Every finding on record at Jan Frances Care Center

On 07/28/25 at 4:01 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to provide supervision and interventions to prevent resident-to-resident abuse. Resident #1 and Resident #2 became involved in an altercation over cigarettes on 07/19/25. Resident #1 hit Resident #2 with a wet floor sign, causing a fracture to Resident #2's left arm. The facility did not implement interventions to prevent another incident. On 07/27/25, Resident #1 and Resident #4 were involved in an altercation over cigarettes which resulted in the residents slapping each other. No interventions or additional supervision were implemented to prevent another resident-to-resident altercation. On 07/28/25 at 4:11 p.m., the administrator was notified of the immediate jeopardy and was provided the immediate jeopardy template. On 07/30/25 at 12:16 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, July 29, 2025Jan [NAME] Care CenterAmended Plan of Removal-Abuse/Resident to Resident Altercation Completion date 07-29-2025 8:00 p.m.All Staff EducationAbuse and Neglect Policy & ProceduresResident-To-Resident AltercationsAll staff will be educated on ensuring the safety and well-being of all residents by preventing, identifying, and managing resident-to-resident altercations. When a resident poses a risk to others, immediate action will be taken including 1:1 supervision and, if necessary, removal or transfer to a more appropriate setting. All staff will be educated on the facility abuse policy, how to identify abuse, the potential for abuse, and the prevention of abuse. [Name withheld], Regional Nurse, will be the instructor for both inservices. [Name withheld] is the Abuse Coordinator and will receive additional education from [name withheld], Regional Nurse. A sign in sheet will be utilized for staff that are currently in the facility. Any remaining staff will be called to the facility for education; or educated over the telephone. Employee names and the time of the telephone call will be documented. This education will be completed by 4:00 p.m. on 7-29-25. Currently in progress:All residents will be assessed for active behavior issues to determine the risks for future altercations. The physician will be notified if any resident is displaying current behaviors. Interventions will be implemented and care plans updated as needed. This was completed on 7-28-25 at 6:00 p.m. Resident #1 will be discharging to another skilled facility today 7-29-25 at 4:00 p.m. Resident #1 is being monitored 1:1 by a CNA and will be monitored until time of discharge today. Resident #1's care plan has been updated. Resident safe surveys were completed by [name withheld], Administrator on 7-28-25 by 6:00 p.m. Non-verbal communication tools such as an emotions picture card will be used to determine if non-verbal residents feel safe. Skin assessments will be completed for all residents that are cognitively impaired to check for bruising or skin tears to rule out physical abuse. Skin assessments were completed by the Regional Nurse, [name withheld]. They were completed 7-29-25 before 8:00 p.m. Upon completion of the immediate corrections, audits and observations will be continued by the Administrator and Interim Director of Nursing for the next 90 days. On 07/31/25, after interviews with facility staff, review of staff in-services and sign-in sheets, resident behavior assessments, resident skin assessments, safe survey forms, and documentation related to one-on-one supervision of Resident #1 prior to discharge, the immediacy was lifted, effective 07/29/25 at 8:00 p.m The deficient practice remained as a pattern harm level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent resident-to-resident abuse for 3 (#1, 2, and #4) of 4 sampled residents reviewed for abuse. The administrator reported two incidents of resident-to-resident abuse in the past 90 days. Findings: An Abuse - Reportable Events policy, dated 08/2019, read in part, It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.It is the responsibility of all facility staff to prohibit resident abuse, neglect, exploitation, and misappropriation of resident's property in any form .All residents will be immediately protected from harm .If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the home's primary concern.1.A care plan, dated 04/22/25, showed Resident #1 exhibited agitation and aggressive behaviors. The care plan was updated on 07/21/25 and showed the resident was combative and had been in an altercation with another resident (Resident #2). A quarterly MDS assessment for Resident #1, dated 05/10/25, showed the resident had diagnoses which included chronic kidney disease, diabetes mellitus, malignant neoplasm of colon, cerebral infarction, insomnia, and hypertension. The assessment showed the resident had a BIMS of 12, which indicated the resident was moderately impaired with cognition. The assessment showed the resident required partial to moderate assistance with activities of daily living. A nurse progress note, dated 07/19/25 at 2:00 p.m., showed Resident #1 was in a resident-to-resident altercation. The note showed Resident #1 picked up a wet floor sign and hit the other resident (Resident #2). The note showed the provider was notified and a new order was received for Buspar 5 milligrams three times a day for anxiety. A nurse progress note, dated 07/27/25 at 6:29 p.m., showed Resident #1 was outside smoking when they got in an argument with another resident (Resident #4). The note showed the residents exchanged words then started slapping each other. On 07/28/25 at 12:15 p.m., Resident #1 was interviewed in the courtyard/smoking area. The resident was asked if they had any issues with other residents. The resident did not mention Resident #2 but stated Resident #4 had accused them the previous day of coming in their room and waking them up. Resident #1 reported they did not want to be in the facility and wanted to go somewhere else. 2. On 07/28/25 at 10:40 a.m., Resident #2 was observed in their room, sitting in their wheelchair and watching television. The resident was observed to have a scratch or skin tear to the left forearm. The resident was observed to use their left arm for repositioning the wheelchair and their right arm was observed to be flaccid (limp and weak). A soft arm brace was observed on the resident's bed. A quarterly MDS assessment for Resident #2, dated 07/07/25, showed the resident had diagnoses which included cerebral infarction, muscle wasting, hypertension, chronic pain, hemiplegia and hemiparesis, and depression. The assessment showed the resident had a BIMS of 15, which indicated the resident was cognitively intact. The assessment showed the resident required set-up assistance or supervision with activities of daily living. A care plan for Resident #2, dated 07/21/25, showed the resident sustained a wrist fracture caused by another resident (Resident #1). On 07/28/25 at 10:45 a.m., Resident #2 was asked about the scratch on their arm and the arm brace. Resident #2 reported Resident #1 had accused them of stealing their cigarettes. Resident #2 reported Resident #1 became more and more angry and picked up a wet floor sign. Resident #2 reported they could tell Resident #1 was going to hit them, so they raised their left arm in defense and Resident #1 hit Resident #2's left arm. Resident #2 reported they have a fracture to the left arm, but the brace gets in the way of using their wheelchair and they were waiting on an appointment with an orthopedic specialist.3. A quarterly MDS assessment for Resident #4, dated 07/17/25, showed the resident had diagnoses which included Parkinson's disease, diabetes, chronic obstructive pulmonary disease, anxiety, and depression. The assessment showed the resident had a BIMS of 13, which indicated the resident was cognitively intact. The assessment showed the resident required set-up assistance with activities of daily living. A care plan for Resident #4, dated 07/28/25, showed the resident was at risk for emotional trauma related to being hit by another resident (Resident #1). On 07/28/25 at 10:57 a.m., Resident #4 reported on the previous day, they woke up to find Resident #1 in their room looking for cigarettes. The resident stated they were startled, but not scared. Resident #4 reported they went outside to smoke, Resident #1 got mad while discussing cigarettes and acted like they were going to hit Resident #4. The resident reported Resident #1 hit them on the arm and Resident #4 told them they would fight back. On 07/28/25 at 11:20 a.m., CNA #1 reported they were working the day of the incident between Resident #1 and Resident #2, when Resident #1 accused Resident #2 of stealing their cigarettes. CNA #1 reported after the incident happened, the nurse was dressing Resident #2's arm when Resident #1 came back around and was still angry. CNA #1 reported the staff had to circle around Resident #2 so the nurse could finish dressing the resident's arm. On 07/28/25 at 11:30 a.m., CNA #2 reported they witnessed the incident between Resident #1 and Resident #2. CNA #2 reported they saw and heard the two residents in the hallway and noticed they became louder and louder. CNA #2 reported they alerted LPN #1, but Resident #1 hit Resident #2 with the wet floor sign before staff could reach them and intervene. On 07/28/25 at 11:55 a.m., LPN #1 reported they witnessed the incident between Resident #1 and Resident #2. LPN #1 reported they heard the residents arguing and gradually getting louder. LPN #1 reported they started down the hall to separate the residents, but Resident #1 hit Resident #2 with the wet floor sign before they could get to them. LPN #1 reported the incident started when Resident #1 accused Resident #2 of stealing their cigarettes. LPN #1 reported they immediately separated the residents but did not interview other residents following the incident. On 07/28/25 at 2:00 p.m., the administrator reported Resident #1 was not happy at the facility, and due to the resident's behaviors, they had been trying to get Resident #1 transferred to another facility, but had been unsuccessful in finding a place that would accept the resident. The administrator reported they were not aware of any other incidents involving Resident #1, until the incident the previous day involving Resident #4. The administrator was asked if there were any interventions in place after the 07/19/25 incident to prevent another incident, or if Resident #1 was receiving closer supervision. The administrator stated, No.

Based on record review and interview, the facility failed to report an incident of misappropriation of property for 1 (#4) of 2 residents sampled for misappropriation of funds. The administrator reported two incidents of misappropriation of resident funds. Findings: An Abuse - Reportable Events policy, dated 08/2019, read in part, It is the responsibility of all facility staff to prohibit resident abuse, neglect, exploitation, and misappropriation of resident's property in any form; and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse, neglect and/or exploitation caused by another person .All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. An OSDH incident report form, dated 06/27/25, showed a previous staff member, social services #1, had taken money from residents on two different occasions. The report listed only one resident by name and gave details of that investigation. A quarterly MDS assessment for Resident #4, dated 07/17/25, showed the resident had diagnoses which included Parkinson's disease, diabetes, chronic obstructive pulmonary disease, anxiety, and depression. The assessment showed the resident had a BIMS score of 13, which indicated the resident was cognitively intact. A care plan for Resident #4, dated 07/28/25, showed the resident had a behavior of manipulation or fabrication toward staff and other residents. On 07/28/25 at 4:15 p.m., the administrator was asked which residents had money taken from the previous social services staff, as only one was listed on the incident report. The administrator reported it was Resident #4, but the administrator was not working at the facility during that time and was not familiar with how the incident was handled. On 07/31/25 at 4:20 p.m., the administrator and regional director of operations were interviewed regarding the social services staff member taking money from Resident #4. The regional director reported the ombudsman informed them about the incident and offered to report the incident to APS. The regional director reported they did an investigation, looked into the resident's bank statements and withdrawals, and ultimately the staff member admitted to taking the money from Resident #4. The regional director reported this was against their policy and the staff member was terminated. The regional director stated they did not report the incident to OSDH, as they thought the ombudsman would report it. On 08/01/25 at 8:45 a.m., the administrator reported they were not working at the facility when the incident occurred with Resident #4 and the previous social services staff. The administrator stated they were the one that reported the incident involving a different resident, and if they had been at the facility, they would have done the same related to the incident with Resident #4. On 08/01/25 at 10:25 a.m., the ombudsman reported they had gone to the facility when Resident #4 called them to say the social services staff had asked to borrow money. The resident told the ombudsman they had given the staff member their debit card and thought they would pay back the money. The ombudsman reported they offered to submit an APS report for the facility regarding the incident. The ombudsman reported they did not know if the facility called the police or did an investigation, but they should have. On 08/01/25 at 10:40 a.m., Resident #4 reported they thought they were friends with the previous social services staff and did not hesitate to give the staff member their debit card. The resident stated they had learned a lesson and would not do it again.

Based on record review and interview, the facility failed to obtain a urinalysis to detect signs of urinary infection and blood for 1 (#1) of 3 residents sampled for unnecessary medication. The AIT identified 48 residents resided in the facility. Findings: Resident #1 had diagnoses which included urinary tract infection, personal history of urinary calci, painful Micturition (painful urination), malignant neoplasm of the prostate and kidney failure. An Encounter Note, dated 01/08/25, showed a TRUS (trans rectal ultrasound) of the prostate had been performed that day. The note showed to obtain a urinalysis to detect signs of urinary infection and blood. The note showed Resident #1 required surgical treatment. There was no documentation to show a urinalysis was obtained in Resident #1's clinical record. A resident care plan, revised 03/17/25, showed Resident #1 had a catheter and was at increased risk for urinary tract infections. On 04/07/25 at 3:27 p.m., the DON was asked to locate the urinalysis requested on the encounter note dated 01/08/25. They stated it may have been thinned and went to look for it. On 04/07/25 at 3:57 p.m., the assistant director of nursing stated they were not able to locate the urinalysis.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were maintained during catheter care for 1 (#2) of 3 sampled residents reviewed for activities of daily living care for dependent residents. The AIT identified 48 residents resided at the facility. Findings: On 04/04/25 at 11:13 a.m., LPN #1 performed hand hygiene, donned gloves, gathered supplies of saline, drain sponge and another sponge, and placed then on the resident's bedside table. LPN #1 removed the old drain sponge from the suprapubic catheter and no drainage observed. LPN #1 cleaned the area, applied an ointment, covered the resident with their blanket, threw away the trash, adjusted the resident's covers, bedside table, television remote, and the resident's phone. LPN #1 did not change their gloves or perform proper hand hygiene during the performance of catheter care. Resident #1 had diagnoses which included painful micturition (act of urinating), personal history of urinary calculi, urinary tract infection, and anxiety disorder. A resident care plan, revised 03/17/25, showed Resident #1 had a catheter and was at increased risk for urinary tract infections. On 04/04/25 at 11:25 a.m., LPN #1 stated they should have changed their gloves after cleaning the tube.

Based on record review and interview, the facility failed to ensure a resident's emergency contact was notified of medication changes and the physician and emergency contact were notified of a change in condition for 1(#1) of 3 sampled residents reviewed for notification of change. The AIT identifed 48 residents resided in the facility. Findings: Resident #1 had diagnoses which included painful micturition (act of urinating), personal history of urinary calculi, urinary tract infection, and anxiety disorder. A resident care plan, revised 03/17/25, showed Resident #1 had a catheter and was at increased risk for urinary tract infections. The care plan showed the resident had chronic pain. A physician's order, dated 03/18/25, showed Ativan (antianxiety medication) 0.5 mg two times a day for seven days. A physician's order, dated 03/20/25, showed pyridium (relieves symptoms caused by urinary tract infections and other urinary problems) 200 mg three times a day for seven days. A physician's order, dated 03/24/25, showed Ativan 0.5 mg two times a day. There was no documentation Resident #1's emergency contact was notified of the change in medication orders. A progress note, dated 03/28/25 at 3:58 a.m., read in part, An aide reported that resident was not acting right, resident just staring at the ceiling, VS [vital signs] 89/52, 92, 18, 98.7, 93% on RA [room air], no distress notes, resident not answer questions, resident had vomited earlier this shift.Had given a pain pill earlier for c/o [complain of] back pain. There was no documentation Resident #1's physician and emergency contact were notified of the change in condition. On 04/04/25 at 2:13 p.m., LPN #1 was asked who was notified for a change in a resident. LPN #1 stated either the resident's physician assistant or doctor. LPN #1 stated administration, the DON, and the family were also notified. LPN #1 stated the staff would assess the resident and notify the doctor of what they found, follow any orders, then notify the DON and the family. On 04/03/25 at 2:25 p.m., LPN #1 was shown the electronic medical record progress notes to review for Resident #1. After review, LPN #1 was asked if the resident's emergency contact was notified for changes to the resident's medication on 03/20/25 for pyridium. LPN #1 stated, Do not see where they did. LPN #1 was asked if the resident's emergency contact was notified for the Ativan order dated 03/24/25 changing to twice a day. They stated, Don't see. LPN #1 was asked where the emergency contact and the physician was notified about Resident #1 Not acting right on 03/28/25. They stated, Don't see. LPN #1 stated they usually completed a note and also an observation note that had all the contact information on it.

