Every finding on record at Medical Park West Rehabilitation & Skilled Care

Based on record review and interview, the facility failed to ensure medications were:a. transcribed following admission orders, andb. blood pressure medications were administered following physician orders to prevent significant medication errors for 2 (#1 and #2) of 3 sampled residents reviewed for medication administration.The administrator identified 95 residents resided in the facility. Findings:1.An undated facility process Drug regimen review and transcribing admission orders showed steps for putting admission orders from the hospital were to print off the discharge orders from the hospital, enter each order, and when all orders are put in, sign and date. The process showed the ADON would take the noted orders to morning meetings, so a drug regimen review could be completed, and the noted orders would then be given to the DON.A hospital discharge medication list, dated 12/23/25, showed Resident #1's medication orders on admission were:a. Eliquis (blood thinner) 5 mg one tablet twice a day,b. Famotidine (acid reflux) 20 mg one tablet at bedtime,c. Culturelle (probiotic supplement) one twice daily, andd. Linezolid (antibiotic) 600 mg one every 12 hours till 12/29/25.Physician's orders, dated 12/23/25, showed medications ordered for Resident #1 were the following:a. Duloxetine HCL (antidepressant) 60 mg one tablet one time a day for depression.b. Amlodipine Besylate (blood pressure) 5 mg one tablet one time a day for hypertension. Hold for systolic BP <110, diastolic BP <60, or pulse <60,c. Atorvastatin calcium (cholesterol/triglyceride reducer) 20 mg one tablet one time a day for hyperlipidemia,d. Levothyroxine (thyroid) 100 mcg one tablet one time a day for hypothyroidisme. Valsartan (blood pressure) 80 mg one tablet one time a day for hypertension, andf. Celecoxib (non-steroidal anti-inflammatory) 200 mg one capsule daily as needed for pain.An admission note, dated 12/23/25, showed Resident #1 arrived at the facility via medical transport from the hospital. The admission note showed the resident was previously seen at the hospital for hematuria and cellulitis and was taking an antibiotic.A medication record, dated 12/23/25 through 01/12/26, showed Resident #1 received the incorrect medication:a. Duloxetine HCL 60 mg 12/24/25 through 01/06/26,b. Amlodipine Besylate 5 mg 12/24/25, 12/25/25, 12/27/25, 12/28/25, 12/30/25, 01/01/26, and 01/03/26 through 01/06/26,c. Atorvastatin calcium 20 mg 12/24/25 through 01/06/26,d. Levothyroxine 100 mcg 12/24/25 through 01/06/26, ande. Valsartan 80 mg 12/24/25, 12/25/25, 12/27/25, 12/28/25, 12/30/25, 01/01/26, and 01/03/26 through 01/06/26.The medication record, dated 12/23/25 through 01/12/26, showed Resident #1 did not receive the ordered medications from the admission orders from the hospital:a. Eliquis 5 mg one tablet twice a day, b. Famotidine 20 mg one tablet at bedtime, c. Culturelle one twice daily 12/24/25 through 01/06/26, andd. Linezolid 600 mg one every 12 hours 12/24/25 through 12/29/25.An admission assessment, dated 12/27/25, showed Resident #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation and wound infection. The assessment showed Resident #1's cognition was moderately impaired with a BIMS score of 11.The medication administration record, dated 01/05/26, showed Resident #1's blood pressure was 105/69 and the blood pressure medication was not held per physician ordered parameters.A care plan note, dated 01/06/26, showed the family expressed concerns regarding the resident's abnormal blood pressure readings and current blood pressure medication orders. The note showed the concerns would be followed up by the doctor.An incident report, dated 01/06/26, showed the pharmacy contacted the DON with a concern for potential alteration in Resident #1's medication. The report showed the resident's medication was reviewed with the physician and new medication orders were received and updated.A Root Cause Analysis Five Ways worksheet, dated 01/07/26, showed:a. Resident #1 was admitted on [DATE], the same day as Resident #2. Resident #2's medications were put on the orders for Resident #1,b. the medication orders for Resident #1 and Resident #2 were put in by the same nurse,c. the drug regimen review was completed by the same nurse that put in the medication orders,d. the ADON did not recheck the drug regimen review,e. The clinical team did not double-check the orders, andf. the vital sign parameters for blood pressure medication were not followed by staff, and abnormalities were not reported to the physician.2. A hospital discharge medication list, dated 12/23/25, showed Resident #2's medication order on admission were:a. Duloxetine HCL 60 mg one tablet one time a day for depression,b. Amlodipine Besylate 5 mg one tablet one time a day for hypertension. Hold for systolic BP <110, diastolic BP <60, or pulse <60,c. Atorvastatin calcium 20 mg one tablet one time a day for hyperlipidemia,d. Levothyroxine 100 mcg one tablet one time a day for hypothyroidism,e. Valsartan 80 mg one tablet one time a day for hypertension,f. Celecoxib 200 mg one capsule daily as needed for pain, andg. Prednisone (steroid) 40 mg one tablet daily.Physician orders, dated 12/23/25, showed medications ordered for Resident #2 included:a. Eliquis 5 mg one tablet twice a day,b. Famotidine 20 mg one tablet at bedtime, andc. Culturelle one twice daily,The medication record, dated 12/23/25 through 01/12/26, showed Resident #2 did not receive the ordered medications from the admission orders:a. Duloxetine HCL 60 mg one tablet one time a day 12/24/25 through 01/06/26,b. Amlodipine Besylate 5 mg one tablet one time a day 12/24/25 through 01/06/26,c. Atorvastatin calcium 20 mg one tablet one time a day 12/24/25 through 01/06/26,d. Levothyroxine 100 mcg one tablet one time a day 12/24/25 through 01/06/26,e. Valsartan 80 mg one tablet one time a day 12/24/25 through 01/06/26,f. Celecoxib 200 mg one capsule daily 12/24/25 through 01/06/26, andg. Prednisone 40 mg one time daily 12/24/25 through 12/29/25.The medication record, dated 12/23/25 through 01/12/26, showed Resident #2 received the incorrect medication:a. Eliquis 5 mg one tablet twice a day 12/24/25 through 01/06/26,b. Famotidine 20 mg one tablet at bedtime 12/24/25 through 01/06/26, andc. Culturelle one twice daily, 12/24/25 through 01/06/26.An admission assessment, dated 12/28/25, showed Resident #2 was admitted on [DATE] with diagnoses which included hypertension and osteoporosis. The assessment showed Resident #2's cognition was intact with a BIMS score of 13.A Root Cause Analysis Five Ways worksheet, dated 01/07/26, showed:a. Resident #2 was admitted on [DATE], the same day as Resident #1. Resident #2's medications were put on the orders for Resident #1,b. the medication orders for Resident #1 and Resident #2 were put in by the same nurse,c. The drug regimen review was completed by the same nurse that put in the medication orders,d. the ADON did not recheck the drug regimen review,e. the clinical team did not double-check the orders, andf. the vital sign parameters for blood pressure medication were not followed by staff, and abnormalities were not reported to the physician.On 01/13/26 at 9:30 a.m., RN #1 stated Resident #1 and Resident #2 were admitted on the same day, the same nurse put in both medication orders, and the nurse switched the orders when entering. RN #1 stated another nurse should have double checked the orders to make sure the orders were entered correctly but that did not happen. RN #1 stated the pharmacy was checking the medications and found there to be possible errors. RN #1 stated this was a serious event, but did not change the residents' condition, and the nurse was suspended. RN #1 stated in-services had been conducted.On 01/13/26 at 12:30 p.m., the DON stated blood pressure medication withhold parameters ordered should be held when the readings were below those parameters.On 01/13/26 at 3:05 p.m., the ADON reported they failed to double check Resident #1 and Resident #2's medications for accuracy. The ADON reported the medication errors were really bad, but no reactions happened to either resident.

On 07/22/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from significant medication errors.On 07/22/25 at 2:11 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 07/22/25 at 2:29 p.m., the administrator, DON, and the corporate nurse consultant were notified of the IJ situation. An IJ template was provided to the administrator.On 07/23/25 at 1:03 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal read in part, Regional Nurse Consultant will educate the Director of Nursing on identification of significant medication errors and administration of medication per physician orders. DON/Designee will educate all licensed nurses and certified medication aides by 2359 [11:59 p.m.] on 7/23/2025 regarding administering medication according to physician orders and identification of significant medication errors. Medication aides and Licensed nurses will document medication administration in the eMAR. Any licensed nurse or certified medication aide not educated by 2359 [11:59 p.m.] on 7/23/2025 will not be allowed to work until they have received education.An audit of current residents missing significant medications for the last 7 days was conducted and completed by 2359 [11:59 p.m.] on 7/23/2025 by nursing management to assure that significant medications are given as ordered by physician.Any significant medication errors found during the audit will be reviewed by the DON. The medical director will be notified of the findings for any further recommendations.The IJ was lifted, effective 07/23/25 at 11:59 p.m., when all components of the plan of removal had been completed. Staff interviews regarding significant medication errors and administering medications as ordered by the physician was completed and all components of the plan of removal was reviewed.Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (#3) of 7 sampled residents reviewed for significant medication errors.The DON reported 94 residents resided in the facility.Findings:An undated medical diagnosis sheet showed Resident #3 admitted to the facility on [DATE] with diagnoses which included seizures, chronic kidney disease, dependence on dialysis, hypothyroidism, cardiomegaly, and atherosclerotic heart disease.A physician order, dated 04/16/25, showed Levetiracetam (an anticonvulsant) 500 mg tablet, one tablet every 12 hours for seizures.A medication administration record, dated 04/16/25 to 05/12/25, showed 9 out of 26 missing morning doses of Levetiracetam (an anticonvulsant) 500mg on 04/18/25, 04/23/25, 04/25/25, 04/28/25, 04/30/25. An emergency department physician note, dated 04/30/25 at 10:50 p.m., showed Resident #3 was presented for seizures and was given Keppra due to the missed doses. The physician noted Resident #3 could discharge and reiterated the importance of twice daily dosing of her Levetiracetam.An interdisciplinary progress note, dated 05/01/25 at 8:02 a.m., showed the Resident returned from the hospital around 3:00 a.m. via EMS. Family reported resident had received IV Levetiracetam for seizure activity. Writer reported to family that her meds will be given prior to Dialysis from now on.On 07/23/25 at 1:05 p.m., the DON stated they were not aware of why the resident went to the emergency room or the significant medication error.

Based on record review and interview, the facility failed to ensure residents who received dialysis had pre and post monitoring for 1 (#3) of 3 sampled residents reviewed for dialysis.The DON reported 94 residents resided in the facility.Findings:The Dialysis-Hemodialysis policy, dated 02/12/20, read in part, Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany the patient to dialysis center.Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to access and complete Section C.Resident #3's undated facesheet showed a diagnosis of dependence on dialysis.A physician order, dated 04/14/25, showed dialysis on Monday, Wednesday, and Friday's.The resident's medical record was reviewed from 04/16/25 through 05/12/25 and showed 1 pre-dialysis communication report dated 05/02/25.On 07/21/25 at 12:56 p.m., the DON reported there should have been a pre and post dialysis form for everyday they went to dialysis.

Based on record review and interview, the facility failed to ensure the physician was notified timely of a urinalysis for 1 (#2) of 3 sampled residents reviewed for lab results.The DON reported 94 residents resided in the facility. Findings:A facility policy titled Laboratory and Radiology Service Coordination, dated 01/26/23, read in part, Notify physician of results; Reference change of condition policy and procedures for immediate and non-immediate notification guidelines; and document physician notification.An undated facesheet showed Resident #2 admitted to the facility with diagnoses of atrial fibrillation, heart failure, and hypertension.A nurse note, dated 03/22/25 at 7:53 p.m., read in part, Patient complained of bladder pain and pressure. New order received for UA. UA was obtained and wnl. Patient and family requested to be sent to ER. Patient and family reinformed the UA results were normal. Patient was still adamant about going to the ER. New orders received to sent [sic] to ER for evaluation.The residents medical record did not show the UA results, or the physician was notified of the results.A hospital Discharge summary, dated [DATE], read in part, Reason for admission: Pseudomonas urinary tract infection. She was having bladder spasms.On 07/21/25 at 1:05 p.m., the DON reported the facility policy was not followed and did not document the physician was notified of the UA results.

Based on record review and interview, the facility failed to: a. monitor and intervene for the absence of bowel movements; and b. complete daily skilled nursing assessments for 1 (#1) of 3 residents sampled for quality of care. The DON identified 85 residents who resided in the facility and 34 residents who received skilled services. Findings: Res #1 admitted to the facility on [DATE] with diagnoses which included stable burst fracture of the vertebrae, pulmonary fibrosis, and anxiety. Res #1 discharged from the facility on 02/27/25. A care plan, dated 02/19/25, showed Res #1 was at risk for problems with elimination. The care plan showed a goal of maintaining or improving Res #1's elimination status. A 5-day minimum data set assessment, dated 02/23/25, showed Res #1 was cognitively intact with a brief interview for mental status score of 15. The assessment showed Res #1 was continent of bowel and required supervision/touch assistance with toileting. An ADL sheet, dated 02/20/25 through 02/27/25, showed Res #1 had a bowel movement on 02/22/25. No additional bowel movements were documented. Daily skilled notes, dated 02/20/25 through 02/26/25, had no documentation of a daily skilled nursing assessments on 02/22/25, 02/23/25, and 02/26/25. On 03/19/25 at 9:00 a.m., RN #1 was asked how often nursing assessments should be completed on residents receiving skilled services. RN #1 stated a skilled assessment was a head-to-toe assessment of all body systems. They stated skilled nursing assessments should be completed at least once daily for all skilled residents. On 03/19/25 at 12:30 p.m., CNA #1 stated the nurse aides documented all bowel movements on the ADL sheets for each resident. CNA #1 stated they monitored residents for bowel movement frequency and reported to the nurse daily whether their residents had a bowel movement. On 03/19/25 at 1:30 p.m., RN #1 stated the nurse aides documented bowel movements on the ADL sheets and the nurses monitored the frequency of the bowel movements. They stated all residents should have a bowel movement at least every three days. RN #1 stated an intervention should be implemented to aid in evacuation if a resident has gone 3 days or longer without having a bowel movement. On 03/19/25 at 1:35 p.m., the DON denied having a written policy for bowel movement monitoring. They stated the facility followed the best standard practices in monitoring for the frequency of bowel movements. The DON stated no bowel movement after three days required intervention. They stated Res #1 should have had an intervention implemented after going three days without having a bowel movement. On 03/19/25 at 1:40 p.m., the DON denied having a written policy for the frequency of skilled nursing assessments. They stated the facility's expectation was completion of a skilled nursing assessment daily on all skilled residents. The DON stated Res #1 should have had an assessment completed daily during their stay.

Based on observation and interview, the facility failed to label and store medications according to acceptable standards of practice for two medications observed during a review of medication/treatment carts and medication storage rooms. The ADON identified nine carts and two medication storage rooms. Findings: On [DATE] at 8:30 a.m., LPN #1 removed a bag labeled for Resident #60. Inside the bag was a multi-use insulin pen which was labeled for Resident #28. LPN #1 removed the bag labeled for Resident #28 which contained an unlabelled multi-use insulin pen with insulin degludec. LPN #1 stated the insulins were probably switched by mistake. After checking the medication room, LPN #1 stated they would have to order insulin for Resident #60 from the pharmacy. On [DATE] at 8:40 a.m., the 600 hall medication storage room was observed with LPN #1. Inside the medication storage room was a refrigerator with a padlock latch present on the main refrigerator door, but no padlock to secure the door. LPN #1 opened the refrigerator and an unlocked metal lock box was observed secured to a shelf in the refrigerator. LPN #1 opened the lock box and found 30 syringes of liquid Ativan (a benzodiazepine). LPN #1 stated the Ativan was labeled for an expired resident. The LPN stated the resident expired a few weeks ago. On [DATE] at 9:20 a.m., the ADON stated they went around to each nurse and medication aide once a week and asked if there were any controlled drugs to destroy. The ADON stated they were not aware the Ativan was in the facility. The ADON stated there was no narcotic count sheet associated with the liquid Ativan. The ADON stated it was the responsibility of the floor nurse receiving the medication to make out the narcotic count sheet if one is not present. The ADON stated medications received from the facility's primary pharmacy had narcotic count sheets attached, but the liquid Ativan was received from a hospice pharmacy. The ADON stated without a narcotic count sheet, none of the nurses were aware of the medication, and the medication was not routinely reconciled for misappropriation. The ADON stated they were aware insulin was ordered for Resident #60. The ADON stated all stored medications required proper labeling.

