Every finding on record at Maple Lawn Nursing and Rehabilitation

Based on record review and interview, the facility failed to designate an RN to serve as the DON on a full-time basis.The administrator identified 39 residents resided in the facility.Findings:An untitled and undated document showed no designated RN as the DON. On 01/21/26 at 12:27 p.m., during entrance conference the administrator stated the facility had not had a DON for about two weeks.On 01/23/26 at 9:23 a.m., RN #1 stated they had put in their resignation in December 2025 and had stayed on until mid-January 2026. They stated they were tired of being a boss. They stated their last day as DON was 01/16/26.On 01/23/26 at 8:16 a.m., the administrator stated the position was posted on a job website and they had reached out to some RNs currently employed to offer the position to them.

Based on observation, record review, and interview, the facility failed to ensure a resident who was not in restraints was not coded for restraints on their MDS assessment for 1 (#18) of 1 sampled resident reviewed for restraints.The MDS coordinator identified six residents had bed rails. Findings:On 01/21/26 at 1:59 p.m., Resident #18 was observed with a quarter bed rail on each side of the head of their bed.An undated Certifying Accuracy of the Resident Assessment policy, read in part, All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment.A physician's order, dated 03/27/24, showed Resident #18 could use bed canes (another name for a bed rail]) for repositioning.A care plan, initiated 03/27/24, showed Resident #18 could use bed canes for repositioning.A quarterly resident assessment, dated 11/12/25, showed Resident #18 had diagnoses which included anxiety and epilepsy. The assessment showed the resident's cognition was intact with a brief interview for mental status score of 15. The assessment coded the use of daily bed rails as restraints.On 01/21/26 at 1:59 p.m., Resident #18 stated they used the bed rails for repositioning.On 01/21/26 at 2:31 p.m., the MDS coordinator stated the restraints on the facility matrix were for residents who had any kind of bed rails for positioning. They stated they marked all repositioning bed rails on the MDS assessments as restraints.On 01/29/26 at 1:06 p.m., the ADON stated Resident #18 had grab bars they used for repositioning and transfer assistance.On 01/29/26 at 1:27 p.m., the MDS coordinator stated the facility called the bed rails canes. They stated since the rails did not restrict Resident #18's movement, they were not considered restraints based on the definition on the MDS assessment.

Based on record review and interview, the facility failed to follow physician's order for obtaining weights for 1 (#1) of 1 sampled resident reviewed for dialysis.The administrator identified one resident resided received dialysis. Findings: An undated Weights policy, read in part, The nursing staff will measure resident weights on admission. If no weight concerns are noted at this point, weights will be measured monthly thereafter or according to the doctors orders.An undated Face sheet showed Resident #1 had diagnosis which included stage 3 chronic kidney disease.A physician's order, dated 10/14/21, showed Resident #1 was to be weighed daily, and notify primary care physician if greater than three pounds weight gain in 24 hours.A Weight Variance Report, dated 07/01/25 through 01/31/26, did not show weights for 12/04/25, 12/07/25, 12/09/25, 12/13/25, 12/14/25, 12/16/25, 12/19/25, 12/20/25, 12/27/25, 12/28/25, 01/03/26, 01/04/26, 01/06/26, 01/07/26, 01/08/26, 01/11/26, 01/13/26, 01/18/26, 01/25/26, 01/26/26, and 01/27/26.On 01/29/26 at 10:09 a.m., the ADON stated Resident #1 was on daily weights due to dialysis, chronic kidney disease, and fluid restrictions.On 01/29/26 at 10:12 a.m., the ADON stated Resident #1 had not been weighed according to physician orders.On 01/29/26 at 10:17 a.m., the administrator stated their expectation for daily weights would be to weigh the resident between 5:00 a.m. and midnight.

Based on record review and interview, the facility failed to ensure a physician's order was obtained for dialysis for 1 (#1) of 1 sampled resident reviewed for dialysis.The administrator identified one resident received dialysis.Findings:An undated Management and Care of the Hemodialysis Resident policy, read in part, All hemodialysis residents will have physician orders for care and monitoring.Orders will be obtained to reflect where the dialysis will take place, to check for thrill and bruit each shift, and to monitor for bleeding upon return from dialysis.Obtain orders for the days of dialysis, where the dialysis will take place and to monitor upon return.An undated Face sheet showed Resident #1 had diagnosis which included stage 3 chronic kidney disease.A Care Plan, dated 11/05/25, read in part, I will be going out of facility every Monday, Wednesday, and Friday for dialysis.A review of Resident #1's physician orders for January 2026 showed no order for Resident #1 to have dialysis, or where the dialysis was to take place.On 01/29/26 at 9:57 a.m., the ADON stated there was no physician's order for Resident #1 to have dialysis.On 01/29/26 at 10:16 a.m., the administrator stated they would assume there would be an order for dialysis. They stated the MDS coordinator would better be able to answer that.On 01/29/26 at 10:21 a.m., the MDS coordinator stated there should be an order on the medication administration record.

Based on record review and interview, the facility failed to ensure a pneumococcal immunization was offered to a resident for 1 (#5) of 5 sampled residents reviewed for immunizations.The administrator identified 39 residents resided in the facility. Findings:An undated Pneumococcal Vaccine policy, read in part, All residents will be offered the pneumococcal vaccine to aid in preventing infections and pneumonia.An INFLUENZA, PNEUMONIA AND COVID VACCINE INFORMATION AND CONSENT FORM, dated 03/07/23, showed Resident #5's representative gave verbal consent for the resident to receive the pneumococcal vaccine.Resident #5's immunization record was reviewed. There was no documentation Resident #5 had been offered a pneumococcal vaccine.On 01/30/26 at 9:07 a.m., the infection preventionist stated they were not sure why Resident #5 did not receive the pneumococcal vaccine.On 01/30/26 at 9:21 a.m., the infection preventionist stated pneumococcal immunizations were offered to all residents upon admission with consent.

Based on observation, record review, and interview, the facility failed to develop a policy to assess a resident's capacity to consent to sexual contact for 2 (#1 and #2) of 4 residents reviewed for consent of sexual relations. The DON reported 37 residents resided in the facility. Findings: The administrator reported the facility did not have a policy for assessment of residents to determine sexual consent. 1. On 05/15/25 at 11:35 a.m., Resident #1 was interviewed in their room. While talking with the resident, Resident #2 was observed to ambulate down the hall outside Resident #1's room. A quarterly assessment, dated 04/22/25, showed Resident #1 was severely cognitively impaired with a BIMS score of 03. The assessment showed the resident was independent with activities of daily living. The assessment showed the resident had diagnoses which included altered mental status, mood disorder, depression, osteoarthritis, Alzheimer's disease, and vascular dementia. A progress note, dated 05/11/25 at 3:17 p.m., showed a CNA reported Resident #1 was observed to wander into Resident #2's room. The note showed when the CNA went to redirect the resident, the CNA observed Resident #2 grab Resident #1 in their vaginal area over their clothes as the resident was walking away. The note showed the residents were separated and Resident #1 was redirected to their room and assessed. A care plan, dated 05/13/25, showed an incident on 03/10/25 in which Resident #1 was observed kissing Resident #2 by a housekeeper. The care plan showed the residents were easily redirected and hourly checks for 48 hours were initiated. The care plan showed on 05/11/25, Resident #1 wandered into Resident #2 room. The care plan showed Resident #2 grabbed Resident #1 in the vaginal area. The care plan showed Resident #1 was redirected to their room, the resident was assessed, and hourly checks were initiated. On 05/15/25 at 11:38 a.m., Resident #1 was asked if they knew Resident #2. Resident #1 stated yes, and reported Resident #2 was their friend. On 05/15/25 at 12:30 p.m., the DON reported Resident #1 and Resident #2 had been together at another facility prior to being admitted to this facility. The DON reported the two residents rode together in the same van when transferred to this facility and were very familiar with each other. The DON reported Resident #1 would seek out Resident #2 and had been observed to hold hands and sit together. On 05/15/25 at 1:12 p.m., Resident #1's family member was interviewed by phone. The family member reported no complaints related to the resident's care and reported they felt their loved one was safe at the facility. The family member reported the facility notified them immediately when the incident happened with Resident #2. On 05/15/25 at 2:20 p.m., CNA #1 reported they were not aware of Resident #2 having any behaviors toward any other resident. The CNA reported Resident #1 seeks out Resident #2 and they have heard Resident #2 tell Resident #1 to leave their room. On 05/15/25 at 4:18 p.m., CNA #2 reported Resident #2 was alert and oriented, knew what they were doing, but Resident #1 was known to seek out Resident #2. The CNA reported if they observed Resident #1 going down the hall, they assumed the resident was going to Resident #2's room, so they immediately redirected the resident. The CNA reported the situation had been better since Resident #1 was moved to a different room further down the hall. 2. A quarterly assessment, dated 04/22/25, showed Resident #2 had diagnoses which included depression, hypertension, mental disorder, amnesia, and insomnia. The assessment showed the resident was cognitively intact with a BIMS score of 15. A care plan, dated 05/14/25, showed an incident on 03/10/25 in which Resident #2 was observed kissing [Resident #1] that had entered the resident's room. The care plan showed the residents were easily redirected and every one-hour checks were initiated for 48 hours. The care plan showed a second incident on 05/11/25 in which Resident #2 was observed to grab[Resident #1] in the vaginal area, while the resident was fully clothed. Hourly checks were initiated for 24 hours. The care plan showed Resident #2 apologized for their behavior and reported it would not happen again. On 05/15/25 at 2:35 p.m., Resident #2 reported Resident #1 used to come to their room a lot before they moved Resident #1 down the hall. Resident #2 stated, I don't want no trouble. The resident went on to say they previously sat at the same dining table with Resident #1 but had recently started sitting at a different table across the dining room. The resident reported they had been at the same facility with Resident #1 before coming to this facility and had known each other a long time. On 05/15/25 at 2:55 p.m., the administrator reported they had interviewed other residents following the incident with Resident #1 and Resident #2. The administrator reported no residents reported an issue with Resident #2 and the resident had no history of being interested in anyone other than Resident #1. On 05/16/25 at 9:14 a.m., CNA #3 reported they witnessed the incident with Resident #1 and Resident #2 on 05/11/25. The CNA reported they were walking down the hall past Resident #2's room when they noticed Resident #1 in the room. The CNA reported they went to redirect Resident #1 and walked the resident out of the room when Resident #2 reached underneath the bedside table and touched Resident #1's vaginal area. The CNA reported they told Resident #2 they should not do that, then reported the incident to the charge nurse. The CNA reported Resident #1 was easily redirected and reported Resident #2 wasn't upset but stated they did not do anything wrong. The CNA reported Resident #2 later went to the charge nurse, apologized, and reported they wouldn't do it again. On 05/16/25 at 9:30 a.m., the administrator reported the facility had no policy or assessment tool to determine a resident's ability to consent to sexual activity. The administrator reported they would normally refer to the resident's BIMS score. The administrator reported this was the first situation in which the couple was not married, with a previous consenting relationship, but they could see the need for this type of assessment in residents who show an interest in sexual activity.

