 01/06/25 and stated metolazone was supposed to be ordered. They stated neither medication was ever administered to Resident #2.

Based on record review and interview, the facility failed to ensure physician ordered labs were obtained for 1 (#2) of 3 sampled residents reviewed for assess monitor and intervene. The director of MDS identified 69 residents resided in the facility. Findings: A facility lab policy, dated 05/2024, read in part, A physician or nurse practitioner order is necessary for any lab specimen collection .Label container with pertinent information .place specimen in designated area .Document in the nursing notes that a specimen was collected and a description of the specimen. Resident #2 had diagnoses which included diverticulitis of the intestine. A physician order, dated 01/04/25, read in part, STOOL SAMPLE NEEDED (CDIFF?) [clotridoides difficile colitis] LEAVE ORDER UNTIL COLLECTED. ONCE COLLECTED CALL LAB TO PICK UP .PRINT ORDER OUT AND PUT IN PURPLE BOOK. A physician progress note, dated 01/06/25, showed Resident #2 had experienced diarrhea since before Thanksgiving. The note showed stool studies collected 01/05/25 and the results were pending. The note was signed by physician #1. There were no stool specimen results located in Resident #2's clinical record for the 01/04/25 physician ordered stool sample. On 03/11/25 at 9:24 a.m., family member #1 stated Resident #2 had experienced diarrhea for an extended period of time (months) and they were concerned a stool specimen wasn't collected. On 03/11/25 at 2:13 p.m., the DON stated they did not believe Resident #2's stool specimen was ever collected. They stated the family had complained about the lab. They stated the facility had changed lab services during the time and had difficulty getting it integrated into their electronic system. The DON stated the facility completed a follow up on the issue, educated staff, and completed a QA. On 03/12/25 at 9:43 a.m. LPN #4 stated when providers ordered labs, they would put it in the electronic system on the treatment administration record. They stated once the specimen was collected, they would label it and notify the lab company it was collected so they could pick it up. On 03/12/25 at 10:43 a.m., the DON stated when providers ordered labs, they would notify the family and put the lab order in the system. They stated staff would collect the labs such as stool specimens, date, sign and label the specimen container, and call the lab to pick it up. On 03/13/25 at 3:15 p.m., LPN #1 stated staff would collect stool, urine, and blood specimens and call the lab for pickup. On 03/13/25 at 3:16 p.m., LPN #1 stated the facility had switched lab services not long ago and received an inservice related to labs. On 03/13/25 at 3:41 p.m., LPN #2 stated when they received an order for labs, they would put it into the electronic system and the lab system. They stated after the lab was collected, they would call the lab to pick it up and mark it off once it was picked up. They stated they had received a recent inservice on labs. On 03/13/25 at 3:47 p.m., LPN #3 stated when they received a lab order they would let the resident know, put it into the computer system, collect the specimen, and click it off the system after it was collected. They stated they had received inservice training recently related to labs. The facility initiated a QA plan of improvement with monitoring on 01/08/25. The facility provided ongoing monitoring related to lab services. A review of the in-service documentation related to the investigation of labs being completed as ordered documented the facility completed an all staff training on 01/22/25. A review of the employee list and signatures indicated all employees had been in-serviced. Interviews with staff during the survey indicated they had knowledge of the in-service education provided regarding the laboratory policy. Staff demonstrated knowledge of the process of obtaining physician ordered labs. The deficiency was determined to be a past noncompliance. The record review and interviews support a past noncompliance.

Based on record review and interview, the facility failed to provide bathing for 1 (#3) of 3 sampled residents reviewed for bathing. The director of MDS identified 69 residents resided in the facility. Findings: A BATHING policy, revised 04/2023, read in part, All residents are given a bath or shower in accordance with preferences. If no preference on a bath is voiced, a bath or shower will be offered twice per week. Resident #3 was admitted on [DATE] and discharged on [DATE]. Resident #3 had diagnoses which included need for assistance with personal care, muscle weakness, and unsteadiness on feet. Resident #3's admission resident assessment, dated 01/02/25, showed the resident required substantial to maximum assistance with bathing. A shower schedule showed Resident #3's weekly shower schedule was Tuesday and Friday. There was no documentation Resident #3 received a bath on 12/27/24, 12/31/24, and 01/07/25 during their admission stay at the facility. On 03/13/25 at 3:19 p.m., certified nurse aide #1 stated resident showers were set to two days a week based on room numbers. They stated they go through the shower book daily to see which residents were scheduled for the day. They stated if a resident refused, they would document on the shower sheet and inform the nurse. On 3/13/25 at 4:52 p.m., the DON stated they could not locate documentation Resident #3 received a bath on 12/27/24, 12/31/24, and 01/07/25.

Based on observation, record review, and interview, the facility failed to adequately supervise and prevent a resident from eloping for one (#2) of three sampled residents identified as exit seeking or confused. The administrator identified 74 residents resided in the facility. Findings: An Elopement Policy, dated November 2018, documented residents identified as having wandering or exit seeking behavior will be assessed and appropriate interventions will be included in the plan of care at the time of identification of the wandering or exit seeking behavior. It documented all exit doors were alarmed with audible alerts. Resident #2 was admitted to the facility on [DATE] with a diagnoses which included nontraumatic intracerbral hemorrhage and hemiplegia. An initial physician history and physical visit for Resident #2, dated 11/20/24, read in part, confused and confabulating [memory loss that effects their higher reasoning] during visit. Nursing reported patient is exit seeking but is easily redirected. Resident #2's MDS, dated [DATE], documented their cognition was moderately impaired. A physician follow-up visit, dated on 11/25/24, documented Resident #2 continued to be confused and confabulating during visit. It documented the resident continued to exit seek. A Combined Initial and Final Incident Report Form, dated 11/27/24, documented at 6:40 p.m. nursing staff noticed Resident #2 was missing. It documented the resident was last seen by nursing staff at 6:00 p.m. It documented the resident was known for wandering and was stationed at the nurses' station prior to going missing. It documented the CNO was notified and management began watching camera footage and found the resident had wheeled themselves through the emergency exit door on hall 200. It documented the resident was found down the road from the facility at 7:10 p.m. It documented a head-to-toe assessment was completed, and no injuries were noted. It documented the resident's family and physician were notified. It documented a one-on-one sitter was put in place that evening and family was asked to come up if possible to assist with close monitoring. It documented social services had already been working on placement in long-term care/memory care. A nurse note, dated 11/27/24 at 8:03 p.m., read in part, Guest was found to be missing around [7:00 p.m.]. All staff immediately went to look for guest, two nurses drove through neighborhood and found guest headed towards the [store] across the street from the facility. On 11/27/24 it was documented the administrator and CNO provided staff with an in-service on elopement. On 12/03/24 at 1:05 p.m., the CNO stated the hall 200 door did not latch and therefore alarm. They stated maintenance was called out and fixed the door immediately. The CNO stated the facility attempted to not bring in confused and exit seeking residents because they are not a memory care facility. On 12/03/24 at 2:26 p.m., LPN #1 was reached via telephone for interview. LPN #1 stated Resident #2 had been exit seeking since about the 20th and they made the physician aware. They stated Resident #2 had been trying that morning so staff placed them at the nurses' station. LPN #1 stated around shift change it was noticed Resident #2 was missing. LPN #1 stated staff were looking for the resident for about 20 minutes before locating them. On 12/03/24 at 4:47 p.m., the administrator stated the exit doors were checked monthly and had last been checked on 11/07/24, but the facility would start checking them weekly for any issues.

Based on observation, record review, and interview, the facility failed to appropriately develop and/or implement comprehensive care plans for two (#2 and #3) of three sampled residents identified as exit seeking or confused. The administrator identified 74 residents resided in the facility. Findings: An Elopement Policy, dated November 2018, documented residents identified as having wandering or exit seeking behavior will be assessed and appropriate interventions will be included in the plan of care at the time of identification of the wandering or exit seeking behavior. 1. Resident #2 was admitted to the facility on [DATE] with diagnoses which included nontraumatic intracerbral hemorrhage and hemiplegia. An initial physician history and physical visit for Resident #2, dated 11/20/24, read in part, confused and confabulating [memory loss that effects their higher reasoning] during visit. Nursing reported patient is exit seeking but is easily redirected. The care plan did not indicate the resident was an elopement risk. Resident #2's MDS, dated [DATE], documented their cognition was moderately impaired. A nurse note, dated 11/27/24 at 8:03 p.m., read in part, Guest was found to be missing around [7:00 p.m.]. All staff immediately went to look for guest, two nurses drove through neighborhood and found guest headed towards the [store] across the street from the facility. The care plan did not indicate the resident was an elopement risk. On 12/03/24 the resident's elopement risk was initiated on the care plan. 2. Resident #3 was admitted on [DATE] with a diagnoses which included dementia. A care plan for elopement risk was initiated. The interventions included disguise exits and decorate doors and doorknobs to look like something else. Resident #3's MDS, dated [DATE], documented their cognition was moderately impaired. On 12/03/24 at 5:15 p.m., the emergency exit door at the end of Resident #3's hall was not decorated or disguised in any way and was clearly marked as an exit. On 12/03/24 at 5:37 p.m., the administrator and CNO stated they were unsure why those interventions were on the care plan and they would look into it.

