Every finding on record at Lexington Nursing Home, Inc.

Based on observation, record review, and interview, the facility failed to ensure proper infection control for 1 (#2) of 1 sampled resident reviewed for catheter care.The DON identified 39 residents resided in the facility. The facility matrix identified two residents had catheters.On 04/27/2026 at 8:06 a.m., CNA #1 and CNA #2 were observed donning personal protective equipment which included gowns and gloves in preparation to assist Res #2 out of bed. CNA #1 emptied the catheter into a urinal and then disposed of the urine in the toilet. CNA #1 returned to assist CNA #2 with transferring Res #2 from bed to wheelchair. CNA #1 did not change their gloves or perform hand hygiene after the catheter care and before continuing to assist Res #2.A Perineal Care Policy and Procedure, updated May 2022, showed gloves should be worn to provide catheter care. Soiled supplies should be placed in the appropriate trash bag. The policy showed remove gloves, perform hand hygiene, and then don clean gloves before continuing care.A quarterly assessment for Res #2, dated 11/03/25, showed the resident admitted [DATE] and was cognitively intact. The assessment showed Res #2 required substantial to maximum assistance with bed mobility, transfers, and catheter care. The assessment showed Res #2's left hand and foot were both contracted.On 04/27/26 at 8:15 a.m., CNA #1 stated I should have changed my gloves after emptying that catheter. On 04/27/26 at 12:26 p.m., LPN #1 stated If staff touched the catheter at all, then they need to wash their hands and apply new gloves before continuing to provide care.

Based on record review and interview, the facility failed to ensure the care plan was revised related to wound care for 1 (#19) of 12 sampled residents reviewed for care plan revision. The DON identified 39 residents resided in the facility. Findings:An undated face sheet showed Res #19 admitted to the facility with diagnoses which included heart disease, muscle wasting and atrophy, and muscle weakness.A progress note, dated 04/20/26, showed Res #19 had an open area to the lateral side of their left foot. The note showed new physician orders for wound care and to wear heel protection boot on the left foot.The care plan was not revised to include the new open area or the heel protector boot for Resident #19.On 04/30/26 at 12:59 at p.m., LPN #1 stated the new wound, and the heel protector should have been care planned.

Based on record review and interview, the facility failed to develop a comprehensive care plan for diabetic monitoring for one (#9) of five residents reviewed for unnecessary medications. MDS coordinator #1 identified eight residents with diabetes. Findings: Res #9 was admitted with diagnoses which included type II diabetes mellitus. A physician order, dated 07/30/23, documented obtaining finger stick blood sugar if resident becomes symptomatic. A physician order, dated 07/30/23, documented offering a diabetic protein snack at bedtime. An admission assessment, dated 08/07/23, documented the resident was cognitively intact and received insulin. A physician order, dated 09/06/23, documented to administer Trulicity 0.75 mg/0.5 ml subcutaneously once a day on Thursdays for diabetes mellitus. A physician order, dated 01/11/24, documented obtaining finger stick blood sugar daily on Wednesdays. A care plan, reviewed 06/27/24, did not document Res #9's diabetic monitoring. On 06/27/24 at 11:30 a.m., MDS coordinator #1 stated they did not know diabetic monitoring needed to be included on the care plan.

Based on observation, record review, and interview, the facility failed to revise the care plan related to falls for one (#9) of three residents sampled for falls. The administrator identified 84 falls in the last six months. Findings: A Managing Falls and Fall Risk policy, revised March 2018, read in parts, .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable . Res #9 had diagnoses which included Alzheimer's disease, seizures, and overactive bladder. A care plan, dated 08/08/23, documented the resident had the potential for falls secondary to balance problems during transition and walking, history of falls prior to admission, and routine antidepressant medication. The eight fall prevention interventions documented under this problem were dated 08/08/23. Incident reports, dated 01/08/24, 01/11/24, 02/02/24, 02/05/24, 02/08/24, 02/12/24, 02/13/24, 02/15/24, 02/18/24, and 02/22/24, documented Res #9 had fell . No additional interventions addressing fall prevention were documented on the care plan after the falls. A quarterly MDS assessment, dated 05/06/24, documented the resident was independent with mobility, transfers, and locomotion with use of a walker. The assessment documented the resident had two or more falls without injury, two or more falls with injury, and one fall with major injury. On 06/24/24 at 9:38 a.m., Res #9 was observed lying in bed. Res #9 stated they had fell on several occasions. Res #9 stated they had a lump on the back of their head from two previous falls which required staples to close the wound. On 06/27/24 at 11:35 a.m., MDS coordinator #1 stated they completed the residents' care plan. They stated after a fall occurs, an incident report is completed, the fall is discussed in an interdisciplinary meeting, and a new fall prevention intervention is added to the care plan. MDS coordinator #1 stated Res #9's care plan had not been revised after every fall but should have been. On 06/27/24 at 1:34 p.m., the DON stated a fall prevention intervention is documented on the incident report after a fall occurs. They stated the care plan should have been updated to reflect these interventions.