Based on record review and interview, the facility failed to notify or consult with the physician to ensure parameters were identified and followed for FSBS and insulin administration for two (#14 and #17) of four sampled residents reviewed for FSBS. The Resident Census and Conditions of Residents report, dated 04/17/23, documented the census was 39. The DON identified nine residents were insulin dependent. Findings: An undated, Change in a Resident's Condition or Status policy, read in parts, .facility shall promptly notify the .attending physician .of changes in the resident's medical .condition and/or status .nurse will notify the resident's attending physician .when there has been .a need to alter the resident's medical treatment .[when there has been] Instructions to notify the physician of changes in the resident's condition . 1. Resident #17 had diagnoses to include type two diabetes mellitus with hyperglycemia. A Physician Order, dated 02/06/23, documented Resident #17 was to be administered glargine, a long acting insulin, 30 units twice a day. An Admission Assessment, dated 02/09/23, documented Resident #17 was cognitively intact and had received insulin injections daily from 02/03/23 through 02/09/23. An Insulin Orders administration form, dated February 2023, documented FSBS had been: a. greater than 350 once, and greater than 400 three times from 02/06/23 through 02/09/23, and b. greater than 400 on 02/26/23. The clinical record did not contain documentation the physician was notified of the elevated FSBS, or consulted regarding no parameters to notify the physician between 02/06/23 through 02/09/23, or on 02/26/23. A Physician's Order, dated 02/28/23, documented Resident #17 was to be administered Aspart [Novolog], a rapid acting insulin, six units at meals. A Physician's Order, dated 03/06/23, documented Resident #17 was to be administered glargine, a long acting insulin, 30 units twice a day. An Insulin Orders, administration record, dated March 2023, documented FSBS: a. were greater than 350 twice, and greater than 400 twice, from 03/01/23 through 03/06/23; and b. were greater than 350 eight times, and greater than 400 ten times between 03/07/23 through 03/16/23. The clinical record did not contain documentation the physician was notified of the elevated FSBS, or consulted regarding no parameters to notify the physician between 03/01/23 through 03/06/23 or between 03/07/23 through 03/16/23. On 04/20/23 at 2:46 p.m., the DON was asked what was the facility protocol or procedure to monitor FSBS. They stated the FSBS and insulin are reviewed daily by the charge nurse when they look at the administration record. The DON was asked how the facility determined when a physician is to be notified of a FSBS. They stated, It should be on the MAR. The DON was asked what the parameters were for FSBS and Resident #17. They stated the parameters are usually to hold insulin if the FSBS is less than 50 and to notify the physician if the FSBS is greater than 350. They stated the staff should have notified the physician each time the FSBS was greater than 350. 41872 2. Resident #14 had diagnoses which included, type two diabetes mellitus, and edema. A Quarterly Assessment, dated 01/02/23, documented Resident #14 had severe cognitive impairment, and had received seven days of Insulin. An Insulin Orders administration record, dated January 2023, read in parts, .Novolog Flex pen 100 unit/ml Administer SQ Per SS AC: 200-250 = 4 units 251-300 = 6 units 301-350 = 8 units ANYTHING <60 Or >350 NOTIFY PCP . The Insulin Orders, documented Resident #14's FSBS was greater than 350 mg/dl five of ninety three times as follows: 01/01/23 FSBS was 396, 01/11/23 FSBS was 355, 01/13/23 FSBS was 379, 01/24/23 FSBS was 372, and 01/30/23 FSBS was 358. There was no documentation the physician had been notified. An Insulin Order administration record, dated 02/01/23 to 02/17/23, read in parts, .Novolog Flexpen 100 unit/ml Administer SQ Per SS AC: 200-250 = 4 units 251-300 = 6 units 301-350 = 8 units ANYTHING <60 OR >350 NOTIFY PCP . An Insulin Order: administration record, dated 02/17/23 to 02/28/23, read in parts, .Novolog Flexpen 100 unit/ml Give per ss BID @ lunch and supper: FSBS 200-250 = 4 units 251-300 = 6 units 301-350 = 8 units Anything <60 or >350 notify PCP . The Insulin Orders administration record, dated February 2023, documented Resident #14's FSBS results were greater than 350 mg/dl three of 73 times as follows: On 02/07/23 FSBS was 353, On 02/17/23 FSBS was 470, and On 02/28/23 FSBS was 352. There was no documentation the physician had been notified. The Insulin Orders administration record, dated March 2023, documented Resident #14's FSBS results were greater than 350 mg/dl five of sixty two times as follows: On 03/11/23 FSBS was 361, On 03/13/23 FSBS was 383, On 03/16/23 FSBS was 375, On 03/20/23 FSBS was 355, and On 03/23/23 FSBS was 380. There was no documentation the physician had been notified. On 04/20/23 at 5:25 p.m., Resident #14's January, February, and March Insulin Orders administration record's, were shown to the DON and asked if the physician had been notified of the FSBS results that were greater than 350. The DON reviewed the documentation and progress notes and stated, No.

Based on interview and record review, the facility failed to ensure insulin was administered according to the physician order for one (#14) of four sampled residents reviewed for insulin administration. The Resident Census and Conditions of Residents report, dated 04/17/23, documented the census was 39. Findings: A Medication Administration and General Guidelines policy, dated 2019 Edition, read in parts, .Medications are administered as prescribed .in accordance with written orders of the attending physician .contact for clarification prior to the administration . Resident #14 had diagnoses which included type two diabetes mellitus, and edema. AnQuarterly Assessment, dated 01/02/23, documented Resident #14 had severe cognitive impairment, and had received seven days of Insulin. An Insulin Order administration record, dated January 2023, read in parts, read in parts, .Novolog Flexpen 100 unit/ml Administer SQ Per SS AC: 200-250 = 4 units 251-300 = 6 units 301-350 = 8 units ANYTHING <60 Or >350 NOTIFY PCP . The January 2023, Insulin Order administration record, documented Resident #14's FSBS was greater than 350 mg/dl, and was administered eight units of insulin on the following dates: 01/01/23 FSBS was 396, 01/11/23 FSBS was 355, 01/13/23 FSBS was 379, 01/24/23 FSBS was 372, and 01/30/23 FSBS was 358. An Insulin Order administration record, dated 02/01/28 to 02/17/23, read in parts, .Novolog Flexpen 100 unit/ml Administer SQ Per SS AC: 200-250 = 4 units 251-300 = 6 units 301-350 = 8 units ANYTHING <60 OR >350 NOTIFY PCP . An Insulin Order administration record, dated 02/17/23 to 02/28/23, read in parts, .Novolog Flexpen 100 unit/ml Give per ss BID @ lunch and supper: FSBS-200-250 = 4 units 251-300 = 6 units 301-350 = 8 units Anything <60 or >350 notify PCP . The February 2023 Insulin Order administration record, documented Resident #14's FSBS results were greater than 350 mg/dl, and was administered eight units of insulin on the following dates: On 02/07/23 FSBS was 353, On 02/17/23 FSBS was 470, and On 02/28/23 FSBS was 352. The March 2023 Insulin Order administration record, documented Resident #14's FSBS results were greater than 350 mg/dl, and was administered eight units of insulin on the following dates: On 03/11/23 FSBS was 361, On 03/13/23 FSBS was 383, On 03/16/23 FSBS was 375, On 03/20/23 FSBS was 355, and On 03/23/23 FSBS was 380. On 04/20/23 at 5:25 p.m., the DON was asked why had staff administered eight units of insulin when the results were greater than 350, was that the physician order. They stated, No, that was an error.

Based on record review and staff interviews, it was determined the facility failed to ensure medications were administered as ordered for one (#142) of five sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 01/28/20, documented 43 residents resided in the facility. Findings: Resident #142 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] Cap(s) (capsules) 300 MG (milligrams) GIVE 3 TIMES at 0800 (8:00 a.m.), 1200 (12:00 p.m.), 2100 (9:00 p.m.) . The (MONTH) 2019 Medication Administration Record [REDACTED]. A nurse's medication notes, dated 12/01 and 12/02/19, documented waiting on delivery, pending at pharmacy and waiting for pharmacy approval. A physician's orders [REDACTED].[MEDICATION NAME] Packet(s) .DAILY MIX ONE PACKET WITH 6-8 OUNCES OF WATER BID (twice daily) WITH NOON MEAL AND EVENING MEAL TO PROMOTE WOUND HEALING . The (MONTH) 2020 MARs documented the [MEDICATION NAME] had been circled for the administrations on 01/06/20 at 12:00 p.m. and 5:00 p.m., on 01/07 at 12:00 p.m. and 5:00 p.m., on 01/08 at 12:00 p.m. and 5:00 p.m. and on 01/09/20 at 5:00 p.m. Nurse's medication notes dated 01/06/20 through 01/09/20, documented waiting for approval from pharmacy, waiting on pharmacy and waiting for delivery. On 01/29/20 at 1:26 p.m., certified medication aide (CMA) #1 was asked what the policy was for administering medications. She stated staff were to wash their hands, check the MAR indicated [REDACTED]. She was asked what the policy was for re-ordering medications. She stated they were to re-order medications when the medication cards were used down to the red area on the card. She stated the red areas differed depending if the medications were daily, twice daily and so on and indicated there was only a few days of the medication remaining before it ran out. She stated staff re-ordered medications by scanning the medication cards. CMA #1 was shown the physician's orders [REDACTED]. She was asked to explain the messages on the medication notes. She stated the computer generated the messages and staff were to inform the nurse's. She was shown the physician's orders [REDACTED]. She stated the [MEDICATION NAME] had been ordered from somewhere other than the pharmacy and when it was low staff were to inform the staff member responsible for ordering supplies. At 1:34 p.m., the director of nursing (DON) was shown the physician's orders [REDACTED]. She was asked if the medications had been administered as ordered. She stated the [MEDICATION NAME] came from their food supplier and staff should have told her they were out. She was asked if the [MEDICATION NAME] had been administered as ordered. She stated, No. She stated she was looking into the [MEDICATION NAME]. At 1:56 p.m., the minimum data set nurse stated the [MEDICATION NAME] had been re-ordered on [DATE] and the pharmacy had been closed. She stated the pharmacy delivered medications in the evenings, so it didn't get delivered until the evening of the 12/02/19. She was asked if the [MEDICATION NAME] had been administered as ordered. She stated, No.

Based on observation and staff interviews, it was determined the facility failed to ensure a narcotics storage container in a medication refrigerator was permanently affixed for one of one medication refrigerator observed. The facility identified one medication refrigerator. Findings: On 01/28/20 at 3:37 p.m., a locked bag was observed inside the medication storage room refrigerator. The bag was not affixed to the refrigerator. Licensed practical nurse #1 stated the bag was for narcotics. She was asked if the bag was able to be removed from the refrigerator. She stated, Yes. At 4:00 p.m., the director of nursing was asked what the policy was for narcotic storage in a medication refrigerator. She stated the facility had a bag with a lock and the charge nurse had the key. She was asked if the narcotic container should be permanently affixed. She stated, Maybe.

Based on observation, staff interviews and review of menus, it was determined the facility failed to ensure: ~ a resident received pureed bread with margarine for one (#6) of one sampled resident with a physician ordered pureed diet and ~ all residents receiving meals from the dietary department were offered margarine for their rolls during the noon meal service on 11/26/18. The facility identified 28 residents who received services from the dietary department and one resident who received nutrition and hydration solely through a feeding tube. Findings: The menu for the noon meal on 11/26/18, documented garlic roasted chicken, parsley penne pasta, beet, carrot, apple salad, roll/margarine, bread pudding and rum sauce. The extended menu for pureed diets for the noon meal on 11/26/18, documented pureed chicken with gravy, pureed penne pasta with gravy, pureed chilled beets, a pureed roll and pureed bread pudding. On 11/26/18 at 11:25 a.m., resident #6 was served her noon meal. There was no pureed bread observed on the plate. At 11:40 a.m., there was no margarine observed on any of the residents' plates in the dining room. At 11:50 a.m., the certified dietary manager (CDM) was asked to read from the extended menu for with a pureed diet was to have received for the noon meal. After she had read the menu, she was asked if the resident had received a pureed roll. Cook #1 stated she had forgot the roll for the resident. The CDM was asked to read the menu for the noon meal. After she had read the menu, she was asked if the residents were served margarine with their rolls. She stated she had buttered the tops of the rolls when they came out of the oven. Cook #1 stated the residents who wanted margarine had asked for it. The CDM and cook #1 were informed if it was listed on the menu it was to be offered to the residents and they should not have to ask for it.