Based on observation and interview, the facility failed to ensure a medication cart was securely locked according to company policy and procedure. The administrator identified 69 residents resided in the facility. Findings: An Administrations of Medications policy, dated 04/2023, read in part, Never leave the medication cart open or unattended. On 11/26/24 at 4:03 p.m., medication cart #1 on hall 400 was found unsecured and unattended. On 11/26/24 at 4:04 p.m., LPN #1 reported the medication cart was supposed to be locked. On 11/26/24 at 4:05 p.m., CMA #1 reported the medication cart was to be locked. On 11/27/24 at 11:25 a.m., the DON reported according to company policy and procedure, medication carts were to be locked.

Based on record review and interview, the facility failed to ensure a medication error did not occur for one (#2) of three sampled residents whose medication regime was reviewed. The assistant general manager identified 74 residents resided in the facility. Findings: An Administration of Medications policy, dated 05/2024, read in part, GENERAL All medications are administered safely and appropriately to aid residents to and help in overcome illness, relieve and prevent symptoms and help in diagnosis. The policy also read, A physician or nurse practitioner order is required for administration of all medications. The policy also read, Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. Read each order entirely. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring .Identify resident by reading wrist band or checking the picture in the MAR. Resident #2 had diagnoses which included acute kidney failure, seizure, sepsis, and acute cystitis. An incident report, dated 07/24/24 at 9:37 a.m., read in part, This nurse was notified by charge nurse on the 100 hall that guest stated [they] got a shot this morning and someone got blood from [their] finger and [they] didn't know what is was for. Guest is not diabetic and has no orders for any shots to be given. Guest is in stable condition at this time. After investigation, it was found that guest was given 25 units of Insulin Glargine. Stable, vs wnl, blood sugar normal. A Health Status Note, dated 07/24/24 at 5:24 p.m., read in part, This nurse was informed by therapy that the night nurse did a fingerstick and gave [them] insulin. Guest is not diabetic and has not taken insulin or had a FSBS since admission. CNO and [provider PA] notified. N/O from [provider PA] to check FSBS TID today. Guest has been monitored today by this nurse and no adverse reactions noted. [Family member] was notified by this nurse. Guest in bed at this time and call light in within reach. An All staff inservice 1 hour, dated 07/24/24, documented the topic was five rights of medication administration. It was documented to verify the label on the medication for the patient the medication was being administered to. It was documented there was no sharing medication amongst patients. A physician's order, dated 07/24/24, documented FSBS TID for 1 day. The July 2024 TAR documented the midday FSBS reading on 07/24/24 was 105 and the evening reading was 96. It was documented the morning FSBS reading on 07/25/24 was 97. A Corrective Action Form dated 07/31/24, documented LPN #1 was suspended for two shifts for the insulin error. It was documented there was a med pass observation on 07/31/24. A QAPI data sheet, dated 08/01/24, documented notes for the medication error for Resident #2. On 10/07/24 at 3:31 p.m., the CNO stated they did speak to LPN#1 and did corrective action. They stated LPN #1 was suspended for two shifts, did QAPI, inserviced all staff, and observed a med pass for LPN #1.

Based on record review and interview, the facility failed to ensure psychotropic medications administered to residents were necessary to treat a specific diagnosis for two (#24 and #158) of five residents who were reviewed for unnecessary medications. The DON identified 74 residents resided at the facility. Findings: 1. Resident #24 admitted with diagnoses which include dementia and anxiety. A Physician's Order, dated 02/27/24, to administer trazodone (an antidepressant medication) 150 mg, 0.5 tablet by mouth at bedtime for depression. A Physician's Order, dated 02/28/24, to administer citalopram hydrobromide (an antidepressant medication) 40 mg 1 tablet by mouth one time a day for depression. The February and March medication administration records for Resident #24 documented both antidepressants were administered as ordered except when the resident was outside of the facility due to hospitalization . The care plan, dated 02/27/24, documented a focus for an antipsychotic, and antianxiety medication, an antidepressant, an anticoagulant, a diuretic, and an opioid medication. The MDS five day assessment dated , 03/15/24, documented active diagnoses, which did not include a diagnosis of depression. On 03/27/24 at 11:20 a.m., MDS Director #1 stated they had completed the five day MDS for Resident #24. They stated Resident #24 was ordered two antidepressants, with no diagnosis of depression. The MDS Director #1 stated themselves and the MDS Director #2 entered the diagnoses received from the hospital records on admission. They stated the medications were unnecessary medications without a diagnosis of depression. On 03/27/24 at 1:20 p.m., the administrator stated they reviewed psychotropic medications during their weekly QA/QAPI meetings. They stated specific diagnoses such as depression and anxiety were not discussed during the meetings. The administrator stated the MDS directors should have looked for diagnoses to justify the use of psychotropic medications, as well as the admission nurse, to ensure all medications had appropriate diagnoses. 45462 2. Resident #158 admitted with diagnoses which included acquired absence of right leg below knee and infection of surgical site. A Physician's Order, dated 03/15/24, documented to administer Sertraline Oral Tablet 25 mg 1 tablet by mouth one time a day for Depression. The MDS admission assessment dated , 03/22/24, documented active diagnoses, which did not include a diagnosis of depression. On 03/27/24 at 11:47 a.m., MDS Director #1 was asked to review the physician's orders and admission MDS diagnoses list for Resident #158. After review, MDS Director #1 acknowledged sertraline for depression would be considered an unnecessary medication for Resident #158 without a diagnosis of depression.

Based on observation and interview, the facility failed to properly sanitize reusable equipment between residents for two (#4 and #6) of three residents observed during the collection of vital signs. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 66 residents resided in the facility. Findings: The facility's Infection Control Policy, revised May 2023, read in part, .disinfection of resident care equipment including equipment shared among residents will be cleaned prior to and after each use including but not limited to: Vital sign devices .portable thermometers, vital sign machines .blood pressure monitoring equipment . On 08/31/23 at 8:12 a.m., CMA #3 was observed while taking Resident #7's temperature, pulse, and blood pressure. Once completed, CMA #3 returned the vital sign devices to the basket on the vital sign cart and exited Resident #7's room. CMA #3 did not sanitize the vital sign devices before moving to the room of Resident #4 and taking their temperature, pulse, and blood pressure. Once completed, CMA #3 returned the vital sign devices to the basket on the vital sign cart and exited Resident #4's room. CMA #3 did not sanitize the vital sign devices before moving on to the room of Resident #6 and taking their temperature, pulse, and blood pressure. Once completed, CMA #3 returned the vital sign devices to the basket on the vital sign cart and exited Resident #6's room. On 08/31/23 at 8:25 a.m., CMA #3 was asked the facility infection control policy on the use of re-usable medical equipment. CMA #3 stated the policy was to sanitize between each person. CMA #3 was asked if they had sanitized the equipment between each person. They stated, I sanitize my hands between each person. Then I do those residents on TBP or isolation last. Then sanitize the whole machine. On 08/31/23 at 11:01 a.m., the ACNO/ICP was asked the facility infection control policy on the use of re-usable medical equipment. They stated re-usable medical equipment was to be sanitized after use on each patient. The ACNO/ICP was given a description of this surveyors' observation of CMA #3 collecting vital signs. The ACNO/ICP acknowledged CMA #3 did not follow the facility's infection control policy.

Based on record review and interview, the facility failed to ensure resident representatives were notified of changes in skin conditions for two (#7 and #18) of three residents reviewed for notification. The assistant administrator identified 68 residents resided in the facility. Findings: 1. Res #7 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Daily Skilled Note, dated 06/13/20 at 2:17 p.m., read in part, .redness to both buttocks . Daily Skilled Notes, dated 06/16/20, 06/17/20, 06/18/20, 06/23/20, and 06/24/20, read in part, .Skin/Wound .Pressure Ulcer . A Physician's Progress Note, dated 06/25/20, read in part, .upon visual inspection it appears as though patient has a open unstageable wound to .buttocks . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Health Status Note, dated 06/30/20 at 8:34 p.m., read in part, .pt seen in virtual visit with wound NP today. Per wound NP N/O's noted: Air Mattress ensure inflation qshift Sacrum: Cleanse with NS, Pat Dry, apply santyl and Boarder [sic] foam q day . On 09/21/21 at 11:00 a.m., the DON stated staff should have notified family of the changes. 2. Res #18 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A skin observation, skin/wound note, wound care specialists notes, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation the family had been notified. On 09/22/21 at 8:45 a.m., the DON was asked if the family had been notified of the pressure ulcer. She stated, Not that I recall, but I will go back and look. No further information had been provided.