Based on record review and interview, the facility failed to ensure weights were obtained and meal percentages were monitored as ordered by the physician for four (#11 and #56, #60, and #63) of four sampled residents reviewed for nutrition The administrator identified 90 residents in the facility. Findings: The Nutritional Services policy, dated 01/12/18, read in parts, Changes are reviewed during morning meeting .Diets .Weights: loss/gain .Appetite: decrease in oral intake of less than 25%. 1. Resident #11 had diagnoses which included cerebral infarction and underweight. A Physician Order, dated 04/20/24, showed a house shake was to be given at breakfast and lunch for the diagnosis of underweight. The care plan, dated 11/11/24, included a plan for altered nutritional status. A Physician Order, dated 12/31/24 showed the resident was to be weighed weekly. The Resident Weight Record for Resident #11 showed weights were obtained monthly, not weekly as ordered, with a weight loss in one month of 4.4 pounds. The ADL worksheet for December 2024 showed 25 meal percentages recorded out of 93 opportunities. The January 2025 ADL record showed 50 meal percentages out of 86 opportunities. 2. Resident #56 had diagnoses which included fracture of the femur. The Care Plan, dated 12/06/24, showed to monitor oral intake of food and fluid. A Physician Order, dated 12/07/24, showed the resident was to be weighed weekly. The ADL worksheet for January 2025 showed 50 meal percentages out of 86 opportunities. 3. Resident #60 had diagnoses which included diabetes mellitus with diabetic chronic kidney disease. A Physician Order, dated 12/11/24 showed the resident was to be weighed weekly. The December 2024 ADL sheet for meal percentages showed four meal percentages out of 93 opportunities. The January 2025 ADL sheet for meal percentages showed 33 meal percentages out of 86 opportunities. A printed list of weights for Resident #60 was provided by the DON. It showed one weight was obtained in December and one weight in January. 4. Resident #63 had diagnoses which included cerebral infarction. The December 2024 MAR showed the resident was to be weighed weekly for 4 weeks. The Resident Weight Record showed the first weight 12 days after admission in December 2024 and a second weight in January. The two weights documented a weight loss of 15.8 pounds. The ADL record for December 2024 documented 34 meal percentages out of 57 opportunities. On 1/28/25 at 3:27 p.m., CNA # 1 stated they were to document meal intake on paper ADL worksheets and inform the nurse if intake less than 50 percent. On 1/28/25 at 2:48 p.m., the ADON stated weight loss was monitored and if it was a five pound loss or more they implemented interventions, including a dietary consult and physician contact. They stated resident meal intake percentage was documented in the ADL. On 1/30/25 at 9:39 a.m., the ADON stated they were responsible for monitoring weights. On 1/30/25 at 10:20 a.m., the ADON stated the facility policy was to weigh all residents on the day of admission or the next day. On 1/30/25 at 3:05 p.m., the DON stated the inconsistent documentation of meal percentages was due to a lack of supervision. 41220 51849

Based on record review and interview, the facility failed to complete a baseline care plan for four (#26, #34, #45, and #60) of seven sampled residents reviewed for baseline care plans. The administrator identified 90 residents in the facility. Findings: 1. Resident #26 had diagnoses which included congestive heart failure. 2. Resident #34 had diagnoses which included non Alzheimer dementia. 3. Resident #45 had diagnoses which included hemiplegia. 4. Resident #60 had diagnoses which included diabetes mellitus with chronic kidney disease Record reviews did not document baseline care plans were completed for these residents. On 01/28/25 at 5:35 p.m., the DON stated they had looked through the records and was unable to locate a baseline care plan for these residents.

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for one (#60) of five sampled residents whose labs were reviewed. The DON identified 45 residents who had routine labs ordered. Findings: Resident #60 had diagnoses which included diabetes mellitus. Physician orders, dated 05/28/24, showed the facility was to complete a CBC every 6 months in March and September; and the facility was to complete a hemoglobin A1C every 3 months in March, June, September, and December. Review of the clinical record did not show a CBC had been completed in September 2024 or that a hemoglobin A1C had been completed in June, September, or December 2024. On 01/28/25 at 5:04 p.m., the DON stated the ADON was responsible to ensure labs were completed as ordered by the physician. They stated labs had not been completed because they were not put into the lab company's ordering system.

Based on record review and interview, the facility failed to ensure medications were reviewed monthly by the consultant pharmacist and the pharmacy recommendations were addressed by the physician for one (#60) of five sampled residents who were reviewed for unnecessary medications. The DON identified 89 residents who received medications in the facility. Findings: The Medication Regimen Review and Reporting policy, dated January 2024, read in part, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. Resident #60 had diagnoses which included chronic pain. The Consultant Pharmacist Recommendation to Physician, dated 05/31/24, read in part, In hemodialysis patients, gabapentin is titrated to effect up to 300 mg 3 times per week given after hemodialysis on dialysis days. Some experts recommend cautious titration to a max of 300 mg/day in select patients requiring additional pain control. It may be reasonable to consider reducing the dose for this medication. The consultant pharmacist report was addressed by the physician and dated 01/29/25. Review of the clinical record and the monthly medication regimen reviews provided by the DON did not show a medication regimen review by the consultant pharmacist had been completed for December 2024. On 01/29/25 at 11:03 a.m., the DON stated they could not locate the medication regimen review for December 2024. They stated they asked the nurse practitioner to review and address the pharmacist recommendation dated 05/31/24 on 01/29/25. They stated they did not know why the 05/31/24 recommendation had not been previously addressed.

Based on record review and interview, the facility failed to ensure residents who received dialysis were assessed after dialysis for one (#60) of one sampled resident who was reviewed for dialysis. The DON identified three residents who required dialysis. Findings: The Dialysis - Hemodialysis policy, dated 02/12/20, read in part, Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany patient to the dialysis center.Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C. Resident #60 had diagnoses which included end stage renal disease. The Dialysis Pre/Post Communication Report forms, read in part, This section to be completed by Nursing Home Staff upon resident return and placed in clinical record .Access Type/Assessment. A physician's order, dated 05/28/24, showed the resident was to receive dialysis weekly on Monday, Wednesday, and Friday. The quarterly assessment, dated 10/27/24, showed the resident was cognitively intact for daily decision making and received dialysis while a resident in the facility. The treatment record, dated December 2024, read in part, Dialysis Monday, Wednesday and Friday on 1 time per day Monitor shunt/graft/fistula for S/X of infection and adequate circulation. The time on the treatment record for the monitoring was documented for 9:00 a.m. The treatment record and the Dialysis Pre/Post Communication Report forms, dated 12/09/25 and 12/16/24, did not show the resident's fistula had been assessed after dialysis. The treatment record, dated January 2025, read in part, Dialysis Monday, Wednesday and Friday on 1 time per day Monitor shunt/graft/fistula for S/X of infection and adequate circulation. The time on the treatment record for the monitoring was documented for 9:00 a.m. The treatment record and the Dialysis Pre/Post Communication Report forms, dated 01/22/25, 01/24/25, and 01/27/25, did not show the resident's fistula had been assessed after dialysis. On 01/28/25 at 11:54 a.m., Resident #60 stated facility nurses assessed their dialysis access site from time to time, but not every time they returned from dialysis. On 01/28/25 at 4:10 p.m., LPN #2 stated residents were assessed after dialysis and they documented on the dialysis communication forms. On 01/28/25 at 4:56 p.m., the DON stated the charge nurses were to assess residents before and after dialysis and document on the dialysis communication forms. The DON stated they added vital signs twice daily and monitoring the dialysis access site on the days the residents were scheduled dialysis because the nurses did not always complete the dialysis communication forms. The stated the administrative staff monitored documentation weekly to ensure residents were assessed before and after dialysis, but they had some staffing changes and the post dialysis assessments had not been consistently completed

Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the resident's stay was completed for one (#70) of two sampled residents who were reviewed for discharge. The administrator identified 90 residents who resided in the facility. Findings: Resident #70 had diagnoses which included hypertension. The Discharge Instructions for Care form showed the resident was discharged from the facility to home on 10/31/24. The undated Interdisciplinary Discharge Summary form in the electronic clinical record was blank in all sections except dietary and activities. The discharge summary did not contain a recapitulation of the resident's stay. On 01/30/25 at 12:30 p.m., the DON stated each department was to complete their section of the Interdisciplinary Discharge Summary form in the electronic clinical record. The DON stated they monitored the discharge summaries and knew they had not been completing them to include a recapitulation of the residents stay.

Based on record review and interview, the facility failed to ensure assessments were encoded and transmitted for two (#70 and #184) of 22 sampled residents whose assessments were reviewed. The administrator identified 90 residents who resided in the facility. Findings: 1. Resident #70 had diagnoses which included hypertension. The electronic health record showed the last assessment completed was a discharge from part A services assessment, dated 10/14/24. The Discharge Instructions for Care form showed Resident #70 was discharged from the facility on 10/31/24. On 01/30/25 at 12:26 p.m., MDS coordinator #1 reviewed the electronic clinical record for Resident #70 and stated they did not know why a discharge return not anticipated assessment had not been completed on 10/31/24 when the resident discharged home. 2. Resident #184 had diagnoses which included paraplegia. The electronic clinical record showed Resident #184 was an active resident. The electronic clinical record showed discharge return anticipated assessments, dated 12/07/24 and 12/24/24, with no re-entry assessments completed. On 01/30/25 at 3:34 p.m., the DON and MDS coordinator #1 reviewed the electronic clinical record for Resident #184. The DON stated the resident had returned to the facility on [DATE] and 12/25/24. MDS Coordinator #1 stated they should have completed re-entry assessments on 12/08/24 and 12/25/24. The DON stated the previous MDS coordinator had not been completing assessments as required.

Based on record review and interview, the facility failed to ensure quarterly assessments were completed not less than once every three months for one (#31) of 22 sampled residents whose assessments were reviewed. The administrator identified 90 residents who resided in the facility. Findings: Resident #31 had diagnoses which included hypertension. The electronic health record showed a quarterly assessment had been completed on 03/27/24 and 06/27/24, and an annual assessment had been completed on 09/25/24. No other assessments had been documented after the 09/25/24 annual assessment. On 01/30/25 at 12:21 p.m., MDS coordinator #1 reviewed the electronic health record for Resident #31 and stated the last assessment completed was the annual assessment on 09/25/24. They stated they did not know why a quarterly assessment had not been completed in December 2024. On 01/30/25 at 12:24 p.m., the DON stated a quarterly assessment should have been completed in December for Resident #31.

Based on record review and interview, the facility failed to ensure proper beneficiary notification was provided for two (#54 and #66) of three sampled residents reviewed for beneficiary notifications. The Beneficiary Notice-Residents discharged Within the Last Six Months form showed seven residents had remained in the facility after they had been discharged from skilled services with skilled days remaining. Findings: 1. The Beneficiary Notice-Residents discharged Within the Last Six Months form showed Resident #54 was discharged from skilled services, had skilled days remaining, and stayed in the facility as a long term care resident after the discharge from skilled services. The SNF Beneficiary Protection Notification Review form showed Resident #54 was discharged from skilled services on 09/29/24 and the resident and/or resident representative had not been provided an ABN. 2. The Beneficiary Notice-Residents discharged Within the Last Six Months form showed Resident #66 was discharged from skilled services, had skilled days remaining, and stayed in the facility as a long term care resident after the discharge from skilled services. The SNF Beneficiary Protection Notification Review form showed Resident #66 was discharged from skilled services on 08/28/24 and the resident and/or resident representative had not been provided an ABN. On 01/28/25 at 5:59 p.m., the social services director stated Resident #54 and Resident #66 had not been provided ABNs. On 01/30/25 at 2:42 p.m., the social services director stated they thought the MDS coordinator had provided the ABNs, but they had not provided one for Resident #54 or Resident #66. On 01/30/25 at 2:46 p.m., the administrator stated they had asked the social services director about ABNs and they stated they had not been trained on beneficiary notifications.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and enhanced barrier precautions were followed during pressure ulcer treatment for one (#10) of two sampled residents reviewed for wound care. The facility matrix identified 10 residents with pressure ulcers. Findings: An Enhanced Barrier Precautions policy, revised 04/01/24, read in parts, Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resistant organisms (MDROs). This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply .Enhanced Barrier Precautions: An infection control intervention designed to reduce transmissions of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Indications .Wounds and/or indwelling medical devices even if the resident is not know to be infected or colonized with an MDRO .Chronic wounds include, but are not limited to, pressure ulcers. Resident #10 admitted on [DATE] with diagnoses which included urinary tract infection and pressure ulcer of left buttock, stage 2. A nursing note, dated 01/13/25, documented WCN in for initial skin assessment noted Lt buttock stage 2, 1.3 cm x 1.0 cm x 0.2 cm, 100% granulation, new order received DuoDerm MWF. On 01/22/25 at 9:55 a.m., the wound care nurse donned gloves, disinfected Resident #10's bedside table, removed gloves, sanitized hands, and obtained supplies for wound care. They obtained permission to enter the room. The wound care nurse entered Resident #10's bathroom and washed and dried their hands. CNA #1 informed the resident they were going to pull back the blankets and remove their brief to assist the wound care nurse with wound care. Resident #10 was assisted to roll to their left side. An open wound approximately 1 cm x 1 cm was observed. The wound care nurse provided wound care and then assisted CNA #1 with replacing the brief, rolling Resident #10 back to their original position, and pulling blankets back over the resident. The wound care nurse removed trash from trash bin, removed gloves, and walked down the hall to place the trash and gloves in a large trash receptacle. They then turned to sink and washed and dried their hands. The wound care nurse did not don a gown prior to entering Resident #10's room. On 01/22/25 at 1:33 p.m., the wound care nurse stated the policy for EBP precautions was if a resident had a more in depth wound, not a superficial wound. On 01/24/25 at 12:34 p.m., the wound care nurse stated they had not taken EBP precautions on Resident #10 because they did not have drainage or a catheter. They stated Resident #10 only had a superficial wound. On 01/24/25 at 12:40 p.m., the DON stated EBP precautions were for anyone who had a catheter, PICC line, peg tube, or a wound that was not a surface wound. On 01/24/25 at 12:54 p.m., RNC #1 stated based on the policy a stage two pressure ulcer would require EBP precautions.

Based on record review and interview, the facility failed to submit accurate payroll based journal staffing data for 24 hour nursing to CMS for three of three months reviewed. The Administrator identified 98 residents resided in the facility. Findings: On 04/24/24 at 12:45 p.m., the QOC monthly reports requested for January, Feburary, and March 2024 were received. The reports documented less than the required 2.9 minimum on 01/14/24, 01/21/24, 01/22/24, 1/28/24, 02/04/24, 02/17/24, 02/18/24, 02/25/24, 03/03/24, 03/16/24, 03/17/24, 03/24/24, and 03/31/24. On 4/26/24 at 2:55 p.m., the Administrator stated the QOC reports did not populate administrative staff that may have worked on those days. They stated that time was entered in to the facility's payroll system but the Corporate system would not recognize the administrative staff worked on the floor. On 04/26/24 at 2:56 p.m., the administrator stated the information was not accurately entered into the payroll based journal to CMS.

Based on record review and interview, the facility failed to provide adequate supervision to prevent a resident from exiting the facility through a door which alarmed, unobserved by staff for one (#1) of three residents reviewed for elopement. The Administrator identified 98 residents resided in the facility. Findings: Resident #1 had diagnoses which included vascular dementia, unsteadiness on feet, and weakness. An elopement risk assessment, dated 02/01/24, documented the resident was at moderate risk for elopement. A Nurses Note, dated 02/01/24, read in part, .Pt up ambulating t/o building. Pt would not stay in WC and would not stay in the lobby or room to be monitored .walked down to the end of 300 hall where staff could cont to monitor .This nurse went to assist with pt and when returned pt was not at the end of 300. This nurse and staff went to check on pt and found the back dining room door alarm going off. Staff checked the perimeter of the building and saw pt walking in the grass and before staff could get to . fell .no complaints of pain able to MAEx4 and was assisted up. Assessed skin and pt had an abrasion to .right cheek .He is now resting in the WC. Notified pt son and Dr. about the incident no new orders to note except start neuros. On 04/25/24 at 3:36 p.m., LPN #1 stated Resident #1 was hard to redirect with exit seeking. LPN #1 stated from day one [Resident #1] was confused and agitated. On 04/25/24 at 3:37 p.m., LPN #1 stated Resident #1 was not observed exiting through the door, the alarm had notified staff of them exiting. On 04/25/24 at 3:38 p.m., LPN #1 stated Resident #1 had been out side for 10 to 15 minutes without supervision. On 04/26/26 at 10:46 a.m., the DON stated there were three residents who currently resided in the facility that were wanderers/elopement risk. On 04/26/24 at 10:57 a.m., the DON stated Resident #1 had one elopement during their stay in the facility.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was implemented to address the residents needs related to elopement for one (#1) of three sampled residents reviewed for care plans. The Administrator identified 98 residents resided in the facility. Findings: A Comprehensive Care Plans policy, reviewed 04/17/23, read in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in a resident's comprehensive assessment . Resident #1 had diagnoses which included vascular dementia, unsteadiness on feet, and weakness. An elopement risk assessment dated [DATE], documented the resident was at moderate risk for elopement. A care plan, dated 01/29/24, for behavioral changes related to elopement in the care area with a goal of resident remaining safe within the facility. There were no interventions for this care area. On 04/26/24 at 11:00 a.m., the DON stated there were no interventions in the elopement care area of the care plan.

