Every finding on record at Meadowlake Estates

Based on observation, record review, and interview, the facility failed to ensure medications were stored securely to prevent unauthorized access during 1 of 2 observations of medication storage.The DON identified 109 residents received medication from the facility.Findings:On 03/25/26 at 10:25 a.m., a white pill identified as a 100 mg gabapentin (an anticonvulsant) was observed laying on top of a medication cart in the hall outside of a resident's room. There was no staff in sight of the medication cart.A facility policy titled Medication Administration General Guidelines, dated 01/2024, read in part, 17. During administration of medications, the medications cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering the medications when unlocked.On 03/25/26 at 10:30 a.m., the DON was shown the pill located on top of the medication cart. The DON stated the pill was a 100 mg gabapentin (an anticonvulsant). The DON stated a resident could have picked up the pill and consumed it. On 03/25/26 at 11:45 a.m., RN #1 stated they punched a 100 mg gabapentin (an anticonvulsant) pill from the card to administer it to a resident. RN #1 stated the pill dropped, and they were unable to locate it. RN #1 stated they got another pill and administered it to the resident. RN #1 stated they did not notify the DON. RN #1 stated another resident could have come by and taken the medication. On 03/31/26 at 12:51 p.m., the DON stated the pill was found unattended on top of the medication cart. The DON stated when RN #1 could not locate the missing medication, RN #1 should have notified someone to help look for the missing medication. The DON stated the pill was found visible on top of the cart where another resident could have consumed the medication. The DON stated all medications should be stored safely and the pill was not stored to prevent unauthorized access to it.

Based on observation, record review, and interview, the facility failed to: a. provide incontinent care to prevent a moisture associated pressure ulcer for 1 (#5); and b. ensure care was provided as ordered by the physician for 1 (#6) of 3 residents sampled for ADL care to prevent/worsening of pressure ulcers. The DON reported 114 residents resided in the facility. Six residents had wounds. Findings: A facility policy titled Prevention of Pressure Ulcers/Injuries, dated July 2018, read in part,Based upon the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to: a. Redistribute pressure (such as repositioning, protecting and/or offloading heels); b. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. 1. Res #5 admitted with diagnoses of muscle wasting and atrophy, major depressive disorder, and muscle weakness. An Incident Investigation Report, dated 02/23/24, read in part, On 02/23/25, it was reported by the 11-7 nurse that the residents: [Res #6], name withheld, name withheld, [Res #5], and name withheld were observed to be brown ringed and soaking wet. Focused assessment completed. Stage II noted to [Res #5]. A skin assessment, dated 02/23/25, showed a pressure wound to the saccrum. A physican order, dated 02/23/25, ordered hydrocolloid three times weekly. A wound care physican note, dated 02/25/25, showed moisture assosicated wound area with surrounding dermatitis. The open area meausred 0.7x1x.01. A wound care physician note, dated 03/06/25, showed the wound was resolved. On 3/12/25 at 2:57 p.m., the DON reported the resident should have been checked every two hours and the CNA had been terminated. 2. On 03/11/25 at 10:50 a.m., Res #6 was observed resting in bed with eyes open. The resident's heels were observed resting directly on the mattress. On 03/12/25 at 8:50 a.m., Res #6 was observed resting in bed with eyes open. The resident's heels were observed resting directly on the mattress. On 03/12/25 at 10:16 a.m., Res #6 was observed resting in bed with eyes closed. LPN #2 was asked to uncover the resident's feet. The resident's feet were observed resting directly on the mattress. Res #6 admitted with diagnoses of dementia, anxiety disorder, and macular degeneration. A physician order, dated 09/11/24, documented treatment every shift float heels while in bed. On 03/12/25 at 2:27 p.m., LPN #2 reported they were not aware of the resident's order to float heels while in bed. On 03/12/25 at 2:54 p.m., the DON reported a physician's order should always be followed.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for 1 (#1) of 5 sampled residents reviewed for assistance with ADLs. The DON identified 114 residents who resided in the facility. Findings: On 03/11/25 at 12:25 p.m., Res #1 was observed lying in bed. The resident's hair was braided and kempt. No odors were observed. A policy titled Bathing, revised 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record. Res #1 was admitted with diagnoses which included quadriplegia, multiple sclerosis, and muscle wasting. A quarterly assessment, dated 11/22/24, showed Res #1 had a brief interview for mental status score of 15 and was cognitively intact. The assessment showed Res #1 was dependent with bathing and mobility. A care plan, dated 12/18/24, showed the resident preferred to be bathed in the morning and for staff to provide the resident assistance with self-care as needed. An undated shower schedule sheet showed Res #1 was to be bathed every Wednesday and Saturday. The shower sheets, dated January 2025, showed the resident was bathed one out of seven opportunities. There were no shower sheets with documentation of completed or refused baths found for February 2025. On 03/11/25 at 12:30 p.m., Res #1 stated their scheduled shower days were every Wednesday and Saturday on the dayshift. Res #1 stated they were frustrated because their showers were often not completed. Res #1 stated their last shower was last Wednesday. They stated the staff do not offer to bathe them at all during some weeks. Res #1 stated when their shower was missed on its scheduled day, the staff never offered to complete the shower later in the day or the following day. On 3/12/25 at 9:36 a.m., CNA #1 stated all showers should be documented on shower sheets as completed or refused. They stated the completed shower sheets were then given to the nurse to review. CNA #1 stated Res #1 had the tendency to refuse baths, but all refusals should have been documented. On 3/12/25 at 9:45 a.m., LPN #1 stated shower sheets were documented as completed or refused. They stated the nursing aides did not always provide refusals to the nurse as they should. LPN #1 stated Res #1 was picky as to who they would let assist them with bathing. They stated there should have been documentation of a completed or refused shower for every scheduled bath day for this resident. On 03/12/25 at 12:00 p.m., the DON stated they could not locate any documentation of completed baths for the missing opportunities in January 2025 or for the month of February 2025 for Res #1. They stated all of Res #1's scheduled baths should have been documented as completed or refused on the shower sheets.

On 01/03/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to follow Resident #10's minced and moist level 5 diet which resulted in the resident choking. A physician's order, dated 11/29/24, documented Resident #10 was to have a minced and moist level 5 diet. An incident report, dated 12/19/24, documented Resident #10 was eating lunch in their room when a medication aide saw that the resident was choking and alerted the nurse who performed the Heimlich maneuver. It documented the brownie was expelled. It documented the nurse practitioner was notified and a x-ray was ordered. It documented family was notified. It documented the facility investigated and determined Resident #10 was given a brownie that was not on their diet. It documented the nurse stated the resident was still moving air and coughing and was able to cough the brownie up with a gentle Heimlich maneuver. It documented the dietary manager was notified and kitchen staff were in-serviced on following the resident's diet on their diet sheet. It documented the resident would be taken to the dining room for meals as tolerated. It documented the care plan and POC had been updated. It documented the incident report was completed by the DON. On 01/02/25 at 1:15 p.m., ACMA #1 stated on the day of the incident they heard Resident #10 grunting and got ADON #1 to perform the Heimlich. ACMA #1 stated they did not know who delivered the tray that day, but if they would have noticed the rest of the food was soft, they would have checked the dietary card to make sure the brownie was OK to give to the resident. On 01/02/25 at 2:47 p.m., the CDM stated, I had a new cook on the line, and they overlooked that [Resident #10] was on a minced and moist diet. I did an in-service to dietary and the dietary aides and whoever is standing at the window. On 01/03/25 at 10:32 a.m., ADON #1 stated on the day of the incident the resident was in their room eating lunch. They stated the med aide was in the room and noticed the resident choking on their food. ADON #1 stated the resident was choking on their brownie. They stated they performed the Heimlich. ADON #1 stated the next step was to notify the nurse practitioner. They stated they received an order for a chest x-ray which was clear. ADON #1 stated they called all of the staff that was present to the nursing station and in-serviced them. They stated they were insistent that everyone was required to watch the tickets and make sure the resident was getting the right kind of diet. ADON #1 stated they encouraged the resident to go to the dining room. They stated the resident was to be supervised when eating in their room. On 01/03/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 01/03/25 at 12:47 p.m., the administrator was notified of the IJ situation and was provided the IJ template On 01/06/25 at 2:03 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented, (1) an audit was conducted and completed by 3:12 p.m. on 01/03/25 by nursing management to verify diet cards and diet orders are correct, (2) director of nursing/designee would educate all clinical staff on checking diet cards and meals prior to serving trays to residents. Nutrition service manager/designee would educate all nutrition staff on verifying diet orders when serving, (3) director of nursing/designee would perform weekly audits to verify the accuracy of those with modified diets for a period of 4 weeks, discrepancies would be addressed immediately and pulled into the monthly QA meeting, monitoring would be extended if discrepancies were identified, (4) director of nursing/designee would audit new admission orders for diet daily during morning meetings. Nutrition service manager/designee would verify diet order accuracy for new admission on tray cards: and (5) dates of completion and/or initiation for all items 1-4. On 01/03/25 at 7:30 p.m. the items listed were completed and monitoring put into place. The IJ was lifted, effective 01/03/25 at 7:30 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained at an isolated with a potential harm. Based on record review and interview, the facility failed to follow the minced and moist level 5 diet for one (#10) of three sampled residents reviewed for diet provided accurately. ADON #1 identified 111 residents resided in the facility and 106 residents were provided food by the kitchen. Findings: Resident #10 had diagnoses which included dysphagia, motor and sensory neuropathy, and epilepsy. A hospital After Visit Summary, dated 11/24/24 through 11/29/24, read in part, patient is 1:1 feed, takes medication while in puree. Diet type diabetic healthy heart. A physician's order, dated 11/29/24, documented Resident #10 was to receive a minced and moist level 5 diet. An admission assessment, dated 12/02/24, documented Resident #10 was on a mechanically altered diet while a resident, required substantial assistance with eating, and they were severely cognitively impaired with a BIMS of 7. A Nutrition Therapy Assessment, dated 12/02/24, documented Resident #10 was at risk for dehydration related to dysphagia and swallowing difficulties. An incident report, dated 12/19/24, documented Resident #10 was eating lunch in their room when a medication aide saw that the resident was choking and alerted the nurse who performed the Heimlich maneuver. It documented the brownie was expelled. It documented the nurse practitioner was notified and a x-ray was ordered. It documented family was notified. It documented the facility investigated and determined Resident #10 was given a brownie that was not on their diet. It documented the nurse stated the resident was still moving air and coughing and was able to cough the brownie up with a gentle Heimlich maneuver. It documented the dietary manager was notified and kitchen staff were in-serviced on following the resident's diet on their diet sheet. It documented the resident would be taken to the dining room for meals as tolerated. It documented the care plan and POC had been updated. It documented the incident report was completed by the DON. On 12/19/24, an in-service was provided to kitchen staff by the CDM. The in-service signature page, read in part, Cooks when plating food make sure you are watching the diets, look for modified diets textures. Aide double check the cooks and watch your desserts. Very important our residents are getting the correct diet; choking could cause serious damage or even death. There were six signatures on the document. On 01/02/25 at 1:15 p.m., ACMA #1 stated on the day of the incident they heard Resident #10 grunting and got ADON #1 to perform the Heimlich. ACMA #1 stated they did not know who delivered the tray that day, but if they would have noticed the rest of the food was soft, they would have checked the dietary card to make sure the brownie was OK to give to the resident. On 01/02/25 at 2:47 p.m., the CDM stated, I had a new cook on the line, and they overlooked that [Resident #10] was on a minced and moist diet. I did an in-service to dietary and the dietary aides and whoever is standing at the window. On 01/03/25 at 10:32 a.m., ADON #1 stated on the day of the incident the resident was in their room eating lunch. They stated the med aide was in the room and noticed the resident choking on their food. ADON #1 stated the resident was choking on their brownie. They stated they performed the Heimlich. ADON #1 stated the next step was to notify the nurse practitioner. They stated they received an order for a chest x-ray which was clear. ADON #1 stated they called all of the staff that was present to the nursing station and in-serviced them. They stated they were insistent that everyone was required to watch the tickets and make sure the resident was getting the right kind of diet. ADON #1 stated they encouraged the resident to go to the dining room. They stated the resident was to be supervised when eating in their room. On 01/03/25 at 10:41 a.m., the DON stated they did not have any documentation to support an in-service was completed for all of the staff concerning the incident with Resident #10. The DON stated QAPI had been skipped the last couple of weeks because of the holidays, but would resume next Thursday. On 01/03/25 at 11:55 a.m., the DON stated, I remember we talked about having speech evaluate [Resident #10] when [Resident #10] first came in. When the resident gets here, we would assess and then possibly have speech evaluate if we had a concern. The DON also stated the ordered diet was initiated probably from report given to the receiving nurse from the hospital discharging staff. On 01/03/25 at 12:31 p.m., the DON stated hospital discharges were scanned in. They stated discharging hospital staff called report to the receiving facility nurse and whatever they told the receiving nurse was what they followed. The DON stated if there was a discrepancy they took it to the nurse practitioner. They stated the diet order they used, came from the report from the hospital, to the nurse on the hall. On 01/03/25 at 1:14 p.m., the DON stated speech therapy did not evaluate Resident #10. On 01/03/25 at 2:04 p.m., after the administrator had been notified of the IJ, the RDO and administrator brought restorative aide #1 to speak with the surveyors. Restorative Aide # 1 stated, I take all the trays down every single day, that particular day [Resident #10] did not get their brownie, so they came back and said they didn't get a brownie, but I didn't have a sheet [Resident #10] is minced moist. We put milk on the brownie and wrapped it and took it down to the room. Restorative Aide #1 stated they took the brownie to the resident themselves. Restorative Aide #1 stated, I can't give random because I have to make sure it is the right diet, so we put wrap on it and I took it down to the resident. Restorative Aide #1 then identified the brownie was given on Friday 12/27/24. On 01/03/25 at 2:05 p.m., the RDO stated, So [Resident #10] did receive a minced moist brownie that day. On 01/03/25 at 2:20 p.m., the DON stated Resident #10 got the brownie from the kitchen. They stated the kitchen staff should have known, but must have just put the wrong thing on the tray. The DON stated, they talked to the CDM and minced and moist was on the ticket. The DON stated Resident #10 should not have received the brownie. On 01/06/25, a handwritten statement was received from restorative aide #1. The statement, read in part, I got the meal ticket to send a brownie to [Resident #10]. The ticket gave the consistency minced, milk was put into the brownie to soak the brownie and foil plastic was put over it. I took it to hall 500. I take all trays daily, so I know what comes and goes. An additional statement from restorative aide #1 was provided. The statement, read in part, In talks with surveyors, I gave the wrong exact date. I work Monday through Friday, so the date was wrong, but I know it was me that did that job. This was the only day that a brownie was given.