Based on record review and interview, the facility failed to ensure residents were free from misappropriation of property for one (#8) of one resident sampled for abuse. The DON identified 68 residents who resided in the facility. Findings: A Misappropriation of Resident Property policy, dated January 2020, read in part, .The misappropriation of the property of a resident will not be condoned at this facility . Resident #8 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident admission assessment, dated 04/30/20, documented the resident had moderately impaired cognition. An email from the assistant administrator, dated 07/25/20, read in part, .5/19- [Resident's family member] called at 6:04pm and stated that someone took $80 from [the resident's] room. She said it happened when he was taking a shower. I went down to [the resident's] room and he said he was missing $20 from his money pouch and $20 from his bedside table. I had [administrator at the time] come down with me to hear his statement and he repeated the same thing . 5/20- Spoke with [resident's family member] today [at] 12:34pm .She stated she wanted his original clothes now. She said she is tired of all he [sic] thieves in our facility. I told [resident's family member] that we would be replacing all of his clothes today . There was no other documentation of the incidents of the resident's money or clothes being misappropriated. On 09/22/21 at 12:10 p.m., the assistant adm was asked what the policy was for a resident who reported missing money or property. He stated they would interview the resident and staff, look at the cameras, complete an investigation, and submit a state incident report. He stated items were replaced on a case by case bases depending on if the allegation was substantiated or unsubstantiated. The assistant adm was asked if the resident or resident's family member had reported any missing money or clothing. He stated the wife had reported $80 was missing but the resident could not remember how much he had and thought it was only $20. He stated a pair of red pajama pants and a pair of blue pajama pants had been reported missing. He was asked if an investigation had been completed for each incident. He stated there was. He was asked if state incident reports had been completed. He stated there should have been. He was asked to provide copies of the investigations and state incident reports. At 1:45 p.m., the assistant adm stated they weren't able to locate any documentation an investigation had been conducted.

Based on record review and interview, the facility failed to implement their abuse policy by not investigating or reporting when a resident/resident's representative reported missing money and clothing for one (#8) of one resident sampled for abuse. The DON identified 68 residents who resided in the facility. Findings: A Misappropriation of Resident Property policy, dated January 2020, read in part, .The misappropriation of the property of a resident will not be condoned at this facility .Procedure .When an incident of misappropriation of a resident's property is reported to the Administrator, an investigation will be initiated immediately .The Administrator or designee conducting the investigation will be provided with a copy of the incident report and other documents relative to the incident .If during the investigation there is any evidence that the incident meets or could meet the above definition of misappropriation of a resident's property, the state survey agency will be notified within twenty-four (24) working hours .The individual conducting the investigation will gather pertinent documents such as the resident's inventory list or the resident's personal fund account records .A list will be compiled of persons who witnessed the incident or have knowledge of the incident .The following individuals will be interviewed .The person making the report .Employees alleged to have been involved in the misappropriation .Employees who have knowledge of the misappropriation .If appropriate, the resident, the resident's roommate, family members and visitors . Interviews will be conducted in a room that provides privacy. It is permissible for the person conducting the interview to have second employee present to record the information obtained in the interview .The individual responsible for the interview will ask each person to discuss the incident or their knowledge related to lost items or misappropriation of the elder's belongings or funds .The resident, the resident's legal representative and/or designated family will be informed of the investigation .In the event the incident relates to a missing item, the person conducting the interview will ask permission from the resident or the resident's legal representative to search the elder's bedroom. The resident or a person representing the resident should be present during the search . Public areas, the laundry and other possible locations will be searched for the missing item .The resident, the resident's legal representative and/or designated family member will be provided with a report of the investigation .During the investigation, any employees alleged to be involved in the incident will not be allowed to enter the facility .The Administrator or designee will complete an abuse, neglect and misappropriation of resident property investigation form. When completed the form will be maintained in a file in the Administrator's office . Resident #8 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #1's admission assessment, dated 04/30/20, documented moderately impaired cognition. An email from the assistant adm regarding Res #1, dated 07/25/20, read in part, .5/19- [Resident's family member] called at 6:04pm and stated that someone took $80 from [the resident's] room. She said it happened when he was taking a shower. I went down to [the resident's] room and he said he was missing $20 from his money pouch and $20 from his bedside table. I had [administrator at the time] come down with me to hear his statement and he repeated the same thing . 5/20- Spoke with [resident's family member] today [at] 12:34pm. She stated she wanted his original clothes now. She said she is tired of all he [sic] thieves in our facility. I told [resident's family member] that we would be replacing all of his clothes today . There was no other documentation of the incidents of the resident's money or clothes being misappropriated. On 09/22/21 at 12:10 p.m., the assistant adm was asked what the policy was for a resident who reported missing money or property. He stated they would interview the resident and staff, look at the cameras, complete an investigation and submit a state incident report. He stated items were replaced on a case by case bases depending on if the allegation was substantiated or unsubstantiated. The assistant adm was asked if the resident or resident's family member had reported any missing money or clothing. He stated the family member had reported $80 was missing but the resident could not remember how much he had and thought it was only $20. He stated a pair of red pajama pants and a pair of blue pajama pants had been reported missing. He was asked if an investigation had been completed for each incident. He stated there was. He was asked if state incident reports had been completed. He stated there should have been. He was asked to provide copies or the investigations and state incident reports. At 1:45 p.m., the assistant adm stated they weren't able to locate any documentation of the investigation.