Based on record review and interview, the facility failed to ensure a resident received a gradual dose reduction after the physician ordered the reduction of an antipsychotic medication for one (#6) of three residents reviewed for pharmacy medication regimen reviews. The administrator reported 93 residents resided in the facility. Findings: Res #6 had diagnoses which included delusional disorders and hallucinations. A physician order, dated 10/02/23, documented to administer Risperdal 0.50 mg at bedtime. A December 2023 pharmacist medication regimen review, signed by the physician on 12/27/23, documented the resident was stable and to reduce the resident's Risperdal from 0.50 mg to 0.25 mg at bedtime. The resident's MAR documented the resident continued to receive the 0.50 mg from 12/27/23 through 01/17/24 and had not been reduced. On 01/18/24 at 1:50 p.m., the DON stated the medication regimen review was noted by the DON. They reported the medication regimen review had not been acted upon by the facility staff and the facility had not reduced the anti-psychotic medication as ordered on 12/27/23.

On 10/31/23 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Res #43's right to be free from emotional distress due to neglect. Res #43 had multiple pressure ulcers upon admission. Physician orders were to change dressings daily in the morning. On 10/31/23 at 3:26 p.m., all wound dressings were dated for 10/29/23. Upon exposure of the resident's back a pungent putrid odor was evident. The dressings on the resident's back were observed to be saturated with drainage. The resident was observed with dried and fresh blood and other brown stains on the absorbent pad under their back. Further brown stains were observed on the sheet between the resident's legs and toward the bottom of the bed. The resident was observed with dried feces on the bottom of their hospital gown. The resident was observed with an ostomy bag on the left side of their abdomen that was full of feces and bloated with gas. The resident's nails were observed to be long, curling, and had brown and black substance under the nails. The resident was observed with a urine collection bag with approximately 700 ml clear yellow urine with sediment accumulation in drainage tube. The resident expressed their current condition made them want to cry and they had given up hope of getting better. They stated they were tired of trying to get care for their wounds and they had given up trying. On 10/31/23 at 5:53 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 10/31/23 at 6:02 p.m., the administrator was notified of the IJ situation. On 11/01/23 at 1:58 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan of Removal 1) DON/Designee will educate all licensed nurses on changing wound dressings per physician order and notification of DON/Administrator if wound care is not completed. Education completed on 10/31/2023 in person and by phone. Nurses who could not be reached by phone will be in- serviced prior to working next schedule shift. 2) All staff will be educated on prevention of neglect and ADL care. All education be completed by in person or by phone by 11:59 pm 10/31/23. If unable to reach for education, staff education will be in-serviced prior to working next scheduled shift. 3) A visual audit was conducted and completed on 10/31/2023 by nursing management to assure that all wound dressings were changed per physician order. 4) DON/designee will do rounds daily to ensure dressings are changed and as ordered by physician. Random visual ADL care audits will be conducted during angel rounds on residents to ensure ADL care is provided. 5) QA Committee meeting held on 10/31/23 with facility staff. Resident #43: On 10/31/2023 wound care completed on all wounds, ADL care provided including nail care, linen and gown changed, foley bag emptied and colostomy bag changed. Charge nurses evaluated resident's psychosocial status throughout shifts. Pysch plus will follow up with resident related to psychosocial needs on 11/1/2023. The IJ was lifted, effective 11/01/23 at 12:58 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the residents. Based on observation, record review, and interview, the facility failed to protect Res #43's right to be free from emotional distress due to neglect. The MDS coordinator identified 98 residents resided in the facility. Findings: A facility abuse policy, effective 06/23/17, documented in part .each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion .Neglect: Failure of the facility, its employees or service providers to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Res #43 admitted to the facility on [DATE] with diagnoses which included pressure ulcers, paraplegia, low BMI, depression, and contractures. A physician order, dated 08/10/23, documented to apply bacitracin topical ointment Monday and Wednesday to pressure ulcer of other site, stage IV. A TAR for August 2023, documented the bacitracin was not administered on two of 9 opportunities. A physician order, dated 08/10/23, documented to cleanse wound to left posterior inferior knee, pat dry, apply bacitracin, apply Xeroform, cover with ABD pad, and wrap with Kerlix and secure with medical tape every Monday, Wednesday, and Friday day shift for pressure ulcer of other site, stage IV. A TAR for August 2023, documented the treatment was not completed two of eight opportunities. A physician order, dated 08/10/23, documented to cleanse wound to right buttock, apply bacitracin, apply Xeroform, and cover with silicone foam adhesive border gauze every Monday, Wednesday, and Friday day shift for pressure ulcer of right buttock, stage III. A TAR for August 2023, documented the treatment was not completed for two of eight opportunities. A physician order, dated 08/10/23, documented to cleanse wound to right medial knee, pat dry, apply bacitracin, apply Xeroform, cover with ABD pad, wrap with Kerlix and secure with medical tape every Monday, Wednesday, and Friday day shift for pressure ulcer of other site, stage III. A TAR for August 2023 documented the treatment was not completed for two of eight opportunities. A physician order, dated 08/10/23, documented to cleanse wound to sacrum, pat dry, apply Xeroform, apply bacitracin, and cover with sacral adhesive silicone border dressing, every Monday, Wednesday, and Friday day shift for pressure ulcer of sacral region, stage IV. A TAR for August 2023 documented the treatment was not completed two of eight opportunities. A physician order, dated 08/10/23, documented to perform colostomy care one time per day for one day. A TAR for August 2023, documented the treatment was completed on 08/11/23. There was no order for ostomy care from 08/11/23 through 08/22/23. An annual MDS, dated [DATE], documented the resident was cognitively intact, required extensive to total assistance with ADLs, had not rejected care, and had three stage III pressure ulcers and one stage IV pressure ulcer. A physician order, dated 08/22/23, documented to complete ostomy care one time per day. A TAR for August 2023, documented the ostomy care was not completed six of nine opportunities. A physician order, dated 08/22/23, documented to complete catheter care every shift. A TAR for August 2023, documented the catheter care was not completed 21 of 30 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to left posterior inferior knee, pat dry, apply gentamicin ointment, apply calcium alginate with silver, cover with ABD pad, wrap with Kerlix and secure with medical tape every day shift for pressure ulcer of other site, stage IV. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to right buttock, apply Santyl nickel thick, apply calcium alginate, and cover with silicone foam adhesive border gauze every day shift for pressure ulcer of right buttock, stage III. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to right medial thigh, pay dry, apply hydrofiber with silver every day shift for pressure ulcer of other site, stage III. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to sacrum, pat dry, apply gentamicin, apply calcium alginate with silver, and cover with sacral adhesive silicone border dressing every day shift for pressure ulcer of sacral region, stage IV. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A TAR for September 2023, documented ostomy care was not completed daily three of 28 opportunities. A TAR for September 2023, documented foley catheter care was not completed every shift three of 81 opportunities. The resident was hospitalized from 09/28/23 through 10/02/23. An undated LTC bath schedule, documented Res #43 was to be bathed on Wednesdays and Saturdays. Upon record review of ADLs in the EHR from 10/02/23 through 11/02/23, bathing had not been documented for the resident in the EHR's ADL tracking. A physician order, dated 10/04/23, documented to cleanse wound to back with hibicleanse, pat dry, apply gentamicin, apply calcium alginate, and cover with large border gauze every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of 14 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to left posterior inferior knee with hibicleanse, pat dry, apply gentamicin ointment, apply calcium alginate with silver, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed four of 27 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to right buttock with hibicleanse, pat dry, apply Santyl ointment nickel thick, apply gentamicin, apply calcium alginate, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 18 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to right medial thigh with hibicleanse, pat dry, and apply hydrofiber with silver every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 26 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to sacrum with hibicleanse, pat dry, apply gentamicin ointment, apply calcium alginate with silver, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of 14 opportunities. A physician order, dated 10/04/23, documented to apply santyl ointment topically to right buttock every day shift for pressure ulcer of other site, stage IV. A MAR for 10/01/23 through 10/31/23 documented the ointment was not administered seven of 27 opportunities. A physician order, dated 10/15/23, documented to cleanse wound to right medial calf with hibicleanse, pat dry, apply gentamicin, apply calcium alginate with silver, cover with ABD pad, wrap with Kerlix and secure with medical tape every day shift for pressure ulcer of other site, stage III. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 16 opportunities. A physician order, dated 10/17/23, documented to cleanse wound to sacrum with hibicleanse, pat dry, apply bacitracin ointment, apply Xeroform gauze, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 14 opportunities. A physician order, dated 10/17/23, documented to cleanse wound to back with hibicleanse, pat dry, apply bacitracin ointment, apply Xeroform gauze, and cover with large border gauze every day shift for pressure ulcer of other site, stage IV. The TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 14 opportunities. A physician order, dated 10/23/23, documented to cleanse wound to right medial knee with hibilcleanse, pat dry, apply gentamicin, apply calcium alginate with silver, cover with ABD pad, wrap with Kerlix, and secure with medical tape every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of eight opportunities. A physician order, dated 10/23/23, documented to cleanse wound to right buttock with hibicleanse, pat dry, apply Santyl ointment nickel thick, apply gentamicin, apply calcium alginate, cover with superabsorbent dressing and bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of eight opportunities. A physician order, dated 10/25/23, documented to cleanse left calf with hibicleanse, pat dry, apply gentamicin, apply calcium alginate with silver, cover with ABD pad, and wrap with Kerlix every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 16 opportunities. On 10/31/23 at 3:09 p.m., Res #43 was observed in their room in their bed. The resident was in a hospital gown with a single sheet over their lower torso. The resident was observed to be severely contracted on their lower extremities and some contractions to the wrist and hands were noted. The feet were exposed and were observed to be dry, cracking, and with long, curling, and discolored toenails. The resident stated they were not receiving wound care. They stated it was supposed to be done daily but it had not been completed since Sunday (10/29/23). They stated they felt their wounds were healing well before admission to this facility and now they were afraid they were worsening. They stated months of work have been undone because they haven't done it. The resident stated they had notified staff today their wound care had not been completed, but it had still not been done. They stated they were told by a nurse [she] can't be doing everyone's job because she had too much to do and then the care was pawned off on another nurse who did not do it. The resident stated they had not received a bath in over a week, and were supposed to get one on Wednesdays. The resident stated the staff never offered to trim their nails. Upon observation, the resident's fingernails were long, curling over the end of their finger, and were discolored with brown and black substances underneath the nails. The resident stated I'm covered in wounds, it just makes me want to cry. The resident became tearful and apologized for getting emotional. They stated I just gave up trying because they always have some excuse as to why they can't do my care. I'm just tired of it. I can't even sleep because i'm so worried about my wounds being wet or becoming septic from them. On 10/31/23 at 3:26 p.m., CNA #10 assisted the resident to reposition for visualization of their wounds. Upon exposure of the resident's back a pungent and putrid odor was evident. Two large bordered dressing were observed on the resident's back from their gluteal cleft extending up to their upper back. Both dressings on the resident's back were dated 10/29/23. The dressings were saturated with yellow, red, and brown drainage. The disposable absorbent pad beneath the resident's back was observed with dried and fresh blood scattered on the pad. The resident was observed with stretch gauze wrapping both lower legs from the knee to the ankle. Pillows were observed being used for positioning between and below the resident's legs. The pillow cases had scattered brown stains. The dressings below the stretch gauze on both legs were dated 10/29/23. The sheet below the resident's legs had scattered brown stains. The resident's ostomy was observed full of feces and bloated with gas. The resident stated the ostomy is not emptied very often and frequently leaked because it was full. The resident's hospital gown was observed with dried feces on the bottom hem. The resident's urinary catheter tubing was observed with sediment and urine in the drainage tubing. The foley catheter bag was observed with approximately 700 ml of clear yellow urine in the collection bag. The resident was unable to recall the last time their foley catheter was changed, but stated they believed it was when they were in the hospital around 10/02/23. The resident stated the staff tending to his needs in presence of surveyors was an act and they would not be helping him if [surveyors] were not here. A nurse progress note, dated 10/31/2023 at 5:41 p.m., the DON documented a medication error was completed related to the wound care missed on 10/31/23. The note documented the wound care was completed on 10/31/23 with no changes in wound characteristics. The note did not document the wounds had an odor. The note documented no new orders were received from the provider. On 11/01/23 at 8:44 a.m., CNA #4 stated Res #43 required a lot of care due to their diagnoses. They stated the resident didn't call for staff very often for assistance. They stated the resident's main care area was related to their wounds. They stated the resident was supposed to be bathed on Wednesday and Saturday. They stated they assisted with bathing prior to wound care, and the resident received a bed bath. They stated they were unsure the last time the resident was bathed. They stated Res #43 was not receiving wound care like they were supposed to. They stated there were times when care for residents was not completed because of lack of staff to ensure the care was done. They stated it was difficult to get the nurses to attend to resident needs because they were told the nurses were too busy. The CNA stated the ostomy was supposed to be emptied by a nurse, but they would do it if they noticed it was full because of the difficulty in getting a nurse to attend to the resident's needs in a timely manner. On 11/01/23 at 8:54 a.m., LPN #5 stated they did not provide care for the resident because they normally did not work the floor. They stated they were a supervisor and didn't typically care for residents and had only been in the facility for three weeks. They stated they would need to look at the orders to see what care the resident required. They stated the wound nurse was responsible for the resident's wound care. They consulted the resident's orders and stated the bag and wafer of the ostomy was ordered to be changed every three days. They stated the orders documented catheter care was supposed to be completed every shift. They stated the CNAs were able to empty the ostomy, but it was best for the nurse to do it so an assessment could be completed. On 11/01/23 at 9:02 a.m., the DON stated the nurses on the floor were responsible for ostomies. They stated the CNAs could empty the ostomies. The DON stated bathing was scheduled for all residents twice per week. They stated the CNAs were to perform ADLs and document every shift in the EHR. They stated linen changes were supposed to be completed daily if soiled, but at a minimum when the resident was bathed. The DON reviewed the EHR and stated they were unable to determine the last time Res #43 was bathed. The DON stated the wound care nurse completed all wound care for residents during the week and the floor nurses on the weekends. They stated all treatments should be documented on the TAR when they were completed. They stated an X on the TAR meant the treatment had not been completed. On 11/01/23 at 11:41 a.m., LPN #5 stated they completed the wound care for Res #43 on 10/31/23. They stated there was an odor present during wound care for the resident. They stated they did not notify the provider of the odor of the wounds. On 11/01/23 at 12:58 p.m., Res #43 was observed receiving wound care from the wound nurse. The two dressings on the resident's back, one to the left hip, and one on the sacrum were observed dated 10/31/23. The four dressings on the resident's legs were dated 10/29/23. The wound to the resident's hip was observed with a nickel sized area of slough in the center of the wound. The wounds on the back were observed with red beefy wound beds and with fresh bleeding upon cleansing. The resident's leg wounds were observed with red beefy wound beds and bleeding with cleansing. The sacral wound was observed with red beefy wound beds and bleeding upon cleansing.

