Every finding on record at Midwest City Post Acute & Rehab

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 2 (#5 and #6) of 3 sampled residents reviewed for timely administration of medications. The DON identified 99 residents received medications in the facility. Findings:An Administering Medications policy, revised 04/2019, read in part, Medications are administered in accordance with prescriber orders, including any required time fame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 1. A significant change assessment for Resident #5, dated 04/28/26, showed the resident had a brief interview for mental status score of 15 indicating their cognition was in intact. A June 2026 MAR for Resident #5 showed they were to be given 0.25 mg of alprazolam (an antianxiety medication) by mouth two times a day for anxiety. An Administration Note, dated 06/21/26 at 5:24 p.m., showed alprazolam was not given because the staff was waiting on pharmacy.An Administration Note, dated 06/22/26 at 7:00 a.m., showed alprazolam was not given because the staff was waiting on delivery.An Administration Note, dated 06/22/26 at 3:11 p.m., showed alprazolam was not given because the staff was waiting on pharmacy.An Administration Note, dated 06/23/26 at 9:22 a.m., showed alprazolam was not given because meds ordered.On 06/25/26 at 3:10 p.m., Resident #5 stated last week they did not get their anxiety medication for several days because the facility ran out.On 06/25/26 at 3:52 p.m., the DON stated medications should be ordered early enough to be available in the facility before the resident ran out of medication. The DON was unable to articulate why the medication was not available in the facility to be given as ordered.2. An Order Summary for Resident #6, dated 06/2026, showed the resident was to receive:a. memantine (a central nervous system agent used to treat Alzheimers) 5 mg 1 tab via peg tube two times a day,b. simvastatin (to lower bad cholesterol) 10 mg 2 tablets by mouth at bedtime,c. dorzolamide hydrochloride-timolol opthalmic solution (reduce pressure in the eye) 1 drop in each eye,d. levothyroxine (to treat underactive thyroid) 100 micrograms 1 tab via peg tube one time a day, e. clopidogrel bisufate (antiplatelet- to prevent blood clots) 75 mg 1 tab via peg tube one time a day, f. furosemide (diuretic) 20 mg 1 tab by mouth one time a day, g. pantoprazole (decreases acid production in the stomach) 40 mg give 1 packet via peg-tube one time a day, and h. vitamin D3 (helps absorb calcium and supports immune system) 5000 units 1 tab by mouth one time a day.A June 2026 MAR for Resident #6 showed blank spots for the following dates:a. 06/19/26- memantine 7:00 p.m. dose; simvastatin evening dose; dorzolamide evening dose; pantaprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose, b. 06/20/26 - pantoprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose, c. 06/21/26 - memantine 7:00 a.m. and 7:00 p.m. dose; simvastatin evening dose; dorzolamide 7:00 a.m. and evening dose; levothyroxine 7:00 am dose, clopidogrel 7:00 a.m. dose, furosemide 7:00 a.m. dose, pantaprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose, d. 06/22/26 - pantaprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose, e. 06/23/26 - memantine 7:00 p.m. dose; simvastatin evening dose; dorzolamide evening dose; pantaprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose, f. 06/24/26 - pantaprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose, and g. 06/25/26 - pantaprazole 7:00 a.m. dose; vitamin D3 7:00 a.m. dose. On 06/25/26 at 12:12 p.m., the DON stated they has asked RN #1 why there were so many blank spaces on Resident 6's medication administration record. The DON stated RN #1 stated they had administered the medication, but just did not have time to chart they were administered. On 06/25/26 at 2:40 p.m., LPN #2 found the box of pantaprazole packets in the medication cart after calling the pharmacy to find out the pantaprazole packets were delivered on 06/18/26. LPN #2 counted the packets and found all 30 were still accounted for. On 06/25/26 at 4:00 p.m., the DON acknowledged the pantaprazole was probably not given if none of the packets were missing from the box.

Based on observation, record review, and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (#1) of 3 sampled residents reviewed for respect and dignity.The administrator identified 72 residents resided in the facility.Findings:On 08/12/25 at 4:22 p.m., Resident #1 was observed sitting on hall 2 in a wheelchair with a t-shirt and a brief. An undated facility policy Resident Rights, read in part, The facility will treat each resident with respect and dignity and care for each resident in a manner and environment that promotes her quality of life, recognizing each resident's individuality.An undated diagnosis sheet, showed Resident #1 had a diagnosis of anoxic brain damage, required assistance with personal care, epilepsy, generalized anxiety disorder and depression.A care plan, dated 06/03/25, read in part, Assist Resident #1 with dressing.[Resident #1] has impaired cognitive function/dementia or impaired thought processes, impaired decision making, neurological symptoms.On 08/12/25 at 4:23 p.m., CMA #1 stated it was not okay for Resident #1 to sit on the hallways without being covered by a towel or blanket.On 08/12/25 at 4:33 p.m., the DON stated staff should have covered Resident #1 with a blanket or towel.

Based on observation, record review, and interview, the facility failed to ensure a medication cart was locked when unsupervised for 1 of 3 medication carts used for dispensing medications.The DON of identified 72 residents resided in the facility.Findings:On 08/12/25 at 2:53 p.m., the medication cart on hall 300 was observed to be unlocked and unattended blocking the doorway in front of room [ROOM NUMBER].On 08/12/25 at 2:54 p.m., upon entering room [ROOM NUMBER], LPN #1 was observed standing behind the closed curtain.An undated facility policy titled Medication Storage and Handling, read in part, 3. The Medication Cart will always be locked unless it is in direct view of the Unit Nurse. No medications should be left unattended: In resident's rooms, on medication carts, At the Nurse's stations.On 08/12/25 at 2:55 p.m., LPN #1 stated they could not see the medication cart because they were standing behind the curtain, blocking their view of the medication cart.On 08/12/25 at 2:56 p.m., LPN #1 stated the medication cart should be locked when someone has stepped away from the medication cart.On 08/12/25 at 4:34 p.m. the DON stated medication carts should be locked and supervised at all times.