Based on record review and interview, the facility failed to provide adequate supervision to prevent elopement for 1 (#1) of 3 sampled residents reviewed for elopement. The assistant administrator reported 50 residents resided in the facility. The facility elopement book identified four residents at risk for elopement. Findings: A policy titled Wandering, Unsafe Resident, dated 12/01/08, read in part, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Resident #1 had diagnoses which included dementia. An elopement risk evaluation, dated 08/19/24, showed Resident #1 was at risk for elopement. A care plan, dated 08/19/24, showed Resident #1 was an elopement risk due to ambulation status, history of elopement, dementia, and wandering. A progress note, dated 01/11/25 at 5:09 a.m., showed the resident got up through the night wandering halls, trying to go into other resident rooms, and was easily redirected. A quarterly assessment, dated 01/13/25, showed Resident #1's cognition was severly impaired and the brief interview for mental status was unable to be scored. A incident report, dated 03/12/25, showed the facility was notified by a realtor at 11:20 a.m. of a possible missing resident. The report showed staff returned Resident #1 to the facility. The report showed the resident's window screen had been removed and the window was open. The report showed the resident had been last seen in the front lobby at 10:30 a.m. A progress note, dated 03/12/25 at 12:16 p.m., showed a real estate office reported a resident was sitting in their office. The progress note showed Resident #1 was picked up by a nurse and the resident reported to the nurse it was a nice day for a walk. The progress note showed it appeared the resident had removed their window screen and climbed out the window. On 03/17/25 at 4:00 p.m., the assistant administrator reported Resident #1 had been moved to a room on the front hall due to plumbing issues from the resident stuffing items down their toilet. The assistant administrator reported after the elopement, another resident reported Resident #1 had been messing with their window before the incident. The assistant administrator reported the resident had been moved back to their old room which improved their wandering behavior.

Based on observation, record review, and interview, the facility failed to provide hot water in resident bathroom sinks for three (#12, 22, and #26) of three residents sampled for comfortable and homelike environment. The administrator reported 46 residents resided in the facility. An undated Maintenance Policy, read in parts, The facility shall complete a routine maintenance and preventive maintenance program to assure the safety and comfort of the residents. The following items shall be tested weekly .water temperature. 1. On 01/07/25 at 11:42 a.m., Resident #12 reported the water in their bathroom sink never got hot. The water was checked with the surveyor holding their hand under the running water for two minutes and the water never warmed up. On 01/09/25 at 10:04 a.m., the water temperature was rechecked in Resident #12's bathroom. After letting the hot water run for two minutes, a digital temperature reading was 68.9 degrees Fahrenheit. The resident reported maintenance staff had been in their room to check the water temperature, but nothing had changed. A maintenance temperature log was reviewed. The log documented the most recent water temperature check for Resident #12's room was on 01/03/25. The temperature reading was 100 degrees Fahrenheit. 2. On 01/07/25 at 1:30 p.m., Resident #22 reported they did not have hot water and the water in their sink never got hot. The resident reported they had previously reported this to maintenance staff. The water was checked by the surveyor holding their hand under the running water for two minutes and the water never warmed up. On 01/09/25 at 9:59 a.m., the water temperature was rechecked in Resident #22's bathroom. After letting the hot water run for two minutes, a digital temperature reading was 83.5 degrees Fahrenheit. A maintenance temperature log was reviewed. The log documented the most recent water temperature check for Resident #22's room was on 12/27/24. The temperature reading was 104 degrees Fahrenheit. 3. On 01/07/25 at 1:45 p.m., Resident #26 reported they did not have hot water in their sink and it was never warm. The resident reported they had previously talked to maintenance staff about the hot water issue. The water was checked by the surveyor holding their hand under the running water for two minutes and the water never warmed up. On 01/09/25 at 9:58 a.m., the water temperature was rechecked at Resident #26's sink. After letting the hot water run for two minutes, a digital temperature reading was 78.8 degrees Fahrenheit. A maintenance temperature log was reviewed. The log documented the most recent water temperature check for Resident #26's room was on 12/27/24, with a temperature reading of 104 degrees Fahrenheit. 4. Resident council meeting minutes, dated 11/26/24, read in part, maintenance forgets to do things. Resident council meeting minutes, dated 12/17/24, read in parts, maintenance is friendly .slow to complete things. On 01/08/25 at 4:29 p.m., the DON reported a clipboard was used to report maintenance issues. The DON reported they kept a copy of the maintenance request then put a copy on the clipboard for maintenance to work from. The DON was uncertain of specific residents who had reported complaints related to lack of hot water in their rooms. On 01/09/25 at 10:29 a.m., maintenance staff reported they checked water temps and air temps on a regular basis. They reported random rooms were checked weekly and temperatures were documented on a log. The maintenance staff reported they had issues off and on with hot water in resident rooms and was aware of the complaints. On 01/09/25 at 10:35 a.m., the corporate administrator reported they currently had maintenance staff checking water temperatures in every room of the building to check for adequate hot water.

Based on observation, record review, and interview, the facility failed to ensure availability of hot water for three (#7, 8, and #9) of nine sampled residents reviewed for reasonable accommodations of needs. The ADON reported 39 residents resided in the facility. Findings: 1. Resident #7 admitted to the facility on [DATE] with diagnoses which included encephalopathy, cerebral infarction, and pressure ulcer of left heel. Resident #7's cognition was moderately impaired. On 10/09/24 at 1:25 p.m., Resident #7 reported they could not shave in their bathroom or wash their hands without hot water. The hot water measured 72.5 degrees Fahrenheit in their bathroom sink. 2. Resident #8 admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, cerebrovascular disease, and acute appendicitis. Resident #8's cognition was intact. On 10/09/24 at 1:29 p.m., Resident #8 reported there was no hot water and they could not shave in their bathroom. The hot water measured 73.4 degrees Fahrenheit. 3. Resident #9 admitted to the facility on [DATE] with diagnoses which included COPD, chronic pain, and diarrhea. Resident #9's cognition was intact. On 10/09/24 at 1:53 p.m., Resident #9 reported it took ten minutes for the water to get hot. They reported they would like to wash their hands with hot water. The hot water measured 93 degrees Fahrenheit. On 10/09/24 at 4:20 p.m., Maintenance reported the water pumps sent out hot water to different areas of the building. They reported two water pumps were not functioning and had been ordered. They reported those rooms did not reach a comfortable temperature and the water temperature should be comfortable for the residents.

Based on record review and interview, the facility failed to have a licensed administrator. Findings: A Administrator policy, dated 07/01/11, read in part .Qualifications/Experience/Requirements: A current, valid state nursing home administrator license is required . The Regional Director reported 32 residents resided in the facility. The staff list provided by the Regional Director, dated 05/21/24, documented no Administrator. On 05/21/24 at 11:05 a.m., the Regional Director reported no licensed Administrator had been hired since the last Administrator walked out in March 2024. The Regional Director reported they had hired a new office staff member that would start Administrator school the first week of June. The Regional Director reported not being a licensed Administrator and was covering until the office staff member was licensed. On 05/22/24 at 10:25 a.m., the Regional Director reported the facility had submitted paperwork to name an Administrator they were operating under. The Regional Director reported the named Administrator was only used for on-call for questions and in the facility as needed. The Regional Director reported the listed Administrator was over two other nursing homes.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours per day, seven days a week. The regional director reported 32 residents resided in the facility. Findings: A staffing policy, not dated, read in part A registered nurse will be employed full time on the day shift, with coverage seven days a week, as the facility's director of nursing service. Clinical staff time detail reports were reviewed for 04/01/24 through 05/21/24. The reports documented no RN coverage in the facility seven days a week. On 05/21/24 at 11:05 a.m., the Regional Director reported the facilty had not hired a DON since the last DON had walked out in March 2024. The Regional Director reported the corporate RN was working as the DON. On 05/22/24 at 10:55 a.m., the Regional Director reported the corporate RN worked in the facility eight hours a day, five days a week. The Regional Director reported the facility had no RN coverage on the weekends.

Based on observation and interview, the facility failed to ensure housekeeping services maintained a clean environment. The ADON reported 32 residents resided in the facility. Findings: The facility Housekeeping Guideline manual, dated 01/01/05, read in part, .Daily cleaning resident rooms .Empty and clean trash cans .Dust mop floors .Damp mop floors . The facility housekeeping checklist order, provided by the Regional Director, not dated, read in part, .Daily order of housekeeping to-dos, this includes sweeping, mopping, picking up trash, making it look presentable .Front entrance/lobby .Around nursing station .Start on a hallway .Take all the trash out of the rooms on the hall .Sweep out all the rooms on the hall .Mop all the rooms on the hall .Sweep and mop the actual hallway itself . On 03/25/24 at 2:15 p.m., upon entrance to the facility, the lobby and hallway floors were observed to be dirty with brown sticky spots in multiple areas. The floors were observed to have dirt debris randomly throughout the lobby and hallways. The lobby area had a strong odor of urine. No housekeeping staff were observed cleaning the facility. On 03/25/24 at 2:30 p.m., resident #2's room was observed to have brown sticky spots on the floor and trash was on the floor around the overflowing trash can. On 03/25/24 at 2:30 p.m., resident #2 reported their room was not cleaned very often. The resident reported the floor in their room was dirty, not just old. The resident reported the floor was not swept and mopped daily. The resident reported not being aware of the last time the room was mopped. On 03/25/24 at 2:35 p.m., resident #1 reported their room was not cleaned very often, and was not aware of the last time it had been mopped. The resident reported the floors were not clean. On 03/26/24 at 11:30 a.m., the Regional Director reported three new housekeeping staff were being trained that day to get the facility cleaned properly. On 03/27/24 at 4:30 p.m., the Regional Director reported being in agreement the facility was dirty on 03/25/24. The Regional Director reported the housekeeping staff needed more training and needed a supervisor.

Based on observation, record review, and interview, the facility failed to ensure residents received showers as scheduled for two (#3 and #6) of six residents reviewed for activities of daily living. The ADON reported 32 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included non-traumatic brain dysfunction and metabolic encephalopathy. Resident #3's assessment, dated 02/20/24 documented cognition severly impaired and dependent on staff for bathing. Resident #3's shower sheets, provided by the Regional Director for February 2024, failed to document scheduled showers were performed for February 1st, 6th, 8th, 10th, 13th, 15th, 17th, 20th, 22nd, 24th, and 29th. Resident #3's shower sheets, provided by the Regional Director for March 2024, failed to document scheduled showers were performed for March 2nd, 5th, 7th, 9th, 16th, 19th, 21st and 23rd. Resident #3's care plan, dated 03/21/24, read in part, .Resident ADL functions: Assist x 1 staff with bathing . The facility's shower schedule, dated 03/26/24, documented resident #3's showers were scheduled on the 6-12 shift for Tuesday, Thursday, and Saturday. On 03/26/24 at 1:51 p.m., Resident #3's family member #2 reported the resident did not receive showers three times a week as scheduled. Family member #2 reported the resident was scheduled for a shower that day but had not received one and the resident's blankets had not been changed. On 03/26/24 at 3:55 pm, the Regional Director reported resident #3 had not received the scheduled shower for that day on the 6-2 shift. On 03/26/24 at 4:00 p.m., CNA #1 reported residents' scheduled showers were not always completed as scheduled due to days when they were short staffed for nurse aides. The CNA reported if showers were missed they would try to get them done the next day. 2. Resident #6 had diagnoses which included vascular dementia and non-traumatic brain dysfunction. The facility's Resident/Family Concern/Grievance form, dated 03/01/24, documented .Resident's family stated that resident hasn't been showered and clothes have not been changed .Nursing department head review and action taken: Resident is being showered immediately and clothes changed .We will monitor showers on the resident . Resident #6's assessment, dated 03/11/24, documented cognition was moderately impaired, partial to moderate staff assistance was required for bathing, and always incontinent of bladder and bowel. The assessment documented moisture associated skin damage. Resident #6's care plan. dated 03/15/24, read in part, .Limited assist x 1 staff with ADLs . Resident #6's shower sheets, provided by the Regional Director for February 2024, failed to document scheduled showers for February 2nd, 5th, 12th, 16th, 23rd, 26th, and 28th. Resident #6's shower sheets, provided by the Regional Director for March 2024, failed to document scheduled showers for March 1st, 6th, and 20th. The facility's shower schedule, dated 03/26/24, documented resident #6's showers were scheduled on the 2-10 shift for Monday, Wednesday, and Friday. On 03/26/24 at 3:25 p.m., Resident #6's family member #1 reported their only concern was the resident had not received showers as scheduled. Family member #1 reported the resident was scheduled for showers three times a week and had only been receiving one a week. On 03/27/24 at 4:30 p.m., the Regional Director reported not being aware of any issue with showers being provided as scheduled. The Regional Director reported documentation was not available to provide proof that resident showers were provided as scheduled or had been refused by the resident.