Based on observation, record review, and interview, the facility failed to ensure a resident received adequate pain management for one (#43) of two sampled residents reviewed for pain management resulting in uncontrolled pain during care. The MDS coordinator identified 98 residents resided in the facility. The DON identified 56 residents on a pain management program. Findings: A facility Pain Management and Basic Comfort Measures policy, effective 08/19/2020, documented in part .Staff will evaluate pain and provide basic comfort measures in accordance with standard practice guidelines . Res #43 admitted to the facility on [DATE] with diagnoses which included pressure ulcers, paraplegia, low BMI, depression, and contractures. An annual MDS, dated [DATE], documented the resident was cognitively intact, required extensive to total assistance with ADLs, had not rejected care, received scheduled pain medication, had not had pain the last five days, and had pressure ulcers upon admission. A physician order, dated 10/02/23, documented to administer acetaminophen 325 mg, two tabs every six hours as needed for pain. An EMAR for October 2023 documented the medication had been administered one time. A physician order, dated 10/02/23, documented to administer methocarbamol 750 mg (a muscle relaxer) one tablet three times per day as needed for spasms. An EMAR for October 2023 documented the medication had been administered 10 times. A physician order, dated 10/02/23, documented to administer oxycodone-acetaminophen 10-325 mg one tablet every six hours at 1:00 a.m., 7:00 a.m., 1:00 p.m., and 7:00 p.m. for pain. A pain care plan, reviewed 10/02/23, documented the following interventions: a. administer pain medications as ordered, b. assess characteristics of pain: location, severity, on a scale of 1-10, type of pain, frequency, precipitating factors, and relief factors using the pain assessment form, c. discuss with physician that for maximum pain relief pain medications are best given around the clock, with PRN's for breakthrough pain, d. give pain medications before pain becomes severe, e. instruct resident/family about pain care and pain medications, f. notify physician of any changes in level or frequency of pain, any increase in use of prn pain medications, and any noted side effects of pain medications, g. observe resident for signs of pain during care and interactions, h. obtain pain history onset, intensity, frequency, etc, i. obtain resident's pain tolerance and attempt to maintain pain tolerance level, and j. reassess interventions with any changes in response to pain or pain medications and with every assessment. A nurse note, dated 10/15/23 at 10:05 a.m., LPN #5 documented the resident was unable to tolerate wound care due to pain. The note documented the resident agreed to allow wound care to resume if their pain decreased. The note did not document the provider was notified of the resident's pain. On 10/31/23 at 3:26 p.m., CNA #10 assisted with positioning of Res #43 to observe their wounds. When being rolled Res #43 expressed pain during repositioning. The MAR for October did not document additional pain medication was administered on 10/31/23. On 11/01/23 at 8:44 a.m., CNA #4 stated the resident often had pain during care and especially during wound care. They stated the staff try to time Res #43's wound care at 2:00 p.m. so their pain medication can have time to work before care. On 11/01/23 at 8:54 a.m., LPN #5 stated they were unfamiliar with the resident or their pain since they do not work the floor often. On 11/01/23 at 9:02 a.m., the DON stated pain control during care was dependent on the patient. They stated Res #43 had a routine pain medication. They stated they were unaware of the patient's response to wound care and would have to check with the wound nurse. They stated the resident had a muscle relaxer and acetaminophen for pain as needed. They stated they were not made aware the resident had increased pain. On 11/01/23 at 11:41 a.m., LPN #5 stated the resident was in pain on the prior day during wound care. They stated they had not notified the provider of pain or administered an as needed medication. An Administrative Medication Report, dated 11/01/23, documented Res #43 received oxycodone-acetaminophen at 12:44 p.m. On 11/01/23 at 12:58 p.m., Res #43 was observed during wound care. The resident was observed to verbalize pain during care as well as non-verbal signs of pain. The resident called out ow and oh throughout the care as well as attempted to brace against the pain, which was limited due to contractures. The resident had a grimace on their face throughout the treatment. CNA #4 was observed rubbing the resident's arm and stating to breathe through it. On 11/01/23 at 2:30 p.m., Res #43 was observed in their bed. They stated their pain was just starting to calm down from the wound care performed. On 11/01/23 at 2:47 p.m., the wound care nurse stated Res #43 had an as needed muscle relaxer ordered for pain. They stated they had notified the med aide to provide the muscle relaxer after care was completed. They stated the wound care was performed after the resident received their pain medication. They stated the pain observed during wound care that day was greater than the residents norm. They stated they had not contacted the provider. There was no documentation in the progress notes an as needed pain medication was administered. On 11/02/23 at 1:29 p.m., the wound care nurse stated Res #43 received their oxycodone at 1:00 p.m., and an as needed methocarbamol at 1:12 p.m. On 11/02/23 at 1:36 p.m., wound care was observed for Res #43. The resident was observed saying ow and grunting multiple times while the leg dressings were changed. On 11/02/23 at 1:54 p.m., upon completion of the leg dressings, Res #43 stated their pain was about to get bad. They stated the leg dressing were not so bad, but the back treatment hurts so bad I can't handle it. On 11/02/23 at 1:58 p.m., Res #43 was observed calling out during repositioning to expose their back. The wound nurse asked the resident if they needed to stop, to which they responded just get it over with. On 11/02/23 at 2:27 p.m., after all treatments were completed the wound nurse asked the resident what their pain was. The resident stated it was an 8 out of 10 on his spine. The wound nurse offered an as needed muscle relaxer. The resident stated they were not experiencing spasms and it would not help. On 11/02/23 at 3:05 p.m., the wound nurse stated they had reported his pain to the nurse practitioner, and the practitioner declined to order any further medications. They stated they did not offer the existing acetaminophen. They stated positioning was completed for comfort. On 11/03/23 at 11:59 p.m., the pharmacist the standard time for effectiveness for oxycodone-acetaminophen was 30 minutes. On 11/01/23, the resident received their oxycodone 14 minutes prior to care. On 11/03/23 at 12:36 p.m., the nurse practitioner stated Res #43 had a history of narcotic use so there was not going to be any increase to their pain management. They stated the resident had been in eight facilities and had a history of pain. They stated they had not been notified of the pain during wound care until 11/02/23. On 11/07/23 at 10:34 a.m., the resident stated they were still not providing pain control. They stated their pain was assessed yesterday while they were sleeping and they were asked the same questions over and over until they answered differently. They stated they had reported their pain management was not working but no changes had been made. They stated repositioning did not help with the pain because they were unable to position differently due to their contractures. They stated their current pain regimen was not effective and it made them sad they were not being taken seriously so they just quit trying.

On 03/09/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to ensure resident #1 was free from accident hazards related to the bed rails on her bed. The resident was entrapped by the bed rails and sustained a laceration on her right mandible. On 03/09/21 at 12:32 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. At 1:35 PM, the administrator (adm) was notified of the IJ situation related to the facility's failure to remove the bed rails which were a known accident hazard. At 3:30 PM, the adm submitted a plan of removal. At 4:57 PM, the plan of removal was not accepted and returned to the adm. At 5:57 PM, the adm submitted an acceptable plan of removal. The plan of removal documented the following: IMMEDIATE JEOPARDY PLAN of REMOVAL for ACCIDENT HAZARDS and BED RAILS 03-09-21 1. Resident #1's assist bars were removed, fall mats remain on both sides of the bed. Resident #1's side rail evaluation was updated, physician/family updated, physicians' orders and care plan and ADL (activities of daily living) Plan of Care updated. 2. Inservice all nursing staff on use of bedrail policy and procedures, to include types of rails, assessment of needs and documentation of rail types on care plan and ADL Plan of Care. This training will be completed by DON (director of nursing) or designee by 6pm on 3.9.21. Any staff not in attendance will be called and the policy and procedures reviewed with them by phone by the DON or designee by the end of today (3.9.21) at 6pm or prior to next shift. All in-services to be completed by 6pm on 3.9.21. 3. All residents will be assessed for side rails and type of rail, such as an assist or mobility bar by 6pm on 3.9.21 and the care plan and ADL plan of care will be updated accordingly. 4. Inservice Nursing Management team by RNC (regional nurse consultant) on need to assess for side rail/mobility bar, review least invasive option, notify Dr (doctor) and family, obtain consent, and update care plan before rails of any kind are in use by 6pm on 3.9.21. On 03/10/21 at 11:36 AM, the adm was informed the immediate jeopardy was removed, as of 03/09/21 at 4:20 PM, after all components of the plan of removal had been completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure a resident was free from accident hazards for one (#1) of three residents reviewed for bed rails and falls. The facility failed to identify and remove a known accident hazard related to bed rails after resident's head was lodged in between her air mattress and bed rail. The resident sustained [REDACTED]. The administrator identified 86 residents who had bed rails. Findings: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated 10/03/19, documented, Assist Rails 1/4 RAILS FOR RESIDENT MOBILITY Dx (diagnosis): Aftercare following joint replacement surgery .D/C (discontinue) .03/09/21 A physician order, dated 10/03/19, documented, LOW BED FOR FALL PRECAUTION every shift Dx: Aftercare following joint replacement surgery . A physician order, dated 10/09/19, documented, Admit to Hospice Dx: [MEDICAL CONDITION] with behavior disturbance . An Incident/Accident Report, dated 10/21/19 at 8:40 AM, documented the resident was observed on the floor near her bed with no injury noted. The report documented the resident was severely cognitively impaired and had impaired judgment. The report documented the resident required extensive assistance with transfers and had impaired standing balance. An Incident/Accident Report, dated 12/20/19 at 10:17 PM, documented the resident was observed on the floor in front of her wheelchair with no injury noted. A Bed Rails Evaluation, dated 01/05/20, documented the resident was not at risk for becoming entrapped if bed rails are used. The evaluation documented the resident could not independently get in and out of bed safely and had a history of [REDACTED]. The assessment documented frequent monitoring, low bed, put to bed when fatigued, and soft mat on the floor for alternatives interventions previously attempted prior to installing bed rails. The evaluation documented a recommendation for bed rails for positioning and safety. An Incident/Accident Report, dated 01/20/20 at 2:05 PM, documented the resident was observed on the floor mat on the right side of the bed with no injury noted. The report documented the resident's cognition was severely impaired and was unable to let someone know what happened or follow simple instructions. The report documented the resident had impaired standing balance and was total dependant with transfers. The report documented the care plan was updated to include monitoring more closely. A Bed Rails Evaluation, dated 05/26/20, documented the resident was 64 inches tall and weighed 143 pounds. The evaluation documented the resident WAS at RISK for becoming entrapped if bed rails were used. The evaluation documented, If you have answered YES to any of the questions above, the IDT needs to review for alternatives to the bed rail, as they NOT an option for this resident. The evaluation documented the resident could not independently get in and out of bed safely and had a history of [REDACTED]. The evaluation documented the resident had trouble falling or staying asleep and had severe cognitive impairment. The evaluation documented a recommendation for bed rails for positioning and safety. An Incident/Accident Report, dated 05/26/20 at 8:00 PM, documented the resident was assisted to bed via mechanical lift 30 minutes prior to nurse going into the room to give medication. The report documented the resident was observed in a kneeling position to the left of her bed, with her upper body against the bed mattress. The report documented both of the resident's legs were wrapped in her sheets and no injury noted. The report documented the resident was severely cognitively impairs, had impaired judgement, inability to understand directions, and evidence of anxiety. The report documented the resident had impaired sitting balance, non-weight bearing, and total dependent with transfers. The report documented to place the resident in open area for maximum observation opportunities, mat at bedside and scoop mattress/bolsters as interventions. A quarterly assessment, dated 11/29/20, documented the resident was severely cognitively impaired; required total assistance of two people with bed mobility, transfer, dressing, and toilet use; total assist of one person with eating; and had impairment of both upper and lower extremities. The assessment documented the resident did not have a fall in the previous three months. An Incident/Accident report, dated 12/27/20 at 8:05 AM, documented, .Resident was found dangling by her head on the side rail .type of injury - Laceration .'' The report documented the resident required extensive assistance, was non-weight bearing, and was sent to the emergency room (ER). The report documented the resident needed a beriactric bed as an intervention. The report documented reviewed fall with IDT (interdisciplinary team) and will assist as needed to decrease falls. The report documented to continue current interventions. An emergency department report, dated 12/27/20 at 8:56 AM, documented the resident had a 2.5 centimeter (cm) laceration on the right jaw over the mandible and a 1.5 cm skin tear to the left hand. The laceration was repaired with sutures and the skin tear with skin adhesive glue. An OSDH incident report, dated 12/27/20, documented the resident was found in her room status [REDACTED]. The report documented the resident needed assistance with ADLs but could move self in bed. The report documented the care plan instructions included anticipating needs and assisting with ADLs as appropriate. The report documented upon investigation it was noted the resident had wiggled out of bed causing an unwitnessed fall. The report documented she was found to be horizontal beside the bed with her neck between the rail and mattress, causing an open area. The report documented the resident was sent to the ER for evaluation and treatment and returned with sutures to her neck. The report documented the resident had bolsters in place on bed to prevent similar recurrence. A Bed Rails Evaluation, dated 02/24/21, documented the resident was NOT at risk for becoming entrapped if bed rails were used. The evaluation documented the resident could not independently get in and out of bed safely and DID NOT have a history of falls. The evaluation documented the resident DID NOT have problems with balance, poor trunk control, and a need for assistance for positioning and mobility. An annual assessment, dated 02/27/21, documented the resident was severely cognitively impaired; required total assistance of two people with bed mobility, transfer, dressing, and toilet use; total assist of one person with eating; and had impairment of both upper and lower extremities. The assessment documented the resident did not have a fall in the previous three months. On 03/08/21 at 12:25 PM, the resident was not in her room. The resident's bed was observed to have an air mattress with approximately three inch high foam bolsters along both sides of the bed. The bed had a rail on each side of the head of the bed, which were approximately 30 inches in length. The right side rail was tight against the bed. The left rail was approximately four inches away from the mattress and a pillow was observed between the mattress and the bed rail. On 03/08/21 at 12:48 PM, licensed practical nurse (LPN) #3 was interviewed regarding the resident's entrapment with the bed rail on 12/27/20. The LPN stated she was on duty when the resident got her head stuck in the rail. She stated a certified nurse aide (CNA) came and got her and they released the resident from the rail. She said the resident's head was caught in the bed rail with her head facing toward the head of the bed. She stated the resident had a cut on the right side of her jaw. The LPN was interviewed in the resident's room. The resident was not in the room at that time. The LPN was asked if the bed, mattress, and rails were the same as when the resident was entrapped. She said they were the same. She stated the bed is a hospice bed. She said the resident had the same bed and rails since she had been on hospice. She was asked why there was a pillow between the rail and mattress. She said she did not know. She said it was the resident's personal pillow which was used for positioning and shouldn't be between the rail and bed. The LPN was asked what interventions changed after the resident became entrapped. She stated the staff checked on her more often and the resident had been brought out of her room more often. She was asked about the beriactric bed intervention which was mentioned on the incident report. She said it was her recommendation but it wasn't put in place. She stated she thought a beriactric bed would put the resident further from the edge. She said the resident still wiggled in bed but not near like she used to. The LPN was asked if the resident used the bed rails. She stated the resident did not use the bed rails. She said she did not know why the resident had the bed rails. She stated she knew the family wanted the resident to have them. On 03/08/21 at 1:03 PM, the resident was observed in the front lobby area sitting in her Broda chair. The resident was unable to be interviewed due to her cognitive status. On 03/08/21 at 2:10 PM, the adm was asked what changed after the resident became entrapped in her bed rail. She stated the facility did frequent monitoring and has had no falls since the one in December. On 03/08/21 at 3:40 PM, the resident was observed on her bed. The bed rails were in the up position and floor mats on both sides of bed. The resident was positioned on her left side facing the door. The resident was observed for several minutes. The resident would move her legs and feet in consistent small movements and her left arm from her elbow was up in the air and moved. The resident would crunch her stomach and raise her upper trunk slightly off the pillow. The resident did not move closer to the edge of the bed during this time. A Bed Rails Evaluation, dated 03/08/21, documented the resident was NOT at risk for becoming entrapped if bed rails were used. The evaluation documented the resident could not independently get in and out of bed safely and had a history of [REDACTED]. The evaluation documented the resident had trouble falling or staying asleep and had severe cognitive impairment. The evaluation documented a recommendation for bed rails for positioning and safety. The evaluation documented in the comment section that the resident had poor cognition and was determined by IDT that the least restrictive devices could be used to promote her ability to assist during ADL care and minimize risk. The comment continued to document Hospice was notified of need for bed rails to be discontinued and mobility bars/U bars be placed. The resident's care plan, updated on 03/08/21 at 1:47 PM, documented the following: .Care Area/Problem Related To: History of Alzheimer's (12/03/20 Onset) .History of Dementia (12/03/20 Onset) .Dependent with mobility (12/03/20 Onset) .Fall (12/27/20 Onset) .Fall Risk Score of 7-8=High Risk (10/07/20 Onset) . Evidence By: .Transfer: Total dependence (12/27/20 Onset) .Mobility: Immobile (12/27/20 Onset) .Weight Bearing Status: Non-weight bearing (02/21/21 Onset) .Assistive Devises used: Geri Chair (12/27/20 Onset) . Goal Resident will be free from complications related to falling over the next 3 days (21/27/20 Onset) .Resident will verbalize understanding of the need for assistance over the next 90 days (10/07/20 Onset) .Resident at Risk for Falls resident safety will be maintained over the next 90 days (10/07/20 Onset) . Interventions: Anticipate residents needs check frequently (12/27/20 Onset) .Assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc. (12/27/20 Onset) .Bed enabler bar/bed cane (10/07/20 Onset) .Broda Chair (10/07/20 Onset) .Monitor for safety (03/02/21 Onset) .Scoop Mattress/bolsters (10/07/20 Onset) . A physician order, dated 03/09/21, documented, Assist Rails Dx: Difficulty in walking, not elsewhere classified, .03/09/21 09:22:29 AM.'' On 03/09/21 at 9:40 AM, the director of nursing (DON) and the MDS/care plan coordinator were asked what interventions had changed after the resident had been entrapped in the bed rail on 12/27/20. The DON stated more frequent checks, anticipating resident's needs, and continue with bolsters were the interventions. The DON was asked if the bed, mattress, and rails were the same as when the entrapment accident happened. She stated they were the same. On 03/09/21 at 10:08 AM, the resident was observed in the lobby area near the nurse station sitting in her Broda chair. The resident had rolled washcloths in her hands. On 03/09/21 at 10:13 AM, the resident's bed was observed with an air mattress and one U rail on the left side. The resident was not in bed. During the observation the maintenance supervisor entered the room and proceeded to add another U rail/grab bar on the right side. He stated he was told to take off the quarter rails and put the U rails on the bed. On 03/09/21 at 10:20 AM, CNA #6, who was working the resident's hall, was asked if the resident used her side rails on her bed. She stated, the resident did not use her side rails. She said the resident had to be transferred by a lift with the help of two staff. The CNA stated the resident's hands were contracted and they had to put wash cloths in her hands so the fingernails would not cut her palms. On 03/09/21 at 1:36 PM, the adm was informed of the facility not assessing the resident correctly concerning the bed rails. She stated the staff needed some instruction on how to fill out the assessments. She stated numerous people, hospice, therapy, and others knew of the bed rails and no one said there was a problem with them. A Bed Rails Evaluation, dated 03/09/21 at 2:56 PM, documented the resident was at risk for becoming entrapped if bed rails were used. The evaluation documented, If you have answered YES to any of the questions above, the IDT needs to review for alternatives to the bed rail, as they NOT an option for this resident. The evaluation documented bed rails are NOT indicated at this time. The evaluation documented in the comment section the order for rails was discontinued and plan of care was updated with removal of the assist rails.

