Every finding on record at Maple Healthcare and Rehab

Based on record review and interview, the facility failed to ensure physician ordered laboratory work was collected and sent for processing for 1 (#1) of 4 sampled residents reviewed for nutrition.The DON identified 24 residents had orders for routine laboratory tests. Findings:A policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated 2005, read in part, The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process the test requisitions and arrange for the tests.A physician's order for Resident #1, dated 03/26/25, showed the resident was to have a HGB A1C (hemoglobin test to check a person's average blood sugar level over a 90 day period).An annual assessment for Resident #1, dated 10/05/25, showed the resident's cognition was severely impaired and they received their nutrition via a PEG (percutaneous endoscopic gastrostomy) tube.On 08/12/26 at 8:56 a.m., the DON stated they had searched Resident #1's medical records and found the resident's HGB A1C tests had not been collected during the past year. They stated they needed to create a system that would ensure the tests had been completed and results were reported to the ordering physician as ordered.

Based on observation, record review, and interview, the facility failed to ensure flies did not infest a resident's room for 1 (#5) of 2 sampled residents reviewed for pest control.The DON identified 25 residents resided in the facility. Findings:On 08/10/26 at 12:36 p.m., Resident #5 was observed eating their afternoon meal in their room. The dish they were eating from had two black house flies walking on the dish, fork, and food. The resident was observed eating from the fly infested dish. The resident was observed waving their hand over the food which caused the flies to leave the dish but return immediately.On 08/11/26 at 9:57 a.m., Resident #5 was observed sitting in their room. Three black house flies were observed flying around the room.On 08/11/26 at 12:16 p.m., Resident #5 was observed eating their afternoon meal in their room. There were two black house flies observed flying around the resident's room next to the window.On 08/12/26 at 7:25 a.m., Resident #5's room was observed with five flies on their recliner and three flies on the resident's bedside table.An undated policy and procedure titled Facility Pest Management Policy: Oklahoma Long-Term Care Standards, read in part, Policy Purpose (sic) The core mission of this policy is to protect the health, welfare, and safety of residents as mandated by 63 O.S. 1-1904. The facility shall utilize an Integrated Pest Management (IPM) approach to prevent, identify, and eliminate pest activity through both chemical and non-chemical means, ensuring an environment free of biological hazards and physical neglect.A Resident Council Monthly Meeting document, dated 07/08/26, showed flies were identified as a problem at the facility.A Resident Council Monthly Meeting document, dated 08/04/26, showed flies were identified as a problem at the facility.On 08/10/2026 at 12:36 p.m., Resident #5 stated the only problem they had at the facility was the flies in the building.On 08/11/26 at 12:16 p.m., Resident #5 stated the only problem they had at the facility was the flies buzzing around their food.On 08/12/26 at 8:27 a.m., Maintenance #1 stated they had been working on the fly problem since May of 2026. They stated they have been having the facility sprayed monthly but now have approval from corporate to spray three times each month. Maintenance #1 stated they had some fly catching lights before, but some did not work and they were limited to where they could plug them in. They stated they will continue to work on the fly problem with their contractor.On 08/12/2026 at 11:56 a.m. the administrator stated they had been working on the fly problem for over a year and would continue to try to get them under control.

Based on record review and interview, the facility failed to ensure a binding arbitration agreement signed by a resident did not include language that a particular group of arbitrators must be used in the event of arbitration for 1 (#5) of 2 sampled residents reviewed for binding arbitration agreements.The DON identified seven residents signed binding arbitration agreements in 2026. Findings:An Arbitration and Limitation of Liability Agreement for Resident #5, dated 06/17/26, read in part, The arbitration proceeding shall be held in accordance with the rules and procedures of the [organization name withheld]. In the event that the [organization name withheld] is unable or unwilling to arbitrate the dispute, the parties agree that the dispute shall be arbitrated before a nationally recognized arbitration organization pursuant to its code of conduct. The arbitration agreement showed Resident #5's family member signed the document in place of the resident's signature.On 08/12/26 at 10:04 a.m., the SSD stated they were the person who was tasked with presenting the binding arbitration agreements to the residents for signature. The SSD stated they were never trained on the specifics of the facility's arbitration agreement and did not understand what each part meant. The SSD stated that when there is a new resident, they tell the resident that anytime they may want to go to court about a problem at the facility, they should come to them and use arbitration instead. They stated they did not know about the legal requirements of the arbitration agreement.On 08/12/26 at 12:27 p.m., the administrator stated they had been unaware of the wording in the document related to choosing an arbitrator.

Based on observation and interview, the facility failed to implement an enhanced barrier precaution policy to prevent the spread of MRDO's in the facility. The DON reported the census in the facility was 24. Findings: On 12/30/24 at 8:45 a.m., a tour of the facility was conducted. No signage was noted indicating enhanced barrier precautions were in place to protect at risk residents. On 01/02/25 at 10:26 a.m., CNA #1 stated the facility did not use EBP. On 01/02/25 at 10:28 a.m., CNA #2 stated they were not familiar with EBP. On 01/02/25 at 10:31 a.m., LPN #1 stated to their knowledge the facility was not using EBP. On 01/02/25 at 10:35 a.m., the DON stated they are currently not using EBP. ' ' ' ''''''''''''''''''''''''''''''''''''

Based on observation, record review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. The DON reported 24 residents receive meals from the kitchen. Findings: An undated facility policy titled food Safety Requirements, read in parts, Dry food storage- keep foods/beverages in a clean dry area off the floor .Holding- staff shall monitor food temperature while holding for delivery to ensure proper hot and cold holding temperatures are maintained .All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. An initial tour of the kitchen was conducted on 12/30/24 at 8:13 a.m. The following observations were made: a. the paper towel dispenser at the handwashing sink was out of paper towels, b. the Low Temperature Dish Machine Temperature Form had no documented temperatures or chemical concentrations since 10/21/24, c. there was an open gallon container of milk without documentation of the date it was opened, d. there was an open container of sliced cheese without documentation of the date it was opened, and e. a case of canned pineapple tidbits and red kidney beans were sitting directly on the floor. On 12/30/24 at 8:30 a.m., the DM stated the chemical concentration and temperature of the dish machine were tested daily, but they were not documented. They also stated all opened items should have the date they were opened documented and food items should not be stored on the floor. On 12/30/24 at 12:55 a.m., a case of cucumbers was observed sitting on top of the hand washing sink. A cardboard box was also observed sitting on top of the lid to the trash can. The box contained trash. On 12/30/24 at 1:15 p.m., the DM stated nothing should be placed on top of the trash can lid or the handwashing sink. On 12/31/24 at 10:04 a.m., the DM was asked to provide documentation of the meal holding temperatures. The DM stated they did not have documentation related to the holding temperatures of meals served in the facility.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#26) of 17 sampled residents whose care plans were reviewed. The DON reported the census was 24. Findings: Resident #26 had diagnoses which included parkinsonism and hypertension. A verbal order form, dated 09/11/24, documented resident #26 was admitted hospice on 09/11/24. Resident #26's care plan was reviewed and the care plan did not incorporate hospice services into the plan of care. On 12/31/24 at 10:11 a.m., the corporate nurse stated hospice services should have been included on the care plan.

Based on record review and interview, the facility failed to ensure residents were educated and offered the opportunity to create advance directive for two (#21 and #23) of 17 sampled residents reviewed for advance directives. A Detail Census Report, dated 12/30/24, documented 24 residents resided at the facility. Findings: 1. Resident #21 was admitted to the facility on [DATE]. A review of Resident #21's electronic health records found no advance directive. 2. Resident #23 was admitted to the facility on [DATE]. A review of Resident #23's electronic health records found no advance directive. On 12/30/24 at 12:00 p.m., Resident #23's representative stated they did not recall talking to the facility staff about advance directives. On 12/31/24 at 8:17 a.m., Resident #21 stated they were unaware of speaking to a staff member about advance directives. On 01/02/25 at 10:21 a.m., the MDS coordinator stated they had not been documenting they offered and educated residents regarding advance directives. They stated there was no documentation in Resident #21 or Resident #23's records of their desire to create an advance directive or if the resident or their POA had declined. They stated they were unaware of when or how often they were supposed to attempt to offer and educate residents about advance directives.