Based on record review and staff interviews, it was determined the facility failed to assess monitor and intervene for a resident who required sliding scale insulin coverage for one (#40) of five sampled residents reviewed for unnecessary medications. The director of nursing identified two residents with orders for [MEDICATION NAME] insulin. Findings: Resident #40 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician order, dated 06/23/17, documented, .[MEDICATION NAME] ml 100 UNIT/ML - FSBS (fingerstick blood sugar) AC (before meals) AND HS with sliding scale fsbs 150-200 give 1 (one) unit, fsbs 201-250 give 2 (two) units, fsbs of 251-300 give 3 (three) units, fsbs of 301-350 give 4 (four) units if fsbs (greater than) 351 call physician . A significant change resident assessment, dated 09/01/17, documented the resident's cognition was intact and did not document the resident received insulin injections during the seven day look-back period. A care plan, dated 09/05/17, documented, .Category Problem .I AM AN INSULIN DEPENDENT DIABETIC WITH [MEDICAL CONDITION] .Category Approach .I AM ORDERED TO HAVE MY FSBS CHECKED AC/HS (AND) MY PCP (PRIMARY CARE PHYSICIAN) WILL BE NOTIFIED OF FSBS (LESS THAN) 60 OR (GREATER THAN) 350 . I WILL BE GIVEN NOVALOG PER SLIDING SCALE WITH [MEDICATION NAME] 50 MG AND [MEDICATION NAME] 15u (units) SQ ROUTINELY . A nurses note, dated 09/05/17 at 2:01 a.m., documented, FAXED CURRENT FINGER STICK LOG TO PCP D/T (DUE/TO) RES (RESIDENT) BLOOD SUGARS HAVE BEEN RAGING (SIC) FROM 200-350. ALSO INCLUDED CURRENT DIABETIC MED (MEDICATION)/INSULIN IF CHANGES NEED MADE . There was no physician response documented in the resident's clinical record. The FSBS logs and insulin administration records for September 2017 documented: ~ On 09/01/17 at 9:27 p.m. a FSBS of 315. The insulin administration record documented 15 units. ~ On 09/02/17 at 8:00 p.m. a FSBS of 241. The insulin administration record documented 15 units. ~ On 09/05/17 at 8:38 p.m. a FSBS of 364. There was no insulin administration record for this time period. There were only three FSBS documented on 09/05/17. ~ On 09/06/17 at 8:58 p.m. a FSBS of 265. There was no insulin administration record for this time period. ~ On 09/09/17 at 7:29 p.m. a FSBS of 253. The insulin administration record documented 15 units. ~ On 09/14/17 at 8:14 p.m. a FSBS of 268. The insulin administration record documented 15 units. ~ On 09/15/17 at 8:00 p.m. a FSBS of 176. The insulin administration record documented 15 units. ~ On 09/21/17 at at 9:27 p.m. a FSBS of 177. The insulin administration record documented 15 units. ~ On 09/22/17 at 8:33 p.m. a FSBS of 223. The insulin administration record documented 15 units. ~ On 09/23/17 at 7:52 p.m. a FSBS of 286. The insulin administration record documented 15 units. ~ On 09/25/17 at 10:10 p.m. a FSBS of 249. There was no insulin administration record for this time period. There was only one FSBS documented on 09/25/17. ~ On 09/27/17 at 5:46 p.m., the insulin administration record documented four units of insulin was administered to the resident. There was no FSBS documented for this administration. At 8:49 p.m., the FSBS was 271. There was no insulin administration record for this time period. ~ On 09/28/17 at 8:25 p.m. a FSBS of 285. The insulin administration record documented 15 units. ~ On 09/29/17 at 9:41 p.m. a FSBS of 350. The insulin administration record documented 15 units. ~ On 09/30/17 at 7:46 p.m. a FSBS of 267. The insulin administration record documented 15 units. The September 2017 medication administration record (MAR) documented initials on the administration of the [MEDICATION NAME] sliding scale insulin. It did not document the amount of [MEDICATION NAME] administered. The FSBS logs and insulin administration records for October 2017 documented: ~ There were only three FSBS documented on 10/04/17. ~ On 10/06/17 at 837 p.m. a FSBS of 222. The insulin administration record documented 15 units. ~ On 10/07/17 at 8:48 p.m. a FSBS of 302. The insulin administration record documented 15 units. ~ On 10/10/17 at 11:24 a.m. a FSBS of 376. The insulin administration record documented four units were administered. There was no documentation the physician was notified. At 5:41 p.m. a FSBS of 221. There was no insulin administration record for this time period. ~ On 10/11/17 at 11:23 a.m. a FSBS of 327. There was no insulin administration record for this time period. ~ On 10/12/17 at 7:09 p.m. a FSBS of 244. The insulin administration record documented 15 units. ~ On 10/13/17 at 8:09 p.m. a FSBS of 248. The insulin administration record documented 15 units. ~ On 10/14/17 at 7:21 p.m. a FSBS of 248. The insulin administration record documented 15 units. ~ On 10/15/17 at 6:57 a.m. a FSBS of 334. There was no insulin administration record for this time period. ~ On 10/16/17 at 7:12 a.m. the insulin administration record documented one unit. There was no FSBS documented for the time period. At 9:17 p.m. a FSBS of 302. There was no insulin administration record for this time period. ~ On 10/17/17 there were only three FSBS documented. ~ On 10/18/17 at 10:16 p.m. a FSBS 250. There was no insulin administration record for this time period. ~ On 10/19/18 there were only three FSBS documented. ~ On 10/20/17 at 12:10 a.m. a FSBS of 175. The insulin administration record documented 15 units. At 7:57 p.m. a FSBS of 350. The insulin administration record documented 15 units. ~ On 10/21/17 at 6:59 p.m. a FSBS of 272. The insulin administration record documented 15 units. ~ On 10/23/17 there were only three FSBS documented. The October 2017 MAR documented initials on the administration of the [MEDICATION NAME] sliding scale insulin. It did not document the amount of [MEDICATION NAME] administered. On 10/24/17 at 2:10 p.m. the director of nursing (DON) was interviewed. The nurse consultant was present during part of the interview. The DON was asked to identify the resident's [MEDICATION NAME]orders. She reviewed the resident's record and stated, 150-200 give one unit. She stated, 201-250 give two. She stated, 251-300 you give three. She stated, 301-350 you give four. She stated staff were to notify the physician for a FSBS greater than 351. She was asked the frequency of the resident's FSBS. She stated, AC and HS. She stated with a sliding scale. The DON was asked to review the resident's FSBS and insulin administration records. She was asked to explain each insulin administration which documented 15 units. She stated all of the 15s documented represented the resident's scheduled [MEDICATION NAME]dose. She acknowledged each of the FSBS which documented 15 units would have also required the sliding scale [MEDICATION NAME]to be administered. She acknowledged there was no amount documented for the resident's sliding scale insulin for those dates and times. The DON was asked when staff were instructed to document FSBS and insulin administration. She stated When they give it. She was asked if FSBS were required for the resident's routine [MEDICATION NAME]administration. She stated this resident had orders for her sliding scale insulin to be due at the same time as her scheduled [MEDICATION NAME] insulin. She stated the FSBS was completed at the same time for the sliding scale insulin. She stated on routine insulin orders, staff generally documented the insulin was given because it was a routine dose. She stated the nurse who documented the 15 units was documenting the amount of the routine insulin administered which was 15. The DON was asked to explain the documentation for the resident's FSBS and insulin administration on 09/05/17. She reviewed the record and stated, Three FSBS, Two doses. She stated it looked like it wasn't given at eight, which would have been the zero. She stated that was all that was documented. She was asked if there was any documentation on the coverage of the 364 FSBS at 8:38 p.m. on 09/05/17. She reviewed the notes and stated, I show that she faxed the doctor regarding his fingerstick, but it doesn't show she actually gave anything. The nurse consultant stated 2:00 a.m. That's when she charted. The DON was asked if she could locate documentation of how much sliding scale [MEDICATION NAME] was administered for the resident's FSBS of 265 on 09/06/17 at 8:58 p.m. She stated, She initialed it was given. She stated, But it doesn't give how much she gave. The DON was asked to explain the resident's FSBS of 249 on 09/25/17 at 10:10 p.m. with no insulin documented. She reviewed the resident's record and stated she did not see where the resident was out of the facility or refused coverage. She was asked to explain the FSBS of 271 on 09/27/17 at 8:49 p.m. with no insulin documented. She reviewed the insulin administration record and stated, It's not showing anything. The DON was asked to identify the reason the resident was not administered her sliding scale insulin. She reviewed the resident's MAR and stated, No, she signs she gave it but there's no amount. The DON was asked to explain the resident's FSBS of 285 on 09/28/17 at 8:25 p.m. with no insulin documented. She was asked if the FSBS would have required sliding scale insulin administration. She stated, It would. She stated, She signed she gave it but there's no amount. She was asked to explain the reason there were only three FSBS documented on 10/04/17. She stated she did not see any documentation of a refusal. She stated, So we missed the dinner one. The DON was asked if the resident's FSBS was documented as 376 on 10/10/17 at 11:24 a.m. She stated, Yes. She was asked if the resident's physician was notified of the FSBS over 350. She stated, There's no documentation the doctor was notified. She was asked if staff should have notified the physician. She stated, Yes. The DON was asked to explain the FSBS of 221 on 10/10/17 at 5:41 p.m. with no insulin documented. She stated, I don't have anything for 10/10. The DON was asked to explain the FSBS of 327 on 10/11/17 at 11:23 a.m. with no insulin documented. She stated there was no insulin administration or refusal documented for the FSBS. She was asked to explain the FSBS of 334 on 10/15/17 at 6:57 a.m. with no insulin documented. She stated, She signed out it was given. She stated the amount was not documented. The DON was asked to explain the FSBS of 302 on 10/16/17 at 9:17 p.m. with not insulin documented. She stated there was no refusal documented. She stated the insulin was marked as given but no amount specified. She was asked to explain the FSBS of 250 on 10/18/17 at 10:16 p.m. with no insulin documented. She stated, That is correct. She stated it was initialed as given but no amount was documented.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure food service equipment was kept clean in the kitchen and the employee locker room. The facility identified a census of 36. Thirty five residents received services from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings: A kitchen cleaning list, documented, .DAILY .Clean grill .WEEKLY .Wipe down .equipment in the kitchen and pantry .Clean oven . A sanitization policy, documented, .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas .shall be kept clean .and protected from rodents .Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . On 02/15/17 at 8:10 a.m., an environmental tour was conducted. The following observations were made: ~ an accumulation of spilled food debris was on the bottom casing of the resident refrigerator in the employee locker room, ~ an accumulation of white and brown residue was on the dish machine in the kitchen and ~ an accumulation of grease and food debris was on the food processor table, stove and convection oven in the kitchen. At 9:37 a.m., the dietary manager was interviewed and asked what the policy was for cleaning food service equipment. She stated equipment such as the dish machine was supposed to be de-limed and cleaned monthly, the stove/oven was to be cleaned once a week and refrigerators were to be cleaned daily. She was made aware of the above observations. She acknowledged the findings.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure: ~ floors were maintained clean in the kitchen and the employee locker room and ~ there were no gaps between or underneath the front double doors. The facility identified a census of 36. Thirty five residents received services from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings: An environmental checklist, dated 08/15/16, documented, .Policy .To provide a safe and clean environment for residents, staff, and visitors .The housekeeping supervisor is responsible for touring the facility weekly to see areas that need to be fixed, repaired, corrected, or painted. This will be done by Monday the following week at the least .Once this checklist is completed the Administrator and Maintenance Supervisor will receive a copy. The Maintenance Supervisor will begin working on correcting the problems . A maintenance policy, dated 08/15/16, documented, .The maintenance department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times .Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .Maintaining the building in good repair and free from hazards .Others that may become necessary or appropriate. On 02/15/17 at 8:10 a.m., an environmental tour was conducted. The following observations were made: ~ black residue, lint, chips, a piece of bacon and trash was on the floor in the employee locker room, ~ an accumulation of black residue and food debris was on the floor under the cook line in the kitchen, ~ an accumulation of black residue was on the floor under the dish wash area in the kitchen and ~ there were gaps between and underneath the front double doors. At 9:37 a.m., the dietary manager was interviewed and asked what the policy was for maintaining the floors in the kitchen clean. She stated dietary staff swept and mopped the kitchen floor after every meal service. She was made aware of the above observations in the kitchen. She acknowledged the findings. At 9:45 a.m., the administrator was interviewed and asked what the policy was for maintaining the floors in the kitchen and employee locker room clean. She stated dietary staff cleaned the kitchen floor daily as they make messes and housekeeping was responsible for cleaning the employee locker room daily. She was asked what the policy was for maintenance of the facility related to exterior doors. She stated the housekeeping supervisor performed weekly environmental checks and if there were any concerns they would contact the maintenance staff for repairs. She was made aware of the above observations. She acknowledged the findings.