Based on observation, record review, and interview, the facility failed to: a. provide incontinent care in a manner which prevented cross contamination for two (#33 and #42) of four sampled residents observed during incontinent care; b. handle linens in a manner which prevented cross contamination for one (#42) of four sampled residents observed during incontinent care; c. ensure proper PPE was worn in a room with a COVID-19 positive resident for three (#46, 55 and #89) of three sampled residents observed with COVID-19; d. ensure the same PPE was not worn when assisting two different residents with COVID-19 in the same room for two (#46 and #55) of three sampled residents observed with COVID-19; and e. medications were not handled with bare hands. The DON identified 67 incontinent residents and four Covid-19 positive residents resided in the facility. ADON #1 identified 111 residents resided in the facility. Findings: A Perineal Care/Incontinent Care policy, effective 04/2012, read in parts, Staff will perform perineal/incontinent care with each bath and after each incontinent episode .Clean groin using sweeping motion .For female .Separate labia and wash downward .then downward on each side of the labia using a different peri wipe with each stroke .Wash downward toward the base of the vaginal opening .Remove gloves and wash hands or alcohol gel and re-glove hands .Turn resident on side facing staff. Roll soiled brief/incontinent pad and apply clean brief and/or incontinent pad. Turn resident away from staff. (ONLY USE ONE WIPE PER SWIPE) .Clean outer hip of buttocks going upwards towards back .Clean anal area with upward motion .Remove gloves and wash hands with alcohol gel . A Glove Use policy, reviewed 01/2022, read in parts, Gloves are worn when .Touching blood or body fluids, except sweat .Touching urine, stool .Handling items or environmental surfaces soiled with blood or body fluids .Gloves are changed between residents .Gloves are changed if contaminated with blood or body fluids before touching other parts of the same resident .Hands are washed immediately after gloves are removed, before contact with another resident or the environment .Hands are washed or decontaminated prior to donning gloves. A COVID-19 policy, revised 08/2023, read in parts, COVID-19 PPE .The required PPE for COVID-19 isolation rooms when providing care or services to a COVID-19 positive resident suspected of having COVID-19, staff should wear an N95, face shield or goggles, gown, and gloves. A Medication Administration policy, dated 01/2024, read in part, Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. A Laundry and Linen Services policy, undated, read in part, All facility staff should handle all used laundry as potentially contaminated and use appropriate precautions .Used laundry should be handled with gowns and gloves to prevent personal clothing from getting contaminated .All contaminated laundry should be bagged in the area it was used prior to transporting to the laundry area. 1. Resident #33 had diagnoses that included lack of history of cerebral infarct, lack of coordination, and muscle weakness. An Admission Resident Assessment, dated 11/14/23, documented Resident #33 required max assist with toileting and dressing. On 12/27/24 at 6:01 a.m., CNA #6 entered Resident #33's room to answer the call light. On 12/27/24 at 6:05 a.m., CNA #6 returned to Resident #33's room with brief, wipes, and trash bags. CNA #6 applied gloves, pulled the resident's covers down, and opened the resident's brief. The resident's peri area was cleaned front to back with multiple wipes. Resident #33 was then rolled to their right side and dark liquid bowel was continuously flowing from their anus. CNA #6 continued to clean the resident until the bowel movement was cleaned up. CNA #6's hair kept falling into the brief and touching the resident while care was being provided. On 12/27/24 at 6:08 a.m., CNA #6 proceeded to move Resident #33's pillow and quilt wearing the same gloves that was used during incontinent care. The CNA then removed their gloves and the remaining personal items were removed from the resident's bed. On 12/27/24 at 6:12 a.m., CNA #6 left the resident's room to get different bedding. On 12/27/24 at 6:17 a.m., CNA #6 returned to Resident 33's room with bedding. The CNA donned new gloves and cream was applied to Resident 33's buttocks. The CNAs gloves were then changed and dirty linens were bagged. On 12/27/24 at 6:24 a.m., CNA #6 completed the bed change and returned personal items to the resident's bed. The call cord was attached to the resident's blanket and dirty laundry and trash were removed from room. On 12/27/24 at 6:28 a.m., CNA #6 took the linens and trash to bins in the soiled utility and washed their hands. On 12/27/24 at 6:31 a.m., CNA #6 stated they had on new gloves when they moved the pillow and quilt, and their hair was usually tied back. They stated they were supposed to change gloves at least three times with a bowel movement and after the third time, they were to wash their hands. The CNA stated residents were to be checked and changed every two hours because most of the residents could not use the call system for assistance. 2. Resident #42 had diagnoses which included UTI. An Admission Resident Assessment, dated 12/18/24, documented Resident #42 had moderate cognitive impairment, was always incontinent of bowel and bladder and required substantial/maximal assistance for toilet hygiene. On 12/27/24 at 6:10 a.m., CNA #1 entered Resident #42's room, placed a disposable brief on the bedside table, donned gloves, and adjusted the resident's bed. On 12/27/24 at 6:12 a.m., CNA #1 removed the resident's linens, unlatched the disposable brief, obtained several disposable wipes, and wiped the resident's peri area front to back removing a small amount of bowel. Resident #42 was rolled to their right side, there was a large amount of bowel observed in the brief and had leaked out of the brief onto the non disposable pad. CNA #1 removed the disposable pad and rolled the non disposable pad and draw sheet under the resident. CNA #1 provided peri care, placed a clean disposable pad under the resident, rolled the resident to the left side, and pulled the soiled linens out from under the resident and threw them on the floor. CNA #1 did not change their gloves or wash/sanitize their hands when going from dirty to clean. Bowel was observed on the non disposable pad and draw sheet that were laying on the floor. CNA #1 started to attach the clean brief. There was a brown substance observed remaining on Resident #42's peri area. On 12/27/24 at 6:16 a.m., CNA #1 was asked to observe Resident #42's front peri area and identify if the resident still had bowel present. CNA #1 opened the brief and stated, It's like pee I think. CNA #1 went through several drawers in the resident's room with the same gloved hands used during incontinent care and obtained another package of disposable wipes. CNA #1 wiped the resident several more times and started to close the resident's brief. There was brown substance observed on the new brief. The CNA did not offer a response when asked about it. On 12/27/24 at 6:18 a.m., CNA #1 again went through several drawers in the room, lowered Resident #42's bed, covered the resident with a blanket, pulled a trash bag off a roll of trash bags, and sat the roll on the resident's bedside table with the same gloved hands used during incontinent care. On 12/27/24 at 6:20 a.m., CNA #1, with the same gloved hands placed the soiled linens from the floor in the trash bag, obtained the bag of trash from the trash can, tied it shut, opened the resident's door to the hallway with the same gloved hands used during incontinent care. Once out in the hall, CNA #1 removed the glove on their right hand, tossed the soiled items in the appropriate barrels, removed their left glove and threw it away. On 12/27/24 at 6:21 a.m., CNA #1 sanitized their hands and obtained a new disposable brief from the cart on hall 200. On 12/27/24 at 6:22 a.m., CNA #1 entered Resident #42's room and donned gloves. ADON #1 also entered the room and picked up the roll of trash bags CNA #1 had previously touched with contaminated gloves with gloved hands hands. ADON #1 placed a trash bag in the trash can. On 12/27/24 at 6:23 a.m., CNA #1 adjusted the bed, turned Resident #42 to their right side, and cleaned additional brown bowel off of the resident using several disposable wipes, and rolled the soiled brief under the resident. On 12/27/24 at 6:25 a.m., CNA #1 removed the soiled brief, placed a new brief under Resident #42 and attached the brief. The CNA did not change their gloves or wash/sanitize their hands when going from dirty to clean. CNA #1 was asked to observe the resident's right thigh. There was a brown circular substance on the resident's right leg. CNA #1 stated, It wasn't BM, it looks like rice cake. CNA #1 removed the substance from Resident #1's leg. CNA #1 adjusted Resident #42's bed, covered them with a blanket, moved the resident's bedside table, glasses, television, and placed the roll of trash bags in their right pants pocket with the same gloved hands used during incontinent care. On 12/27/24 at 6:28 a.m., CNA #1 opened the door to the hall with the same gloved hands used during incontinent care, took the trash to the soiled utility room on the hall, removed their right glove, opened the door, placed the items in the trash, and washed their hands with soap and water. On 12/27/24 at 6:30 a.m., CNA #1 stated incontinent care was to be provided every two hours. On 12/27/24 at 6:31 a.m., CNA #1 stated staff were to make sure soiled linens were bagged before leaving the resident's room. They stated the soiled linens would be placed in the soiled linen container. CNA #1 stated they sanitized their hands every time they came out of a room. They stated by the second resident, they would wash their hands. CNA #1 stated they did not know if that was the facility's policy, but it was their policy. On 12/27/24 at 6:32 a.m., CNA #1 stated they were supposed to change gloves every time they came out of a room and between residents. CNA #1 stated they were supposed to change gloves between everything. On 12/27/24 at 6:40 a.m., LPN #1 stated they let staff know what residents were incontinent. They stated staff were to complete first round checks on everyone. They stated incontinent care was to be provided every two hours. On 12/27/24 at 6:42 a.m., LPN #1 stated staff were to either place soiled linens directly in the soiled linen container, or bag them and then place them in the container. LPN #1 stated they had seen it done both ways. On 12/27/24 at 6:44 a.m., LPN #1 stated staff were to sanitize their hands after every interaction with a resident. They stated staff were to wash their hands after they had used sanitizer twice. On 12/27/24 at 6:45 a.m., LPN #1 stated anytime staff were dealing with something dirty, they had to change their gloves before touching something clean. They stated staff were to change gloves between residents, and were not supposed to wear gloves in the hall. They stated a lot of staff did wear gloves in the hall when transporting trash. On 12/31/24 at 2:32 p.m., the DON stated staff were to wash their hands prior to providing care and after care. They stated staff were supposed to wash their hands between care if they had to go from dirty to clean. On 12/31/24 at 2:33 p.m., the DON stated anytime staff went from dirty to clean they should change their gloves. The DON stated soiled linens should be placed in a bag and placed in the hopper room. They stated they should never be on the floor. On 12/31/24 at 2:34 p.m., the DON stated staff were to provide incontinent care by wiping from the perineum to the rectum using one wipe per swipe. They stated staff were to turn the resident, clean all areas of the buttock, remove gloves, perform hand hygiene, and apply new gloves before placing a new brief. 3. Resident #89 had diagnoses which included COVID-19. COVID-19 testing logs documented Resident #89 tested positive for COVID-19 on 12/17/24. On 12/26/24 at 1:52 p.m., CMA #4 was observed placing the lid of a meal tray on the counter in Resident #89's room. CMA #4 did not have a gown, gloves, face shield, or N95 mask on while in the COVID-19 room. CMA #4 only had a standard face mask on. CMA #4 exited the room with a standard face mask on. CMA #4 stated they were delivering the meal tray to Resident #89. CMA #4 was asked to explain the COVID-19 sign on the outside of Resident #89's door. They stated, You are supposed to gown up. They stated they did not put a gown on before entering Resident #89's room. The red COVID-19 sign documented use PPE when caring for patient with COVID-19 or suspected COVID-19. It documented PPE must be donned correctly before entering patient area. 4. Resident #46 had diagnoses which included COVID-19. COVID-19 testing logs documented Resident #46 tested positive for COVID-19 on 12/23/24. A Physician Order, dated 12/23/24, documented isolation full transmission based precautions every shift, droplet precautions along with gown, gloves, N95 mask, and face shield or goggles. 5. Resident #55 had diagnoses which included COVID-19. COVID-19 testing logs documented Resident #55 tested positive for COVID-19 on 12/23/24. A Physician Order, dated 12/23/24, documented isolation full transmission based precautions every shift, droplet precautions along with gown, gloves, N95 mask, and face shield or goggles. On 12/26/24 at 12:20 p.m., CNA #5 was observed wearing two standard face masks. They donned a gown and gloves and entered room [ROOM NUMBER] where Resident #46 and #55 resided. CNA #5 did not have a N95 face mask or a face shield/goggles before entering the COVID-19 positive room. CNA #5 adjusted Resident #55's bed, rolled the resident to the right side, and placed a pillow under the resident's back. Resident #55 did not like the position so CNA #5 went to the right side of the bed, rolled the resident further to the right using the draw sheet, and placed a pillow behind their back. CNA #5 adjusted the resident's bed to the low position, pushed the bed to the wall, and lifted the head of the bed until the resident was comfortable. CNA #5 pulled the trash bag out of Resident #55's trash container, tied it shut, and placed another bag in the trash can. On 12/26/24 at 12:23 p.m., CNA #5 changed their gloves, walked over to Resident #46 with the same gown and masks used during care of Resident #55, picked up linens off of the resident's floor, placed them in a trash bag, and removed their gloves. On 12/26/24 at 12:30 p.m., CNA #5 walked over to Resident #55 with the same masks and gown on, adjusted the resident's bed and handed Resident #55 a box of tissues with their bare hands. CNA #5 then washed their hands with soap and water and stated, I'm going to have to get a new gown since I'm taking care of [Resident #46] OK. CNA #5 removed their gown, placed it in the trash can, and tried to hand Resident #55 their TV remote. The resident did not take the remote. CNA #5 then handed Resident #55 their call light and bed control with their bare hands wearing no gown. On 12/26/24 at 12:34 p.m., CNA #5 entered room [ROOM NUMBER] with a new gown on and donned a pair of gloves at the door in the room. CNA #5 still had two regular face masks on and no face shield. On 12/26/24 at 12:35 p.m., CNA #5 handed Resident #55 their bed remote on request and changed their gloves. CNA #5 got a washcloth off the counter in the room, wet it, and walked over to Resident #46, sat in a chair next to the resident and washed their face and hands off with the washcloth. CNA #5 lifted the resident's head with the bed controller and offered the resident a drink of water with a straw. CNA #5 wiped down Resident #46's bedside table with a disposable wipe and lowered the resident's head back down. On 12/26/24 at 12:38 p.m., CNA #5 removed their gown and gloves, moved over to Resident #55 and moved their bedside table without a gown or gloves on. CNA #5 donned a pair of gloves, wiped off items on the bedside table with a wet wipe, handed Resident #55 their phone wearing just the two regular face masks and gloves. CNA #5 then wet a rag and wiped something off the resident's floor. On 12/26/24 at 12:44 p.m., CNA #5 washed their hands with soap and water, took the soiled linens and trash out of room [ROOM NUMBER] and placed them in the soiled utility room on hall 200. CNA #5 was still wearing both of the standard non disposable face masks. On 12/26/24 at 12:45 p.m., CNA #5 stated staff were to gown and glove before going into a COVID-19 positive room. They stated they were to use a new gown between residents. They stated they did the best they could. They stated there were a lot of needs in the COVID-19 rooms. They stated they tried to make sure the linens and areas were clean to try to stop the process of infection by changing the linens. CNA #5 stated they tried to change their gloves and gown between Resident #55 and #46, but Resident #55 was needy. CNA #5 stated they usually did not wear the same masks in and out of a COVID-19 positive room, but they did today. They stated they should have worn a N95 mask. CNA #5 stated they place COVID-19 soiled items in the regular bin on the hall as instructed. On 12/27/24 at 6:02 a.m. the call light in room [ROOM NUMBER] activated. CNA #1 donned a gown, gloves, N95 mask and face shield, and stated all of the PPE items were needed to enter a COVID-19 room. As CNA #1 approached room [ROOM NUMBER], CNA #3 was exiting and did not need anything. CNA #1 removed their PPE and disposed of it. On 12/27/24 at 6:50 a.m., LPN #1 stated complete PPE, a gown, N95 mask, face shield/goggles, and gloves were to be worn in COVID-19 rooms. On 12/27/24 at 6:54 a.m., LPN #1 stated if staff were caring for two residents in a COVID-19 room, they should change PPE between residents. On 12/30/24 at 12:28 p.m., the DON stated staff were to wear a N95 mask, face shield, gown, and gloves to enter a COVID-19 room. The DON stated the trash from a COVID-19 room was to be placed in the regular trash in the resident's room. On 12/31/24 at 2:37 p.m., the DON stated staff were to switch out all PPE, wash their hands, and completely change out their PPE when caring for two residents in a COVID-19 room. 6. On 01/03/25 at 7:47 a.m., RN #1 was observed popping an unidentified pill from the blister pack that was removed from the secondary lock box inside the medication cart into their bare hands. The pill was then placed into a medication cup. Their nails had red fingernail polish on them. On 01/03/25 at 7:53 a.m., RN #1 stated the policy was to put gloves on, then get the medications out of the cart and give them to the resident, come out, then wash or sanitize their hands again. On 01/03/25 at 7:56 a.m., RN #1 stated they did not put gloves on before touching the medication. They stated the purpose of the gloves was as a safety precaution and gloves were to be used for everything. 49701

Based on observation, record review and interview, the facility failed to ensure: a. raw meat items were stored in a manner to prevent cross contamination; b. dented cans were removed from circulation in the dry storage; c. leftover food items were discarded within the appropriate timeframe; d. food items in the refrigerator were stored in a sealed container; e. expired food items were removed from circulation; and f. food items were appropriately dated and labeled during the kitchen observation. The DON identified 106 residents received services from the kitchen. Findings: A Use of Leftovers policy, dated [DATE], read in parts, Leftovers will be properly handled and used .Leftovers should be covered, labeled, dated and stored appropriately .Unless otherwise indicated on package, leftover food is used within 72 hours or discarded. A Food Storage policy, dated [DATE], read in parts, Storeroom .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened .All stock is rotated with each new order received using a First In, First Out system .Canned and dry foods without expiration dates are used within six months of delivery .All foods are covered, labeled and dated. Defrosting meat, eggs and milk shakes are labeled with date pulled for thawing .Any item out of the original case must be properly secured and labeled. A General Food Preparation and Handling policy, dated [DATE], read in part, Questionable foods (from broken packages, swollen cans, food with abnormal appearance or odor) are not served. On [DATE] at 10:18 a.m., the dry storage area was observed in the kitchen. There was one 111 oz can of light red kidney beans with a large dent in the back of the can. There was one six lb 6.5 oz can of diced tomatoes in tomato juice with a small dent in the edge of the can toward the top. On [DATE] at 10:26 a.m., the CDM removed the can of beans and stated it needed to go away. The CDM stated because the can was dented, it was possibly in the seam and it should not be in here. On [DATE] at 10:28 a.m., the CDM stated if staff identified a canned good that had been damaged they would bring it to the CDM so it would be returned to the company or disposed of. The CDM observed the dent in the can of tomatoes and stated since the dent was not in the seam, it was OK. On [DATE] at 10:46 a.m., two 6.63 lb cans of pumpkin were observed, one with a large dent in the side, and one with a smaller dent in the top edge of the can. The CDM stated, We aren't using them. The CDM stated they were definitely in the seams. On [DATE] at 10:48 a.m., a one gallon container of salad dressing was observed in the dry storage with a best by date of [DATE]. The CDM stated the best by date had elapsed by a couple of days. On [DATE] at 10:54 a.m., the reach in cooler was observed to have a white plastic container with an original label of cottage cheese and a handwritten label on blue tape that read tartar sauce [DATE]. On [DATE] at 10:55 a.m., the DON stated the facility would keep tartar sauce after they made it until the next day. They stated, Yeah it should have been thrown away. On [DATE] at 10:59 a.m., a large clear bag containing grated Parmesan cheese, open date [DATE], was observed to be open to air in the reach in cooler. The CDM stated the bags sometimes opened when they moved them. They stated it was supposed to be closed. On [DATE] at 11:01 a.m., there were ten unlabeled cups of a dark material located in the walk in cooler. The CDM stated it was the minced and moist snack for today. They stated it looks like chocolate pudding. The CDM was asked how floor staff would know what was in the cups. The CDM stated neither of the kitchen staff members could write English, so they would ask the CDM or the cook to write it on the containers before they went out to the floor. The CDM began labeling the items. On [DATE] at 11:05 a.m., a box of chocolate health shakes with directions keep frozen on the box was observed in the walk in cooler. The box did not contain a date the box was pulled from the freezer and placed in the cooler. The CDM stated they did not know the date the shakes were moved into the cooler. They stated staff should have put a pull date on the box. On [DATE] at 11:09 a.m., a large metal cookie sheet was observed on the bottom shelf of the middle rack in the walk in cooler. There were five long pieces of raw meet thawing on the rack. Two of the pieces of meat were labeled ground beef and were hanging over the edges of the pan. The CDM stated the purpose of the tray was if the items leaked, they would not go onto the floor. The CDM stated the meat should have been in a single layer. The CDM stated the pork should have been on one tray and the beef on the other. On [DATE] at 11:15 a.m., the other three pieces of raw meat were observed for a label. The only label observed was butcher's block with a yellow sticky note with a pull date of [DATE] written on it. The CDM stated it was pork loin. When asked how they knew what the meat was without a label, the CDM stated the facility only got pork loin and pork butt that looked similar. They stated there was a new staff member who pulled the meat before they left and were still in training. On [DATE] at 11:29 a.m., the CDM stated the facility used the first in first out method for rotating stock in the kitchen. The CDM stated staff were to date food items when they came in. They stated staff would also date items when they opened them. On [DATE] at 11:30 a.m., the CDM stated left over items that had been served out of could be kept for 24 hours. They stated items such as cheeses, staff would use the date on the package.