Based on record review and interview, the facility failed to ensure a gradual dose reduction was addressed by the physician and residents did not receive psychotropic medications on an as needed basis for more than 14 days for one (#16) of five sampled residents reviewed for unnecessary medications. The DON reported 21 residents received psychotropic medications. Findings: Resident #16 had diagnoses which included generalized anxiety disorder and major depressive disorder. A physician's order, dated 09/11/23, documented the resident was to receive alprazolam (an antianxiety medication) 0.5 mg as needed every 8 hours. The order did not have an end date. A GDR, dated 04/02/24, read in parts, This resident is currently on PRN alprazolam 0.5mg q8h with the following diagnosis: anxiety .Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration for the PRN order . The GDR was not signed by the physician and no rationale was provided. A review of Resident #16's medical record did not document a rationale from the physician as to why the medication was indicated for more than 14 days. On 01/02/25 at 9:55 a.m., the DON stated as needed psychotropics should only be prescribed for 14 days unless a rationale was provided by the physician. They also stated the GDR dated 04/02/24 had not been addressed by the physician.

Based on observation, record review, and interview, the facility failed to implement a comprehensive care plan intervention regarding falls for one (#21) of three sampled residents reviewed for accident hazards. A Detail Census Report, dated 12/30/24, documented 24 residents resided at the facility. Findings: A facility policy titles Fall Prevention Program, read in part, High Risk Protocol: a. The resident will be place on the facility's Fall Prevention Program. i. Indicate fall risk on the care plan. ii. Place Fall Prevention indicator (such as star, color coded sticker) on the name plate to the resident's room. A fall risk focus in Resident #21's care plan, dated 10/20/24, read in part, Follow facility fall protocol. A fall risk assessment, dated 11/16/24, documented Resident #21 was scored as a high risk for falls. On 12/31/24 at 1:11 p.m., Resident #21's room door was inspected for an indication they were on the fall protocol. No indicator on the resident's door or walker was observed. On 01/02/25 at 9:38 a.m., LPN #1 stated there was no indicator on the door or in the room of Resident #21 that indicated they were a high risk for falls. They stated they received annual training on the fall protocol, but was unaware of the need for markers on the doors. On 01/02/25 at 9:49 a.m., DON stated the facility had not been able to start the fall protocol yet, but were in the process. They stated they are going to use an apple sticker to indicate high fall risk. They stated they dropped the ball on not starting the program.

Based on record review and interview, the facility failed to ensure a significant change assessment was completed after a resident was admitted to hospice for one (#26) of one sampled resident reviewed for hospice. The DON reported the census was 24. Findings: Resident #24 had diagnoses which included parkinsonism and hypertension. A verbal order form, dated 09/11/24, documented Resident #24 was admitted to hospice on 09/11/24. The resident's medical record was reviewed and did not document a significant change assessment had been completed. On 12/31/24 at 10:11 a.m., the corporate nurse stated a significant change assessment should have been completed within 14 days of the resident being admitted to hospice.

Based on record review and interview, the facility failed to ensure accurate and complete documentation for one (#10) of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided at the facility. Findings: Resident #10 had diagnoses which included unspecified dementia. A physician order, dated 01/15/23, documented the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. A physician order, dated 08/15/23, documented the resident's Lorazepam order was changed to 0.5mg every six hours as needed for anxiety. Review of the August 2023 MAR revealed the resident had received an as needed dose of Lorazepam 0.5mg 18 times, including a one time order, from 08/10/23 through 08/30/23 The Controlled Drug Record, dated 08/10/23 through 08/30/23, documented Lorazepam 0.5mg tablet had been signed out 34 times. On 08/31/23 at 9:54 a.m., CMA #2 was asked what the facility protocol was for documentation of narcotic medications. They stated they signed the medication out on the controlled drug record and documented on the MAR in the electronic clinical record. On 08/31/23 at 9:56 a.m., the DON was asked how many doses of Lorazepam the resident had received in August 2023. They reviewed the electronic clinical record and stated 19 dosages had been administered. They were asked why 34 dosages had been signed out on the controlled drug record. They stated they did not know and would need to check. On 08/31/23 at 10:08 a.m., the DON stated after reviewing the electronic record and the controlled drug record they had determined CMA #2 signed the medication out on the controlled drug record but failed to document on the MAR. On 08/31/23 at 10:10 a.m., CMA #2 was asked why they had not documented the administration of the Lorazepam on the MAR. They stated they had forgotten to document on the MAR. On 08/31/23 at 10:19 a.m., the DON was asked how MARs and controlled drug records were monitored to ensure documentation was accurate and complete. The DON stated, I'm gonna have to start watching that.

Based on record review and interview, the facility failed to provide a clinical rationale for PRN antianxiety medication use past 14 days for one (#10) of five residents who were reviewed for unnecessary medications. The DON identified five residents who were ordered PRN psychotropic medications. Findings: 1. Resident #10 had diagnoses which included unspecified dementia. A physician order, dated 01/15/23, documented the resident was ordered Lorazepam (an antianxiety medication) 0.5mg every 12 hours as needed for anxiety. The Note to Attending Physician/Prescriber report from the Consultant Pharmacist, dated 02/04/23, read in part, .This resident is currently on PRN Lorazepam 0.5mg q12h with the following diagnoses: anxiety. Please .evaluate continued need . The pharmacy recommendation was not addressed by the physician. Review of the February 2023 MAR revealed the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. Review of the March 2023 MAR revealed the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. The Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking a Final Response report from the Consultant Pharmacist, dated 04/07/23, read in part, .This resident is currently on PRN Lorazepam 0.5mg q12h with the following diagnoses: anxiety. Please .evaluate continued need . The pharmacy recommendation was not addressed by the physician. Review of the April 2023 MAR revealed the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. Review of the May 2023 MAR revealed the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. Review of the June 2023 MAR revealed the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. The quarterly assessment, dated 07/31/23, documented the resident was moderately impaired in cognition for daily decision making, received an antianxiety medication for seven of seven days during the look back period, a gradual dose reduction had not been attempted, and the physician had not documented a gradual dose reduction was clinically contraindicated. Review of the July 2023 MAR revealed the resident was ordered Lorazepam 0.5mg every 12 hours as needed for anxiety. A physician order, dated 08/15/23, documented the resident's Lorazepam order was changed to 0.5mg every six hours as needed for anxiety. On 08/31/23 at 9:41 a.m., LPN #1 was asked why the resident's Lorazepam had been changed from every twelve hours as needed to every six hours as needed on 08/15/23. They stated they did not know. They were asked when the stop date was for the as needed Lorazepam. They reviewed the electronic clinical record and stated there was not a stop date documented. On 08/31/23 at 9:48 a.m., the DON was asked why the frequency of the as needed Lorazepam had been increased on 08/15/23. They stated the resident had experienced anxiety before it was time for the next dose. The DON was asked when the prn Lorazepam was scheduled to be discontinued. They stated there was not an end date but it should have been discontinued yesterday. They were asked what the facility's protocol was for as needed psychotropic medications. The DON stated they did not know. The DON was asked where clinical rationale for the continuation of the PRN Lorazepam had been documented since 01/14/23. They reviewed the electronic clinical record and stated there was not a documented clinical rationale.

Based on record review and interview, the facility failed to develop a comprehensive care plan for three (#5, 10, and #16) of 14 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Care Plans, Comprehensive Person Centered policy, dated December 2016, read in part, .The comprehensive person-centered care plan is developed within seven .days of the completion of the required comprehensive assessment . 1. Resident #10 had diagnoses which included unspecified dementia. An admission assessment, dated 01/28/23, documented the resident was severely impaired in cognition for daily decision making. The Care Plan documented it was initiated on 08/29/23. The electronic clinical record did not contain any other comprehensive care plans for Resident #10. 2. Resident #16 had diagnoses which included major depressive disorder. An admission assessment, dated 01/05/23, documented the resident was severely impaired in cognition for daily decision making. The Care Plan documented it was initiated on 08/18/23. The electronic clinical record did not contain any other comprehensive care plans for Resident #16. 3. Resident #5 had diagnoses which included schizophrenia and chronic obstructive pulmonary disease. An admission record documented resident #5 had been admitted to the facility on [DATE]. A review of the resident's medical records found the comprehensive care plan had been initiated on 08/28/23. On 08/30/23 at 11:03 a.m., the DON was asked why resident #5's comprehensive care plan had been initiated on 08/28/23 when they had been admitted on [DATE]. They stated when they had started as DON they had discovered the resident did not have a comprehensive care plan and they created one. On 08/30/23 at 11:51 a.m., the DON was asked why comprehensive care plans had not been developed until August 2023 for Resident #10 and Resident #16. They stated they did not know. They stated they had conducted an audit approximately three weeks ago upon employment and found four or five residents who had not had a comprehensive care plan developed.