Based on observation, record review and staff interview, it was determined the facility failed to ensure a resident's wound was assessed on admission and did not deteriorate for one (#4) of three sampled residents reviewed for wound care which resulted in actual harm. The facility identified 13 residents with wounds. Finding: Resident #4 admitted on [DATE] with [DIAGNOSES REDACTED]. A hospital note, dated 02/13/21, documented, .Open wound of midline back .Wound Location: back .Treatment Measurements (L x W x D in cm) (length times width times depth in centimeters): 3.6x1.2x2 .drainage .minimal .Complicating Factors to Wound Healing: Immobility and infection . A facility admission note, dated 02/16/2021 at 5:09 p.m., documented, Admission Summary .Resident arrived at the facility at 1630 (4:30 p.m.) Guest has a wound at his lower back which he said he got it from a surgery he had about a year ago. Its been there for about a year, I had a surgery, fell and it become complicated, they just fill it with gauze and cover it . There were no measurements or assessment of the wound. A skin observation note, dated 02/16/21 at 6:12 p.m., failed to document the wound to the back. A physician progress notes [REDACTED]. There was no document of an assessment of the wound to the back. A physician's order, dated 02/17/21, documented Keflex 500 milligrams by mouth twice daily for chronic osteo[DIAGNOSES REDACTED] to the spine. A wound summary, dated 02/23/21, documented, . Wound Information .Surgical .Present-on admission .Length .1.20cm .Width .4.00cm .Depth 3.00cm . A physician progress notes [REDACTED].Patient has a chronic back infection and had wound vac before for wound to midline back .Initial wound encounter measurements are 3.5cm length x 1.5cm width x 2.5cm depth . A physician's order, dated 02/24/21, documented, .Apply wound vac to lower mid back at 125mmhg (millimeters of mercury) change 3x (times) a week on Monday, Wednesday, and Friday .related to OSTEO[DIAGNOSES REDACTED] OF VERTEBRA, LUMBAR REGION . A skin wound note, dated 02/26/21 at 3:15, documented, Focused assessment r/t (related to) wounds following wound rounds with Dr. (name deleted) on 2/24/21. Guest admitted with a surgical wound to mid lower back .Surgical wound to mid lower back measures 3.5x1.5x2.5 cm. Wound bed 100% pink. Rates pain at 3 of 10. Minimal serous drainage noted. New orders received from Dr. (name deleted) to apply wound vac at 125 mmhg . A facility plan of correction, dated 03/01/21, documented, .Identified Problem .Identified opportunity to improve timeliness and acuracy of physician ordered wound and skin treatments .Intervention .Current guest's TAR (treatment administration record) reviewed to establish baseline for the current ordered wound and skin treatments. The wound nurse/physician will document the current status of wounds. Licensed staff will be inserviced on physician notification and initiation of treatment the day of admit for any skin issues. Licensed staff will be inserviced on the expectation and importance of completing treatments as ordered as well as how to perform each treatment. At this time, floor nurses will perform wound treatments and admin (administrative) nursing team will complete all head to toe and wound round assessments until new wound nurse hired . An in-service training form, dated 03/05/21, documented, SUBJECT .admit checklist-including skin assessment .All guests admitting with wounds and no orders need to have physician notification and treatment order in place day of admit. Wound care team will do head to toe assessment within 24 hours of admit . A physician's order, dated 03/10/21, documented, .Wound care to mid lower back: Cleanse with NS (normal saline), pat dry, pack with calcium alginate, cover with dry dressing, secure with tape one time a day every other day . On 03/15/21 at 12:50 p.m., the director of nursing (DON) was asked what type of wound the resident had to his back. She stated it was chronic osteomylitis. She stated he had previously had a wound vac and that he had no orders for the area on admit. She stated when the wound care doctor was made aware of the area on 02/23/21 he came and saw him the next day and wrote orders for a wound vac. The DON was asked who was responsible for skin assessments on admit. She stated she and another nurse conducted the assessments within 24 hours Monday through Friday and a weekend nurse conducted them on the weekends. She stated the weekend nurse had contacted her on 02/20/21 to notify her that the resident still had a dressing to his back that had been placed in the hospital. She was asked what the admitting nurse should do if a resident was admitted with a dressing in place and had no physician's orders. She stated she should put in a consult for wound care and contact the wound care doctor. The DON was asked who should have been notified of the wound on admit. She stated the primary care physician. She was asked if the primary care physician had been notified. She stated the admission note doucumented the physician had been notified of his admit but did not document everything he was notified of. On 03/16/21 at 9:32 a.m., the DON was shown the measurements of the back wound from the 02/13/21 hospital notes and the facility measurements on 02/23/21. She was asked if the wound had worsened. She stated, This was just our baseline measurements. She was asked if the 1.2 x 4.0 x 3 was accurate. She stated the length and width had been documented incorrectly and should have been 4.0 x 1.2 x 3. She was made aware no skin assessment had been conducted until seven days after admission. At 10:05 a.m., licensed practical nurse (LPN) #2 was observed providing wound care to the residents back wound. The wound had a dressing intact to area dated 03/14/21. The nurse was observed to remove the dressing. There was scant light yellow drainage to dressing. She was observed to clean the area with sterile normal saline and gauze. The are appeared to have slough present with surrounding area pink in color. The nurse was observed to pack the wound with calcium alginate, covered the wound with gauze and secured it with [MEDICATION NAME] tape. The resident was asked during the treatment if he had any pain to the area. He stated, No. LPN #2 was asked if the wound had improved. She stated, Oh, yes. At 11:52 a.m., the wound care physician was asked when wounds should be assessed. He stated, On admit, of course. He was asked if the wound had improved since treatment had been initiated. He stated it had.

On 06/25/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician and or family of a resident who had a change in condition. The resident was sent to the emergency room per family request and was admitted to ICU with [MEDICAL CONDITION]. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 5:35 p.m.,the Administrator, Executive Director, Regional Director and the DON were informed of the IJ situation. At 8:15 p.m., the Administrator presented an acceptable plan of removal which was dated 06/25/15. The plan of removal documented: The facility was identified as having an IJ related to the assessment, monitoring, and intervening with a change of condition. An IJ for the notification of change in condition to the physician, family, or appropriate family representative was also identified. To remove the immediacy, all staff including nursing and therapy, will be inserviced by 1700 on 06/26/2015 on the following: 1. When to notify the family and physician related to a change of condition. This will be completed by 1700 on 06/26/2015. 2. All nursing staff will be in serviced on assessment, monitoring, and intervening to include how to identify a change of condition, excess diarrhea episodes, and changes in skin integrity. This will be completed by 1700 on 06/26/2015. 3. The therapy and CNA staff will be in serviced on how to recognize a change of condition and when to report it to the nurse. The nurse will them contact the physician, family or appropriate family representative and implement any new orders received. This will be completed by 1700 on 06/26/2015. 4. All nurses will be in serviced on contacting the physician for an order for [REDACTED]. 5. The nurses will be in serviced on ensuring CNA documentation is being completed during their shift and looking for any change in conditions that may occur. This will be completed by 1700 on 06/26/2015. On 06/26/15 at 5:00 p.m., the immediate jeopardy situation was removed after determining by interviews and record review all components of the plan of removal had been implemented, including in-service for all licensed staff on how to assess, monitor and intervene with significant changes in resident condition when indicated. The deficient practice remained at a pattern with actual harm. Based on interview, record review and policy and procedure review it was determined the facility failed to notify the physician and or family for one (#1) of nine sampled residents reviewed for a change in condition. The resident was sent to the emergency room per family request and was admitted to ICU with [MEDICAL CONDITION]. This had the potential to affect all 71 residents who resided in the facility. Findings: A policy, titled Change in a Resident's Condition or Status, documented, . Policy Statement Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been . d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly . 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . A policy, titled Wound Management Program, documented, . Policy Statement The organization is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being . Policy Interpretation and Implementation . 5. Discussion with the attending physician and resident/responsible party includes notification of any skin impairment identified . Resident #1 had [DIAGNOSES REDACTED]. A care plan, dated 03/24/15, documented, .Problems . is at risk for impaired skin integrity . Goals .will remain free of skin breakdown through the next review . Interventions . Report any signs of skin breakdown . A care plan, dated 03/24/15, documented .is at Risk for Infection R/T .comorbidities . Interventions . Assess, document and report signs of systemic or localized infection . Assess and document skin for color, moisture, texture, and turgor. Report any abnormal findings . Consult with physician .as indicated . An ADL Verification Worksheet documented, . 06/02/15 22:13 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/03/15 .Time 13:24 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/03/15 .Time 21:18 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/04/15 .Time 03:26 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/04/15 .Time 14:11 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/05/15 .Time 14:12 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/05/15 .Time 21:30 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/06/15 .Time 22:03 .Bowel- Consistency .Loose .Bowel-how many 2 . A quarterly assessment, dated 06/06/15, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of two people for transfers and toilet use. She required extensive assistance of one person for dressing, personal hygiene and bathing. She was always incontinent of bowel and bladder. She was at risk for developing pressure ulcers. An ADL Verification Worksheet documented, . 06/08/15 .Time 14:34 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/08/15 .Time 14:34 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/08/15 .Time 21:43 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/09/15 .Time 02:53 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/09/15 .Time 14:17 .Bowel- Consistency .Loose .Bowel-how many 4 . 06/10/15 .Time 02:36 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/10/15 .Time 14:22 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/11/15 .Time 04:26 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/11/15 .Time 13:00 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/12/15 .Time 04:42 .Bowel- Consistency .Loose .Bowel-how many 1 . A Clinical Note Entry, dated 06/12/15, documented, . Subject Skin Effective Date/Time 6/12/2015 5:18 p.m. Entered By (LPN #1) . Note .skin assessment complete, dryness and redness .is noted to her buttocks, coccyx and sacrum. No open areas noted .N/O to cleanse coccyx w/NS, pat dry, apply duoderm and change q 5days d/t redness and dryness . A physician's telephone order, dated 06/12/15, documented, .Cleanse coccyx c (sic) ns, pat dry, apply duoderm + (sic) q 5days d/t redness and dryness .Signature of Physician ( physician name deleted) Date JUN 18 2015 . A care plan update, dated 06/12/15, documented, Cleanse coccyx c (sic) NS, pat dry apply duoderm .q 5 days D/T redness . An ADL Verification Worksheet documented, . 06/12/15 .Time 20:44 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/13/15 .Time 13:42 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/14/15 .Time 21:28 .Bowel- Consistency .Loose .Bowel-how many 1 . An in-service record, dated 06/15/15, documented, .CNA's if a patient has diarrhea notify your charge nurse as this could be a s/s of cdiff .Dr (physician name deleted) must be notified and his response to notification must be charted . An ADL Verification Worksheet documented, . 06/15/15 .Time 05:08 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/15/15 .Time 21:32 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/16/15 .Time 04:38 .Bowel- Consistency .Loose .Bowel-how many 2 . There was no documentation in the clinical record to indicate the physician was notified for the loose stools. A physician's telephone order, dated 06/16/15, documented the resident was sent to the emergency room per family request. A hospital history and physical, dated 06/16/15, documented, .ED Provider Notes .at 06/16/2015 7:57 PM . HISTORY OF PRESENT ILLNESS ( Resident #1), a 83 y.o. female presents to the ED with a Chief complaint of Shortness of Breath . A hospital history and physical, dated 06/17/15, documented, .H&P by (physician name deleted) at 6/17/2015 1:18 AM . PULM/CC ICU admission H&P Subjective: (Resident #1) .admitted to ICU with [MEDICAL CONDITION] .profound dehydration and acidemia from chronic diarrhea . In ER .She had significant diarrhea .tested positive for Cdiff .Assessment .[MEDICAL CONDITIONS] . A hospital lab order and result, dated 06/17/15, documented, .06/17/15 0429 (Abnormal) .C DIFFICILE TOXIN .Positive . An [MEDICATION NAME][MEDICATION NAME] Therapy Assessment, dated 06/17/15, documented, .Consults .6/17/2015 5:59 AM . [MEDICATION NAME][MEDICATION NAME] Therapy Assessment . Assessment: stage III pressure ulcer to the coccyx . On 06/25/15 at 11:00 a.m., the POA was asked if she was present at the time of the resident's discharge to the hospital. She stated yes and she was the one that made them send the resident to the hospital. She went into her room and saw her lying in a fetal position and not responsive so she went to the nurses's station and told them something was wrong. She stated the nurse looked at her and asked if she wanted her sent to the hospital. She told her of course. She stated that she went back into the room when the aides were changing her and she saw the brief full of diarrhea and observed sores on her buttocks. She stated it looked like ground meat and was very red. At 1:00 p.m., the DON was asked if skin issues were observed during the audit what would happen. She stated the wound care nurse would make recommendations and then forward to the wound physician to be seen the following Wednesday. She was asked if a reddened coccyx would be a change in condition. She stated, Yes. She was asked if the primary care physician would be notified of the change in skin condition. She stated, I would not off the bat. I would notify the skin nurse and let her handle it. She is the specialized nurse for wounds. She was asked what was the qualifications of the wound care nurse. She stated, Experience not education. We plan to send her for training. She was asked what the process was for a resident who has a change in condition. She stated, Notify the physician, get orders and implement and follow up. She was asked how long residents were followed after a change of condition. She stated, Pass on to the next shift and follow up. She was asked if there was a continued decline what would be done. She stated, Call the doctor. The families would also be called. She was asked where would it be documented. She stated, In the nurse notes with the time. At 1:10 p.m., LPN #1 was asked if she did the wound assessment on 06/12/15 for resident #1. She stated, Yes. She was asked if she notified the primary care physician and family. She stated, No. She was asked if any of the nursing staff had notified the physician or family of the skin problem. She stated, If it is not documented then it wasn't done. We wouldn't notify the doctor for just a reddened area. She was asked who was responsible for notifying the physician and family of skin problems. She stated, Whoever finds it. She was asked how resident #1 obtained an order for [REDACTED]. He comes in three times a week and that is how he is notified of the wounds. At 1:55 p.m., LPN #1 approached the survey team and stated, I went back and looked at my note. I didn't feel like there was a change in condition. She was asked who would determine if a resident had a change in condition. She stated, The doctor. She was asked if she notified the wound physician. She stated that she had not notified the wound physician because there was not an issue. She was asked if there was no skin issue why was an order written [REDACTED]. At 3:00 p.m., the Regional Director was asked who monitors nurse aide documentation. She stated the ADON monitors the documentation.