Based on observation, record review, and interview, the facility failed to maintain housekeeping services necessary to provide a clean, comfortable, and homelike environment. The Administrator reported 27 residents resided in the facility. Findings: The facility Housekeeping Service Policy, not dated, documented in part, .the facility shall be maintained in a clean, sanitary, orderly and attractive condition .daily room care shall be provided for each resident of the facility .deep cleaning of resident rooms will be performed on schedule .floors shall be maintained in clean and safe condition .housekeeping employees will be available to assist with spills and other accidents throughout the day . On 12/03/23 at 4:00 p.m., a tour of the facility was conducted. The floors in the lobby and all hallways were observed to be dirty with brownish-black spots observed in several areas, as well as trash and general debris on the floors. Resident rooms were observed to be cluttered with trash on the floors and cluttered bedside tables. No housekeeping staff was observed in the building. On 12/04/23 at 8:36 a.m., resident #1's family member reported the facility was filthy on a regular basis. They stated they had cleaned the hall bathroom before themselves, swept the floor of trash, and had noticed the same dirty footprints in the hall for several days straight. They stated the facility had housekeeping staff but their hours had been cut so much that they weren't in the facility long enough to clean well. On 12/04/23 at 10:34 a.m., resident #21's room was observed to have trash and debris scattered on the floor. An empty medicine cup, a plastic spoon, an old hospital ID bracelet, and a plastic vial was observed in addition to several pieces of paper. [NAME] stains were observed on the floor which appeared to be liquid spills. The resident pointed out brown stains under their bed and stated those had been there at least a couple of weeks since they were admitted to the facility. The resident reported they saw housekeeping staff in the hallway occasionally but they did not come into their room. On 12/04/23 at 10:50 a.m., , resident #10's room was observed to have a dirty floor with debris and dust, the window seal with light colored dust and debris, clothing in the corner between the bed and wall, and pieces of trash and paper scattered along the baseboards. The toilet was observed to have a brownish-black buildup of residue in the toilet bowl. The resident reported they did not see housekeeping staff come in their room to clean but occasionally the aides emptied the trash. On 12/04/23 at 1:38 p.m., resident #25's toilet was observed to have a brownish-black ring around the toilet bowl and brown splatters and stains on the wall around the toilet and door frame. On 12/04/23 at 2:05 p.m., resident #32's room was observed to have a dirty floor with what appeared to be spills and a sticky substance. The sink in the bathroom was observed to have brown stains and debris at the sink drain. The toilet was observed with a black buildup of residue. On 12/05/23 at 10:23 a.m., the housekeeping supervisor reported the facility's housekeeping staff had recently had their hours cut back to six or six and a half hours per day. They stated there was housekeeping staff scheduled every day, with a part-time housekeeper on the weekend. The supervisor was asked if staff had a cleaning checklist to refer to and she stated they didn't use a checklist but staff had been trained on how to properly clean and deep-clean a resident's room. The supervisor reported this past weekend she had an employee out sick and didn't have anyone to work in their place. The condition of restrooms and toilets was discussed and the supervisor reported the products they had been using were not getting the toilets clean. The supervisor stated they had used the same cleaning products for a long time, from the same company, and she was uncertain if they would be allowed to try something different. The condition of the floors was discussed and the supervisor stated they worked on the black spots every now and then but currently did not have anyone to buff the floors. On 12/05/23 at 3:52 p.m., the DON provided documentation of weekly cleaning schedules, assignments to be completed by the CNA's for equipment, etc, and reported there was no documentation that cleaning tasks had been performed. The DON toured the facility with the surveyor and observed a resident's wheelchair with debris buildup on the seat and lock bases, a sit-to-stand unit with dust and debris on the base and foot rest, a resident's electric wheelchair with crumbs and debris on the seat, hand controls, and foot rest, and bedside tables throughout the facility that were dirty with food, trash, and debris. On 12/07/23 at 9:54 a.m., the administrator reported the facility had housekeeping staff every day of the week but hours had been cut related to low census. She stated they normally had two housekeepers who worked the same hours, but stated she was trying to change the schedules where they would overlap to cover more hours during the day. The administrator stated she had talked to the housekeeping supervisor as recent as the previous week and told them they needed to step it up. On 12/07/23 at 10:12 a.m., a telephone interview was conducted with an anonymous concerned visitor to the facility. They stated they visited the facility often and it was always filthy. They reported the bathrooms were nasty and stated they were worse than a gas station bathroom.

Based on record review, observation, and interview, the facility failed to prevent abuse, and implement interventions to prevent further abuse, for three (#2, #7, and #9) of three residents sampled for abuse. The administrator reported two incidents of abuse in the previous six months. Findings: A facility policy, Abuse - Reportable Events dated 08/2019, read in part, .It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form .Physical action within the definition of abuse, including, but not limited to hitting, slapping, punching, and kicking .Sexual abuse .non-consensual sexual contact of any type with a resident .The facility will attempt to screen for potentially abusive residents via the admission .If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options .The safety and protection of other residents is the home's primary concern . 1. Res #2 was admitted on [DATE] with diagnoses which included end stage renal disease, diabetes, restlessness/agitation, anxiety, depression, legally blind, and peripheral vascular disease. A quarterly MDS assessment for Res #2, dated 05/15/23, documented the resident was cognitively intact. The assessment documented the resident was independent with most activities of daily living and exhibited verbal behaviors towards others. An OSDH incident report form, dated 06/28/23, documented an incident involving Res #2 and Res #7. The report documented Res #7 was outside smoking when Res #2 started rubbing Res #7's upper arm and upper back. Res #7 told Res #2 to stop, the resident would not stop, and Res #7 slapped Res #2 across the face. Interventions documented Res #2 would be discharging to another facility. No other interventions related to protecting other residents was documented on the report. An OSDH incident report form, dated 06/29/23, documented Res #9 was sitting in the lobby when Res #2 came up and pulled Res #9's ears and hit the resident on the back of the head. Res #9 was assessed and did not require medical attention. The report documented Res #2 would be discharging to another facility. No other interventions related to protecting other residents was documented on the report. Res #2's care plan, updated 07/05/23, documented in part, .Assess if the resident's behavioral symptoms present a danger to the resident and/or others. Intervene as needed .Inappropriate sexual behavior .gestures .bold behaviors .allow privacy .help resident find other placement .Risk for combative or aggressive behaviors to residents/staff . Res #2 discharged from the facility on 07/06/23. 2. Res #7 had diagnoses which included diabetes, heart disease, osteoarthritis, depression, and anxiety. An annual MDS assessment for Res #7, dated 04/16/23, documented the resident was cognitively intact and was independent with most activities of daily living. A care plan for Res #7, updated 07/06/23, documented the resident had exhibited agitation and aggressive behavior when the resident slapped another resident. There was no other documentation related to behaviors. On 07/11/23 at 3:05 p.m., Res #7 was asked if they were aware of any abuse or had experienced any abuse while living at the facility. The resident reported an incident when Res #2 had touched them inappropriately. Res #7 stated they immediately reported the incident and Res #2 no longer lived at the facility. 3. Res #9 had diagnoses which included Alzheimer's disease, dysphagia, psychosis, muscle wasting, conduct disorder, and traumatic brain injury. An annual MDS assessment for Res #9, dated 04/25/23, documented the resident was moderately cognitively impaired and required extensive assistance with most activities of daily living. A care plan for Res #9, updated 07/05/23, documented the resident had behaviors of using foul language toward staff and socially inappropriate behaviors/comments. The care plan documented the resident had a history of hitting another resident defending himself. On 07/12/23 at 10:00 a.m., the administrator was interviewed regarding Res #2's behaviors. The administrator reported she had been at the facility approximately one month and had submitted two incident reports to OSDH involving Res. #2 and resident to resident abuse. The administrator reported the resident had been transferred to another facility the previous week. On 07/12/23 at 4:43 p.m., the ADON was interviewed regarding Res #2's behaviors and interventions to prevent abuse. The ADON stated they had been looking for another facility to transfer the resident to for quite some time, but it had been difficult due to his need for dialysis treatments. On 07/13/23 at 1:34 p.m., LPN #3 reported Res #2 liked to play and would sometimes get too rough with Res. #9. The LPN stated that although Res #2 was legally blind, the resident was cognitively intact and could move about the facility independently. The LPN stated staff routinely kept an eye on Res #2 when he was out of his room and interacting with other residents. On 07/13/23 at 1:48 p.m., LPN #1 reported Res #2 was known to agitate other residents and wouldn't keep his hands to himself. When asked what the LPN meant by this, she stated he would pick at other residents, touch staff inappropriately, and he had touched one female resident inappropriately (Res #7). The LPN stated staff always monitored Res #2 when he was out and about in the facility.

Based on record review and interview, the facility failed to notify a resident's representative, when the resident was sent to the emergency room for treatment, for one (#10) of three residents reviewed for notification of changes. The Resident Census and Conditions of Residents form, dated 07/12/23, documented 32 residents resided in the facility. Findings: Resident #10 had diagnoses which included dementia, psychosis, anxiety, and depression. A significant change MDS assessment, dated 04/05/23, documented the resident was moderately impaired with cognition and was independent with most activities of daily living. A progress note, dated 05/31/23 at 1:12 p.m., documented the resident returned to the facility with a family member. The note documented the resident became dizzy when getting out of the car and almost fell . The note documented staff assessed the resident, called the medical provider, and received an order to send the resident to the emergency room for evaluation and treatment. The note documented the resident's son and daughter were present. The note did not document the resident's representative/POA was notified of the incident. A progress note, dated 05/31/23 at 7:37 p.m., documented the resident returned to the facility via private vehicle. There was no documentation to indicate the resident's representative/POA was notified. On 07/13/23 at 11:30 a.m., resident #10's clinical record was reviewed and documented the resident's representative/POA was listed as the first emergency contact. On 07/13/23 at 1:48 p.m., LPN #1 was interviewed regarding the facility process for notification. The LPN reported any time there was an incident with a resident, the resident's physician, family, DON, and administrator would be notified as soon as possible. The LPN reported the emergency contact information could be located in the resident's clinical record. On 07/13/23 at 3:30 p.m., LPN #2 was asked what the facility's policy and procedure was for notification of resident representatives. The LPN reported any time there was an incident involving a resident, the resident's physician, family, DON, and administrator was notified. The LPN reported the emergency contact information could be found in the resident's clinical record, and stated if they couldn't reach the first contact they would go down the list until a family member or representative could be reached.

Based on record review, observation, and interview, the facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility for one (#1) of three residents reviewed for rehabilitative or restorative services. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: Res #1 had diagnoses which included hydrocephalus, dysphagia, psychotic disorder, and anxiety. A care plan for Res #1, dated 04/04/22, documented the facility was to implement an exercise program for the resident which targeted strength, gait, and balance. A quarterly MDS assessment, dated 01/13/23, documented Res #1 was severely impaired with daily decision making and required extensive to total assistance with ADLs. The assessment documented the resident did not have a ROM deficit and did not receive physical, occupational, speech therapy, or restorative services. On 01/25/23 at 1:19 p.m., Res #1 was observed sitting in a wheelchair and listening to the radio. The resident was dressed appropriately, clean, hair combed into a pony tail, and had a sucker. When the resident was asked if she went to activities, she stated, No, as she was handicapped but the staff visited her in her room. On 01/26/23 at 1:09 p.m., PT #1 stated the facility did not have a restorative program. On 01/26/23 at 1:50 p.m., CNA #1 and CNA #2 reported they did not provide any PROM or ROM for the residents in the facility. They stated only physical therapy could do ROM. When asked about Res #1 they stated she could not assist them to stand and did not walk. On 01/26/23 at 1:55 p.m., the corporate director of operations stated the facility did not have a restorative program. On 01/26/23 at 1:57 p.m., the corporate RN stated the facility did not train CNAs on PROM, ROM, or any functional maintenance or restorative care at that time. She stated the facility had a restorative policy but had not implemented it yet.

Based on record review and interview, the facility failed to appoint an administrator who was licensed by the State of Oklahoma. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: On 01/25/23 at 12:30 p.m., on entrance to the facility the Corporate Director of Operations reported the facility did not currently have an administrator who was licensed in the State of Oklahoma. She stated she was currently managing the facility until the AIT could complete the required training and receive their license as an administrator.