Based on record review, and interview the facility failed to provide an Advance Beneficiary Notice of Non-coverage to one (#14) of three residents reviewed for beneficiary notifications. The Entrance Conference Worksheet Beneficiary Notice - Resident discharged Within the Last Six Months form, documented three residents, who had discharged in the previous six months prior to the survey, had remained in the facility after a discharge from a Medicare Part A stay. Findings: Resident #14 had diagnosis which included bipolar disorder and anxiety disorder. A progress note written by the SSD, dated 07/26/23, documented the resident was transferred to an acute care hospital on that date. A progress note written by LPN #3, dated 08/03/23, documented resident #14 was readmitted to the facility on that date. On 08/31/21 the Administrator returned a completed SNF Beneficiary Notification Review form which documented resident #14 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form related to the transfer to an acute care hospital on 07/26/23. At 9:27 a.m., the Administrator was asked why the resident had not received the SNF ABN. They stated it was because of their misunderstanding of the regulations.

Based on record review and interview the facility failed to ensure an incident of physical assault on a resident was reported to the facility administration and state agency for one (#24) of 16 residents assessed for abuse. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided at the facility. Findings: Resident #24 had diagnosis which included cognitive communication disorder and pneumonia. An abuse investigation and reporting policy, revised date July 2017, read in part, . All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . A nursing note, dated 05/31/23 at 7:08 p.m., documented a resident's family member had attempted to force the resident from their bed. The note read in part, .[they] yanked the blankets off, pulled [their] heel protectors off, pulled on [their] upper body after shaking [them] rigorously yelling wake up . The noted further documented LPN #4 was able to get the family member to put the resident back down and educated them on the resident's condition. There was no documentation the facility administrator or any government agency was notified of the assault. 08/31/23 12:08 p.m., the administrator was asked if the assault described in LPN #4's nursing note, dated 05/31/23, was reported to them. They reported having no knowledge of the incident but would look into it and report back. At 12:38 p.m., the administrator stated today was the first he heard about the assault so had not investigated or reported it. They were asked if LPN #4 was still employed at the facilty. They stated they were no longer an employee. At 12:53 p.m., the administrator attempted to contact the weekend registered nurse, RN#1, to see if the assault incident was reported to them. At 1:02 p.m., RN #1 was interviewed via telephone. RN #1 was asked what they knew about an assault on a resident in May 2023. RN #1 said no one had informed them of such an incident. RN #1 was given the name of the resident, date of the incident, the name of the nurse involved, and that the accused was a family member. They stated no one told them or they would have immediately reported it to state.

Based on record review and interview it was determined the facility failed to notify a resident representative of changes in condition and treatment for one (#15) of two residents reviewed for notification of change. The Residents Census and Condition of Residents report, dated 08/29/23, documented 23 residents resided at the facility. Findings: A Change in Resident's Condition or Status policy, revised date 2017, read in part .Our facility will promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) . A medication order, dated 07/30/23, documented resident #15 was to be administered Tylenol #3 [acetaminophen with codeine] 300-30 mg every six hours as needed for pain. A progress noted, dated 07/30/23, documented a new order for Tylenol #3 had triggered a drug interaction alert. The alert stated the medication Tylenol #3 could interact with the resident's prescribed medication Mirtazapine [an oral antidepressant medication]. On 08/30/23 at 8:02 a.m., resident #15's family member reported that a medication change had occurred in July 2023 and no one notified them of the change. They stated the medication caused resident #15 to hallucinate more than usual. On 08/31/23 at 2:00 p.m., the LPN #1 was asked to explain the process of receiving a medication order. They included in their explanation that the resident and their representative would be contacted. They were asked if that was always done. They stated it was not but it was suppose to happen. At 2:23 p.m., the DON was asked to describe the process when new medication orders were received. They included in their explanation that the resident and their representative would be notified about the medication order. They were asked if that was the required process at the facility. They stated it was. They were asked if their expectation was the process would be followed each time. They stated yes. They were asked to check resident #15's Tylenol #3 order of 07/30/23 and see if the resident's family had been contacted. At 2:38 p.m., the DON was asked if resident #15's family had been contacted in regards to the Tylenol #3 order dated 07/30/23. They stated that looking at the resident's medical records there was not documentation of the family having been contacted.

Based on record review and interview the facility failed to provide a written notice of transfer to one (#24) of one resident reviewed for hospitalization s. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided at the facility. Findings: Resident #24 had diagnosis which included cognitive communication disorder and pneumonia. A nursing noted, dated 05/31/23 at 9:08 p.m., documented the resident was transferred to an acute care hospital related to low blood pressure. On 08/31/23 at 12:08 p.m., the administrator was asked if resident #24 was given a written notice of transfer and the bed hold policy prior to being sent to a hospital on 05/31/23 as indicated by a nurse note of the same date. They stated they would need to check in the resident's records. At 12:38 p.m., the administrator was asked about the written notice of transfers prior to hospitalization for resident #24. They stated they were aware of the regulation but had not found a copy or documentation that the letter was given in the residents records.

Based on observation, record review, and interview the facility failed to ensure a PASRR level one assessment form had been completed for one (#1) of one residents reviewed for preadmission screening. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: Resident #1 had diagnoses which included paranoid schizophrenia and major depressive disorder with severe psychotic symptoms. An admission record, print date 08/29/23, documented the resident was admitted to the facility on [DATE]. On 08/29/23, resident #1's medical records were reviewed for the presence of a Preadmission Screening and Resident Review (PASRR) form. None was located in the electronic medical record or paper chart. At 12:10 p.m., resident #1 was observed in their room and an attempt to question them was made. The resident was not interviewable. On 08/30/23 an Oklahoma Healthcare Authority Nursing Facility Level of Care Assessment form, dated 08/30/23, was observed in the resident's electronic medical record. The form documented the resident had been admitted in the year 2020 and the PASRR for the resident had not been found. It further documented a representative of the Oklahoma Healthcare Authority had been notified of the situation. On 08/31/23 at 7:35 a.m., the DON was asked if resident #1 had a PASRR level one or two. They stated a thorough search of the resident's medical records did not result in either of those documents being found. They stated they had contacted they had contacted the Oklahoma Healthcare Authority on 08/30/23 about the missing document. The DON was asked if the resident had entered the facility with a severe psychiatric diagnosis. They stated they did enter with the diagnoses of paranoid schizophrenia and major depression with psychosis. They were asked if the PASRR should have been completed as part of the admission process. They stated, yes.

Based on record review and interview the facility failed to conduct care plan meetings for one (#15) of six residents reviewed for care plans. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered policy, revised date December 2016, read in part . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . Resident #15 had diagnoses which included vascular dementia. On 08/30/23 at 8:02 a.m., a resident representative reported they had not been invited to or attended an interdisciplinary treatment team meeting since resident #15 had resided at the facility. On 08/31/23 at 1:25 p.m., the DON was asked to describe the process for developing a comprehensive care plan. They stated a baseline care plan was created upon admit and a comprehensive within seven days. They stated the care plan would be reviewed quarterly and revised as necessary. They were asked who participated in the comprehensive care plan meeting. They stated the DON, SSD, the resident, the residents representative, nurses, and nurse aides. They were asked if the medical director attended the meetings. They stated, no as they come in a review the care plan during their visits. They were asked if he resident and/or representative participate in the meeting. They stated the resident and family would give information on particular wants of the resident. They stated there were no formal meetings but they take advantage of when representatives come by to visit and go over the care plan then. They were asked if formal meeting which included the IDT in attendance with the resident and/or representative had taken place. They stated yes and presented a binder which included documentation of care plan meetings from 2022. They were asked if any care plan meeting had occurred with the legal representative of resident #15 and if so was it documented. The SSD answered and stated they recalled having meetings with the representative but there was no documentation those meeting occurred. The SSD also reported a former DON had shredded the 2023 care plan documents. At 1:42 p.m., the Administrator was asked to describe their expectations as to how care plan meeting would occur. They stated the SSD had been instructed previously they could no longer conduct informal care plan meetings and formal meetings were required with the interdisciplinary treatment team in attendance. They were asked if they were aware of a former DON having destroyed all the 2023 care plan meeting documentation. They stated they were unaware of that.