On 06/25/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene for a resident who had a change in condition. The resident was sent to the emergency room per family request and was admitted to ICU with [MEDICAL CONDITION]. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 5:35 p.m.,the Administrator, Executive Director, Regional Director and the DON were informed of the IJ situation. At 8:15 p.m., the Administrator presented an acceptable plan of removal which was dated 06/25/15. The plan of removal documented: The facility was identified as having an IJ related to the assessment, monitoring, and intervening with a change of condition. An IJ for the notification of change in condition to the physician, family, or appropriate family representative was also identified. To remove the immediacy, all staff including nursing and therapy, will be inserviced by 1700 on 06/26/2015 on the following: 1. When to notify the family and physician related to a change of condition. This will be completed by 1700 on 06/26/2015. 2. All nursing staff will be in serviced on assessment, monitoring, and intervening to include how to identify a change of condition, excess diarrhea episodes, and changes in skin integrity. This will be completed by 1700 on 06/26/2015. 3. The therapy and CNA staff will be in serviced on how to recognize a change of condition and when to report it to the nurse. The nurse will them contact the physician, family or appropriate family representative and implement any new orders received. This will be completed by 1700 on 06/26/2015. 4. All nurses will be in serviced on contacting the physician for an order for [REDACTED]. 5. The nurses will be in serviced on ensuring CNA documentation is being completed during their shift and looking for any change in conditions that may occur. This will be completed by 1700 on 06/26/2015. On 06/26/15 at 5:00 p.m., the immediate jeopardy situation was removed after determining by interviews and record review all components of the plan of removal had been implemented, including in-service for all licensed staff on how to assess, monitor and intervene with significant changes in resident condition when indicated. The deficient practice remained at a pattern with actual harm. Based on interview, record review and policy and procedure review it was determined the facility failed to assess, monitor and intervene for one (#1) of nine sampled residents reviewed for a change in condition. The resident was sent to the emergency room per family request and was admitted to ICU with [MEDICAL CONDITION]. This had the potential to affect all 71 residents who resided in the facility. Findings: A policy, titled Routine Resident Checks, documented, .Routine resident checks shall be made to assure that the resident's safety and well-being are maintained . 2. Routine resident checks involve entering the resident's room to determine if the resident's needs are being met, if there has been a change in the resident's condition . 3. Changes in the resident's condition and medical needs that cannot be performed by the person conducting the routine check must be reported to the nurse supervisor/charge nurse at once. 4. Documentation supporting the time .and outcome of each check .Note: CNAs may record this information and provide it to the nurse supervisor/charge nurse . A policy, titled Change in a Resident's Condition or Status, documented, . Policy Statement Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been . d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly . 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . A policy, titled Wound Management Program, documented, . Policy Statement The organization is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being . Policy Interpretation and Implementation . 5. Discussion with the attending physician and resident/responsible party includes notification of any skin impairment identified . Resident #1 had [DIAGNOSES REDACTED]. A care plan, dated 03/24/15, documented, .Problems . is at risk for impaired skin integrity . Goals .will remain free of skin breakdown through the next review . Interventions . Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown . A care plan, dated 03/24/15, documented .is at Risk for Infection R/T .comorbidities . Interventions . Assess, document and report signs of systemic or localized infection . Assess and document skin for color, moisture, texture, and turgor. Report any abnormal findings . Consult with physician .as indicated . An ADL Verification Worksheet documented, . 06/02/15 22:13 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/03/15 .Time 13:24 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/03/15 .Time 21:18 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/04/15 .Time 03:26 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/04/15 .Time 14:11 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/05/15 .Time 14:12 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/05/15 .Time 21:30 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/06/15 .Time 22:03 .Bowel- Consistency .Loose .Bowel-how many 2 . A quarterly assessment, dated 06/06/15, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of two people for transfers and toilet use. She required extensive assistance of one person for dressing, personal hygiene and bathing. She was always incontinent of bowel and bladder. She was at risk for developing pressure ulcers. An ADL Verification Worksheet documented, . 06/08/15 .Time 14:34 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/08/15 .Time 14:34 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/08/15 .Time 21:43 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/09/15 .Time 02:53 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/09/15 .Time 14:17 .Bowel- Consistency .Loose .Bowel-how many 4 . 06/10/15 .Time 02:36 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/10/15 .Time 14:22 .Bowel- Consistency .Loose .Bowel-how many 3 . 06/11/15 .Time 04:26 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/11/15 .Time 13:00 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/12/15 .Time 04:42 .Bowel- Consistency .Loose .Bowel-how many 1 . A Clinical Note Entry, dated 06/12/15, documented, . Subject Skin Effective Date/Time 6/12/2015 5:18 p.m. Entered By (LPN #1) . Note .skin assessment complete, dryness and redness .is noted to her buttocks, coccyx and sacrum. No open areas noted .N/O to cleanse coccyx w/NS, pat dry, apply duoderm and change q 5days d/t redness and dryness . A physician's telephone order, dated 06/12/15, documented, .Cleanse coccyx c (sic) ns, pat dry, apply duoderm + (sic) q 5days d/t redness and dryness .Signature of Physician ( physician name deleted) Date JUN 18 2015 . A care plan update, dated 06/12/15, documented, Cleanse coccyx c (sic) NS, pat dry apply duoderm .q 5 days D/T redness . An ADL Verification Worksheet documented, . 06/12/15 .Time 20:44 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/13/15 .Time 13:42 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/14/15 .Time 21:28 .Bowel- Consistency .Loose .Bowel-how many 1 . An in-service record, dated 06/15/15, documented, .CNA's if a patient has diarrhea notify your charge nurse as this could be a s/s of cdiff .Dr (physician name deleted) must be notified and his response to notification must be charted . An ADL Verification Worksheet documented, . 06/15/15 .Time 05:08 .Bowel- Consistency .Loose .Bowel-how many 2 . 06/15/15 .Time 21:32 .Bowel- Consistency .Loose .Bowel-how many 1 . 06/16/15 .Time 04:38 .Bowel- Consistency .Loose .Bowel-how many 2 . There was no documentation in the clinical record to indicate the physician was notified for the loose stools. A physician's telephone order, dated 06/16/15, documented the resident was sent to the emergency room per family request. A hospital history and physical, dated 06/16/15, documented, .ED Provider Notes .at 06/16/2015 7:57 PM . HISTORY OF PRESENT ILLNESS ( Resident #1), a 83 y.o. female presents to the ED with a Chief complaint of Shortness of Breath . A hospital history and physical, dated 06/17/15, documented, .H&P by (physician name deleted) at 6/17/2015 1:18 AM . PULM/CC ICU admission H&P Subjective: (Resident #1) .admitted to ICU with [MEDICAL CONDITION] .profound dehydration and acidemia from chronic diarrhea . In ER .She had significant diarrhea .tested positive for Cdiff .Assessment .[MEDICAL CONDITIONS] . A hospital lab order and result, dated 06/17/15, documented, .06/17/15 0429 (Abnormal) .C DIFFICILE TOXIN .Positive . An [MEDICATION NAME][MEDICATION NAME] Therapy Assessment, dated 06/17/15, documented, .Consults .6/17/2015 5:59 AM . [MEDICATION NAME][MEDICATION NAME] Therapy Assessment . Assessment: stage III pressure ulcer to the coccyx . On 06/25/15 at 11:00 a.m., the POA was asked if she was present at the time of the resident's discharge to the hospital. She stated yes and she was the one that made them send the resident to the hospital. She went into her room and saw her lying in a fetal position and not responsive so she went to the nurses's station and told them something was wrong. She stated the nurse looked at her and asked if she wanted her sent to the hospital. She told her of course. She stated that she went back into the room when the aides were changing her and she saw the brief full of diarrhea and observed sores on her buttocks. She stated it looked like ground meat and was very red. At 1:00 p.m., the DON was asked if skin issues were observed during the audit what would happen. She stated the wound care nurse would make recommendations and then forward to the wound physician to be seen the following Wednesday. She was asked if a reddened coccyx would be a change in condition. She stated, Yes. She was asked if the primary care physician would be notified of the change in skin condition. She stated, I would not off the bat. I would notify the skin nurse and let her handle it. She is the specialized nurse for wounds. She was asked what were the qualifications of the wound care nurse. She stated, Experience not education. We plan to send her for training. She was asked what the process was for a resident who has a change in condition. She stated, Notify the physician, get orders and implement and follow up. She was asked how long residents were followed after a change of condition. She stated, Pass on to the next shift and follow up. She was asked if there was a continued decline what would be done. She stated, Call the doctor. The families would also be called. She was asked where would it be documented. She stated, In the nurse notes with the time. At 1:10 p.m., LPN #1 was asked if she did the wound assessment on 06/12/15 for resident #1. She stated, Yes. She was asked if she notified the primary care physician and family. She stated, No. She was asked if any of the nursing staff had notified the physician or family of the skin problem. She stated, If it is not documented then it wasn't done. We wouldn't notify the doctor for just a reddened area. She was asked who was responsible for notifying the physician and family of skin problems. She stated, Whoever finds it. She was asked how resident #1 obtained an order for [REDACTED]. He comes in three times a week and that is how he is notified of the wounds. At 1:55 p.m., LPN #1 approached the survey team and stated, I went back and looked at my note. I didn't feel like there was a change in condition. She was asked who would determine if a resident had a change in condition. She stated, The doctor. She was asked if she notified the wound physician. She stated that she had not notified the wound physician because there was not an issue. She was asked if there was no skin issue why was an order written [REDACTED]. At 3:00 p.m., the Regional Director was asked who monitors nurse aide documentation. She stated the ADON monitors the documentation. She was asked what prompted the wound audit performed on 06/12/15. She stated another family member had reported to the facility that another resident had a wound observed at the emergency room . She stated the facility decided to do wound assessments on everyone to identify any other skin issues not previously reported.