On 03/09/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to accurately assess resident #1 for the risks of entrapment from bed rails. The bed rails were contraindicated according to the resident's 05/26/20 bed rail evaluation. The resident was entrapped by the bed rails and sustained a laceration to her right mandible on 12/27/20. The resident's bed was observed on 03/08/21 and verified by staff to have the same air mattress and bed rails as it did when the previous entrapment occurred. The resident had the likelihood of being seriously injured because of the continued use of the bed rails. On 03/09/21 at 12:32 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. At 1:35 PM, the administrator (adm) was notified of the IJ situation related to the facility's failure to accurately assess the resident for risks of entrapment prior to installing bed rails. At 3:30 PM, the adm submitted a plan of removal. At 4:57 PM, the plan of removal was not accepted and returned to the adm. On 03/09/21 at 5:57 PM, the adm submitted an acceptable plan of removal. The plan of removal documented the following: IMMEDIATE JEOPARDY PLAN of REMOVAL for ACCIDENT HAZARDS and BED RAILS 03-09-21 1. Resident #1's assist bars were removed, fall mats remain on both sides of the bed. Resident #1's side rail evaluation was updated, physician/family updated, physicians' orders and care plan and ADL (activities of daily living) Plan of Care updated. 2. Inservice all nursing staff on use of bedrail policy and procedures, to include types of rails, assessment of needs and documentation of rail types on care plan and ADL Plan of Care. This training will be completed by DON (director of nursing) or designee by 6pm on 3.9.21. Any staff not in attendance will be called and the policy and procedures reviewed with them by phone by the DON or designee by the end of today (3.9.21) at 6pm or prior to next shift. All in-services to be completed by 6pm on 3.9.21. 3. All residents will be assessed for side rails and type of rail, such as an assist or mobility bar by 6pm on 3.9.21 and the care plan and ADL plan of care will be updated accordingly. 4. Inservice Nursing Management team by RNC (regional nurse consultant) on need to assess for side rail/mobility bar, review least invasive option, notify Dr (doctor) and family, obtain consent, and update care plan before rails of any kind are in use by 6pm on 3.9.21. On 03/10/21 at 11:36 AM, the adm was informed the immediate jeopardy was removed, as of 03/09/21 at 4:20 PM, after all components of the plan of removal had been completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to accurately assess the resident and review the risks for entrapment prior to the installation of bed rails for one (#1) of three residents reviewed for bed rails. The bed rails were contraindicated according to the resident's 05/26/20 bed rail evaluation. The resident was entrapped by the bed rails and sustained an injury on 12/27/20. The resident's bed was observed on 03/08/21 and verified by staff to have the same air mattress and bed rails as it did when the previous entrapment occurred. The resident sustained [REDACTED]. The facility failed to review the risks and benefits of bed rails with the residents or residents' representatives, and obtain an informed consent for two (#1 and #2) of three residents reviewed for bed rails. The administrator identified 86 residents who had bed rails. Findings: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order, dated 10/03/19, documented, Assist Rails 1/4 RAILS FOR RESIDENT MOBILITY Dx (diagnosis): Aftercare following joint replacement surgery .D/C (discontinue) .03/09/21.'' A physician order, dated 10/03/19, documented, LOW BED FOR FALL PRECAUTION every shift Dx: Aftercare following joint replacement surgery . A physician order, dated 10/09/19, documented, Admit to Hospice Dx: [MEDICAL CONDITION] with behavior disturbance . An Incident/Accident Report, dated 10/21/19 at 8:40 AM, documented the resident was observed on the floor near her bed with no injuries noted. The report documented the resident was severely cognitively impaired and had impaired judgment. The report documented the resident required extensive assistance with transfers and had impaired standing balance. An Incident/Accident Report, dated 12/20/19 at 10:17 PM, documented the resident was observed on the floor in front of her wheelchair with no injuries noted. A Bed Rails Evaluation, dated 01/05/20, documented the resident was not at risk for becoming entrapped if bed rails are used. The evaluation documented the resident could not independently get in and out of bed safely and had a history of [REDACTED]. The assessment documented frequent monitoring, low bed, put to bed when fatigued, and soft mat on the floor for alternative interventions previously attempted prior to installing bed rails. The evaluation documented a recommendation for bed rails for positioning and safety. An Incident/Accident Report, dated 01/20/20 at 2:05 PM, documented the resident was observed on the floor mat on the right side of the bed with no injury noted. The report documented the resident's cognition was severely impaired and was unable to let someone know what happened or follow simple instructions. The report documented the resident had impaired standing balance and was total dependant with transfers. The report documented the care plan was updated to include monitoring more closely. A Bed Rails Evaluation, dated 05/26/20, documented the resident was 64 inches tall and weighed 143 pounds. The evaluation documented the resident WAS AT RISK for becoming entrapped if bed rails were used. The evaluation documented, If you have answered YES to any of the questions above, the IDT needs to review for alternatives to the bed rail, as they NOT an option for this resident. The evaluation documented the resident could not independently get in and out of bed safely and had a history of [REDACTED]. The evaluation documented the resident had trouble falling or staying asleep and had severe cognitive impairment. The evaluation documented a recommendation for bed rails for positioning and safety. An Incident/Accident Report, dated 05/26/20 at 8:00 PM, documented the resident was assisted to bed via mechanical lift 30 minutes prior to nurse going into the room to give medication. The report documented the resident was observed in a kneeling position to the left of her bed, with her upper body against the bed mattress. The report documented both of the resident's legs were wrapped in her sheets and no injury noted. The report documented the resident was severely cognitively impaired, had impaired judgement, inability to understand directions, and evidence of anxiety. The report documented the resident had impaired sitting balance, was non-weight bearing, and total dependent with transfers. The report documented to place the resident in open area for maximum observation opportunities, mat at bedside, and scoop mattress/bolsters as interventions. A quarterly assessment, dated 11/29/20, documented the resident was severely cognitively impaired; required total assistance of two people with bed mobility, transfers, dressing, and toilet use; total assist of one person with eating; and had impairment of both upper and lower extremities. The assessment documented the resident did not have a fall in the previous three months. An Incident/Accident report, dated 12/27/20 at 8:05 AM, documented, .Resident was found dangling by her head on the side rail .type of injury - Laceration .'' The report documented the resident required extensive assistance, was non-weight bearing, and was sent to the emergency room (ER). The report documented the resident needed a beriactric bed intervention. The report documented reviewed fall with IDT (interdisciplinary team) and will assist as needed to decrease falls. The report documented to continue current interventions. An emergency department report, dated 12/27/20 at 8:56 AM, documented the resident had a 2.5 centimeter (cm) laceration on the right jaw over the mandible and a 1.5 cm skin tear to the left hand. The laceration was repaired with sutures and the skin tear with skin adhesive glue. An OSDH 283 incident report, dated 12/27/20, documented the resident was found in her room status [REDACTED]. The report documented the resident needed assistance with ADLs but could move self in bed. The report documented the care plan instructions included anticipating needs and assisting with ADLs as appropriate. The report documented upon investigation it was noted the resident had wiggled out of bed causing an unwitnessed fall. The report documented she was found to be horizontal beside the bed with her neck between the rail and mattress, causing an open area. The report documented the resident was sent to the ER for evaluation and treatment and returned with sutures to her neck. The report documented the resident had bolsters in place on bed to prevent similar recurrence. A Bed Rails Evaluation, dated 02/24/21, documented the resident was NOT at risk for becoming entrapped if bed rails were used. The evaluation documented the resident could not independently get in and out of bed safely and DID NOT have a history of falls. The evaluation documented the resident DID NOT have problems with balance, poor trunk control, and a need for assistance for positioning and mobility. An annual assessment, dated 02/27/21, documented the resident was severely cognitively impaired; required total assistance of two people with bed mobility, transfers, dressing, and toilet use; total assist of one person with eating; and had impairment of both upper and lower extremities. The assessment documented the resident did not have a fall in the previous three months. On 03/08/21 at 12:25 PM, the resident was not in her room. The resident's bed was observed to have an air mattress with approximately three inch high foam bolsters along both sides of the bed. The bed had a rail on each side of the head of the bed, which were approximately 30 inches in length. The right side rail was tight against the bed. The left rail was approximately four inches away from the mattress and a pillow was observed between the mattress and the bed rail. On 03/08/21 at 12:48 PM, licensed practical nurse (LPN) #3 was interviewed regarding the resident's entrapment with the bed rail on 12/27/20. The LPN stated she was on duty when the resident got her head stuck in the rail. She stated a certified nurse aide (CNA) came and got her and they released the resident from the rail. She said the resident's head was caught in the bed rail with her head facing toward the head of the bed. She stated the resident had a cut on the right side of her jaw. The LPN was interviewed in the resident's room. The resident was not in the room at that time. The LPN was asked if the bed, mattress, and rails were the same as when the resident was entrapped. She said they were the same. She stated the bed is a hospice bed. She said the resident had the same bed and rails since she had been on hospice. She was asked why there was a pillow between the rail and mattress. She said she did not know. She said it was the resident's personal pillow which was used for positioning and shouldn't be between the rail and bed. The LPN was asked what interventions changed after the resident became entrapped. She stated the staff checked on her more often and the resident had been brought out of her room more often. She was asked about the beriactric bed intervention which was mentioned on the incident report. She said it was her recommendation but it wasn't put in place. She stated she thought a beriactric bed would put the resident further from the edge. She said the resident still wiggled in bed but not near like she used to. The LPN was asked if the resident used the bed rails. She stated the resident did not use the bed rails. She said she did not know why the resident had the bed rails. She stated she knew the family wanted the resident to have them. On 03/08/21 at 1:03 PM, the resident was observed in the front lobby area sitting in her Broda chair. The resident was unable to be interviewed due to her cognitive status. On 03/08/21 at 2:10 PM, the adm was asked what changed after the resident became entrapped in her bed rail. She stated the facility did frequent monitoring and the resident has had no falls since the one in December. On 03/08/21 at 3:40 PM, the resident was observed lying on her bed. The bed rails were in the up position and floor mats on both sides of bed. The resident was positioned on her left side facing the door. The resident was observed for several minutes. The resident would move her legs and feet in consistent small movements and her left arm from her elbow was up in the air and moved. The resident would crunch her stomach and raise her upper trunk slightly off the pillow. The resident did not move closer to the edge of the bed during this time. A Bed Rails Evaluation, dated 03/08/21, documented the resident was NOT at risk for becoming entrapped if bed rails were used. The evaluation documented the resident could not independently get in and out of bed safely and had a history of [REDACTED]. The evaluation documented the resident had trouble falling or staying asleep and had severe cognitive impairment. The evaluation documented a recommendation for bed rails for positioning and safety. The evaluation documented in the comment section that the resident had poor cognition and was determined by IDT that the least restrictive devices could be used to promote her ability to assist during ADL care and minimize risk. The comment documented Hospice was notified of need for bed rails to be discontinued and mobility bars/U bars be placed. The resident's care plan, updated on 03/08/21 at 1:47 PM, documented the following: .Care Area/Problem Related To: History of Alzheimer's (12/03/20 Onset) .History of Dementia (12/03/20 Onset) .Dependent with mobility (12/03/20 Onset) .Fall (12/27/20 Onset) .Fall Risk Score of 7-8 = High Risk (10/07/20 Onset) . Evidence By: .Transfer: Total dependence (12/27/20 Onset) .Mobility: Immobile (12/27/20 Onset) .Weight Bearing Status: Non-weight bearing (02/21/21 Onset) .Assistive Devises used: Geri Chair (12/27/20 Onset) . Goal: Resident will be free from complications related to falling over the next 3 days (21/27/20 Onset) .Resident will verbalize understanding of the need for assistance over the next 90 days (10/07/20 Onset) .Resident at Risk for Falls resident safety will be maintained over the next 90 days (10/07/20 Onset) . Interventions: Anticipate residents needs check frequently (12/27/20 Onset) .Assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc. (12/27/20 Onset) .Bed enabler bar/bed cane (10/07/20 Onset) .Broda Chair (10/07/20 Onset) .Monitor for safety (03/02/21 Onset) .Scoop Mattress/bolsters (10/07/20 Onset) . A physician order, dated 03/09/21, documented, Assist Rails Dx: Difficulty in walking, not elsewhere classified, .03/09/21 09:22:29 AM.'' On 03/09/21 at 9:40 AM, the director of nursing (DON) and the MDS/care plan coordinator were asked what interventions had changed after the resident had been entrapped in the bed rail on 12/27/20. The DON stated more frequent checks, anticipating resident's needs, and continue with bolsters were the interventions. The DON was asked if the bed, mattress, and rails were the same as when the entrapment accident happened. She stated they were the same. On 03/09/21 at 10:08 AM, the resident was observed in the lobby area near the nurse station sitting in her Broda chair. The resident had rolled washcloths in her hands. On 03/09/21 at 10:13 AM, the resident's bed was observed with an air mattress and one U rail on the left side. The resident was not in bed. During the observation the maintenance supervisor entered the room and proceeded to add another U rail/grab bar on the right side. He stated he was told to take off the quarter rails and put the U rails on the bed. On 03/09/21 at 10:20 AM, CNA #6, who was worked the resident's hall, was asked if the resident used her side rails on her bed. She stated, the resident did not use her side rails. She said the resident had to be transferred by a lift with the help of two staff. The CNA stated the resident's hands were contracted and they had to put wash cloths in her hands so the fingernails would not cut her palms. On 03/09/21 at 11:03 AM, the resident's representative stated the facility had not reviewed the risk and benefits of the bed rails. The representative stated a consent had not been presented or signed. The representative stated she/he was aware of the physician order [REDACTED].>On 03/09/21 at 1:36 PM, the adm was informed of the facility not assessing the resident correctly concerning the bed rails. She stated the staff needed some instruction on how to fill out the assessments. She stated numerous people, hospice, therapy, and others knew of the bed rails and no one said there was a problem with them. A Bed Rails Evaluation, dated 03/09/21 at 2:56 PM, documented the resident was at risk for becoming entrapped if bed rails were used. The evaluation documented bed rails are NOT indicated at this time. The evaluation documented in the comment section the order for rails was discontinued and plan of care was updated with removal of the assist rails. On 03/09/21 at 2:57 PM, the adm was asked if the resident's representative was informed of the risk and benefits of the bed rails and a signed consent obtained. The adm stated she did not know a consent was necessary until recently. 2. Resident #2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. On 03/08/21 at 4:00 p.m., the resident's bed was observed to have grab bars/quarter bed rails attached to the bed. The grab bars and quarter rails were one and the same, but only the grab bar or the quarter rail could be in the up position at one time. The quarter bed rails were not in use at this time. The grab bars were in the up position for use. The resident was seated in her wheelchair at that time. The resident was asked if she used the handrails to help her get up out of bed. The resident did not respond. On 03/09/21 at 1:10 p.m., certified nurse aid (CNA) #6 said the resident used the rails to get out of bed. The resident's records were reviewed. The records did not have a signed consent form for the use of bed rails. 3. Resident #3 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. On 03/08/21 at 10:08 a.m., the resident's bed was observed to have both quarter side rails up. On 03/09/21 at 3:04 p.m., licensed practical nurse (LPN) #2 was asked if the resident was able to use the side rails. She said the resident was alert and oriented a couple of days ago. She used the rails to roll over due to the tumors she had in her stomach. She said the resident was now unresponsive and did not use the quarter rails. The resident's records were reviewed. The records did not have a signed consent form for bed rails. On 03/09/21 at 2:57 p.m., the administrator was asked if the resident had signed consent forms. She said the facility was not aware they needed them until recently.