Based on record review and interview, the facility failed to ensure code status was accurate for one (#8) of 16 sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents form, dated 08/29/23, documented 23 residents resided in the facility. Findings: The Advance Directives policy, dated December 2016, read in part, .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . Resident #8 had diagnoses which included unspecified dementia. The Admission Record form documented the resident had a DNR. A physician order, dated 08/05/22, documented the resident was a full code. Review of the electronic clinical record revealed an undated, signed DNR had been uploaded on 08/09/22. On 08/30/23 at 10:11 a.m., LPN #1 was asked what the code status was for Resident #8. They reviewed the electronic clinical record and stated the resident was a full code. They were asked what the signed DNR was dated. They reviewed the DNR and stated the form was not dated. On 08/30/23 at 10:16 a.m., the DON was asked how staff were made aware of a resident's code status. They stated it was in the electronic clinical record and if they had a signed DNR it would be uploaded. The DON was asked what the code status was for Resident #8. They reviewed the electronic clinical record and stated the resident was a full code. They were asked what the signed DNR was dated. They stated the DNR was not dated and only half of the document was available. The DON was asked why the electronic clinical record had conflicting information regarding the code status for Resident #8. They stated they did not know.

On 05/24/17 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to perform initial and ongoing thorough skin and wound assessments; consistently administer pressure ulcer treatments to prevent the worsening of pressure ulcers; notify the physician of new wounds or worsening of existing wounds; and obtain wound consultations. Resident #3 was admitted to the facility with a large fluid filled blister to his right buttock. The resident developed an unstageable necrotic wound to his right buttock that measured 15 x 10 cm with surrounding [MEDICAL CONDITION]. The resident was transfered to the hospital per the family's request. The resident had [MEDICAL CONDITION], was admitted to ICU and required surgical debridement of the wound. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:05 p.m., the administrator was informed of the IJ regarding pressure ulcers and that a plan of removal were required. She was informed this placed the facility in an extended survey. At 7:14 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Plan of Removal, May 24, 2017 All residents will receive complete skin assessments by 5/25/17 to include description and measurements of current skin issue, and description of current wound status. Skin assessments will be done on all residents in the facility. (name deleted), RN, will review all assessments and sign off on them. Any resident found to have skin fissures will be reported to their physician regarding the assessed skin condition, applicable orders will be obtained and implemented. Residents with wounds will be reassessed, and physician notified of identification of the wound. (size, depth, and stage, etc.) All Nursing staff will be educated on pressure ulcers, skin assessments, treatments, physician notification, and documentation. All nursing staff will be inservied(sic) by 4:00 pm 5/25/2017. The IJ was removed effective 05/25/17 at 7:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ perform initial and ongoing thorough skin and wound assessments; ~ notify the physician of new wounds or the worsening of existing wounds; ~ obtain wound consultations; ~ obtain physician orders for wound treatments in a timely manner; ~ consistently provide wound care and treatments; and/or ~ develop and/or update the care plans to address pressure ulcers, changes in pressure ulcers or pressure ulcer care for three (#3, #4 and #5) of three sampled residents who had pressure ulcers. The facility identified two residents with pressure ulcers who currently resided in the facility. Resident #3 was admitted to the facility with a large fluid filled blister to his right buttock. The resident developed an unstageable necrotic wound to his right buttock that measured 15 x 10 cm with surrounding [MEDICAL CONDITION]. The resident was transfered to the hospital per the family's request. The resident had [MEDICAL CONDITION], was admitted to ICU and required surgical debridement of the wound. Findings: An undated facility policy, titled Resident Assessment Protocol: Pressure Ulcers, documented, .Assessment goals are: (1) to ensure that a treatment plan is in place for residents with pressure ulcers; and (2) to identify residents at risk for developing a pressure ulcer who are not currently receiving some type of preventive care program .Interventions/Programs to Consider if the Resident Develops a New Pressure Ulcer, or an Ulcer Being Treated is Not Resolved .review the resident's medical condition, medications, and other risk factors to determine whether or not the care plan (for prevention or cure) addresses all potential causes or complications. Review the care plan to determine whether or not it is actually being followed (e.g., is the resident being turned often enough to prevent ulcer formation) . A facility policy, revised January 2002, titled Wound Care, documented, .Documentation .The following information should be recorded in the resident's medical record .the type of wound care given .the date and time the wound care was given .the position in which the resident was placed .the name and title of the individual performing the wound care .any change in the resident's condition .all assessment date (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .how the resident tolerated the procedure .any problems or complaints made by the resident related to the procedure .if the resident refused the treatment and the reason(s) why .the signature and title of the person recording the date .notify the supervisor if the resident refuses the wound care . 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary dated 03/30/17, documented, .Discharge Incision/Wound Care: Clean with soap and water, pat dry, apply [MEDICATION NAME] lotion as needed . An admission nursing summary, dated 03/30/17, documented, .Skin Condition .Lg fluid filled blister to R buttocks dk red in color to surrounding area - wife here and aware of area .Special Treatments & Procedures: tx to cleanse area with soap and water, pat dry apply [MEDICATION NAME] lotion prn . There were no measurements of the size of the blister or of the area of dark redness to the surrounding tissues. admission orders [REDACTED]. There was no documentation to indicate the resident's physician had been notified the resident had been admitted to the facility with a fluid-filled blister to his right buttock, or if treatment orders had been received. A nursing summary form, dated 03/30/17, was blank in the area to document skin conditions, ulcers, other skin problems, and skin treatments. Narrative Nursing Notes at 6 p.m. documented, Upon sk (skin) assessment res has a lg fluid filled blister to R buttocks area around is red and dk (dark) red in color .sk dry lotion prn . There was no documentation the wound had been treated. A Braden scale assessmenrt, dated 03/30/17, documented the resident had a score of 16 and was at risk for the development of pressure sores. A nursing summary form, dated 03/31/17 contained no documentation of the fluid-filled blister to the resident's right buttock, or if the wound had been assessed or treated. Monthly physician's orders, dated April 2017, contained no orders regarding the treatment of [REDACTED]. Nursing summary forms, dated 04/01/17 through 04/05/17, contained no documentation of the fluid-filled blister to the resident's right buttock, or if the wound had been assessed or treated. A treatment flowsheet for 03/30/17 through 04/29/17, documented, Head to toe Assessment (Skin) weekly on Wednesdays. 3/31/17 . The form indicated this assessment was to be done on 04/05/17. The area on the form to sign if completed was blank. A five day assessment, dated 04/06/17, documented the resident had long and short term memory problems and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance of two plus persons for bed mobility, transfers, dressing, and toileting, and required extensive assistance of one person for locomotion on and off the unit, personal hygiene, and bathing, had [DIAGNOSES REDACTED]. The assessment documented the resident was at risk of developing pressure ulcers, had no current pressure ulcers or other skin conditions, and had a pressure reducing device for his chair and bed. Nursing summary forms, dated 04/06/17 through 04/11/17, contained no documentation of the fluid-filled blister to the resident's right buttock. There was no documentation the wound had been assessed or treated. A Braden scale assessment, date 04/12/17, documented the resident had a score of 11 and was at risk for the development of pressure sores. A weekly skin assessment, dated 04/12/17, documented the resident had a Stage II pressure ulcer to his right buttock that measured 9.5 cm x 8.5 cm with an open area that was 4 cm x 5.5 cm. The assessment documented there was no exudate and no odor. The wound bed was beefy red. The surrounding skin color was black/brown. There was no documentation the resident's physician had been notified of the change in the condition of the wound to the resident's right buttock. An admission assessment, dated 04/12/17, documented the resident had long and short term memory problems and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance of two plus persons for transfers, dressing, toileting, and personal hygiene, and required extensive assistance of one person for bed mobility, locomotion on and off the unit, and bathing. The assessment documented the resident had one unstageable pressure ulcer that measured 9.5cm x 8.5cm x 0.0cm with eschar, had a pressure reducing device for his bed, and had been receiving pressure ulcer care. A nursing summary form, dated 04/13/17, documented, .Skin Conditions .