On 07/06/12 at 1:15 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision to prevent falls, and to identify and implement interventions to aid in the prevention of falls for two (#1and #4) of four sampled residents who had experienced falls in the facility. Resident #1 had three falls within one month. The third fall resulted in a hip fracture which required surgical intervention. At 1:25 p.m., the OSDH (Oklahoma State Department of Health) verified the existence of the IJ situation. At 1:30 p.m., the administrator and DON were informed of the IJ situation and were asked to provide the surveyors with a plan of removal. At 3:15 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: "1. New system implemented effective July 6, 2012 - When patient discharges to hospital, the hospital liaison or their designee will follow-up with hospital case manager for admitting [DIAGNOSES REDACTED]. - Care Plans will actively reflect individualized interventions. - Facility will utilize a fall investigation worksheet as its investigation tool and documentation. - Social Services Director or their designee will follow up with hospital liaison regarding discharged patient status and document. 2. Director of Nursing or their designee will report all actual harm incidents to appropriate agencies. 3. Facility will assess all current patients for fall risk, identify those at risk and assure care plans are reviewed and newest interventions documented. (To be completed by 3:00 p.m. Sunday, July 8, 2012) 4. An inservice for all current licensed nursing staff who assess for patient fall risk will be given by DON and or her designee regarding fall risk assessment and documentation, with appropriate interventions and updating care plans to reflect those interventions. (Inservicing to be completed by 3:00 p.m. Sunday July 8, 2012.) Licensed personnel who are unable to be physically present for scheduled inservices, will be inserviced by phone. Upon returning to facility those nurses will sign inservice form stating they were inserviced by phone and the date of that inservice, prior to assuming their responsibilities in the facility." The DON presented samples of a 'Falls Investigation Worksheet' that the facility would implement following the Inservice to the staff. On 07/09/12 at 11:45 a.m., the IJ was removed back to the plan of removal time on the completion of the inservice on Sunday July 8, 2012 at 3:00 p.m. The licensed nursing staff when interviewed were able to verify their knowledge and understanding of the inservices presented as a result of the IJ situation. The deficient practice remained at a level of actual harm at a pattern. Based on observation, record reviews and staff interviews, it was determined the facility failed to provide adequate supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#1 and #4) of four sampled residents who had experienced falls in the facility. The facility identified 53 residents who were at risk for falls. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An 'Initial Plan of Care', dated 05/15/12, documented, "...if res is increase fall risk, alarm on at all times..." A history and physical report, dated 05/22/12, documented the resident was admitted to the facility for rehabilitation following joint replacement of the right hip due to a previous fall with a fracture. A 'Physical Therapy Evaluation and Plan of Care', dated 05/15/12, documented, "...Prior level of function: She lived at home alone, she was (independent) without an (assistive) device...Comments: basically uncooperative during her (evaluation) even with her daughter coaxing her to try to get her to cooperate..." An 'Occupational Therapy Evaluation and Plan of Care', dated 05/16/12, documented, "...very agitated confused and verbally inappropriate..." The PT (physical therapy) and OT (occupational therapy) evaluations documented: "...Considerations in Treatment Plan Development: Safety, Cognition, Endurance, Pain, and Ability to retain new information..." An 'incident/accident report', dated 05/19/12 at 6:55 a.m., documented, "...resident states she wanted to get out of bed and rolled off consequently fell to the floor...(see nurses' notes for details)... Additional comments and/or steps taken to prevent recurrence: X-ray obtained, keep bed low position." A nurse's note, dated 5/19/12 at 11:38 a.m., documented, "...during change of shift this morning at 0655 (6:55 a.m.) this nurse was alerted by aide that resident was found on the floor, admitted having pain to the right side that she had the surgery, pain meds (administered), x-ray done, no apparent injury." The comprehensive admission assessment for resident #1, dated 05/23/12, documented the resident had dementia, was alert and confused, had inattention and disorganized thinking. She had severe cognitive impairment. The resident required extensive assistance of two staff members for transfers, ambulation, dressing and personal hygiene. The assessment documented the resident had a fall prior to admission, but did not document the fall on 05/19/12. A 'Care Plan Report', initiated 5/29/12, documented: "Problem: Had a non injury fall while in facility, remains at risk for fall related injuries due to inability to recognize her own limitations, poor balance, unsteady gait. Goals: Maintain/improve current level of mobility with no increase in the incidence of falls/injuries. Interventions: 1. Wear non-slick footwear that fits. 2. Engage in activities that improve strength, balance and posture. 3. Instruct on safety measures to reduce the risk of falls. Physical and occupational therapies to continue to treat until max potential is reached. 4. Keep area free of obstructions to reduce the risk of falls or injury. 5. Keep nurse call light within easy reach. Instruct to use call bell or call out for assistance. 6. Keep personal items within easy reach; bed to be in lowest position with wheels locked." An 'Incident/Accident Report', dated 06/02/12 at 6:00 a.m., documented, "...Patient was found sitting on the floor after alarm went off, stated she was trying to get to her chair. Denied pain or hitting her head. Additional comments and/or steps taken to prevent recurrence: (Patient) put back in bed, alarm on, call light within reach, bed lowest postion, care plan reviewed." A nurse's note, dated 06/02/12, documented, "Pt. has reddened area to bottom left side. Pt. was redirected back to bed, bed alarm on, bed at lowest level and call light in reach." The 'Care Plan Report', dated 06/02/12, documented, "...Problem: observed sitting on floor - no injuries." The clinical record did not document interventions to prevent further falls. A facility policy titled, 'Accicents and Incidents - Investigating and Reporting', dated April 2001 documented, "...The following data, as it may apply, must be included on the form...11. Any corrective action taken..." An 'Incident/Accident Report', dated 06/15/12 at 2:15 a.m., documented, "Guest was attempting to ambulate without assistance. fell to her L (left) side, c/o (complains of) L hip pain..." The report documented the physician was notified and ordered the resident to be sent to the emergency room for evaluation and treatment. An ambulance service was contacted at 2:50 a.m. A nurse's note, dated 06/15/12 at 3:03 a.m., documented, "Sustained fall while attempting to ambulate from bed to door, confused per normal, c/o severe pain to left hip, left foot rotated outwards slightly, pain upon any type of movement, received orders to transfer to (Name deleted) hospital for eval. (evaluation) and tx. (treatment)" The 'Care Plan Report', dated 06/15/12, documented, "Problem: Guest attempted to ambulate without assist; fall on L side - sent to ER for evaluation." There was no further documentation on the care plan. A facility discharge assessment, dated 06/15/12, documented the resident had a fall prior to admission, but did not document the falls on 05/19/12, 06/02/12 and 06/15/12 since the admitted . The 'Hospital emergency room Record,' dated 06/15/12 at 6:45 a.m., documented, ..."left extremity positive for injury or acute deformity, decreased range of motion, pain." A hospital 'Discharge Summary,' dated 06/19/12, documented, "left femur fracture, taken to the OR (operating room) and the ORIF (open reduction internal fixation) was completed without incident. The family has decided on a nursing facility and the patient is stable to discharge on 06/19/2012..." At 11:20 a.m., the DON was asked who investigated falls. She stated, "I investigate all falls. The charge nurses are responsible to document new interventions on the incident reports after a fall. If new interventions fail, we will have a family conference and they may use sitters to stay with the resident. We may move the resident closer to the nurses' station." The DON was asked who updated the care plans following a fall, she stated, "the nurses do that." "We interview the family, staff, check current labs, Dr. orders and medications to see what we need to monitor. The nursing administrative staff makes rounds and reviews all residents at risk for falls." The DON was shown the incident reports and care plans for resident #1. She was asked what new interventions were put in place for this resident following the falls on 6/02/12 and 06/15/12. She stated, " There was no documentation of any new intervention following the fall on 06/02/12." She stated the care plan was reviewed but it did not document the bed alarm, but the call light was in reach. The DON was asked if having the call light in reach was an appropriate intervention for resident #1. She stated, "No, the resident was very demented." The DON was asked about the fall on 06/15/12. She stated the resident went to the hospital and the facility was unaware of the outcome. She did not know if the community liaison checked on the resident. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/06/12, documented the cognition for resident #4 was moderately impaired. The resident required extensive assistance of two staff members for transfers, ambulation, dressing and personal hygiene. The assessment documented she had one fall with injury. The care plan, dated 05/18/12, documented, "Problem: (Resident) is at risk for falls due to history of multiple pathologic fractures, poor balance and gait due to recent surgeries. Goals: (Resident) will maintain / improve current level of mobility with no increase in the incidents of falls/injuries. Interventions: Assist (Resident) to wear non-stick footwear that fits. Engage (Resident) in activities that improve strength, balance and posture. Instruct (Resident) on safety measures to reduce the risk of falls (posture, changing positions, use of handrails). Physical and occupational therapies to continue to treat (Resident) until max potential is reached. Keep areas free of obstructions to reduce the risk of falls or injury. Keep nurse call light within easy reach. Instruct (Resident) to use call bell or call out for assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked." The care plan, updated 05/29/12, documented, "Problem: Found on floor next to bed swelling to forehead. Intervention: Sent to ER." An incident report, dated 05/29/12 at 6:30 a.m., documented the resident was found laying on the floor near her bed. There was swelling noted to the left side of her forehead. The resident rated her pain at a 10/10. Bruising was noted to her forehead on the left side and a laceration was noted on top of the swelling. The additional comments and/or steps taken to prevent recurrence documented she was sent to the emergency room for an evaluation. A nurse's note, dated 05/29/12 at 1:30 p.m., documented the resident came back from the hospital at 10:00 a.m. with a hematoma to the left frontal area. The clinical record did not contain documentation of new interventions to prevent further falls. The care plan, updated 06/06/12, documented, "Found on floor in front of bathroom door - laceration to back of bed. (sic)" An incident report, dated 06/06/12 at 1:45 p.m., documented, "...Pt was found on R side c blood pouring out of back of head in front of bathroom door...The additional comments and/or steps taken to prevent recurrence: obtain a chair alarm.." A nurse's note, dated 06/06/12 at 7:57 p.m., documented the resident returned from the hospital with a small laceration on the back of her head and two staples in place. On 07/06/12 at 11:50 a.m., the DON was asked about the falls for resident #4. She stated she did not write down her investigations. The DON was asked about new interventions to prevent further falls. She stated they review the care plan and previous interventions. She stated after the second fall the resident was moved closer to the nurse's desk and a chair alarm was placed. She was asked about interventions after the first fall on 05/29/12 in which the resident received a laceration to her forehead. After she reviewed the care plan the DON stated, "We did not document any new interventions on the care plan or the incident report. She reviewed the nurses' notes and stated, "We never documented that we put an alarm on her initially."