Based on record review, observation, and interview, the facility failed to administer medications according to physician orders for six (#5, 8, 11, 42, 45, and #72) of 13 residents reviewed for medication administration. The Resident Census and Conditions of Residents form documented 44 residents resided in the facility. Findings: 1. Res #5 had diagnoses which included heart failure and hypertension. A physician order, dated 10/24/22, documented to administer [MEDICATION(S)] 25 mg twice a day for hypertension. The order documented to hold the medication if the systolic BP was less than 100 or the diastolic BP less than 60. The November 2022 MAR documented on 11/07/22 a BP of 100/54. The [MEDICATION(S)] medication was administered and not held. On 11/13/22 at 3:51 p.m., the DON stated the medication should have been held. 2. Res #8 had diagnoses which included A-fib and secondary hypertension. A physician order, dated 05/31/22, documented to administer [MEDICATION(S)] 25 mg every six hours for hypertension. The order documented to hold the medication if the systolic BP was less than 100 or the diastolic BP less than 60. The October 2022 MAR documented on 10/25/22 a BP of 123/57. The [MEDICATION(S)] medication was administered and not held. On 11/13/22 at 3:52 p.m., the DON stated the medication should have been held. 3. Res #11 had diagnoses which included hypertension. A physician order, dated 03/16/22, documented [MEDICATION(S)] HCL 0.1 mg, administer 1/2 tab to equal 0.05 mg twice a day PRN for BP higher than 160/90. The October 2022 MAR documented on 10/25/22 a BP of 164/97. According to the MAR, [MEDICATION(S)] was not administered. The November 2022 MAR documented on 11/01/22 a BP of 161/90, on 11/08/22 a BP of 167/90, and 11/12/22 a BP of 167/83. According to the MAR, [MEDICATION(S)] was not administered. On 11/13/22 at 3:50 p.m., the DON stated the [MEDICATION(S)] should have been given as ordered. 4. Res #42 had diagnoses which included hypertension, heart failure, and A-fib. A physician order, dated 08/06/21, documented to administer [MEDICATION(S)] (an antiarrhythmic medication) 200 mg once a day for persistent [CONDITION(S)]. The October 2022 MAR documented the [MEDICATION(S)] medication was held on the 14th, 20th, 24th, 26th, 29th, 30th, and the 31st. There were no parameters documented to hold the medication. The November 2022 MAR documented the [MEDICATION(S)] medication was held on the 1st, 6th, 8th, and the 9th. There were no parameters documented to hold the medication. On the back side of the MAR, there was hand written documentation the [MEDICATION(S)] was held due to low BP readings. On 11/10/22 at 4:40 p.m., CMA #1 was asked why the [MEDICATION(S)] was held on the above dates. She stated usually if other BP medications were held then she thought that all heart medications should be held due to the parameters of the other medications. On 11/10/22 at 4:45 p.m., the DON was shown the MARs where the [MEDICATION(S)] had been held. She stated the [MEDICATION(S)] was for A-fib and should not have been held. 5. Res #45 had diagnoses which included [CONDITION(S)] pectoris and hypertension. A physician order, dated 10/30/22, documented [MEDICATION(S)] 30 mg once a day for hypertension. The order documented to hold the medication if the systolic BP was less than 105. The November 2022 MAR documented on the 4th the resident's BP was 102/90 and the [MEDICATION(S)] medication was administered. On 11/13/22 at 3:53 p.m., the DON stated the medication should have been held. 6. Res #72 had diagnoses which included [CONDITION(S)] heart disease of native coronary artery without [CONDITION(S)] pectoris and hypertension. A physician order, dated 04/14/22, documented [MEDICATION(S)] 10 mg once a day for [CONDITION(S)] heart disease. There were no ordered parameters to hold the medication. The October 2022 MAR documented on the 16th, 23rd, 29th, 30th, and the 31st the medication was not administered. The November 2022 MAR documented on the 6th the medication was not administered. On 11/10/22 at 4:41 p.m., CMA #1 was asked why the [MEDICATION(S)] was held on the above dates. She stated usually gives the medication but sometimes she thought if the BP was low then all the BP medications should be held. On 11/10/22 at 4:46 p.m., the DON was shown the MARs where the [MEDICATION(S)] had been held. She stated the medication should not have been held.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to designate a registered nurse to serve as DON on a full-time basis and ensure a registered nurse served in the facility for at least eight consecutive hours a day, seven days a week to assess residents and provide oversight for facility staff. Res #152 admitted to the facility from the hospital on [DATE] for skilled nursing services. Res #152's medical records did not document an admission assessment, skilled services progress notes, ADL documentation, meal or fluid intake, completed Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no registered nurse or DON to manage staff or provide oversight to ensure these tasks were completed seven days per week from [DATE] to [DATE]. Res #152 expired in the facility four days after admission. On [DATE] at 1:13 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related lack of DON and full-time registered nurse coverage. On [DATE] at 1:19 p.m., the administrator was notified of the IJ situation. On [DATE] at 9:32 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [DATE] Jan [NAME] Care Center Plan of Removal for 4 IJs Completion Date [DATE] 11:00 p.m. All education will be done by the Regional Nurse, [name deleted], and [name deleted] Regional Director. All Staff Education Abuse and Neglect Policy & Procedures. Identify types of abuse and neglect with feedback from the participants through group discussion. Clinical Staff Education Medication Administration Policy & Procedure. Discussed medication availability, timely administration of all medications, resident refusal of medications. Reviewed the process for significant medication errors. Vital Sign Documentation Reviewed the importance of obtaining vitals signs for the surveillance monitoring daily; and resident assessments and skilled documentation when required. Resident Assessment/Change of Condition/Interventions. Reviewed the importance of resident assessments for new admissions, readmissions, and when the resident has a change of condition. Reviewed appropriate and timely interventions. ADL Documentation. Handout given to all participants. Reviewed what ADLs are and how to document them each shift. Discussed the importance of accurate coding. Reviewed person-centered care and resident independence when possible. Reviewed decline in function and range of motion. Skilled Nursing Documentation- Implemented all residents will be assessed and documented on when they are receiving skilled nursing care on each shift. Reviewed skill documentation guidelines. Instructed the nurses where their nursing resource book is at the nurses station and the importance of referring to it when the need arises. Upon completion of the immediate corrections; audits and observations will continue by the DON or designee for 60 days. Audit Skilled Nursing Documentation Surveillance Monitoring on all Residents Medication Administration/Documentation Observation. Audit of all medications to ensure availability, accuracy of physician orders, and accuracy of medication administration records. Nurse assessment on all Residents for change of condition, decline in function, and appropriate interventions. Audit ADL Documentation Regional Nurse will assume the Interim DON position immediately. She is currently at the facility. An additional RN has been hired for two days a week to relieve the DON, to ensure 7 day a week RN coverage. On [DATE] and [DATE], interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Documentation was provided related to the medication cart and ADL documentation audits. Documentation was provided to verify a full time DON and a PRN registered nurse had been hired to provide coverage seven days a week. The IJ was lifted, effective [DATE] at 5:58 p.m., when all components of the plan of removal had been completed. The deficiency remained at a widespread level of actual harm. Based on observation, record review, and interview, the facility failed to designate a registered nurse to serve as DON on a full-time basis and ensure a registered nurse served in the facility for at least eight consecutive hours a day, seven days a week to assess residents and provide oversight for facility staff. The Residents Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: Resident #152 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital record, dated [DATE], read in parts, .was found to have DVT in R soleus vein on b/l Doppler LE studies. AC therapy discussed with pharmacy and detailed below .For follow-up provider .Further [CONDITION(S)] work-up indicated. PFTs as able .discharged with Foley for significant [CONDITION(S)] and tamsulosin/[MEDICATION(S)] therapy. Recommend routine Foley replacement and monitoring of kidney function .[MEDICATION(S)] 40 mg SQ daily. Continue until Cr improves. Monitor BMP daily. When Cr clearance, do full dose therapeutic [MEDICATION(S)] BID 1mg/kg dosing. Monitor for signs of bleeding. Check Xa level ,d+[DATE]hrs post dose per provider discretion .7. Acute respiratory failure with [CONDITION(S)] and hypercapnia .To need home O2 on discharge. Desats to low-mid 80's on room air trial .Hemorrhagic shock .Continue [MEDICATION(S)] 10mg TID . A nurse progress note by LPN #5, dated [DATE] at 6:00 p.m., documented Res #152 was transferred to the facility for skilled nursing care via a private vehicle by his family. He was assisted to a room via wheelchair and required two staff to transfer into bed. The resident was alert and oriented times one, confused, and disoriented. The note documented the resident had even and non-labored respirations without cough or congestion. The resident was incontinent of bowel and bladder. Skin integrity was documented and noted issues measured. The note documented the resident required assistance with all ADLs, and must be spoon fed meals. The note documented the resident's vital signs. The progress note did not include documentation of supplemental oxygen therapy or the presence of a urinary catheter. An LTC -Admission Assessment/Observation Documentation form, dated [DATE], had no resident observations or assessments documented by the LPN #5 who opened the document. A LTC - 48 Hour Baseline Care Plan form, dated [DATE], documented interventions which included the following: anticipate the resident's needs and observe for non-verbal cues; consult PT, OT, ST as needed; provide one staff assist with bathing/hygiene; provide one staff assist with dressing/grooming; provide one staff assist with eating; provide one to two staff assist with toileting; provide two staff assist with ambulation/transferring; administer medications as ordered; assess, monitor; and document mood; keep call bell in reach and encourage use; weigh weekly for four weeks; monitor meal percentages; encourage fluids; monitor for signs/symptoms of dehydration; obtain laboratory work as ordered; provide hydration per guidelines; monitor for [CONDITION(S)]/dyspnea; perform oral care twice daily; turn every two hours and as needed; report to charge nurse any redness/skin breakdown immediately; perform breathing treatments; monitor lab work as ordered; monitor for signs/symptoms of bleeding; monitor pain; assess vital signs; monitor endurance/complications; monitor [CONDITION(S)]; monitor for signs/symptoms of heart failure and dyspnea; check O2 saturation every shift; assess for pain; and assess for constipation. A MAR, dated [DATE] to [DATE], documented [MEDICATION(S)] 1% topical, apply two grams to affected area four times daily. There were no documented administrations of this medication. A respiratory flowsheet, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented [MEDICATION(S)] 175 mcg nebulization daily. This medication was not documented to be administered on [DATE]. The respiratory flowshet documented [MEDICATION(S)] 15 mcg nebulization twice daily at 08:00 a.m. and 08:00 p.m. This medication was not documented to be administered on [DATE] for the p.m. dose and [DATE] for the a.m. or p.m. dose. A TAR, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented to clean left heel blister with normal saline, apply skin prep twice per day. The [DATE] morning treatment was not documented as completed. A MAR, dated [DATE] to [DATE], documented the facility was to administer [MEDICATION(S)] 60 mg two capsules at bedtime, [MEDICATION(S)] 15 mg one tablet every day, [MEDICATION(S)] 10 mg three times daily, [MEDICATION(S)] one packet two times daily, [MEDICATION(S)] two tablets twice daily, tamsulosin 0.4 mg at bedtime, [MEDICATION(S)] one tablet twice daily, [MEDICATION(S)] 1000 units daily, [MEDICATION(S)] 5 mg daily, [MEDICATION(S)] 1 mg daily, [MEDICATION(S)]-m one tablet daily, and [MEDICATION(S)] 100 mg daily. There were no documented administrations for any of the above medications. No vital signs or ADL care were documented from [DATE] to [DATE]. No progress notes or assessments were documented on [DATE] or [DATE]. A review of the resident's clinical records did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An admission MDS assessment completed by the LPN MDS coordinator, dated [DATE], documented the resident was severely cognitively impaired, required limited assistance of one staff for bed mobility, locomotion, dressing, eating, and personal hygiene; extensive assistance of two staff for transfers and toilet use; extensive assistance of one staff for bathing, had limited range of motion in both lower extremities, was always incontinent of bowel and bladder, had shortness of breath with exertion, when sitting, and when lying flat, received no medications, and received oxygen therapy. A nursing progress note documented by the LPN MDS coordinator, dated [DATE] at 6:11 p.m., documented therapy staff notified a nurse Res #152 needed to be assessed. The note documented when the nurse assessed the resident a temperature of 97.8 degrees F was obtained and a blood pressure could not be obtained. The note documented the nurse contacted EMS to transfer the resident to the emergency room . The note documented Res #152 expired before emergency personnel arrived to the facility. A State of Oklahoma Certificate of Death, dated [DATE], documented Res #152's immediate cause of death as [CONDITION(S)], with acute respiratory failure documented as a condition that lead to death, and interstitial pulmonary disease documented as the underlying cause of death. The death certificate documented other significant conditions contributing to death as chronic obstructive pulmonary disease. On [DATE] at 2:28 p.m., LPN #3 stated there was not a system in place to monitor the CNAs to ensure the required care was completed, and the nurses did not double check any documentation completed by the CNAs. On [DATE] at 7:58 a.m., the LPN ADON stated she remembered going into Res #152's room to place a pillow under his feet. She stated he had family in the room at the time and they requested another blanket for the resident. She stated there were no other issues with the resident at that time. She did not provide a date for this interaction. On [DATE] at 8:00 a.m., the LPN MDS coordinator stated she remembered Res #152 and had taken his vitals. She was unable to locate the vital signs in the EHR. She stated she had assisted him by feeding him. She stated she was the nurse who charted the progress note on [DATE] when the resident expired. She stated the nurses on the floor were responsible for completing the 48 hour care plan. On [DATE] at 10:10 a.m., the corporate RN was shown the missing documentation on the [DATE] and [DATE] MAR. She stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the facility not having a DON to monitor documentation has contributed to this problem. On [DATE] at 10:15 a.m., corporate RN #1 stated there was no DON at the facility and she was the highest level nurse in the facility. She stated the only time she saw Res #152 was when she performed a COVID-19 test. She was provided with documentation from Res #152's medical record to review. She stated according to the documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurses should not have wasted their time writing a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated they should have completed the admission process and ensured everything was in place. She stated the white copy of the orders should have been sent to the pharmacy and she would check to see if his medications were ever sent. She stated Res #152 should have had a full assessment every shift since he was a skilled resident. She stated she did not perform an assessment on Res #152. She stated if the documentation was blank the care did not happen. She stated she was normally at the facility two days a week. On [DATE] at 3:32 p.m., the administrator stated the facility had placed an advertisement for an RN and RN DON and had been running ads for sometime. On [DATE] at 10:24 a.m., the administrator stated he expected a new admission to have their documentation completed as soon as they enter the facility including a full head to toe assessment, orders entered, skin issues documented, and hospital discharge documentation reviewed as applicable. He stated he expected residents to be assessed and receive medications as ordered. He stated the facility has a morning meeting to discuss new admissions to ensure the process is followed. He was unsure if a record was kept of what was discussed during the morning meeting regarding Res #152 since the facility only sometimes kept written records of these meetings. On [DATE] at 3:06 p.m., the BOM stated the facility had not had a full time RN or DON since [DATE].