# of unstageable: 1 R buttocks .Other Skin Problems .Moisture associated skin damage .Skin Treatments .pressure relieving device for chair and bed .turning/repositioning .ulcer care .7p-7a .Upon assessment, large unopened area of black necrotic tissue noted to residents R buttocks. Also several open areas noted along crackline of buttocks. All areas cleansed with NS, patted dry, and cream (Lantaseptic) applied. Resident turned off of buttocks to prevent further skin damage .DON, administration, and Dr (name deleted) notified of areas . A physical examination sheet, dated 04/13/17, documented, .Diagnosis: [REDACTED]. A telephone order, dated 04/13/17, documented, .Refer to (name deleted) wound care of 5 cm x 6 cm Stage II Rt buttock decubitus .obtain fasting CBC, CMP, TcH, Pre-[MEDICATION NAME] Level, CRP .clean wound buttock BID with [MEDICATION NAME] .offload Rt buttock Q 1 h for 15 minutes . There was no documentation of an appointment being made for the resident to be seen at the wound clinic. An undated interim plan of care, documented, .turn q 1 hr and position .off load L buttocks every hour w/pressure on L buttocks [MEDICATION NAME] no more than 15 minutes .preventive care .lotion after bath .wound care .pressure ulcer .Stage II decubitus cleanse with Hibicleanse (sic) BID . There was no comprehensive care plan for the resident. The treatment record for April 2017 documented, Clean wound R buttock area Bid c [MEDICATION NAME] 4/13/17 Off load R buttocks Q 1 (hour) for 15 mins 4/13/17 . This was inititated on 04/13/17. No other wound care was documented on the treatment records prior to 04/13/17. A nursing summary form, dated 04/14/17, documented, .Skin Conditions .# of unstageable: 1 R buttocks .Other Skin Problems .Moisture associated skin damage .Skin Treatments .pressure relieving device for chair and bed .turning/repositioning .ulcer care .7p-7a .large area of black necrotic tissue continues to R buttocks. Cleansed with [MEDICATION NAME] as ordered, lightly patted dry. [MEDICATION NAME] applied to buttocks and resident kept turned off of area to prevent further skin damage . The treatment administration record, dated 04/14/17, documented, .Clean wound R buttock area BID with [MEDICATION NAME] .offload R buttocks Q 1 hr for 15 mins . There was no documentation the wound had been cleansed on 04/14/17. There was no documentation the R and L buttock had been offloaded every hour for 15 minutes. Thirteen hours were undocumented. A nursing summary form, dated 04/15/17, documented, .Skin Conditions .# of unstageable: 1 R buttocks .Other Skin Problems .Moisture associated skin damage .Skin Treatments .pressure relieving device for chair and bed .turning/repositioning .ulcer care .7p-7a .large area of black necrotic tissue (decubitus) remains to R buttocks. Cleansed with [MEDICATION NAME] as ordered. Resident conts to be turned q 2 hrs and PRN for pressure relief off of buttocks. Barrier cream conts to prevent further skin breakdown . The treatment administration record, dated 04/15/17, documented, .Clean wound R buttock area BID with [MEDICATION NAME] .offload R buttocks Q 1 hr for 15 mins .offload L buttocks Q 1 hr for 15 mins . There was no documentation the R and L buttock had been offloaded every hour for 15 minutes. Eleven hours were undocumented. The treatment administration record, dated 04/16/17, documented, .Clean wound R buttock area BID with [MEDICATION NAME] .offload R buttocks Q 1 hr for 15 mins .offload L buttocks Q 1 hr for 15 mins . There was no documentation the R and L buttock had been offloaded every hour for 15 minutes. Twelve hours were undocumented. A nursing summary form, dated 04/17/17, documented, .Skin Conditions (blank) .Other Skin Problems .(blank) .Skin Treatments .turning/repositioning .7P-7A .Decubitus to buttocks cleaned et redressed, resident has lge (large) area with eschar et draining serous liquid. Around area buttocks is red, pt turned q 2 hrs .11A .Tx done to L buttock prior to getting up. Area is black et hard like a scab .Res resting in bed T 101.3 .Dr. (name deleted) notified of elevated temp et dark urine .buttock (L) off loaded 15 min q hrs . The nurse documented a treatment had been administered to the L buttock. There was no documentation the resident had a wound to the L buttock. There was no documentation the physician had been notified of the pressure ulcer draining serous liquid, or the area around the buttocks being red in color. A referral form, dated 04/17/17, documented the resident was being referred to the wound care specialists at (name deleted) hospital for a wound to his right buttock, by the resident's physician. A facility status change sheet, dated 04/18/17, documented the wound clinic had responded that the physician at the wound clinic could not see the resident until the next week and had asked if the facility could obtain a culture of his wound. An order was received from the resident's primary care physician, which documented, yes. This order was signed by the physician on 04/19/17. A nursing summary form, dated 04/18/17, documented, .Skin Conditions .# of Stage II pressure ulcers: 1 .Skin Treatments .pressure relieving device for chair and bed .turning/repositioning .7P-7A .Tx to coccyx .Res repos.(sic) q 2 hrs et positioned off of L buttock for 15 min q hr . The nurse documented a treatment had been administered to the coccyx. There was no documentation the resident had a wound to his coccyx. The treatment administration record, dated 04/18/17, documented, .Clean wound R buttock area BID with [MEDICATION NAME] .offload R buttocks Q 1 hr for 15 mins .offload L buttocks Q 1 hr for 15 mins . There was no documentation the R and L buttock had been offloaded every hour for 15 minutes. Eight hours were undocumented. A recommendation by the dietitian, dated 04/18/17, documented, .New Admit Review: at risk for skin break down, metabolic issues .DX of .decub Stge (sic) II on buttock .Intervention: add multivitamin with mineral - 1 Q day; [MEDICATION NAME] 1 pkg in 6 oz water BID; double eggs am; double meat at lunch and dinner . The recommendation was not signed or dated by the physician. The April 2017 treatment administration record documented, Head to toe assessment (skin) weekly on Wednesdays. The record documented this assessment was to be performed on 04/19/17. The assessment date was not initialed as being completed. The April treatment administration record also documented, .Clean wound R buttock area BID with [MEDICATION NAME] .offload R buttocks Q 1 hr for 15 mins .offload L buttocks Q 1 hr for 15 mins . There was no documentation the weekly skin assessment had been completed for 04/19/17. There was no documentation the wound had been cleansed on 04/19/17, or the R and L buttock had been offloaded every hour for 15 minutes. A nursing summary form, dated 04/19/17, documented, .Skin Conditions (blank) .Skin Treatments .pressure relieving device for chair and bed .turning/repositioning .7P-7A .cont with TX coccyx L buttocks res to be off load Q 1 hr .7A-7P .Drsg to R buttocks (changed) per order. Area dk black in wound bed (with) foul odor. Wife here, res has become very lethargic, had elevated temp last couple of days. Wife requests res be sent to ER for eval. Ambulance called. Out of facility 5 pm . A hospital history and physical report, dated 04/19/17, documented, .nursing home resident sent over due to decreased level of consciousness, evaluated in the Emergency Department and found to have UTI .he did have bibasilar infiltrates on his chest x-ray. Also evaluated was a large sacral decubitus wound, thought to be possible infected. Infection was felt to be the source of his altered mental status. He did meet the criteria for [MEDICAL CONDITION], was admitted ot the ICU . Integument: The patient has a large sacral decubitus wound just to the right of midline involving the upper buttocks. The area is not actively draining. It does smell foul and has a necrotic black appearance to the center without eschar . Assessment and Plan: .Altered mental status/acute [MEDICAL CONDITION]ly due to infection .[MEDICAL CONDITION] secondary to urinary tract infection, sacral decubitus wound and possible healthcare-associated pneumonia .Unstageable sacral decubitus wound .Protein calorie malnutrtion . A physician consultation documented, .The patient has a very large 15 cm x 10 cm round necrotic wound consistent with a decubitus ulcer overlying the sacrum. This is unstageable due to the eschar. He has surrounding [MEDICAL CONDITION] and the skin is warm to touch. I believe this is the source of [MEDICAL CONDITION] based on examination . An operative and procedure information report, dated 04/24/17, documented, .Date of Procedure: 04/21/ . Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Description of procedure: .It was immediately apparent that this wound was quite deep, nothing that I initially incised bled. I continued going deeper and deeper with my incision until we reached the sacrum. This patient had a complete loss of all tissue from the skin to the sacrum. Nothing bled at the central portion of this wound. It was very malodorous and there was purulence within the tissues. The fat underneath the skin was all completely necrotic. Once the main plug of necrotic tissue was removed, I then continued sharp debridement around the edges of the wound just extending out until I reached tissue that actually had a blood supply. This continued out further than originally anticipated. I was able to press superior to the wound and expressed some pus down into the wound itself, so I continued superiorly. The final measurements of the debrided area were 18 x 10 x 4.5 cm deep . A Discharge Summary, dated 04/25/17, documented, .Noted to have altered mental status .He met criteria for [MEDICAL CONDITION] and was admitted to the hospital for the same. Hospital Course: The patient had [MEDICAL CONDITION] due to the possibility of a number of sources .Urine culture was negative; however, subsequent cultures of his decubitus wound did [MEDICAL CONDITION], Proteus mirabilis, and [MEDICATION NAME] faecalis. It is believed that this was the source of infection . On 05/23/17 at 10:15 a.m., the DON was asked why the resident had not been seen by the wound specialist. He stated, We got an order for [REDACTED]. The DON provided a referral form from the wound clinic at the hospital (name deleted), dated 04/17/17. He was asked why it had taken from 04/13/17 until 04/17/17 to get the referral form filled out and faxed to the clinic. He stated, I don't know. The business office manager did that and she no longer works here. The DON provided a status change sheet, dated 04/18/17, requesting an order to get a wound culture of the resident's wound since he would not be able to see the wound specialist for another week. There was no documentation a wound culture had been obtained. He was asked why there was no care plan regarding the wound to the resident's right buttock. He stated, We were using the interim care plan. We had not developed a comprehensive care plan yet. On 05/24/17 at 9:39 a.m., The administrator was asked if the physician had examined the resident's pressure ulcer. She stated, The physician (name deleted) saw the resident on the 13th of April. I asked him if he had looked at the resident's bottom. He stated he hadn't, so I went with him to the resident's room and looked at his bottom. He (the physician) thought it looked like a dark birthmark at first. I had a CNA come in to turn the resident over and pull down his brief to get a better look. He measured the wound and documented on his progress note regarding the stage II 6 x 5 cm decubitus to the resident's right buttock. At 11:25 a.m., CNA #1 was asked if the resident had any special requirements for his care. CNA #1 stated he was to be turned every couple of hours and was to have oxygen on at all times. He was asked if the resident had any wounds. He stated he had noticed a small sore on the residents buttocks about a week before the resident went to the hospital. At 1:53 p.m., LPN #2 was asked if she had worked any shifts between the dates of 03/30/17 through 04/12/17. She stated, Yes. She was asked if she had taken care of the resident during that time. She stated, Yes. She was asked if she had done any treatments on the resident's right buttocks during that time period. She stated, Yes, we put a dressing on it daily. I think from the time he was admitted . I was putting Lantaseptic on after I had washed the area with soap and water. She was asked where those treatments had been documented. She stated, Maybe in the nurse's notes. She was informed there was no documentation of the treatments being completed during that time period. She was asked why there was no documentation of the treatments being completed. She did not comment. She was asked if she assessed the resident's wound. She stated, I would assess the wound every day I was here. If there were changes I would have put them in the nurse's notes. If the were no changes, I would not have documented anything. She was informed there was no documentation of the wound being assessed during the time period of 03/30/17 through 04/12/17. LPN #2 was asked how someone would know the condition of the wound during that time period since there was no documentation of the wound being assessed. She stated, I'm not sure how to answer. Maybe I just didn't write down what I saw. At 3:25 p.m., the administrator was asked when the skin assessments were completed. She stated they should be done weekly on all skin. On 05/25/17 at 1:10 p.m., LPN #1 was asked what the process was for completing skin assessments. She stated, I complete a head to toe assessment, usually on Wednesdays, on everyone in the facility. She was asked where she documented the weekly skin assessments. She stated she documented in the nurse's notes, the skin/wound healing record, and the skin condition sheets. She was asked what she did if she noticed skin changes on a resident. She stated, I would document in a nurse's note that I had notified the doctor, and I would also document on the assessment sheet. She was asked if she had completed a skin assessment for the resident on 04/04/17. She stated, I would have to look for it. No documentation of the assessment was provided. She was asked why the treatment administration sheet had not been initialed for the dates of 04/05/17, 04/12/17, and 04/19/17, regarding the order for a head to toe assessment weekly on Wednesdays. She stated, I may not have initialed it. She was asked why the resident had not been seen by the wound specialist. She stated, He had an appointment with the wound doctor and they canceled the appointment. She was asked if she notified the resident's primary physician to let him know the appointment had been canceled. She stated, I don't think I called. The DON may have called. The administrator was asked if the resident's pressure ulcer had been documented on the care plan. She stated it should have been documented/updated as needed regarding the wound, treatment and interventions. She stated there had been a change in staffing regarding assessments/care plans and all had not been completed or updated. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 02/17/17, contained no documentation of the resident having any skin conditions. The skin condition portion of the assessment was blank. An admission assessment, dated 03/12/17, documented the resident had a BIMS score of zero. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required total assistance of two plus persons for transfers, locomotion on and off the unit, toileting, and personal hygiene. The assessment also documented the resident had [DIAGNOSES REDACTED]. A care plan, dated 03/29/17, documented, Problem: .pressure ulcer .resident is at risk for pressure ulcer due to bedfast/mobility .Goal: .intact skin without evidence of redness, irritation, maceration, or open areas . Approach: .elevate heels off bed or use heel protectors .position prone if appropriate or elevate HOB no more than 30 degrees .position with pillows to elevate pressure points off the bed .skin assessment and inspection every wed with close attention to heels .teach or do frequent small shifts of body weight .turn and reposition every 2 hours and PRN .nursing staff applying sure prep daily to right heel .use moisture barrier ointments . Monthly physician orders, dated April 2017, contained no treatment orders regarding the resident's right heel. A nursing summary form, dated 04/18/17, documented, .one stage I pressure ulcer .Res has dark purple-red area on rt heel. Soft to touch. Dr. (name deleted) via text and awaiting responce (sic). Sure prep applied to area at this time. Res denies pain to area . There was no documentation of a response from the physician, or of a treatment order being received. A skin condition record, dated 04/18/17, documented, .no sk problems .bruising to ext . A nurse's note, dated 04/18/17, documented, Assessment complete res has no open areas red to coccyx. Area to R heel, red/black measures 3.5 x 2 .bruising to ext . Nursing summary forms, dated 04/19/17 and 04/20/17, documented, .one stage I pressure ulcer . There was no documentation the wound to the resident's right heel had been assessed or a treatment had been performed. A nursing summary form, dated 04/22/17, documented, Skin w/d intact. Heel protector to rt. heel at all times due to redness and possible breakdown . There was no documentation the resident had received any treatments to her right heel. A nursing summary form, dated 04/24/17, documented, .one stage I pressure ulcer . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, drainage, or if a treatment had been performed. A nursing summary form, dated 04/25/17, documented, .one stage I pressure ulcer .Heel protector to right heel, sure prep applied to rt heel . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, or drainage. A nursing summary form, dated 04/26/17, documented, .one stage I pressure ulcer . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, drainage, or if a treatment had been performed. A skin condition record, dated 04/26/17, documented, .area to R heel 3.5 x 2 . There was no documentation the wound had been assessed regarding color, odor, or drainage. There was no documentation the physician had been notified of the change in the condition of the resident's skin. No physician orders were received regarding wound treatments. A nurse's note, dated 04/26/17, documented, .assessment complete res has no open areas .area to R heel 3.5 x 2 .no change in condition . A 60 day assessment, dated 04/26/17, documented the resident had a BIMS score of zero. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required total assistance of two plus persons for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment also documented the resident had [DIAGNOSES REDACTED]. The care plan was not updated to include the resident had a wound to the right heel as a focused area with a goal and interventions. A nursing summary form, dated 04/27/17, documented, .one stage I pressure ulcer .Heel protector to right heel, sk prep applied and area cont. to heal . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, or drainage. Nursing summary forms, dated 04/28/17 and 04/30/17, documented, .one stage I pressure ulcer . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, drainage, or if a treatment had been performed. Monthly physician orders, dated May 2017, contained no orders regarding the pressure ulcer to the resident's right heel. A treatment flowsheet, dated May 2017, contained no documentation of treatments for the pressure ulcer to the resident's right heel. Nursing summary forms, dated 05/01/17 and 05/02/17, documented, .one stage I pressure ulcer .9A (a.m.) .sure prep applied to right heel .heel protector in place .7P-7A .sure prep conts to R heel. Heel protectors intact . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, or drainage. A nursing summary form, dated 05/03/17, documented, .one stage I pressure ulcer . There was no documentation the wound to the resident's right heel had been assessed regarding size, color, odor, drainage, or if a treatment had been performed. A skin condition record, dated 05/03/17, documented, .area to R heel 3.5 x 2 .no change . There was no documentation the wound had been assessed regarding color, odor, or drainage. There was no documentation the physician had been notified of the change in the condition of the resident's skin. No physician orders were received regarding wound treatments. A nurse's note, dated 05/03/17, documented, .assessment complete