Based on record review and interview, the facility failed to ensure resident assessments were accurately coded for one (#111) of 27 sampled residents reviewed for resident assessments. ADON #1 identified 111 residents resided in the facility. Findings: A Resident Assessment policy, revised [DATE], read in part, Each individual who completes a portion of the assessment will sign to certify the accuracy of that portion of the assessment. Resident #111 had diagnoses which included history of seizures and history of traumatic brain injury. A Nurse Note, dated [DATE], documented at 5:25 p.m., Resident #111 coded, CPR was started, emergency personnel arrived, and eventually restored Resident #111's pulse. It documented Resident #111 transferred from the facility to the hospital. The note was electronically signed by the DON on [DATE]. A Transfer Form, dated [DATE], documented Resident #111's blood pressure was ,d+[DATE], pulse 68, respirations 18, oxygen 95 percent, and the resident was transferred to the hospital. Resident #111's hospital record, dated [DATE], documented after consultation with GI, the resident's family had elected comfort measures only at the hospital. A Resident Assessment, dated [DATE], documented Resident #111 had died in the facility. On [DATE] at 9:39 a.m., the DON stated they had closed out the nurse note for Resident #111 on [DATE]. They stated the nurse who had written it worked on the weekends. They stated it appeared Resident #111 coded, CPR was started, and emergency personal took over and restored the resident's pulse. They stated the resident was transferred to the hospital. On [DATE] at 9:46 a.m., the DON reviewed the resident assessment dated [DATE] and stated they were not sure of the reason it was marked death in the facility. They stated the staff member who filled out the assessment no longer worked for the facility. The DON stated the resident did not die at the facility and the assessment was coded incorrectly. On [DATE] at 2:09 p.m., the DON stated Resident #111 expired at the hospital. On [DATE] at 2:11 p.m., the DON stated the resident assessment was not coded correctly. 48344

Based on observation and interview, the facility failed to ensure a outdated medication was removed from stock for one of one medication storage observation. ADON #1 identified 111 residents resided in the facility and 111 residents were administered medications by the nursing staff. Findings: A medication storage policy, dated ,d+[DATE], read in part, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. On [DATE] at 11:02 a.m., a magnesium chloride with calcium bottle was observed to be expired. The best by date was ,d+[DATE]. On [DATE] at 11:03 a.m., ACMA #2 stated someone was supposed to check the expiration dates and rotate the stock. They identified the best by date to be ,d+[DATE] and stated the medication would not be appropriate to use. On [DATE] at 11:13 a.m., CMA #3 stated they checked the medications last on [DATE]. They stated they were surprised to know that something was expired. They stated they rotated the stock by putting the new medications at the back and moving the older medications to the front to be used first. They stated the magnesium may have been one that had fallen behind or under the cart and they did not look to see if it was good or not. They stated, As far as I know they look at any expiration dates before they dispense to the residents. CMA #3 stated the magnesium had already been opened so maybe someone took it off their cart. CMA #3 stated, I don't know why it would be up their and open. On [DATE] at 11:15 a.m., a vitamin E bottle with an expiration date of ,d+[DATE] was observed in the back of the rotation to be used last, while the vitamin E to be used first had an expiration date of ,d+[DATE]. On [DATE] at 11:15 a.m., CMA #3 stated they did not know why it would be arranged like that, but it was not in correct rotation order. On [DATE] at 2:15 p.m., the DON stated the medications were supposed to be rotated to prevent medications from being able to expire.

Based on record review and interview, the facility failed to ensure MDS entry tracking was completed per RAI guidelines for one (#45) of 27 sampled residents who were reviewed for resident assessments. ADON #1 identified 111 residents resided in the facility. Findings: A Resident Assessment policy, revised 01/12/20, read in parts, Purpose: To enter this assessment data into a computerized format that will be transmitted to the Center for Medicare/Medicaid Services (CMS). The policy also read, Tracking records .will be transmitted electronically, in a CMS specified format. Resident #45's MDS list documented a discharge return anticipated on 05/19/23. It documented a quarterly assessment dated [DATE]. There was no entry tracking record. On 12/31/24 at 10:42 a.m., the clinical reimbursement specialist stated the resident went to the hospital and did need an entry. They stated the RAI was not followed.

Based on observation, record review and interview, the facility failed to provide incontinent care in a manner to prevent UTI's for one (#42) of four sampled residents observed during incontinent care. The DON identified 67 incontinent residents resided in the facility. Findings: A Perineal Care/Incontinent Care policy, effective 04/2012, read in parts, Staff will perform perineal/incontinent care with each bath and after each incontinent episode .Clean groin using sweeping motion .For female .Separate labia and wash downward .then downward on each side of the labia using a different peri wipe with each stroke .Wash downward toward the base of the vaginal opening .Remove gloves and wash hands or alcohol gel and re-glove hands .Turn resident on side facing staff. Roll soiled brief/incontinent pad and apply clean brief and/or incontinent pad. Turn resident away from staff. (ONLY USE ONE WIPE PER SWIPE) .Clean outer hip of buttocks going upwards towards back .Clean anal area with upward motion .Remove gloves and wash hands with alcohol gel. Resident #42 had diagnoses which included UTI. A Physician Order, dated 12/17/24, documented culture urine one time only. An Admission Resident Assessment, dated 12/18/24, documented Resident #42 had moderate cognitive impairment, was always incontinent of bowel and bladder and required substantial/maximal assistance for toilet hygiene. Urine culture laboratory results, final release 12/21/24, documented Escherichia Coli was detected low. A Physician Order, dated 12/22/24, documented ertapenem (antibiotic) one gram intramuscular every morning shift for seven days for a diagnoses of UTI. On 12/27/24 at 6:10 a.m., CNA #1 entered Resident #42's room, placed a disposable brief on the bedside table, donned gloves and adjusted the resident's bed. On 12/27/24 at 6:12 a.m., CNA #1 removed the resident's linens, unlatched the disposable brief, obtained several disposable wipes, and wiped the resident's peri area front to back removing a small amount of bowel. Resident #42 was rolled to their right side, there was a large amount of bowel observed in the brief and had leaked out of the brief onto the non disposable pad. CNA #1 removed the disposable pad and rolled the non disposable pad and draw sheet under the resident. CNA #1 provided peri care, placed a clean disposable pad under the resident, rolled the resident to the left side, and pulled the soiled linens out from under the resident. CNA #1 started to attach the clean brief. There was a brown substance remaining on Resident #42's peri area. On 12/27/24 at 6:16 a.m., CNA #1 was asked to observe Resident #42's front peri area and identify if the resident still had bowel present. CNA #1 opened the brief and stated, It's like pee I think. CNA #1 wiped the resident several more times and started to close the resident's brief. A brown substance was observed on the new brief. The CNA did not offer a response when asked about it. On 12/27/24 at 6:21 a.m., CNA #1 obtained a new disposable brief from the cart on Hall 200. On 12/27/24 at 6:23 a.m., CNA #1 turned Resident #42 to their right side, and cleaned additional brown bowel off of the resident using several disposable wipes. On 12/27/24 at 6:25 a.m., CNA #1 removed the soiled brief, placed a new brief under Resident #42 and attached the brief. CNA #1 was asked to observe the resident's right thigh. There was a brown circular substance on the resident's right leg. CNA #1 stated, It wasn't BM, it looks like rice cake. CNA #1 removed the substance from Resident #42's leg. On 12/27/24 at 6:30 a.m., CNA #1 stated incontinent care was to be provided every two hours. CNA #1 was asked how they ensured incontinent care was complete before placing a clean brief. CNA #1 stated, We had some mistakes. CNA #1 stated Resident #42 was not completely clean. CNA #1 stated staff were to keep wiping until the resident was clean. On 12/27/24 at 6:40 a.m., LPN #1 stated they let staff know what residents were incontinent. They stated staff were to complete first round checks on everyone. They stated incontinent care was to be provided every two hours. On 12/27/24 at 6:41 a.m., LPN #1 stated staff were supposed to visualize the resident to ensure they were clean before placing a new brief. LPN #1 stated there had been times they observed incontinent care and had to remind staff a resident was not completely clean. On 12/31/24 at 2:34 p.m., the DON stated staff were to provide incontinent care by wiping from the perineum to the rectum using one wipe per swipe. They stated staff were to turn the resident, clean all areas of the buttock, remove gloves, perform hand hygiene, and apply new gloves before placing a new brief. On 12/31/24 at 2:37 p.m., the DON stated staff should be able to visually tell all urine and feces was removed prior to placing a clean brief on a resident.

Based on observation and interview, the facility failed to ensure the walk in freezer was in safe operating condition. The DON identified 106 residents received services from the kitchen. Findings: On 12/31/24 at 11:20 a.m. the walk in cooler located in the kitchen was observed to have an internal temperature of 34.7 degrees. On 12/31/24 at 11:21 a.m., the walk in freezer entrance was observed inside the walk in cooler. There was an accumulation of ice buildup observed on the doorway of the freezer. While standing outside the entrance door of the freezer, light was observed from inside the freezer with the door closed as far as it would go. Ice accumulation was observed on the upper section of the freezer door all the way down the inner part of the doorframe where the door should seal. Icicles varying in size were observed on the underside of the three level green metal shelving located inside the freezer. There was a clump of ice, larger than the size of a softball, located on the middle shelf. There was ice observed covering the floor of the entrance to the freezer. The CDM stated it was supposed to have a heater on the door, but because it was old, the facility had people out looking at it in the past. The CDM stated it had been a process that had been going on for at least a year. The CDM stated they would come in every couple of weeks or so and use a hammer on the ice so the door would shut all the way. On 12/31/24 at 11:27 a.m., the CDM stated the last time the freezer was worked on was last month. On 12/31/24 at 1:57 p.m., the DON stated they were unable to locate a maintenance policy for the kitchen equipment.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered and a concentrator had a filter and was dust free for one (#1) of one sampled resident reviewed for respiratory care. The DON identified 24 residents who received oxygen therapy in the facility. Findings: The OXYGEN THERAPY, CONCENTRATOR INITIATION policy, revised 01/12/20, read in part, The licensed staff will provide the prescribed amount of oxygen therapy to the residents as prescribed by physician and according to practice guidelines. Resident #1 had a diagnosis of chronic obstructive pulmonary disease. A physician's order, dated 12/27/24, documented oxygen 2 liters per minute inhalation every shift via nasal cannula, may remove for ADLs. On 12/30/24 at 11:58 a.m., Resident #1 was observed receiving oxygen via a nasal cannula. The concentrator vent had extreme dust build up. On 01/02/25 at 11:33 a.m., Resident #1 was observed receiving oxygen via a nasal cannula at 3 liters per minute. On 01/02/25 at 1:32 p.m., RN #1 reviewed Resident #1's oxygen order. They stated the resident was to receive 2 liters oxygen per minute inhalation. On 01/02/25 at 1:35 p.m., RN #1 stated maintenance personnel took care of the filters on the oxygen concentrators. 01/02/25 at 1:39 p.m., RN #1 observed Resident #1's concentrator. They stated it was set at 3 liters per minute. They stated the concentrator vent had a lot of dust build up. They stated the concentrator was not cleaned in a while. On 01/02/25 at 1:41 p.m., RN #1 stated Resident #1 did not receive the correct oxygen as ordered. RN #1 adjusted the oxygen to 2 liters per minute. 01/02/25 at 1:51 p.m., the regional maintenance director stated they checked concentrator cords and filters. They stated they were not sure how often concentrators were cleaned, but could be quarterly. 01/02/25 at 2:11 p.m., the maintenance director and regional maintenance director observed Resident #1's concentrator. They stated there was dust build up and the filter was missing from the vent. On 01/02/25 at 2:14 p.m., the DON stated oxygen should be administered as ordered. 51977

Based on record review and interview, the facility failed to ensure a discharge summary was completed for five (#41, 44, 99, and #115) of five sampled residents reviewed for discharge summaries. The DON identified 114 residents resided in the facility. Findings: A facility policy titled Recapitulation Summary, revised on 01/12/202, read in part, .Standard of Practice: The staff will complete a recapitulation summary per standard guidelines in order to ensure the facility communicates necessary information to the resident, continuing care provider .Procedure: Follow Discharge Process or residents discharging from the facility .The summary should be completed within 20 days of the date of discharge. 1. Res #41 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, CVA affecting non-dominant side, chronic pain, insomnia, GERD, depression, muscle spasms, and hyperlipidemia. An admission/discharge summary report, dated 01/01/24 through 02/13/24, documented the resident was discharged to another facility on 01/12/2024. There was no documentation a discharge summary had been completed. 2. Res # 44 was admitted to the facility 12/24/23 with diagnoses which included UTI, CVA, personal history of malignant neoplasm of breast, muscle spasms, atrial fibrillation, insomnia, hyperlipidemia, and HTN. An admission/discharge summary report, dated 01/01/24 through 02/13/24, documented the resident was discharged to the hospital on 01/03/24. There was no documentation a discharge summary had been completed. 3. Res #99 was admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome, diabetes, COPD, and HTN. An admission/discharge summary report, dated 01/01/24 through 02/13/24, documented the resident was discharged to home with home health services on 01/01/24. There was no documentation a discharge summary had been completed. 4. Res #115 was admitted to the facility on [DATE] with diagnoses which included CVA, HTN, diabetes, CKD, hypothyroidism, and neuromuscular disorder of the bladder. An admission/discharge summary report, dated 01/01/24 through 02/13/24, documented the resident was discharged to home with home health services on 01/02/24. There was no documentation a discharge summary had been completed. On 02/16/24 at 3:10 p.m., the DON was asked if a discharge summary had been completed for residents #41, 44, 99, and #115. They stated if the discharge summary is blank in the EHR then a discharge summary was not completed. They stated the MDS coordinator was responsible for completing the discharge summaries.

Based on record review, observation, and interview, the facility failed to provide enough staff on a 24-hour basis to meet the needs of the residents for one (#48) of six residents reviewed for ADL care. The DON identified 114 residents resided in the facility. Findings: A Staffing policy, revised 03/27/23, read in part, Policy: A facility must develop and implement staffing policies, which require staffing ratios based upon the needs of the residents .Procedure: 1. The Director of Resident Care Services will determine staffing ratios based on the level of care required by the residents . Res #48's quarterly assessment, dated 11/17/23 documented the resident's cognition was intact, required substantial assistance with most ADL's, and was always incontinent of bowel and bladder. Daily Staffing sheets, dated from 01/26/24 to 02/13/24, documented 27 of 57 shifts did not meet the staffing ratio requirements for the facility census. On 2/14/24 at 2:14 p.m., Res #48 was asked if they had any concerns regarding her care. They stated no one had been in to change their brief today. They were asked when it was changed last. They stated at 9:00 p.m. last night. The resident stated when she turned her call light on the CNAs come in and turn it off and say they will be right back and they hardly ever come back. They stated they have to call the DON at home to get a CNA to change their brief. CNA #9 was asked how often they check on their incontinent residents. They stated at least every two hours. They were asked when the last time they checked on Res #48. They stated they had not been in the resident's room today. CNA #9 was asked to demonstrate incontinent care on Res #48. The resident's brief was soaked with urine dripping onto their bed pad. On 2/14/24 at 2:27 p.m., CNA #5 was asked how often they check on their incontinent residents. They stated every hour and a half to two hours. They were asked when the last time they checked on resident #48. They stated they had not been in the resident's room today. On 2/14/24 at 2:34 p.m., CNA #6 was asked how often they check on their incontinent residents. They stated at least every hour. They were asked when the last time they checked on resident #48. They stated they had not been in the resident's room today. 02/15/24 at 6:43 a.m., RN #2 was asked if they felt they had adequate staff on the 11 p.m. to 7 a.m. shift. They stated not always. On 02/15/24 at 6:50 a.m., LPN #4 was asked if they felt they had adequate staff on the 11 p.m. to 7 a.m. shift. They stated they did not. On 02/15/24 at 12:25 p.m., CNA #7 was asked if they felt they had adequate staff on the 7 a.m. to 3 p.m. shift. They stated they did not have adequate staff on the shift. On 02/16/24 at 3:07 p.m., the DON was made aware of the insufficient staffing. They stated it is the staffing coordinator's responsibility to ensure the facility has adequate staff to meet the needs of the residents. The DON stated Res #48 often calls her at home to receive care.

Based on observation, interview, and record review the facility failed to follow physician orders to provide diabetic residents with an HS snack and ensure snacks were served to all residents at times in accordance with resident's needs, preferences, and requests for four (#18, 26, 32, and #38) of four sampled residents reviewed for food and nutrition services. The DON identified 34 residents diagnosed with diabetes resided in the facility. Findings: A facility policy titled, Snacks and Supplements, dated 08/01/2018, read in part, .The Nutrition Services employee will prepare snacks and supplements in accordance with physician's order .1. Physician-ordered supplements (or snacks) and all-purpose snacks are prepared and available to residents three times daily .4. HS snacks will include a variety of foods to ensure each resident has an opportunity for a snack . 1. Resident #18 had diagnoses which included diabetes mellitus and protein-calorie malnutrition. A physician order, dated 03/02/22, documented to provide a daily bedtime snack. On 02/13/24 at 2:10pm., Res #18 was asked if they were offered a bedtime snack. They stated they rarely received a bedtime snack. 2. Resident #26 had diagnoses which included diabetes mellitus with diabetic polyneuropathy. A physician order, dated 03/29/22, documented to provide a daily bedtime snack. On 02/13/24 at 1:39 p.m., Res #26 was asked if they were offered bedtime snacks. They stated they rarely received a bedtime snack and if they got one, they have to go into the hall and ask for a snack. They stated most of the time there are not any snacks left. They stated they have observed the staff eating the residents' snacks. 3. Resident #32 had diagnoses which included diabetes mellitus. A physician order, dated 03/17/23, documented to provide a daily bedtime snack. On 02/14/24 at 9:45 a.m., Res #32 was asked if they were offered bedtime snacks. They stated no snacks have not been offered for quite a while. 4. Resident #38 had diagnoses which included diabetes mellitus. A physician order, dated 03/31/22, documented to provide a daily bedtime snack. On 02/15/24 at 8:25 a.m. Res #38 was asked if they were offered bedtime snacks. They stated they never receive a bedtime snack. 5. A resident council meeting form, dated 08/10/23, read in part, .Dietary .Snacks need to be passed by aides . A resident council meeting form, dated 09/07/23, read in part, .Dietary .Need more snacks. Snacks not being given to diabetic residents . A resident council meeting form, dated 12/05/23, documented, .Dietary .Need more snacks . On 2/13/24 at 12:13 p.m., the DM was asked about the resident snack schedule. They stated they prepare snacks for the residents at 10 a.m., 2 p.m., and a bedtime snack around 7 p.m. They stated fruit, sandwiches, and cake were usually available. They were asked what snacks are offered to the diabetics. They stated fruit, sandwiches, and the icing is left off the cake for the diabetics. On 02/15/24 at 1:14 p.m., the DON was made aware of the above stated. They stated they were not aware the residents were not being offered bedtime snacks.