Based on observation, record review and interview, the facility failed to fully investigate: a. an allegation of abuse for one (#9); and b. an injury of unknown origin for one (#11) of four sampled residents reviewed for reportable incidents. The administrator identified 53 residents resided in the facility. Findings: An Abuse Prevention Program, policy, dated 10/22/22, read in part, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator .The Administrator is the Abuse Coordinator .IF YOU SUSPECT ABUSE .Notify a Supervisor/Nurse Immediately .Notify the Administrator and Director of Nursing .The Administrator or designee utilizing the state specific Incident Reporting System will immediately notify the Department of Health by the Incident Reporting System .Investigation .All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .All personnel must promptly report any incident or suspected incident of abuse, mistreatment or neglect, including injuries of unknown origin. (An injury should be classified as an Injury of unknown origin when the source of the injury was not observed or known by any person, and the initial Risk Management investigation could not determine the cause of the injury). 1. Resident #9 had diagnoses which included cognitive communication deficit and generalized anxiety. An Admission Assessment, dated 11/06/24, documented Resident #9 was cognitively intact, but was dependent on staff for bathing, lower body dressing, and toileting hygiene. It documented Resident #9 required moderate assistance with bed mobility, transfers, and upper body dressing. It documented walking did not occur. On 01/27/25 at 12:58 p.m., Resident #9 stated one of the weekend CMAs threw pills at them and used curse words. Resident #9 stated they reported the incident to the weekend charge nurse. On 01/28/25 at 11:55 a.m., the administrator stated Resident #9 was confused. The administrator then stated they had a representative from the state come out in January to investigate an allegation of someone slamming Resident #9 against the bed. The administrator stated once the representative completed their investigation they told the administrator to hold off on the state reportable. On 01/28/25 at 12:04 p.m., the DON stated they had not been made aware of any allegations that were about this past weekend. They stated they had been gone the past three weeks and had only returned last week. The DON stated anything during that time would have went through the administrator. On 01/28/25 at 12:12 p.m., the ADON stated they were on call this weekend and were not called for any abuse allegations over the weekend. The ADON stated they knew Resident #9 had reported a situation about two weeks ago because Adult Protective Services came to the facility to investigate. On 01/28/25 at 12:19 p.m., CMA #2 stated they were the CMA for hall 200 this past Sunday. CMA #2 stated they were unaware of Resident #9 making allegations against staff this past weekend. On 01/28/25 at 4:20 p.m., the administrator provided their written statement, dated 01/15/25, which read in part, At about 1:13 p.m., a representative from the state [name withheld] came by the facility. [They] mentioned that a case was called in for [Resident #9] that someone pushed [them] against the bed. The representative then asked is there a staff [CNA #3] that works here? I said yes. [They] proceeded to speak with the resident. I called staff [CNA #3] to write me a statement and I was ready to suspend [them] pending investigations. [APS representative] told me to wait as [they] would like to finish [their] investigations first. [They] met with the resident and staff. [Their] conclusion for exit was with me, the DON and the staff. [They] told us not to report anything and that if [they] needed any additional information, [they] would let us know. I clarified if it was reportable. [They] said no and left the facility. Myself and the ADON went to meet with the resident and [Resident #9] could not recall any incident and [they] felt safe in the facility. The document was signed by the administrator. The administrator provided a written statement, dated 01/15/25, that was signed by CNA #3. It read in part, On the 15th a state [representative] came and asked me a few questions. I did not really know what [they] were talking about. [They] said that [Resident #9] was confused and did not remember anything and that everything is good after [they] did the investigation. On 01/28/25 at 4:25 p.m., Resident #9's POA stated the only allegation they were aware of was that a CNA had thrown their hands up and stated they were not going to do that again referring to cleaning up Resident #9's diarrhea. The POA stated they had talked to the DON about that allegation. The POA stated Resident #9 had a hard time processing and had confusion. The POA stated in the past when Resident #9 had a UTI, the POA would get calls from Resident #9 that someone was trying to break into the hospital. The POA stated they were at the facility about every two days and had not heard any new allegations. There was no incident report for the allegation that was investigated by Adult Protective Services on 01/15/25. There was no mention of any of the allegations in any of the progress notes. The only documentation of that incident was the written statement by the administrator and CNA #3 2. Resident #11 had diagnoses which included stage three chronic kidney disease and dementia. An Annual Resident Assessment, dated 11/29/24, documented Resident #11 had severe cognitive impairment and required substantial/maximal assistance for toilet hygiene, upper body dressing, lower body dressing, personal hygiene, rolling to left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. It documented the task of walk ten feet did not occur. A Nurse's Note, dated 12/27/24, documented Resident #11 was noted with purple discoloration under the left breast/ribs and left upper and forearm. It documented the ADON, administrator, and NP were notified. It documented orders were obtained for a stat x-ray: left rib series with posterior and anterior chest three view, left humerus two view, left forearm two view for a diagnosis of pain and discoloration. It documented the family was notified of the discoloration and new order. There was no origin of the bruising identified in the nurse note. The note was signed by LPN #1. An Incident Report, dated 12/27/24, documented Resident #11 was noted with purple discoloration under their left breast/ribs and left upper and forearm. It documented the resident was unable to give a description. It documented the ADON, administrator, and NP were notified and new orders were received for stat x-ray: left rib series with posterior and anterior chest three view, left humerus two view, left forearm two view for a diagnosis of pain and discoloration. It documented the family was notified of the new order and discoloration. It documented injuries observed at time of incident: bruise left forearm, bruise left upper arm, bruise other describe (nothing was described in this section). The notes section documented discoloration to left upper and lower arm, left breast, and left side. It documented no injuries were observed post incident. It read in part, No statements found. There was no origin of the bruising identified in the incident report. A Nurse's Note, dated 12/30/24, documented continue focused charting related to left upper extremity, side, and breast. It documented no worsening discoloration noted. It documented no new injuries noted. It documented the resident did show signs and symptoms of pain and PRN pain medication was administered in the morning and was effective. It documented continue to use a full body lift with transfer, mobile by wheelchair pushed by staff. It documented Resident #11 would at times self propel with their feet. It documented staff were to anticipate needs and assist with all transfers and adls. There was no documentation the injury of unknown origin was reported to the SA. A Physician Order, late entry date 01/03/25, read in part, PT Clarification Order to eval only for suspicious bruising and d/c from PT services upon completion of eval. On 01/28/25 at 10:29 a.m., a phone call was placed to family member #1. The family member did not answer the call and did not return the call. On 01/29/25 from 10:29 a.m. through 10:36 a.m., LPN #1 and ACMA #1 were observed providing incontinent care to Resident #11 and transferred the resident to a wheelchair using a full body mechanical lift. There were no bruises observed on the resident's skin. On 01/29/25 at 10:43 a.m., ACMA #1 stated Resident #11 used to use the sit to stand lift, but did not anymore. ACMA #1 stated staff had to turn the resident in bed and was a total assist for transfers, dressing, toileting, and bathing. On 01/29/25 at 10:47 a.m., ACMA #1 stated they just recently started using the total body lift on Resident #11. On 01/29/25 at 10:49 a.m., ACMA #1 stated they were not aware of any incidents involving Resident #11 in the last two months. On 01/29/25 at 10:51 a.m., CNA #3 stated Resident #11 was a total body lift for transfers. They stated staff had to do everything for the resident. On 01/29/25 at 10:54 a.m., CNA #3 stated they had been using the full body lift on Resident #11 for about a month. CNA #3 stated Resident #11 had experienced bruising. They stated they did not know who first observed the bruising, but the facility started to use a full body lift. On 01/29/25 at 11:31 a.m., LPN #1 reviewed the nurse's note for Resident #11, dated 12/27/24, and stated the CNAs had come to LPN #1 and reported some discoloration. LPN #1 stated they went and looked at Resident #11's skin and their left side, upper arm down to the lower arm, ribs and under breast were involved. LPN #1 stated they notified the ADON, administrator, and NP who gave orders for the x-rays. LPN #1 stated they also notified the family. LPN #1 stated the x-rays did not show injuries, but the facility changed from using the sit to stand lift to the full body lift. LPN #1 stated anytime they identified new bruising on a resident they would view the skin themselves, notify the provider, and notify the abuse coordinator who was the administrator so they could investigate. On 01/29/25 at 11:35 a.m., LPN #1 stated therapy had evaluated the resident after the bruising and they thought that was where the full body lift came from. On 01/29/25 at 11:39 a.m., LPN #1 was asked if the facility had identified the origin of the bruising. LPN #1 stated, Let me go ask the people who did the investigation. On 01/29/25 at 11:42 a.m., LPN #1 returned and stated the administrator was who completed the investigation. LPN #1 did not provide the origin of the bruising. On 01/29/25 at 12:49 p.m., the administrator was asked for all information related to the incident on 12/27/24 involving Resident #11. On 01/29/25 at 1:07 p.m., CNA #3 stated if they observed abuse or neglect, or it was reported to them, they would notify the nurse. On 01/29/25 at 1:14 p.m., LPN #1 stated if they observed abuse or neglect they would notify the abuse coordinator, the physician, and the resident's responsible party. On 01/29/25 at 1:15 p.m., LPN #1 stated the types of abuse they observed for were physical, mental, emotional, isolation, seclusion, and sexual abuse. On 01/29/25 at 2:01 p.m., the administrator was asked again if they had any additional information related to the incident involving Resident #11. The administrator stated it was in their office. The surveyor followed the administrator to their office. The administrator stated they had completed interviews with staff and was still waiting for them to be scanned in. The administrator stated, I didn't do a Reportable though. The administrator stated, I just did staff interviews. On 01/29/25 at 2:03 p.m., the administrator was asked to identify what they considered to be abuse or neglect. The administrator stated, Whether it's factual or not, if you have a reportable, or if you have an incident you are unsure of, you report it. The administrator stated, Whether it's physical, verbal, emotional, misappropriation of funds, if there is any injury like an unknown injury, we report that. The administrator stated what qualified as unknown was, If after your investigation that you have that it happened, while you are investigating, if you still can't find the reason that it happened, of course we report it. On 01/29/25 at 2:05 p.m., the administrator stated when an incident was reported to them, they started an investigation. They stated they would write out statements from everybody. They stated if it was on the hall, they would get statements from whomever was involved. The administrator stated they report it if it was something unusual. The administrator stated, If it's something that needs to go to the State, I report it to the State if we cannot find out what happened, and then report it. On 01/29/25 at 2:07 p.m., the administrator stated abuse was to be reported within two hours, and an injury of unknown origin had to be reported. On 01/29/25 at 2:08 p.m., the administrator stated they were notified Resident #11 had a bruise, so they went down and looked at the resident. The administrator stated the bruising was to the left arm, ribs, left side, and breast area. The administrator stated the CNA was giving the resident a bed bath and that was when it was reported to the administrator. The administrator stated they spoke with the nurse who reported the CNA had reported it to them, the doctor was called, and an x-ray was ordered. On 01/29/25 at 2:10 p.m., the Administrator stated they asked CNA #5 about the bruising and the CNA stated the bruising was not there the day before. The administrator stated they pulled the shower sheets and the bruising definitely was not there. The administrator stated the only thing they could think of that caused the bruising was the sit to stand lift. The administrator stated they completed an inservice the same day for the sit to stand lift. The administrator stated they changed Resident #11 from a sit to stand lift to a full body lift. The administrator stated they had instructed the ADON to have therapy evaluate the resident for transfer skills. On 01/29/25 at 2:14 p.m., the therapy program manager arrived and stated they had evaluated the resident for suspicious bruising. On 01/29/25 at 2:15 p.m., the administrator was asked where all the interviews were at. They stated the medical records staff resigned and they needed to look through a stack of papers. On 01/29/25 at 2:17 p.m., the therapy program manager stated Resident #11 had very decreased cognition and increased muscle resistance. They stated it was heavily recommended for the resident to be a full body lift for safety. The therapy program manager stated from what they understood about the suspicious bruising, was that it was related to bed mobility. On 01/29/25 at 2:19 p.m., the therapy program manager stated they were never told about a concern with the sit to stand, and therapy did not evaluate Resident #11 for a sit to stand. On 01/29/25 at 2:20 p.m., the administrator stated an injury was unknown if they could not find the reason. The administrator stated they knew it was the equipment because staff stated they had informed the nurse several days about pain with transfers. On 01/29/25 at 2:22 p.m., the administrator was asked if that information was documented anywhere. They stated, I don't see anything on here for that. On 01/29/25 at 2:23 p.m., the administrator was asked what the Initial Risk Management was. They stated, It will be everything that I write. On 01/29/25 at 2:25 p.m., the administrator was asked where the information was located. They stated they were looking through a stack of papers. On 01/29/25 at 2:26 p.m., the administrator was asked if the facility determined the origin of the bruising. The administrator stated, From the sit to stand. They were asked how they determined that. The administrator stated, Because the CNA told me. They stated based on the two CNA statements on the hall. On 01/29/25 at 2:28 p.m., the administrator had the ADON join the interview. The ADON stated the facility completed an inservice about safety and utilizing two people for a full mechanical lift as well as the proper use of a sit to stand lift. The ADON stated x-rays were obtained and they spoke with therapy to complete an eval. The ADON stated Resident #11 was changed to a full body lift that day, but nothing else form us. On 01/29/25 at 2:31 p.m., the administrator asked the ADON about the shower sheets to verify there was no bruising on Resident #11 the day before. The ADON did not respond. On 01/29/25 at 2:34 p.m., the administrator was asked where the interviews for the investigation were located. The administrator walked to another office then returned to their office. On 01/29/25 at 2:44 p.m., the DON provided a sign in sheet for a full body transfer lift and sit to stand transfer inservice dated 12/27/24. There was no additional information related to this inservice provided to the survey team prior to exit. After filtering through a stack of papers on the desk, the administrator stated they had found the interviews and provided the following forms: a. a Resident Interview form for Resident #11. It read in part, Use as part of an Abuse investigation. There was no date on the form and the interviewer section was blank; b. a Confidential Witness Statement, dated 12/27/24, signed by CNA #5 and the administrator, read in part, I was about to give a bed bath, I notified a bruise to [their] left breast, ribs, upper arm forearm. I went to go get the nurse. I took care of her the day before and the bruise was not there. However [they] did complain it hurts during transfer with the sit-to-stand.; c. a Confidential Witness Statement, dated 12/27/24, signed by LPN #1 and the administrator, read in part, I was notified by the CNA that there was a bruise to [left] arm and rib cage. I went to do an assessment. I called the NP, family and [unknown] order for X-ray. This bruise was not there the day prior.; and d. a Confidential Witness Statement, dated 12/27/24, signed by CNA #2 and the administrator, read in part, I observed that the sit to stand equipment hurts [Resident #11] arms when we tried to transfer. I notified the nurse. I was unaware of the bruise. The administrator stated they had interviewed Resident #11 the day of the incident. The administrator was asked to explain use as part of an abuse investigation on the interview form. The administrator stated they had ruled out abuse because after the interview, they determined it was the equipment that caused it. On 01/29/25 at 2:48 p.m., the administrator was asked where they documented they had identified the cause of the bruise in their investigation. The administrator stated, From what staff told me. The administrator stated they reviewed the record and the resident had no incident and no fall. The administrator was shown the incident report dated 12/27/25 for Resident #11 and was asked if they had anything that documented the findings of their investigation. The administrator was unable to locate this documentation at the time. On 01/29/25 at 2:58 p.m., LPN #2 stated they were made aware the administrator had the staff fill out the forms related to the bruising on Resident #11 today. LPN #2 stated they did not want staff getting in trouble for the administrator completing interviews after the fact when the investigation should have been done. On 01/30/25 at 8:21 a.m., LPN #1 was asked to explain the confidential witness statement, dated 12/27/24, signed by them. On 01/30/25 at 8:23 a.m., LPN #1 stated the had went over what happened with the administrator yesterday. LPN #1 stated, I did not want to sign the form. They stated, It was yesterday. LPN #1 stated, I feel I should not have been put in that position. LPN #1 stated, I was told to sign it by The administrator. LPN #1 stated no one had asked LPN #1 about any statements prior to yesterday. LPN #1 stated everything was in their nurse's notes. LPN #1 stated they made sure the x-ray order was in for the bruising. They stated they told the ADON and administrator and contacted the doctor. LPN #1 stated there was an inservice the following week regarding the lifts. On 01/30/25 at 8:28 a.m., CNA #2 stated the administrator had filled out the confidential witness statement and had me sign it. They stated it was completed yesterday. CNA #2 stated, It bothered me all day yesterday. They stated, I couldn't sleep. CNA #2 stated, [They] made it like we would be in some sort of trouble if we didn't sign it. CNA #2 stated it was filled out yesterday by the administrator who instructed CNA #2 to put the 12/27/24 date. CNA #2 stated they questioned the administrator about the date and the administrator informed them State would come and talk to them and instructed CNA #2 to tell them the date on the form. CNA #2 stated when the incident occurred, they told them about it. On 01/30/25 at 8:32 a.m., CNA #2 stated the day the incident occurred 12/27/24 with Resdient #11, they went to help CNA #5. CNA #2 stated the resident was laying in bed and when they removed Resident #11's clothes we noticed bruising all over [them]. CNA #2 stated the nurse was notified at the time. CNA #2 sated they did not know where the bruising came from. On 01/30/25 at 8:47 a.m., CNA #5 stated the administrator had written out the entire witness statement. CNA #5 stated they did not know anything about the statement until the administrator called them into the office yesterday. CNA #5 stated they had reported the bruising to the nurse the day it occurred. They stated yesterday the administrator told them I'm going to write this statement, I'm going to need you to sign it. CNA #5 stated the administrator stated if anyone asked, they were to say it was already documented. CNA #5 stated they did not feel good about it because it was forging something and they didn't want to get in trouble. CNA #5 stated the administrator instructed, You sign it but, I'm going to write it. CNA #5 stated, I didn't want to sign it because it wasn't in my handwriting and this wasn't my report. CNA #5 stated it was weeks ago and they should have already had it together. On 01/30/25 at 8:50 a.m., CNA #5 stated on 12/27/24 they walked into Resident #11's room to give them a bed bath with CNA #2. CNA #5 stated the resident was still in bed. CNA #5 stated as they removed the resident's clothes, they observed a bruise to their back and breast area. CNA #5 stated they were to get the nurse who examined the resident. CNA #5 stated they did not know where the bruising came from. They stated they received an inservice on lifts on a Tuesday because they always received inservices on paydays (12/27/24 was a Friday). They stated they could not remember the exact date of the inservice. 49701