Based on interview and record review, it was determined the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent a pressure ulcer for one (#4) of one sampled resident with a pressure ulcer. Resident #4 developed a pressure sore in the palm of her hand that became infected. The director of nursing stated there were no residents who resided in the facility who had a pressure ulcer at the time of the survey. Findings: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility care plan, dated [DATE] and last updated [DATE], documented, "...I have developed a contracture of my L (left) hand. Keeping it closed causes it to be moist, and have an odor...I will have no further deterioration of my L hand X (times) 90 days. I will not have any skin breakdown of my L hand X 90 days. I will have my hand roll in my hand during the days. Staff will que (sic) me to leave the hand roll in place. Staff will clean my hand frequently & (and) examine for skin breakdown..." A facility care plan, dated [DATE], documented, "...No improvement.... The care plan documented the resident would not leave the hand roll in place and that the resident refused attempts to clean the left hand and trim the nails. No further updates were found in resident #4's clinical record regarding the resident's left hand contracture. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 11 times out of 30 opportunities. The resident refused ROM 6 times. A physician progress notes [REDACTED]. hand severe flexion contracture 2 (secondary to) [MEDICAL CONDITION] joint disease...P (plan) small hand roll to prevent palm pressure sore..." There were no physician's orders, facility treatment sheets, or nurses notes found in the resident's clinical record documenting the placement of a small hand roll to resident #4's left hand. A physician progress notes [REDACTED]. An annual assessment, dated [DATE], documented resident #4 was severely cognitively impaired and needed total to extensive assist with all activities of daily living (ADLs). The assessment also documented the resident had one-sided upper and lower extremity impairment. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 9 times out of 30 opportunities. The resident refused ROM 8 times. A nurse's note, dated [DATE], documented, "...3 AM. C/O (complained of) nails cutting hand on L (left) ([MEDICAL CONDITION]) ([MEDICAL CONDITION]) Nails reduced - on both hands. Nails long and cutting skin @ (at) site of contracture..." A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 12 times out of 31 opportunities. The resident refused ROM 7 times. A nurse's note, dated [DATE], documented, "...1330 (1:30 p.m.)...client has some contracture to L hand..." A facility document, dated February 2012, titled "Nursing Restorative Care Program," documented the resident received ROM to his/her upper extremities, 12 times out of 28 opportunities. The resident refused ROM 5 times. A nurse's note, dated [DATE], documented, "...To see (physician's name deleted) re: (regarding) (L) hand..." A physician's telephone order, dated [DATE], documented, "...Soak L hand in [MEDICATION NAME] & water q day..." A nurse's note, dated [DATE], documented, "...10 AM Appt. (appointment) made for 330 pm c (with) (physician's name deleted) re: (regarding) left hand contracture it is starting to have drng. (drainage)..." A nurse's note, dated [DATE], documented, "...430 pm Res. (resident) returned to facility. New order received for Bactrim DS BID (two times per day) X (times) 10 days. Res. (resident) had a [MEDICATION NAME] shot @ (at) Dr. office..." A physician's office visit form, dated [DATE], documented, "...Nsg. home pt. (patient)-They have been soaking it c [MEDICATION NAME]-She's had open sore for about a month...Lt. hand-severe contractures fingers c 3rd digit embedded in ulcer in palm-foul odor-wound C & S (culture and sensitivity) obtained-unable to straight 3rd digit...Impressions or Analysis: 1) Stage ,[DATE] wound Lt. palm 2) Severe contractures Lt. [MEDICATION NAME] Gm (gram) one IM (intramuscularly) Bactrim DS BID X 10 days I will discuss c (physician's name deleted) re further ortho treatment..." A physician's order, dated [DATE], documented, "...Send resident to (physician's name deleted) for eval (evaluation) of L hand contracture..." A nurse's note, dated [DATE], documented, "...0215 (2:15 a.m.) Resident yelling out 'Help my hand is hurting worse than ever'..." A nurse's note, dated [DATE], documented, "...SK (skin) assesment (sic) complete 0 open areas...L hand contracture--has sore to palm d/t (due to) finger nails. Unable to open hand to assess. Res c/o (complains of) pain to hand..." A physician's progress note, dated [DATE], documented, "...Has left hand flexor tendon release by (physician's name deleted) scheduled...Severe left flexor contraction ,[DATE] finger get tendon release done..." A physician's discharge summary, dated [DATE], documented resident #4 expired on [DATE]. On [DATE] at 10:10 a.m., the director of nursing (DON) was asked what was done to prevent prevent or treat the contracture to resident #4's left hand. He stated, "We got her some part B (Medicare) O/T (occupational therapy) to work with her." The DON also stated the physician felt the best thing would be to do a tendon release and an amputation of the middle finger. On [DATE] at 11:30 a.m., the DON was asked when the wound on resident #4's left hand was discovered. He stated it wasn't documented until she went to (physician's name deleted) office. They forced it open at her appointment on [DATE]. He also stated, "We knew it smelled bad before the appointment, but we couldn't get her hand open before that." On [DATE] at 11:30 a.m., the DON was asked what the facility had done for the resident's wound. He stated the certified nurse aides would soak resident #4's hand in Listerine before they received the order to use [MEDICATION NAME]. He also stated the facility did not get an order to use the Listerine, nor did they document the soaking on the treatment sheet. The DON was then asked when resident #4 developed the contracture. He stated the resident had developed the contracture while in the facility. On [DATE] at 9:20 a.m., the DON was asked if resident #4 was provided with occupational therapy (OT) for her contractured left hand since 2010. He stated she did not have physical therapy (PT) or OT. There was no documentation found in the resident's clinical record documenting the resident was provided PT or OT between her admit in 2010 and 2012.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent a contracture for two (#1 and #4) of two sampled residents who were observed for contractures. The resident developed a pressure sore in the palm of her hand related to the contractures. The director of nursing identified one resident with a contracture who resided in the facility. Resident #4 no longer resided at the facility. Findings: A facility policy titled, "Guidelines for Contractures Revised: [DATE]," documented, "Policy: Residents of the facility will be given care to prevent formation and progression of contractures and deformities. Procedure: If a contracture is assessed on a resident, the physician will be notified. If indicated, orders will be received from the physician specific to the contracture and the resident." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Hospice "...IDT (interdisciplinary team) Plan of Care Update...," dated [DATE], documented, "...contracture left hand three fingers. hand rolls ordered..." The last care plan dated [DATE], and last updated [DATE], documented, "...I have developed a contracture of my L (left) hand. Keeping it closed causes it to be moist, and have an odor...I will have no further deterioration of my L hand X (times) 90 days. I will not have any skin breakdown of my L hand X 90 days. I will have my hand roll in my hand during the days. Staff will que (sic) me to leave the hand roll in place. Staff will clean my hand frequently & (and) examine for skin breakdown..." A Hospice "...IDT Plan of Care Update...," dated [DATE], documented, "...contracture left hand three fingers. hand roll placed on hand numerous times daily according to staff as pt (patient) continues to remove roll..." A facility care plan, dated [DATE], documented, "...No improvement.... The care plan documented the resident would not leave the hand roll in place and that the resident refused attempts to clean the left hand and trim the nails. No further updates were found in resident #4's clinical record regarding the resident's left hand contracture. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 11 times out of 30 opportunities. The resident refused ROM 6 times. A physician progress notes [REDACTED]. hand severe flexion contracture 2 (secondary to) [MEDICAL CONDITION] joint disease...P (plan) small hand roll to prevent palm pressure sore..." There were no physician's orders, facility treatment sheets, or nurses notes found in the resident's clinical record documenting the placement of a small hand roll to resident #4's left hand. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 12 times out of 31 opportunities. The resident refused ROM 5 times. A quarterly assessment dated [DATE], documented resident #4 was severely impaired cognitively, and was totally dependent for all ADLs. The assessment also documented resident #4 had a one-sided impairment to upper and lower extremities. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 17 times out of 31 opportunities. The resident refused ROM 3 times. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 20 times out of 30 opportunities. A physician progress notes [REDACTED]. An annual assessment, dated [DATE], documented resident #4 was severely cognitively impaired and needed total to extensive assist with all activities of daily living (ADLs). The assessment also documented the resident had one-sided upper and lower extremity impairment. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 9 times out of 30 opportunities. The resident refused ROM 8 times. A nurse's note, dated [DATE], documented, "...3 AM. C/O (complained of) nails cutting hand on L (left) ([MEDICAL CONDITION]) ([MEDICAL CONDITION]) Nails reduced - on both hands. Nails long and cutting skin @ (at) site of contracture..." No other documentation was found in the resident's clinical record regarding the wound on the resident's left hand, identified in the nurse's note dated [DATE], until the physician's visit on [DATE]. A minimum data set assessment, section special treatments and procedures, dated [DATE], documented the resident received ROM, undefined as to what part of the body received the range of motion, 12 times out of 31 opportunities. The resident refused ROM 7 times. A nurse's note, dated [DATE], documented, "...1330 (1:30 p.m.)...client has some contracture to L hand..." A quarterly assessment dated [DATE], documented resident #4 was severely impaired cognitively, needed extensive assistance with ADLs. The assessment also documented resident #4 had no impairment in upper and lower extremities. A facility document, dated February 2012, titled "Nursing Restorative Care Program," documented the resident received ROM to his/her upper extremities 12 times out of 28 opportunities. The resident refused ROM 5 times. A February 2012 treatment record documented, "[MEDICATION NAME] Soak-Soak L hand in [MEDICATION NAME]/water solution q (every) day. [DATE]..." A nurse's note, dated [DATE], documented, "...To see (physician's name deleted) re: (regarding) (L) hand..." A physician's order, dated [DATE], documented, "...Soak L hand in [MEDICATION NAME] & (and) water q (every) day..." A nurse's note, dated [DATE], documented, "...SK (skin) assessment complete 0 (no) open areas peri area red [MEDICATION NAME] prn (as needed)..." A monthly physician's order, dated [DATE], with a start date of [DATE], "...HEAD TO TOE SKIN ASSESSMENT TO BE DONE WEEKLY WITH DOCUMENTATION IN SKIN BOOK. NAILS ARE TO BE CHECKED AND TRIMMED..." No documentation was found on the resident's treatment sheets regarding weekly nail checks and/or trim. A nurse's note, dated [DATE], documented, "...10 AM Appt. (appointment) made for 330 pm c (with) (physician's name deleted) re: (regarding) left hand contracture it is starting to have drng. (drainage)..." A nurse's note, dated [DATE], documented, "...430 pm Res. (resident) returned to facility. New order received for Bactrim DS BID (two times per day) X (times) 10 days. Res. (resident) had a [MEDICATION NAME] shot @ (at) Dr. office..." A physician's office visit form, dated [DATE], documented, "...Nsg. home pt. (patient)-They have been soaking it c [MEDICATION NAME]-She's had open sore for about a month...Lt. hand-severe contractures fingers c 3rd digit embedded in ulcer in palm-foul odor-wound C & S (culture and sensitivity) obtained-unable to straight 3rd digit...Impressions or Analysis: 1) Stage ,[DATE] wound Lt. palm 2) Severe contractures Lt. [MEDICATION NAME] Gm (gram) one IM (intramuscularly) Bactrim DS BID X 10 days I will discuss c (physician's name deleted) re further ortho treatment..." There was no documentation found in the resident's clinical record regarding identification of an open wound on the resident's left hand. A physician's order, dated [DATE], documented, "...Send resident to (physician's name deleted) for eval (evaluation) of L hand contracture..." A nurse's note, dated [DATE], documented, "...0215 (2:15 a.m.) Resident yelling out 'Help my hand is hurting worse than ever'..." A nurse's note, dated [DATE], documented, "...SK (skin) assesment (sic) complete 0 open areas...L hand contracture--has sore to palm d/t (due to) finger nails. Unable to open hand to assess. Res c/o (complains of) pain to hand..." A nurse's note, dated [DATE], documented, "...1230 AM Pt. c/o pain to hand. Prescribed pain medicine given..." A physician's progress note, dated [DATE], documented, "...Has left hand flexor tendon release by (physician's name deleted) scheduled...Severe left flexor contraction ,[DATE] finger get tendon release done..." A physician's discharge summary, dated [DATE], documented resident #4 expired on [DATE]. On [DATE] at 10:10 a.m., the director of nursing (DON) was asked what was done to prevent wounds to resident #4's left hand. He stated, "We got her some part B (Medicare) O/T (occupational therapy) to work with her." The DON also stated the physician felt the best thing would be to do a tendon release and an amputation of the middle finger. On [DATE] at 11:30 a.m., the DON was asked when the wound on resident #4's left hand was discovered. He stated it wasn't documented until she went to (physician's name deleted) office. They forced it open at her appointment on [DATE]. He also stated, "We knew it smelled bad before the appointment, but we couldn't get her hand open before that." On [DATE] at 11:30 a.m., the DON was asked what the facility had done for the resident's wound. He stated the certified nurse aides would soak resident #4's hand in Listerine before they received the order to use [MEDICATION NAME]. He also stated the facility did not get an order to use the Listerine, nor did they document the soaking on the treatment sheet. The DON was then asked when resident #4 developed the contracture. He stated resident #4 had been in and out of the facility since 2006 and she developed the contracture after that date. On [DATE] at 9:20 a.m., the DON was asked if resident #4 was provided with occupational therapy (OT) for her contractured left hand since 2010. He stated she did not have physical therapy (PT) or OT. There was no documentation found in the resident's clinical record documenting the resident was provided PT or OT between her admit in 2010 and 2012. 2. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated [DATE] documented, "...Resident to wear elbow & wrist brace to R arm & hand for contracture..." A care plan, dated [DATE], documented, "...Contracture R (right) arm & wrist...Resident to wear brace for elbow & wrist during the day, off at night...Monitor hand for S&S (signs and symptoms) of brace being too tight-swelling, discoloration in fingers, temperature..." An annual assessment, dated [DATE], documented the resident was severely cognitively impaired and needed limited to extensive assistance with ADLs. On [DATE], at 5:00 p.m., resident #1 was observed in the dining room at the assisted dining table waiting for the evening meal to be served. Resident #1 had her right arm at her side with her arm bent up towards her chest. There was no brace on her right arm. On [DATE], at 8:20 a.m., resident #1 was observed in the TV room with her right arm bent up towards her chest. There was no brace on her right arm. On [DATE], at 9:26 a.m., the DON was asked why the resident had not been wearing her brace. He stated the facility had issues with the aides putting the brace on. Now, the only ones that can put it on are the nurses and restorative aide (RA). He also stated the charge nurse had not found time to put the brace on this morning, "...but it is on now." On [DATE], at 10:17 a.m., LPN #1 was asked how often resident #1 wore the right arm brace. After reviewing the resident's record LPN #1 replied, "I can't find anything in the treatment sheets, nurses' notes, or doctor orders regarding a brace. The OT were working with her a few months back." LPN #1 was asked if she had put the brace on resident #1 that morning. She replied, "I didn't." No treatment sheets were provided documenting the right arm brace for resident #1.