Based on observation, record review, and interview, the facility failed to ensure residents' call lights were in reach for five (#3, 5, 21, 50 and #64) of five sampled residents who were reviewed for call light placement. The DON identified 114 residents resided in the facility. Findings: A Call Lights: Answering policy, dated 01/19/23, read in part, .Procedure .7. When leaving the room, be sure the call light is placed within the resident's reach. 1. Res #3 had diagnoses which included dementia, overactive bladder, difficulty in walking, chronic pain, dizziness, and HTN. A quarterly assessment, dated 11/08/23, documented the resident's cognition severely impaired, always incontinent of bowel and bladder, required substantial assistance with most ADLs. On 02/14/24 at 8:10 a.m., observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/14/24 at 1:20 p.m., observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/15/24 at 8:06 a.m. observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/15/24 at 10:38 a.m., the resident was asked if they were able to reach their call light. They stated there were not able to reach their call light. CNA #6 handed the Res the call light. The resident was able to demonstrate how to utilize their call light. They were asked if they knew what the call light was for. They stated to call the nurses. 2. Res #5 had diagnoses which included non-traumatic intracerebral hemorrhage, unsteadiness on feet and chronic kidney disease. A quarterly assessment, dated 12/17/23, documented the resident's cognition was moderately impaired, no impairment to their upper or lower extremities, required substantial assistance with all their ADLs, and was always incontinent of bowel and bladder. A quarterly assessment, dated 02/02/24, documented the resident's documented the resident's cognition was intact, had impairment no impairment to their extremities, required moderate assistance with their ADLs, and was always incontinent of bowel and bladder. On 02/14/24 at 8:19 a.m., observed the resident in bed and their call light was hanging from the wall between the wall and the end of their bed. On 02/14/24 at 1:32 p.m., observed the resident in recliner and and their call light was hanging from the wall between the wall and the end of their bed. On 02/15/24 at 8:22 a.m. observed the resident in bed and their call light was hanging from the wall between the wall and the end of their bed. On 02/15/24 at 10:47 a.m., the resident was asked if they were able to reach their call light. They stated there were not. CNA # 9 handed the resident their call light. The resident was able to demonstrate how to utilize their call light. 3. Res #21 had diagnoses which included atherosclerosis heart disease, diabetes, polyneuropathy, and CHF. A significant change assessment, dated 06/05/23, documented the resident's cognition was severely impaired, had impairment to both of their lower extremities, required limited assistance with their ADLs, and was always incontinent of bowel and bladder. A quarterly assessment, dated 12/06/23, documented the resident's cognition was severely impaired, had impairment to both of their lower extremities, required limited assistance with their ADLs, and was always incontinent of bowel and bladder. On 02/14/24 at 8:12 a.m., observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/14/24 at 1:22 p.m., observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/15/24 at 8:08 a.m. observed the resident in bed and their call light was hanging from the wall at the end of their bed. On 02/15/24 at 10:42 a.m., the resident was asked if they were able to reach their call light. They stated there were not. The resident was able to demonstrate how to utilize their call light. They were asked if they knew what the call light was for. They stated they use it to call the CNA's and nurses. 4. Res #50 had diagnoses which included CVA, cardiomegaly, and atrial fibrillation. A quarterly assessment, dated 02/02/24, documented the resident's cognition was intact, had no impairment to their extremities, required moderate assistance with their ADLs, and was occasionally incontinent of bowel and bladder. On 02/14/24 at 8:20 a.m., observed resident in their wheelchair beside their bed and their call light was hanging from the wall between the wall and the end of their bed. On 02/14/24 at 3:35 p.m., observed resident in bed and their call light was underneath the end of the bed. On 02/15/24 at 8:24 a.m., observed resident in bed and their call light was underneath the end of the bed. On 02/15/24 at 10:57 a.m., the resident was asked if they were able to reach their call light. They stated there were not. CNA #9 handed the resident their call light. The resident was able to demonstrate how to utilize their call light. 5. Res #64 had diagnoses which included diabetes and pain. An annual assessment, dated 11/16/23, documented the resident's cognition was moderately impaired, had no impairment to their extremities, required moderate assistance with their ADLs, and was always incontinent of bowel and bladder. On 02/14/24 at 9:19 a.m., observed the resident in bed and their call light was in the top drawer of their bedside table. The drawer was closed on the call light. On 02/14/24 at 2:32 p.m., observed the resident in bed and their call light was in the top drawer of their bedside table. The drawer was closed on the call light. On 02/15/24 at 8:39 a.m., observed the resident in bed and their call light was in the top drawer of their bedside table. The drawer was closed on the call light. On 02/15/24 at 10:51 a.m., the resident was asked if they were able to reach their call light. They stated there were not. CNA #10 handed the resident their call light. The resident was able to demonstrate how to utilize their call light. On 02/15/24 at 2:02 p.m., RN #2 was asked where the residents' call lights should be placed. They stated within their reach. They were asked how they ensured the residents' call lights were within reach. They stated when they go into a resident's room, they look to ensure the light is within the resident's reach. On 02/15/24 at 2:02 p.m., CNA #6 was asked where the residents' call lights should be placed. They stated within their reach. On 02/16/24 at 3:09 p.m., the DON was made aware of the above. They stated the call lights should be within the residents' reach at all times.

Based on record review and interview, the facility failed to obtain signatures by the responsible party on admissions agreements for one (#44) of one resident reviewed for admissions. The director of nursing identified 114 residents who resided in the facility. A facility policy titled, Admissions, revised 03/13/2023, read in part, .Pre- Admission: .4. the director of admissions or designee will meet with the resident or the resident's agent or guardian .and will answer all questions pertaining to admission to the community .5. An acknowledgment Form, indicating that these items have been discussed with the resident/guardian, will be signed and dated by the resident/guardian and witnessed by the community representative. A copy of this signed form will be given to the resident . Findings: Res #44 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, UTI, hyponatremia, CVA, and bulimia. The facility's admission packet, at the time of the resident's admission, contained the following: ~ Patient information, ~ Medicare Secondary Payer Screening Form, ~ Resident Influenza, Pneumococcal, COVID-19 Vaccine and Tuberculosis Consent. ~ Informed Consent for Telemedicine Services, ~ Advance Directive Acknowledgment and Request Form, ~ Resident and Family Handbook Receipt, ~ Consent to Treatment and Release of Medical Information, ~ Exhibit A to Resident Admission Agreement, ~ Resident Admission Agreement, ~ Advanced Directive Acknowledgement, ~ Authorization to Release Medical Information, On 02/13/24 at 10:25 a.m., during a phone interview with Res #44's representative, they stated they were never asked to and did not sign any admission paperwork when their family member was admitted to the facility nor were they asked to sign admission paperwork after the admission. No admission paperwork was located in the clinical record. On 02/16/24 at 3:46 p.m., the admission coordinator was asked what their procedure was for admissions. They stated they conducted the admission paperwork in the facility upon admission or emailed the admission packet to the resident's responsible party. They were asked if they had a signed consent to treat for Res #44. They stated they did not.

Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The DON identified 114 residents resided in the facility. Findings: On 02/13/23 through 02/16/23 hall 200 nurse staffing information was not posted. On 02/13/23 through 02/16/23 hall 300 nurse staffing information was not posted. On 02/13/23 through 02/16/23 hall 400 nurse staffing information was not posted. On 02/13/23 through 02/16/23 hall 500 nurse staffing information was not posted. On 02/16/24 at 3:03 p.m., the DON reported the nurse staffing information should have been posted in a prominent area daily.

Based on observation, record review, and interview, the facility failed to administer medications as ordered for two (#2 and #79) of six sampled residents reviewed for medications. ADON #1 identified 105 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included HTN. Physician orders, dated 09/29/23, documented atenolol (a beta blocker) 25 mg tablet one per day. Hold if SBP less than 100, hold if DBP less than 60, hold if pulse less than 60; and losartan (an angiotensin converting enzyme inhibitor) 50 mg tablet two times per day. Hold if SBP less than 100, hold if DBP less than 60, hold if pulse less than 60. The October 2023 MAR documented atenolol was not held one out of five opportunities when the SBP was less than 100, DBP less than 60, pulse less than 60. It was documented losartan was not held three out of 12 opportunities when the SBP was less than 100, DBP less than 60, pulse less than 60. The November 2023 MAR documented losartan was not held five out of six opportunities when the SBP was less than 100, DBP less than 60, pulse less than 60. On 11/29/23 at 2:13 p.m., the DON was asked to review the resident's physician orders and MARs for atenolol and losartan. They were asked to verify when the medications were to be held. They stated when the SBP was less than 100, DBP less than 60, pulse less than 60 hold the medications. They stated the medications should have been held. 46387 2. Res #79 had diagnoses which included diabetes. A facility Documentation - Clinical policy, revised 01/12/2020, documented in part .Medication is due at this time (all scheduled medication trigger 1 hour prior to scheduled time) .Medication is late (all medications trigger 1 hour after scheduled medication time) . A physician order, dated 03/23/23, documented to administer 17 units of insulin detemir every 12 hours at 8:00 a.m. and 8:00 p.m. An EMAR for June 2023, documented the insulin was administered greater than one hour before or after the ordered time 22 of 41 opportunities. A physician order, dated 06/21/23, documented to administer 17 units of insulin detemir daily at 8:00 p.m. An EMAR for June 2023, documented the insulin was administered greater than one hour before or after the ordered time two of five opportunities. A physician order, dated 06/22/23, documented to administer 20 units of insulin detemir one time per day at 08:00 a.m. An EMAR for June 2023, documented the insulin was administered greater than one hour before or after the ordered time one of five opportunities. A physician order, dated 06/26/23, documented to administer 20 units of insulin detemir twice daily at 8:00 a.m. and 5:00 p.m. An EMAR for June 2023, documented the insulin was administered greater than one hour before or after the ordered time five of nine opportunities. An EMAR for July 2023, documented the insulin detemir was administered greater than one hour before or after the ordered time 31 of 62 opportunities. An EMAR for August 2023, documented the insulin detemir was administered greater than one hour before or after the ordered time 24 of 62 opportunities. An EMAR for 09/01/23 through 09/07/23, documented the insulin detemir was administered greater than one hour before or after the ordered time for four of 13 opportunities. A physician order, dated 09/07/23, documented to administer 23 units of insulin detemir twice per day at 8:00 a.m. and 5:00 p.m. An EMAR for 09/07/23 through 09/28/23 documented the insulin was administered greater than one hour before or after the ordered time 12 of 42 opportunities. A physician order, dated 09/28/23, documented to administer 26 units of insulin detemir twice per day at 8:00 a.m. and 5:00 p.m. An EMAR for 09/28/23 through 09/30/23 documented the insulin was administered greater than one hour before or after the ordered time for one of five opportunities. A quarterly MDS, dated [DATE], documented Res #79 was cognitively intact, and received insulin seven days during the review period. An EMAR for October 2023, documented the insulin detemir was administered greater than one hour before or after the ordered time 22 of 62 opportunities. A physician order, dated 10/17/23, documented to administer 10 units of insulin aspart three times per day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. An EMAR for October 2023, documented the insulin was administered greater than one hour before or after the ordered time 17 of 42 opportunities. An EMAR for 11/01/23 through 11/29/23, documented the insulin aspart was administered greater than one hour before or after the ordered time 46 of 85 opportunities. An EMAR for 11/01/23 through 11/29/23, documented the insulin detemir was administered greater than one hour before or after the ordered time 24 of 56 opportunities. On 11/28/23 at 9:18 a.m., Res #79 was observed in their wheelchair in their room. They stated they were receiving their insulin late. On 11/28/23 at 9:24 a.m., LPN #3 was observed obtaining a FSBS for Res #79. They returned and administered their insulin according to physician orders. On 11/29/23 at 11:51 a.m., LPN #3 stated insulin should be administered within one hour of the ordered time. On 11/29/23 at 12:02 p.m., the DON stated insulin should be administered within one hour before or after the ordered time. They were made aware of and acknowledged the late administrations for Res #79.

Based on record review and interview, the facility failed to ensure resident records were accurate for two (#51 and #98) of two sampled residents for accurate records. ADON #1 identified 105 residents resided in the facility. Findings: The Documentation - Clinical policy, revised 01/12/20, read in parts, .The IDT will be responsible for recording, care and treatment, observations and assessments and other appropriate entries in the resident clinical record according to professional practice guidelines . 1. Resident #98 had diagnoses which included cerebral infarction, peripheral vascular disease, dysphasia, and aphasia. A care plan intervention, dated 11/07/23, documented to monitor oral intake of food and fluid. A comprehensive MDS, dated [DATE], documented Resident #98's cognition was impaired. An ADL performance monitoring sheet, dated 11/29/23 at 11:45 a.m., documented Res #98 consumed 75 % of the lunch meal. On 11/29/23 at 12:25 p.m., Res # 98 was observed in bed sleeping with bed side table nearby. The resident had not been served lunch. Hall trays were being passed on the hall. On 11/29/23 at 12:39 p.m., CNA #5 was asked about the ADL performance monitoring sheet documentation. The CNA stated the amount documented was the amount the resident usually consumed and the resident had not received their meal tray. The CNA stated they documented the amount the resident usually ate so they documented before the lunch meal was consumed. On 11/29/23 at 12:48 p.m., the DON was shown the Resident 98's lunch meal which was observed on the bed side not eaten. The DON was asked if resident had consumed any of their meal. The DON replied, No. The DON stated they overheard what the CNA told the surveyor and that the amount eaten should of been documented after the meal was consumed and the CNA did not follow the policy for accurate documentation. 46387 2. Res #51 had diagnoses which included HTN, history of stroke, depression, and obesity. A care plan intervention, dated 02/10/23, documented Res #51 would be assisted with incontinence care every two hours and as needed. A quarterly MDS, dated [DATE], documented Res #51 was cognitively intact, was always incontinent of urine, and required moderate assistance with toileting hygiene. On 11/28/23 at 10:38 a.m., Res #51 was observed in their room resting in bed. The resident stated they were not receiving incontinent care in a timely manner. An ADL record for 11/01/23 through 11/29/23, documented incontinent care was not recorded 11/01/23 through 11/06/23, 11/08/23 through 11/12/23, 11/16/23 through 11/19/23, 11/21/23, 11/23/23 through 11/26/23, and 11/28/23. On 11/30/23 at 9:46 a.m., CNA #3 stated incontinent care was documented in the EHR. They stated the documentation should be completed at least once per shift. They stated Res #51 was provided incontinent care at least every two hours, but often hourly. They stated they did not always document when incontinent care was provided since it was only triggered once per shift. On 11/30/23 at 9:50 a.m., the DON stated incontinent care should be documented in the EHR for each episode of care provided. They stated Res #51 was provided incontinent care regularly. They stated they were positive the care was being completed as the resident would contact them directly if there were any issues. They stated the documentation was not accurate for the care provided.

On 09/14/23 at 10:50 a.m., the Oklahoma State Department of Health (OSDH) confirmed the existence an immediate jeopardy situation existed due to the facilities failure to have a system in place to ensure residents were not missing from the facility. On 09/08/23 the facility was notified by someone in the community that Resident #8 was outside behind the facility on the ground. During an interview with LPN #1, they stated Resident #8 had been outside 30 minutes or less. They stated Resident #8 was found with wet muddy shoes and pants. They stated the resident was able to exit through the back door that went to the smoking area due to the door being broke, and the code and alarm do not work. LPN #1 stated it appeared that the resident had exited a gate behind the facility, as it was found to be open when they went to the back where Resident #1 was located in the alley behind the facility. On 09/14/23 at 10:50 a.m., the administrator was informed of the immediate jeopardy situation. On 09/14/23 at 6:02 p.m., an acceptable plan of removal was received. The plan of removal documented: The following plan of removal to the IJ called on 9/14/23 at 10:50 am for the facility's alleged violation of failing to ensure and exit door was secured for the safety of the residents who are at risk of elopement. Plan of removal Meadowlake Estates: 1. DON/Designee will Inservice/educate all staff (all departments) on elopement policy and procedure to include notification to DON/Administrator if residents are exit seeking. All education be completed by in person or by phone by 11:59 pm 9/14/2023. If unable to reach for education, staff education will be in-serviced prior to working next scheduled shift. 2. An audit was conducted and completed by nursing management to Evaluate all elopement assessments on residents are complete and accurate. 3. DON/designee Updated all residents at risk to elopement book kept at the nurses station. 4. DON/designee will update all care plans for residents identified at risk for elopement by 11:59 on 9-14-23. 5. Maintenance Director/designee has evaluated all doors for operability status. a. A total of 1 door was identified to need repair. b. DON/Designee educated staff about process of visual checks on doors that need repair. c. Staff has been posted within visual range of door identified to need repair. d. Repairman scheduled 9/14/23 by 2 pm. e. Door will be monitored by staff in visual range until repairs are complete. 6. Medical Director has been notified 9.14.23 @ 12:08. 7. QA Committee meeting held 9/14/23 Plan of Removal Date: 9/14/2023 11:59 PM On 09/15/23, after interviews with facility staff, review of elopement assessments for residents, care plans for high risk residents, and in-services, the immediacy was lifted at 12:09 p.m. The deficient practice remained at an isolated harm to the resident. Based on observation, record review, and interview, the facility failed to ensure exit doors were secured to prevent a wandering resident from exiting the facility for one (#8) of three sampled residents reviewed for elopement. The DON identified three residents currently residing in the facility were at risk for elopement. Findings: Resident #8 had diagnoses which included Alzheimer's disease and other speech and language deficits following a cerebral infarction. An elopement risk assessment dated , 09/08/23 documented Resident #8 was at a moderate risk for elopement. A nursing note, dated 09/08/23, read in parts, A gentleman reported to staff that resident was on the floor at the back of the facility, staff went out immediately and found resident on a sitting position at the back of the building with [Resident #8] both legs straighten out in front .had wet mud around the pants and shoes .staff saw resident coming out of [their] room and was walking on the hallway at approximately 0115, staff took patient back to bed and [Resident #8] was seen again at approximately 0145 trying to come out of [their] room then [they] went back in bed . A review of the comprehensive care plan, updated 09/12/23, read in parts, .Wandering/At risk for elopement .Related to: Alzheimer's .Evidenced by: highly confused or demented [11/22/21 : Onset] . An Incident/Accident Report, faxed to OSDH on 09/12/23, read in parts, .Resident [name withheld] exited facility and had to be assisted back inside . On 09/14/23 at 5:46 a.m., LPN #1 was asked if they had any residents try to elope recently. They stated yes, she is not here anymore. LPN #1 was asked to explain the incident. They stated at 1:15 a.m., resident was trying to get OOB, we saw Resident #8 and put Resident #8 back to bed. LPN #1 stated at 1:45 a.m., Resident #8 got up and we took them back to bed. We got busy and between 2:00 - 2:30 a.m., an employee rushed in and said that a gentlemen told him a resident was outside. We rushed out and Resident #8 was sitting in the alley in back of the facility. On 09/14/23 at 7:58 a.m., LPN #1 was asked how long Resident #8 had been out of the facility. LPN #1 stated, I believe [Resident #8] wasn't out more than 30 minutes, [they] still had wet mud on [their] pants and shoes. LPN #1 stated that the door to the smoke area was broken. On 09/14/23 at 8:00 a.m., the exit door to the patio was observed to be opened by a resident without using a code. No alarm sounded when the resident opened the exit door. On 09/14/23 at 9:43 a.m., the DON was asked if they had any residents at risk for elopement. They stated there were three. The DON was asked what interventions were put in place for elopement residents. They stated an elopement assessment was completed, it was care planned, and there was an elopement book at the front desk and one at the nurses station. On 09/15/23 at 08:41 a.m., the DON was asked about the incident with Resident #8. They stated it occurred on 09/08/23 around 2:20 a.m. They stated from an interview with LPN #1, the resident went out the gate and down the alley in the gravel area.