Based on observation, record review, and interview, the facility failed to report to the SA: a. an allegation of abuse for one (#9); and b. an injury of unknown origin for one (#11) of four sampled residents reviewed for reportable incidents. The administrator identified 53 residents resided in the facility. Findings: An Abuse Prevention Program policy, dated 10/22/22, read in parts, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator .The Administrator is the Abuse Coordinator .IF YOU SUSPECT ABUSE .Notify a Supervisor/Nurse Immediately .Notify the Administrator and Director of Nursing .The Administrator or designee utilizing the state specific Incident Reporting System will immediately notify the Department of Health by the Incident Reporting System .Investigation .All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .All personnel must promptly report any incident or suspected incident of abuse, mistreatment or neglect, including injuries of unknown origin. (An injury should be classified as an Injury of unknown origin when the source of the injury was not observed or known by any person, and the initial Risk Management investigation could not determine the cause of the injury). 1. Resident #9 had diagnoses which included cognitive communication deficit and generalized anxiety. An Admission Assessment, dated 11/06/24, documented Resident #9 was cognitively intact, but was dependent on staff for bathing, lower body dressing, and toileting hygiene. It documented Resident #9 required moderate assistance with bed mobility, transfers, and upper body dressing. It documented walking did not occur. On 01/28/25 at 11:55 a.m., the administrator stated Resident #9 was confused. The administrator then stated they had a representative from the state come out in January to investigate an allegation of someone slamming Resident #9 against the bed. The administrator stated once the representative completed their investigation, they told the administrator to hold off on the state reportable. On 01/28/25 at 12:12 p.m., the ADON stated they knew Resident #9 had reported a situation about two weeks ago because Adult Protective Services came to the facility to investigate. On 01/28/25 at 4:20 p.m., the administrator provided their written statement, dated 01/15/25, which read in part, At about 1:13 p.m., a representative from the state [name withheld] came by the facility. [They] mentioned that a case was called in for [Resident #9] that someone pushed [them] against the bed. The representative then asked is there a staff [CNA #3] that works here? I said yes. [They] proceeded to speak with the resident. I called staff [CNA #3] to write me a statement and I was ready to suspend [them] pending investigations. [ APS representative] told me to wait as [they] would like to finish [their] investigations first. [They] met with the resident and staff. [Their] conclusion for exit was with me, the DON and the staff. [They] told us not to report anything and that if [they] needed any additional information, [they] would let us know. I clarified if it was reportable. [They] said no and left the facility. Myself and the ADON went to meet with the resident and [Resident #9] could not recall any incident and [they] felt safe in the facility. The document was signed by the administrator. The administrator provided a written statement, dated 1/15/25, which was signed by CNA #3. It read in part, On the 15th a state [representative] came and asked me a few questions. I did not really know what [they] were talking about. [They] said that [Resident #9] was confused and did not remember anything and that everything is good after [they] did the investigation. On 01/28/25 at 4:25 p.m., Resident #9's POA stated the only allegation they were aware of was that a CNA had thrown their hands up and stated they were not going to do that again referring to cleaning up Resident #9's diarrhea. The POA stated they had talked to the DON about that allegation. The POA stated Resident #9 had a hard time processing and had confusion. The POA stated in the past when Resident #9 had a UTI, the POA would get calls from Resident #9 that someone was trying to break into the hospital. The POA stated they were at the facility about every two days and had not heard any new allegations. There was no incident report for the allegation that was investigated by Adult Protective Services on 01/15/25. There was no mention of any of the allegations in any of the progress notes. The only documentation of that incident was the written statement by the administrator and CNA #3. 2. Resident #11 had diagnoses which included stage three chronic kidney disease and dementia. An Annual Resident Assessment, dated 11/29/24, documented Resident #11 had severe cognitive impairment and required substantial/maximal assistance for toilet hygiene, upper body dressing, lower body dressing, personal hygiene, rolling to left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. It documented the task of walk ten feet did not occur. A Nurse's Note, dated 12/27/24, documented Resident #11 was noted with purple discoloration under the left breast/ribs and left upper and forearm. It documented the ADON, administrator, and NP were notified. It documented orders were obtained for a stat x-ray: left rib series with posterior and anterior chest three view, left humerus two view, left forearm two view for a diagnosis of pain and discoloration. It documented the family was notified of the discoloration and new order. There was no origin of the bruising identified in the nurse note. The note was signed by LPN #1. An Incident Report, dated 12/27/24, documented Resident #11 was noted with purple discoloration under their left breast/ribs and left upper and forearm. It documented the resident was unable to give a description. It documented the ADON, Administrator, and NP were notified and new orders were received for stat x-ray: left rib series with posterior and anterior chest three view, left humerus two view, left forearm two view for a diagnosis of pain and discoloration. It documented the family was notified of the new order and discoloration. It documented injuries observed at time of incident: bruise left forearm, bruise left upper arm, bruise other describe (nothing was described in this section). The notes section documented discoloration to left upper and lower arm, left breast, and left side. It documented no injuries were observed post incident. It read in part, No statements found. There was no origin of the bruising identified in the incident report. A Nurse's Note, dated 12/30/24, documented continue focused charting related to left upper extremity, side, and breast. It documented no worsening discoloration noted. It documented no new injuries noted. It documented the resident did show signs and symptoms of pain and prn pain medication was administered in the morning and was effective. It documented continue to use a full body lift with transfer, mobile by wheelchair pushed by staff. It documented Resident #11 would at times self propel with their feet. It documented staff were to anticipate needs and assist with all transfers and ADLs. There was no documentation the injury of unknown origin was reported to the SA. On 01/28/25 at 10:29 a.m., an phone call was placed to family member #1. The family member did not answer the call and did not return the call. On 01/29/25 from 10:29 a.m. through 10:36 a.m., LPN #1 and ACMA #1 were observed providing incontinent care to Resident #11 and transferred the resident to a wheelchair using a full body mechanical lift. There were no bruises observed on the resident's skin. On 01/29/25 at 10:43 a.m., ACMA #1 stated Resident #11 used to use the sit to stand lift, but did not anymore. ACMA #1 stated staff had to turn the resident in bed and was a total assist for transfers, dressing, toileting and bathing. On 01/29/25 at 10:47 a.m., ACMA #1 stated they just recently started using the total body lift on Resident #11. On 01/29/25 at 10:49 a.m., ACMA #1 stated they were not aware of any incidents involving Resident #11 in the last two months. On 01/29/25 at 10:51 a.m., CNA #3 stated Resident #11 was a total body lift for transfers. They stated staff had to do everything for the resident. On 01/29/25 at 10:54 a.m., CNA #3 stated they had been using the full body lift on Resident #11 for about a month. CNA #3 stated Resident #11 had experienced bruising. CNA #3 they stated they did not know who first observed the bruising, but the facility started to use a full body lift. On 01/29/25 at 11:31 a.m., LPN #1 reviewed the nurse's note for Resident #11 dated 12/27/24, and stated the CNAs had come to LPN #1 and reported some discoloration. LPN #1 stated they went and looked at Resident #11's skin and their left side, upper arm down to the lower arm, ribs and under breast were involved. LPN #1 stated they notified the ADON, administrator, and NP who gave orders for the x-rays. LPN #1 stated they also notified the family. LPN #1 stated the x-rays did not show injuries, but the facility changed from using the sit to stand lift to the full body lift. LPN #1 stated anytime they identified new bruising on a resident, they would view the skin themselves, notify the provider, and notify the abuse coordinator who was the administrator so they could investigate. On 01/29/25 at 11:39 a.m., LPN #1 was asked if the facility had identified the origin of the bruising. LPN #1 stated, Let me go ask the people who did the investigation. On 01/29/25 at 11:42 a.m., LPN #1 returned and stated the administrator was who completed the investigation. LPN #1 did not provide the origin of the bruising. On 01/29/25 at 12:49 p.m., the administrator was asked for all information related to the incident on 12/27/24 involving Resident #11. On 01/29/25 at 1:07 p.m., CNA #3 stated if they observed abuse or neglect, or it was reported to them, they would notify the nurse. On 01/29/25 at 1:14 p.m., LPN #1 stated if they observed abuse or neglect they would notify the abuse coordinator, the physician, and the resident's responsible party. On 01/29/25 at 1:15 p.m., LPN #1 stated the types of abuse they observed for were physical, mental, emotional, isolation, seclusion, and sexual abuse. On 01/29/25 at 2:01 p.m., the administrator was asked again if they had any additional information related to the incident involving Resident #11. The administrator stated it was in their office. The surveyor followed the administrator to their office. The administrator stated they had completed interviews with staff and was still waiting for them to be scanned in. The administrator stated, I didn't do a Reportable though. The administrator stated, I just did staff interviews. On 01/29/25 at 2:03 p.m., the administrator was asked to identify what they considered to be abuse or neglect. The administrator stated, Whether it's factual or not, if you have a reportable, or if you have an incident you are unsure of, you report it. The administrator stated, Whether it's physical, verbal, emotional, misappropriation of funds, if there is any injury like an unknown injury, we report that. The administrator stated what qualified as unknown was, If after your investigation that you have that it happened, while you are investigating, if you still can't find the reason that it happened, of course we report it. On 01/29/25 at 2:05 p.m., the administrator stated when an incident was reported to them, they started an investigation. They stated they would write out statements from everybody. They stated if it was on the hall, they would get statements from whomever was involved. The administrator stated they report it if it was something unusual. The administrator stated, If it's something that needs to go to the State, I report it to the State if we cannot find out what happened, and then report it. On 01/29/25 at 2:07 p.m., the administrator stated abuse was to be reported within two hours and an injury of unknown origin had to be reported. On 01/29/25 at 2:08 p.m., the administrator stated they were notified Resident #11 had a bruise, so they went down and looked at the resident. The administrator stated the bruising was to the left arm, ribs, left side, and breast area. The administrator stated the CNA was giving the resident a bed bath and that was when it was reported to the administrator. The administrator stated they spoke with the nurse who reported the CNA had reported it to them, the doctor was called, and a x-ray was ordered. On 01/29/25 at 2:10 p.m., the administrator stated they asked CNA #5 about the bruising and the CNA stated the bruising was not there the day before. The administrator stated they pulled the shower sheets and the bruising definitely was not there. The administrator stated the only thing they could think of that caused the bruising was the sit to stand lift. The administrator stated they completed an inservice the same day for the sit to stand lift. The administrator stated they changed Resident #11 from a sit to stand lift to a full body lift. On 01/29/25 at 2:14 p.m., the therapy program manager arrived and stated they had evaluated the resident for suspicious bruising. On 01/29/25 at 2:17 p.m., the therapy program manager stated Resident #11 had very decreased cognition and increased muscle resistance. They stated it was heavily recommended for the resident to be a full body lift for safety. The therapy program manager stated from what they understood about the suspicious bruising, was that it was related to bed mobility. On 01/29/25 at 2:19 p.m., the therapy program manager stated they were never told about a concern with the sit to stand and therapy did not evaluate Resident #11 for a sit to stand. On 01/29/25 at 2:20 p.m., the administrator stated an injury was unknown if they could not find the reason. The administrator stated they knew it was the equipment because staff stated they had informed the nurse several days about pain with transfers. On 01/29/25 at 2:22 p.m., the administrator was asked if that information was documented anywhere. They stated, I don't see anything on here for that. On 01/29/25 at 2:26 p.m., the administrator was asked if the facility determined the origin of the bruising. The administrator stated, From the sit to stand. They were asked how they determined that. The administrator stated, Because the CNA told me. They stated based on the two CNA statements on the hall. On 01/29/25 at 2:44 p.m., after filtering through a stack of papers on the desk, the administrator stated they had found the interviews and provided the following forms: a. a Resident Interview form for Resident #11. It read in part, Use as part of an Abuse investigation. There was no date on the form and the interviewer section was blank; b. a Confidential Witness Statement, dated 12/27/24, signed by CNA #5 and the administrator, read in part, I was about to give a bed bath, I notified a bruise to [their] left breast, ribs, upper arm forearm. I went to go get the nurse. I took care of [them] the day before and the bruise was not there. However [they] did complain it hurts during transfer with the sit-to-stand.; c. a Confidential Witness Statement, dated 12/27/24, signed by LPN #1 and the administrator, read in part, I was notified by the CNA that there was a bruise to [left] arm and rib cage. I went to do an assessment. I called the NP, family and [unknown] order for X-ray. This bruise was not there the day prior.; and d. a Confidential Witness Statement, dated 12/27/24, signed by CNA #2 and the administrator, read in part, I observed that the sit to stand equipment hurts [Resident #11] arms when we tried to transfer. I notified the nurse. I was unaware of the bruise. The administrator stated they had interviewed Resident #11 the day of the incident. The administrator was asked to explain use as part of an abuse investigation on the interview form. The administrator stated they had ruled out abuse because after the interview, they determined it was the equipment that caused it. On 01/29/25 at 2:48 p.m., the administrator was asked where they documented they had identified the cause of the bruise in their investigation. The administrator stated, From what staff told me. The administrator stated they reviewed the record and the resident had no incident and no fall. The administrator was shown the incident report, dated 12/27/25, for Resident #11 and was asked if they had anything that documented the findings of their investigation. The administrator was unable to locate this documentation for the surveyor at the time. On 01/30/25 at 8:32 a.m., CNA #2 stated the day the incident occurred 12/27/24 with Resdient #11, they went to help CNA #5. CNA #2 stated the resident was laying in bed and when they removed Resident #11's clothes we noticed bruising all over [them]. CNA #2 stated the nurse was notified at the time. CNA #2 sated they did not know where the bruising came from. On 01/30/25 at 8:50 a.m., CNA #5 stated on 12/27/24 they walked into Resident #11's room to give them a bed bath with CNA #2. CNA #5 stated the resident was still in bed. CNA #5 stated as they removed the resident's clothes they observed a bruise to their back and breast area. CNA #5 stated they were to get the nurse who examined the resident. CNA #5 stated they did not know where the bruising came from. 49701

Based on record review and interview, the facility failed to ensure resident assessment were accurately coded for four (#10, 21, 43, and #54) 17 sampled residents reviewed for resident assessments. The administrator identified 53 residents resided in the facility. Findings: A Guidelines for Assessments policy, dated 05/29/24, read in part, It is the policy of the facility to ensure that assessments of the residents take place timely, at the appropriate time and are accurate. 1. Resident #10 had diagnoses which included Alzheimer's. A Care Plan, dated 07/20/23, documented Resident #10 was at risk for elopement due to wandering and verbalizing wanting to leave the facility. A Wound Care Specialist Progress Note, dated 10/23/24, documented Resident #10 had a stage 3 pressure ulcer to left heel and a stage 4 pressure ulcer to sacrum. Resident #10's Quarterly Resident Assessment, dated 11/13/24, documented not applicable for walking 50 feet or more. It also documented they had one stage 3 pressure ulcer, but no other pressure ulcers. On 01/29/25 at 12:19 p.m., the DON stated Resident #10 was constantly walking around the facility. They were unable to find documentation the stage 4 of the sacrum had healed. They stated the assessment was coded incorrectly. 2. Resident #21 admitted with a diagnosis of chronic pain. A physician's order, dated 11/07/23, documented oxycodone HCI (a narcotic) 10mg q 6hrs as needed for pain. The January 2025 TAR documented the resident was administered PRN pain medication daily from 01/02/25 through 01/08/25. A quarterly assessment, dated 01/08/25, documented the resident did not take any PRN pain medication in the five day look back period. On 01/30/25 at 1:10 p.m. the regional MDS consultant was made aware the MDS documented the resident did not receive any PRN pain medication during the look back period and the TAR documented the resident received pain medication daily from 01/02/25 to 01/08/25. The regional MDS consultant reported the assessment was incorrect. 3. Resident #43 had diagnoses which included dementia, generalized anxiety disorder, and atherosclerotic heart disease of native coronary artery. A Physician Order, dated 10/30/24, documented to admit to hospice care services for diagnoses of senile degeneration. Resident #43's Quarterly Resident Assessment, dated 12/20/24, documented under the prognosis section, the life expectancy of less than six months was documented as no. The special treatments, procedures, and programs section did not document the resident received hospice care while a resident. On 01/29/25 at 1:07 p.m., CNA #3 stated Resident #43 was receiving hospice services. On 01/29/25 at 1:13 p.m., LPN #2 stated Resident #43 was receiving hospice services and they started a couple months ago. On 01/29/25 at 1:26 p.m. , the DON stated regional staff were completing resident assessments and they would try to get hold of someone. On 01/29/25 at 1:45 p.m., the MDS consultant was identified by the DON as being able to answer resident assessment questions. The DON called them on speaker phone and remained in the room. The MDS consultant stated they used the resident's medical record and an assessment of the resident in person which was a collaboration of the interdisciplinary team to complete resident assessments. On 01/29/25 at 1:46 p.m., the MDS consultant stated they ensured the assessments were accurately coded by making sure it aligned with the resident assessment instrument manual. On 01/29/25 at 1:48 p.m., the MDS consultant reviewed Resident #43's quarterly resident assessment, dated 12/20/24, and stated the prognosis life expectancy of less than six months was coded no. They stated it documented the resident did not receive hospice services under the special treatments, procedures, and programs section. On 01/29/25 at 1:49 p.m., the MDS consultant stated the resident was receiving hospice services as of 10/30/24 and the assessment was not accurately coded. 4. Resident #54 admitted to the facility on skilled services with diagnoses of anxiety, depression, and fracture of right femur. A discharge summary, dated 11/23/24, documented the resident was discharged home. A discharge assessment, dated 11/23/24, documented the resident was discharged to the hospital. On 01/29/25 at 3:18 p.m., the DON reported the discharge assessment was coded wrong. 43023 49701

Based on observation and interview, the facility failed to ensure a call cord was within reach for one (#23) of 13 sampled residents whose call cord availability was observed. The administrator identified 53 residents resided in the facility. Findings: An undated Call Lights policy, read in part, Always be sure the resident has a functioning call light that is the easiest type for them to use. Always place the call light in an accessible location to where the resident is located in their room. Resident #23 had diagnoses which included cerebral infarction and hemiplegia of dominant side. Resident #23's quarterly assessment, dated 11/07/24, documented the resident had functional range of motion limitations to all four extremities and was dependent on staff for all activities of daily living. On 01/27/25 at 12:51 p.m., a touch pad call light was observed attached to the curtain against the wall while Resident #23 was in a specialized mobile chair in front of their bed. The touch pad was not within their reach. On 01/27/25 at 12:53 p.m., LPN #1 stated Resident #23's touch pad call light was not where it should have been and then clipped the touch pad to Resident #23's blanket in their lap. LPN #1 stated Resident #23 would be unable to call for assistance without the touch pad call light in reach. On 01/30/25 at 9:01 a.m., the ADON stated call lights were to always be in reach of the residents.