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure ensure residents were free of significant medication errors. Res #152 admitted to the facility on [DATE] for skilled nursing services with orders including [MEDICATION(S)] (a medication that raises blood pressure) 10 mg three times daily. Medication administration records documented Res #152 did not receive this medication at any time during his admission. Res #152 expired in the facility four days after admission. During the course of the investigation, five additional residents (#3, 14, 34, 40, and #56) were found to have significant medication errors. On [DATE] at 1:13 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to a significant medication error for Res #152 On [DATE] at 1:19 p.m., the administrator was notified of the IJ situation. On [DATE] at 9:32 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [DATE] Jan [NAME] Care Center Plan of Removal for 4 IJs Completion Date [DATE] 11:00 p.m. All education will be done by the Regional Nurse, [name deleted], and [name deleted], Regional Director. All Staff Education Abuse and Neglect Policy & Procedures. Identify types of abuse and neglect with feedback from the participants through group discussion. Clinical Staff Education Medication Administration Policy & Procedure. Discussed medication availability, timely administration of all medications, resident refusal of medications. Reviewed the process for significant medication errors. Vital Sign Documentation Reviewed the importance of obtaining vitals signs for the surveillance monitoring daily; and resident assessments and skilled documentation when required. Resident Assessment/Change of Condition/Interventions. Reviewed the importance of resident assessments for new admissions, readmissions, and when the resident has a change of condition. Reviewed appropriate and timely interventions. ADL Documentation. Handout given to all participants. Reviewed what ADLs are and how to document them each shift. Discussed the importance of accurate coding. Reviewed person-centered care and resident independence when possible. Reviewed decline in function and range of motion. Skilled Nursing Documentation- Implemented all residents will be assessed and documented on when they are receiving skilled nursing care on each shift. Reviewed skill documentation guidelines. Instructed the nurses where their nursing resource book is at the nurses station and the importance of referring to it when the need arises. Upon completion of the immediate corrections; audits and observations will continue by the DON or designee for 60 days. Audit Skilled Nursing Documentation Surveillance Monitoring on all Residents Medication Administration/Documentation Observation. Audit of all medications to ensure availability, accuracy of physician orders, and accuracy of medication administration records. Nurse assessment on all Residents for change of condition, decline in function, and appropriate interventions. Audit ADL Documentation Regional Nurse will assume the Interim DON position immediately. She is currently at the facility. An additional RN has been hired for two days a week to relieve the DON, to ensure 7 day a week RN coverage. On [DATE] and [DATE], interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Documentation was provided related to the medication cart and ADL documentation audits. The IJ was lifted, effective [DATE] at 5:58 p.m., when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. Based on observations, record review, and interview, the facility failed to ensure residents were free of significant medication errors for six (#3, 14, 34, 40, 56, and #152) of 13 residents reviewed for medications. The Residents Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: An undated facility policy, titled Charting and Documentation read in part, .All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . An undated facility policy, titled Medication Errors and Drug Reactions read in part, .Report all medication errors and drug reactions immediately to the attending physician, Director of Nursing Service and Administrator . A undated facility policy titled Identifying and Managing Medication Errors and Adverse Consequences read in parts, .The staff and practioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur .1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Resident #152 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital record, dated [DATE], read in parts, .was found to have DVT in R soleus vein on b/l Doppler LE studies. AC therapy discussed with pharmacy and detailed below .For follow-up provider .Further [CONDITION(S)] work-up indicated. PFTs as able .discharged with Foley for significant [CONDITION(S)] and tamsulosin/[MEDICATION(S)] therapy. Recommend routine Foley replacement and monitoring of kidney function .[MEDICATION(S)] 40 mg SQ daily. Continue until Cr improves. Monitor BMP daily. When Cr clearance, do full dose therapeutic [MEDICATION(S)] BID 1mg/kg dosing. Monitor for signs of bleeding. Check Xa level ,d+[DATE]hrs post dose per provider discretion .7. Acute respiratory failure with [CONDITION(S)] and hypercapnia .To need home O2 on discharge. Desats to low-mid 80's on room air trial .8. Hemorrhagic shock .Continue [MEDICATION(S)] 10mg TID . An LTC -Admission Assessment/Observation Documentation form, dated [DATE], had no resident assessment or observations documented. A nurses progress note, dated [DATE] at 6:00 p.m., documented Res #152 was transferred to the facility for skilled nursing care via a private vehicle by his family. He was assisted to a room via wheelchair and required two staff to transfer into bed. The resident was alert and oriented times one, confused, and disoriented. The note documented the resident had even and non-labored respirations without cough or congestion. The resident was incontinent of bowel and bladder. Skin integrity was documented and noted issues measured. The note documented the resident required assistance with all ADLs, and must be spoon fed meals. The note documented the resident's vital signs. The progress note did not include documentation of supplemental oxygen therapy or the presence of a Foley catheter. A LTC - 48 Hour Baseline Care Plan form, dated [DATE], documented interventions which included anticipate the resident's needs and observe for non-verbal cues; administer medications as ordered; perform breathing treatments; monitor lab work as ordered; monitor for signs/symptoms of bleeding; monitor pain; assess vital signs; monitor endurance/complications; monitor [CONDITION(S)]; monitor for signs/symptoms of heart failure and dyspnea; check O2 saturation every shift; assess for pain; and assess for constipation. A MAR, dated [DATE] to [DATE], documented the facility was to administer [MEDICATION(S)] 1% topical, apply two grams to affected area four times daily. There were no documented administrations of this medication. A respiratory flowsheet, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented [MEDICATION(S)] 175 mcg nebulization daily. This medication was not documented as administered on [DATE]. The respiratory flowsheet documented to administer [MEDICATION(S)] 15 mcg nebulization twice daily at 08:00 a.m. and 08:00 p.m. This medication was not documented as administered on [DATE] for the p.m. dose and [DATE] for the a.m. or p.m. dose. A TAR, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented to clean left heel blister with normal saline, apply skin prep twice per day. The [DATE] morning treatment was not documented as administered. A MAR, dated [DATE] to [DATE], documented the facility was to administer: - [MEDICATION(S)] 60 mg two capsules at bedtime, - [MEDICATION(S)] 15 mg one tablet every day, - [MEDICATION(S)] 10 mg three times daily, - [MEDICATION(S)] one packet two times daily, - [MEDICATION(S)] two tablets twice daily, - tamsulosin 0.4 mg at bedtime, - [MEDICATION(S)] one tablet twice daily, - [MEDICATION(S)] 1000 units daily, - [MEDICATION(S)] 5 mg daily, - [MEDICATION(S)] 1 mg daily, - [MEDICATION(S)]-m one tablet daily, and - [MEDICATION(S)] 100 mg daily. There were no documented administrations for any of the above medications. An admission MDS assessment, dated [DATE], documented the resident was severely cognitively impaired, required limited assistance of one staff for bed mobility, locomotion, dressing, eating, and personal hygiene; extensive assistance of two staff for transfers and toilet use; extensive assistance of one staff for bathing, had limited range of motion in both lower extremities, was always incontinent of bowel and bladder, had shortness of breath with exertion, when sitting, and when lying flat, received no anticoagulant medication, and received oxygen therapy. A nursing progress note, dated [DATE] at 6:11 p.m., documented therapy staff notified a nurse Res #152 needed to be assessed. The note documented when the nurse assessed the resident a temperature of 97.8 degrees F was obtained and a blood pressure could not be obtained. The note documented the nurse contacted EMS to transfer resident to the emergency room . The note documented Res #152 expired before emergency personnel arrived to the facility. A State of Oklahoma Certificate of Death, dated [DATE], documented Res #152's immediate cause of death as [CONDITION(S)], with acute respiratory failure documented as a condition that lead to death, and interstitial pulmonary disease documented as the underlying cause of death. The death certificate documented other significant conditions contributing to death as chronic obstructive pulmonary disease. On [DATE] at 2:25 p.m., CNA #3 stated Res #152 wasn't in the facility very long, but she remembered he was doing good when he first admitted and was eating well. She stated the resident was total care. She stated two days after the resident admitted to the facility he stopped eating and responding to staff and died shortly after. She stated she would have reported it to the nurse if she felt like a resident was not receiving care or being neglected. She stated she did not notify the nurse for any change in condition or suspicion of neglect for Res #152. On [DATE] at 7:58 a.m., the ADON stated she remembered going into Res #152's room to place a pillow under his feet. She stated he had family in the room at the time and requested another blanket for the resident. She stated there were no other issues with the resident at that time. She did not provide a date for this interaction. On [DATE] at 8:00 a.m., the MDS coordinator stated she remembered Res #152 and had taken his vitals. She was unable to locate the vital signs in the EHR. She stated she had assisted him by feeding him. She stated she was the nurse who charted the progress note on [DATE] when the resident expired. On [DATE] at 10:15 a.m., corporate RN #1 stated there was no DON at the facility and she was the highest level nurse in the facility. She stated the only time she saw Res #152 was when she Covid tested him. She was provided with documentation from Res #152's medical record to review. She stated according to the documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurses shouldn't have wasted their time writing a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated they should have completed the admission process and ensured everything was in place. She stated the white copy of the orders should have been sent to the pharmacy and she would check to see if his medications were ever sent. She stated Res #152 should have had a full assessment every shift since he was a skilled resident. She stated if the documentation was blank the care did not happen. On [DATE], the facility provided additional documentation for Res #152's medical record. These included: a pharmacy drug order fill sheet which documented Res #152's blood thinner, [MEDICATION(S)], had been delivered to the facility on [DATE], an additional MAR, a progress note from the physician dated [DATE], and a progress note from the physician assistant dated [DATE]. On [DATE] at 10:24 a.m., the administrator stated he expected a new admission to have their documentation completed as soon as they enter the facility including: a full head to toe assessment, orders entered, skin issues documented, and hospital discharge documentation reviewed as applicable. He stated he expected residents to be assessed and received medications as ordered. He stated the facility has a morning meeting to discuss new admissions to ensure the process is followed. He was unsure if a record was kept of what was discussed during the morning meeting regarding Res #152 since the facility only 2. Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented to give [MEDICATION(S)] 6.25 mg by mouth twice per day and hold medication for systolic blood pressure below 100, diastolic blood pressure under 60, and heart rate below 55. Physician orders, dated [DATE], documented to give [MEDICATION(S)] 2.5 mg twice per day and documented nursing was to monitor residents on anticoagulants for bleeding every shift. An annual MDS, dated [DATE], documented the resident was severely cognitively impaired and received anticoagulants seven out of seven days during the review period. On [DATE] at 8:20 a.m., CMA #1 was observed during medication pass taking VS for Res #14 which included a blood pressure reading of ,d+[DATE]. The CMA stated that she was going to hold the resident's blood pressure medication because of the reading. The CMA prepared the medications and included the [MEDICATION(S)]. The medications passed did not include the resident's dose of [MEDICATION(S)]. On [DATE] at 4:12 p.m., CMA #1 stated that she did not give the [MEDICATION(S)] for Res #14 because it was not available in the cart and had to be ordered from the pharmacy. She stated she should have held Res #14's [MEDICATION(S)] based on the blood pressure reading. On [DATE] at 10:02 a.m., the corporate RN stated for medications that were not on the cart the staff should have gone into their cubbies in the medication room to make sure it was not in there, then check to see if it was ordered, and if ordered, check if it was delivered and look for it. She stated if a resident had an out of parameter blood pressure reading the medication should have been held and the nurse notified so that it could be re-checked. 3. Res #56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] FlexTouch U-100 insulin pen, 60 units subcutaneous twice a day. A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] [MEDICATION(S)] Insulin, 25 units subcutaneous before meals. An admission assessment, dated [DATE], documented the resident was intact in cognition and required limited to total assistance. The assessment documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse note, dated [DATE] at 8:50 p.m., documented a nurse had administered the wrong insulin to Res #56. The note documented the nurse gave Novalog insulin instead of [MEDICATION(S)]. The note documented the PA was notified and the resident was sent to the hospital. On [DATE] at 2:54 p.m., Res #56 was observed sitting in her room. She stated she had to go to the hospital because the facility administered too much insulin. On [DATE] at 9:51 a.m., the corporate director of operations provided a copy of the incident report which documented the staff member who self reported the insulin error had been in-serviced on the five rights of medication administration. Res #56's insulin records were reviewed and the records did not document [MEDICATION(S)] was administered on [DATE], [DATE], [DATE], and [DATE], for the evening dose. The records did not document [MEDICATION(S)] was administered on [DATE] before breakfast, [DATE] before the noon meal, and [DATE] before the evening meal. One dose on [DATE] documented the resident's blood sugar was 110 prior to the noon meal and no insulin was given. On [DATE] at 10:28 a.m., the ADON reviewed the [DATE] diabetic records and stated if the missing doses were not documented they were not administered. She confirmed on the date of [DATE] at the noon dose, the resident should have received 25 units of [MEDICATION(S)] as the physician ordered. She stated this was a significant error. 4. Res #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] capsule (an anticonvulsant medication sometimes used for chronic pain) 300 mg twice daily for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] (an anticoagulant medication) 2.5 mg twice a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] (an antidepressant medication) 50 mg daily for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] (an antianxiety medication) 5 mg three times daily. A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] (an antibiotic medication) twice daily for 10 days. A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Res #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] (an antidepressant medication sometimes used to increase a patient's appetite) 15 mg once daily for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] (an antipsychotic medication) 2 mg twice a day. A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] Gel (an antianxiety medication) 1 ml every four hours for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the facility was to administer [MEDICATION(S)] 0.5 mg once a day at noon. A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:18 p.m., the corporate RN confirmed she was aware there was an issue with medications being administered as ordered. She stated errors or omissions of doses of medications such as insulin or [CONDITION(S)] medications were considered significant. 5. Res #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated [DATE], documented [MEDICATION(S)] administer 5 units subcutaneous with meals. This order was not on the order set, dated [DATE]. A physician order, dated [DATE] and continued on [DATE], read in part, [MEDICATION(S)] U-100 Insulin [MEDICATION(S)] (insulin [MEDICATION(S)] u-100) solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 101 to 120, give 3 Units. If Blood Sugar is 121 to 150, give 4 Units. If Blood Sugar is 151 to 200, give 5 Units. If Blood Sugar is 201 to 250, give 8 Units. If Blood Sugar is 251 to 300, give 10 Units. If Blood Sugar is 301 to 350, give 12 Units. If Blood Sugar is 351 to 400, give 16 Units. If Blood Sugar is greater than 400, call MD. subcutaneous Three Times A Day 07:00 AM, 11:30 AM, 04:30 PM A five day assessment, dated [DATE], documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident received insulin four days during the look back period. A care plan, last reviewed [DATE], documented Res #40 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented to administer medications and insulins as ordered. Review of the diabetic flow sheets for Res #40, dated [DATE] - [DATE], reveled six missed doses of [MEDICATION(S)] 5 units to be given with meals. On [DATE] on the morning shift, the diabetic flow sheet documented a BS of 121 with 0 insulin given. The sliding scale order documented the resident should have received 4 units. On [DATE] on the evening shift, the diabetic flow sheet documented a BS of 236 with 4 units of insulin given. The sliding scale order documented the resident should have received 8 units. A physician order, dated [DATE], documented to administer [MEDICATION(S)] (a type of insulin) 18 units subcutaneous twice daily. On [DATE] on the morning shift, the diabetic flow sheets, documented a BS of 253 and the resident was administered 5 units of [MEDICATION(S)] insulin. The sliding scale order documented the resident should have received 10 units. [MEDICATION(S)] insulin was not documented as being administered on [DATE] and [DATE]. On [DATE] at 10:20 a.m., LPN #2 stated with a BS of 253, the resident should have received 10 units when it documented 5 units was given. The LPN stated with a BS of 236, the resident should have been given 8 units and was given 4 units. The LPN stated with a BS of 121, the resident was given zero units and should have received 4 units. LPN #2 stated it looked like it was two different nurses who had made the insulin errors. LPN #2 stated the errors were significant medication errors. The LPN stated when there are blanks for the insulin on the MAR, if it was not documented given it was not done.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor and provide interventions for Res #152. Res #152 admitted to the facility from the hospital on [DATE] for skilled nursing services. Res #152's medical records did not document an admission assessment, skilled services progress notes, ADL documentation, meal or fluid intake, completed Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #152 expired in the facility four days after admission. On [DATE] at 1:13 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 1:19 p.m., the administrator was notified of the IJ situation related to quality of care for Res #152. On [DATE] at 9:32 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [DATE] Jan [NAME] Care Center Plan of Removal for 4 IJs Completion Date [DATE] 11:00 p.m. All education will be done by the Regional Nurse, [name deleted], and [name deleted], Regional Director. All Staff Education Abuse and Neglect Policy & Procedures. Identify types of abuse and neglect with feedback from the participants through group discussion. Clinical Staff Education Medication Administration Policy & Procedure. Discussed medication availability, timely administration of all medications, resident refusal of medications. Reviewed the process for significant medication errors. Vital Sign Documentation Reviewed the importance of obtaining vitals signs for the surveillance monitoring daily; and resident assessments and skilled documentation when required. Resident Assessment/Change of Condition/Interventions. Reviewed the importance of resident assessments for new admissions, readmissions, and when the resident has a change of condition. Reviewed appropriate and timely interventions. ADL Documentation. Handout given to all participants. Reviewed what ADLs are and how to document them each shift. Discussed the importance of accurate coding. Reviewed person-centered care and resident independence when possible. Reviewed decline in function and range of motion. Skilled Nursing Documentation- Implemented all residents will be assessed and documented on when they are receiving skilled nursing care on each shift. Reviewed skill documentation guidelines. Instructed the nurses where their nursing resource book is at the nurses station and the importance of referring to it when the need arises. Upon completion of the immediate corrections; audits and observations will continue by the DON or designee for 60 days. Audit Skilled Nursing Documentation Surveillance Monitoring on all Residents Medication Administration/Documentation Observation. Audit of all medications to ensure availability, accuracy of physician orders, and accuracy of medication administration records. Nurse assessment on all Residents for change of condition, decline in function, and appropriate interventions. Audit ADL Documentation Regional Nurse will assume the Interim DON position immediately. She is currently at the facility. An additional RN has been hired for two days a week to relieve the DON, to ensure 7 day a week RN coverage. On [DATE] and [DATE], interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Documentation was provided related to the medication cart and ADL documentation audits. The IJ was lifted, effective [DATE] at 5:58 p.m., when all components of the plan of removal had been completed. The deficiency remained at a isolated level of actual harm. Based on record review and interview, the facility failed to assess, monitor, and provide interventions for one (#152) of seven residents reviewed for quality of care. Res #152's medical records did not document an admission assessment, skilled services progress notes, ADL documentation, meal or fluid intake, completed Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #152 expired in the facility four days after admission. The Residents Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: An undated facility policy, titled Documentation of Medication Administration read in part, .Administration of medication must be documented immediately after (never before) it is given . An undated facility policy, titled Charting and Documentation read in part, .All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . An undated facility policy, titled Activities of Daily Living, read in parts, .It is our responsibility to support residents at their highest level of function .recognize if there is a decline in the resident's abilities, report decline, make referrals for appropriate programs and develop a plan of care that meets the resident needs, preferences and choices . Facility inservice records documented staff received training on neglect on [DATE], [DATE], and [DATE]. Resident #152 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital record, dated [DATE], read in parts, .was found to have DVT in R soleus vein on b/l Doppler LE studies. AC therapy discussed with pharmacy and detailed below .For follow-up provider .Further [CONDITION(S)] work-up indicated. PFTs as able .discharged with Foley for significant [CONDITION(S)] and tamsulosin/[MEDICATION(S)] therapy. Recommend routine Foley replacement and monitoring of kidney function .