On 04/26/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify physician of unavailable medications in the facility. APRN stated she was never made aware that the medication was not available or not administered. Resident #1 had a cardiac arrest that resulted in death. The facility's physician notification process was not effective, staff was not following through with the process of notifying physician timely and there was no facility monitoring of staff notification to physician. On 04/26/23 at 4:57 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/26/23 at 5:15 p.m., The Administrator and the DON were notified of the IJ situation. On 04/26/23 at 8:37 p.m., a plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal was reviewed and revision was warranted. The revised plan of removal was submitted on 04/27/23 at 4:55 p.m., and given acceptance to move forward with the plan of removal date of 04/27/23 at 11:59 p.m. The plan of removal sent via email documented: The following is a plan of removal to the IJ called 4/26/2023 at 5:15 PM for the facility's alleged violation of failed to notify physician of unavailable medications. The administrator will be responsible for oversight of the plan of removal. Notification of IJ status was made by the Administrator to the Medical Director, on 4/26/2023 at 7:00 PM. The Medical Director has made themselves available to the team as needed. Plan of Removal 1. DON/Designee will educate all licensed nurses and certified medication aides by 2359 on 4/27/2023 that when medication is not available the physician will be notified via phone upon identification of unavailable medications along with the DON/Designee for further guidance. Licensed nurses will document notification in the chart to the physician with any further recommendation. Any licensed nurse or certified medication aide not educated by 2359 on 4/27/2023 will not be allowed to work until they have received education. 2. An audit was conducted and completed by 2359 on 4/27/2023 by nursing management to assure that medications that are ordered by physician are available to licensed nurses and Certified Medication Aides on their medication carts. The pharmacy was contacted via phone to obtain medication that was not available. The physician will be notified of medication that was found to not be available by 2359 on 4/27/2023. 3. DON/Designee will follow-up during morning clinical meeting, five days a week, Monday through Friday, on all pending prior authorizations for medication, if mediations are needing prior authorization and the medication is not available the provider will be notified for additional guidance. On 04/28/23, staff were interviewed regarding training/updates in regard to notifying physician when medication is not available. Staff stated they had received in-person and/or phone calls from various members of administrative nursing employees and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On 04/28/23 at 11:37 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 04/27/23 at 11:59 p.m. The deficiency remained at an isolated level of actual harm. Based on record review and interview, the facility failed to notify physician that a cardiac medication Apixaban had not been given to one (#1) of three sampled residents reviewed for notification of change. The Resident Census and Conditions of Residents form, dated 04/19/23, documented 101 residents resided in the facility. Findings: Resident #1 was readmitted on [DATE] with diagnoses which included atrial flutter, congestive heart failure, coronary artery disease, hemiplegia and hemiparesis following cerebral infarction, chest pain and hypertension. A Physician's Order, dated 06/23/22 documented Apixaban 5mg be administered twice daily for atrial fibrillation. The MAR for January 2023 documented the resident had not been given Apixaban for 13 out of 48 opportunities. The MAR for December 2022 documented the resident had missed opportunities for administration of Apixaban. There was no documentation the physician was notified of medications not administered. On 04/25/23 at 4:25 p.m., the DON was asked what do you expect your nurse to do when the medication aide had not given residents their medication. The DON stated the nurse should also notify the physician. On 04/25/23 at 4:30 p.m., the DON was asked to review Resident #1 January 2023 MAR. The DON reviewed and acknowledge that Apixaban was not administered 13 times. The DON was asked to show documentation the physician was notified of the medication not given. On 04/25/23 at 5:09 p.m., the DON stated, The ADON should have let the doctor know. On 04/26/23 at 12:03 p.m., the APRN was asked if they were ever made aware that Resident #1 had no been receiving their Apixaban twice a day per order. The APRN appeared shocked and stated, No was never made aware [named Resident] was not getting Apixaban. On 04/26/23 at 12:10 p.m., the APRN stated it was their expectation for staff to notify them or the [named physician] when medication was not given or not available.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to administer a cardiac medication Apixaban 5mg twice daily as ordered for Resident #1. Resident #1 had missed 15 out of 54 opportunities to receive the physician ordered cardiac medication. Resident #1 had a cardiac arrest which resulted in death. The facility had no guidelines in place to ensure physician ordered medication was administered, that monitoring was in place to avoid missed doses, and that the facility had intervened timely. Resident #1 had an original admitted [DATE] to the facility with diagnoses which included Schizophrenia, hypertension, anxiety and diabetes mellitus type two. Resident #1's records indicated that resident had a cerebral vascular accident with hemiparesis and hemiplegia in [DATE] and had additional diagnoses which included atrial flutter, heart failure, coronary artery disease, chest pain and shortness of breath. Resident #1's most recent readmission was [DATE]. Resident's medical records indicated their atrial flutter was well controlled on Apixaban and continued to be anticoagulated on the Apixaban. Documents reviewed stated the resident utilized Apixaban for stroke prevention. Resident was seen by their cardiologist every two to three months. The MAR documented that resident's Apixaban had been documented as held/not given by the medication aides 15 times out of 54 opportunities from [DATE] to [DATE]. The records had no documentation of the reason not given or what was done by the nursing staff. The Resident's records documented that on [DATE] the resident was observed on the floor from a fall from bed and shortly went unresponsive. The Resident's records documented CPR was initiated by facility's staff and OKCFD took over CPR until EMSA personnel arrived. EMSA report documented the chief complaint was cardiac arrest with secondary compliant of unresponsiveness. EMSA report documented the resident was in asystole had no rhythm change with continuous CPR and medications. EMSA personnel received order from physician to discontinued CPR efforts. The resident was pronounced dead. The facility's APRN who followed the care of Resident #1 stated that the adverse reaction for a resident who had cardiac diagnosis to miss dosages of the apixaban would be the possibility to develop blood clot to the extremities or lungs. On [DATE] at 4:57 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 5:15 p.m., The Administrator and the DON were notified of the IJ situation. On [DATE] at 8:37 p.m., a plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal was reviewed and revision was warranted. The revised plan of removal was submitted on [DATE] at 4:55 p.m., and given acceptance to move forward with the plan of removal date of [DATE] at 11:59 p.m. The plan of removal sent via email documented: The following is a plan of removal to the IJ called [DATE] at 5:15 PM for the facility's alleged violation of failed to administer Apixaban 5mg BID as ordered, the resident missed 15 out of 54 doses. The administrator will be responsible for oversight of the plan of removal. Notification of IJ status was made by the Administrator to the Medical Director, on [DATE] at 7:00 PM. The Medical Director has made themselves available to the team as needed. Plan of Removal 1. DON/Designee will Educate all licensed nurses and Certified Medication Aides on administering medications per physician orders by 2359 on [DATE], any licensed nurse and/or Certified Medication Aide not educated by 2359 on [DATE] will not work until education has been completed. 2. An audit was conducted and completed by 2359 on [DATE] by nursing management to assure that all medications that is ordered by physician is available to licensed nurses and Certified Medication Aides on their medication carts. The pharmacy was contacted via phone to obtain medication that was not available. Physician was notified of medication that was found to not be available by 2359 on [DATE]. 3. DON/Designee will monitor medication administration records to assure that medication is administered records as ordered in clinical morning meeting, five times a week, Monday through Friday. Designated nursing manager will monitor medication administration records on Saturday and Sunday to assure that medications are administered as ordered. On [DATE], staff were interviewed regarding training/updates in regard to administering medications per physician orders. Staff stated they had received in-person and/or phone calls from various members of administrative nursing employees and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On [DATE] at 11:37 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of [DATE] at 11:59 p.m. The deficiency remained at an isolated level of actual harm. Based on record review and interview, the facility failed to follow physician's orders to administer medication for one (#1) of three sampled residents who were reviewed for medication administration. The Resident Census and Conditions of Residents form, dated [DATE], documented 101 residents resided in the facility. Findings: Resident #1 was readmitted to the on [DATE] with diagnoses which included atrial flutter, congestive heart failure, coronary artery disease, hemiplegia and hemiparesis following cerebral infarction, chest pain and hypertension. A Physician's Order, dated [DATE] documented Apixaban 5mg be administered twice daily for atrial fibrillation. The MAR for [DATE] documented the resident had not been given Apixaban for 13 out of 48 opportunities. On [DATE] at 4:25 p.m., the DON was asked what do you expect your nurse to do when the medication aide had not given residents their medication. The DON stated she expected the nurses to find out why the medication was not given. There was no documentation in the resident's medical records to indicate the reason the physician ordered Apixaban was not followed. On [DATE] at 12:01 p.m., the APRN was asked what would be the adverse effects of a resident with atrial fibrillation/atrial flutter who had not been receiving their prescribed apixaban 13 out of 48 opportunities for the month of January. The APRN stated, Apixaban is a blood thinner so it is to prevent blood clots. If not given it would do the opposite. Possible blood clot in extremities or lungs. On [DATE] at 12:07 p.m., the APRN was asked about their visit with the resident on [DATE]. The APRN stated, If [Resident #1] developed a blood clot don't know. Chest x-ray showed possible pneumonia in this case. [Resident #1] also takes it for flutter and blood clot prevention.