Based on record review and interview, it was determined the facility failed to thoroughly assess and monitor the urinary system for one (#1) of four sampled residents who were reviewed for the use of an indwelling catheter. Resident #1 had received an IV antibiotic from [DATE] through [DATE] for a UTI. An assessment of the resident's urine was not documented from [DATE] through [DATE]. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE] with the cause of death septic shock,[MEDICAL CONDITION], urinary tract infection and acidosis. The facility identified 10 residents who required an indwelling catheter. Findings: Resident #1 had [DIAGNOSES REDACTED]. A comprehensive assessment, dated [DATE], documented she was severely impaired in cognitive skills for daily decision making and required extensive assistance of two persons for all activities of daily living. A care plan, updated on [DATE], documented, .Problem .Urinary Catheter .Goal .will be free of complications of indwelling catheter over the next 90 days .Interventions .Maintain closed, sterile system, tubing free of kinks .Monitor urine appearance, amount, odor, clarity . A urinalysis report, dated [DATE], documented, .collected [DATE] 3:00PM .COLOR,URINE .YELLOW .APPEARANCE,URINE .TURBID . MUCUS,URINE .LARGE .Urine Culture has been reflexed to add to this urine specimen . A Nurses Note, dated [DATE] at 5:43 p.m., documented, ,[DATE] Soiled linen noted during rounds with wound care nurse, (name deleted). This nurse & (CNA's name deleted) assisted pt in changing linen. Foley was found to be under patient & kinked. Nurse straighten the catheter & urine started to flow patent. Urine is dark with a lot of sediment. Nurse obtained urine sample from foley bag & obtain order to get UA c/s. A Nurses Note, dated [DATE] at 6:05 p.m., documented, Nurse went to check to see if resident bed was dry .noted .bed was wet again .CNA assisted .to change linen and attempt to change foley. Foley had 250cc cloudy dark yellow/brownish urine .Removed catheter using aseptic technique. Catheter tip was full of yellow/white pus looking substance .Attempted to insert 16fr .catheter .attempt to get a flash of urine was unsuccessful. A Nurses Note, dated [DATE] at 6:37 p.m., documented, 2nd attempt to insert foley .While placing foley this nurse noted a lot of vaginal white discharge . A Nurses Note, dated [DATE] at 6:52 p.m., documented, Recheck to see if foley has produced urine yet. No urine noted .3rd attempt to insert foley by night nurse .Removed catheter .When nurse deflated balloon gross amount of urine came out with the foley cath . A urine culture report, dated [DATE], documented, URINE CULTURE Final Organism 1 PROVIDENCIA STUARTII >100,000 COLONIES/ML .Organism 2 MORGANELLA MORGANII >100,000 . A Nurses Note, dated [DATE] at 5:43 p.m., documented, N.O. [MEDICATION NAME] 3.375mg IV q 6 hrs x 7 days. for UTI . A Nurses Note, dated [DATE] at 11:05 p.m., documented, .initial dose of [MEDICATION NAME] started . An emergency department report, dated [DATE] at 5:30 a.m., documented, .presents .complaints of [MEDICAL CONDITION] .Currently she is 90% on room air and goes up in the mid 90s on oxygen .somewhat tachypneic and [MEDICAL CONDITION] on arrival with no febrile state .05:31 .Pulse 146 .Resp .25 .B/P XXX,[DATE] .Pulse Ox .99 Room Air .alert conscious oriented x 3 no acute distress .has a Foley catheter present .05:46 .[NAME] Blood Count 12.8 H .Attending Provider Note .Took over care for this patient at 6:00 a.m .presentation is concerning [MEDICAL CONDITION] with [MEDICAL CONDITIONS] pallor, and patient being awake and alert but feeling unwell .chronic indwelling Foley .prone to UTIs .Lab work is concerning [MEDICAL CONDITION] with markedly elevated lactic acid at 10 .noted to the ICU for ongoing care .have spoken with her son about her critical condition . A urinalysis report from the ED, dated [DATE] at 6:38 a. m., documented, .Urine Color .YELLOW .Urine Appearance .TURBID H .Urine Mucus .LARGE H .Urine Culture Reflexed . A Nurses Note, dated [DATE] at 7:19 a.m., documented, was called to res room by aide. Res was pale and resp at 26 b/p ,[DATE] pulse 94, Po2 83% placed res on O2, at 3L/NC no improvement. Attempted to contact Dr .no answer. Called 911 .when emsa was leaving with her, PO2 was 86% and hypoxic . There was no documentation in the clinical record related to an assessment of the resident's urine from the time of the first attempt to change the indwelling catheter on [DATE] until the resident was transported to the hospital on [DATE] (a period of 17 days during which the resident had received an IV antibiotic for a UTI from [DATE] through [DATE]). An ED RN patient note, dated [DATE] at 8:23 a.m., documented, IRRIGATED FOLEY AND REMOVED LARGE AMOUNT OF SEDIMENT AND MUDDY MATTER . A History and Physical report, dated [DATE], documented, .In the emergency room , the patient did not have a fever, but blood pressure was low. She was [MEDICAL CONDITION]. Foley catheter was not draining well. It was changed, and purulent creamy urine came out .Was admitted to ICU with [DIAGNOSES REDACTED]. A consultation report, dated [DATE] at 5:25 p.m., documented, .REASON FOR CONSULTATION: Septic shock .Urine was grossly infected .Rectal temp 102 .Septic shock: urine is essentially pus .Severe metabolic acidosis: cause is clear .Acute kidney injury: foley may have been blocked. CT with hydro[DIAGNOSES REDACTED]. Once replaced, patient had grossly purulent output . A discharge summary, dated [DATE], documented, .date of death : [DATE] .TIME OF DEATH: 2328 .CAUSE OF DEATH:[MEDICAL CONDITION], septic shock, UTI. Other causes extensive decubitus ulcer, [MEDICAL CONDITION], hydro[DIAGNOSES REDACTED], acidosis, bacteremia .patient was DNR . A certificate of death, dated [DATE], documented, .CAUSE OF DEATH .SEPTIC SH[NAME]K .SEPSIS .URINARY TRACT INFECTION .ACIDOSIS . A laboratory report, dated [DATE], documented, .BLOOD CULTURE .Final [DATE] .Organism 1 .PROVIDENCIA STUARTII .RECOVERED FROM BOTH BOTTLES .Organism 2 .PROVIDENCIA STUARTII#2 DRUG-RESISTANT [MEDICATION NAME] .RECOVERED FROM BOTH BOTTLES . On [DATE] at 3:25 p.m., the DON was asked what interventions the staff implemented to prevent complications related to the use of an indwelling catheter. He stated the nurse changed the catheter every month and as needed and performed catheter care every shift and the aide performed catheter care any time the resident was incontinent of bowel or had a bath. He was asked where they documented the assessment of a resident's urine. He stated they documented by exception and would only document if there was a problem. On [DATE] at 9:15 a.m., the DON was asked what he expected the nurses to assess related to the use of an indwelling catheter. He stated the urine output every shift, the color and clarity of the urine and if the urine had an odor, if the resident had lower abdominal pain or a fever. He was asked where they documented the assessment of the urine. He stated if the resident was skilled it was documented on the daily skilled assessment and if the resident was long term care they documented by exception in the nurses notes. At 12:58 p.m., the DON was asked if resident #1 had an indwelling catheter. He stated yes. He was asked what orders they had in place related to the use of the catheter. He stated they had orders to change the catheter every month and as needed and catheter care every shift. The DON was asked what was documented in the nurses notes on [DATE] related to the catheter. He stated they had difficulty placing the catheter, a large amount of urine was noted when they deflated the bulb and white vaginal discharge. He was asked what was documented related to the assessment of the urine. He stated the urine was dark with a lot of sediment and they had obtained a urine sample. He was asked what orders they had received on [DATE]. He stated she was started on an IV antibiotic for a UTI for seven days. He was asked if they had completed a urinalysis upon completion of the antibiotic to ensure the infection had been resolved. He stated it was not their protocol to do a follow-up U[NAME] He stated they would watch the resident for signs and symptoms of a UTI instead. The DON was asked why the resident was transferred to the hospital on [DATE]. He stated she was pale with a blood pressure of ,[DATE], pulse 94 and oxygen saturation 83%. He stated she was started on oxygen without improvement and she was hypoxic. The DON was asked when they had documented the last assessment of the resident's urine prior to the discharge on [DATE]. He stated on [DATE] at 5:43 p.m. He was asked if the nurse had documented an assessment of the resident's urine since [DATE] at 5:43 p.m. He stated no, the nurse had assessed the urine daily but they had not documented the assessment of the urine. The DON was asked what the assessment of the resident's urine consisted of after [DATE]. He stated they did not have an assessment of the urine documented in the nurses notes after [DATE]. He was asked if they had an assessment documented in any other location in the clinical record. He stated he did not see anything else. He stated, That's the bad thing when you chart by exception. The DON was asked if the resident's urine had been assessed in theER on [DATE] to be dark and purulent would the urine have been dark and purulent when she had been transferred from the facility on [DATE]. He stated yes. He was asked if the nurse had documented an assessment of the resident's urine on [DATE] before she was transferred to the hospital. He stated no. At 3:00 p.m., the DON provided documentation by the CNAs. He stated the aides had documented the resident's urine had not been abnormal from the baseline. He stated, Her urine always looked like garbage so it was not abnormal to them.

Based on observations, record review and interviews, it was determined the facility failed to ensure the necessary care was provided to prevent the development and worsening of pressure ulcers for one (#65) of four sampled residents who were reviewed for pressure ulcers. This resulted in the resident developing an unstageable pressure ulcer to the right calf and the progression of a blister into an unstageable necrotic pressure ulcer to the right heel. The facility identified six residents who resided in the facility with pressure ulcers. Findings: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. She was to be non-weight bearing on the right lower extremity. An admission data assessment, data 02/18/19, documented the residents skin was intact. A care plan, developed on 02/18/19, documented measures will be taken to prevent skin breakdown. The staff was to inspect the skin daily with care and bathing, and report any changes to the charge nurse. A skin data form, dated 02/19/19, documented the resident had a blister on her right heel and no wounds. A nurse's note, dated 02/19/19, documented a large blister to the right heel was observed while completing the admission skin assessment. The blister was noted to be intact with redness around the heel. A new order was received to apply skin prep to bilateral heels daily. Daily skilled notes, from 02/19/19 through 02/22/19, documented the resident had no blisters, no wounds and no open [MEDICAL CONDITION]. An admission assessment, dated 02/25/19, documented the resident's cognition was intact, she required extensive assistance with bed mobility, transfers and ambulation, and was at risk for pressure ulcers. The resident had one unstageable pressure ulcer with suspected deep tissue injury (SDTI) in evolution which was documented as present upon admission/entry. A skin data form, dated 02/25/19, documented the resident had no blisters and no wounds. A daily skilled note, dated 02/25/19, documented the resident had no blisters, no wounds and no open [MEDICAL CONDITION]. A wound evaluation and summary, dated 02/25/19, documented the resident was seen by the wound physician for treatment of [REDACTED]. The pressure ulcer measured 4.1 x 2.8 x not measurable centimeters (cm) with a surface area of 11.48. The care plan, updated on 02/26/19, documented the resident had a pressure ulcer to the right heel. Staff was to inspect the skin from head to toe weekly, inspect and chart skin integrity daily, and assess the skin under and around the edges of the splint/brace. The resident was to be positioned properly using pressure-reducing devices if indicated. Daily skilled notes, from 02/26/19 through 03/01/19, documented the resident had no blisters, no wounds and no open [MEDICAL CONDITION]. A progress note from the orthopedic physician, dated 02/27/19, documented the resident was seen in the office. X-rays were taken and displacement was observed to the right tibial fracture. The physician documented it was unknown if the resident had been walking on the leg since she had left the hospital. The resident was to continue to wear the brace, non-weight bearing on the right leg and follow-up in four weeks. A skin data form, dated 03/04/19, documented the resident had wounds and open [MEDICAL CONDITION] to the right foot and to the right leg. The form documented the resident was seen by the wound physician and new orders were received. The wound summary, dated 03/04/19, documented the resident was seen by the wound physician for treatment of [REDACTED]. The pressure ulcer of the heel measured 5.3 x 2.5 x not measurable centimeters (cm) with a surface area of 13.25 and required debridement (a surgical procedure to remove the thick adherent eschar and devitalized tissue). The physician ordered to float the heels in bed and recommended an EZ boot (helps eliminate pressure on the heel) to be worn in bed and the chair to off-load the wound. The pressure ulcer of the right, lateral calf had light sero-sanguinous exudate and measured 12.0 x 7.0 x not measurable cm with a surface area of 84.00. The EZ boot was not observed to be worn by the resident while in the bed or in the chair. A nurse's note, dated 03/06/19, documented the wound to the right, lateral calf appeared to be worsening due to the placement of the brace causing pressure. The wound care orders were changed and the brace was re-adjusted to the leg and applied properly. A nurse's note, dated 03/08/19 at 3:04 p.m., documented the wound to the right lower extremity appeared to be declining due to the brace and the resident had complaints of pain with movement of the leg. The orthopedic physician's follow-up appointment was moved to an earlier date. A nurse's note, dated 03/08/19 at 8:43 p.m., documented the nurse practitioner was in the facility and ordered antibiotics and wound care for the unstageable wound to the heels. A progress note from the orthopedic physician, dated 03/11/19, documented the resident was seen for a reevaluation. The physician noted the resident thought the brace rubbed and caused a wound on the back of her leg. She notified the physician the facility had been dressing the wound and placed her on antibiotics. Upon his examination, the physician documented the observation of a large pressure ulcer on the posterior aspect of the calf and a pressure ulcer developing on the heel. It was also documented the physician notified the facility of the pressure ulcers and the need to be treated immediately. A nurse's note, dated 03/11/19, documented a new order was received to discontinue use of the brace. A nurse's note, dated 03/12/19, documented the wound physician ordered a second antibiotic for the resident related to the DTI to the right calf area. Signs and symptoms of redness/[MEDICAL CONDITION] and pain had been observed during the dressing change. The care plan, updated on 03/19/19, documented the resident had a wound to the right calf. There was no documentation on the care plan to indicate new interventions were implemented. The wound summary, dated 03/25/19, documented the resident was seen by the wound physician for treatment of [REDACTED]. The pressure ulcer of the heel measured 4.5 x 2.6 x not measurable centimeters (cm) with a surface area of 11.70 and required a surgical debridement procedure. The physician ordered EZ boots to be worn in bed and the chair to off-load the wound. The pressure ulcer of the right, lateral calf had light serous exudate and measured 9.9 x 8.8 x not measurable cm with a surface area of 87.12. On 03/25/19 at 3:58 p.m., the resident was observed sitting her chair. An EZ boot was not observed to be worn by the resident. On 03/27/19 at 9:25 a.m., the wound care nurse, director of nursing (DON) and corporate nurse were asked about the pressure ulcers of the resident. The wound care nurse stated she first observed the blister on the right heel of the resident on 02/19/19 while completing the admission skin assessment. She stated it was only a blister so skin prep was to be applied daily and the heels were to be floated. She felt it was fine to wait until the following week for the resident to be seen by the wound physician. She was asked if she documented the measurements and description of the wound when it had been first identified. The wound care nurse stated she would describe it as a blister with no drainage. There were no measurements because she was not able to measure on her own. The corporate nurse stated yes she could, she does not know who would have instructed her she could not. They were asked when the pressure ulcer on the resident's calf was first identified. The wound care nurse stated the staff had her look at it on the 03/06/19 but the wound physician would have observed it on 03/04/19 with his weekly visit. She was asked why it was not observed before it developed to be an unstageable pressure ulcer if the nursing staff would have been completing skin data forms and daily skilled notes. No response was given. They were asked why x-rays were taken on 02/27/19. The DON stated the resident had complained of pain and the results showed nothing new. They were asked if it would have been observed due to the resident complaining of pain. The wound care nurse stated there would pain with a broken leg. The DON stated the order was not to remove the brace. They were asked what interventions were implemented to prevent the development and/or worsening of the pressure ulcers. No documentation was provided to indicate the facility implemented and provided care to prevent the development and/or worsening of the pressure ulcers to the resident. On 03/27/19 at 12:30 p.m., the resident was observed sitting her chair. An EZ boot was not observed to be worn by the resident. On 04/01/19 at 9:50 a.m., the resident was observed laying in bed. An EZ boot was not observed to be worn by the resident. The wound care nurse and assistant director of nursing (ADON) #2 were asked if the resident was ordered to wear a special boot due to her wounds. They both stated no, they were not aware of one.