[MEDICATION(S)] 40 mg SQ daily. Continue until Cr improves. Monitor BMP daily. When Cr clearance, do full dose therapeutic [MEDICATION(S)] BID 1mg/kg dosing. Monitor for signs of bleeding. Check Xa level ,d+[DATE]hrs post dose per provider discretion .7. Acute respiratory failure with [CONDITION(S)] and hypercapnia .To need home O2 on discharge. Desats to low-mid 80's on room air trial .Hemorrhagic shock .Continue [MEDICATION(S)] 10mg TID . A nurses progress note, dated [DATE] at 6:00 p.m., documented Res #152 was transferred to the facility for skilled nursing care via a private vehicle by his family. He was assisted to a room via wheelchair and required two staff to transfer into bed. The resident was alert and oriented times one, confused, and disoriented. The note documented the resident had even and non-labored respirations without cough or congestion. The resident was incontinent of bowel and bladder. Skin integrity was documented and noted issues measured. The note documented the resident required assistance with all ADLs, and must be spoon fed meals. The note documented the resident's vital signs. The progress note did not include documentation of supplemental oxygen therapy or the presence of a Foley catheter. An LTC -Admission Assessment/Observation Documentation form, dated [DATE], had no resident observations or assessments documented. A LTC - 48 Hour Baseline Care Plan form, dated [DATE], documented interventions which included the following: anticipate the resident's needs and observe for non-verbal cues; consult PT, OT, ST as needed; provide one staff assist with bathing/hygiene; provide one staff assist with dressing/grooming; provide one staff assist with eating; provide one to two staff assist with toileting; provide two staff assist with ambulation/transferring; administer medications as ordered; assess, monitor; and document mood; keep call bell in reach and encourage use; weigh weekly for four weeks; monitor meal percentages; encourage fluids; monitor for signs/symptoms of dehydration; obtain laboratory work as ordered; provide hydration per guidelines; monitor for [CONDITION(S)]/dyspnea; perform oral care twice daily; turn every two hours and as needed; report to charge nurse any redness/skin breakdown immediately; perform breathing treatments; monitor lab work as ordered; monitor for signs/symptoms of bleeding; monitor pain; assess vital signs; monitor endurance/complications; monitor [CONDITION(S)]; monitor for signs/symptoms of heart failure and dyspnea; check O2 saturation every shift; assess for pain; and assess for constipation. A MAR, dated [DATE] to [DATE], documented [MEDICATION(S)] 1% topical, apply two grams to affected area four times daily. There were no documented administrations of this medication. A respiratory flowsheet, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented [MEDICATION(S)] 175 mcg nebulization daily. This medication was not documented to be administered on [DATE]. The respiratory flowshet documented [MEDICATION(S)] 15 mcg nebulization twice daily at 08:00 a.m. and 08:00 p.m. This medication was not documented to be administered on [DATE] for the p.m. dose and [DATE] for the a.m. or p.m. dose. A TAR, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented to clean left heel blister with normal saline, apply skin prep twice per day. The [DATE] morning treatment was not documented as completed. A MAR, dated [DATE] to [DATE], documented the facility was to administer [MEDICATION(S)] 60 mg two capsules at bedtime, [MEDICATION(S)] 15 mg one tablet every day, [MEDICATION(S)] 10 mg three times daily, [MEDICATION(S)] one packet two times daily, [MEDICATION(S)] two tablets twice daily, tamsulosin 0.4 mg at bedtime, [MEDICATION(S)] one tablet twice daily, [MEDICATION(S)] 1000 units daily, [MEDICATION(S)] 5 mg daily, [MEDICATION(S)] 1 mg daily, [MEDICATION(S)]-m one tablet daily, and [MEDICATION(S)] 100 mg daily. There were no documented administrations for any of the above medications. No vital signs or ADL care were documented from [DATE] to [DATE]. No progress notes or assessments were documented on [DATE] or [DATE]. A review of the resident's clinical records did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An admission MDS assessment, dated [DATE], documented the resident was severely cognitively impaired, required limited assistance of one staff for bed mobility, locomotion, dressing, eating, and personal hygiene; extensive assistance of two staff for transfers and toilet use; extensive assistance of one staff for bathing, had limited range of motion in both lower extremities, was always incontinent of bowel and bladder, had shortness of breath with exertion, when sitting, and when lying flat, received no medications, and received oxygen therapy. A nursing progress note, dated [DATE] at 6:11 p.m., documented therapy staff notified a nurse Res #152 needed to be assessed. The note documented when the nurse assessed the resident a temperature of 97.8 degrees F was obtained and a blood pressure could not be obtained. The note documented the nurse contacted EMS to transfer the resident to the emergency room . The note documented Res #152 expired before emergency personnel arrived to the facility. A State of Oklahoma Certificate of Death, dated [DATE], documented Res #152's immediate cause of death as [CONDITION(S)], with acute respiratory failure documented as a condition that lead to death, and interstitial pulmonary disease documented as the underlying cause of death. The death certificate documented other significant conditions contributing to death as chronic obstructive pulmonary disease. On [DATE] at 2:25 p.m., CNA #3 stated Res #152 was not in the facility very long, but she remembered he was doing good when he first admitted and was eating well. She stated the resident was total care. She stated two days after the resident admitted to the facility he stopped eating and responding to staff and died shortly after. She stated she would have reported it to the nurse if she felt like a resident was not receiving care or being neglected. She stated she did not notify the nurse for any changes for Res #152. On [DATE] at 2:28 p.m., LPN #3 stated she did not remember any details of Res #152's care because she had just started at the facility around the time he was a resident. She stated to ensure residents received care she would help the CNAs whenever she could with call lights. She stated the CNAs were expected to check and change residents every two hours and turn them on the same interval. She stated the aides were supposed to fill out a shower sheet which was turned in to the nurses. She stated there was not a system in place to monitor the CNAs to ensure the required care was completed, and the nurses did not double check any documentation completed by the CNAs. On [DATE] at 7:58 a.m., the ADON stated she remembered going into Res #152's room to place a pillow under his feet. She stated he had family in the room at the time and they requested another blanket for the resident. She stated there were no other issues with the resident at that time. She did not provide a date for this interaction. On [DATE] at 8:00 a.m., the MDS coordinator stated she remembered Res #152 and had taken his vitals. She was unable to locate the vital signs in the EHR. She stated she had assisted him by feeding him. She stated she was the nurse who charted the progress note on [DATE] when the resident expired. She stated the nurses on the floor were responsible for completing the 48 hour care plan. On [DATE] at 10:15 a.m., corporate RN #1 stated there was no DON at the facility and she was the highest level nurse in the facility. She stated the only time she saw Res #152 was when she performed a COVID-19 test. She was provided with documentation from Res #152's medical record to review. She stated according to the documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurses should not have wasted their time writing a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated they should have completed the admission process and ensured everything was in place. She stated the white copy of the orders should have been sent to the pharmacy and she would check to see if his medications were ever sent. She stated Res #152 should have had a full assessment every shift since he was a skilled resident. She stated if the documentation was blank the care did not happen. On [DATE], the facility provided additional documentation for Res #152's medical record. These included: a pharmacy drug order fill sheet which documented Res #152's blood thinner had been delivered to the facility on [DATE], an additional MAR, a progress note from the physician dated [DATE], and a progress note from the physician assistant dated [DATE]. On [DATE] at 10:24 a.m., the administrator stated he expected a new admission to have their documentation completed as soon as they enter the facility including a full head to toe assessment, orders entered, skin issues documented, and hospital discharge documentation reviewed as applicable. He stated he expected residents to be assessed and receive medications as ordered. He stated the facility has a morning meeting to discuss new admissions to ensure the process is followed. He was unsure if a record was kept of what was discussed during the morning meeting regarding Res #152 since the facility only sometimes kept written records of these meetings.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from neglect. Res #152 admitted to the facility from the hospital on [DATE] for skilled nursing services. Res #152's medical records did not document an admission assessment, skilled services progress notes, ADL documentation, meal or fluid intake, completed Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #152 expired in the facility four days after admission. On [DATE] at 1:13 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 1:19 p.m., the administrator was notified of the IJ situation related to neglect for Res #152. On [DATE] at 9:32 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [DATE] Jan [NAME] Care Center Plan of Removal for 4 IJs Completion Date [DATE] 11:00 p.m. All education will be done by the Regional Nurse, [name deleted], and [name deleted], Regional Director. All Staff Education Abuse and Neglect Policy & Procedures. Identify types of abuse and neglect with feedback from the participants through group discussion. Clinical Staff Education Medication Administration Policy & Procedure. Discussed medication availability, timely administration of all medications, resident refusal of medications. Reviewed the process for significant medication errors. Vital Sign Documentation Reviewed the importance of obtaining vitals signs for the surveillance monitoring daily; and resident assessments and skilled documentation when required. Resident Assessment/Change of Condition/Interventions. Reviewed the importance of resident assessments for new admissions, readmissions, and when the resident has a change of condition. Reviewed appropriate and timely interventions. ADL Documentation. Handout given to all participants. Reviewed what ADLs are and how to document them each shift. Discussed the importance of accurate coding. Reviewed person-centered care and resident independence when possible. Reviewed decline in function and range of motion. Skilled Nursing Documentation- Implemented all residents will be assessed and documented on when they are receiving skilled nursing care on each shift. Reviewed skill documentation guidelines. Instructed the nurses where their nursing resource book is at the nurses station and the importance of referring to it when the need arises. Upon completion of the immediate corrections; audits and observations will continue by the DON or designee for 60 days. Audit Skilled Nursing Documentation Surveillance Monitoring on all Residents Medication Administration/Documentation Observation. Audit of all medications to ensure availability, accuracy of physician orders, and accuracy of medication administration records. Nurse assessment on all Residents for change of condition, decline in function, and appropriate interventions. Audit ADL Documentation Regional Nurse will assume the Interim DON position immediately. She is currently at the facility. An additional RN has been hired for two days a week to relieve the DON, to ensure 7 day a week RN coverage. On [DATE] and [DATE], interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Documentation was provided related to the medication carts and ADL documentation audits. The IJ was lifted, effective [DATE] at 5:58 p.m., when all components of the plan of removal had been completed. The deficiency remained at a isolated level of actual harm. Based on record review and interview, the facility failed to ensure residents were free from neglect for one (#152) of two residents reviewed for death in the facility. Res #152's medical records did not document an admission assessment, skilled services progress notes, ADL documentation, meal or fluid intake, completed Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #152 expired in the facility four days after admission. The Residents Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: A facility abuse policy, dated ,d+[DATE], documented the definition of neglect read in parts, .The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .It is the responsibility of every employee to report immediately anything that could adversely affect the health and welfare of any resident . An undated facility policy, titled Documentation of Medication Administration read in part, .Administration of medication must be documented immediately after (never before) it is given . An undated facility policy, titled Charting and Documentation read in part, .All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . An undated facility policy, titled Activities of Daily Living, read in parts, .It is our responsibility to support residents at their highest level of function .recognize if there is a decline in the resident's abilities, report decline, make referrals for appropriate programs and develop a plan of care that meets the resident needs, preferences and choices . Facility inservice records documented staff received training on neglect on [DATE], [DATE], and [DATE]. Resident #152 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital record, dated [DATE], read in parts, .was found to have DVT in R soleus vein on b/l Doppler LE studies. AC therapy discussed with pharmacy and detailed below .For follow-up provider .Further [CONDITION(S)] work-up indicated. PFTs as able .discharged with Foley for significant [CONDITION(S)] and tamsulosin/[MEDICATION(S)] therapy. Recommend routine Foley replacement and monitoring of kidney function .[MEDICATION(S)] 40 mg SQ daily. Continue until Cr improves. Monitor BMP daily. When Cr clearance, do full dose therapeutic [MEDICATION(S)] BID 1mg/kg dosing. Monitor for signs of bleeding. Check Xa level ,d+[DATE]hrs post dose per provider discretion .7. Acute respiratory failure with [CONDITION(S)] and hypercapnia .To need home O2 on discharge. Desats to low-mid 80's on room air trial .Hemorrhagic shock .Continue [MEDICATION(S)] 10mg TID . A nurses progress note, dated [DATE] at 6:00 p.m., documented Res #152 was transferred to the facility for skilled nursing care via a private vehicle by his family. He was assisted to a room via wheelchair and required two staff to transfer into bed. The resident was alert and oriented times one, confused, and disoriented. The note documented the resident had even and non-labored respirations without cough or congestion. The resident was incontinent of bowel and bladder. Skin integrity was documented and noted issues measured. The note documented the resident required assistance with all ADLs, and must be spoon fed meals. The note documented the resident's vital signs. The progress note did not include documentation of supplemental oxygen therapy or the presence of a Foley catheter. An LTC -Admission Assessment/Observation Documentation form, dated [DATE], had no resident observations or assessments documented. A LTC - 48 Hour Baseline Care Plan form, dated [DATE], documented interventions which included the following: anticipate the resident's needs and observe for non-verbal cues; consult PT, OT, ST as needed; provide one staff assist with bathing/hygiene; provide one staff assist with dressing/grooming; provide one staff assist with eating; provide one to two staff assist with toileting; provide two staff assist with ambulation/transferring; administer medications as ordered; assess, monitor; and document mood; keep call bell in reach and encourage use; weigh weekly for four weeks; monitor meal percentages; encourage fluids; monitor for signs/symptoms of dehydration; obtain laboratory work as ordered; provide hydration per guidelines; monitor for [CONDITION(S)]/dyspnea; perform oral care twice daily; turn every two hours and as needed; report to charge nurse any redness/skin breakdown immediately; perform breathing treatments; monitor lab work as ordered; monitor for signs/symptoms of bleeding; monitor pain; assess vital signs; monitor endurance/complications; monitor [CONDITION(S)]; monitor for signs/symptoms of heart failure and dyspnea; check O2 saturation every shift; assess for pain; and assess for constipation. A MAR, dated [DATE] to [DATE], documented [MEDICATION(S)] 1% topical, apply two grams to affected area four times daily. There were no documented administrations of this medication. A respiratory flowsheet, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented [MEDICATION(S)] 175 mcg nebulization daily. This medication was not documented to be administered on [DATE]. The respiratory flowsheet documented [MEDICATION(S)] 15 mcg nebulization twice daily at 08:00 a.m. and 08:00 p.m. This medication was not documented to be administered on [DATE] for the p.m. dose and [DATE] for the a.m. or p.m. dose. A TAR, dated [DATE] to [DATE] was provided to surveyors on [DATE]. It documented to clean left heel blister with normal saline, apply skin prep twice per day. The [DATE] morning treatment was not documented as completed. A MAR, dated [DATE] to [DATE], documented the facility was to administer [MEDICATION(S)] 60 mg two capsules at bedtime, [MEDICATION(S)] 15 mg one tablet every day, [MEDICATION(S)] 10 mg three times daily, [MEDICATION(S)] one packet two times daily, [MEDICATION(S)] two tablets twice daily, tamsulosin 0.4 mg at bedtime, [MEDICATION(S)] one tablet twice daily, [MEDICATION(S)] 1000 units daily, [MEDICATION(S)] 5 mg daily, [MEDICATION(S)] 1 mg daily, [MEDICATION(S)]-m one tablet daily, and [MEDICATION(S)] 100 mg daily. There were no documented administrations for any of the above medications. No vital signs or ADL care were documented from [DATE] to [DATE]. No progress notes or assessments were documented on [DATE] or [DATE]. A review of the resident's clinical records did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An admission MDS assessment, dated [DATE], documented the resident was severely cognitively impaired, required limited assistance of one staff for bed mobility, locomotion, dressing, eating, and personal hygiene; extensive assistance of two staff for transfers and toilet use; extensive assistance of one staff for bathing, had limited range of motion in both lower extremities, was always incontinent of bowel and bladder, had shortness of breath with exertion, when sitting, and when lying flat, received no medications, and received oxygen therapy. A nursing progress note, dated [DATE] at 6:11 p.m., documented therapy staff notified a nurse Res #152 needed to be assessed. The note documented when the nurse assessed the resident a temperature of 97.8 degrees F was obtained and a blood pressure could not be obtained. The note documented the nurse contacted EMS to transfer the resident to the emergency room . The note documented Res #152 expired before emergency personnel arrived to the facility. A State of Oklahoma Certificate of Death, dated [DATE], documented Res #152's immediate cause of death as [CONDITION(S)], with acute respiratory failure documented as a condition that lead to death, and interstitial pulmonary disease documented as the underlying cause of death. The death certificate documented other significant conditions contributing to death as chronic obstructive pulmonary disease. On [DATE] at 2:25 p.m., CNA #3 stated Res #152 was not in the facility very long, but she remembered he was doing good when he first admitted and was eating well. She stated the resident was total care. She stated two days after the resident admitted to the facility he stopped eating and responding to staff and died shortly after. She stated she would have reported it to the nurse if she felt like a resident was not receiving care or being neglected. She stated she did not notify the nurse for any changes for Res #152. On [DATE] at 2:28 p.m., LPN #3 stated she did not remember any details of Res #152's care because she had just started at the facility around the time he was a resident. She stated to ensure residents received care she would help the CNAs whenever she could with call lights. She stated the CNAs were expected to check and change residents every two hours and turn them on the same interval. She stated the aides were supposed to fill out a shower sheet which was turned in to the nurses. She stated there was not a system in place to monitor the CNAs to ensure the required care was completed, and the nurses did not double check any documentation completed by the CNAs. On [DATE] at 7:58 a.m., the ADON stated she remembered going into Res #152's room to place a pillow under his feet. She stated he had family in the room at the time and they requested another blanket for the resident. She stated there were no other issues with the resident at that time. She did not provide a date for this interaction. On [DATE] at 8:00 a.m., the MDS coordinator stated she remembered Res #152 and had taken his vitals. She was unable to locate the vital signs in the EHR. She stated she had assisted him by feeding him. She stated she was the nurse who charted the progress note on [DATE] when the resident expired. She stated the nurses on the floor were responsible for completing the 48 hour care plan. On [DATE] at 10:15 a.m., corporate RN #1 stated there was no DON at the facility and she was the highest level nurse in the facility. She stated the only time she saw Res #152 was when she performed a COVID-19 test. She was provided with documentation from Res #152's medical record to review. She stated according to the documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurses should not have wasted their time writing a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated they should have completed the admission process and ensured everything was in place. She stated the white copy of the orders should have been sent to the pharmacy and she would check to see if his medications were ever sent. She stated Res #152 should have had a full assessment every shift since he was a skilled resident. She stated if the documentation was blank the care did not happen. On [DATE], the facility provided additional documentation for Res #152's medical record. These included: a pharmacy drug order fill sheet which documented Res #152's blood thinner had been delivered to the facility on [DATE], an additional MAR, a progress note from the physician dated [DATE], and a progress note from the physician assistant dated [DATE]. On [DATE] at 10:24 a.m., the administrator stated he expected a new admission to have their documentation completed as soon as they enter the facility including a full head to toe assessment, orders entered, skin issues documented, and hospital discharge documentation reviewed as applicable. He stated he expected residents to be assessed and receive medications as ordered. He stated the facility has a morning meeting to discuss new admissions to ensure the process is followed. He was unsure if a record was kept of what was discussed during the morning meeting regarding Res #152 since the facility only sometimes kept written records of these meetings.