Based on record review and interview, the facility failed to ensure medications were coded accurately on MDS assessments for two (#1 and #3) of 12 sampled residents MDS were reviewed. The Administrator identified 43 residents who resided in the facility. Findings: 1. Resident #1 had diagnoses which included Alzheimer's disease. A Quarterly assessment, dated 04/22/24, documented Resident #1 received anticoagulant. There was no documentation the resident received an anticoagulant during the look back period. 2. Resident #3 had diagnoses which included acute cystitis. A Quarterly assessment, dated 04/01/24, documented Resident #3 received an antidepressant. There was no documentation the resident received an antidepressant during the look back period. On 06/27/24 at 11:24 a.m., MDS coordinator #2 stated they review the documentation in the EHR to ensure the MDS was coded accurately. They reviewed Resident #1 and #3's assessments and stated they were not coded accurate regarding their medications.

Based on record review and interview, the facility failed to ensure proper antibiotic stewardship was completed for two (#8 and #30) of two residents reviewed for antibiotic use. The Resident Census and Conditions of Residents form, dated 6/19/23, documented a census of 39. Findings: A facility Policy and Procedure for Proper Antibiotic Stewardship Program, read in part .the proper use of antibiotics while ensuring the safety and well-being of the residents .specific criteria, McGeer criteria, the facility has adopted for assisting in prescribing antibiotics .follow the McGeer criteria for assisting in the diagnosis of infections that require antibiotics . 1. Res #8's physician order, dated 02/04/23, documented the resident was to receive an antibiotic for 10 days due to cellulitis. The resident's MAR for April 2023 documented the antibiotic was completed per the physician orders. The clinical record did not document specific criteria to ensure the proper use of antibiotics was conducted. A quarterly assessment, dated 6/12/23, documented the resident had severely impaired cognition. 2. Res #30's physician order, dated 02/22/23, documented the resident was to receive an antibiotic for 10 days to treat cellulitis. An annual assessment, dated 04/10/23, documented the resident was moderately cognitively impaired. The February MAR documented the antibiotic was completed per the physician's order. The clinical record did not document specific criteria to ensure the proper use of antibiotics. On 06/21/23 at 10:30 a.m., the ADON and consultant RN #1 reviewed the clinical records and reported the antibiotic stewardship policy was not followed and the criteria was not completed for the antibiotic use for Res #8 and Res #30.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in facility. Findings: On 06/19/23 at 8:25 a.m., a tour of the kitchen was conducted. The following observations were made: a. floor tiles were missing, b. oven hood lights were burned out and/or not working, c. there was an accumulation of brown and black residue on the floor under equipment, d. there was an accumulation of brown residue inside of the cabinets, e. there was an accumulation of brown and black residue on the dish machine, chest freezer, stove, three door reach in cooler, dish cart, and stand mixer, and f. there was an accumulation of lint on the oven hood filters. On 06/19/23 at 8:45 a.m., the CDM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated they had a cleaning schedule and reported maintenance concerns to the maintenance director. The CDM was shown the above observations.

Based of record review and interview, the facility failed to obtain physician ordered labs for one (#24) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #24 had diagnoses which included congestive heart failure, hyperlipidemia, hypokalemia, and diabetes mellitus. A physician order, dated 02/07/23, documented CBC, CMP, and magnesium level on the 4th Wednesday of the month. There was no documentation the labs were obtained in April 2023 On 06/20/23 at 1:45 p.m., the DON was asked to locate documentation a CBC, CMP, and magnesium level was obtained in April 2023 for Res #24. On 06/20/23 at 3:00 p.m., the DON stated the labs were not collected in April 2023.