Based on observation, interview and record review, it was determined the facility failed to ensure new interventions were implemented to prevent further falls for two (#8 and #9) of three sampled residents who were reviewed for fall supervision. Resident #9 was admitted to the facility 04/05/18 for skilled therapy related to a fractured femur. She sustained three falls between admission and 07/13/18 with the last fall resulting in a fracture to the right elbow and shoulder. The facility failed to determine the root cause of the falls and implement new interventions to prevent further falls. The facility identified 35 residents who resided in the facility that were a high risk for falls. Findings: 1. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. An Admission Data form, dated 04/05/18, documented the resident had a fall score of 11. A score of 7-18 indicated the resident was a high risk for falls. The data form documented the resident had adequate vision, used a wheelchair, was full weight bearing and required extensive asssistance with transfers. A care plan, dated 04/05/18, documented, Problem .cognitive status .mildly/moderately impaired .Goal resident is at risk for falls resident safety will be maintained .Fall risk .interventions assess contributing factors related to fall history An admission assessment, dated 04/12/18, documented the residents cognition was severely impaired and had a fall with a fracture prior to her admission to the facility. The resident's Baseline Care Plan and Discharge Planning form, dated 04/17/18, documented the resident was a high risk for falls and needed asssistance with activities of daily living such as transfers. An incident report, dated 05/24/18, documented the resident had a fall in her room attempting to transfer herself to bed unassisted. The interventions documented to use a low bed and call light in reach. It also documented the resident was educated on using her call light to ask for assistance. A nurse's note, dated 05/24/18 at 1:20 p.m., documented, @ (at) 1205 (12:05 p.m.), this nurse was walking down the hall when noticed resident on the floor in her room Resident said 'I was trying to get in bed and I fell on the floor .no injury .assisted off the floor to her w/c (wheelchair) X (times) 2 persons assist. Ecourager (sic) resident to use call light to .call for help and to wait until assisted, and not transfer herself. Educate staff to assist resident to bed after breakfast and to offer bathroom privilege . A care plan, updated 05/24/18, documented the resident had a fall. The Goal documented, Resident will be free from complications related to falling Interventions educated resident to use call light for staff assistance . The fall risk assessments, dated 06/05/18, documented the resident a was a high risk for falls with a score of 11. A score of 7-18 indicated the resident was a high risk for falls. A care plan, updated 06/05/18, documented, Problem .problem with balance .transfer with extensive assistance .falls risk score of 7-18 = (equals) high risk .goal .resident will verbalize understanding of the need for assistance .interventions .assess medications for contributing factors .assist resident with ADLs as needed .assist with toileting as needed .keep call light and most frequently used personal items within reach .wheelchair . A nurse's note, dated 06/14/18 at 9:38 a.m., documented, Residents room mate came and reported to this nurse that resident has fallen on the floor .This nurse asked resident what happened, resident stated 'I was trying to get in my chair by myself, lost my balance and slid to the floor. I tried to get up myself but I can't . A care plan, updated 06/14/18, documented, Problem .Resident had a fall in room by attempting to transfer self. No injuries .interventions . complete physical exam for injuries .monitor X 72 hours for possible delayed injury related to fall .notify physician and family/responsible person of fall .shoes well fitting with non-slip-soles . The fall risk assessments, dated 06/15/18, documented the resident a was a high risk for falls with a score of 10. A score of 7-18 indicated the resident was a high risk for falls. An updated problem and intervention on the care plan, dated 06/15/18, documented, Transfer .limited asssistance .vision wears glasses .Keep glasses clean and fit with adequate prescribtion (sic) . An incident report dated 07/13/18 at 4:30 p.m., documented the resident had a fall in her room attempting to self transfer self to her wheelchair from her bed. The resident had sustained injuries of bruising, abrasion and had pain while moving. Immediate action taken was a physical exam, doctor notified and an x-ray. Additional interventions listed on the incident report were documented as call light in reach, bed in the lowest position and reinforced the resident needed to use the call light to call for asssistance. A final radiology report, dated 07/13/18 at 5:55 p.m., documented, .Exam XR (xray) right elbow .findings .bones/joints .nondisplaced [MEDICAL CONDITION] ulna, just distal to the sublime tubercle .soft tissue issues .minimal soft tissue swelling .impression . nondisplaced [MEDICAL CONDITION] ulna, just distal to the sublime tubercle . A nurse's note, dated 07/13/18 at 4:59 p.m., documented, Resident was attempting to get up from bed to transfer self to wheelchair and slipped to the floor hitting right elbow on the floor, complains on movement, small abrasion to elbow .orders rec'd (received) for x-ray to right elbow . A nurse's note at 9:49 p.m., documented, Received xray results for resident's Rt (right) elbow stating impression nondisplace fx (fracture) of the proximal ulna, just distal to the sublime tubercle .received new orders for elbow splint, shoulder sling and ortho (orthopedic) consult . The fall risk assessments, dated 07/13/18, documented the resident a was a high risk for falls with a score of 9. A score of 7-18 indicated the resident was a high risk for falls. A nurse's note, dated 07/23/18 at 5:09 p.m., documented, pt c/o (complained of) R (right) shoulder pain since fall on 07/13/18, son wants her to go to ER (emergency room ) for xray, told him we could have an xray here and he wanted that instead, order for xray to R shoulder, notified at 2145 (9:45 p.m.) that pt (patient) has fracture . A final radiology report, dated 07/23/18 at 9:59 p.m., documented, .Exam XR right shoulder complete, 2 or more views .bones/joints .there is an impacted right humeral head and neck fracture .impression . impacted right humeral head and neck fracture . A care plan, updated 07/13/18, documented, Problem .Resident had a fall in room attempting to transfer self, C/O (complains of) right elbow pain. X-ray shows fracture .interventions .educated to use call light for assistance . There was no documentation the facility had assessed the root cause of the falls and implemented new interventions to aide in the prevention of further falls. The same interventions were in place leading up to and following each fall. The fall risk assessments, dated 07/26/18, documented the resident a was a high risk for falls with a score of 10. A score of 7-18 indicated the resident was a high risk for falls. On 08/02/18 at 12:05 p.m., the resident was observed in her room being transferred to her wheelchair by a therapist. The resident had a low bed, a sling and brace was in place on her right arm. The therapist and resident stated she had a fracture and needed to wear the sling and brace. On 08/08/18 at 9:43 a.m., registered nurse (RN) #1 was asked if resident #9 was at risk for falls on admission. She looked through the electronic health record and stated, Yes. She was admitted with a [DIAGNOSES REDACTED]. She was asked what interventions were in place to aide in the prevention of falls at the time of admission. She stated the only intervention she knew of when she was transferred from the skilled hall was a low bed. She again looked through the health record and stated that was the the only intervention in place when first admitted . She then stated the resident had a decline after the fall with a fractured elbow and was not trying to transfer herself anymore. At 10:40 a.m., RN #1 was asked to describe the decline the resident had experienced after her fall on 07/13/18. She stated, The resident became weaker and unsure of herself. She is afraid of falling again after the fall. She was asked what the resident's cognition level was. She stated the resident was oriented to name and place but not time. She then added the resident had short term memory problems and could not remember things very long after it had been told to her. She was asked if the facility had increased supervision as result of the resident's fall risk. She stated, Not that I can see. It was not a documented intervention and she was checked on like all of the other residents. She was asked if there were any additional interventions that had been implemented. She stated she would look and see if there were any interventions other then educate on call light, low bed and non-skid shoes. At 11:00 a.m., RN #2, a nurse on the hall the resident resided on during her skilled therapy, was asked if the resident was a risk for falls on admission. She stated, Not until she started progressing with therapy. She then stated the resident had a fracture on admission and was needing close supervision because of the fracture. She was asked what interventions were in place for fall prevention. She stated the resident had a low bed and received therapy. She then stated the resident could use her call light to call for help. She was asked what the residents cognition was. She stated the resident was confused and she became more mobile once working with therapy. She then stated the resident could not remember long after she was told something. On 08/08/18 at 11:12 a.m., licensed practical nurse (LPN) #1,the unit manager for the skilled hall, was asked if the resident was at risk for falls when she was admitted for therapy. She stated, Yes. I think everyone is at risk for falls. She then stated the resident's risk for falls increased once she had been working with therapy. She was asked if there were any assessments to indicate the level of risk for the resident and falls on admission. She stated, She was a high risk for falls on admission. She then added her admission fall risk score was an eleven which indicated a high risk. She was asked what interventions were implemented on admission for her falls risk. She stated, Quarter rails, low bed and therapy. She was asked to describe the resident's cognition. She stated the resident had short term memory and not long term memory. She was asked if the interventions of completing a physical exam, monitoring for 72 hours, notifying family and physician were interventions for falls. She stated they were what they did after a fall, not interventions to prevent falls. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. An incident/accident report, dated 05/15/18, documented, .2300 (11:00 p.m.)-Cna (sic/certified nurse aide) reported the resident was on the floor. When asked what happened? The resident replied, I was trying to get in bed and sat on the floor. Resident has full ROM (range of motion) of all extremities and A&O (alert and oriented) x3 (person, place, time). When asked if she hit her head? The resident replied No. This nurse and 2 CNA's assisted resident in to bed. No c/o (complaint of) pain or discomfort at this time . The comments documented, .Resident educated to use call light for assist . An incident/accident report, dated 06/18/18, documented, .CNA reported to charge nurse that resident was on the floor. charge nurse went to room and observed resident sitting on the floor with back to wheelchair by the bed. when asked what happened resident stated I was trying to get into bed and slipped on my bottom. Resident appears to have no apparent injury or bruising to bottom area. Resident has no c/o pain. Resident denies hitting her head on anything. Resident advised to use call light when in need of assistance Call light and bedside table within reach . The comments documented, .Resident to have non-slip well fitting shoes on with transfers . A quarterly assessment, dated 06/29/18, documented the resident's cognition was moderately impaired. She required extensive assistance with mobility, transfers, toileting and activities of daily living. An incident/accident report, dated 07/26/18, documented, .Resident sitting on floor in room. Bed in lowest position. Resident stated she was trying to get out of bed unassisted when she slid from the side of her bed to the floor and landed on her bottom. No c/o pain at this time. No apparent injury noted at this time. Did not hit head. Resident assisted off floor to w/c (wheelchair) by three staff members. Resident was then assisted to the bathroom by the CNA to get ready for the day. Resident is currently up in w/c and headed to dining room for breakfast . An addendum note documented, Resident assisted off the floor by myself and two other CNAs. Resided assisted to w/c and then assisted to bathroom to get ready for the day by the CNA. Resident is currently up in chair headed to dining room for breakfast. (Name deleted physician) in facility doing rounds, notified of incident . A care plan, dated 07/31/18, documented the resident was a fall risk related to cognition deficit, impaired function status and incontinence. It continued to document the resident had a fall on 05/15/18 in attempt to transfer herself, and a fall on 07/26/18 which the resident slid from her bed. The care plan interventions included to assess contributing factors related to fall history, assist and educate resident with activities of daily living as needed, and the use of her call light when needing assistance. It continued to document to ensure staff members were aware of the resident's high risk for fall, fall precautions, call light and frequent used items in reach and to have a low bed for fall precautions. On 08/01/18, a physical therapy discharge summary documented the resident was maximum assistance with bed mobility and transfers, and moderate assistance performing a sit to stand position. It continued to document for basic mobility, the resident was substantial/maximal assistance from lying to sitting, sitting to lying, rolling left and right, chair or bed to chair transfer and toilet transfers. A therapy referral note documented, .Recommendations-Initiate/review Restorative Program .End of Therapy Referral to Nursing-Lower extremity ROM (range of motion): Maintain/Improve residents ability to move hip, knee, ankle and daily participation in ADLs (activities of daily living),-Transferring: Maintain/Improve residents ability to safely transfer to and from bed, chair and toilet with daily participation in ADLs (activities of daily living) . On 08/08/18 at 11:50 a.m., resident #8 was asked what she would do when she needed assistance while she was in her room. She stated she would push her light (call light button). She was asked what happened on her recent fall. She stated she forgot to lock the wheels on her wheelchair, and when she tried to get into her chair, it rolled away from her and she landed on her bottom on the floor. She was asked if her call light was in reach. She stated yes because she pushed the button. She was asked if she had to call her family member to get help. She stated yes because no one would come answer her light. On 08/09/18 at 9:30 a.m., resident #8 was asked if she needed assistance to get up from bed or her wheelchair. She stated she does, but the staff would tell her she needed to try to get up on her own. At 11:20 a.m., certified medication aide (CMA) #3 was asked if she remembered resident #8's fall which occurred on 07/26/18. She stated she was unaware the resident fell . She was asked if she was aware if any of the direct care staff had told the resident to get up on her own. She stated yes. She continued to state the resident was suppose to try to do things on her own including getting up. She was asked if the resident was to have a lift used for transfers. She stated no. The CMA continued to state physical therapy discontinued the lift because she was becoming too dependent on the lift and was not trying to attempt self care. She stated the resident could stand, but she didn't want to do it. She continued to state the resident was a stand by assist and could get up on her own. CMA #3 was asked who decided if a resident was to do transfers and self care on their own, and not to use a lift on a resident. She stated she did not know, but she thought it would be the therapy department. At 11:30 a.m., an occupational therapist was asked if she was familiar with resident #8. She stated she was. She was asked if direct care staff were told the resident needed to get up on her own and not use a lift for transfers. She stated no, not when the resident was in long term care and had the deterioration resident #8 had ([MEDICAL CONDITION]). She continued to state the resident was evaluated by physical and occupational therapy because she had been having falls. She reviewed the clinical record and stated the resident was seen by physical and therapy from 06/22/18 through 07/31/18. She was asked if the therapy department discourages direct care staff to not use resident lifts for transfers. She stated no. She continued to state the lifts needed to be used for resident safety.