Based on observation, record review and staff interviews, it was determined the facility failed to maintain an effective pest control program to ensure evidence of rodents was not present in the kitchen, employee locker room and the West central supply closet. The facility identified a census of 36. Thirty five residents received services from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings: A pest control policy, revised 05/08, documented, .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . A sanitization policy, documented, .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas .shall be kept clean .and protected from rodents . On 02/15/17 at 8:10 a.m., an environmental tour was conducted. Multiple rodent droppings were observed on top of the wall mounted lockers in the employee locker room. Multiple rodents droppings were observed on the shelving and on the floor throughout the West central supply room. Multiple rodent droppings were observed in the kitchen area on the following surfaces: ~ on top of the dish machine, ~ on top of the convection oven, ~ on the floor behind the convection oven, ~ on the floor under food storage racks in the dry storage room, ~ on top of cases of salt, pepper and ketchup on the shelving in the dry storage room, ~ on top of boxes of honey buns, cream of wheat, lemon bar filling mix and pancake mix on the shelving in the dry storage room, ~ on top of cans of key lime pie and apple pie filling on the shelving in the dry storage room, ~ on top of containers of barbecue sauce and oatmeal on the shelving in the dry storage and ~ on clean serving platters on the shelving in the dry storage room. At 9:37 a.m., the dietary manager was interviewed and asked what the policy was for pest control. She stated pest control came out once a month to provide services. She stated the pest control company sprayed and put traps out. She was asked if the facility had any current issues with rodents. She stated they had in the past. She stated they had seen a few rodent droppings. She was asked what the policy was if dietary saw evidence of rodents. She stated they swept, mopped and cleaned the area. She was made aware of the above observations in the kitchen. She acknowledged the findings. At 9:45 a.m., the administrator was interviewed and asked what the policy was for pest control. She stated pest control provided services once a month. She was asked if the facility had any current issues with rodents. She stated they had an issue with mice in the employee locker room. She was asked what the policy was if staff saw evidence of rodents. She stated when they had the issue with mice last week, they cleaned the employee locker room and put traps down in the locker room and the central supply room. She was made aware of the above observations. She acknowledged the findings.

Based on record review and staff interviews, it was determined the facility failed to notify the physician as ordered when a resident experienced a three pound or greater weight gain in a 24 hour period for two (#3 and #10) of three sampled residents reviewed for weight loss. The facility identified eight residents with orders for daily weights resided in the facility. Findings: A facility change in a resident's condition or status policy, undated, documented, .Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. (for example), changes in level of care, billing/payments, resident rights, etc.) .The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been .Instructions to notify the physician of changes in the resident's condition . 1. Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].WEIGH DAILY - OBTAIN & (AND) RECORD WEIGHT DAILY (NOTIFY PCP (PRIMARY CARE PHYSICIAN) OF GAIN 3LB (POUND) IN 24 HOURS) . A physician's orders [REDACTED]. A dietitian notification, dated 08/16, documented, .5.7% (percent) wt (weight) (increase) x(times) 1 mo (month), 11 % (increase) x 3 mo (and) 8.8 % (increase) x 6 mo (with) BMI (body mass index) 29 .Monitor wt . The document was signed by the physician, dietitian and the DON (director of nursing). Facility weight records from 06/14/16 to 09/14/16 were reviewed. It documented resident #3's weight on 07/24/16 was 146.7 pounds and on 07/25/16 was 150 pounds. It documented the resident's weight on 07/30/16 was 148 pounds and on 07/31/16 152 pounds. No documentation of the physician having been notified of the resident's weight gain in 24 hours was located in the resident's clinical record. On 09/14/16 at 5:25 p.m., the DON was asked to locate any documentation resident #3's physician had been notified of the three pound or greater weight gain in 24 hours on 07/25/16 and 07/31/16. On 09/15/16 at 9:50 a.m., the DON returned and stated she had spoken with resident #3's physician. She stated the physician had not been notified of the resident's weight gain on 07/25/16 or 07/31/16. She was asked if the staff should have notified the physician of the three pound or more weight gain since it was ordered. She stated, Yes. 2. Resident #10 had [DIAGNOSES REDACTED]. A care plan, dated 11/21/15, documented, [MEDICAL TREATMENT] Care Plan for (resident #10) .I am weighed daily & my PCP is notified of weight gain of 3lbs in 24 hours . A doctor's order sheet, dated May 2016, documented, 06/30/15 WEIGHT - OBTAIN WEIGHT DAILY, NOTIFY PCP IF (greater than) 3LB WT GAIN x 24HR (hour). The resident's clinical record was reviewed. The May 2016 weight record documented resident #10's weight on 05/04/16 was 208 and on 05/05/16 was 212. The 05/15/16 weight was 210.8 and the 05/16/16 weight was 216. The 05/19/16 weight was 204 and the 05/20/16 weight was 210. The 05/22/16 weight was 212 and the 05/23/16 weight was 216. The 05/28/16 weight was 202 and the 05/29/16 weight was 208. The 05/30/16 weight was 206 and the 05/31/16 weight was 212.4. The July 2016 weight record documented resident #10's weight on 07/01/16 was 191 and on 07/02/16 the weight was 196. The 07/03/16 weight was 197 and on 07/04/16 the weight was 203. On 09/16/16 at 8:47 a.m., the DON was asked to locate documentation the physician had been notified of the three pound or greater weight gain in 24 hours for the dates listed above. At 9:45 a.m., the DON stated she could not locate any documentation the physician had been notified of the weight gain for the above dates. She was asked if the physician should have been notified. She stated, Yes.

Based on record review and staff and resident interviews, it was determined the facility failed to: ~ complete new employee reference checks for two (certified medication aide (CMA) #1 and certified nurse aide (CNA) #4) of five new employee records reviewed for employee reference checks and ~ complete a thorough investigation following a resident's allegation of abuse for one (#10) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents report, dated 09/14/16, documented 40 residents resided in the facility. The facility identified 16 new employees had been hired in the past four months. Findings: A facility background screening investigation policy, undated, documented, .Our facility conducts employment background screening checks, finger printing, reference checks and criminal conviction investigation checks on individuals making application for employment with our facility . The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction check on persons making application for employment with this facility. Such investigation will be initiated within two days of employment or offer of employment . A facility abuse investigations policy, undated, documented, .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management . Should an incident or suspected incident of resident abuse, mistreatment, neglect, injury of unknown source, resident to resident abuse or resident to staff abuse be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .An incident report will be completed for any allegation of abuse, neglect, and injuries of unknown source . The individual conducting the investigation will, as a minimum .Review the completed incident report .Review the resident's medical record to determine events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident . A facility abuse prevention program, undated, documented, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual . Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The protection of residents during abuse investigations .Timely and thorough investigations of all reports and allegations of abuse .The reporting and filing of accurate documents relative to incidents of abuse .An ongoing review and analysis of abuse incidents .The implementation of changes to prevent future occurrences of abuse . 1. Five employee files were reviewed. No documentation of reference checks having been conducted for CNA #4 and CMA #1 was located in the employee files. On 09/15/16 at 3:35 p.m., the administrator (ADM) was asked to locate documentation of a reference check having been completed for CNA #4 and CMA #1. On 09/16/16 at 8:30 a.m., the ADM was asked if reference checks were completed for CNA #4 and CMA #1. She stated the director of nursing (DON) had completed reference checks. However there was no documentation it was done. She stated, If it's not documented it's not done. She was asked what the policy was for reference checks. She stated she did not know the exact policy but the reference checks should be performed before employment to check for abuse and it should be documented. 2. Resident #10 had [DIAGNOSES REDACTED]. The resident's clinical record was reviewed. A late entry nurse's note, dated 05/30/16 at 6:30 a.m., documented, resident #10 had made an allegation of sexual abuse with a staff member to the staff who was providing him with bathing assistance. It documented this staff member informed the nurse on duty of the allegation. An Oklahoma State Department of Health (OSDH) incident report form, dated 05/30/16, documented resident #10's allegation of sexual abuse with a staff member. It documented an investigation had been started. On 09/16/16 at 9:11 a.m., the DON was asked what the policy was for reporting and investigating allegations of abuse. She stated they would interview the residents and staff involved. She stated they would review the findings and determine if further investigation was needed. She stated the administrator would sometimes do an additional investigation. The DON was asked to review the allegations made by resident #10. She was asked if an investigation had been completed. She stated, Yes. She was asked if the staff member accused of the allegation had been interviewed. She stated she would have to look. She was asked to locate staff and resident interviews related to the allegations. At 9:35 a.m., the DON stated she could not locate any investigative reports related to the allegation. She was asked if a thorough investigation had been conducted. She stated, I would say no. She was asked if a thorough investigation should have been conducted. She stated, Yes.