Based on record review and interview, the facility failed to ensure side effects were monitored for the use of psychoactive medications for one (#36) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 31 residents who received psychoactive medications. Findings: Res #36 had diagnoses of anorexia, insomnia, and depression. Physician orders, dated 03/28/23, documented Lexapro (antidepressant medication) 20 mg once a day; Remeron (antidepressant medication) 15 mg at bedtime; and temazepam (benzodiazepine medication) 30 mg at bedtime. A care plan, dated 04/05/23, documented the resident was receiving Lexapro, Remeron, and temazepam. It was documented for staff to screen and observed for suspected side effects according to the behavior monitoring record. There was no documentation side effect monitoring was conducted for May 2023. On 06/20/23 at 10:01 a.m., the DON was asked to provide side effect monitoring documentation for the month of May 2023 for the resident's use of Lexapro, Remeron, and temazepam. On 06/20/23 at 10:25 a.m., the DON stated they could not locate documentation side effects were monitored for May 2023. They stated a side effect monitoring sheet should have been completed.

Based on record review and interview, the facility failed to ensure the results of the use of PRN pain medications were obtained for one (#36) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in the facility. It documented 21 residents were on a pain management program. Findings: Res #36 had diagnoses which included pain. A physician order, dated 03/28/23, documented hydrocodone-acetaminophen (pain medication) 7.5-325 mg one tab orally every six hours as needed. The April and May 2023 MARs were reviewed. There were no results for the administration of hydrocodone-acetaminophen on 04/19/23 and 05/22/23. On 06/20/23 at 10:01 a.m., the DON was asked what was the protocol for administering as needed pain medications. The DON stated the date, time, staff initials, medication, the reason the medication was administered, and the result should be documented on the back of the MAR. They were shown the resident's April and May 2023 MARs where there was no documented result on 04/19/23 and 05/22/23 for the administration of hydrocodone-acetaminophen.

Based on record review and interview, the facility failed to ensure there was sufficient documentation for basis of a resident discharge for one (#42) of one sampled resident review for discharge. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #42 was admitted to the facility on [DATE] with diagnoses which included burn of second degree of right and left foot, burn of second degree of right lower leg, presence of cardiac pacemaker, osteoarthritis, hypothyroidism, diabetes mellitus, hyperkalemia, HTN, heart failure, and COPD. A daily meeting minutes report, dated 04/12/23 at 8:55 a.m., documented Res #42 to discharge with a question mark behind their name. A nurse progress note, dated 04/12/23 at 1:12 p.m., documented the facility had a morning meeting concerning the behavior of the resident. It was documented a decision was made for the resident to be discharged from the facility. It was documented MDS coordinator #1 spoke with the resident's family member making them aware of the pending discharge for this morning. It was documented the family member stated they would be at the facility around 10:15 a.m. - 10:30 a.m. to get their family member. It was documented the resident's personal belongings and medications were released to the family member. It was documented there was no outside agency referral at the request of the family member. It was documented the resident left in a private vehicle from the facility at 10:25 a.m. A discharge summary, dated 04/12/23, documented the resident was discharged unexpectedly due to inappropriate behavior toward staff members. There was no documentation of any incidents where the resident had inappropriate behaviors. On 06/20/23 at 3:04 p.m., the DON was asked about the circumstance surrounding the resident's discharge. They stated they would need to find out what they could say about the discharge. On 06/20/23 at 3:16 p.m., the DON stated when the resident came in they had refused to cooperate with medical treatment. They stated the resident asked a staff member to dance for them and the staff member was very offended. They stated the next morning there was a meeting with the administrator. The resident's family member was informed of the behaviors and they signed the resident out of the facility voluntarily. They stated that was the reason there was no documentation of the incident. They stated the staff member did not want to fill out an incident report. They stated the staff member was crying and very offended. The DON was asked to provide documentation the resident's family member voluntarily discharged the resident from the facility. There was no documentation the resident refused to cooperate with medical treatment. On 06/20/23 at 3:23 p.m., the resident's family member was called and a message was left for a return call. On 06/20/23 at 3:45 p.m., the DON stated the voluntary discharge paperwork was in the resident's chart. They provided the resident's face sheet. On the bottom of the sheet was hand written documentation the resident was discharged home with a family member 04/11/23. The family member's signature was on the facesheet. The DON was made aware the resident was discharged on [DATE] and the documentation did not indicate the discharge was voluntary. On 06/20/23 at 4:00 p.m., the administrator was asked about the resident's discharge. They stated when they got to work on the morning of 04/12/23 everyone came in their office and there was a quick discussion about the resident. They were asked what behaviors did the resident exhibit. They stated the sexual stuff with the nurse, but it was all hearsay. The administrator was asked if anyone was endangered by the resident's behavior. They stated they were not. They stated that was just the initial report they got. They stated they had not even starting investigating. They stated they had a meeting and the resident's family member was contacted about what was happening. They stated sometime that day the resident's family member came and picked them up and they discharged . The administrator was asked about documentation related to the resident's discharge. They stated they had them sign the facesheet, medication sheets, and inventory sheet. They stated they do not have a form for residents who discharge voluntarily. The administrator was made aware there was no documentation related to any inappropriate behavior displayed by the resident or the resident refusing to cooperate with care. They were made aware the nurse's progress note read a decision was made by the facility to discharge the resident and the resident's family member was notified of the pending discharge. They were made aware there was no documentation the resident's family member voluntarily discharged the resident from the facility. On 06/21/23 at 2:30 p.m., a return call was received from Res #42's family member. They were was asked about the circumstance surrounding the resident's discharge. They stated the facility called them to come get Res #42 on 04/12/23. They stated they could not say what behaviors Res #42 had, but there had been a disagreement between the owner and Res #42. They stated the only meeting they had with the facility was before Res #42 was admitted .