Based on record review and interview, the facility failed to ensure resident records were complete and accurate for one (#11) of four sampled residents reviewed for reportable incidents. The administrator identified 53 residents resided in the facility. Findings: Resident #11 had diagnoses which included stage three chronic kidney disease and dementia. A Nurse's Note, dated 12/27/24, documented Resident #11 was noted with purple discoloration under the left breast/ribs and left upper and forearm. It documented the ADON, administrator, and NP were notified. It documented orders were obtained for a stat x-ray: left rib series with posterior and anterior chest three view, left humerus two view, left forearm two view for a diagnosis of pain and discoloration. It documented the family was notified of the discoloration and new order. There was no origin of the bruising identified in the nurse note. The note was signed by LPN #1. An Incident Report, dated 12/27/24, documented Resident #11 was noted with purple discoloration under their left breast/ribs and left upper and forearm. It documented the resident was unable to give a description. It documented the ADON, administrator, and NP were notified and new orders were received for stat X-ray: left rib series with posterior and anterior chest three view, left humerus two view, left forearm two view for a diagnosis of pain and discoloration. It documented the family was notified of the new order and discoloration. It documented injuries observed at time of incident: bruise left forearm, bruise left upper arm, bruise other describe (nothing was described in this section). The notes section documented discoloration to left upper and lower arm, left breast, and left side. It documented no injuries were observed post incident. It read in part, No statements found. There was no origin of the bruising identified in the incident report. On 01/29/25 at 2:44 p.m., the DON provided a sign in sheet for a full body transfer lift and sit to stand transfer inservice dated 12/27/24. There was no additional information related to this inservice provided to the survey team prior to exit. After filtering through a stack of papers on the desk, the administrator stated they had found the interviews and provided the following forms: a. a Resident Interview form for Resident #11. It read in part, Use as part of an Abuse investigation. There was no date on the form and the interviewer section was blank.; b. a Confidential Witness Statement, dated 12/27/24, signed by CNA #5 and the administrator read in part, I was about to give a bed bath, I notified a bruise to [their] left breast, ribs, upper arm forearm. I went to go get the nurse. I took care of her the day before and the bruise was not there. However [they] did complain it hurts during transfer with the sit-to-stand.; c. a Confidential Witness Statement, dated 12/27/24, signed by LPN #1 and the administrator, read in part, I was notified by the CNA that there was a bruise to [left] arm and rib cage. I went to do an assessment. I called the NP, family and [unknown] order for X-ray. This bruise was not there the day prior.; and d. a Confidential Witness Statement, dated 12/27/24, signed by CNA #2 and the administrator, read in part, I observed that the sit to stand equipment hurts [Resident #11] arms when we tried to transfer. I notified the nurse. I was unaware of the bruise. The administrator was asked about the blanks on the resident interview form and they stated they had interviewed Resident #11 the day of the incident. On 01/29/25 at 2:58 p.m., LPN #2 stated they were made aware the administrator had the staff fill out the forms related to the bruising on Resident #11 today. LPN #2 stated they did not want staff getting in trouble for the administrator completing interviews after the fact when the investigation should have been done. On 01/30/25 at 8:21 a.m., LPN #1 was asked to explain the confidential witness statement dated 12/27/24 signed by them. On 01/30/25 at 8:23 a.m., LPN #1 stated the had went over what happened with the administrator yesterday. LPN #1 stated, I did not want to sign the form. They stated, It was yesterday. LPN #1 stated, I feel I should not have been put in that position. LPN #1 stated, I was told to sign it by The administrator. LPN #1 stated no one had asked them about any statements prior to yesterday. LPN #1 stated everything was in their nurse's notes. LPN #1 stated they made sure the x-ray order was in for the bruising. They stated they told the ADON and administrator and contacted the doctor. LPN #1 stated there was an inservice the following week regarding the lifts. On 01/30/25 at 8:28 a.m., CNA #2 stated the administrator had filled out the confidential witness statement and had me sign it. They stated it was completed yesterday. CNA #2 stated, It bothered me all day yesterday. They stated, I couldn't sleep. CNA #2 stated, [They] made it like we would be in some sort of trouble if we didn't sign it. CNA #2 stated it was filled out yesterday by the administrator who instructed CNA #2 to put the 12/27/24 date. CNA #2 stated they questioned the administrator about the date and the administrator informed them State would come and talk to them and instructed CNA #2 to tell them the date on the form. CNA #2 stated when the incident occurred, they told them about it. On 01/30/25 at 8:32 a.m., CNA #2 stated the day the incident occurred 12/27/24 with Resdient #11, they went to help CNA #5. CNA #2 stated the resident was laying in bed and when they removed Resident #11's clothes we noticed bruising all over [them]. CNA #2 stated the nurse was notified at the time. CNA #2 sated they did not know where the bruising came from. On 01/30/25 at 8:47 a.m., CNA #5 stated the administrator had written out the entire witness statement. CNA #5 stated they did not know anything about the statement until the administrator called them into the office yesterday. CNA #5 stated they had reported the bruising to the nurse the day it occurred. They stated yesterday the administrator told them I'm going to write this statement, I'm going to need you to sign it. CNA #5 stated the administrator stated if anyone asked, they were to say it was already documented. CNA #5 stated they did not feel good about it because it was forging something and they did not want to get in trouble. CNA #5 stated the administrator instructed, You sign it but, I'm going to write it. CNA #5 stated, I didn't want to sign it because it wasn't in my handwriting and this wasn't my report. CNA #5 stated it was weeks ago and they should have already had it together. On 01/30/25 at 8:50 a.m., CNA #5 stated on 12/27/24 they walked into Resident #11's room to give them a bed bath with CNA #2. CNA #5 stated the resident was still in bed. CNA #5 stated as they removed the resident's clothes, they observed a bruise to their back and breast area. CNA #5 stated they were to get the nurse who examined the resident. CNA #5 stated they did not know where the bruising came from. They stated they received an inservice on lifts on a Tuesday because they always received inservices on paydays (12/27/24 was a Friday). They stated they could not remember the exact date of the inservice.

Based on record review and interview, the facility failed to ensure a resident who received a psychotropic medication had an acceptable diagnosis/indication for the use of the medication for one (#9) of five sampled residents reviewed for unnecessary medications. The administrator identified 53 residents who resided in the facility. Findings: A Guidelines for Psychotropic Medication policy, dated 06/05/23, read in part, Based upon each individual resident's comprehensive assessment, the facility will ensure that residents who have not previously been on a psychotropic drug are not given these meds unless the medication is necessary to treat a specific condition/diagnosis, that is documented in the medical record by the physician. Resident #9 had diagnoses which included generalized anxiety disorder. There were no other psychiatric or mood disorder diagnoses. A physician's order, dated 10/31/24, documented the resident was to receive olanzapine (an antipsychotic) 5 mg two times a day. An Admission Assessment, dated 11/06/24, documented Resident #9 was cognitively intact with a BIMS score of 15. It documented Resident #9 was receiving an antipsychotic medication and not an antianxiety medication. A Progress Note completed by the APRN, dated 12/12/24, documented anxiety disorder. There were no other psychiatric or mood disorder diagnoses. A Progress Note completed by the medical doctor, dated 12/13/24, documented anxiety disorder. There were no other psychiatric or mood disorder diagnoses. On 01/29/25 at 12:13 p.m., the DON reviewed the resident's clinical record. The DON stated they only found general anxiety in the diagnoses list.

Based on observation, record review, and interview, the facility failed to prevent a decrease in range of motion for one (#51) of one sampled resident reviewed for decrease in range of motion. The administrator identified 53 residents resided in the facility. Findings: Resident #51 had diagnoses which included central cord syndrome of cervical spine paraplegia and muscle wasting. An Admission Assessment, dated 10/24/24, documented Resident #51 was cognitively intact, but had functional limitation in range of motion in both upper extremities. A Physician's Order, dated 10/28/24, documented right hand wrist contracture splint. A Physician's Order, dated 11/07/24, read in part, request adaptive equipment for eating: rocker knife, plate guard, and thick handled bent/curved silverware for left hand. Bedside commode for toilet training and to decrease assistance from care givers. On 01/30/25 at 9:49 a.m., the PTA stated while Resident #51 was on skilled they were able to walk using a specialized platform walker, but they could not let Resident #51 keep using it because it belonged to therapy. They PTA stated they had to use it for other residents. The PTA stated they did order one for Resident #51, but the specialized walker had still not arrived. The PTA stated they did not put Resident #51 on restorative because an insurance transition was supposed to be happening, and they were planning on picking Resident #51 up on part B services. The PTA stated the facility was supposed to provide the needed equipment, but they were not sure how that worked when residents were on private pay. On 01/30/25 at 9:57 a.m., the BOM stated it was not the therapy departments job to worry about insurance. The BOM stated therapy should order whatever needed to be ordered and they would worry about payment of services. On 01/30/25 at 10:04 a.m., the ADON stated they remembered the PTA having to remove the platform walker to take back to therapy. They stated adaptive equipment for eating had been ordered, but was not there yet. They were unsure about the splints having been ordered. On 01/30/25 at 10:19 a.m., the PTA stated they had ordered the bedside commode more than once, but they may not have put the platform walker order into the book for the physician to sign. They stated the wrist splint was ordered on 10/29/24, but had still not arrived. On 01/30/25 at 10:25 a.m., the dietary manager stated they had just got the order for the specialized adaptive equipment for eating. They stated the order was initiated 11/07/24. They stated they just now got the approval to order it and they instructed central supplies to put the order in on Monday 01/27/25. On 01/30/25 at 10:34 a.m., Resident #51 stated they had not had a bedside commode in their room since they had been in the facility. They also stated if they had the specialized platform walker they would be doing so much better. They stated when they were able to use one on skilled care they were able to stand up to be changed and cleaned. They stated they were unable to use their right hand due to the contracture and the utensils provided were very hard to use with their left hand. On 01/30/25 at 11:13 a.m., the PTA stated they found out today they should have taken a signed copy of the physician's order and given it to dietary, nursing, and the floor nurse. They stated they were still looking to see what happened to the order for the platform walker. On 01/30/25 at 11:45 a.m., the administrator stated they were putting in new procedures to make sure when therapy wrote orders, they gave them to all the departments involved to make sure the orders did not get missed.

Based on record review and interview, the facility failed to ensure a significant change resident assessment was completed when a resident was placed on hospice services for one (#43) of two sampled residents reviewed for hospice services. The DON identified three hospice residents resided in the facility. Findings: A Guidelines for Assessments policy, dated 05/29/24, read in part, It is the policy of the facility to ensure that assessments of the residents take place timely, at the appropriate time and are accurate. Resident #43 had diagnoses which included dementia, generalized anxiety disorder, and atherosclerotic heart disease of native coronary artery. A Physician Order, dated 10/30/25, documented admit to hospice care services for diagnosis of senile degenerate. There was no significant change resident assessment completed when the resident began hospice services in Resident #43's clinical record. On 01/29/25 at 1:07 p.m., CNA #3 stated Resident #43 was receiving hospice services. On 01/29/25 at 1:13 p.m., LPN #2 stated Resident #43 was receiving hospice services and they started a couple months ago. On 01/29/25 at 1:26 p.m., the DON stated regional staff were completing resident assessments and they would try to get hold of someone. On 01/29/25 at 1:45 p.m., the MDS consultant was identified by the DON as being able to answer resident assessment questions. The DON called them on speaker phone and remained in the room. On 01/29/25 at 1:46 p.m., the MDS consultant stated a significant change resident assessment was completed when a resident had two areas of decline or improvement that required care plan revision due to a change in their baseline. The MDS consultant stated a significant change resident assessment was to be completed when a resident went on hospice services. On 01/29/25 at 1:49 p.m., the MDS consultant stated the resident was receiving hospice services as of 10/30/24 and a significant change should have been completed.

Based on record review and interview, the facility failed to ensure restorative therapy was provided to a resident with limited ROM for one (#3) of three sampled residents reviewed for therapy services. The DON identified 11 residents who received restorative therapy resided in the facility. Findings: A Restorative Nursing policy, revised 05/16/19, read in part, .the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable .Restorative Services .actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning .A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy . Resident #3 had diagnoses which included cerebral infarction, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. An Admission Resident Assessment, dated 08/15/24, documented Resident #3's cognition was intact, and they had limited ROM in both sides of their upper extremities and one side of their lower extremities. It documented Resident #3 was dependent for the task of lying to sitting on the side of the bed and required partial/moderate assistance for the sit to stand task. A Physical Therapy Discharge Summary, discontinue date 08/15/24, documented recommendations which included RNP/FMP to facilitate resident maintaining current level of performance and in order to prevent decline. The September 2024 nursing rehab documentation for Resident #3, read in part, .CNA to assist with Transfers, using Gait Belt and staff assist, have resident sit on side of bed, push up from bed with arms. When standing, support self with wheelchair and pivot towards wheelchair. When in position, using arms of wheelchair to support, lower self down. Repeat steps for at lest 15 minutes a day as tolerated, for at least 6 days a week . It documented the nursing rehab task began on 09/12/24 and the resident received 10 minutes of rehab three times and 30 minutes of rehab one time for the month. A Physician Order, dated 10/08/24, documented restorative nursing care for mobility. The October 2024 nursing rehab documentation for Resident #3, read in part, .CNA to assist with Transfers, using Gait Belt and staff assist, have resident sit on side of bed, push up from bed with arms. When standing, support self with wheelchair and pivot towards wheelchair. When in position, using arms of wheelchair to support, lower self down. Repeat steps for at lest 15 minutes a day as tolerated, for at least 6 days a week . It documented the resident received 15 minutes of rehab eight times and five minutes of rehab twice. On 10/16/24 at 11:05 a.m., LPTA #1 stated Resident #3 was receiving skilled services on admission. They stated the resident's insurance changed and it would no longer cover therapy serviced. LPTA #1 stated Resident #1 needed therapy. On 10/17.24 at 9:45 a.m., Resident #3 stated they had received therapy at the facility for a few days. They stated they were no longer receiving therapy due to insurance. Resident #3 stated they could stand with assistance. The resident did not mention restorative therapy services. On 10/17/24 at 11:34 a.m., the DON stated the facility had a restorative aide, but the aides on the floor also assisted with restorative services. The DON provided documentation of Resident #3's nursing rehab started on 09/12/24. On 10/17/24 at 11:48 a.m., the restorative aide stated Resident #3 required two-person assistance for transfers with a gait belt. They stated they had a list of residents who received restorative services. They stated a CNA could provide restorative services to the resident. The restorative aide stated the NA charted for Resident #3's nursing rehab might have been because the resident did not want to do it. They stated, I don't know why they didn't mark refused. On 10/17/24 at 1:15 p.m., LPN #1 stated Resident #3 was a one to two person assist with transfers. On 10/17/24 at 1:18 p.m., LPN #1 stated Resident #3 had experienced a stroke and required assistance with everything. They stated once the resident was up in the wheelchair they could move around independently. On 10/17/24 at 1:22 p.m., LPN #1 stated Resident #3 was on restorative care for mobility. On 10/17/24 at 1:35 p.m., the DON stated Resident #3's ordered therapy was before they came into the DON role. The administrator stated they believed the resident refused restorative at times. The administrator stated they did not know the reason NA was documented for the restorative therapy.