On 09/09/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the residents received necessary treatment and services for pressure ulcers. There were no routine skin assessments, pressure ulcer assessments, and routine physician ordered treatments being conducted for Res #5 and #9. This resulted in Res #5 being admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/09/22 at 1:02 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/09/22 at 1:10 p.m., the regional director and the corporate RN were notified of the IJ situation. On 09/09/22 at 4:36 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: ''September 9, 2022 Jan [NAME] Care Center IJ Plan of Removal F686 Completion Date 9-9-22 10:30 p.m. Clinical Staff Education 1. CNA Shower List 2. CNA Skin Observation Communication Forms 3. Skin Policy and Procedures 4. Weekly Skin Assessments 5. Wound Assessments 6. Treatment Completion and Documentation 7. Physician Orders for treatments 8. F-Tag 686 9. Skin Care Plans Full Skin Observation on all Residents Skin Assessments Documented on all Residents Wound Assessments Completed if applicable Physician treatment orders obtained if applicable Scheduled treatments completed and documented On 09/12/22, interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Documentation was provided related to the skin assessments for all the residents which were completed. Wound assessment documentation was provided for the residents who had wounds. Physician orders were obtained and ordered treatments were conducted. The IJ was lifted, effective 09/12/22 at 2:15 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at a pattern. Based on observation, record review and staff interviews, the facility failed to ensure the residents received the necessary treatment and services for pressure ulcers for three (#5, 9, and #10) of three sampled residents reviewed for pressure ulcers. There were no routine skin assessments, pressure ulcer assessments, and routine physician ordered treatments being conducted for Res #5, 9, and #10. This resulted in Res #5 being admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #9 had multiple stage III and stage IV pressure ulcers which were not being routinely assessed and treated. The ''Resident Census and Conditions of Residents form documented 57 residents resided in the facility and four residents had pressure ulcers. Findings: 1. Res #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 06/28/22, documented to clean the left lateral thigh with NS, pat dry, fill with calcium alginate, silver rope, and cover with gauze and dressing every Monday, Wednesday, and Friday morning. A Weekly Wound Documentation assessment, dated 06/28/22, documented the resident had stage III pressure ulcer on the left hip. The measurements were 1.5 x 2.0 x 1.5 cm. The assessment documented the ulcer had 75% granulation, 25% slough, undermining at 2 o'clock location, moderate serosanguineous drainage. An admission MDS assessment, dated 07/01/22, documented the resident was severely impaired in cognition and required total assistance of two people with bed mobility and transfers. The assessment documented the resident had an unhealed stage III pressure ulcer on admission. The July 2022 TAR documented the resident did not receive pressure ulcer treatments to the left lateral thigh nine days of 13 opportunities. The July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/05/22, documented [MEDICATION(S)] (an antibiotic) 800-160 mg, 1 tablet twice a day for 10 days for a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2022 TAR documented the resident did not receive pressure ulcer treatments to the left lateral thigh six days of 11 opportunities. The August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note, dated 08/13/22 at 10:41 a.m., documented a 6.0 x 7.0 cm purple and red discoloration to the resident's coccyx. The note documented no open areas noted. The note documented [MEDICATION(S)] put in place and resident placed on left side at this time. A nurse note by LPN #2, dated 08/22/22 at 2:14 p.m., read Upon giving res bed bath and wound care nurse noted unstageable wound to coccyx. Nurse notified [corporate RN name deleted]. Nurse received order from [PA name deleted] for wound care see orders. At this time nurse applied wound treatment.'' A physician order, dated 08/22/22, documented cleanse area to coccyx with NS, pat dry, apply collagen sprinkles, apply calcium alginate, then absorbent dressing every day in the morning. An August 2022 TAR documented the resident did not receive pressure ulcer treatments to the coccyx one day of four opportunities. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital admission record, dated 08/25/22, documented the resident had septic shock secondary to [CONDITION(S)] and [CONDITION(S)] associated with chronic decubitus. On 09/08/22 at 12:11 p.m., the corporate RN stated she could not find any skin assessments or wound assessments for the resident except for the one on 06/28/22 when the resident entered the facility. She stated she did not know why the assessments and treatments had not been done. She stated she was usually in the facility two days a week. On 09/08/22 at 1:48 p.m., LPN #2 stated on 08/22/22, that she and LPN #2 were giving the resident a bed bath because the resident smelled. She stated she worked PRN for the facility. She stated she knew the resident had a pressure ulcer on her left hip, but on that day she said she did not see it and it must have healed. She stated when they rolled the resident onto her side she saw Duo-Derm dressing. She stated the dressing was very dark colored and there was a stench or foul odor. She stated she removed the dressing and saw an approximate 4.5 x 5.0 inch (equals 11.4 x 12.7 cm) pressure ulcer. She said the ulcer was covered with white slough. She stated she did not know the resident had a pressure ulcer on her coccyx. She stated she called the physician and received an order because there was not one in place. LPN #2 stated that, on 08/25/22, the next time she worked, she noticed the resident was not acting her usual. She stated her urine was dark very dark and looked like it had blood in it. She stated the resident had a low grade fever. She stated she called the physician and sent her to the hospital. The LPN was asked about the assessments and treatments which were not completed and she stated sometimes there was only one nurse and it was hard to get everything completed. A nurse note, dated 08/25/22 at 6:42 p.m., read in part, Resident sent to [Hospital name deleted] ER for eval, blood in urine abnormal vitals, was pale delusional, had decrease in LOC. Call ER to get report and nurse stated she had been admitted to ICU with dx [CONDITION(S)] and [CONDITION(S)] . On 09/12/22 at 11:16 a.m., the ADON was interviewed related to the residents pressure ulcers, treatments, and medications. The ADON stated she noticed a dark red purplish area on the resident's coccyx on 08/13/22. The ADON stated she called the physician and received and order for a [MEDICATION(S)] dressing and put it on the resident's bottom. The ADON was informed the order did not show up on the resident's list of orders or the TAR. She stated she did not know why the order was not documented on the TAR. She was asked why the treatments and assessments for the resident's left hip and coccyx were not conducted. She stated she did not notice an ulcer on the left hip at that time. She stated she knew the facility was short staffed. She stated she was giving medications this morning because their only CMA was not present. She stated today they had two nurses, two CNAs and one uncertified nurse aide. 2. Res #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly wound assessment, dated 05/25/22, documented a stage IV pressure ulcer to the left hip/buttock measured 13.0 x 2.0 x 2.2 cm. A weekly wound assessment, dated 05/25/22, documented a stage IV pressure ulcer to the left hip/buttock measured 5.0 x 3.4 x 3.0 cm. No assessments of the sacrum, right heel, right hip, or left ankle were documented at admission. A physician order, dated 05/25/22, documented to cleanse left hip with normal saline, pat dry, apply [MEDICATION(S)], negative pressure wound treatment (NPWT) at 125 mmHg continuous, change Monday, Wednesday, Friday, and as needed once a day. A TAR for May 2022 was not provided. A physician order, dated 05/25/22, documented to cleanse right hip with normal saline, pat dry, apply [MEDICATION(S)], NPWT at 125 mmHg continuous, change Monday, Wednesday, Friday and as needed once a day. A physician order, dated 05/25/22, documented to cleanse wound near rectum with normal saline, pat dry, pack with Aquacell Ag rope, cover with ABD pad, change Monday, Wednesday, Friday, and as needed once a day. A physician order, dated 05/25/22, documented to offload heels and place boots once per day. A physician order, dated 05/25/22, documented for remaining superficial wounds between wound vac's, cleanse with normal saline, pat day, apply Aquacell Ag, apply barrier cream mixed with anti-fungal cream to surrounding areas, cover all with ABD pads, secure with tape, change Monday, Wednesday, Friday, and as needed. The TAR for June 2022 documented the wound vac treatments were not completed on 06/08/22, 06/10/22, 06/22/22, and 06/27/22. The TAR for June 2022 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR for June 2022 documented the offloading of heels and placement of boots were not completed on 06/02/22, 06/10/22, 06/11/22, 06/16/22, 06/18/22, 06/25/22, 06/26/22, and 06/27/22. The TAR June 2022 documented the treatment to superficial wounds were not completed on 06/08/22, 06/10/22, and 06/27/22. A Weekly Wound Documentation assessment, dated 06/01/22, documented a stage IV pressure wound to left buttock measured 7.0 x 2.0 x 4.0 cm. A Weekly Wound Documentation assessment, dated 06/01/22, documented a stage IV pressure ulcer on the left hip which measured 12.0 x 2.6 x 2.7 cm with 100% granulation tissue. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A ''Weekly Skin Integrity Review, dated 06/20/22, documented the resident had skin intact, redness, and buttock wounds. The areas documented were coccyx, left buttock, right buttock, and right lower extremity. Further description documented .see wkly assessment of wounds for measurements . A nurse progress note, dated 06/21/22 at 1:45 p.m., documented Res #9 was transferred to the hospital due to altered mental status. A nurse progress note, dated 06/24/22 at 6:49 p.m., documented Res #9 returned to the facility. The progress note did not include a wound assessment or mention of wounds. A nurse progress note, dated 06/28/22 at 11:20 a.m., documented Res #9 was transferred to the hospital due to altered mental status. A nurse progress note, dated 07/03/22 at 6:58 p.m., documented Res #9 returned to the facility and .multiple wounds to buttocks, wound to right shin, redness to right heel and covered with dressing, dressing to left posterior lower leg -has slight redness to area . A nurse progress note, dated 07/07/22 at 9:32 a.m., documented .resume previous wound care orders . The TAR for 07/07/22 through 08/06/22 documented the wound vac treatments for the left and right hips were not completed on 07/08/22, 07/20/22, 07/22/22, 07/25/22, 07/29/22, 08/01/22, 08/03/22, and 08/05/22. The TAR for 07/07/22 through 08/06/22 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR for 07/07/22 through 08/06/22 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/07/22, documented heel protectors every shift. The TAR for 07/07/22 through 08/06/22 documented the heel protectors were not placed for 43 out of 93 opportunities. A nurses note, dated 07/09/22, documented .noticed discolored areas on resident's right and left inner heels, left upper ankle, right inner foot, right inner lower leg and left lower leg, fluid filled blister to top of right foot, applied skin prep to all areas and left open to air, pillow placed under legs to help off-set any possible pressure . No physician orders until 07/11/22. No measurements of the blister or other areas were documented. A nurses note, dated 07/10/22 at 10:43 p.m., documented Res #9 was sent to the ER due to altered mental status. A nurses note, dated 07/11/22 at 2:44 a.m., documented Res #9 returned to the facility and .blister to top of right foot has opened, realigned skin and used steri strips . No assessments of the wounds were conducted. A physician order, dated 07/11/22, documented to clean open blister to top of right foot with NS and apply steri strips. (one time order) A physician order, dated 07/11/22, documented to monitor open blister on top of right foot daily for signs and symptoms of infection. The TAR for 07/11/22 to 08/10/22 documented the monitoring was not completed on 07/12/22 through 07/20/22, 07/22/22 through 07/26/22, and 07/29/22. A physician order, dated 07/11/22, documented to apply skin prep to right inner foot, right heel, left upper ankle, left heel, and left lower outer leg twice daily until healed. The TAR for 07/11/22 to 08/10/22 documented the treatment to the right inner foot and left upper ankle was not completed for 10 of 28 opportunities. The TAR for 07/11/22 to 08/10/22 documented the treatment to the right heel was not completed for 13 of 40 opportunities. The TAR for 07/11/22 to 08/10/22 documented the treatment to the left heel was not completed for 11 of 40 opportunities. The TAR for 07/11/22 to 08/10/22 documented the treatment to the left lower leg was not completed for 10 of 32 opportunities. The TAR for August 2022 documented the skin prep treatment was scheduled for once daily instead of twice daily and was not completed on 08/11/22, 08/12/22, 08/13/22, 08/19/22, 08/22/22, 08/24/22, 08/25/22, 08/26/22, 08/30/22, and 08/31/22. A physician order, dated 07/17/22, documented wet to dry dressing, resume wound vac once per day. (Order did not specify location or indication for treatment) The TAR for 07/17/22 to 08/01/22 was not provided. The TAR for August 2022 documented the treatment was not conducted on 08/02/22 and the order was discontinued 08/09/22. The resident was out of the facility from 08/03/22 to 08/08/22. A nurse progress note, dated 07/27/22, documented the physician assistant was updated on Res #9's wounds and gave new orders for treatment to left lateral lower leg. A physician order, dated 07/27/22, documented to cleanse left outer lower leg wound with normal saline, pat dry, apply Santyl ointment to wound bed, cover with dressing, change daily for 14 days, and re-evaluate. The TAR for 07/27/22 to 07/31/22 was not provided for this order. The TAR for August 2022 documented the order was discontinued 08/02/22. A physician order, dated 07/29/22, documented to cleanse the left and right hip with normal saline, pat dry, apply [MEDICATION(S)] to wounds, NPWT at 125 mmHg continuous, change Monday, Wednesday, Friday, and as needed once per day. The TAR for 07/29/22 to 07/31/22 was not provided. The TAR for August 2022 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/29/22, documented to cleanse wound near rectum with normal saline, pat dry, pack with Aquacell Ag rope, cover with ABD pad, change Monday, Wednesday, Friday, and as needed once per day. The TAR for 07/29/22 to 07/31/22 was not provided. The TAR for August 2022 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/29/22, documented for remaining superficial wounds between wound vacs, cleanse with normal saline, pat dry, apply Aquacell Ag, apply barrier cream mixed with anti-fungal cream to surrounding areas, cover with ABD pads, secure with tape, change Monday, Wednesday, Friday, and as needed once per day. The TAR for 