Based on observation, clinical record review, policy and procedure review, and interviews, it was determined the facility failed to: a. assess and monitor a resident for oversedation for one (#1) of five sampled residents who were receiving narcotic pain medications. The resident required transfer to the hospital with altered mental status and required administration of medications to reverse the effects of the narcotics. This deficient practice resulted in an immediate jeopardy situation. This had the likelihood to affect 64 residents identified by the facility as receiving as needed pain medications; and b. assess a resident's pain level prior to the administration of an as needed pain medication for three (#1, 2, #5) of five sampled residents receiving as needed pain medication. This had the potential to affect 64 residents identified by the facility as receiving as needed pain medications. Findings: A facility policy, titled Change in a Resident's Condition or Status, documented, "...Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental; condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.)... Policy Interpretation and Implement: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been... d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the residents medical treatment significantly... g. A need to transfer the resident to a hospital/treatment center... i. Instructions to notify the physician of changes in the resident's condition..." A facility Policy, titled Charting and documentation, documented, "...Policy Statement: All services provided to the resident, or any change of the resident's medical or mental condition, shall be documented in the resident's medical record... Policy Interpretation and Implement: 1. All observations, medications administered, services provided, etc., must be documented in the residents clinical record..." A facility Policy, titled Administering Pain Medications, documented, "...Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administrating non-narcotic or narcotic [MEDICATION NAME] Documentation: The following information should be recorded in the resident's medical record: 1. Subjective evidence of pain. 2. Objective evidence of pain. 3. Condition of the pain site, if appropriate. 4. The drug name, dose, time, date, and route of administration. 5. The resident's response to the medication. 6. The name and title of the individual assessing the resident for pain and administrating the medication..." A facility Policy, titled Pain Assessment, documented, "...Purpose: The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control which is mutually established with the resident, family and members of the health care team... General Guidelines:... 4. Pain will be assessed and documented at regular interval, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable go the resident will occur within 2 hours of administration... Documentation:... 4. All assessment data obtained during the procedure including location of pain, level of pain using the pain scale, and type of pain relief used. 5. 2-hour reassessment of pain and the resident's response to the pain relief used..." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Individual Patient's Narcotic Record for the resident, documented, " [MEDICATION NAME]/[MEDICATION NAME] (narcotic [MEDICATION NAME]) 7.5/325 tablet 2 tabs by mouth every 4 hrs. as needed... 11/08 - 1938(7:38 p.m.) 60 - ii (two removed) - 58 11/09 - 0155(1:55 a.m.) 58 - ii (two removed) - 56 11/09 - 0555(5:55 a.m.) 56 - ii (two removed) - 54 11/09 - 12 (12:00 p.m.) 54 - ii (two removed) - 52." A Clinical Notes Report, dated 11/08/11 at 11:35 p.m., documented, "...pt was sedated on arrival and during assessment pt was not responsive..." The residents Initial Care Plan, dated 11/08/11, documented, "...#3 Pain/Discomfort [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5/325 i/ii (1-2) q 4 (hours) prn., 1.) Assess resident for pain or discomfort... 3.) Assess pain type, location and duration...assess pain hourly after medication administered..." A Clinical Notes Report, dated 11/09/11 at 12:36 p.m., documented, "Res alert and very sleepy today..." There was no documentation of the four doses of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 (two tablets) on the electronic MAR. The residents clinical record contained no documentation of assessing the resident for pain or the effectiveness the four doses of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 (two tablets) administered to the resident. An ambulance service document, dated 11/09/11 at 6:24 p.m., documented, "...Pts. family witnessed pt have an unresponsive episode that lasted '15 minutes'...Upon arrival, pt is responsive to voice...Pt. was given 0.5 mg of [MEDICATION NAME] IVP. After [MEDICATION NAME] administered, pt is A&Ox1(awake alert and orient times one) (normal mentation)..." An emergency room Report, dated 11/09/11 at 9:35 p.m., and signed by the emergency room physician, documented, "...When EMSA arrived according to the reports, they tapped him on his shoulder and he opened eyes and responded...He was given [MEDICATION NAME] (narcotic reversal agent) by EMSA... He did arouse after this..." On 11/16/11 at 9:40 a.m., the ADON was asked where as needed pain medication would be charted in the clinical record and would there be any reason it would not be charted. She stated, "There is no reason it should not be charted." At 11:10 a.m., the DON was asked where as needed pain medication would be charted in the clinical record and would there be any reason it would not be charted. She stated, "It should be charted on the MAR and there should be no reason for no documentation." At 12:05 p.m., CMA#3 was asked where she would document the administration of prn medications and what would she document. She stated, "document on the MAR and the pain level and time." At 12:10 p.m., CMA#3 was asked the level of consciousness of the resident when she administered the pain medication on 11/09/11. She stated, "He was not alert his wife wanted so it wouldn't start trying to get up and move around." At 3:00 p.m., the DON was asked who would document the prn pain administered. She stated, "If the CMA administered it they document it in the MAR." At 3:20 p.m. LPN #4 was asked the level of consciousness of the resident during his stay at the facility. She stated he was the same the whole time. She stated the hospital reported he was unresponsive. On 11/16/11 at 2:33 p.m., the OSDH was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to assess the resident's condition, monitor his status, and intervene according to the standards of care when the resident had a significant change in condition. At 3:00 p.m., the administrator and the DON were notified of the IJ situation related to the facility's failure to assess, monitor and intervene for a significant change in condition for resident #1. They were notified the IJ situation indicated substandard quality of care and the facility would enter into an extended survey. On 11/16/11 at 4:55 p.m., the facility submitted an acceptable Plan of Removal. The Immediate Jeopardy Plan of Removal documented, "In-Service education will be provided to direct care staff by midnight on 11/16/11. Those direct care individuals not present for the in-service will be in-serviced via telephone by midnight on 11/16/11. Should any remaining direct care individuals not personally or via telephone receive the in-service in the time described above, they will be removed from the employment responsibilities. Assess and monitor in a timely manner. All direct care staff should be aware of changes in the resident's health status, communicating such changes on identification to the appropriate charge nurse, immediately. Changes in the resident's health status can include (but are not limited to): ? Communication style or ability to understand resident ? Changes in cognition. Example: A resident who was previously alert and oriented has become disoriented or confused, lethargic or unable to arouse. ? Changes in transfer, ambulation or gait. ? Changes in continence. ? Vital sign fluctuations. ***This is not an all-inclusive list, but only an example of some situations of changes in resident health status that should be communicated immediately to the charge nurse.*** Charge nurses will act immediately on any identification of changes in resident status. The charge nurse will assess the resident; if emergency protocols are necessary, such will be provided and implemented immediately on identification; in absence of emergency situation, the charge nurse will consult the physician based on assessment findings resulting from the health status change and follow any physician ordered interventions. The charge nurse will document all interactions relative to the resident's health status and any changes or updates to care relative to those changes. The charge nurse will notify any interested and approved persons to receive healthcare information regarding status and care updates. The above referenced in-service education specifications will be implemented and achieved on 11/16/2011 by midnight." On 11/17/11 at 8:30 a.m., facility staff were interviewed about training regarding significant changes in a resident's condition and reporting of theses changes. They were not able to give examples of changes in conditions such as vital sign fluctuation, continence, ambulation, pain, etc.. At 9:05 a.m., the administrator and DON were notified of the staff's lack of knowledge about residents' changes in condition. The administrator was asked to submit an amended plan of removal to address the staff's knowledge deficit regarding significant changes. At 10:30 a.m., an amended plan of removal was submitted and accepted by the survey team. The amended plan documented, "It was determined that several direct care nursing staff needed a clarification in-service on Thursday morning by the facility and survey team. It was also determined that the facility's contracted therapy personnel need to be in serviced regarding the incident and reporting and documentation any change of condition to the charge nurse before continuing with treatment." At 10:20 a.m., the IJ situation was removed. The deficiency remained at a level of actual harm with one or a very limited number of residents affected. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's Initial Care Plan, dated 10/29/11, documented, "...#3 Pain/Discomfort [MEDICATION NAME] (narcotic [MEDICATION NAME])7.5/325. 1.) Assess resident for pain or discomfort... 3.) Assess pain type, location and duration...assess pain hourly after medication administered..." An admission assessment, dated 11/05/11, documented the resident's cognition was moderately impaired and required extensive assistance by staff with transfers, dressing and bathing. The resident's November MAR, documented, "[MEDICATION NAME] 400 mg (1) ...give Q 4hrs prn pain...11/1/2011 6:17 administered...7:17 results relief..." "Tylenol 325mg (2) ...give Q 4hrs prn pain...11/16/2011 6:04 administered...7:04 results effective..." "[MEDICATION NAME] 7.5-325 mg (1)...Q 4hrs prn pain...11/3/2011 20:09 (8:09 p.m.) administered...21:09 (9:09 p.m.) results relief..." "[MEDICATION NAME] 7.5-325 mg (1)...11/14/2011 19:50 (7:50 p.m.) administered...20:50 (8:50 p.m.) results effective..." "[MEDICATION NAME] 7.5-325 mg (1)...11/15/2011 19:29 (7:29 p.m.) administered...20:29 (8:29 p.m.) results relief..." The clinical record contained no documentation of a pain assessment prior to the administration of prn pain medications. On 11/16/11 at 9:40 a.m., the ADON was asked where as needed pain medication would be charted in the clinical record and would there be any reason it would not be charted. She stated, "There is no reason it should not be charted." At 11:10 a.m., the DON was asked where as needed pain medication would be charted in the clinical record and would there be any reason it would not be charted. She stated, "It should be charted on the MAR and there should be no reason for no documentation." At 12:05 p.m., CMA#3 was asked where she would document the administration of prn medications and what would she document. She stated, "document on the MAR and the pain level and time." At 4:00 p.m., the resident was observed in her room lying on the bed. She was asked if she was having any pain. She stated, "No, they ask me if I'm having pain." 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing assessment completed on admission documented the resident was cognitively impaired. A pain screening documented the resident was able to point to wrong faces (face pain scale used) and was able to verbalize pain. On 11/16/11 the resident's electronic MAR documented, "Tylenol Extra Strength 500 mg (1) Enteral Tube As Needed starting 11/15/11." One dose was documented as administered on 11/16/11 at 9:00 a.m. The resident's treatment record, dated November 2011, documented, a zero pain level for the first shift pain screening. The resident's clinical record contained no documentation of the resident's pain being assessed prior to the administration of the above mentioned pain medication.