Based on record review and staff interviews, it was determined the facility failed to implement their abuse policy by failing to: ~ complete new employee reference checks for two (certified medication aide (CMA) #1 and certified nurse aide (CNA) #4) of five new employee records reviewed for employee reference checks and ~ complete a thorough investigation following a resident's allegation of abuse for one (#10) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents report, dated 09/14/16, documented 40 residents resided in the facility. The facility identified 16 new employee had been hired in the past four months. Findings: A facility background screening investigation policy, undated, documented, .Our facility conducts employment background screening checks, finger printing, reference checks and criminal conviction investigation checks on individuals making application for employment with our facility . The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction check on persons making application for employment with this facility. Such investigation will be initiated within two days of employment or offer of employment . A facility abuse investigations policy, undated, documented, .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management . Should an incident or suspected incident of resident abuse, mistreatment, neglect, injury of unknown source, resident to resident abuse or resident to staff abuse be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .An incident report will be completed for any allegation of abuse, neglect, and injuries of unknown source . The individual conducting the investigation will, as a minimum .Review the completed incident report .Review the resident's medical record to determine events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident . A facility abuse prevention program, undated, documented, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual . Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The protection of residents during abuse investigations .Timely and thorough investigations of all reports and allegations of abuse .The reporting and filing of accurate documents relative to incidents of abuse .An ongoing review and analysis of abuse incidents .The implementation of changes to prevent future occurrences of abuse . 1. Five employee files were reviewed. No documentation of reference checks having been conducted for CNA #4 and CMA #1 was located in the employee files. On 09/15/16 at 3:35 p.m., the administrator (ADM) was asked to locate documentation of a reference check having been completed for CNA #4 and CMA #1. On 09/16/16 at 8:30 a.m., the ADM was asked if reference checks were completed for CNA #4 and CMA #1. She stated the director of nursing (DON) had completed reference checks. However there was no documentation it was done. She stated, If it's not documented it's not done. She was asked what the policy was for reference checks. She stated she did not know the exact policy but the reference checks should be performed before employment to check for abuse and it should be documented. 2. Resident #10 had [DIAGNOSES REDACTED]. The resident's clinical record was reviewed. A late entry nurse's note, dated 05/30/16 at 6:30 a.m., documented, resident #10 had made an allegation of sexual abuse with a staff member to the staff who was providing him with bathing assistance. It documented this staff member informed the nurse on duty of the allegation. An Oklahoma State Department of Health (OSDH) incident report form, dated 05/30/16, documented resident #10's allegation of sexual abuse with a staff member. It documented an investigation had been started. On 09/16/16 at 9:11 a.m., the DON was asked what the policy was for reporting and investigating allegations of abuse. She stated they would interview the residents and staff involved. She stated they would review the findings and determine if further investigation was needed. She stated the administrator would sometimes do an additional investigation. The DON was asked to review the allegations made by resident #10. She was asked if an investigation had been completed. She stated, Yes. She was asked if the staff member accused of the allegation had been interviewed. She stated she would have to look. She was asked to locate staff and resident interviews related to the allegations. At 9:35 a.m., the DON stated she could not locate any investigative reports related to the allegation. She was asked if a thorough investigation had been conducted. She stated, I would say no. She was asked if a thorough investigation should have been conducted. She stated, Yes.

Based on record review and staff interviews, it was determined the facility failed to obtain physician ordered daily weights for two (#3 and #10) of three sampled residents reviewed for weight loss. The facility identified eight residents with orders for daily weights resided in the facility. Findings: A facility weights policy, documented, The nursing staff and the Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents .Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record . 1. Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].WEIGH DAILY - OBTAIN & (AND) RECORD WEIGHT DAILY (NOTIFY PCP (PRIMARY CARE PHYSICIAN) OF GAIN 3LB (POUND) IN 24 HOURS) . A physician's orders [REDACTED]. The care plan, dated 06/09/16, documented, .I am weighed daily and use [MEDICATION NAME] 40 mg. (milligram) daily. Staff reports weight gain in 24 (hour) period per PCP parameters . A dietitian notification, dated 08/16, documented, .5.7% (percent) wt (weight) (increase) x(times) 1 mo (month), 11 % (increase) x 3 mo (and) 8.8 % (increase) x 6 mo (with) BMI (body mass index) 29 .Monitor wt(weight) . The document was signed by the physician, dietitian and the DON (director of nursing). The weight record for the past three months for resident #3 was reviewed. No documentation of the resident having been weighed on 06/18, 06/27, 07/06, 07/09, 07/10, 07/11, 07/13, 07/14, 07/18, 07/21, 08/02, 08/04, 08/05, 08/06, 08/07, 08/09, 08/10, or 08/15/16 was located in the resident's clinical record. On 09/14/16, at 5:00 p.m., the DON was asked to provide documentation explaining the reason resident #3 had not been weighed daily as ordered by the physician. On 09/15/16 at 9:05 a.m., the DON stated she was unable to provide any documentation as to why the resident had not been weighed daily. She was asked if the facility staff should have weighed the resident daily or charted refusal in the clinical record for resident #3. She stated, Yes. She was asked if the physician's orders [REDACTED]. 2. Resident #10 had [DIAGNOSES REDACTED]. A care plan, dated 11/21/15, documented, [MEDICAL TREATMENT] Care Plan for (resident #10) .I am weighed daily & (and) my PCP (primary care physician) is notified of weight gain of 3lbs (pounds) in 24 hours . A doctor's order sheet, dated May 2016, documented, 06/30/15 WEIGHT - OBTAIN WEIGHT DAILY, NOTIFY PCP IF (greater than) 3LB WT GAIN x 24HR (hour). The May 2016 weight record did not document a weight for 05/01/16 or 05/16/16. The June 2016 weight record did not document a weight for 06/01/16. The July 2016 weight record did not document a weight for 07/05, 07/06, 07/09, 07/10, 07/11, 07/12, 07/13 or 07/18/16. On 09/16/16 at 8:45 a.m., the minimum data set (MDS) coordinator was asked what the policy was for obtaining resident's weights. She stated, Per physician orders. The standard order is monthly. At 9:47 a.m., the DON was asked if the daily weights had been obtained as ordered. She stated, No. She was asked if they should have been obtained as ordered. She stated, Yes.

Based on observation, record review, and staff interviews, it was determined the facility failed to maintain water temperatures at a safe level for two (room #13 and #15) of three resident rooms observed with hand sinks. The facility identified eight resident rooms with hand sinks. Findings: A facility water temperature policy, last revised December 2009, documented, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heaters that service resident rooms, bathroom, common areas, and tub/shower areas shall be set to temperatures of no more than 115 (degrees) . On 09/14/16 at 9:25 a.m., an environmental tour of the facility was conducted. The water temperature at the hand sink in room #13 was 127 degrees Fahrenheit. At 9:30 a.m., the water temperature at the hand sink in room #15 was 130 degrees Fahrenheit. At 9:40 a.m., the hand sink water temperature was 128 degrees Fahrenheit. At 10:40 a.m., the director of nursing (DON) was asked what the policy was for maintaining safe water temperatures. She stated they checked the water temperatures in the resident rooms weekly and adjusted them to stay below 106 degrees Fahrenheit. She was informed of the above findings. She was asked if she would consider those safe water temperatures. She stated, I think they would need to be adjusted. At 10:45 a.m., the housekeeping supervisor was informed of the above findings. She stated she checked the water temperatures daily.