On 04/26/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to maintain adequate supply of Eliquis (apixaban) to meet the needs of residents. Resident #1 had a cardiac arrest resulting in death. The DON stated that all Apixaban required prior authorization for medication to be filled. The APRN stated they were not made aware that Resident #1 had prior authorization request for the medication to be refilled. The facility had no system in place to monitor the adequate supply of medication available on hand and to address the request for prior authorization to be fully completed to ensure delivery and availability. On 04/26/23 at 4:57 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/26/23 at 5:15 p.m., The Administrator and the DON were notified of the IJ situation. On 04/26/23 at 8:37 p.m., a plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal was reviewed and revision was warranted. The revised plan of removal was submitted on 04/27/23 at 4:55 p.m., and given acceptance to move forward with the plan of removal date of 04/27/23 at 11:59 p.m. The plan of removal sent via email documented: The following is a plan of removal to the IJ called 4/26/2023 at 5:15 PM for the facility's alleged violation of failed to assure that the facility had adequate amount of Eliquis to meet the needs of the resident. Notification of IJ status was made by the Administrator to the Medical Director, on 4/26/2023 at 7:00 PM. The Medical Director has made themselves available to the team as needed. Plan of Removal 1. An audit was conducted and completed by 2359 on 4/27/2023 by nursing management to assure that all medications that is ordered by physician is available to licensed nurses and Certified Medication Aides on their medication carts. The pharmacy was contacted via phone to obtain medications that were not available. Physician was notified of medication that was found to not be available by 2359 on 4/27/2023. 2. DON/Designee will educate all licensed nurses and certified medication aides by 2359 on 4/27/2023 to order all medication when there are five days left on the medication cart and if medication is not received the following day, they are to notify DON/Designee. On 04/28/23, staff were interviewed regarding training/updates in regard to ensuring that all medications that is ordered by physician is available to licensed nurses and certified medication aides on their medication carts to meet the needs of the residents. Staff stated they had received in-person and/or phone calls from various members of administrative nursing employees and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On 04/28/23 at 11:37 p.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 04/27/23 at 11:59 p.m. The deficiency remained at an isolated level of actual harm. Based on record review, and interview, the facility failed to ensure adequate supply of Eliquis (apixaban) was maintained for one (#1) of three sampled resident reviewed for medication availability to meet the needs of the residents. The Resident Census and Conditions of Residents form, dated 04/19/23, documented 101 residents resided in the facility. Findings: Resident #1 was readmitted to the on 06/23/22 with diagnoses which included atrial flutter, congestive heart failure, coronary artery disease, hemiplegia and hemiparesis following cerebral infarction, chest pain and hypertension. A Physician's Order, dated 06/23/22 documented Apixaban 5mg be administered twice daily for atrial fibrillation. An Electronic Shipping Manifest dated 12/06/22, documented that 14 Eliquis 5mg dosage had been delivered. This supply would have been sufficient for 7 days. An Electronic Shipping Manifest dated 12/16/22, documented that 28 Eliquis 5mg dosage had been delivered. This supply would have been sufficient for 14 days. A Petition/Response for Medication Prior Authorization form, dated 12/28/22, documented previous authorization, fill date and the quantity filled. The request for medication prior authorization documented the form was incomplete. There was no additional shipping manifest provided to show that Eliquis (apixaban) was delivered after 12/16/22. The MAR was reviewed for 12/29/22 through 01/24/23. The documents showed that resident had 15 out of 54 missed opportunities to receive Apixaban 5mg which was ordered to be given twice daily. On 04/25/23 at 5:09 p.m., the DON stated CMA #3 had informed them that prior authorization was needed and that ADON was informed, pharmacy was notified but the medication was never delivered. The DON was asked what is the facility protocol when medication is not available. The DON stated, They need to notify the physician. ADON should have let the doctor know. On 04/25/23 at 5:15 p.m., the DON was asked how could the medication aides give medication if the medication was not available. The DON stated, You would have to ask them. The DON stated that with all apixaban order prior authorization was needed. On 04/25/23 at 5:17 p.m., the DON was asked who monitored to ensure medication is available. The DON stated, We try to run through clinical every morning. On 04/26/23 at 12:05 p.m., the APRN was asked if they were ever made aware that prior authorization was needed for Resident #1 Eliquis (apixaban) to be filled by pharmacy. The APRN stated that prior authorization was dependent on the payor source. The APRN stated, For me personally, no I did not have to fill out prior authorization for the resident. The APRN stated, I had no idea there was a request for prior authorization for any of (Resident #1) medications. On 04/26/23 at 12:10 p.m., the APRN stated it was their expectation for staff to notify them or the [named physician] when medication was not given or not available. On 04/27/23 at 11:53 a.m., the ADON was asked to review Resident #1 MAR for date 01/02/23. The ADON acknowledge that they were the charge nurse assigned to Resident #1 that date. The ADON stated they were not made aware that the Eliquis (apixaban) was not administered that shift. The ADON stated pharmacy would not send out a full 30-day supply of the medication. The ADON stated the medication would not be available because of a combination of both physician signature and insurance. On 04/27/23 at 3:32 p.m., CMA #3 stated, I put it (Eliquis) on hold if the medication is not in the building. CMA #3 stated, Sometimes a medication needs a PA but I would not know until it did not come in. CMA #3 stated they would ask the ADON or would leave a note on the ADON desk.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were free from abuse for one (#9) of four sampled residents reviewed for accidents/supervision. Resident #9 required physical assistance with transfers from the bed to the wheel chair. Certified nurse aide (CNA) #6 was present in the room and did not provide assistance to the resident. As a result of not providing the needed assistance the resident fell to the floor causing a laceration above the right eye requiring eight to nine sutures and severe bruising to the face, neck and chin. The resident experienced increased pain and use of routine and as needed pain medications experienced after theses injuries. Findings: Resident #9 had [DIAGNOSES REDACTED]. The Morse Fall Scale dated 03/29/19 , documented, .Gait .impaired .difficulty rising from chair, uses chair arms to get up, bounces to rise .grasps furniture, person or aid when ambulating . The resident was a moderate risk for falls with a score of 25. A score of 25 - 44 indicated a moderate risk. A quarterly assessment, dated 05/30/19, documented the resident's cognition was intact, had clear speech, was able to understand as well and could be understood by others. The resident required one person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had no falls since the previous assessment was completed. The assessment further documented the resident was not steady and only able to stabilize self with staff assistance while moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The assessment defined surface to surface transfers as those between bed and chair or wheelchair. The Morse Fall Scale dated 05/30/19, documented, .Gait .impaired .difficulty rising from chair, uses chair arms to get up, bounces to rise .grasps furniture, person or aid when ambulating . The resident was a moderate risk for falls with a score of 25. A score of 25 - 44 indicated a moderate risk. A care plan intervention for falls, dated 06/04/19, documented, Assist resident with ADLs (activities of daily living) as needed . A review of the Medication Administration Record [REDACTED]. The pain level at the time of administration was zero. An incident report, dated 08/05/19 at 10:50 p.m., documented, CNA notified this nurse while transferring res (resident) from bed to w/c (wheelchair) res got lightheaded, slipped and landed on floor .type of injury laceration .sent to ER (emergency room ) . A nurse's note, dated 08/05/19 at 11:00 p.m., documented, CNA notified this nurse that resident fell during transfer. CNA transferring res from bed to w/c to take to restroom. Res lightheaded and fell to floor. Res lying face down, bleeding from laceration above (R) (right) eye . The nurse's note and the incident report were both completed by licensed practical nurse (LPN) #7. An After Care Summary, dated 08/05/19, documented, .reason for visit fall .[DIAGNOSES REDACTED].facial laceration .instructions .Go to (name deleted) emergency department in 1 week (around 08/13/19) .for suture removal . A nurse's note, dated 08/06/19 at 11:00 a.m., documented, The resident returned from the ER with discharge orders and instructions of care for sutures of laceration above the right eye .orders to return to the ER to have sutures removed in 7-10 days .resident requested morning medications and only wanted her pain medication .resident refused her meal . A nurse's note at 1:00 p.m., documented, .Resident cont (continues) to have multiple bruises to face and laceration . A review of the MAR for 08/06/19 through 08/13/19, documented the resident's pain level was between a five and seven when the [MEDICATION NAME] was administered. In addition the resident was requesting her [MEDICATION NAME] (an opioid pain medication) as needed pain medication daily with a pain level at the time of administration between five and seven. An initial report to the Oklahoma State Department of Health (OSDH), documented, Date of incident 08/05/19 .incident type .allegation of neglect .Part B description of incident .Resident reported the CNA (name deleted) didn't help her and she fell and hit her head on the floor. CNA reported that while transferring resident from bed to wheelchair, resident got lightheaded, slipped and landed on the floor. Resident obtained a cut on her right eyebrow area that required her to go to ER for further evaluation and treatment. She returned a few hours later with about 8 stitches to her right eyebrow area. CNA (name deleted) was immediately suspended pending outcome of investigation relevant resident history .patent is a 79 y.o. (year old) .AAO (alert and oriented) X 3 Hx (history) of muscle wasting, cerebral infarction, [MEDICAL CONDITION], lack of coordination, abnormal posture . A final report to the OSDH documented, .Part C Investigation could not substantiate allegation. Interview with CNA revealed that he had assisted this resident many times in the recent past and resident did get lightheaded and fell . CNA was assisting resident from behind and could not break fall Attached to the report was a written statement on a nurse's note from CNA #6 The statement documented. Around 10:45 (10:45 p.m.) I was called to (resident's) room to assist her to the restroom. She sat up at the edge of the bed and I guided her to her w/c. She took a couple of steps and before I could react she had fell forward and hit the floor. I ran to grab the nurse on duty and called 9-11. Notes from questions asked by the administrator documented the CNA stated he was aware the resident required one person stand by assist and he did not know why the resident would claim he did not help her. The initial report was sent to OSDH on 08/06/19 at 4:18 p.m., over 12 hours after the resident had told the charge nurse of the abuse. There was no documentation the facility interviewed and obtained a statement from the resident or the charge nurse related to the allegation of abuse. There was no documentation the facility interviewed other residents regarding the care they received from the CN[NAME] On 08/13/19 at 12:45 p.m., the resident was observed in her wheelchair outside her room. She had sutures above her right eye and had numerous amounts of bruising on the right side of her face including her cheek, jaw and neck. The resident stated she fell while getting out of bed. She stated the CNA came in, put her side rail down then stood behind the wheelchair and did not assist her with the transfer. She stated she required the use of a side rail and staff to help her with the transfer. She stated she had been at the facility a long time and never had a fall prior to this. She stated all the other CNAs will help her by the arm. She stated she had told the charge nurse he did not help like he should have and she told the CNA to get out of her room and not to come back in. The resident stated it happened a week ago on Monday night around 10:30 p.m., she had to go to the bathroom, she turned on her call light three times and was told other residents were on the toilet and she could not be helped. She then stated she called the charge nurse on the phone and she had the CNA come to her room. She stated her pain was a 10 on a scale of one to ten and she had to take pain medications two to three times a day now. She identified CNA #6 as the CNA working when she had the fall. At 3:00 p.m., the resident stated she fell she fell forward from the bed landing near the recliner and the night stand. She stated no one from the facility had asked her what happened, and the surveyor was the first to talk to her about it. She stated there was still blood on the carpet where her head landed. She then stated she was not dizzy, the CNA did not help her and that was the cause of the fall. On 08/14/19 at 8:16 a.m., LPN #7 stated she was counting medications in the medication room when the CNA came in and told her the resident had a fall while being transferred. She stated she asked the CNA if the resident hit her head and the response was no. She stated when she entered the room, she found the resident lying on the floor face down with her head near the recliner and night stand. She stated the resident kept yelling and cursing at the CNA to get out because he did not help her and she fell . LPN #7 stated the CNA did not tell her the resident was bleeding when it was reported. The nurse stated the resident required staff to physically assist her and if he was assisting her she can not figure out how the fall occurred. She stated the side rail was down when she came into the room. She stated the resident was very with it and knows what was going on. She stated she did not ask the resident anything more because she was sent to the hospital and she only works part time at the facility. She then added that no one had taken a statement of the event from her and the surveyor was the first one to ask her about it. She stated the resident did not have any complaints to her about being dizzy. At 8:41 a.m., CNA #7 stated the resident required physical assistance with transfers. She stated the CNAs need to help with her one arm as she pushed up on the side rail. She then stated the resident was able to tell you everything and had no cognitive defects. At 8:45 a.m., registered nurse (RN) #2 stated the resident required limited one person physical assistance with her transfers for stability and guidance. She then stated there had been a lot of complaints about the care provided by CNA #6 and he was moved from hall to hall. She stated she did not know why he ended up working on hall 400. At 9:08 a.m., the director of nursing (DON) stated there had been several complaints about CNA #6 and his work. She stated the complaints came from family about not giving proper care and from other staff about his work. She stated she did not remember investigating any part of the fall and was not sure what the outcome was. She stated the administrator would have the investigation if there was one. She stated she was not sure what level of assistance the resident required and did not know much about the resident except for the fall that occurred the previous week. She stated she would see if she could find any information regarding the investigation behind the fall. At 10:04 a.m., the DON stated she reviewed all documentation from the investigation with the administrator. She stated the resident reported the CNA did not assist with the transfer and she fell because of it. She then stated there was no interview with the charge nurse working at the time, the resident and no interviews with other residents. She then stated, based on what was reviewed, a thorough investigation was not conducted. She then stated the resident was awake and alert after the fall. She added that the administrator might have more documentation then what was reviewed with him. At 11:55 a.m., the administrator stated he talked with the resident but did not have a written statement. He then stated he only looked at the nurses note and incident report and did not talk with the charge nurse who was working at the time of the incident. He stated other residents were interviewed and he would look for them. He stated he had the social service director conduct the interviews. When asked about previous complaints of care not being provided or done correctly he stated the CNA who was involved had one other incident that was for lack of care that he knew of. The administrator then stated the CNA did confirm to him that he knew the resident required assistance with her transfer. At 12:20 p.m., the social service director stated he did not remember conducting any resident safe interviews and if he did the the administrator would have them. The administrator provided no additional investigative documentation into the abuse and the fall.