Based on observation, record review, and interview, the facility failed to ensure a resident was treated with dignity during a transfer for one (#27) of one sampled resident observed for dignity. The Resident Census and Conditions of Resident report, dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #27 had diagnoses which included acute cystitis without hematuria, osteoarthritis, HTN, and inflammatory spondylopathy. A quarterly resident assessment, dated 03/20/23, documented the resident required extensive assistance with transfers. On 06/20/23 at 11:07 a.m., CNA #1 was observed in the resident's room assisting them out of their recliner to their wheelchair. The resident was observed to bear weight by the CNA placing their hand under the resident's right arm. After the resident completed the pivot to their wheelchair the CNA was observed lowering the resident by their pants into their wheelchair. On 06/20/23 at 11:14 a.m., CNA #1 was asked when they transferred Res #27 from their recliner to their wheelchair, should they have assisted them by placing their hand under the resident's arm or by using their pants. They stated they should have used a gait belt. On 06/20/23 at 11:26 a.m., the DON was asked what was the protocol for a one person transfer. They stated staff should use a gait belt. They were made aware of the above observation.

Based on observation, record review, and interview, the facility failed to change and label oxygen tubing and concentrator reservoir according to physician orders for one (#11) of one residents sampled for respiratory treatments. The Resident Census and Conditions of Residents form dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #11 had diagnoses which included COPD. A physician order, dated 04/29/23, documented to clean filter on oxygen concentrator and date bottle with time and initial. The order documented to change oxygen tubing with date and initials every Friday. An admission assessment, dated 05/06/23, documented the resident was cognitively intact, had shortness of breath, and received oxygen therapy. On 06/20/23 at 9:25 a.m., Res #11 was observed during a breathing treatment. The resident had oxygen delivered by nasal cannula at three liters per minute. The oxygen concentrator was observed at the foot of the bed. The concentrator humidification bottle was observed with a tape label on the bottle that documented 06/03/23. On 06/20/23 at 9:27 a.m., LPN #1 stated the concentrator bottle should be changed weekly on Friday by 3-11 shift. LPN #1 was shown the bottle label and stated it was not changed as ordered.

Based on record review and interview, the facility failed to prevent misappropriation of resident property for one (#1) of five sampled residents reviewed for abuse/misappropriation. The Resident Census and Conditions of Residents report, dated 07/28/22, documented 48 residents resided in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 07/03/22, documented the resident's family reported the resident's purse was missing from their room. It was documented the facility made two separate attempts to find the purse, but they were unable to locate it. It was documented local law enforcement was notified. It was documented laundry was notified to monitor incoming linens for the missing item. A follow up incident report, dated 07/05/22, documented local law enforcement reviewed video from the date of the incident and were unable to identify who had taken the resident's purse. A final incident report, dated 07/08/22, documented staff and resident interviews were conducted, and no one had observed anyone going into the resident's room alone. The facility concluded the investigation. On 7/28/22 at 12:25 p.m., the DON stated they had not instituted any additional interventions after the incident to prevent recurrence, but had provided education to staff that was not documented. The DON also stated through their investigation that someone had actually taken the purse, was not found and it was able to be determined who took it.