Based on observation, staff interviews and record review, it was determined the facility failed to ensure a resident without a pressure ulcer did not develop one and failed to ensure the resident received the necessary treatment and preventive measures to promote healing for one (#21) of two sampled residents who had a pressure ulcer. This resulted in actual harm to the resident. The Resident Census and Conditions of Residents report, dated 11/16/15, documented 39 residents resided in the facility. The facility identified two residents who had pressure ulcers. Findings: Resident #21 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 10/09/15, documented, . ADL (activity of daily living) functional/rehab (rehabilitation) potential . Category Problem I am capable of participation in my care, but am requiring extensive assistance at this time . Goal I will continue participation in adls, with staff assistance .Approach I prefer to sleep in my recliner, but still have a bed in my room . Pressure ulcers .Category Problem I am at risk for pressure ulcers due to impaired mobility, incontinence and recent admission .Goal I will have no skin impairments observed and or reported daily over the next 90 days .Approach I use my wheelchair for mobility (and) prefer to sleep in my recliner. The staff encourage me to sleep in a completely reclined position to alleviate pressure The staff assists me with transfers, toileting and position changes I have a pommel cushion in my wheelchair, to prevent sliding, and a gel cushion in my recliner . My skin is assessed weekly by the nurse and anything unusual is reported to my pcp (primary care physician) . A resident admission assessment, dated 10/11/15, documented the resident's cognition was intact and she required extensive assistance of two or more people for bed mobility and transfers. It documented the resident was frequently incontinent of bowel and bladder. The resident did not have any weight loss. It documented the resident was at risk for pressure ulcers, but did not have any pressure ulcers. It was documented the resident had a pressure reducing device for her bed. A nurse's skin note, dated 10/13/15, documented the resident had no open areas or redness. A nurse's note, dated 10/19/15 at 2:41 p.m., documented the resident was found to have two open areas on her upper buttocks. The following was documented: ~ First open area 2 cm (centimeters) x 1.5 cm x 0.2 cm with yellow slough on the wound bed, macerated but attached wound edges; and ~ Second open area 1 cm x 1 cm x 0.2 cm with beefy red wound bed with normal edges. The nurse's note documented the areas were covered with hydrogel and covered with a foam dressing; the physician and family were notified; pressure prevention interventions were initiated and the resident was educated on pressure sores and encouraged to stay in bed on her side. The note further documented the resident continued with pressure cushion while in her recliner and wheelchair and, .This nurse notifies staff stating they CNA's x2 had previously reported an open area last week, DON (director of nursing) notified at this time . A physician fax communication, dated 10/20/15, documented the resident had an unstageable pressure ulcer to her coccyx measuring 2.0 cm x 1.5 cm x 0.2 cm with yellow slough to wound bed. The edges were noted to have granulation surrounding tissue appearing to be scar tissue. No reports of a previous wound. Would like to start on decubivite and or zinc. Maybe if possible wound care suggestions to follow later today. A wound care/skin integrity/evaluation, dated 10/20/15, documented the resident had a wound on her coccyx with an onset date of 10/19/15. The pressure ulcer was unstageable and measured 2.0 cm x 1.5 cm and the depth was utd. The drainage consistence: serosanguinous, acquisition: facility acquired, intervention: cleanse with wound cleanser and pat dry, skin prep surrounding tissue, apply TAO, santyl then hydrogel pad to wound bed only, cover with nonbordered foam, secure with transparent film and change q (every) day. A weekly pressure ulcer record, dated 10/20/15, documented the wound stage as unstageable, size: 2 cm x 1.5 cm, depth: 0.2 cm, exudate type/amount:slight serosanguinous drainage, wound bed: slough, surrounding skin color: purple, surrounding tissue/wound edges: granulated, preventative measures/progress: turned q 2 hours , pressure relieving interventions: cushion in wheelchair and recliner. A care plan dated 10-20-15, documented, . I have a UTD (unable to determine stage of pressure ulcer) of 2 x (by) 1.5. x 0.2 to my coccyx . My UDT will be healed in the next 60 days .Turn side to side while in bed. Only one (hour) at a time in recliner. Ask for decubivite daily. Pressure relieving mattress .Daily tx (treatment) of TAO (triple antibiotic ointment)/santyl/hydrogel. Weekly measurement .pcp notified of declines .Zinc Part B eval (evaluation) (and) tx (treat) . A nurse's note, dated 10/20/15 at 9:05 a.m., documented the resident continued with an open area with dressing in place, pcp notified one day prior, no new order was received. A nurse's note, dated 10/20/15 at 10:48 a.m., documented the resident had one unstageable area on the coccyx, measuring 2 cm x 1.5 cm x 0.2 cm with 95% yellow slough, edges slightly granulated, slight serosanguinous drainage, surrounding skin purplish, faxed PCP for wound orders and possible decubivite. The resident had a gel cushion in her wheelchair and in her recliner, resident was to be turned every two hours while in bed. A nurse's note, dated 10/20/15 at 11:52 a.m., documented a new order was received to cleanse the wound to the coccyx area with Vashe wound cleanser, pat dry, skin prep around skin, and small amount of TAO to wound bed, cover with santyl, hydrogel sheet, foam dressing, change daily and as needed. A nurse's note, dated 10/22/15 at 2:51 p.m., documented, .wound care done as ordered .Slough is app (approximately) 50% to wound bed, 50% granulation, moderated amount of no odor serosang exudate. Area appears to be healing well .cont (continue) with Pommel cushion in w/c (wheelchair) and gel cushion in recliner . A weekly pressure ulcer record, dated 10/28/15, documented the stage as unstageable, size: 2 cm x 1.3 cm, depth: 0.2 cm, exudate type/amount: slight serosanguinous, wound bed: slough, surrounding skin color: purple, surrounding tissue/wound edges: granulated, response to tx/comments: santyl/tao, hydrogel, foam dressing, preventative measures/progress: turned q 2 hrs pressure relieving interventions: cushion in wheelchair and recliner. A weekly pressure ulcer record, dated 11/02/15, documented the stage as unstageable, size 1.5 cm x 1cm, depth: 0.2 cm, wound bed: beefy, surrounding skin color: normal, surrounding tissue/wound edges: unattached, response to treatment/comments: change treatment to powered collagen, cover with foam, change dressing daily and as needed. A care plan dated 11/2/15, documented, . Daily tx (treatment) of Pwd (powered) Collagen to wound bed . A diet consult recommendation, dated 11/03/15, documented the resident had a wound on her coccyx with an [MEDICATION NAME] level of 2.9. The registered dietitian (RD) recommended for the resident to have milk with meals or an extra one ounce of protein with meals. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A weekly pressure ulcer record, dated 11/09/15, documented the stage as unstageable, size: 1 cm x 1 cm, depth: 0.1 cm, wound bed: beefy, surrounding skin color: normal, surrounding tissue/wound edges: unattached, macerated, response to treatment/comments: continue current treatment, preventative measures/progress: turned q 2 hrs, pressure relieving interventions: cushion in wheelchair and recliner. A weekly pressure ulcer record, dated 11/11/15, documented the stage as unstageable, size 1 cm x 1 cm, depth 0.1 cm, wound bed: beefy, surrounding skin color: normal, surrounding tissue/wound edges: unattached, response to treatment/comments: changed dressing to powdered collagen then hydrogel sheet, cover with foam, preventative measures/progress: turned q 2 hrs, pressure relieving interventions. gel cushion in wheelchair and in recliner, multivitamins: Zinc. A care plan dated 11/11/15, documented, .Cleanse (with) Vashe. pat dry. apply Collagen Pwd. Apply hydrogel. cover (with) foam drg (dressing) . A weekly pressure ulcer record, dated 11/18/15, documented the stage as unstageable, size: 1.4 cm x 1.4 cm, depth: 0.2 cm , exudate type/amount: minimal serosanguinous drainage, wound bed: granulation with slough, surrounding skin color: pink, surrounding skin tissue: unattached, preventative measures/progress: turned q 2 hrs, pressure relieving interventions: cushion in chair. On 11/18/15 at 7:54 a.m., the resident was observed in the dining room sitting on a pommel cushion in her wheelchair. No pressure relieving device was observed in her wheelchair. At 8:21 a.m., the resident was observed sitting in her recliner in her room on a gel cushion. A pommel cushion was observed in her wheelchair in her room. At 10:06 a.m., the resident was observed propelling herself down the hall from the physical therapy room to the front lobby for balloon therapy in her wheelchair. She was sitting on a pommel cushion in her wheelchair. No pressure relieving device was observed in her wheelchair. At 10:48 a.m., the resident was observed propelling herself in her wheelchair to the dining room from balloon therapy. A pommel cushion was observed in her wheelchair. No pressure relieving device was observed in her wheelchair. At 11:11 a.m., the resident was observed in the dining room receiving her lunch. Her plate contained a hamburger on a bun, chips, garnish, cake and coffee. There was no milk observed or an extra one ounce of protein with the lunch meal. At 12:46 p.m., an observation was made of the resident's pressure ulcer. The resident was observed lying in bed on her right side. The wound had no dressing. Licensed practical nurse (LPN) #2 was asked if the resident should have had a dressing in place. She stated the dressing was off due to being soiled. The wound had a scant amount of white slough. The wound was approximately 1.5 cm around on the coccyx. LPN #2 was asked the stage of the wound. She stated the wound was considered to be unstageable due to slough being present in the wound initially. LPN # 2 was asked if the resident was admitted with the wound. She stated no. She stated she was told by staff the dressing was soiled and had been taken off around 12:15 p.m. LPN #2 was asked what the policy was if a resident's dressing had become soiled. She stated she would normally re-dress the wound. At 3:35 p.m., certified nursing aide (CNA) #1 was asked if the resident had any skin breakdown. She stated yes. She was asked where the skin breakdown was located. She stated she had skin breakdown on her bottom. She was asked what interventions were in place to help prevent/heal the resident's pressure ulcer. She stated she was supposed to put the resident on her side in her bed and put a pillow behind her back and bottom. She stated she also put cream on her bottom. She was asked the purpose of the pommel cushion in the resident's wheelchair. She stated she had a pommel cushion in her wheelchair to prevent her from sliding out of her wheelchair. At 3:50 p.m., LPN #1 was asked if the resident had a pressure ulcer. She stated she had a pressure ulcer on her coccyx. She was asked when the pressure ulcer developed. She stated she developed one pressure ulcer on 10/20/15. She was asked to clarify the nurse's note which documented the resident had two pressure ulcers on 10/19/15. She stated she didn't know it was documented the resident had two pressure ulcers. She stated she observed the wound on 10/20/15, and there was only one. She was asked what interventions were implemented to aid in the healing of her pressure ulcer. She stated the resident had a gel cushion in her recliner and in her wheelchair, vitamins, a pressure relieving mattress and she was turned at night every two hours. She was asked what was the purpose of the pommel cushion in her wheelchair. She stated the resident slid down in her wheelchair and it was also being used as a pressure relieving device. She was asked what pressure relieving devices were in place for the resident. She stated the resident had a gel cushion in her recliner, a pressure relieving mattress and a pommel cushion in her wheelchair. She was asked how did the resident develop the pressure ulcer. She stated she didn't really know. She stated lack of care maybe. At 4:31 p.m., LPN #2 was asked to review the nurse's note dated 10/19/15, in regard to the two pressure ulcers noted to the resident's upper buttocks. She stated she thought it looked like there were two pressure ulcers so she was instructed by the director of nursing (DON) to chart what she saw and was told the wound care nurse would be in the next day to assess the wound. She stated knowing what she knows now, because she was in-serviced, the second one was a shear. At 4:29 p.m. the resident was observed propelling herself in her wheelchair to the dining room. A pommel cushion was observed in her wheelchair. A gel cushion was observed in the recliner in her room. No pressure relieving device was observed in her wheelchair. At 4:38 p.m., the DON was asked if the resident was at risk for pressure ulcers when she was admitted to the facility. She stated yes. She was asked what interventions were implemented to prevent the development of pressure ulcers because she was at risk. She stated skin assessments were done weekly and during bathing, peri care after incontinent episodes and she was repositioned every two hours as needed. She was asked how the resident developed a pressure ulcer. She stated the resident slept in her recliner for a couple of weeks when she got here. She stated if she had to guess the resident developed the pressure ulcer because she wanted to stay in her recliner. She stated the resident would refuse to get out of her recliner and would be asked to be left alone. She was asked what interventions were in place currently to aid in the healing of the pressure ulcer. She stated the resident received wound care, had a cushion in her recliner, skin assessments were done weekly during bathing, she was repositioned in bed, had a cushion in her wheelchair, a pressure relieving mattress and vitamins. She was asked how the pommel cushion was a pressure relieving device. She stated to an extent the pommel cushion was a pressure relieving device. She stated the pommel cushion was used to keep the resident's thighs apart and keep her from sliding which caused friction which could lead to a pressure ulcer or shearing or cause more pressure. The resident had been using a Pommel cushion since prior to her developing a pressure ulcer, as documented in the care plan (dated 10/09/15). On 11/19/15 at 8:20 a.m., the dietary manager (DM) was asked how dietary was informed of diet changes or updates to the resident's diet orders. She stated dietary received a communication form when there were changes made. She was shown the meal card for the resident, which indicated the resident was to receive a regular diet and regular portions with meals. She was asked if she had received a communication form for the resident to receive milk and an extra protein with meals. She stated the registered dietitian made a recommendation on 11/03/15, but dietary hadn't been notified of any changes yet. At 9:00 a.m., the DON was asked what the policy was when there was a recommendation from the RD in regard to a residents diet. She stated the recommendation was sent to the doctor for approval. If it was approved there would be a communication form provided to the nurses/dietary. She was asked to look at the resident's physician's orders [REDACTED]. She was informed the resident's dietary meal card did not indicate the resident was to receive milk and an extra protein with her meals. She was made aware the resident did not receive extra protein or milk with her lunch tray on 11/18/15. She was asked if the resident should have received extra milk and protein with her meals. She stated she should have. At 4:30 p.m., the regional director of nursing agreed the pommel cushion was not a pressure relieving cushion.