07/29/22 to 07/31/22 was not provided. The TAR for August 2022 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 07/29/22, documented to offload heels and place boots once per day. The TAR for 07/29/22 to 07/31/22 was not provided. The TAR for August 2022 documented the offloading and boot placement were not completed on 08/13/22, 08/19/22, 08/21/22, 08/22/22, 08/24/22 through 08/26/22, and 08/28/22 through 08/31/22. A physician order, dated 07/31/22, documented to cleanse the top right foot wound with normal saline, apply skin prep to eschar tissue twice daily and re-evaluate in 14 days. The TAR for 07/31/22 was not provided. The TAR for August 2022 documented the treatment was not completed for one of two opportunities and the order was discontinued on 08/02/22. A nurses progress note, dated 08/02/22, documented Res #9 was sent to the ER. A physician order, dated 08/02/22, documented to cleanse the left posterior leg with normal saline, pat dry, apply calcium alginate, and cover with dressing once a day. The TAR for 08/02/22 through 09/01/22 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/02/22, documented to cleanse the top of right foot with normal saline, pat dry, apply Santyl and cover once per day. The TAR for 08/02/22 through 09/01/22 documented the right foot treatment was not completed on 08/11/22 through 08/13/22, 08/19/22, 08/21/22, 08/22/22, 08/24/22 through 08/26/22, and 08/29/22 through 09/01/22. A nurses progress note, dated 08/09/22, documented Res #9 returned to the facility with no change to the wounds. A ''Weekly Wound Documentation, assessment, dated 08/09/22, documented a left side coccyx wound was a stage III pressure ulcer measuring 3.0 x 1.0 x 0.1 cm. This is the first mention of a stage III ulcer on the coccyx. No physician orders were documented for a stage III ulcer on the coccyx. A ''Weekly Wound Documentation, assessment, dated 08/09/22, documented a left hip stage IV pressure ulcer measuring 10.0 x 2.5 x 2.7 cm. No assessments were documented from 06/20/22 until 08/09/22. A physician order, dated 08/09/2022, documented to apply skin prep to right inner foot, right heel, left upper ankle, left heel, and left lower outer leg twice daily until resolved. The TAR for August 2022 documented the skin prep treatment was scheduled for once daily instead of twice daily and was not completed on 08/11/22, 08/12/22, 08/13/22, 08/19/22, 08/22/22, 08/24/22, 08/25/22, 08/26/22, 08/30/22, and 08/31/22. The TAR for September 2022 documented the skin prep treatment was not scheduled twice daily as ordered and was not completed on 09/01/22 and 09/05/22 through 09/08/22. A physician order, dated 08/09/2022, documented to cleanse left and right hip with normal saline, pat dry, apply [MEDICATION(S)] to wounds, NPWT at 125 mmHg continuous, change Monday, Wednesday, Friday, and as needed. The TAR for September 2022 documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/09/2022, documented to cleanse the wound near the rectum with normal saline, pat dry, pack with Aquacell Ag rope, cover with ABD pad, change Monday, Wednesday, Friday, and as needed. The TAR for September 2022 documented the rectum treatment was not completed on 09/05/22 and 09/07/22. A physician order, dated 08/09/2022, documented to cleanse the left posterior leg, with normal saline, pat dry, apply calcium alginate, cover with dressing, change daily. The TAR for September 2022 documented the treatment was not completed on 09/01/22 and 09/05/22 through 09/07/22. A physician order, dated 08/09/22, documented to offload heels and place boots once per day. The TAR for September 2022 documented the offloading and boot placement was not completed on 09/01/22, and 09/05/22 through 09/07/22. A physician order, dated 08/09/22, documented for remaining superficial wounds between wound vacs, cleanse with normal saline, pat day, apply Aquacell Ag, apply barrier cream mixed with anti-fungal cream to surrounding areas, cover all with ABD pads, secure with tape, change Monday, Wednesday, Friday, and as needed. The TAR for September 2022 documented the superficial wound treatments were not completed on 09/05/22 and 09/07/22. A physician order, dated 08/09/22, documented to cleanse the top of right foot with normal saline, pat dry, apply Santyl ointment, cover with dressing, change daily. The TAR for September 2022 documented the right foot treatment was not completed 09/01/22 and 09/05/22 through 09/07/22. A physician order, dated 08/24/22, documented to cleanse left outer posterior leg and pat dry, apply collagen powder and cover with calcium alginate, wrap with dressing once per day. The TAR for 08/24/22 through 09/23/22 documented the left leg treatment was not completed on 08/24/22 through 08/26/22, and 08/30/22 through 09/07/22. An MDS assessment, dated 08/27/22, documented Res #9 was cognitively intact, did not have rejection of care behaviors, required extensive to total assistance with ADLs, had two stage II pressure ulcers not present on admission, four stage IV pressure ulcers not present on admission, and one unstageable pressure ulcer not present at admission. On 09/09/22 at 9:51 a.m., Res #9 stated she was not getting regular treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no pressure reducing devices observed on the resident's feet. The blanket near the left foot had dried blood and a yellow substance on it. The left foot was partially adhered to the blanket below it with fresh blood and yellow fluid on the blanket where it was touching the foot. A stage III pressure ulcer was observed on the left outer posterior leg. The wound bed was red with scant amounts of yellow slough and was weeping. There were no treatments or dressings in place. The right foot was observed with a stage III pressure ulcer to the top of the foot. The wound bed was yellow and had bright red surrounding tissues. There were no dressings or treatments on the wound. The right foot had a dried black scab to the inner aspect of the foot without dressings or treatments in place. The center of the right ankle had a wound approximately quarter to half dollar size in diameter with red wound bed without weeping or exudate. The right heel had a stage II pressure ulcer approximately nickel size in diameter with red pinpoint center. On 09/09/22 at 10:35 a.m., staff assisted resident with privacy to allow visualization of a red flaky rash to underside of right breast. The resident stated it was painful and was not being treated. The resident asked CNA to place offloading boots on her feet. On 09/09/22 at 11:00 a.m., the corporate RN stated the treatments were not getting done because the facility did not have enough staff, and she was doing all of the treatments today along with finger-sticks and insulin. On 09/09/22 at 11:30 a.m. Res #9 stated she had not had the wound vacs in place for a few weeks now. One wound vac was observed in the floor to the left of the bed. The tubing was not attached to anything and the device did not appear to have power. A wound vac was observed in the floor to the right side of the bed near a bedside dresser. The tubing was observed piled on top of the device and was not attached to the resident. The device did not appear to have power. The resident stated the staff had not regularly placed them since she admitted to the facility. On 09/09/22 at 2:00 p.m., the corporate RN stated she was unsure if the resident was being seen by a wound care specialist or consultant. The surveyor requested documentation of any wound consultant notes or orders. The facility was unable to provide documentation regarding a wound care consultant by the end of survey. 3. Resident #10 admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No weekly skin assessments were documented in July 2022. An initial MDS assessment, dated 07/20/22, documented the resident was cognitively intact; required total assistance with transfers, toileting, and bed mobility; and had a facility acquired stage II pressure ulcer. A skin assessment, dated 08/02/22, documented a stage II pressure ulcer to the buttocks/coccyx measured 1.0 x 1.0 cm. No physician orders were present for the pressure ulcer. A skin assessment, dated 08/10/22, documented a stage II pressure ulcer wound to the buttocks/coccyx measured 0.5 x 0.4 cm. A skin assessment, dated 08/19/22, documented a stage II pressure ulcer to the buttocks and no measurements. A skin assessment, dated 08/22/22, documented a stage II pressure ulcer to the buttocks/coccyx measured 2.0 x 3.0 cm. A skin assessment, dated 08/29/22, documented a stage II pressure ulcer to the buttocks/coccyx measured 2.0 x 3.0 cm. A nurse note, dated 09/05/22, documented a wound to the buttocks/coccyx wound measured 1.2 x 3.5 x 0.1 cm. A physician order, dated 09/05/22, documented to clean open area to coccyx with normal saline and apply [MEDICATION(S)] dressing three times per week on Monday, Wednesday, and Friday on evening shift. A skin assessment, dated 09/07/22, documented a new deep tissue injury to left foot/heel. No measurements were provided. A physician order, dated 09/07/22, documented to apply skin prep to left heel three times per day and put on heel protectors. On 09/09/22 at 10:38 a.m., Res #10 was observed without heel protectors on prior to wound care. The buttocks and heel were treated at that time. A new stage I pressure injury was identified on left great toe. The corporate RN measured the deep tissue heel injury as 4 x 4 cm. On 09/09/22 at 10:40 a.m., treatment records for July and August 2022 were requested and not provided. On 09/09/22 at 11:00, the corporate RN stated that treatments were not being done because there was not enough staff. She stated she was the only nurse doing treatments, finger sticks, and insulin in the building that day. On 09/09/22 at 12:45 p.m., treatment records for July and August 2022 were requested again and not provided. A treatment record for September 2022 documented treatments to left heel were not completed for four of six scheduled treatments. Treatment records for July and August were not provided by the end of survey.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents remained free from accident hazards for one (#29) of 14 residents reviewed. The facility failed to ensure resident #29 was transferred safely and free from harm. The ADM reported 40 residents lived in the facility. Findings: A policy titled Transfer Activities documented, .Transfer from bed to wheelchair (Resident unable to assist) .2. Obtain assistance of another person, if necessary, for safe transfer . Resident #29 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 08/28/17, documented the resident required extensive assistance of two staff members for bed mobility and transfers with a full body lift as a problem. One approach listed was for the staff to use a full body lift with two staff members for transfers. An annual assessment, dated 10/30/17, documented the resident was severely impaired with cognition, required total assistance of two or more staff member for transfers, bed mobility, and bathing. The assessment documented the resident required total assistance of one staff member for dressing, eating, and hygiene. The assessment documented the resident was always incontinent of bowel and bladder. A physician's orders [REDACTED].FULL BODY LIFT WHEN TRANSFERRING RESIDENT . A nurse's note, dated 11/14/17 at 2:02 p.m., documented, CNA weighing resident and attempted to transfer resident unassisted to weigh w/c (wheelchair) and caught resident leg on metal around wheel of w/c causing approximated 10cm (centimeter) to 12cm in length and 1cm deep laceration to right lower leg direct pressure applied and covered with moist gauze wrapped and secured Dr (name deleted) N.O. (new order) send to (name deleted) ER to eval (evaluate) and tx (treat) as indicated EMS (Emergency medical service) call for transport family member (name deleted) notified and adm. notified. A nurse's note, dated 11/14/17 at 6:30 p.m., documented, Resident returned from hospital (name deleted) with 14 sutures to RT (right) lower leg. V/S (vital signs) 110/66, 67, 18, 97.8, 96% RA (room air). Resident with no s/s (signs or symptoms) or verbal c/o (complaints of) pain noted. Resting in bed with 02 @ directed. Son aware of resident return to facility. An OSDH incident report, dated 11/14/17, documented a CNA was weighing a resident and attempted to transfer the resident unassisted and caught the resident's leg on the metal on the wheelchair causing a 10 cm to 12 cm by 1 cm deep laceration to the right lower leg. The report documented the resident was sent to the local emergency department for treatment. The report documented the resident required 14 sutures to close the laceration. The OSDH incident report also documented after the review of the incident all nursing staff was in-serviced regarding the use of the full body lift. The report documented the CNA received disciplinary action for not following the care plan. In-services, dated 11/17/17, documented all nursing staff had completed in-service regarding transfers with the use of all lifts. A notice of disciplinary action, dated 11/17/17, documented CNA #3 did not follow the care plan to use a lift. The notice documented the resident was transferred without using a lift as directed by the care plan and thus caused laceration to the resident's right leg. On 11/29/17 at 12:48 p.m., the DON was asked if the resident should have been transferred with the assistance of one staff member. The DON reported there should have been two staff assisting with the resident's transfer. On 11/29/17 at 1:00 p.m., the ADM was asked if the incident involving the resident had been reported to the state health department. The ADM provided information regarding the investigation. The ADM reported the resident should have been transferred with the full body lift with the assistance of two staff members. The ADM reported the CNA involved received verbal instruction for transfer assistance on the day of the occurrence (11/14/17) and later received written disciplinary action on 11/17/17. On 11/30/17 at 2:29 p.m., the resident was observed lying in bed on her back with her eyes closed. On 11/30/17 at 4:21 p.m., CNA #1 and CNA #2 were observed to transfer the resident safely with the use of a full body lift. Both CNAs reported they had been in-serviced regarding the proper use of all lifts within the past month. On 12/04/17 at 10:06 a.m., CNA #3 was asked to explain what happened when transferring the resident which caused a laceration to the resident's lower extremity. The CNA reported she was trying to weigh the resident and could not find anyone to assist her with the transfer so she transferred the resident by herself. The CNA reported she had the resident put her arms around her neck and lifted the resident under her arms. The CNA reported when she transferred the resident back to her wheelchair her leg got caught on the wheelchair causing the laceration. The CNA was asked if she knew how the resident was supposed to be transferred. The CNA reported the resident was supposed to be transferred with the lift and two staff members. The CNA was then asked if she had been in-serviced regarding the use of lifts. The CNA reported she had been in-serviced on how to use the lift and resident transfers. The CNA was asked when the in-service had occurred. The CNA reported a couple of days after the incident. On 12/04/17 at 4:13 p.m., facility incident reports were reviewed since 11/14/17. No incidents of staff/resident had occurred regarding unsafe transfers. On 12/04/17 at 4:20 p.m., the staffing schedule for 11/14/17 was reviewed. The facility had the appropriate amount of staff available.