Based on observation, record review and interview, the facility failed to ensure a gait belt was used during a two-person physical assist transfer for one (#7) of three sampled residents reviewed for accident hazards. The administrator identified 58 residents resided in the facility. Findings: A Bed Mobility and Transfers policy, undated, read in part, .Sit to Stand Transfer Procedure .With hands securely on the safety/gait belt, instruct the resident to stand .Bed to/From Wheelchair .Secure a gait belt around the resident's waist .Make sure your hands are securely on the safety/gait belt . Resident #7 had diagnoses which included Parkinson's disease and tremor. A Quarterly Resident Assessment, dated 07/09/24, documented Resident #7 had severe cognitive impairment and required partial/moderate assistance for the sit to stand task and the transfer to and from a bed to a wheelchair task. On 10/16/24 at 9:48 a.m., CNA #5 and CNA #6 were observed placing one arm under each of Resident #7's arms, held the backside of Resident #7's pants, and hoisted the resident up from their wheelchair onto Resident #7's bed. A gait belt was not utilized during the transfer. On 10/16/24 at 9:57 a.m., CNA #5 stated Resident #7 was a two-person transfer. They stated they would utilize a gait belt for residents who where able to do more and were stronger. On 10/16/24 at 10:00 a.m., CNA #6 stated gait belts should be used any time during a one to two person assist. They stated Resident #7 was able to help stand. On 10/16/24 at 1:10 p.m., LPN #2 stated the facility was a no lift facility. They stated staff were to use a gait belt for residents who could stand and pivot. They stated the facility also had lifts to assist with transfers. On 10/16/24 at 1:12 p.m., the DON stated staff should use gait belt with all transfers.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent significant medication errors for Resident #2. Resident #2 was ordered Morphine 20mg/ml give 0.5ml every four hours as needed. The Controlled Drug Receipt/Record/Disposition Form, dated [DATE], documented LPN #1 administered Morphine 0.5ml at 6:00 a.m., 10:15 a.m., and 2:30 p.m. The Controlled Drug Receipt/Record/Disposition Form, dated [DATE], documented LPN #1 administered an additional dose of Morphine 0.5ml at 10:15 a.m., 2:30 p.m., and 3:00 p.m. per family request. The MAR, dated [DATE], documented LPN #1 administered Morphine 0.5ml at 5:58 a.m., 11:15 a.m., and 2:23 p.m. On [DATE], LPN #1 stated they had not contacted the physician for orders for the additional doses of Morphine administered to Resident #2. LPN #1 stated the entries on the Controlled Drug Receipt/Record/Disposition Form, dated [DATE], were administered on [DATE] but they had documented the wrong date. Resident #2 expired on [DATE] at 4:13 p.m. On [DATE] at 5:33 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 5:38 p.m., the administrator was notified of the IJ situation. On [DATE] at 10:14 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: .Plan of Removal for Immediate Jeopardy February 15, 2024 As requested by state and federal law, the facility, Landmark of Midwest City, is respectfully submitting the following credible allegation of compliance to request removal of the Immediate Jeopardy citation which was issued on February 15, 2024 related to a medication error. Disclaimer Statement: The completion and submission of this credible allegation of compliance does not constitute an admission that the facility agrees with the allegation in the notification of Immediate Jeopardy. The facility is completing the allegation of compliance because it is requested by state and federal law. The facility may disagree with and dispute the alleged deficiency as stated in the Immediate Jeopardy Template. This includes but is not limited to the alleged content, summary, the chronological timing of sequence of events, and the description of care including medication administration to the specified resident. The facility reserves its right to continue disputing, appealing, and contesting this alleged deficiency, and any actions related to and arising therefrom in any forum as needed. According to the Immediate Jeopardy Template, the facility failed to ensure medications were administered as ordered to prevent a significant medication error. Corrective action taken for resident affected by the deficient practice: Nurse #1 was immediately interviewed and suspended pending investigation on [DATE] following the discovery of the potential medication error, thus removing the potential to affect other residents. Nurse #1 has not worked since [DATE]. Nurse #1 was terminated on [DATE] after not showing up for her scheduled meeting, competency validation, and continued employment evaluation. Resident #2 was receiving hospice care and in the dying process at the time of the potential medication error. Resident #2 passed on [DATE]. How other residents of the facility were identified to potentially be affected: Narcotic count sheets were audited on [DATE] to verify accurate count recorded and matching count of medications. Physician's Ordered were validated to match the Medication Administration Record and administration times were verified to be within acceptable range. What measures were put into place and what systemic changes will be made to ensure the deficient practice does not recur: Licensure verification for licensed nurses and CMA's were completed [DATE]. Licensed Nurses and CMA's were inserviced on medication administration of routine and as needed medication, following physician's orders, physician notification, change of condition, medication orders/requests, additional medication doses, adverse reactions, and new admission process on [DATE]. Phone calls with a verbal inservice will be given if any staff are on vacation of able to come to the facility for an in person inservice. Competency validations began on [DATE] for all licensed nurses and CMA's to be successfully completed prior to administering medication and/or providing care. Newly hired nurses and CMA's will be educated upon hire and competence validated prior to administering medications to any resident. How the corrective actions will be monitored to ensure the deficient practice does not recur: An Ad-Hoc QAPI Meeting was held by the Administrator, the Interdisciplinary Team and Medical Director on [DATE] to review and approved the Plan of Removal and Allegation of Compliance. Audit Tools were created on [DATE] to include monitoring of medication delivery including following physician's orders, narcotic count and accuracy of count compared to actual medication daily for two weeks, weekly for three weeks, and monthly for three months or until substantial compliance is achieved. The QAPI Committee will review the audit tools on a monthly basis and will determine compliance. Any concerns will have been addressed. If indicated, additional Action Plans will be recommended and/or written by the QAPI Committee. All Action Plans will be monitored weekly by the Administrator to ensure substantial compliance. Plan of removal will be completed by [DATE] at 20:00. The IJ was lifted, effective [DATE] at 3:53 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 prevent significant medication errors for one (#2) of three sampled residents reviewed for medications administered per physician orders. The DON identified 64 residents who were ordered medications in the facility. Findings: A Medication Error policy, dated [DATE], read in parts, .The facility strives to ensure that residents .will not .have their health and safety placed in jeopardy due to a medication error .Procedure .Administer medications within prescribed time frames .Administer medications according to the frequency, route, and dose prescribed . A Guidelines for Physician Orders policy, dated [DATE], read in parts, .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received . Resident #2 had diagnoses which included nontraumatic intracerebral hemorrhage. A physician order, dated [DATE], documented Resident #2 was ordered lorazepam 2mg/ml give one milliliter every four hours as needed for anxiety. An Order Note, dated [DATE] at 4:26 p.m., documented a new order from hospice had been received for morphine 20mg/ml every four hours as needed for pain/shortness of breath. The Controlled Drug Receipt/Record/Disposition Form, documented on [DATE], LPN #1 administered morphine 0.5ml at 6:00 a.m., 10:15 a.m., and 2:30 p.m. The Controlled Drug Receipt/Record/Disposition Form, dated [DATE], documented LPN #1 administered an additional dose of morphine 0.5ml at 10:15 a.m., 2:30 p.m., and 3:00 p.m. per family request. The form documented 13.5ml of morphine, was in the bottle, before the 6:00 a.m. dose was administered by LPN #1. The entry at 3:00 p.m. documented 8ml Morphine, remained in the bottle, after the 3:00 p.m. dose was administered by LPN #1. The MAR, dated [DATE], did not contain documentation morphine 20mg/ml give 0.5ml every four hours had been administered to Resident #2 on [DATE]. The MAR documented Resident #2 had been administered morphine 0.5ml on [DATE] at 5:58 a.m., 11:15 a.m., and 2:23 p.m. by LPN #1. A Medication Administration Note, dated [DATE] at 5:58 a.m., documented the family for Resident #2 was concerned the resident was hurting and starting to stress. The note documented LPN #1 administered Morphine 0.5ml po to Resident #2. A Medication Administration Note, dated [DATE] at 5:59 a.m., documented the family for Resident #2 was concerned the resident was starting to hurt and get stressed because of increased respirations. The note documented LPN #1 administered lorazepam 1ml po to Resident #2. A Medication Administration Note, dated [DATE] at 11:15 a.m., documented LPN #1 administered lorazepam 1ml po and morphine 0.5ml po to Resident #2. A Medication Administration Note, dated [DATE] at 2:23 p.m., doucmented LPN #1 administered lorazepam 1ml po and morphine 0.5ml po to Resident #2. These medications were administered three hours and eight minutes after the last documented doses on the MAR at 11:15 a.m. A Medication Administration Note, dated [DATE] at 4:22 p.m., documented Resident #2 was without heart sounds, respirations and pulse at 4:13 p.m. The ODH Form 283, read in parts, .Incident date: [DATE] .Part B .On [DATE] [LPN #1] was the nurse for [Resident #2]. Resident was on hospice and had a physician order for morphone [sic] 0.5ml q4 hours PRN. [LPN #1] stated that [they] administered this medication outside of physician order and time regulations. [LPN #1] stated [they] filled a 10ml syringe with 3ml of morphine and used this to administer several doses to the resident within [their] shift. Resident expired on [DATE]. [LPN #1] was suspended pending the outcome of the investigation .Part C .[LPN #1] was suspended. [LPN #1] will have another nurse sign off on any narcotics given since [they are] not allowed to be terminated. Education was given to the nurses on following physician orders and how to accurately draw medication with a syringe . A written statement by LPN #1, dated [DATE], read in parts, .concerning the scribbled on in-haste morphine count sheet containing liquid morphine prescribed for [Resident #2] .There are missing entries for [DATE] per the ,d+[DATE] shift and entries missing for the [DATE]th 2024 ,d+[DATE] shift. The ledgers were made in haste without thinking. At the time those scribbles were written in I had a family emergency and was unable to think clearly for all the nonsense I was writing in order to take responsibility for the discrepancy. I had thought to appease the oncoming nurse to show in good faith I had entries I needed to justify so that [they] would take the cart keys at that time. We noted the amount of 8ml left in the bottle at that time [at] [DATE] 2222 [10:22 p.m.] .Several days later in attempts to explain my weekend, especially, the events of [Resident #2] actually actively dying .[Resident #2] was noted to be mottled and [their] respirations presented as Cheyne-Stokes at approx 1500 [3:00 p.m.] and the wife and daughter of the actively dying patient became more distraught with anxiety and grief. I had noticed in my attempts to relieve their anxiety and comfort them I assisted with the patients comfort medication morphine; it was at that time 1500 [3:00 p.m.] I noticed the 1ml syringe was not to be found .I sought to find a substitute syringe from the treatment cart. There were several 3ml syringes .I removed the needle from one of the sterile packages, poured morphine into a med cup and drew up approx ,d+[DATE] of the syringe or less of the morphine; located a blue huer cap to secure the morphine from leaking and went to the .bedside. It might be good here to note that every dose of morphine expressed into [Resident #2's] mouth would immediately drool out of [their] mouth onto [their] beard and this had made the daughter [name withheld] question if [they] actually got any of the medicine .with the 10:00 [10:00 a.m.] dose and the 1400 [2:00 p.m.] doses .When the breathing pattern would return to a more slowed pace I would return to the med/treatment cart and lock up the syringe with morphine. Just about every 15 minutes a family member or a friend would find me on the hall .I would stop what I was doing; unlock the syringe of morphine educating the family that I have only an order for every 4 hours with the comfort meds and that only the hospice nurse can redirect the administration. At 1550 [3:50 p.m.] the resident dying hospice pt was noted increasingly blue mottled and with gasping type Kussmual breaths or Cheyne-Stokes .I had educated the family that [they were] actively leaving us and not much else I can do at this time. Placing a very small amount of the morphine onto [Resident #2's] lip crease cheek area to comfort more the family. This would stay drying on [their] mouth and beard and family would wipe [their] mouth with tissue .At approx 1605 [4:05 p.m.] a man rushes up to me .and states 'he has stopped breathing' .I was unable to detect an apical heartbeat. No pulse was noted. No respirations were noted .Into the 2100 [9:00 p.m.] hour I had not even thought about the morphine at all and it wasn't clear the syringe of wasted morphine .the oncoming nurse and myself witnessed that there was a discrepancy from the 12.0 ml to the 8.0 ml. It was at this sense of urgency that I told [them] I take full responsibility attempting to fill in accurate times with the majority missing and unsure how to chart the wasted amounts, I nonsensically scribbled in numbers, squeezed in numbers and scribbled family request at bedside and whatever else with my signature so that oncoming nurse can be held at no fault with the discrepancy. 8ml was in the bottle [at] that date [DATE] 2222 [10:22 p.m.] .I attempted to correct my scribbles on the legal document and justify my actions, the entries and the waste asking for assistance in charting and learning protocol with the charting .I was not allowed the original legal document and was asked to write out my best recollection after attempting to explain in a phoned meeting all together unsure . On [DATE] at 3:09 p.m., the bottle of morphine 20mg/ml for Resident #2 was observed with the DON to have 8mls remaining in the bottle. On [DATE] at 12:10 p.m., the DON stated LPN #1 reported to them, the regional nurse, and the ADON they had thrown the original dosing syringe away, utilized a 10ml syringe, drew up an unknown amount of morphine to administer to Resident #2 in an attempt to appease the family. The DON stated LPN #1 reported they had added entries to the narcotic record so the oncoming nurse would take the keys. The DON stated they had interviewed LPN #1 three times and each time LPN #1 stated they utilized a 10ml syringe after the dosing syringe had been lost but documented a 3ml syringe on their written statement. The DON stated they suspended LPN #1 pending investigation. They stated they wanted to terminate LPN #1 but had been told corporate would not allow them to terminate LPN #1. The DON stated they felt LPN #1 was a danger to the residents because they had not followed physician orders and did not know how much morphine they had administered to Resdient #2. On [DATE] at 12:34 p.m., the administrator stated LPN #1 reported to them after the original dosing syringe was lost for the Morphine for Resident #2 they drew up 3ml of morphine into a 10ml syringe and utilized that to administer as needed doses on [DATE]. They stated LPN #1 had to have another nurse co-sign any narcotic administration when they returned to work. They stated LPN #1 would have access to narcotic medications so they did not know how that intervention would protect the residents. On [DATE] at 1:23 p.m., the medical director stated LPN #1 had not followed physician orders for morphine for Resident #2. They stated it was gross negligence. The medical director stated Resident #2 was an end of life resident but administering medications outside of physician orders should have never happened. On [DATE] at 2:17 p.m., Regional nurse consultant #1 stated LPN #1 reported to them they had lost the dosing syringe for the morphine for Resident #2. They stated LPN #1 reported they had obtained a 3ml, 5ml, or 10ml syringe, drew up 3mls of Morphine, and administered Morphine from it to Resident #2 when the family requested it. Regional nurse consultant #1 stated LPN #1 reported to them that they would squirt the morphine in the resident's mouth, it would run out, the family would ask for more to be administered and LPN #1 would squirt more in the resident's mouth. Regional nurse consultant #1 stated LPN #1 was an active employee but was suspended pending investigation.