Based on record review, observation, and interview, the facility failed to ensure staff utilized two staff members for a full body mechanical lift transfer for one (#2) of three sampled resident's reviewed for transfers. The ethics and compliance director identified four residents that required use of a full body mechanical lift. Findings: Resident #2 had diagnoses which included Wernicke's [CONDITION(S)] and stroke. An annual resident assessment, dated 07/18/22, documented Resident #2 was moderately cognitively impaired, and required extensive assistance with two or more staff for transfers. On 07/28/22 at 5:24 a.m., CNA #1 was observed transferring Resident #2 from their bed to a geri-chair with a full body mechanical lift. There were no other staff members in the room at the time of the transfer. On 07/28/22 at 6:27 a.m., CNA #1 stated she shouldn't use the lift alone, and should look for someone else to help since it was a rule. She stated she did not do this for Resident #2. On 07/28/22 at 12:25 p.m., the DON stated two people were required to operate a mechanical lift. On 07/28/22 at 1:47 p.m., the ethics and compliance director stated the standard procedure for a full body mechanical lift was to use two people. She stated the staff were trained and instructed to use two people.

Based on record review, observation, and interview, the facility failed to develop and implement a comprehensive care plan for one (#3) of 13 residents whose care plans were reviewed. The administrator identified five residents who were assessed for smoking. Findings: Res #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A SMOKING ASSESSMENT, dated 02/22/21, documented the resident had requested or expressed a desire to smoke. The assessment documented the resident was independent with smoking and understood the smoking policy. The care plan, dated 11/22/21, did not include the resident was a smoker or a smoking plan of care for the resident. On 05/26/22 at 1:08 p.m., the resident was observed outside in the facility smoking area. The resident was able to light her own cigarette and smoke independently without difficulty. On 05/26/22 at 2:04 p.m., the care plan/MDS staff #1 stated the resident and four other residents had been assessed for smoking. The staff stated the five residents assessed for smoking did not have care plan for smoking.

Based on record review, observation, and interview, the facility failed to monitor and document operability of safety device to prevent an elopement for one (#32) of one sampled resident reviewed for elopement risk. The resident was admitted to the facility on [DATE] with diagnoses of dementia. A physician order, dated 03/29/22, documented the resident's wander guard device was to be monitored on Monday, Wednesday, and Friday for operability. An incident report, dated 05/13/22, documented the resident was found about one block away from the facility by a staff member that had left to run a personal errand. The report documented the resident's wander guard bracelet had been checked on 05/11/22 and was working. On 05/31/22 at 1:28 p.m., the administrator reported documentation for the wander guard bracelet should be documented by the charge nurse on the medication administration report. On 05/31/22 at 1:35 p.m., the TAR contained no documentation that the resident's wander guard bracelet had been monitored for operability. On 06/01/22 at 11:13 a.m., the Director of Nursing was shown the resident's TAR. The DON reported there was no documentation the resident's Wander Guard bracelet had been working properly.

Based on record review and interview, the facility failed to develop and implement an abuse policy for reporting an allegation of abuse to the state agency within two hours for one (#25) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents report, dated 05/25/22, documented 46 residents resided in the facility. Findings: An undated facility policy titled ABUSE, NEGLECT, AND EXPLOITATION POLICY AND PROCEDURE was reviewed. The policy did not contain the required timeframe for reporting allegations of abuse or the use of multimedia involving the residents. Res #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/24/22 at 10:34 a.m., the resident voiced a concern regarding a staff member who provided care. The resident stated she had not told anyone in the facility. On 05/24/22 at 10:43 a.m., the administrator entered the resident's room to talk about their concerns. The resident stated a staff member had abused them. An incident report, dated 05/24/22, documented an allegation of abuse for the resident. A fax transmission report, dated 05/24/22 at 3:49 p.m., documented the Oklahoma State Department of Health (OSDH) had received the incident report regarding the allegation of abuse for the resident. On 05/31/22 at 9:44 a.m., the administrator stated he was responsible for allegations of abuse in the facility. The administrator stated the current policy was undated and had been used since his hire in 2014. The administrator stated the policy did not document the required timeframe for reporting allegations of abuse and to his knowledge the reporting timeframe was 24 hours. The administrator was unaware of the two hour reporting timeframe for allegations of abuse.

Based on observation and interview, the facility failed to post nurse staffing information, which included all of the required components, in an area where it could be viewed by all residents. The Resident Census and Conditions of Residents form documented 46 residents resided in the facility. Findings: On 05/25/22 at 12:20 p.m., the nurse staffing information was not posted. On 05/31/22 at 8:46 a.m., the nurse staffing information was not posted. On 06/01/22 at 8:20 a.m., the nurse staffing information was not posted. On 06/01/22 at 11:13 a.m. the DON reported the nurse staffing information should have been posted.