Based on record review and interview, it was determined the facility failed to ensure: ~ medications were acquired to administer to residents for one (#1) of two sampled residents who received vitamin K. This resulted in the resident being sent to the emergency room for the administration of vitamin K and a blood transfusion, ~ medications were administered as ordered by the physician for one (#3) of three sampled residents who received [MEDICATION NAME], and ~ maintain emergency medications in the emergency medication kit. The facility identified six residents who received [MEDICATION NAME] therapy. The facility identified 77 residents who currently resided in the facility. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. The orders documented if the INR was less than two or greater than three, the physician was to be notified. A care plan, dated 03/08/18, documented interventions for anticoagulant therapy included to administer the medication as ordered. An admission assessment, dated 03/12/18, documented the resident's cognition was moderately impaired and he received anticoagulant therapy five days during the seven day look back period. On 03/26/18 at 7:12 a.m., a [MEDICATION NAME] time (PT) with an international normalized ratio (INR) was obtained. The lab report documented the PT was 97.2 seconds (The reference range for a PT was 9.7 - 13.5 seconds). The INR was documented at 7.96 (The reference range for an INR was 0.85 - 1.12). The lab report further documented, .Critical results called to (RN #1) at .1137 (11:37 a.m.) .on .03/26/18 . by .(lab staff name deleted) .Result rechecked, readback was correct . At 6:47 p.m., a physician's orders [REDACTED]. A nurse's note, dated 03/26/18 at 10:30 p.m., documented, .This nurse attempted give vit (vitamin) K as ordered order said to notify pharm (pharmacy) if (no) in house. @ this time (no) vit K inject (injection) delivered called pharm and spoke (with name deleted pharmacist) and he stated they do not stock vit k inject, but the EKit (emergency kit) had oral vit K .checked EKit a (after) calling Dr. (doctor) and (no) vit K in EKit. Called pharm multiple X's through different number. (no) reply. This nurse faxed over order and wrote vit K, po (by mouth) out of stock in the EKit send STAT. Before faxing this nurse rec'd (received) order for po vit K to be given instead of IM (intramuscular) inject this nurse reported to oncoming shift about situation and to look for medication . A nurse's note, dated 03/27/18 at 7:20 a.m., documented, .pharmacy called facility that they don't have the injectable of Vit K but will send the tablet . A nurse's note at 11:30 a.m. documented, .Vit K 100Mcg (micrograms) of was send by pharmacy which was the wrong dose. Pharmacy called to confirm that they send the wrong dose of the medication and they were going to send the correct dose . A nurse's note at 12:00 p.m., documented, .ADON (assistant director of nursing) notified (name deleted physician) new order for STAT CBC (complete blood count) . At 12:40 p.m., the resident's lab was obtained. The lab results documented the hemoglobin was 5.3 grams per deciliter (the referance range is 13.5 - 17.5 G/DL). The hematocrit was 18.0 percent (with the reference range of 41.0 - 53.0 %). The lab results documented, .Critical result called to (LVN #2) .at 1347 (1:47 p.m.) .on .03/27/18 .Result rechecked, readback was correct . The PT was 152.7 seconds and the INR was 12.40. The lab results documented, .Critical result called to (LVN #2) . at . 1420 (2:20 p.m.) . on . 03/27/18 . Result rechecked, readback was correct . A nurse's note on 03/27/18 at 1:30 p.m., documented, .received CBC lab result, dr. notify, new order to send resident to ER (emergency room ) for further eval (evaluation). Call ER to lab to report CBC and PT/INR lab results . An emergency room history and physical, dated 03/27/18, documented the resident arrived at 2:32 p.m. and was admitted with a [DIAGNOSES REDACTED]. The note documented laboratory tests were completed with a hemaglobin of 5.1, PT was 142.8, INR was 11.61 and hematocrit was 17.7. It further documented the resident received a bolus of 80 mg of [MEDICATION NAME], 10 mg of vitamin K and two units of packed red blood cells and one unit fresh frozen plasma. On 04/24/18 at 9:10 a.m., the assistant director of nursing (ADON) was asked when the physician ordered the vitamin K. She stated he gave the order for the vitamin K at the time he was making his rounds on 03/26/18 about 4:00 p.m. She was asked what time the order was sent to the pharmacy. She stated she thought the time was around 6:30 p.m. She was asked what the order was for the vitamin K. She stated, Vitamin K 10 mg IM due today. She continued to state, I put it in to be given at 10 o'clock (10:00 p.m.) so it would be given on the 26th (03/26/18). The ADON was asked when the vitamin K was administered. She stated on the next day, but it was the wrong dose. She was asked to review the Medication Administration Record [REDACTED]. At 12:15 p.m., the ADON was asked why the resident had an order for [REDACTED]. She stated yes, she called him and he ordered the stat CBC. She was asked for documentation to indicate the vitamin K 10 mg had been delivered. The facility did not provide any documentation to indicate the medication was delivered. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A significant change assessment, dated 01/15/18, documented the resident's cognition was intact. A care plan, dated 03/13/18, the resident was receiving anticoagulant therapy. An intervention documented to administer the medication as ordered. The physicians orders documented for (MONTH) 2, (YEAR), documented the resident was to receive [MEDICATION NAME] (an anticoagulant medication) 2 milligrams (mg) every other day and [MEDICATION NAME] 1.5 mg every other day. A laboratory result for a PT/ INR ([MEDICATION NAME] time/internal normalized ratio - a measure to test how quickly blood clots), dated 04/02/18, documented a PT with a result of 18.6 (range 9.7 - 13.5). The report documented the INR was at 1.58 (range for a [DIAGNOSES REDACTED]. A handwritten note at the bottom of the page documented the facility received a new order to administer [MEDICATION NAME] 4 mg every day. A facility '[MEDICATION NAME] Log' for long term care documented on 04/02/18, a new order for [MEDICATION NAME] 4 mg every day was received. This order was not documented on the following line for the resident to indicate the change in the medication dosage. The Medication Administration Record [REDACTED]. On 04/24/18 at 3:30 p.m., licensed vocational nurse (LVN) #1 was asked about the new order received. She stated she guessed she never put it in the computer. She was asked if she should have put the order in the computer at the time she received it. She stated yes. She was asked according to the MAR, did the resident receive the increase in [MEDICATION NAME] as ordered. She stated no, I can't remember everything. 3. On 04/25/18 at 1:20 p.m., the director of nurses (DON) was asked who was responsible for the emergency medication kits prior to 03/27/18. She stated, That was a little gray. We would send the requisition (that a medication had been removed) to the pharmacy and they were to fill it. She stated the pharmacy would not always refill the kit. The DON was asked how often the emergency medication kits were switched out prior to 03/27/18. She stated, They were supposed to be switched out by the pharmacy weekly. She was asked if the kits were switched out weekly. She stated, No. The DON was asked if the kits not being switched out led to the Vitamin K not being in the kit when it was needed. She stated, Yes.

Based on record review and interview, it was determined the facility failed to ensure the physician was notified: ~ of critical lab values in a timely manner for one (#1) of three sampled residents who received [MEDICATION NAME] therapy, ~ one (#3) of three sampled residents was not administered their physician ordered [MEDICATION NAME] therapy; and ~ one (#1) of two sampled residents was not administered their physician ordered vitamin K. This resulted in resident #1 being sent to the hospital to receive the medication and a blood transfusion. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The admission physicians orders, dated 03/05/18, documented the resident was to receive [MEDICATION NAME] ([MEDICATION NAME] - a blood thinner) 7.5 milligrams (mg) on Tuesday and Thursday, and [MEDICATION NAME] 5 mg on Monday, Wednesday, Friday, Saturday and Sunday evening. The order documented if the INR (international normalized ratio) was less than two or greater than three, the physician was to be notified. An admission assessment, dated 03/12/18, documented the resident's cognition was moderately impaired and he received anticoagulant therapy five days during the seven day look back period. On 03/26/18 at 7:12 a.m., a [MEDICATION NAME] time (PT) with an INR was obtained. The lab report documented the PT was 97.2 seconds (The reference range for a PT was 9.7-13.5 seconds). The INR was documented at 7.96 (The reference range for an INR was 0.85-1.12). The lab report documented, .Critical results called to (RN #1) at .1137 (11:37 a.m.) .on .03/26/18 . by .(lab staff name deleted) .Result rechecked, readback was correct . At 6:47 p.m., a physician's orders [REDACTED]. A nurse's progress note, dated 03/26/18 at 8:10 p.m., documented, .(name-deleted physician) HERE TO REVIEW MEDICATIONS AND LABS. NEW ORDERS .GIVE DOSE OF VITAMIN K 10MG X (times) 1 DUE TO INR LEVEL .RESIDENT NOTIFIED OF NEW ORDERS . There were no documentation to indicate the physician was notified of the critical lab values prior to 6:47 p.m. A nurse's note, dated 03/26/18 at 10:30 p.m., documented, .This nurse attempted give vit (vitamin) K as ordered order said to notify pharm (pharmacy) if (no) in house. @ this time (no) vit K inject (injection) delivered called pharm and spoke (with name deleted pharmacist) and he stated they do not stock vit k inject, but the EKit (emergency kit) had oral vit K .checked EKit a (after) calling Dr. (doctor) and (no) vit K in EKit. Called pharm multiple X's through different number. (no) reply. This nurse faxed over order and wrote vit K, po (by mouth) out of stock in the EKit send STAT. Before faxing this nurse rec'd (received) order for po vit K to be given instead of IM (intramuscular) inject this nurse reported to oncoming shift about situation and to look for medication . A nurse's note, dated 03/27/18 at 7:20 a.m., documented, .pharmacy called facility that they don't have the injectable of Vit K but will send the tablet . A nurse's note at 11:30 a.m. documented, .Vit K 100Mcg (micrograms) of was send by pharmacy which was the wrong dose. Pharmacy called to confirm that they send the wrong dose of the medication and they were going to send the correct dose . A nurse's note at 12:00 p.m. documented, .ADON (assistant director of nursing) notified (name deleted physician), new order for STAT CBC (complete blood count) . At 12:40 p.m., the resident's lab was obtained. The lab results documented the hemoglobin was 5.3 grams per deciliter (G/DL) (the reference range of 13.5-17.5 G/DL). The hematocrit was 18.0 percent (%), with the reference range of 41.0-53.0 %. The lab results documented, .Critical result called to (LVN #2) .at 1347 .on .03/27/18 .Result rechecked, readback was correct . The PT was 152.7 seconds and the INR was 12.40. The lab results documented, .Critical result called to (LVN #2) . at . 1420 . on . 03/27/18 . Result rechecked, readback was correct . A nurse's note, dated 03/27/18 at 1:30 p.m., documented, .received CBC lab result, dr. notified, new order to send resident to ER (emergency room ) for further eval (evaluation). Call ER to lab to report CBC and PT/INR lab results . An emergency room history and physical, dated 03/27/18, documented the resident arrived at 2:32 p.m. and was admitted with a [DIAGNOSES REDACTED]. The note documented laboratory tests were completed with a hemaglobin of 5.1, PT was 142.8, INR was 11.61 and hematocrit was 17.7. It further documented the resident received a bolus of 80 mg of [MEDICATION NAME], 10 mg of vitamin K and two units of packed red blood cells and one unit fresh frozen plasma. On 04/24/18 at 9:10 a.m., the ADON was asked when the physician ordered the vitamin K. She stated he gave the order for the vitamin K at the time he was making his rounds on 03/26/18 about 4:00 p.m. She was asked what time the order was sent to the pharmacy. She stated she thought the time was around 6:30 p.m. She was asked what the order was for the vitamin K. She stated, Vitamin K 10 mg IM due today. She continued to state, I put it in to be given at 10 o'clock (10:00 p.m.) so it would be given on the 26th (03/26/18). The ADON was asked when the vitamin K was administered. She stated on the next day. She continued to state at 10:00 p.m. on 03/26/18, the evening nurse called the pharmacy to see why the medication had not been delivered to the facility. She stated, They (the pharmacy) would have to wait to get the po (by mouth; vitamin K). It wasn't a STAT order. She was asked when the vitamin K arrived at the facility. She stated on 03/27/18 at 11:00 a.m. She continued to state, I was not told the vitamin K was not sent until the morning of the 27th (03/27/18). She was asked if the evening nurse should have contacted the pharmacy prior to 10:00 p.m. to question when the vitamin K was going to be delivered. She stated, No because we have to give the pharmacy four to five hours before calling them; even on STAT orders. The ADON was asked if the physician was notified the medication was not delivered. She stated no, there was no documentation the physician was notified. She was asked when should the physician should have been notified that the medication was not given. She stated on 03/26/18 when it was realized the vitamin K was not delivered at 10:00 p.m. The ADON was asked to review the Medication Administration Record [REDACTED]. After reviewing the MAR, she stated the medication was not administered. She was asked if there was any documentation to indicate the physician had been notified the resident was not administered the vitamin K as ordered. She stated no. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A significant change assessment, dated 01/15/18, documented the resident's cognition was intact. A care plan, dated 03/13/18, documented the resident was receiving anticoagulant therapy. An intervention documented to administer the medication as ordered. The physicians orders, dated (MONTH) 2, (YEAR), documented the resident was to receive [MEDICATION NAME] (an anticoagulant medication) 2 mg every other day and [MEDICATION NAME] 1.5 mg every other day. A laboratory result for a PT/ INR ([MEDICATION NAME] time/internal normalized ratio - a measure to test how quickly blood clots), dated 04/02/18, documented a PT with a result of 18.6 (range 9.7 - 13.5). The report documented the INR was at 1.58 (range for a [DIAGNOSES REDACTED]. A handwritten note at the bottom of the page documented the facility received a new order to administer [MEDICATION NAME] 4 mg every day. A facility '[MEDICATION NAME] Log' for long term care, documented on 04/02/18, a new order for [MEDICATION NAME] 4 mg every day was received. This order was not documented on the following line for the resident to indicate the change in the medication dosage and the resident continued to be administered 2 mg every other day and 1.5 mg every other day. A nurse's note, dated 04/03/18 at 3:36 p.m., documented the physician was notified of the laboratory results and an order was received to change the [MEDICATION NAME] to 4 mg every day. The Medication Administration Record [REDACTED]. A laboratory result for a PT/INR, dated 04/09/18, documented a PT level of 22.8 and an INR level of 1.92. A hand written note at the bottom of the page documented the resident was receiving [MEDICATION NAME] 4 mg every other day. The 4 was written over with a 3.5. The MAR indicated [REDACTED]. A laboratory result for a PT/INR, dated 04/16/18, documented the result of the PT was 21.0, and the INR result was 1.85. A hand written note at the bottom of the page documented the resident was receiving [MEDICATION NAME] 3.5 mg every other day. A nurse's note, dated 04/17/18 at 12:24 p.m., documented the laboratory result was called to the physician and no new orders were received for a change in the [MEDICATION NAME] dose. On 04/24/18 at 3:30 p.m., licensed vocational nurse (LVN) #1 was asked about the new order received to increase the [MEDICATION NAME] to 4 mg a day. She stated she guessed she never put it in the computer. She was asked if she should have put the order in the computer at the time she received it. She stated yes. She was asked according to the MAR, did the resident receive the increase in [MEDICATION NAME] as ordered. She stated no, I can't remember everything. The LVN was asked if the physician had been notified the medication had not been administered as ordered. She stated no. The LVN was asked about the written documentation in which the numbers were crossed out. She stated she thought it was 4.5 mg and she wrote a 4 over the 3, or a 3 over the 4 she did not remember what she did. She was asked what dosage of [MEDICATION NAME] the resident was supposed to be receiving. She stated she did not know. She was informed of the incorrect dosage which was presented to the physician. She stated she messed up, she did not know. The corporate nurse instructed the LVN to notify the physician now of the medication that was not administered as ordered, and he was given mis information regarding the dosage of [MEDICATION NAME] the resident was actually receiving.

***Supplemental*** Based on record review and interviews, it was determined the facility failed to ensure they implemented corrective actions to correct quality deficiencies. The administrator identified 77 residents who currently resided in the facility. Findings: 1. The facility failed to have corrective actions in place to correct outstanding deficiencies related to assessment, monitoring and intervention. Refer to the statement of deficiencies at F-684. 2. The facility failed to have corrective actions in place to correct outstanding deficiencies related to medication being provided as ordered. Refer to the statement of deficiencies at F-755.

***Supplemental*** Based on record review and interviews, it was determined the facility failed to ensure they implemented corrective actions to correct quality deficiencies. The administrator identified 77 residents who currently resided in the facility. Findings: 1. The facility failed to have corrective actions in place to correct outstanding deficiencies related to assessment, monitoring and intervention. Refer to the statement of deficiencies at F-684. 2. The facility failed to have corrective actions in place to correct outstanding deficiencies related to medication being provided as ordered. Refer to the statement of deficiencies at F-755.

Based on record review and interview, it was determined the facility failed to ensure medications were administered per physician's orders for one (#2) of three sampled residents who were reviewed for medication administration. The facility identified 92 residents resided in the facility. Findings: The facility policy for 'Administering Medications', dated 04/2007, documented the medications must be administered in accordance with the orders, including any required time frame. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 03/15/18, documented a care area or problem as the resident was to receive an antibiotic related to [MEDICATION NAME] (an antibiotic) for ten days for pneumonia. Interventions included to administer the medication as ordered. The admission physician orders documented to administer [MEDICATION NAME] every 12 hours for nine days. The clinical record documented the resident arrived at the facility at 5:00 p.m. A tracking form, provided by the pharmacy, documented the medication was delivered to the facility on [DATE] at 9:50 p.m. The 03/2018 Medication Administration Record [REDACTED] On 03/20/18 at 3:10 p.m., licensed practical nurse #1 was asked when the medication was delivered. She stated the pharmacy only sent one dose on the 15th. She was asked if there was a count sheet to document the medication. She stated she could not find a count sheet. She was asked if the dose was administered. She stated according to the MAR, the first dose was administered the next morning. At 3:35 p.m., the assistant director of nursing stated there was a new nurse on the floor and she was not informed the medication was delivered, so she did not administer it. She was asked if the first dose of antibiotic should have been administered that evening. She stated absolutely, if it comes in at 10:00 p.m. you give it then and change the times accordingly.