Based on observations, record review and staff interviews, it was determined the facility failed to ensure residents received the assistance required to transfer safely and staff followed the resident's plan of care for one (#21) of one sampled resident whose record was reviewed for assistance with activities of daily living. This resulted in an actual harm of a leg laceration requiring 12 sutures to the resident. The Resident Census and Conditions report, dated 11/16/15, documented 20 residents required assistance of one or two staff for transfers. The facility identified 22 residents who used a wheelchair for mobility. Findings: Resident #21 had [DIAGNOSES REDACTED]. A care plan, dated 10/09/15, documented, .ADL functional/rehab (rehabilitation) potential .Category Problem I am capable of participation in my care, but am requiring extensive assistance at this time Category Goal I will continue participation in adls, with staff assistance over the next 90 days. Category Approach I am able to assist with transfers, but have days when I don't want to and make staff bear my full weight . Falls . Category Problem I have a history of falls and am at risk for falls Category Goal I will have no falls with major injury over the next 90 days Category Approach .I am able to help with transfers, to some degree but there are days when I don't make any effort and make the staff bear my full weight. The staff use the sit to stand or hoyer lift as needed I use my call light and have not attempted to transfer or perform ADL care without staff assistance . A resident admission assessment, dated 10/11/15, documented the resident's cognition was intact. It was documented the resident required extensive assistance of two or more people for bed mobility and transfers and utilized a wheelchair as a mobility device. A nurse's note, dated 10/22/15 at 9:52 p.m., documented, .AT APPROX (approximately) 2020 (8:20 p.m.) CMA (certified medication aide) (name deleted) NOTIFIES THIS NURSE THAT RES (resident) WITH WOUND OR CUT TO LOWER EXTREMITIY (sic). UPON ENTERING ROOM # 24A, BLOOD NOTED ON FLOOR AND RES NOTED IN BED WITH CMA (name deleted) HOLDING TOWEL ON LLE (left lower extremity). CMA REPORTS HE IS NOT SURE WHAT RES GOT LEG CAUGHT ON BUT DURING TRANSFER FROM W/C (wheelchair) TO BED AFTER HE STOOD RES UP SHE YELLED OUT AND POINTED TO HER LT (left) LEG. HE THEN REPORTS THAT HE NOTICED BLOOD ON FLOOR AND LACERATION ON RES LLE. HE REPORTES (sic) HE CALLED FOR HELP AND FINISHED POSITIONING RES IN BED TO ELEVATE LLE AND PUT A TOWEL ON LACERATION ON LT LEG AND HELD PRESSURE. THIS NURSE REMOVED TOWEL AND A 8 CM (centimeter) (L) (length) X (by) 6 CM (W) (width) WITH APPROX DEPTH OF 2 CM. VISIBLE YELLOW FATTY TISSUE SEEN. CLEANSED AREA WITH NSS (normal saline solution), NO VISIBLE BLEEDING NOTED. APPLIED WET TO DRY DRESSING WITH NSS AND WRAPPED WITH ROLL GAUZE. INSTRUCTED CMA TO ADM (administer) PRN (as needed) PAIN MED (medication) AND PRN [MEDICATION NAME] ADM. VS (vital signs): 97.2 AX (axilliary)-70-20 B/P (blood pressure) 166/54 SPO2 (oxygen saturation) 97% ON R/A (room air). RES REMIANS (sic) IN BED WITH LT LEG ELEVATED ON PILLOW. WILL ASSESS ENVIREMENT (sic) FOR POSSIBLE CAUSE OF INCIDENT AFTER RES SENT TO ER (emergency room ). CALL LIGHT IN REACH . A nurse's note, dated 10/22/15 at 9:56 p.m., documented, .2035 (8:35 p.m.) PHONED RES PCP (primary care physician) (doctors name) AND INFORMED HIM OF LACERATION TO LLE AND NEED TO SEND TO ER FOR STITCHES. PCP GAVE OKAY TO SEND TO ER FOR EVAL (evaluation) AND TX (treatment). ORDER WRITTEN TO SEND TO ER . A nurse's note, dated 10/22/2015 at 9:57 p.m., documented, .2040 (8:40 p.m.) PHONED FOR AMBULANCE TRANSFER TO (hospital name deleted) ER .2042 (8:42 p.m.) PHONED RES RESP (responsible) PARTY (name deleted) AND INFORMED HER OF RES OBTAINING DEEP LACERATION TO LLE AND THAT RES WILL BE SENT TO HOSP (hospital) FOR STITCHES. SHE ASKED HOW RES WAS DOING AND INFOMRED (sic) HER THAT RES IN BED AND AREA OF LT LEG WRAPPED AND ELEVATED. THAT RES WAS ADM PRN [MEDICATION NAME] AT 2023 (8:23 p.m.). SHE ASKED THIS NURSE TO NOTIFY (name deleted), RES GRANDSON FROM (city name deleted). DID AS DAUGHTER ASKED AND PHONED (name deleted) DIRECTLY AFTER. HE REPORTED HE WAS UNABLE TO MEET RES AT ER D/T (due to) HE IS OUT OF TOWN. HE ASKED HOW INCIDENT OCCURRED AND THIS NURSE REPORTED THAT SHARP AREA NOTED ON W/C (wheelchair) WHICH MOST LIKELY CAUSED LACERATION. HE ASKED TO BE PHONED WITH ANY UPDATES ON RES STATUS. INFOMRED (sic) HIM THIS NURSE WOULD DO SO. NO OTHER CONCERNS VOCIED (sic) . A nurse's noted, dated 10/22/15 at 10:05 p.m., documented, . 2050 (8:50 p.m.) AMBULANCE WITH EMT'S (emergency medical technician) ARRIVED AT FACILIY (sic). INFORMED RES THAT FAMILY NOTIFIED AND THAT SHE IS GOING TO ER FOR STITCHES TO LEG. RES STATED, OH IT DOESN'T NEED STITCHES. INFORMED RES SHE NEEDED TO GET AREA LOOKED AT BY DR. (doctor) RES OKAY WITH THIS AND BEING SENT TO ER. RES TRANSFERRED TO GURRNEY (sic). EMT REMOVED DRESSING TO ASSESS LACERATION. EMT STATED, LAST TIME WE SEEN ONE LIKE THIS IT WAS DUE TO W/C. RES LEFT FACILITY VIA AMBULANCE. RES AAO (awake/alert/oriented) X 3 AND ASKING QUESTIONS FREQUENTLY. SHE DENIES PAIN OF ANY KIND. PROPER PAPERWORK SENT WITH EMT . A nurse's note, dated 10/22/15 at 10:30 p.m., documented, .ASSESSED RES W/C AND SHARP EDGE NOTED ON AREA WHERE FOOT PEDLES (sic) HOOK TO W/C. PLACED PADDING TO W/C AND SECURED WITH TAPE . A nurse's note, dated 10/22/15 at 10:32 p.m. .RECEIVED PHONE CALL FROM NURSE AT (hospital name deleted) ER AND SHE REPORTED RES READY FOR PICK UP. RES RECEIVED 12 SUTURES TO LLE. TO KEEP DRESSING IN PLACE FOR 3 DAYS. REMOVE SUTURES IN 14 DAYS AND THEN DO DAILY TX (treatment). PHONED TRANSPORT STAFF AND INFOMRED (sic) HER OF NEED TO PICK UP RES FROM HOSP (hospital) . A nurse's note, dated 10/22/15 at 11:57 p.m., documented, .2320 (11:20 p.m.,) RES RETURNED VIA FACILITY VAN AND STAFF ACCOMPANING. RES ENTERED FACILITY VIA W/C WITH STAFF PROPEL. RES REPROTS (sic) SHE IS TIRED AND NEEDS TO USE TOIELT (sic). STAFF ASSISTED RES TO HER ROOM. VS UPON RETURN: 96.5 AX-75-18 168/72 SPO2 96% ON R/A. RES WITH PINK COBAN WRAP TO LLE. ASSISTED RES TO TOILET WITH 2 PERSON ASSIST. RES VOIDED. PERI CARE PROVIDED AND RES TRANSFERRED (sic) TO BED WITH 2 ASSIST. PER FACILITY POLICY, UNWRAPPED COBAN TO LLE, UNDER COBAN ROLL GAUZE REMOVED. 4X4'S AND NON STICK DRESSING WITH MIN (minimal) AMT (amount) BLOOD NOTED OVER LACERATION. NO ACTIVE BLEEDING NOTED. 12 TOTAL SUTURS (sic) NOTED INTACT. 3 SUTURE LIN3S (sic) NOTED IN A W PATTERN. FIRST LINE WITH (with) 5 SUTURES NOTED APPROX 5 CM LENGTH, SECOND LINE WITH (sic) 3 SUTURES INTACT APPROX 3.5 CM LENGTH AND THIRD SUTURE LINE WITH 4 SUTURES IN TACT (sic) APPROX (approximately) 4 CM LENGTH. RES REPRTED (sic) PAIN TO AREA WITH TOUCH. REAPPLIED CLEAN NON STICK DRESSING, COVERED WITH 4X4 GAUZE, WRAPPED WITH ROLL GAUZE THEN WITH COBAN. RES TOL (tolerated) WELL. NO FURTHER C/O (complaints) ANY (sic) VOICED. RES LYING ON RT (right) SIDE WITH CALL LIGHT IN REACH. PILLOWS UNDER LLE AND BEHIND BACK FOR COMFORT . On 11/18/15 at 12:37 p.m., certified nurses aide #9 (CNA) was asked to describe the incident that occurred on 10/22/15 when resident #21 was transferred from her wheelchair to her bed and obtained a laceration to her left lower leg. He stated he had transferred the resident from her w/c to her bed. When he was turning the resident she got her calf caught on something. He stated he wasn't sure what she cut her leg on. He stated he didn't know if she cut her leg on her w/c or on her bed. He stated her leg didn't start bleeding right away. He stated her leg didn't start bleeding until she was sat on the bed. He stated the resident yelled out half way between the w/c and the bed. He noticed a little blood on her sock at that point. He stated her leg started bleeding and he got a towel to put on her leg. There was already a puddle of blood on the floor. He stated he yelled for help from the certified medication aide (cma) in the hallway to get the nurse. He stated he was the only one in the room at the time. He was asked what assistance the resident required with transfers. He stated the resident was a one person assist and at times she would be a two person assist depending on who was assisting her. He stated he's not sure what assistance she required now. He stated he usually worked the west hall which is heavier assist. At 1:01 p.m., resident #21's wheelchair was observed. The foot pedal attachments on the wheelchair had rough, sharp edges. At 3:35 p.m., CNA #1 was asked how many staff members were required to transfer resident #21. She stated it took two staff members to transfer the resident. She was asked how she knew how many people were required to transfer residents. She stated she thought it was in the resident's charts. She was asked how she knew resident #21 was a two person assist with transfers. She stated she just knows she is a two person assist. At 3:50 p.m., LPN #1 was asked how many staff members were required to transfer resident #21. She stated the transfer depends on the person. She stated the resident may require anywhere from one to two people for transfers. She was asked how the resident cut her leg. She stated the resident cut her leg on the side of her wheelchair. She stated the resident bumped her leg on the side while being transferred. She was asked how do staff know how many people are required for transfers. She stated through verbal communication. She was asked what interventions were put into place after the incident. She stated staff were educated on proper transfer technique. She was asked if there were issues with the resident's w/c. She stated there were no issues with the resident's wheelchair. At 4:58 p.m., the director of nursing was asked to look at resident #21's wheelchair and determine if the foot pedal attachment edges were rough and sharp. She stated all of the wheelchairs were like that. She didn't consider the wheelchair to have rough or sharp edges. She stated the w/c the resident was in now was a different one from the w/c that cut the residents leg. On 11/19/15 at 9:05 a.m., the minimum data set (mds) coordinator was asked to review resident #21's admission assessment, dated 10/11/15, and explain how she determined what assistance the resident required with transfers. She stated she looked at the adls and nurses' notes. She stated based on the information documented, the resident required extensive assistance during the look back period.