Based on record review and interview, the facility failed to review and revise a care plan for one (#32) of 13 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report documented 46 residents resided in the facility. Findings: The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 03/29/22, documented the resident's wander guard device was to be monitored on Monday, Wednesday, and Friday for operability. The care plan, dated 05/07/22, read in part, .STAFF TO PERFORM ROUTINE CHECK OF WANDERGUARD BRACELET SYSTEM PER PHYSICIAN ORDER [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 05/13/22, documented the resident was found about one block away from the facility by a staff member that had left to run a personal errand. On 05/31/22 at 1:28 p.m., the administrator reported the resident's care plan should have also been updated after his elopement. On 05/31/22 at 2:00 p.m., the MDS coordinator #2 reported if there was any changes or updates to the resident's care plan it would be on the back of each topic sheet. The MDS coordinator #2 reported there was nothing updated on the care plan.

On 02/11/14 at 12:55 p.m., an IJ (immediate jeopardy) situation was determined to exist due to the facility's failure to provide adequate supervision and a functioning security device to prevent a cognitively impaired resident from exiting the building in the middle of the night during sub-freezing temperatures. On 02/07/14, between the hours of 1:00 a.m. and 2:00 a.m., the temperature was 14 degrees Fahrenheit. Staff was unaware the resident had exited the building until she alerted staff she was at the front door and wanted to return inside. At 1:00 p.m., the Oklahoma State Department of Health was notified and confirmed the existence of an IJ situation. At 1:10 p.m., the administrator and director of nursing were notified of the existence of the IJ. At 4:30 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: "Plan of Removal of Immediate Jeopardy in Connection with Staff Supervision of Wanderers and Use of Sufficient Safety Mechanisms to Prevent Elopement. Wanderguard warning system will be installed at all means of egress. The stationary alarm that is installed at the exits, will be placed on a schedule, (Mon.-Wed.-Fri.) check by the maintenance personnel. A record of the dated checked and results of the check will be maintained and available upon request. T(h)is will begin February 11, 2014 at 5:00 p.m. At this time, there is a door going out of the back lobby which will have a new Wander Guard stationary alarm put in to place by Thursday, February 13, 2014, at 5:00 p.m. This alarm has already been ordered and should by here tomorrow. If it arrives, as hoped, this area will be secured tomorrow as soon as the alarm arrives. The two dining room doors, which are not emergency exits, will be secured so that a resident may not exit at this area. This will be done by Wednesday, February 12, 2014 at 5:00 o'clock. Each resident who is wearing a Wanderguard bracelet, will be listed on the TAR. It will be the responsibility of the charge nurse to test the bracelet worn by these residents and document on the TAR. This check will be done 3 times weekly on Monday, Wednesday and Friday then noted on the TAR. The TAR has been updated to reflect these changes Tuesday, February 11, 2014 at 4:30 p.m. All staff members, (with emphasis on direct care nursing staff), will be inserviced over what constitutes elopement, knowing who is at risk for elopement, and preventative measures, such as visual observance of the resident, between scheduled checks, added involvement with activities, etc. Inservice will be Thursday, February 13, 2014 at 2:30 p.m. This will be a mandatory inservice. Any one missing this inservice, will not receive their check until they receive this information. We can have inservice training over this subject on an individual or small group basis, as along as it is before 02-13-2014. This information will also be added to the new employee orientation packet." The IJ was removed on 02/13/14 at 3:00 p.m., when all the components of the plan of removal had been completed. The deficient practice remained at an isolated level of potential for harm. Based on observation, clinical record review, staff interview, and facility policy and procedure review, the facility failed to provide adequate supervision and a functional security device to prevent a cognitively impaired resident from exiting the building in the middle of the night during sub-freezing temperatures for one (#1) of six sampled residents who were identified as elopement risks. This resulted in an immediate jeopardy situation. The facility identified six residents who were determined to be elopement risks and had orders for a Wanderguard security device. Findings: A facility policy and procedure titled, Resident Leave and Elopement Policy and Procedures, documented: "...4. For resident's at risk this facility uses the Wonder Guard System. The System is placed on the two doors (front and back) that opens to an area of possible traffic. The other doors open out into, fenced in areas..