Based on observation, record review and interviews, it was determined the facility failed to ensure: ~ a change in skin condition was thoroughly assessed, monitored and interventions were implemented in a timely manner for two (#1 and #4) of three sampled residents reviewed for wounds. Due to the failure to assess, monitor and intervene in a timely manner for resident #1, the treatment for [REDACTED]. The facility identified nine residents with pressure ulcers; ~ [NAME] hose were in place as ordered by the physician for one (#2) of three sampled residents reviewed for physician's orders [REDACTED].>~ Follow up appointments were made for two (#7 and #9); and ~ Physician orders [REDACTED].#7). The facility identified 108 residents resided in the facility. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A quarterly assessment, dated 05/24/19, documented the resident's cognition was severely impaired, she required total assistance for activities of daily living and was at risk for pressure ulcers. A weekly pressure ulcer record, dated 06/24/19, documented a stage III pressure ulcer to the right heel which measured 1.5 x 3.0 x 0.1. The form documented an onset date of 06/23/19. On 06/26/19, a specialty physician for wound evaluation and management assessed the resident due to a Stage-3 pressure wound of the right heel. A physician's orders [REDACTED]. A treatment administration record (TAR) record, dated 06/01/19 through 06/30/19, documented to cleanse the right heel with normal saline, pat dry and apply silver alginate and dry dressing every day with a start date of 06/26/19. Another notation documented to monitor skin integrity weekly and if there were any skin problems noted to document them in the progress notes. This was initiated on 03/13/19. There was no documentation in the clinical record on 06/23/19 to indicate a change in skin status was observed. On 07/10/19 a specialty physician for wound evaluation and management assessed the resident due to a Stage-3 pressure wound of the right heel and an unstageable deep tissue injury to the left heel. The care plan, last updated 07/12/19, documented the resident had pressure ulcers to her left heel. Interventions included: a complete body inspection was to be completed every week and documented and daily skin inspections were to be completed during care/bathing and report any changes to the charge nurse. On 07/17/19, a weekly pressure ulcer record documented new onset of moisture associated trauma to her right buttock. A specialty physician for wound evaluation and management documented, .wound of the right buttock for at least 1 days duration . A new order was received for Extra Protective Cream (EPC) to be applied every shift for 30 days. On 07/22/19 at 10:30 a.m., certified nurse aides (CNA) #1 and #2 were observed to assist the resident for transfer and undress in preparation for a shower. CNA #2 stated the resident had an open area to her coccyx. She positioned the resident to reveal a discoloration, approximately 5 centimeter (cm), to the coccyx area. There was an open area approximately 6 cm on the lower/outer right buttock. A skin monitoring/certified nurse aide shower review, dated 07/22/19, documented the resident had rashes on the front inner thighs and coccyx/sacrum area. The clinical record did not indicate the licensed nurses, physician or family were aware of skin impairment to the coccyx. The clinical record did not contain measurements or description of the wounds on the right buttock or coccyx. At 11:45 a.m., licensed practical nurse (LPN) #4 was observed to provide wound treatment to the resident's heels. There was no treatment provided to the coccyx or buttock. At 2:10 p.m., the director of nurses (DON), and assistant director of nurses (ADON) #1 were asked to clarify the the location of an open wound to her buttock or coccyx. ADON #1 stated the resident was being treated for [REDACTED]. She stated the cream for shearing would be applied by the charge nurse, not the wound nurse. ADON #1 stated the open area was located in the center area and gestured to the coccyx/sacral area. They were asked if the resident had an open area to the coccyx. They stated not that they were aware and referred to LPN #5 for clarification. At 2:45 p.m., LPN #5 was asked if the resident had open wounds on her buttocks or coccyx. He stated the resident had treatment orders for a shearing of the outer right buttock. He denied the resident had additional skin impairment of the coccyx. LPNs #4 and #5, and CNA #2 returned to the resident's room for a skin audit. The resident was observed to have an open area approximately 6 cm on the lower/outer right buttock and an open slit, approximately 5 cm, on the coccyx. CNA #2 stated she had been using barrier cream on the coccyx wound. LPNs #4 and #5 stated the cream was for shearing of the buttock and they were unaware of the coccyx wound. CNA #2 stated she was unaware of the shearing of the buttock but had been placing the barrier cream to the coccyx wound when she worked the past weekend. Discussion between the LPNs and CNA were unable to determine when the coccyx wound had opened. At 3:34 p.m., the specialty physician for wounds was asked if there were concerns of the resident's skin issues. She stated the heel wounds were of sudden onset and Doppler studies reveal significant vascular deficiencies. She stated information was being obtained for a cardiologist referral had begun for further testing/interventions. On 08/14/19 at 12:50 p.m., LPN #5 and the director of nursing (DON) were asked about the new wound identified on 06/23/19. The LPN was asked when the stage III pressure ulcer was first identified. He stated LPN #2 observed it on 06/23/19 and reported it to me the next day. He was asked when the physician was notified. He stated the morning of the 24th. He was shown the physician's telephone order and the TAR and asked why they were dated 06/26/19. He stated he just got busy and forgot to write the order and he did not have access to the TAR to write it down. At 1:00 p.m., the DON was asked if LPN #2 should have called the physician when he observed it on 06/23/19. She stated yes, LPNs can call the physician. She was asked if the skin impairment should have been documented on the day it was observed. She stated yes. 2. Resident #2 had [DIAGNOSES REDACTED]. A review of the resident's current treatment orders documented, .Thigh high [NAME] Hose on in the AM, off in the PM . The order was first written on 01/19/16. A telephone order, dated 06/05/19, documented, [NAME] Hose thigh high 16.5 inches . On 07/23/19 at 10:20 a.m., the resident's family stated the resident did not have any [NAME] hose in the room and there were none available for put on her. The family stated this was reported to the evening charge nurse on 07/20/19. On 07/23/19 from 11:35 a.m. through 4:25 p.m., the resident was observed at random times without [NAME] hose in place. The room was observed without any [NAME] hose visible. A drawer tabled [NAME] Hose and socks was observed without any [NAME] hose or socks. At 3:30 p.m., LPN #1 stated the family had told her about the [NAME] hose and she looked in both the room and laundry for them. She stated she could not find any [NAME] hose for the resident. She stated she did not report it to anyone that the resident did not have any to put on. At 4:00 p.m., LPN #2 stated he was aware the family had complained about no [NAME] hose over the weekend and was not sure what had been done about it. On 07/24/19 at 8:30 a.m., 9:25 a.m., and 11:45 a.m., the resident was observed without her [NAME] hose in place. On 07/24/19 at 9:25 a.m., LPN #3 stated the resident was suppose to wear [NAME] hose everyday. She then observed the resident and stated she does not have any on and she would have to look in the room and laundry. She then stated the physician's orders [REDACTED]. 3. Resident #9 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/30/19, documented the resident's cognition was intact, had clear speech and was able to understand as well and be understood by others. The resident required one person physical asssistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment documented the resident had no falls since the previous assessment was completed, the resident was not steady and only able to stabilize self with staff asssistance while moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The assessment defined surface to surface transfers as those between bed and chair or wheelchair. An incident report, dated 08/05/19 at 10:50 p.m., documented, CNA notified this nurse while transferring res (resident) from bed to w/c (wheelchair) res got lightheaded, slipped and landed on floor .type of injury laceration .sent to ER (emergency room ) . A nurse's note, dated 08/05/19 at 11:00 p.m., documented, CNA notified this nurse that resident fell during transfer. CNA transferring res from bed to w/c to take to restroom. Res lightheaded and fell to floor. Res lying face down, bleeding from laceration above (R) (right) eye . An After Care Summary, dated 08/05/19, documented, .reason for visit fall .[DIAGNOSES REDACTED].facial laceration .instructions .Go to (name deleted) emergency department in 1 week (around 08/13/19) .for suture removal . A telephone order, dated 08/06/19, documented, .Sutures to be removed in ER (emergency room ) 7-10 days . A care plan intervention for skin breakdown related to right eyebrow sutures, dated 08/06/19, documented, .sutures to removed in 7-10 days . A nurse's note, dated 08/06/19 at 11:00 a.m., documented, The resident returned from the ER with .orders to return to the ER to have sutures removed in 7-10 days . On 08/13/19 at 12:45 p.m., the resident was observed in her wheelchair outside her room. She had sutures above her right eye and had numerous amounts of bruising on the right side of her face including her cheek, jaw and neck. On 08/14/19 at 4:00 p.m., the social service director stated the resident did not have any appointments for the sutures to be removed. He provided a list of appointments through 08/17/19 and stated he did not know the resident had orders for an appointment to be scheduled. 4. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge paperwork, dated 07/16/19, documented, .schedule an appointment with (Name Deleted) DO as soon as possible for a visit in 2 weeks . A social service progress note, dated 08/01/19, documented, SSD (social service director) made appointment with Dr. (name deleted) for ortho follow up on 08/12/19 at 8:45 a.m. The resident should have had the follow up appointment scheduled for no later then 07/30/19. A nurse's note, dated 08/06/19 at 3:25 p.m., documented, Spoke with Dr. (name deleted) ortho surgeon office and have N.O. (new order) to not remove staples . A physician's telephone order, dated 08/07/19, documented, Remove staples from (R) (right) hip. The order was from the resident's attending physician. The order was noted by licensed practical nurse (LPN) #6. A treatment sheet for (MONTH) 2019 documented, Remove Staples from left hip 8-7-19 .hours 3-11 . The box for the 7th was initialed and circled indicating the nurse had attempted to complete the order. There was no documentation to indicate why and if the staples had been removed. There was no documentation the facility received a clarification order from the orthopedic surgeon after the attending physician wrote the order to remove the staples. On 08/13/19 at 9:55 a.m., the social service director stated he did not know about the appointment. He stated the admission charge nurse are suppose to provide a copy of all appointments that are needed on admission and they did not do that. He then stated the appointment did not get scheduled like the doctor wanted. At 11:40 a.m., LPN #6 stated the attending physician gave the order to remove the staples because they had been for a month. She stated the on coming charge nurse was to remove the staples because the doctor was in at the end of the shift. She then stated she was not aware of the order from the orthopedic doctor to not remove the staples. At 3:55 p.m., LPN #8 stated she was the nurse that was going to remove the staples. She then stated she was not able to remove the staples because she did not have the supplies for the procedure. She then stated they were going to be removed to make the family happy. She stated she did not call and get a clarification between the orders and the page was missing where she documented why she could not remove them. At 4:15 p.m., LPN #4 stated the orthopedic surgeon did not want them removed and there should never have been another order written. At 4:20 p.m., the DON stated the nurses should have called the orthopedic surgeon for clarification and let the attending physician now what was said. She then stated until today she was not aware of the conflicting orders. 5. Resident #4 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/06/19, documented the resident's cognition was moderately impaired and required extensive assistance with activities of daily living: except eating, which required supervision. A physician's orders [REDACTED]. A nurse's note, dated 07/22/10 at 7:00 p.m., documented a new order for a cream to treat the resident's skin rash had been received. A physician's orders [REDACTED]. The 07/2019 treatment administration record (TAR) documented the first application of the TMC cream was on 07/24/19 at 8:00 a.m. A nurse's note, dated 08/06/19, documented a head to toe skin assessment had been conducted an there were no skin issues at this time. The TAR, dated 08/2019, documented the staff was still applying the cream. On 08/12/19 at 4:41 p.m., the DON was asked if she had ever had a conversation with a staff nurse and a family member about the nurse having forgotten to notify the physician of the resident's rash; after the family member had brought it to the nurse's attention. She stated she had. She was asked if the nurse had forgotten to assess the rash and failed to notify the physician. The DON stated the nurse had forgotten to assess the rash and notify the physician when the presence of a rash had been brought to her attention She was asked if she remembered the date, the family member had informed the nurse of the rash. She stated she didn't remember the exact date, but the rash was not assessed for several days. She was asked if she meant several days prior to 07/22/19. She said, Yes. She was asked if a family member had informed her the nurse had been made aware of the rash on 07/19/19. She said, Possibly. I'm not sure of the exact date. At 11:00 p.m., the resident's chest and back were observed in the presence of the assistant director of nurses (ADON) and charge licensed practical nurse. Her back was observed to be free from a rash. Her chest was observed to have a slight rash; mainly a small cluster which appeared to have a small residual of a topical cream. The ADON stated the rash on the resident's back and chest had resolved, but the rash on her chest was new. On 08/13/19 at 4:00 p.m., corporate nurse #2 and the wound nurse were asked about the physician's orders [REDACTED]. They were asked to review the physician's orders [REDACTED]. They were asked if the cream should have been discontinued when the rash had resolved. They stated it should have been stopped. They were asked if staff was continuing to administer the cream. They stated the staff had continued to apply the cream and it was still being applied. The corporate nurse #2 stated they would contact the physician and inform him of the error. They were informed of the earlier skin observation. They stated they would conduct another skin assessment. At 5:00 p.m., the wound nurse provided documentation the physician had been notified the cream had not been discontinued. She added she had also notified the physician the rash had reoccurred and a new order to treat the skin rash was received.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were assisted with transfers for one (#9) of four sampled residents reviewed for falls. Resident #9 required physical asssistance with transfers from the bed to the wheelchair. Certified Nurse Aide (CNA) #6 was present in the room and did not provide the asssistance. As a result of not providing the needed asssistance the resident fell to the floor causing a laceration above the right eye requiring eight to nine sutures and severe bruising to the face, neck and chin. These injuries caused increased pain and use of routine and as needed pain medications. The facility identified 77 residents who required assistance with transfers. Findings: 1. Resident #9 had [DIAGNOSES REDACTED]. The Morse Fall Scale dated 03/29/19, documented, .Gait .impaired .difficulty rising from chair, uses chair arms to get up, bounces to rise .grasps furniture, person or aid when ambulating . The resident was a moderate risk for falls with a score of 25. A score of 25 - 44 indicated a moderate risk. A quarterly assessment, dated 05/30/19, documented the resident's cognition was intact, she had clear speech and was able to understand as well and be understood by others. The resident required one person physical asssistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment documented the resident had no falls since the previous assessment was completed, was not steady and only able to stabilize self with staff asssistance while moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The assessment defined surface to surface transfers as those between bed and chair or wheelchair. The Morse Fall Scale dated 05/30/19, documented, .Gait .impaired .difficulty rising from chair, uses chair arms to get up, bounces to rise .grasps furniture, person or aid when ambulating . The resident was a moderate risk for falls with a score of 25. A score of 25 - 44 indicated a moderate risk. A care plan intervention for falls, dated 06/04/19, documented to assist the resident with activities of daily living as needed. A review of the Medication Administration Record [REDACTED]. The pain level at the time of administration was zero. There was no documented use of any as needed pain medications. An incident report, dated 08/05/19 at 10:50 p.m., documented, CNA notified this nurse while transferring res (resident) from bed to w/c (wheelchair) res got lightheaded, slipped and landed on floor .type of injury laceration .sent to ER (emergency room ) . A nurse's note, dated 08/05/19 at 11:00 p.m., documented, CNA notified this nurse that resident fell during transfer. CNA transferring res from bed to w/c to take to restroom. Res lightheaded and fell to floor. Res lying face down, bleeding from laceration above (R) (right) eye . The nurse's note and the incident report were both written by licensed practical nurse (LPN) #7. An After Care Summary, dated 08/05/19, documented, .reason for visit fall .[DIAGNOSES REDACTED].facial laceration .instructions .Go to (name deleted) emergency department in 1 week (around 08/13/19) .for suture removal . A nurse's note, dated 08/06/19 at 11:00 a.m., documented, The resident returned from the ER with discharge orders and instructions of care for sutures of laceration above the right eye .orders to return to the ER to have sutures removed in 7-10 days .resident requested morning medications and only wanted her pain medication .resident refused her meal . A note at 1:00 p.m., documented, .Resident cont (continues) to have multiple bruises to face and laceration . A review of the MAR for 08/06/19 through 08/13/19, documented the resident's pain level was between a five and seven when the [MEDICATION NAME] was administered. In addition, the resident was requesting her [MEDICATION NAME], as needed pain medication, daily with a pain level at the time of administration between five and seven. An initial report to the Oklahoma State Department of Health (OSDH), documented, Date of incident 08/05/19 .incident type .allegation of neglect .Part B description of incident .Resident reported the CNA (name deleted) didn't help her and she fell and hit her head on the floor. CNA reported that while transferring resident from bed to wheelchair, resident got lightheaded, slipped and landed on the floor. Resident obtained a cut on her right eyebrow area that required her to go to ER for further evaluation and treatment. She returned a few hours later with about 8 stitches to her right eyebrow area. CNA (name deleted) was immediately suspended pending outcome of investigation relevant resident history .patent is a 79 y.o. (year old) .AAO (alert and oriented) X 3 Hx (history) of muscle wasting, cerebral infarction, [MEDICAL CONDITION], lack of coordination, abnormal posture . A final report to the OSDH documented, .Part C Investigation could not substantiate allegation. Interview with CNA revealed that he had assisted this resident many times in the recent past and resident did get lightheaded and fell . CNA was assisting resident from behind and could not break fall Attached to the report was a written statement on a nurse's note from CNA #6. The statement documented. Around 10:45 (10:45 p.m.) I was called to (resident's) room to assist her to the restroom. She sat up at the edge of the bed and I guided her to her w/c. She took a couple of steps and before I could react she had fell forward and hit the floor. I ran to grab the nurse on duty and called 9-11. Notes from questions asked by the administrator documented the CNA stated he knew the resident required one person stand by assist and he did not know why the resident would claim he did not help her. The initial report was sent to OSDH on 08/06/19 at 4:18 p.m., over 12 hours after the resident had told the charge nurse of the abuse. There was no documentation the facility interviewed the resident and charge nurse or obtained a statement concerning what happened. On 08/13/19 at 12:45 p.m., the resident was observed in her wheelchair outside her room. She had sutures above her right eye and had numerous amounts of bruising on the right side of her face including her cheek, jaw and neck. The resident stated she fell while getting out of bed. She stated the CNA came in, put her side rail down then stood behind the wheelchair and did not assist her with the transfer. She stated she required the side rail and staff to help her with the transfer. She stated she had been at the facility a long time and never had a fall prior to this. She stated all the other CNAs would help her by the arm. She stated she had told the charge nurse he did not help like he should have and she told the CNA to get out of her room and not to come back in. The resident stated it happened a week ago on Monday night around 10:30 p.m. She had to go to the bathroom, she turned on her call light three times and was told other residents were on the toilet and she could not be helped. She then stated she called the charge nurse on the phone and she had the CNA come to her room. She stated her pain was a 10 on a scale of one to ten and she had to take pain medications two to three times a day now. She identified CNA #6 as the CNA working when she had the fall. At 3:00 p.m., the resident stated when she fell , she fell forward from the bed landing near the recliner and the night stand. She stated no one from the facility had asked her what happened, and the survyeor was the first to talk to her about it. She stated there was still blood on the carpet where her head landed. She then stated she was not dizzy, the CNA did not help her and that was the cause of the fall. On 08/14/19 at 8:16 a.m., LPN # 7 stated she was counting medications in the med room when the CNA came in and told her the resident had a fall while being transferred. She asked the CNA if the resident hit her head and the response was no. She stated when she entered the room, she found the resident lying on the floor face down with her head near the recliner and night stand. She stated the resident kept yelling and cursing at the CNA to get out because he did not help her and she fell . She stated the CNA did not tell her she was bleeding when it was reported. The nurse stated the resident required staff to physically assist her and if he was assisting her, she could not figure out how the fall occurred. She stated the side rail was down when she came into the room. She stated the resident was very with it and knows what was going on. She stated she did not ask the resident anything more because she was sent to the hospital and she only works part time at the facility. She then added that no one had taken a statement of the event from her and the surveyor was the first one to ask her about it. She stated the resident did not have any complaints to her about being dizzy. At 8:41 a.m., CNA #7 stated the resident required physical asssistance with transfers. She stated the CNAs need to help with her one arm as she pushed up on the side rail. She then stated the resident was able to tell you everything and had no cognitive defects. At 8:45 a.m., registered nurse (RN) #2 stated the resident required limited one person physical asssistance with her transfers for stability and guidance. She then stated there had been a lot of complaints about the care provided by CNA #6 and he was moved from hall to hall. She stated she did not know why he ended up working on hall 400. At 9:08 a.m., the director of nursing (DON) stated there had been several complaints about CNA #6 and his work. She stated the complaints came from not giving proper care from family and from other staff about his work. She stated she did not remember investigating any part of the fall and was not sure what the outcome was. She stated the administrator would have the investigation if there was one. She stated she was not sure what level of asssistance the resident required and did not know much about the resident except for the fall that occurred the previous week. She stated she would see if she could find any information regarding the investigation behind the fall. At 10:04 a.m., the DON stated she reviewed all of the documentation from the investigation with the administrator. She stated the resident reported that the CNA did not assist with the transfer and she fell because of it. She then stated there was no interview with the charge nurse working at the time, the resident and no interviews with other residents. She then stated, based on what was reviewed the investigation was not conducted thoroughly. She then stated the resident was awake and alert after the fall. She added that the administrator might have more documentation then what was reviewed with him. At 11:55 a.m., the administrator stated he talked with the resident but did not have a written statement. He then stated he only looked at the nurses note and incident report and did not talk with the charge nurse who was working at the time of the incident. He stated other residents were interviewed and he would look for the documentation. The administrator then stated the CNA did confirm to him that he knew the resident required asssistance with her transfer. The administrator provided no additional investigative documentation into the abuse and the fall. 2. Resident #1 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A quarterly assessment, dated 05/24/19, documented the resident's cognition was severely impaired, she required total assistance for activities of daily living and had one fall with major injury since the prior assessment. An incident report, dated 05/12/19, documented at 4:00 p.m., the resident sustained [REDACTED]. The right arm was bent backward and underneath her bottom with obvious deformity. The resident's left knee bent under her. Additional comments and/or steps to prevent recurrence documented to place the bed at the lowest position available and place a fall mat. An incident report faxed to the Oklahoma State Department of Health documented the resident was transported to the emergency room and was diagnosed with [REDACTED]. The resident was educated on the use of the call light. A care plan, dated 05/29/19, documented the resident was a fall risk related to history of [MEDICAL CONDITION], history of a stroke and lower extremity weakness/decline. Interventions documented the resident continued to attempt to get out of bed by herself, a fall occurred on 05/12/19 and the bed was to be in the low position, a fall mat in place, keep the call light and most frequently used personal items within reach. On 08/12/19 at 9:40 a.m. and 08/13/19 at 3:30 p.m., the resident was observed in her bed with the lower rails down. The bed was raised, and her left leg was draped over the side of the bed. She was tying to get the attention of the staff using hand gestures. The fall mat was observed folded up under the bed and the bedside table was not within reach of the resident. On 08/13/19 at 3:34 p.m., CNA #8 was asked how long she had worked at the facility. She stated two weeks. She was asked if she was familiar with the residents on hall 200. She stated she had worked about five times on the hall. She was asked if any resident's were considered a high fall risk. She stated quite a few. She was asked how she was informed of this information. She stated if the residents were up in a chair, they have a board that has that information and if they were a two person assist. She was shown the room [ROOM NUMBER] and asked if the residents were a fall risk. She pointed to the bed of resident #1 and stated she was not really so much a fall risk. She was asked if the resident had any previous falls. She stated she did not know. At 3:40 p.m., LPN #8 was asked how long she had worked at the facility. She stated about three weeks. She was asked what halls she had been assigned to. She stated only hall 200. She was asked about the residents who were fall risks. She stated resident #1 can be weight bearing on the left side, so she did not feel she would be a high fall risk. She was asked if the resident had any previous falls. She stated not that she knew of. She was asked if there were any inventions in place for this resident to prevent falls. She stated she had a fall mat but her daughter stated she did not want it by the bed. On 08/14/19 at 12:06 p.m., the DON was asked if the resident was a fall risk. She stated she would think so. She was asked if she was aware of any falls with fractures. She stated yes. She was asked what intervention were in place to prevent further falls. She stated she would have to look at the care plan. She was informed of the documentation from the care plan requiring a low bed and a fall mat and the observations made. She was asked if the interventions were being implemented to prevent falls for the resident. She stated if those were the observations and interventions, then no.