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure adequate transfer assistance was provided and resident care equipment was maintained in a manner to prevent a resident from sustaining a leg injury while being transferred for one (#21) of one sampled resident reviewed for accidents. This resulted in an actual harm of a leg laceration requiring 12 sutures to the resident. The Resident Census and Conditions of Residents report, dated 11/16/15, documented 20 residents required assistance of one or two staff for transfers. The facility identified 22 residents who used a wheelchair for mobility. Findings: Resident #21 had [DIAGNOSES REDACTED]. A care plan, dated 10/09/15, documented, .ADL functional/rehab (rehabilitation) potential .Category Problem I am capable of participation in my care, but am requiring extensive assistance at this time Category Goal I will continue participation in adls, with staff assistance over the next 90 days. Category Approach I am able to assist with transfers, but have days when I don't want to and make staff bear my full weight . Falls . Category Problem I have a history of falls and am at risk for falls Category Goal I will have no falls with major injury over the next 90 days Category Approach .I am able to help with transfers, to some degree but there are days when I don't make any effort and make the staff bear my full weight. The staff use the sit to stand or hoyer lift as needed I use my call light and have not attempted to transfer or perform ADL care without staff assistance . A resident admission assessment, dated 10/11/15, documented the resident's cognition was intact. It was documented the resident required extensive assistance of two or more people for bed mobility and transfers and utilized a wheelchair as a mobility device. A nurse's note, dated 10/22/15 at 9:52 p.m., documented, .AT APPROX (approximately) 2020 (8:20 p.m.) CMA (certified medication aide) (name deleted) NOTIFIES THIS NURSE THAT RES (resident) WITH WOUND OR CUT TO LOWER EXTREMITIY (sic). UPON ENTERING ROOM # 24A, BLOOD NOTED ON FLOOR AND RES NOTED IN BED WITH CMA (name deleted) HOLDING TOWEL ON LLE (left lower extremity). CMA REPORTS HE IS NOT SURE WHAT RES GOT LEG CAUGHT ON BUT DURING TRANSFER FROM W/C (wheelchair) TO BED AFTER HE STOOD RES UP SHE YELLED OUT AND POINTED TO HER LT (left) LEG. HE THEN REPORTS THAT HE NOTICED BLOOD ON FLOOR AND LACERATION ON RES LLE. HE REPORTES (sic) HE CALLED FOR HELP AND FINISHED POSITIONING RES IN BED TO ELEVATE LLE AND PUT A TOWEL ON LACERATION ON LT LEG AND HELD PRESSURE. THIS NURSE REMOVED TOWEL AND A 8 CM (centimeter) (L) (length) X (by) 6 CM (W) (width) WITH APPROX DEPTH OF 2 CM. VISIBLE YELLOW FATTY TISSUE SEEN. CLEANSED AREA WITH NSS (normal saline solution), NO VISIBLE BLEEDING NOTED. APPLIED WET TO DRY DRESSING WITH NSS AND WRAPPED WITH ROLL GAUZE. INSTRUCTED CMA TO ADM (administer) PRN (as needed) PAIN MED (medication) AND PRN ULTRAM ADM. VS (vital signs): 97.2AX (axilliary)-70-20 B/P (blood pressure) 166/54 SPO2 (oxygen saturation) 97% ON R/A (room air). RES REMIANS (sic) IN BED WITH LT LEG ELEVATED ON PILLOW. WILL ASSESS ENVIREMENT (sic) FOR POSSIBLE CAUSE OF INCIDENT AFTER RES SENT TO ER (emergency room ). CALL LIGHT IN REACH . A nurse's note, dated 10/22/15 at 9:56 p.m., documented, .2035 (8:35 p.m.) PHONED RES PCP (primary care physician) (doctors name) AND INFORMED HIM OF LACERATION TO LLE AND NEED TO SEND TO ER FOR STITCHES. PCP GAVE OKAY TO SEND TO ER FOR EVAL (evaluation) AND TX (treatment). ORDER WRITTEN TO SEND TO ER . A nurse's note, dated 10/22/2015 at 9:57 p.m., documented, .2040 (8:40 p.m.) PHONED FOR AMBULANCE TRANSFER TO (hospital name deleted) ER .2042 (8:42 p.m.) PHONED RES RESP (responsible) PARTY (name deleted) AND INFORMED HER OF RES OBTAINING DEEP LACERATION TO LLE AND THAT RES WILL BE SENT TO HOSP (hospital) FOR STITCHES. SHE ASKED HOW RES WAS DOING AND INFOMRED (sic) HER THAT RES IN BED AND AREA OF LT LEG WRAPPED AND ELEVATED. THAT RES WAS ADM PRN ULTRAM AT 2023 (8:23 p.m.). SHE ASKED THIS NURSE TO NOTIFY (name deleted), RES GRANDSON FROM (city name deleted). DID AS DAUGHTER ASKED AND PHONED (name deleted) DIRECTLY AFTER. HE REPORTED HE WAS UNABLE TO MEET RES AT ER D/T (due to) HE IS OUT OF TOWN. HE ASKED HOW INCIDENT OCCURRED AND THIS NURSE REPORTED THAT SHARP AREA NOTED ON W/C (wheelchair) WHICH MOST LIKELY CAUSED LACERATION. HE ASKED TO BE PHONED WITH ANY UPDATES ON RES STATUS. INFOMRED (sic) HIM THIS NURSE WOULD DO SO. NO OTHER CONCERNS VOCIED (sic) . A nurse's noted, dated 10/22/15 at 10:05 p.m., documented, . 2050 (8:50 p.m.) AMBULANCE WITH EMT ' S (emergency medical technician) ARRIVED AT FACILIY (sic). INFORMED RES THAT FAMILY NOTIFIED AND THAT SHE IS GOING TO ER FOR STITCHES TO LEG. RES STATED, OH IT DOESN ' T NEED STITCHES. INFORMED RES SHE NEEDED TO GET AREA LOOKED AT BY DR. (doctor) RES OKAY WITH THIS AND BEING SENT TO ER. RES TRANSFERRED TO GURRNEY (sic). EMT REMOVED DRESSING TO ASSESS LACERATION. EMT STATED, LAST TIME WE SEEN ONE LIKE THIS IT WAS DUE TO W/C. RES LEFT FACILITY VIA AMBULANCE . RES AAO (awake/alert/oriented) X 3 AND ASKING QUESTIONS FREQUENTLY. SHE DENIES PAIN OF ANY KIND. PROPER PAPERWORK SENT WITH EMT . A nurse's note, dated 10/22/15 at 10:30 p.m., documented, .ASSESSED RES W/C AND SHARP EDGE NOTED ON AREA WHERE FOOT PEDLES (sic) HOOK TO W/C. PLACED PADDING TO W/C AND SECURED WITH TAPE . A nurse's note, dated 10/22/15 10:32 p.m. .RECEIVED PHONE CALL FROM NURSE AT (hospital name deleted) ER AND SHE REPORTED RES READY FOR PICK UP. RES RECEIVED 12 SUTURES TO LLE. TO KEEP DRESSING IN PLACE FOR 3 DAYS. REMOVE SUTURES IN 14 DAYS AND THEN DO DAILY TX (treatment). PHONED TRANSPORT STAFF AND INFOMRED (sic) HER OF NEED TO PICK UP RES FROM HOSP (hospital) . A nurse's note, dated 10/22/15 at 11:57 p.m., documented, .2320 (11:20 p.m.,) RES RETURNED VIA FACILITY VAN AND STAFF ACCOMPANYING. RES ENTERED FACILITY VIA W/C WITH STAFF PROPEL. RES REPROTS (sic) SHE IS TIRED AND NEEDS TO USE TOIELT (sic). STAFF ASSISTED RES TO HER ROOM. VS UPON RETURN: 96.5 AX-75-18 168/72 SPO2 96% ON R/A. RES WITH PINK COBAN WRAP TO LLE. ASSISTED RES TO TOILET WITH 2 PERSON ASSIST. RES VOIDED. PERI CARE PROVIDED AND RES TRANSFERRED (sic) TO BED WITH 2 ASSIST. PER FACILITY POLICY, UNWRAPPED COBAN TO LLE, UNDER COBAN ROLL GAUZE REMOVED. 4X4'S AND NON STICK DRESSING WITH MIN (minimal) AMT (amount) BLOOD NOTED OVER LACERATION. NO ACTIVE BLEEDING NOTED. 12 TOTAL SUTURS (sic) NOTED INTACT. 3 SUTURE LIN3S (sic) NOTED IN A W PATTERN. FIRST LINE WITH (with) 5 SUTURES NOTED APPROX 5 CM LENGTH, SECOND LINE WITH (sic) 3 SUTURES INTACT APPROX 3.5 CM LENGTH AND THIRD SUTURE LINE WITH 4 SUTURES IN TACT (sic) APPROX (approximately) 4 CM LENGTH. RES REPRTED (sic) PAIN TO AREA WITH TOUCH. REAPPLIED CLEAN NON STICK DRESSING, COVERED WITH 4X4 GAUZE, WRAPPED WITH ROLL GAUZE THEN WITH COBAN. RES TOL (tolerated) WELL. NO FURTHER C/O (complaints) ANY (sic) VOICED. RES LYING ON RT (right) SIDE WITH CALL LIGHT IN REACH. PILLOWS UNDER LLE AND BEHIND BACK FOR COMFORT . On 11/18/15 at 8:02 a.m., resident #21's call light was activated. The director of nursing (DON) answered the call light and went in to assist the resident to the restroom. The DON told the resident she would have to help her with standing up. The DON pushed the resident into the restroom and told her to reach for the grab bar. The DON pulled the resident up by her right arm and it took three attempts for the resident to stand up and grab the grab bar before she turned to the toilet. The resident stated, It's pinching me. The DON stood the resident up again and repositioned her three times on the toilet seat. The DON was asked if the resident was a one person assist. She stated usually. She stated she had a knee that buckles. She stated normally she was a one person assist for transfers. The DON asked the resident if she was finished. The resident stated yes. The DON told the resident she was going to have to stand up, big and tall. The resident stood up to grab the grab bar. The DON then assisted the resident with peri care. The resident was able to back up into the wheelchair with the assistance of the DON. The DON asked the resident if she wanted in her recliner. The resident stated yes. The DON transferred the resident to her recliner with both of her arms under the residents arms and around her back. At 12:37 p.m., certified nurses aide #9 (CNA) was asked to describe the incident that occurred on 10/22/15 when resident #21 was transferred from her wheelchair to her bed and obtained a laceration to her left lower leg. He stated he had transferred the resident from her w/c to her bed. When he was turning the resident she got her calf caught on something. He stated he wasn't sure what she cut her leg on. He stated he didn't know if she cut her leg on her w/c or on her bed. He stated her leg didn't start bleeding right away. He stated her leg didn't start bleeding until she was sat on the bed. He stated the resident yelled out half way between the w/c and the bed. He noticed a little blood on her sock at that point. He stated her leg started bleeding and he got a towel to put on her leg. There was already a puddle of blood on the floor. He stated he yelled for help from the certified medication aide (cma) in the hallway to get the nurse. He stated he was the only one in the room at the time. He was asked what assistance the resident required with transfers. He stated the resident was a one person assist and at times she would be a two person assist depending on who was assisting her. He stated he's not sure what assistance she required now. He stated he usually worked the west hall which is heavier assist. At 1:01 p.m., resident #21's wheelchair was observed. The foot pedal attachments on the wheelchair had rough, sharp edges. At 3:35 p.m., CNA #1 was asked how many staff members were required to transfer resident #21. She stated it took two staff members to transfer the resident. She was asked how she knew how many people were required to transfer residents. She stated she thought it was in the resident's charts. She was asked how she knew resident #21 was a two person assist with transfers. She stated she just knows she is a two person assist. At 3:50 p.m., LPN #1 was asked how many staff members were required to transfer resident #21. She stated the transfer depends on the person. She stated the resident may require anywhere from one to two people for transfers. She was asked how the resident cut her leg. She stated the resident cut her leg on the side of her wheelchair. She stated the resident bumped her leg on the side while being transferred. She was asked how staff knew how many people are required for transfers. She stated through verbal communication. She was asked what interventions were put into place after the incident. She stated staff were educated on proper transfer technique. She was asked if there were issues with the resident's w/c. She stated there were no issues with the resident's wheelchair. At 4:58 p.m., the director of nursing was asked to look at resident #21's wheelchair and determine if the foot pedal attachment edges were rough and sharp. She stated all of the wheelchairs were like that. She didn't consider the wheelchair to have rough or sharp edges. She stated the w/c the resident was in now was a different one from the w/c that cut the residents leg. On 11/19/15 at 9:05 a.m., the minimum data set (mds) coordinator was asked to review resident #21's admission assessment, dated 10/11/15, and explain how she determined what assistance the resident required with transfers. She stated she looked at the adls and nurses' notes. She stated based on the information documented, the resident required extensive assistance during the look back period.