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/26/14, documented the resident could make herself understood and could understand others. She had severely impaired cognitive skills for daily decision making. She required minimal staff assistance for activities of daily living. A January 2014 physician's orders [REDACTED]. "...start date 04/08/13 -open ended Wander Guard bracelet to alert staff of elopement Q shift (DX: Alzheimer's disease) Q shift - Every Shift 7-3, 3-11, 11-7..." A care plan, updated 01/27/14, documented: "...Problem... (Resident) has poor safety awareness and balance problems... ...Approaches:.. Wanderguard bracelet to alert staff of possible elopement..." A fax to the physician, dated 01/26/14, documented: "...Signs/Symptoms: Resident up all night Sat. 01/25/14. This am (Sun) she is crying, wanting to go home, doesn't think she is supposed to be here. She has not been doing this for quite a while. Zyprexa (decreased) to 5 mg from 7.5 mg last week..." A nurse's progress note, dated 01/26/14 at 10:23 a.m., documented: "Resident up to nurse's desk several times this AM, crying. Was up all night reportedly. Wanting to go home, insists she is not supposed to be here, she has things she 'has to take care of'..." A nurse's progress note, dated 02/07/14 at 1:21 a.m., documented: "SNN for 11/7. VS 96.8, 80, 20, 148/74, O2 sats-93%RA. Resident noted knocking on front door. Staff assisted resident into the facility, noted her Wanderguard bracelet did not alarm. Assisted resident to bathroom then to bed. Pleasant with staff. Upon investigating resident went out south end door and unlocked gate, then walked around to front door. Staff will notify DON about Wanderguard and have it replaced. Noted resident occ. looking out bedroom door then closing it. Call light in reach. Quiet night. No other problems noted." On 02/11/14 at 12:35 a.m., the facility was entered and an initial tour was conducted. At 12:55 a.m., CNA #1 was asked if alarms sounded when the doors were opened. She stated the doors would not alarm unless the resident was wearing a Wanderguard bracelet. At 1:00 a.m., CNA #3 was asked which doors had Wanderguard alarms. She stated the boxes with the red lights on the south, north, east and front entrances had alarms for Wanderguard devices. At 1:10 a.m., LPN #1 was asked when the the resident had last been seen by staff on 02/07/14 before she came to the front door wanting to be let inside. She stated it would have been about 1:00 a.m., during bedcheck. She stated she believed the resident left through the south exit. The back and sides of the building are enclosed in a chainlink fence. She stated the south gate allowing access to the front of the building was open and she believed the resident had left the building using that exit. At 1:15 a.m., observations were made of all the doors allowing entry and exit from the facility. Three doors were observed to not have Wanderguard alarms systems. The doors were located in the main dining room (sliding doors), the assisted dining room, and the back lobby (lounge). At 12:00 noon, CNA #1 was re-interviewed. She stated it was approximately 11:00 p.m., the last time she had visual contact with the resident. She stated the resident was walking around the hallways which was normal behavior for her. She stated she was doing bedchecks with CNA #2 on the south hall and was not aware the resident had exited the building and came to the front door of the facility wanting to be let inside. She stated they had not yet toileted the resident for the 12:00 a.m. bedcheck. She stated the resident's Wanderguard alarm did not go off. After the resident was brought back into the facility, they checked the Wanderguard and it was not functional. At 12:10 p.m., a telephone interview was conducted with CNA #2. She stated at midnight the resident was wandering and she assisted her to bed. She stated she and CNA #1 started doing bedchecks on the south hall. She stated as they came out of a resident's room, LPN #1 notified them the resident had been outside the facility and came to the front door to get back inside. At 12:30 p.m., the maintenance supervisor and the director of nursing were asked to demonstrate how the Wanderguard bracelets activated the door alarms for the doors at the west, north, south, and main entrance. The alarms would sound once a magnetic connection on the door was broken when opened. The alarm would remain on until manually reset. The DON was asked if the facility had a process in place to periodically check the Wanderguard security devices to determine if they were functioning correctly. She stated she had been checking weekly to determine if they were functional but did not have documentation. She provided a treatment sheet for the resident that documented the Wanderguard had been monitored on 02/10/14, but no other entries were made prior to that date. She further stated they were checked every shift to ensure they were in place and had not been removed, but that did not include if they were functioning. During the door check, the DON identified three doors which did not have a Wanderguard security system and did not alarm when opened. Those doors were located in the main dining area, the assisted dining area, and the lounge/back lobby. The DON acknowledged a resident could leave the building through one of those exits and the staff be unaware.