Based on record review and interview, the facility failed to ensure records were accurate for one (#2) of five sampled residents whose records were reviewed. The DON identified 64 residents resided in the facilty. Findings: Resident #2 had diagnoses which included nontraumatic intracerebral hemorrhage. A physician order, dated [DATE], documented Resident #2 was ordered lorazepam 2mg/ml give one milliliter every four hours as needed for anxiety. An Order Note, dated [DATE] at 4:26 p.m., documented a new order from hospice had been received for morphine 20ml/mg every four hours as needed for pain/shortness of breath. The Controlled Drug Receipt/Record/Disposition Form, documented on [DATE], LPN #1 administered morphine 0.5ml at 6:00 a.m., 10:15 a.m., and 2:30 p.m. The Controlled Drug Receipt/Record/Disposition Form, dated [DATE], documented LPN #1 administered an additional dose of morphine 0.5ml at 10:15 a.m., 2:30 p.m., and 3:00 p.m. per family request. The MAR, dated [DATE], did not contain documentation morphine 20mg/ml give 0.5ml every four hours had been administered to Resident #2 on [DATE]. The MAR documented Resident #2 had been administered morphine 0.5ml on [DATE] at 5:58 a.m. with a pain rating of five, 11:15 a.m. with a pain rating of seven, and 2:23 p.m. with a pain rating of four by LPN #1. The MAR documented Resident #2 had lorazepam 2mg/ml - give 1ml ordered daily at 5:00 p.m. and 10:00 p.m. The Medication Administration Note, dated [DATE] at 4:22 p.m., documented the Resident #2 was without heart sounds, respirations, and pulse at 4:13 p.m. The note read in part .LORazepam Oral Concentrate 2 MG/ML Give 1 ml by mouth one time a day for Anxiety . The Medication Administration Note, dated [DATE] at 8:35 p.m., read in part, .LORazepam Oral Concentrate 2 MG/ML Give 1 ml by mouth one time a day for Anxiety . On [DATE] at 11:19 a.m., LPN #1 stated the entries on the Controlled Drug Receipt/Record/Disposition Form that were dated [DATE] were supposed to have been dated [DATE]. They stated they had administered two to three 0.5ml doses of morphine on [DATE] but had not had a chance to document it. On [DATE] at 12:10 p.m., the DON stated LPN #1 documented a dose of lorazepam had been administered to Resident #2 after they had expired. The DON stated LPN #1 had reported to them it was a late entry. The DON stated the electronic health record would not allow a nurse to document a medication was administered unless it was due. On [DATE] at 12:12 p.m., the DON stated when a pain medication was administered the electronic health record indicated a pain level needed to be documented. The DON stated they did not know how a pain rating had been determined for Resident #2 on [DATE] because LPN #1 had reported to them the resident was out of it when the doses of morphine were administered. The DON stated they reviewed a 24 hour report to monitor for complete and accurate clinical records and would ask the nurses for clarification if needed.

Based on record review and interview, the facility failed to ensure licensed nurses received competency/skills checks for two (LPN #1 and LPN #3) of five employee files reviewed for competency/skills checks. The DON identified 16 nurses who currently worked at the facility. Findings: 1. LPN #1 was hired on [DATE]. The ODH Form 283, read in parts, .Incident date: [DATE] .Part B .On [DATE] [LPN #1] was the nurse for [Resident #2]. Resident was on hospice and had a physician order for morphone [sic] 0.5ml q4 hours PRN. [LPN #1] stated that [they] administered this medication outside of physician order and time regulations. [LPN #1] stated [they] filled a 10ml syringe with 3ml of morphine and used this to administer several doses to the resident within [their] shift. Resident expired on [DATE]. [LPN #1] was suspended pending the outcome of the investigation .Part C .[LPN #1] was suspended. [LPN #1] will have another nurse sign off on any narcotics given since [they are] not allowed to be terminated. Education was given to the nurses on following physician orders and how to accurately draw medication with a syringe . Review of the employee file for LPN #1 did not reveal a competency/skills check had been completed. 2. LPN #3 was hired [DATE]. Review of the employee file for LPN #3 did not reveal a competency/skills check had been completed. On [DATE] at 8:40 a.m., the DON stated nurses received training and competency/skills checks during orientation and then annually. They stated the competency/skills check should be in the employee file. The DON stated competencies had not been documented for LPN #1 or LPN #3.

Based on observation, record review, and interview, the facility failed to ensure a homelike environment by maintaining comfortable water temperatures for two (300 hall and 400 hall) of two shower rooms observed for comfortable water temperatures. The maintenance supervisor identified two shower rooms in the facility. Findings: The Water Temperatures, Safety of policy, dated December 2009, read in parts, .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than ____ [degrees] F ., or the minimum allowable temperature per state regulation .Maintenance staff is responsible for checking thermostats and temperature controls and record the water temperatures in a safety log . On 02/13/24 at 11:09 a.m., Resident #6 stated the water in the shower rooms were hard to adjust. They stated the water was either too hot or too cold. On 02/13/24 at 11:16 a.m., the 300 hall shower room was observed. The shower on the left side was observed to register 84 degrees F with only the hot water running. At 11:18 a.m., the shower on the left side was observed to be 87 degrees F. On 02/13/24 at 11:28 a.m., Resident #4 stated sometimes they had to wait a while for the water to warm up in the 300 hall shower room. They stated the water in the 300 hall shower room was cold but the staff were aware of the concern. Resident #4 stated they did not know what the facility was doing to address the concern. On 02/14/24 at 8:49 a.m., Resident #1 stated they had been choosing bed baths rather than their preferred shower because the water temperature was either hot or cold. They stated there was no in between comfortable temperature. On 02/14/24 at 9:02 a.m., CNA #1 stated the water temperature in the 400 hall shower room would turn cold after a comfortable water temperature was set for the residents. They stated they thought the maintenance supervisor was aware of the issue with inconsistent water temperatures. On 02/14/24 at 9:25 a.m., CNA #2 stated for the past couple of months they have had to turn both showers on in the 400 hall shower room to maintain comfortable water temperatures. They stated if both showers were not running at the same time the water would go from warm to cold. On 02/14/24 at 9:40 a.m., the 400 hall shower room was observed with the maintenance supervisor. They stated in November 2023 they had replaced a mixing valve but was unaware of any current water temperature concerns. On 02/14/24 at 9:48 a.m., the maintenance supervisor obtained the water temperature in the shower on the right side of the 400 hall shower room. They stated the water temperature was 55 degrees F with only the hot water running. At 9:51 a.m., the maintenance supervisor stated the water temperature in the shower in the right side of the 400 hall shower room had reached 65 degrees F. They stated the left side had the better water temperature but it was registering 65 degrees F as well. On 02/14/24 at 9:53 a.m., the maintenance supervisor stated the shower on the left side was registering 60 degrees F and the shower on the right side registered 122 degrees F. On 02/14/24 at 10:14 a.m. the maintenance supervisor stated they only monitored the water temperature for one shower in each of the two shower rooms. They stated the mixing valves may need to be replaced. On 02/14/24 at 5:36 p.m., the administrator stated the maintenance supervisor monitored water temperatures in the shower rooms to ensure comfortable water temperatures were obtained.

Based on observation, record review, and interview, the facility failed to ensure controlled medications were reconciled when they were delivered from the pharmacy for one (#2) of three sampled residents whose medications were reviewed. The DON identified 50 residents had orders for controlled medications. Findings: The Accepting Delivery of Medications policy, dated April 2007, read in parts, .Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt .A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery . Resident #2 had diagnoses which included nontraumatic intracerebral hemorrhage. A physician order, dated 01/24/24, documented an order for morphine 20ml/mg every four hours as needed for pain/shortness of breath. A Packing Slip dated 01/24/24, documented the pharmacy had filled 20mls of morphine 20mg/ml for Resident #2. A Prescription History, dated 01/24/24, documented the pharmacy had delivered the morphine to the facility and it had been signed for by LPN #2. The Controlled Drug Receipt/Record/Disposition Form, dated 01/24/24, documented 15mls of morphine 20mg/ml had been received for Resident #2. The ADON signed the form as the nurse receiving the medication. On 02/13/24 at 3:09 p.m., the bottle of morphine 20mg/ml for Resident #2 was observed with the DON. The label indicated the quantity was 20 mls. On 02/14/24 at 10:05 a.m., the ADON stated the nurse had given them the bottle of 15mls of morphine for Resident #2 to lock on the medication cart. They stated they thought the hospice nurse had delivered the medication to the facility. On 02/14/24 at 10:07 a.m., the DON stated once they received medications from pharmacy they documented how much was delivered. They stated they did not compare what the pharmacy documents they sent to what was actually received. They stated they needed to implement a protocol to account for narcotic reconciliation when they were delivered from the pharmacy. On 02/14/24 at 11:56 a.m., LPN #2 stated they had signed for the medication for Resident #2 but they had not verified how much Morphine had been delivered. They stated they had given it to the nurse to be logged and locked up on the medication cart.

Based on record review and interview, the facility failed to order and administer medication as ordered for one [#1] of four sampled residents reviewed for medication. The Administrator identified 73 residents resided in the facility. Findings: The facility's Medication Administration policy, dated 05/2017, read in part, .PRN medication, reason for administration, and effectiveness in the Nursing Notes or on the back of the MAR .Dispense Medication as ordered . Resident #1 has a diagnosis of anxiety disorder, schizophrenia, dementia along with mood, behavior and agitation deficits. Physician's order: dated 02/26/23, documented Xanax(alaprazolam) 0.25 mg Give 1 tablet by mouth every 6 hours as needed for anxiety. On 12/07/23 at 3:43 p.m., DON stated, according to Resident #1 charts, they missed the 17:45 dose. They stated they put in a order for the medication to be refilled 08/31/23 at 21:43, because they ran out. On 12/06/23 at 3:41 p.m., DON stated Resident #1 nursing notes says they requested a prn dose of Xanax at 1500. On 12/06/23 at 3:23 p.m., DON stated, medications are to be dispensed as ordered. They stated, according nursing notes, Resident #1 did not get 17:45 dose.

Based on record review and interview, the facility failed to ensure residents were allowed the opportunity to formulate or decline an advanced directive for two (#12 and #50) of 18 sampled residents reviewed for advance directive. The Resident Census and Conditions of Residents report, dated 10/17/23, documented 70 residents resided in the facility. Findings: An Advance Directives Policy and Procedure policy, undated, read in parts, .The facility provides to all residents the right to accept or refuse .formulate an advance directive . 1. Resident #12 was admitted to the facility on [DATE]. 2. Resident #50 was admitted to the facility on [DATE]. There was no documentation Residents #12 and #50 were provided the opportunity to formulate an Advance Directive or declined. On 10/18/23 at 9:33 a.m., Medical Records stated there was no advanced directive for Resident #12 or Resident #50. On 10/18/23 at 1:20 p.m., The Administrator stated residents were offered the option of formulating or declining an advance directed during the admission process.