Based on observations, record review and interviews, it was determined the facility failed to ensure adequate supervision and the implementation of appropriate interventions to prevent further falls for two (#43 and #76) of four sampled residents who were reviewed for falls. This resulted in resident #43 sustaining a fracture to the left hip, a laceration to the forehead and a second head injury causing the laceration to the forehead to reopen; and resident #76 sustained a laceration to her head which required four staples to close the laceration. The facility identified five falls which resulted in major injuries in the last three months. Findings: The Facility Van Driver Policy, documented .Operators and passengers are required to wear seatbelts at all times and wheelchairs shall be secured in a safe position with the appropriate securing devices in place and the brakes locked during transport . 1. Resident #43 had [DIAGNOSES REDACTED]. A care plan, with an onset date of 04/05/18, documented the resident was at risk for falls related to a history or falls and [MEDICAL CONDITION], use of anti-depressant medication and the use of anti-anxiety medication. Interventions documented staff was to provide adequate lighting, anticipate the resident's needs, assist with the resident's ADL, ensure the soft bolsters were applied to the bed, perform hourly safety checks, keep the call light in reach, have the low bed with fall mat in place and non skid socks or shoes on when the resident was out of bed. A quarterly assessment, dated 10/04/18, documented the resident's cognition was severely impaired, was totally dependent on staff for assistance with all her activities of daily living (ADL), had 2 falls without injury and 1 fall with a minor injury since the previous assessment. An incident report, dated 11/10/18 at 6:36 a.m., documented the resident was found on the floor yelling for help and had knee pain radiating to the pelvic area. An x-ray was negative for fractures. The intervention put in place was to secure the bed bolsters and instruct the resident to use the call light. There was no documentation to indicate a new intervention was implemented. An incident report, dated 11/12/18 at 11:10 p.m., documented the resident was found on the floor next to the night stand. The resident stated she hit her head. No visible injuries were noted. The intervention put in place was to re-secure the bed bolsters, instruct the resident to ask for help and not throw her legs over the bed. There was no documentation to indicate a new intervention was implemented. An incident report, dated 11/20/18 at 3:20 a.m., documented the resident was found on the floor mat next to the bed. The interventions put in place were to tighten the bed bolsters, clip the call light to the pillow and for staff to make frequent safety checks. There was no documentation to indicate a new intervention was implemented. An incident report, dated 11/20/18 at 11:50 a.m., documented the resident climbed over the bed bolsters and was found on the floor next to the bed. The intervention put in place was to plug the call light in and keep it in reach at all times. There was no documentation to indicate a new intervention was implemented. An incident report, dated 11/27/18 at 8:30 p.m., documented the resident was found on the floor mat at her bedside. The intervention put in place was frequent room checks. A wider bed was also ordered for the resident. An incident report, dated 12/11/18 at 11:10 p.m., documented the resident was found on the floor mat at her bedside. The intervention put in place was for staff to make frequent room checks. There was no documentation to indicate a new intervention was implemented. An incident report, dated 12/26/18 at 9:30 a.m., documented the resident was found on the floor mat next to the bed. The intervention put in place was to have night shift check on the resident early in the morning. There was no documentation to indicate a new intervention was implemented. A quarterly assessment, dated 01/04/19, documented the resident's cognition was severely and was totally dependent on staff for ADLs. The assessment documented she had two or more falls with no injury since the prior assessment. An incident report, dated 01/18/19 at 1:30 a.m., documented the resident was found on the floor between her bed and chair. She complained of pain to the left shoulder, severe head pain and had difficulty moving her left leg. The resident was sent to be evaluated at the emergency department. The interventions put in place upon the resident's return from the hospital included staff in-service on appropriate placement of the bed bolsters and the mattress was changed from a air loss mattress to a regular mattress to prevent sliding. A hospital record, dated 01/19/19, documented the resident was treated for [REDACTED]. There was no documentation to indicate the resident had an injury to the head or left shoulder. An incident report, dated 01/21/19 at 9:15 p.m., documented the resident was found on the floor with the fall mat in place. The intervention put in place was for staff to make frequent checks during their shift. There was no documentation to indicate a new intervention was implemented. An incident report, dated 01/28/19 at 7:45 a.m., documented the resident was found on the floor mat beside the bed. The resident reopened the laceration from a previous fall. The intervention put in place was to educate staff on placing the bed in low position. There was no documentation to indicate a new intervention was implemented. There was no documentation of a previous fall which had resulted in a laceration to the head. An incident report, dated 02/16/19 at 7:50 a.m., documented the resident was found on the floor by the recliner in her room. The intervention put in place was to keep the resident in the common area in her wheelchair. On 02/25/19 at 4:10 p.m., the room of resident #43 was observed. The bed was against the wall with a soft bed rail bolster on the other side. A night stand was next to the bed. No fall mat was observed near the bed. On 02/27/19 at 3:05 p.m., the resident was observed asleep in bed with the bed bolsters in place. The room was dark, the nightstand was beside the bed and the call light was observed hanging on the wall out of reach from the resident. On 03/05/19 at 10:46 a.m., the resident was observed sitting in the chair in her room in the dark. The chair was sitting sideways reclined back and body pillows were on either side of the resident. The resident had her leg over the pillow and arm of the chair as she flapped her arm and legs up and down. At 11:47 a.m., the corporate nurse was asked to look at the resident's falls and interventions for the falls. She was asked if interventions were appropriately implemented. She stated she would look into it, she was not as familiar with resident #43. At 3:06 p.m., the corporate nurse and assistance director of nurses (ADON) #2 provided information regarding the falls. The corporate nurse stated more interventions had been put in place for the resident. The nurse provided documentation of frequent checks to be performed by staff on 11/20/18 and an intervention of administering medication for anxiety and pain on 11/27/18. She was asked if these were actually new interventions since frequent checks had already been implemented and the monitoring of medication side effects was documented as a fall intervention on the care plan. ADON #2 stated the staff was always taught to keep the call light in place. She was asked if using the call light would be an appropriate intervention for a resident who was cognitively impaired. She stated staff were still taught to place the call light in reach. They were then asked if the last intervention put in place, for the resident to have been kept in the common area while in her chair, was no longer being implemented. They were informed of the observation of the resident being alone in her dark room with her leg hanging over the side of the chair. The corporate nurse stated, well today they were not. On 03/06/19 at 9:26 a.m., resident #43 was observed sitting alone in her dark room in her chair. The chair was reclined back with a body pillow on one side of her and another body pillow laying on the floor. 2. Resident #76 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/26/19, documented the resident's cognition was intact, required limited assistance of one staff member for transfers, dressing, bed mobility, and personal hygiene. The assessment documented the resident had no range of motion limitations and required the use of a wheelchair for mobility. The resident's care plan, updated 02/18/19, documented: Related to: . laceration to head with staples .Treatments and dressings as ordered per physician A history and physical form from a local emergency room , dated 02/18/19, documented the reason for the patient's visit was a fall while being transported in a nursing facility van. The patient had a 3 centimeter (cm) scalp laceration due to head trauma, which required the placement of four staples. There was no documentation a numbing medication was injected prior to the placement of the staples. The discharge instructions from the emergency room , dated 02/18/19, documented the patient was discharged back to the nursing home and she was to have four scalp staples removed in five days. On 02/24/19 at 3:47 p.m., the resident was observed sitting on the edge of her bed. She was rubbing the back of her neck and appeared to be in pain. She stated she had been involved in a fall while being transported in the facility van to her physician's office. She explained that the transport driver had not secured her wheelchair with the locking straps in the floor of the van. She also added that she was not been secured with a seat belt during the trip. The resident added that on the trip back the driver hit the van brakes and turned the van sharply, which caused the resident to fly out of the wheelchair and strike her head against something in the front seat. The resident stated she had cut her head and had been taken to a local emergency room for evaluation. She stated they had put staples in the cut on her head. She added the emergency room physician had not numbed the laceration prior to inserting the staples and it really hurt. The resident stated that was the one and only time she had been transported in the facility van. The clinical records documented the resident had orders, dated 01/03/19, in place for [MEDICATION NAME] 10 milligrams (mg) three times a day for pain and for [MEDICATION NAME] 5 mg, dated 01/02/19, every four hours as needed for pain. The record documented the resident's request for pain medication and her ratings of pain intensity had not increased since the fall in the van. On 02/24/19 at 7:10 p.m., the corporate nurse provided documentation of an investigation and copies of incident reports to the state department of health. The nurse added this was the first and only time the resident had been transported in the facility van She stated the certified nurse aide (CNA)/transport driver had been suspended pending an investigation. She stated the CNA had admitted to not securing the resident's wheelchair and/or the resident with seatbelts during the round trip to the physician's office. The corporate nurse added the CNA had stated the van locking system was not compatible with the resident's electric wheelchair but they were running late for the resident's appointment so she decided not to remove the resident from the van and place her in another wheelchair that was compatible with the van locking system. The corporate nurse provided documentation that the use of the facility van had been suspended until another inservice, on safe transportation, had been provided to the staff. She stated the CNA had been provided an inservice on use of the van's wheelchair locking system when they purchased the van eight months ago. The CNA had been transporting residents for the last eight months without incident. The corporate nurse was asked if the CNA had transported the resident in accordance with the facility policy. She stated the CNA had not.

Based on observation, record review and interview, it was determined the facility failed to provide adequate supervision during the provision of care for one (#1) of three sampled residents who were reviewed for falls. Resident #1 who was a two person assist for bed mobility and transfers sustained a fracture to the fibula while one person assisted him with bed mobility. The facility identified 28 residents as being on the falling leaves program. Findings: A facility policy, titled Patient Handling Policy and Procedure, documented, .Each resident will be provided the proper amount of assistance needed when being moved from place to place and during position changes .Use assistive devices as necessary .TOTAL LIFT DEVICE .The patient is unable to offer assistance .The patient requires lifting from the floor .PATIENT HANDLING PR[NAME]EDURES: Direct Care Staff .should assess their own capabilities and assess the resident prior to patient handling .The resident will be lifted according to the level of the assessed lift/transfer as noted on the assessment. A direct care staff can always increase the level of the lift required, but never decrease the level .For example, if a two-person lift is required, a direct care staff my decide to use a mechanical lift if the circumstances permit, but never reduce the level to a one-person lift . Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An interdisciplinary care plan, no date, documented the resident was a two person, total dependence for bed mobility and transfers and required a mechanical lift. It stated the resident was always incontinent of bowel and bladder and required two persons for assistance. A Nursing Rehab/Restorative Screen, dated 11/16/17, documented the resident was a total mechanical lift for transfers, required assistance of two persons. A quarterly assessment, dated 05/19/18, documented the resident's cognition was severely impaired, was totally dependent with two or more persons with physical assistance in bed mobility and transfers. The assessment documented the resident was always incontinent of bladder and bowel. A care plan, dated 05/25/18, documented the resident was a fall risk. Interventions included to assist resident with activities of daily living (ADLs) as needed, falling leaves program and a full body lift for all transfers. It continued to document the resident required assistance with ADLs related to total dependence to turn and reposition, and total dependence to transfer. Interventions documented the resident was a full body lift for all transfers. A nurse's note, dated 08/10/18 at 6:10 a.m., documented, .CNA (certified nurse aide) notified this nurse that as she was getting res (resident) out of bed that she had to lower res to floor when res began to slide. (no) injuries/pain/discomfort/falling . An incident report, dated 08/10/18, documented .Approx (approximately) 9:00 a.m .CNA (CNA #6) was providing peri-care, CNA turned resident facing her (and) fell to floor on her L (left) side. No distress noted. No c/o (complaints of) pain or discomfort . A nurse's note, dated 08/10/18 at 10:00 a.m., documented, .at approximately 0900 (9:00 a.m.) (name deleted) daughter asked this nurse if any falls had been reported. This nurse confirmed that there was no falls or documentation of any fall that night or occurred for the past few days. (name deleted-daughter) began to pull her cell phone and asked me to look at the video recorded. Video showed CNA (name deleted - CNA #6) providing peri-care (and) while turning (resident) towards her (resident) rolled out of bed on her left side. Charge nurse on hall notified (and) completed head to toe assessment c (with) this nurse present .slight discoloration to left lower extremity. Physician notified. New order for Left (and) Right legs to be x-rayed. Daughter (name deleted) aware of order . A physician's orders [REDACTED]. A radiology addendum report, dated 08/10/18, documented, .an oblique fracture involving the proximal fibular diaphysis is seen .IMPRESSION .Nondisplaced acute oblique fracture involving the proximal fibula . A physician's orders [REDACTED]. A hospital physician progress notes [REDACTED]. .Posterior long leg splint applied to left lower extremity. Perform neurovascular status evaluation of left lower extremity every hour for the first 12 hours and then every 4 hours Follow up with orthopedics in 5-7 days . On 08/29/18 at 5:30 a.m., LPN #2 was asked if she remembered a recent incident involving the resident. She stated yes, the CNA told her while she was getting the resident up she ended up lowering the resident to the floor. She continued to state the policy, to her understanding, was if a resident was lowered to the floor, it was not considered a fall and an incident report did not need to be completed. She was asked if she assessed the resident after the CNA told her about the incident. She stated she went to the resident's room and asked the resident if she was in any pain and she was not. She continued to stated she did not complete a full head to toe assessment because the resident indicated she was fine. She stated she documented the incident in the nurse's notes. She was asked if she notified the physician or the family. She stated no, she did not think she needed to because the resident was lowered to the floor. On 08/30/18 at 1:09 p.m., the ADON was asked about the incident involving the resident. She stated on 08/10/18 around the end of the breakfast meal, the resident's daughter asked her if anyone had reported the resident had fallen. The ADON stated no, but she would look through the incident reports. She continued to state the daughter stopped her and stated the resident fell , then proceeded to show the ADON the video on her phone of what happened with the resident. She stated the video had a very low sound level, but she could see what happened. The ADON was asked what she saw. She stated she saw the resident fall on her left side while the CNA was performing incontinent care. She continued to state the CNA pulled the resident with a draw sheet toward her, then the resident fell half way out of the bed. She stated she could hear the resident's left leg hit the floor from the video. She stated the video continued to show the CNA assisted the rest of the resident's upper body to the floor and went to get the nurse. The ADON stated after she viewed the video, her and the charge nurse performed a head to toe assessment on the resident. She stated the resident denied pain or discomfort, but she was rubbing her right leg. The ADON stated the physician was notified and orders were received for a left and right leg x-ray due to the impact the resident sustained [REDACTED]. The ADON was asked what actions were taken following the incident. She stated a statement was obtained from CNA #6. She continued to state she was suspended She was asked why they suspended CNA #6. The ADON stated because the facility did not feel she reported the fall to the nurse appropriately by stating the resident was lowered to the floor when the resident actually fell . She continued to state when CNA #6 was interviewed, she was nervous and stated she did not think it was a fall. The ADON asked her why she didn't tell the nurse of the fall. CNA #6 did not say anything after this. The ADON was asked what actions were taken with LPN #2 following the incident. She stated the director of nursing (DON) stated the LPN needed to be suspended. She continued to state LPN #2 was notified by phone due to not returning phone calls. The ADON was asked what the definition of a fall was. She stated it was when there was a change in a position level of resident and an incident report should be completed. The ADON was asked how many staff members were on hall 500 on 08/10/18 during the night shift. She stated there were three CNAs on the hall. She continued to state she asked CNA #6 why she did not ask for help. She stated the CNA did not respond. The ADON was asked if LPN #2 assessed the resident. She stated on the video she observed LPN #2 enter the room, left, came back with two other staff, looked at the resident and walked out. She was asked if LPN #2 lifted the covers or put hands on the resident for assessment. She stated the video did not show her to touch the resident. She continued to stated LPN #2 was suspended due to not assessing the resident or completing an incident report. The ADON was referred to the 08/10/18 facility incident report. She was asked who completed the report. She stated she completed it because she felt it needed to be done. The ADON was referred to the 05/25/18 care plan for falls. She was asked what full body lift for all transfers meant. She stated it was a type of lift that uses a sling to lift the whole body of a resident. She was asked if resident #1 was a full body lift. She stated yes. She was asked if the resident was a one person assist or a two person assist before the incident occurred. She stated the resident had always been a two person assist. On 08/30/18 at 3:00 p.m., CNA #2 was asked how long she worked at the facility. She stated one year. She was asked if she was familiar with resident #1. She stated yes. She was asked if the resident was a one person or a two person assist. She stated the resident was a two person assist. She was asked how many staff did were needed for bed mobility, including incontinent care. She stated two staff. She was asked if the resident had always been a two person assist for bed mobility, including incontinent care. She stated yes. She continued to state the resident had been a two person assist as far as she knew. She was asked how she knew what care and help to provide a resident. She stated there was an ADL book with a kardex that tells the CNAs how to care for the residents. At 3:30 p.m., MDS coordinator #1 approached the surveyors and stated she spoke with the DON and wanted to let the surveyors know she matched the 05/19/18 MDS with the ADL care plan. She was referred to the ADL care plan and acknowledged it documented the resident required total assistance with two persons for bed mobility. She was asked if the resident was a two person assist prior to the incident on 08/10/18. She stated there was not a specific order for the resident to have two people to assist her at the time the (MONTH) MDS was completed. She was asked if a physician order [REDACTED]. She stated if there was something specific with the resident which required that resident to need two people to assist, a telephone order was written for a two person assist. MDS coordinator #1 was asked if the resident had an order to have two people assist her. She stated, No. I can't find it.

Based on record review and interview, it was determined the facility failed to provide supervision to prevent falls for a resident with a history of falls for one (#7) of three sampled residents whose clinical records were reviewed for falls. This lack of supervision resulted in the resident falling out of her wheelchair and sustaining a laceration to her forehead which required sutures and a [DIAGNOSES REDACTED]. The facility identified 111 residents resided in the facility. Findings: Resident #7 had [DIAGNOSES REDACTED]. The care plan fall log documented on 09/15/17, the resident had been found lying on the floor beside the mat and she had no injuries. The intervention initiated due to the fall was when up needs to be in recliner not (wheelchair) The fall log documented on 11/04/17, the resident was observed with the lower half of her body on the mat. The intervention initiated due to the fall was [MEDICATION NAME] to buttocks. The quarterly assessment, dated 02/17/18, documented the resident had severe cognitive impairment; was dependent upon staff for all activities of daily living (ADLs); did not ambulate and had not fallen since the prior assessment. The Morse Fall Scale, dated 02/17/18, documented the resident had a high risk for falling with a score of 75. (A score of 45 or higher indicated a high risk for falling.) The care plan, updated 04/06/18, documented the resident has a potential for falls related to: impaired balance, Dementia, impaired hearing, use of antianxiety medication. The goal was for the resident to be free of falls through the target date. An intervention was to remind (resident #7) every shift not to attempt to get up unassisted. An incident report, dated 03/19/18 at 10:45 a.m., documented the resident was confused and was observed on the floor lying on her right side in the shower room area while waiting for a shower to be given. No injuries were sustained from the fall. An intervention documented on the incident report was for staff to remain with resident when in shower. Steps taken to prevent recurrence was for a Dyson (a non-skid mat) to be placed on the wheelchair seat. An incident report, dated 04/06/18 at 1:00 p.m., documented the resident was confused and was observed lying on the floor on her right side with a dime-size [MEDICAL CONDITION] to her mid-forehead/hairline. She also sustained abrasions to both knees and her pupils were unequal sizes. Steps to prevent recurrence was non-slip pad to wheelchair. The reportable incident form, dated 04/06/18, submitted to the Oklahoma State Department of Health regarding the resident's fall on 04/06/18, documented certified nurse aide (CNA) #3 had assisted resident #7 into her wheelchair and gathered all supplies to assist the resident into the shower room. The report documented the CNA gathered dirty sheets and linens, since beds were to be stripped on residents' bath days, and walked out of the room to take the dirty laundry to the dirty utility room. (This was approximately 75 feet from the residents room.) When the CNA got back to the room, the resident was observed on the floor. The form documented the care plan and staff had been updated to reflect care. Discharge instructions from the hospital emergency room (ER), dated 04/06/18, documented the resident had been treated for [REDACTED]. The form documented the resident had received sutures and steristrips to her [MEDICAL CONDITION]. The discharge instructions also documented she had a computed tomography (CT) scan during the ER visit. The care plan, updated on 04/06/18, documented a non-slip pad was to be used in the wheelchair. The care plan did not address the fall on 03/19/18. The Care Plan Fall Log documented the fall which occurred on 04/06/18, but did not address the fall which had occurred on 03/19/18. Kardex care plans located in the ADL book, which was kept on the resident halls for review by the CNAs, documented the care/assistance requirements for each resident. This information was made easily available for CNAs to learn the residents' abilities with ADLs and other pertinent information about their status/care. The kardex care plan had a section which, if marked, indicated the resident was at risk for falls and had space to document falls. The kardex care plan for resident #7 did not document the resident was a fall risk and/or that she had fallen out of her wheelchair on 03/19/18 or 04/06/18. On 05/08/18 at 1:23 p.m., the above findings was reviewed with the director of nurses (DON). She was also reminded of the resident's fall in the shower room on 03/19/18 and the intervention in which staff were to remain with the resident when she was in the shower room. The DON was asked if, on 04/06/18, the resident should have been left unattended in her wheelchair in her room. She stated, No. The DON was asked if the resident had received the supervision needed/required to prevent the falls on 03/19/18 and 04/06/18. She stated, No. If they walked off and left her, no. The DON was asked if staff had followed the care plan to ensure the resident was in the recliner when up in her room and not in her wheelchair. She stated, No. At 1:54 p.m., the DON returned to the surveyor and stated since the resident was in her wheelchair to be transported to the bathing room, it was okay for the staff member to leave her unattended since he was going to be right back. At 2:17 p.m., the surveyor asked licensed practical nurse #1, CNA #1 and CNA #2 if resident #7 should be left unattended in her wheelchair. They all stated, No. They were asked if the resident should be left unattended in her wheelchair, even briefly. The all stated, No. CNA #2 further stated, Not at all. On 05/09/18 at 2:37 p.m., the surveyor reviewed the incident report, dated 04/06/18, with CNA #3 and asked if the resident was supposed to be left unattended in her wheelchair in her room. He stated, They didn't say anything about her being a fall risk. He was asked if he thought the resident would have fallen out of her wheelchair if she had not been left unattended or if she would have been placed in her recliner. He stated, She's never fallen out of her wheelchair. He was asked if he was aware the resident had fallen out of her wheelchair in the shower room on 03/19/18. He stated he did not know she had fallen from her wheelchair on 03/19/18.