Based on record review, observation, and interview, it was determined the facility failed to provide care/services to prevent the development of pressure ulcers for 1 (#27) of 2 sampled residents whose clinical record was reviewed for pressure ulcers. The resident had been admitted to the facility with 2 "old" pressure ulcers to the right heel. No preventative approaches were implemented to prevent recurrence and a pressure ulcer developed within 11 days of admission. The QCLI report identified no additional residents with pressure ulcers. Findings: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. The resident-data collection record and the admission nurse's note, both dated 08/10/11, documented the resident had 2 "old" decubitus ulcers on the right heel. No description and/or size of the areas was documented in the clinical record. The admission physician's orders did not include orders for a preventative treatment or preventative care to be provided for the resident's right heel. The admission assessment, dated 08/16/11, documented the resident had moderate cognitive impairment, required extensive assistance with bed mobility, was at risk for the development of pressure ulcers, and had no unhealed pressure ulcers at the time of the assessment. The care plan, dated 08/17/11, documented the resident had a "potential for pressure ulcer(s), due to urinary and bowel incontinence, and bed mobility problem(s)..." The care plan addressed approaches for the prevention of pressure ulcers related to the bowel/bladder incontinence, but did not address approaches to be implemented to prevent recurrence of the "old" decubitus ulcers to the right heel. Nurses' notes, dated 08/10/11 through 08/23/11 on the night shift, documented the resident was turned and repositioned every 2 hours. There was no documentation to indicate the resident's heels were elevated off the bed during the day and/or evening shifts during those dates. There was no documentation in the nurses' notes, on treatment sheets, and/or on ADL flowsheets from 08/10/11 through 08/23/11, to indicate heel protectors were used. A Braden Scale, completed on 08/17/11, documented the resident was at moderate risk for the development of pressure ulcers. A nurse's note, dated 08/21/11 on the day shift, documented the resident had a pressure sore on his right heel. The note documented the area was cleaned, a 4X4 was taped over the area, and the heels were elevated on a pillow when he was in bed. There was no description, size or stage of the wound documented. A nurse's note, dated 08/23/11 on the evening shift, documented a "2X3 area noted to (right) heel. (Name deleted, physician) faxed for further orders..." There was no description, depth or stage of the wound documented. There was no documentation to indicate the physician had been notified of the pressure ulcer to the right heel until 08/23/11. A physician's telephone order, dated 08/24/11, documented zinc 220 mg was to be administered daily for wound healing. Nurses' notes, dated 08/10/11 through 08/24/11, documented the resident's skin was within normal limits and the resident had no pressure ulcers. A physician's telephone order, dated 08/25/11, documented the right heel was to be cleaned with normal saline and patted dry. [MEDICATION NAME] spray was to be applied twice daily. Heel protectors were to be used when the resident was in bed. A nurse's note, dated 08/26/11 on the evening shift, documented the [MEDICATION NAME] spray had arrived at the facility and the treatment was started. The weekly nursing assessment, dated 08/27/11, documented the resident had no decubitus ulcer. The treatment sheets, dated 09/2011 and 10/2011, documented the wound to the right heel had been measured weekly. The measurement included the height and width of the wound, but the depth was never recorded. The wound was not staged at any point since it was identified. On 11/01/11 at 10:42 a.m., during an interview with the DON, the surveyor reviewed the above findings regarding the notification of the physician when the pressure ulcer was identified on 08/21/11. The DON reviewed the clinical record and acknowledged the physician had not been notified for 2 days after the wound was first observed. The surveyor asked if the pressure ulcer was a significant change for which the physician should have been notified when it was observed. She stated, "Yes." On 11/02/11 at 10:45 a.m., the surveyor observed LPN #2 provide wound care for the resident's right heel pressure ulcer. The wound was observed to be approximately 3 cm by 3 cm. Minimal drainage was observed on the dressing removed. The surveyor asked LPN #2 to stage the wound. She stated she did not know how to stage wounds. On 11/03/11 at 4:30 p.m., the surveyor reviewed the above findings with the DON, the RN consultant and LPN #1. The RN consultant acknowledged the depth of the right heel pressure ulcer had not been documented nor had the pressure ulcer been staged. The surveyor asked what measures the facility had implemented to prevent recurrence of the pressure ulcer to the right heel. She stated, "The first thing I would do is float the heels, but," and she did not finish her sentence. The surveyor asked if, based on the documentation in the clinical record, the facility provided the care/services to prevent the development of the pressure ulcer of the resident's right heel. LPN #1 stated, "Not that I can find."