Based on observation, record review, and interviews, it was determined the facility failed to ensure there was a sufficient supply of portable oxygen for two (#10 and #11) of three sampled residents who were reviewed for the use of oxygen per nasal cannula. The facility identified eleven residents who had orders to receive oxygen per nasal cannula. Resident #10 was oxygen dependent related to end stage [CONDITION(S)] and [CONDITION(S)] with [CONDITION(S)]. On the morning of 10/15/20 the resident was transported to a physician appointment unaccompanied by a staff member. Upon arrival to the physician's office the resident was in respiratory distress, had an oxygen saturation level of 57%, had an empty 02 tank, and could not answer any questions except to give a name. The resident was transported from the physician office to the emergency room . Hospital notes documented the resident's oxygen saturation level at 40% on room air, the resident was experiencing severe [CONDITION(S)], and shortness of breath, had a vision deficit (was legally blind), a hearing deficit, and a cognitive communication deficit with somnolence. The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A facility policy and procedure titled Oxygen Administration, dated October 2010, documented: .check tank to be sure they are in good working order . .observe the resident upon set-up and periodically thereafter . .After completing the oxygen set-up or adjustment .document the rate of oxygen flow . A facility policy and procedure titled Change in a Resident's Condition or Status, dated September 2013 documented: .3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: .b. There is a significant change in the resident's physical, mental, or psychosocial status; .e. it is necessary to transfer the resident to a hospital/treatment center . .5. Except in emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 1. Resident #10 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen at 2 l/m to 5 l/m per nasal cannula as needed for SOB/Respiratory Compromise to maintain 02 sats above 90%. A St. Louis University Mental Status Evaluation for the resident from the 09/2020 VA Hospital stay documented the resident's cognition with a score of 16, the most severe category for dementia, and the residents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial assessment, dated 9/21/20, documented, .BIMS of 11 .Moderate difficulty hearing .Severely impaired with Vision-no vision or sees only light, colors or shapes . .Functional Cognition assessed .needs partial assistance from another person in order to complete .regular tasks such as shopping or remembering to take medication . .Self-Care .needs assistance with bathing, dressing, using the toilet, or eating .Indoor Mobility .needs assistance with walking . A care plan, dated 09/30/20, documented, .resident has Oxygen Therapy r/t sob .will have no s/sx of poor oxygen absorption through the next review date (11/30/20) .Monitor/document side effects and effectiveness .Monitor for s/sx of respiratory distress and report to MD PRN: Respirations .Lethargy .Confusion .Atelectasis .Cough . .Provide reassurance and allay anxiety . .resident is at risk for falls/injury R/T assistance required with ADL function and mobility, incontinence and use of [CONDITION(S)] medications side effects .anticipate and meet individual needs of the resident . .resident presents with a Self-Care deficit in Symptoms & Problems are manifested by: Cognitive impairment .Symptoms & Problems are manifested by: General weakness .requires extensive assistance with (Bathing .Bed mobility .Dressing/Hygiene .Eating .Toileting .Transfers .Explain purpose & expected tasks .Break tasks down into simple sub-tasks .with one staff .Give sufficient time to accomplish each task . .resident is at risk for .respiratory distress R/T: Congestive Heart Failure .An increased risk for .shortness of breath .Observe for Shortness of breath .Allow rest periods .Monitor lung sounds .Use oxygen as ordered .Monitor oxygen saturation as ordered and as needed . .has an alteration in communication R/T: hard of hearing .Ask simple direct questions .Repeat .quiet area so better to understand . .has respiratory risk R/T asthma/[CONDITION(S)], Problem manifested by: Respiratory infection .Difficulty breathing .Monitor breath/lung sounds prn .Offer reassurance and emotional support .Observe .for any s/sx of infection . .has [CONDITION(S)] and is at risk for altered tissue perfusion .Administer 02 PRN for SOB . .at risk for decreased vision R/T: [CONDITION(S)] .Provide large printed reading . Progress notes, evaluations, tasks and assessments for resident #10, dated 09/16/20 through 10/15/20, had no documentation reflecting the amount of oxygen the resident was being administered or the amount of oxygen in the resident's tank had been assessed or recorded. A Speech Therapy Treatment Encounter Note, dated 10/15/20, documented, the resident performed judgement tasks at 50% accuracy given mod-max verbal/visual cues when assessed for functional cognition in preparation for the morning's scheduled physician appointment .Resident required increased encouragement for participation .resident (experiencing) increased lability this session .left in care of MedRide . A facility document provided by the DON titled, Who Can Ride in Transport documented: .Policy: .The facility will dictate which assistants will accompany transport . On 06/23/20 at 09:30 a.m., the Medical Director of the physicians office stated the patient arrived at the physician's office for a scheduled appointment the morning of 10/15/20. Upon arrival the patient's oxygen tank was empty, was in respiratory distress exhibiting signs of shortness of breath and cognition deficit, the resident's oxygen saturation level was 57% and the resident's oxygen tank was empty. The resident needed to have a staff member from the nursing home facility accompany her to the physician appointment due to having severe physical limitations and cognition deficits. The patient was transported to the hospital emergency room . A emergency room physician's note, dated 10/15/20, documented, .Nursing home resident. Was dropped off at ENT clinic with no NH staff remaining with her. Clinic staff found her to be hypoxic. Patient is on 3LNC home oxygen but her tank is empty. Upon contacting the nursing home they told the clinic they were 'short staffed and unable to help them' .Patient answers her name but nothing further . .Review of Systems .fatigue, eye disease injury/blurry-double vision, hearing deficit .shortness of breath .Auscultation of the chest reveals diminished breath sounds at the bases .positive for shortness of breath . .Chronic [CONDITION(S)]/[CONDITION(S)] .Noted to be hypoxic in waiting room .Oxygen tank was empty .patient chronically on 3L, abnormal ABG's . .awakens but is somnolent .Pneumonia, CXR reveals R UL infiltrate not previously noted on comparison from 09/12/20 .Cognitive communication deficit . .The patient who arrives today with chief complaint of [CONDITION(S)] .was dropped off at the doctor's appointment by med ride, she did not have an attendant with her, the doctor's office noticed that the patient oxygen tank was low and called EMS. Upon arrival here the patient was hypoxic in at 40% .complains of generalized body aches .Decreased breath sounds present . There was no documentation in the resident's medical record indicating a staff member from the facility or a family member had accompanied the resident to the physician appointment. A Weights and Vitals Summary, dated September 2020 through October 2020, documented the resident was administered oxygen 69 out of 106 shifts. The Weights and Vitals Summary, dated September 2020 and October 2020, had no documentation reflecting the amount of oxygen being administered each shift. On 6/21/21 at 1:00 p.m., the social services director stated they scheduled all outside appointments, usually if the resident had a BIMS of 12 or under they sent a staff member with them. They stated they were responsible for contacting the family to let them know about the appointment or any other resident related issues and to see if they would be able to accompany them to the appointment. They stated there was no documentation showing the family had been contacted regarding the doctor appointment. At 1:43 p.m., The DON stated the nurse assigned to that resident should have documented where the appointment was, what ride the resident was using, who the resident was going with, the condition of the resident before leaving the facility, any communication with the family related to the appointment and the level of oxygen in the resident's tank. At 1:46 p.m., the DON confirmed there was no documentation in the medical record showing the resident's family had been notified regarding the doctor appointment and change in condition. At 1:48 p.m., the DON was asked what system was in place to ensure the residents with oxygen ordered had enough oxygen in their tank. The DON stated they usually checked the tank was full before they exited the facility, if they were on oxygen they sometimes put a treatment in the TAR to check the oxygen bottle at certain intervals, whoever took them to the doctor should check their oxygen tank level. She stated nurses were the only staff members able to change out the 02 tanks. The DON was asked if any staff member checked the resident's oxygen tank level before the resident left the faciity on [DATE]. She stated, I don't know. There was no documentation in the resident's medical record the resident's oxygen tank level was assessed or when the last time the 02 tank or bottle had been replaced. There was no documentation in the resident's medical record facility staff had reported the resident's frequent use of the as needed oxygen from 09/16/20 through 10/15/20 to the physician. There was no documentation in the resident's medical record a staff member accompanied the resident to the out of facility physician appointment to assist the resident with physical limitations (legally blind, hard of hearing, in need of assistance with ADL's, and 02 dependent) and cognitive deficits (BIMS of 11, speech therapy cognitive assessment at 50% the morning of the physician appointment). The TAR, dated 09/2020 and 10/2020, did not include documentation the levels of oxygen being administered had been assessed, monitored and recorded in order to assess trending oxygen needs. On 06/23/21 at 10:00 a.m., LPN #2 stated she knew the resident was one of those that would be not totally with it. She stated she would have assessed her somewhere in the ballpark of 7:00 a.m. the morning of the physician visit, but recorded it late. She stated there was no report communicated to her the resident had someone from the facility able to act as an attendant to the physician appointment scheduled. She stated it would have benefited the resident to have someone go with her since she was oxygen dependent, had cognitive and severe physical deficits and was legally blind. At 12:28 p.m., the administrator was asked about the hospital ER note that documented, called the facility and they said, we didn't have enough staff to send with her, I'm sorry. The administrator stated, Yes, it was COVID, we probably didn't have enough staff to send. At 3:15 p.m., the Medical Director stated after reviewing the medical record of the resident, it was determined the resident was hypoxic on arrival to the hospital emergency room . The director stated somebody from the facility had needed to go with the resident to the physician appointment. The therapy cognition assessment the morning of the physician appointment was at 50%, .this assessment alone meant a staff member should have gone to the appointment with the resident. At 3:20 p.m., the Medical Director was asked about the prn oxygen orders for the resident. The Director stated he would have to fix the prn oxygen orders, but the resident with end stage [CONDITION(S)] and [CONDITION(S)] with [CONDITION(S)] should have been on continuous oxygen. He stated an as needed oxygen order is for someone that is crashing, this resident should have been on continuous oxygen. 2. Resident #11 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/23/21 at 11:00 a.m., the resident was observed in a wheelchair at front desk with an oxygen tank that was in a 02 tank bag on the back of the wheelchair. The 02 tank was 1 tab away from the red area indicating the oxygen level in the tank was low or empty. The resident was observed for two hours self-propelling the wheelchair at the front desk area, in hall 200 and in hall 300 with his oxygen tank needle in the red area indicating low or no oxygen was in the tank. At 01:00 p.m., the DON, the Social Services Director, and the Infection Control Nurse pushed the resident in his wheelchair to the end of hall 200 and proceeded to replace his oxygen tank. The group was asked what level the old oxygen tank had reflected. The DON stated just above the red, the Infection Control Nurse stated it was in the red and low but we changed the tank out. At 1:03 p.m., the group was asked if the tank should have fallen to the red area level indicating low/almost empty oxygen. The DON stated, No. The facility staff group of three were asked when the last time the oxygen tank level had been assessed. The DON stated, I don't know. There was no documentation in the resident's medical record from the latest admit on 06/04/21 through 06/23/21 which indicated qualified, competent staff had assessed oxygen tank levels or detailing oxygen tank level replacements. At 1:05 p.m., the DON was asked why the oxygen tank level had dropped to the red area level indicating low/almost empty before staff checked the oxygen level. The DON stated, I am just beside myself, I am not sure. At 1:10 p.m., the DON was asked what process was in place in order to ensure resident's that were 02 dependent had oxygen in their tank. The DON stated, The nurse on the hall should be checking, anyone should be checking, but it isn't happening. At 3:20 p.m., the Medical Director was asked about the prn oxygen orders for the resident. The medical director stated he was going to have to fix the as needed oxygen orders for the long term care residents in this facility. He stated as needed oxygen orders are not for these residents that are end stage [CONDITION(S)] and in [CONDITION(S)], the resident should have been administered continuous oxygen. The director stated an as needed oxygen order was for someone that was crashing, this resident should have been on continuous oxygen at all times. There was no documentation in the resident's medical record from 06/04/21 through 06/23/21 of an assessment by qualified, competent staff of the resident's need for continuous oxygen.

Based on observation, record review and interview, it was determined the facility failed to: ~ ensure residents were free of falls involving bedrails for one (#8) of three sampled residents who were reviewed for falls, Resident #8 had a fall which required being sent to the emergency room after hitting the left side of her head. The resident had a small laceration which required sutures, and ~ implement fall precautions for two (#1 and #3) of three sampled residents who were reviewed for falls. The facility identified 11 residents with interventions for falls. Findings: A policy titled side rails and beds, dated 01/2018, documented side rail latches shall be secure and stable so that the side rail does not fall from the up position when shaken or bumped. 1. Resident #8 was admitted on [DATE]. Her admission diagnoses were cerebral infarction and [CONDITION(S)]. An assessment, dated 01/15/20, documented the resident had severely impaired cognition and required extensive two person assist. An incident report, dated 05/16/20, documented after the facility investigated the fall, it was determined equipment failure and human error contributed to the resident falling. A hospital physician progress note, dated 05/19/20, documented the resident was sent to the emergency room for a recent fall hitting the left side of her head. She had a small laceration to her head. The emergency room repaired the wound with sutures. A care plan, dated 05/19/20, documented the resident was at risk for falls related to decreased mobility, dependence on staff for transfers/mobility and decrease cognition. The care plan documented side rails times two to assist with turning and repositioning. The care plan had been updated on 05/16/21 to document the resident was a two person assist. On 06/16/21 at 2:00 p.m., licensed practical nurse #5 stated they only had one aide on the floor that night. They usually had more than one aide. The aide had not asked for help. She was doing peri care by herself, the rail fell and the resident fell off the bed to the floor. At 2:52 p.m., CNA #7 said the resident was a one to two person assist. She said she was doing her last rounds and providing peri care to the resident. She said she had to force the bed rail up due to the mattress not fitting properly. She said the mattress was so big it made it hard to lock the rail in place. She stated the rail fell down while she was providing peri care and the resident fell to the floor hitting her head. On 06/17/21 at 9:15 a.m., maintenance staff #1 said the bed had multiple problems. There were multiple beds in the facility with bed rails that did not fit correctly. The bed was an old hospital bed with half rails. The resident had always complained about her bed rails not working. He stated he told the administrator about the issues with the bed and the administrator had ordered her a new bed. At 9:27 a.m., certified nurse aide (CNA) #7 was asked how many people it took to provide peri care to the resident. She said she always used two people because if the resident started to roll off the bed she could not stop herself. At 9:33 a.m., CNA #6 was asked how many people it took to provide peri care for the resident. She said it took two people because the resident was stiff and had pain. The resident was not able to assist with repositioning. They always used two people. At 10:09 a.m., the director of nursing (DON) was asked how many people should assist the resident with bed mobility. She said the assessment documented extensive two person assist. At 12:44 p.m., the DON and administrator were notified of the findings. They both acknowledged the concerns. 2. Resident #3 had diagnoses which included seizures, heart failure and dysphagia. An incident report (IR), dated 02/23/21, documented new wedge interventions to prevent falls. A quarterly assessment, dated 04/19/21, documented the resident's cognition severely impaired and extensive two person assist with bed mobility. On 06/16/21 at 11:58 a.m., the resident was observed in bed with a fall mat at bedside. The wedge was not in place. On 06/21/21 at 8:30 a.m., the resident was observed with a fall mat at bedside and the wedges were not in place. At 1:00 p.m., the resident was observed in bed with a fall mat at bedside, but the wedge was not in place and the resident had slid down sideways in the bed. On 06/23/21 at 11:30 a.m., certified nurse aide #2 and #6 were asked if the resident had wedges as an intervention to prevent falls. They both agreed the wedges should have been in place to prevent falls. They were asked where the wedges were located. CNA #2 stated the wedges were located in another resident's room. She said someone keeps using them for another resident. At 9:47 a.m., the director of nursing (DON) was notified of the observations. She acknowledged the concerns. 3. Resident #1 was admitted to the facility with diagnoses which included [CONDITION(S)], Unsteady on Feet, Muscle weakness, Chronic Kidney Disease and [CONDITION(S)]. The care plan, dated 06/19/19, documented, .Interventions .Low bed with mats . Internal incident reports documented resident #1 has had multiple falls since 12/11/2020: On 12/11/20 at .11:30 a staff member notified the nurse the resident was on the floor. The nurse observe the resident sitting on the floor beside her bed. No injuries reported . On 01/02/21 at .23:02 the nurse was called to the resident room, the resident was lying on the floor with urine and feces around her, sheets were wet on the side of the mattress. No injuries noted .Intervention .place fall mats beside the bed . On 01/04/21 at .21:49 this nurse was notified by the staff member patient sitting on the floor. Walked to patient room and observed patient sitting on the floor with her back leaning on the wheelchair. No injuries noted . On 01/09/21 at .19:07 CNA (Certified nursing assistant) reported to nurse that resident fell out of wheelchair. Upon entry nurse observed resident on floor grimacing in pain. States her left knee hurts. No open areas to left knee at this time. No other injuries assessed or observed . On 04/21/21 at .04:50 Nurse aide notified nurse pt in room on floor. Upon entry to room pt observed sitting on her bottom with her back against the bed . On 04/29/21 at .08:19 Nurse was standing at treatment cart when heard a loud crash and cry for help. Upon entering residents room resident was observed lying in front of her bed on left lateral side. Resident was asked if she had hit her head and stated yes. Upon assessment resident was noted to have a hematoma to the left front of her head measuring 3cmx2cm and a small abrasion to the left knee measuring 1cmx1cm . On 05/24/21 at 1700 . The CNA notified this nurse patient sitting on the floor in front of the wheelchair. This nurse walked in the patients room immediately and observed resident sitting on the floor in front of her wheelchair . On 06/17/21 at 1:19 p.m., the resident was observed lying in bed, eyes closed, no fall mat in place. On 06/21/21 at 8:16 a.m., the resident was observed in bed with breakfast tray on over the bed table. A fall mat was not in place, it was folded at the top of the bed between the bed and the dresser. At 10:05 a.m., the resident was observed lying in bed with the over the bed table over the bed. No fall mat was in place. At 10:08 a.m., CNA #3 (certified nursing assistant) was asked if resident #1's fall mat was beside her bed. She stated, No, we just got done changing her so we didn't put it back cause of the bedside table. At 11:06 a.m., the resident was observed in bed, no fall mat on the floor near the bed. At 1:04 p.m., the ADON (assistant director of nursing) was asked if resident #1 had a fall mat and when it was supposed to be put into place. She replied, When she is in bed. On 06/22/21 at 8: 15 a.m., resident #1 was observed sitting up in bed eating breakfast, no fall mat on the floor near bed. The fall mat was folded up at the head of the bed. At 8:40 a.m., observations were made with the (DON) director of nursing. Resident #1 was observed sitting in bed with the over the bed table across the bed. No fall mat was observed in place on the floor. The DON was asked if the fall mat should be in place on the floor near the bedside table, she replied, yes is should be. The fall mat was observed folded up at the head of the residents' bed. On 06/23/21 at 12:14 p.m., resident #1 was observed sitting in her bed eating lunch. The bedside table was over the bed. The fall mat was not in place on the floor near the bed.

Based on observation, record review, and interviews, it was determined the facility failed to: ~ ensure a staff member accompanied one (#10) of one sampled resident who was reviewed for safety procedures during a scheduled, out of facility physician appointment and ~ ensure there was a sufficient supply of portable oxygen for two (#10 and #11) of three sampled residents who were reviewed for the use of oxygen per nasal cannula. Resident #10 was oxygen dependent related to end stage [CONDITION(S)] and [CONDITION(S)] with [CONDITION(S)]. On the morning of 10/15/20 the resident was transported to a physician appointment unaccompanied by a staff member. Upon arrival to the physician's office the resident was in respiratory distress, had an oxygen saturation level of 57%, had an empty 02 tank, and could not answer any questions except to give a name. The resident was transported from the physician office to the emergency room . Hospital notes documented the resident's oxygen saturation level at 40% on room air, the resident was experiencing severe [CONDITION(S)], and shortness of breath, had a vision deficit (was legally blind), a hearing deficit, and a cognitive communication deficit with somnolence. The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility identified eleven residents who had orders to receive oxygen per nasal cannula. Findings: A facility policy and procedure titled Oxygen Administration, dated October 2010, documented: .check tank to be sure they are in good working order . .observe the resident upon set-up and periodically thereafter . .After completing the oxygen set-up or adjustment .document the rate of oxygen flow . A facility policy and procedure titled Change in a Resident's Condition or Status, dated September 2013 documented: .3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: .b. There is a significant change in the resident's physical, mental, or psychosocial status; .e. it is necessary to transfer the resident to a hospital/treatment center . .5. Except in emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 1. Resident #10 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen at 2 l/m to 5 l/m per nasal cannula as needed for SOB/Respiratory Compromise to maintain 02 sats above 90%. A St. Louis University Mental Status Evaluation for the resident from the 09/2020 VA Hospital stay documented the resident's cognition with a score of 16, the most severe category for dementia, and the residents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial assessment, dated 9/21/20, documented, .BIMS of 11 .Moderate difficulty hearing .Severely impaired with Vision-no vision or sees only light, colors or shapes . .Functional Cognition assessed .needs partial assistance from another person in order to complete .regular tasks such as shopping or remembering to take medication . .Self-Care .needs assistance with bathing, dressing, using the toilet, or eating .Indoor Mobility .needs assistance with walking . A care plan, dated 09/30/20, documented, .resident has Oxygen Therapy r/t sob .will have no s/sx of poor oxygen absorption through the next review date (11/30/20) .Monitor/document side effects and effectiveness .Monitor for s/sx of respiratory distress and report to MD PRN: Respirations .Lethargy .Confusion .Atelectasis .Cough . .Provide reassurance and allay anxiety . .resident is at risk for falls/injury R/T assistance required with ADL function and mobility, incontinence and use of [CONDITION(S)] medications side effects .anticipate and meet individual needs of the resident . .resident presents with a Self-Care deficit in Symptoms & Problems are manifested by: Cognitive impairment .Symptoms & Problems are manifested by: General weakness .requires extensive assistance with (Bathing .Bed mobility .Dressing/Hygiene .Eating .Toileting .Transfers .Explain purpose & expected tasks .Break tasks down into simple sub-tasks .with one staff .Give sufficient time to accomplish each task . .resident is at risk for .respiratory distress R/T: Congestive Heart Failure .An increased risk for .shortness of breath .Observe for Shortness of breath .Allow rest periods .Monitor lung sounds .Use oxygen as ordered .Monitor oxygen saturation as ordered and as needed . .has an alteration in communication R/T: hard of hearing .Ask simple direct questions .Repeat .quiet area so better to understand . .has respiratory risk R/T asthma/[CONDITION(S)], Problem manifested by: Respiratory infection .Difficulty breathing .Monitor breath/lung sounds prn .Offer reassurance and emotional support .Observe .for any s/sx of infection . .has [CONDITION(S)] and is at risk for altered tissue perfusion .Administer 02 PRN for SOB . .at risk for decreased vision R/T: [CONDITION(S)] .Provide large printed reading . Progress notes, evaluations, tasks and assessments for resident #10, dated 09/16/20 through 10/15/20, had no documentation reflecting the amount of oxygen the resident was being administered or the amount of oxygen in the resident's tank had been assessed or recorded. A Speech Therapy Treatment Encounter Note, dated 10/15/20, documented, the resident performed judgement tasks at 50% accuracy given mod-max verbal/visual cues when assessed for functional cognition in preparation for the morning's scheduled physician appointment .Resident required increased encouragement for participation .resident (experiencing) increased lability this session .left in care of MedRide . A facility document provided by the DON titled, Who Can Ride in Transport documented: .Policy: .The facility will dictate which assistants will accompany transport . A emergency room physician's note, dated 10/15/20, documented, .Nursing home resident. Was dropped off at ENT clinic with no NH staff remaining with her. Clinic staff found her to be hypoxic. Patient is on 3LNC home oxygen but her tank is empty. Upon contacting the nursing home they told the clinic they were 'short staffed and unable to help them' .Patient answers her name but nothing further . .Review of Systems .fatigue, eye disease injury/blurry-double vision, hearing deficit .shortness of breath .Auscultation of the chest reveals diminished breath sounds at the bases .positive for shortness of breath . .Chronic [CONDITION(S)]/[CONDITION(S)] .Noted to be hypoxic in waiting room .Oxygen tank was empty .patient chronically on 3L, abnormal ABG's . .awakens but is somnolent .Pneumonia, CXR reveals R UL infiltrate not previously noted on comparison from 09/12/20 .Cognitive communication deficit . .The patient who arrives today with chief complaint of [CONDITION(S)] .was dropped off at the doctor's appointment by med ride, she did not have an attendant with her, the doctor's office noticed that the patient oxygen tank was low and called EMS. Upon arrival here the patient was hypoxic in at 40% .complains of generalized body aches .Decreased breath sounds present . There was no documentation in the resident's medical record indicating a staff member from the facility or a family member had accompanied the resident to the physician appointment. A Weights and Vitals Summary, dated September 2020 through October 2020, documented the resident was administered oxygen 69 out of 106 shifts. The Weights and Vitals Summary, dated September 2020 and October 2020, had no documentation reflecting the amount of oxygen being administered each shift. On 6/21/21 at 1:00 p.m., the social services director stated they scheduled all outside appointments, usually if the resident had a BIMS of 12 or under they sent a staff member with them. They stated they were responsible for contacting the family to let them know about the appointment or any other resident related issues and to see if they would be able to accompany them to the appointment. They stated there was no documentation showing the family had been contacted regarding the doctor appointment. At 1:43 p.m., The DON stated the nurse assigned to that resident should have documented where the appointment was, what ride the resident was using, who the resident was going with, the condition of the resident before leaving the facility, any communication with the family related to the appointment and the level of oxygen in the resident's tank. At 1:46 p.m., the DON confirmed there was no documentation in the medical record showing the resident's family had been notified regarding the doctor appointment and change in condition. At 1:48 p.m., the DON was asked what system was in place to ensure the residents with oxygen ordered had enough oxygen in their tank. The DON stated they usually checked the tank was full before they exited the facility, if they were on oxygen they sometimes put a treatment in the TAR to check the oxygen bottle at certain intervals, whoever took them to the doctor should check their oxygen tank level. She stated nurses were the only staff members able to change out the 02 tanks. The DON was asked if any staff member checked the resident's oxygen tank level before the resident left the faciity on [DATE]. She stated, I don't know. There was no documentation in the resident's medical record the resident's oxygen tank level was assessed or when the last time the 02 tank or bottle had been replaced. There was no documentation in the resident's medical record facility staff had reported the resident's frequent use of the as needed oxygen from 09/16/20 through 10/15/20 to the physician. There was no documentation in the resident's medical record a staff member accompanied the resident to the out of facility physician appointment to assist the resident with physical limitations (legally blind, hard of hearing, in need of assistance with ADL's, and 02 dependent) and cognitive deficits (BIMS of 11, speech therapy cognitive assessment at 50% the morning of the physician appointment). The TAR, dated 09/2020 and 10/2020, did not include documentation the levels of oxygen being administered had been assessed, monitored and recorded in order to assess trending oxygen needs. On 06/23/21 at 9:30 a.m., the Medical Director of the physicians office stated the patient arrived at the physician's office for a scheduled appointment the morning of 10/15/20. Upon arrival the patient's oxygen tank was empty, was in respiratory distress exhibiting signs of shortness of breath and cognition deficit, the resident's oxygen saturation level was 57% and the resident's oxygen tank was empty. The resident needed to have a staff member from the nursing home facility accompany her to the physician appointment due to having severe physical limitations and cognition deficits. The patient was transported to the hospital emergency room . On 06/23/21 at 10:00 a.m., LPN #2 stated she knew the resident was one of those that would be not totally with it. She stated she would have assessed her somewhere in the ballpark of 7:00 a.m. the morning of the physician visit, but recorded it late. She stated there was no report communicated to her the resident had someone from the facility able to act as an attendant to the physician appointment scheduled. She stated it would have benefited the resident to have someone go with her since she was oxygen dependent, had cognitive and severe physical deficits and was legally blind. At 12:28 p.m., the administrator was asked about the hospital ER note that documented, called the facility and they said, we didn't have enough staff to send with her, I'm sorry. The administrator stated, Yes, it was COVID, we probably didn't have enough staff to send. At 3:15 p.m., the Medical Director stated after reviewing the medical record of the resident, it was determined the resident was hypoxic on arrival to the hospital emergency room . The director stated somebody from the facility had needed to go with the resident to the physician appointment. The therapy cognition assessment the morning of the physician appointment was at 50%, .this assessment alone meant a staff member should have gone to the appointment with the resident. At 3:20 p.m., the Medical Director was asked about the prn oxygen orders for the resident. The Director stated he would have to fix the prn oxygen orders, but the resident with end stage [CONDITION(S)] and [CONDITION(S)] with [CONDITION(S)] should have been on continuous oxygen. He stated an as needed oxygen order is for someone that is crashing, this resident should have been on continuous oxygen. 2. Resident #11 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/23/21 at 11:00 a.m., the resident was observed in a wheelchair at front desk with an oxygen tank that was in a 02 tank bag on the back of the wheelchair. The 02 tank was 1 tab away from the red area indicating the oxygen level in the tank was low or empty. The resident was observed for two hours self-propelling the wheelchair at the front desk area, in hall 200 and in hall 300 with his oxygen tank needle in the red area indicating low or no oxygen was in the tank. At 01:00 p.m., the DON, the Social Services Director, and the Infection Control Nurse pushed the resident in his wheelchair to the end of hall 200 and proceeded to replace his oxygen tank. The group was asked what level the old oxygen tank had reflected. The DON stated just above the red, the Infection Control Nurse stated it was in the red and low but we changed the tank out. At 1:03 p.m., the group was asked if the tank should have fallen to the red area level indicating low/almost empty oxygen. The DON stated, No. The facility staff group of three were asked when the last time the oxygen tank level had been assessed. The DON stated, I don't know. There was no documentation in the resident's medical record from the latest admit on 06/04/21 through 06/23/21 which indicated qualified, competent staff had assessed oxygen tank levels or detailing oxygen tank level replacements. At 1:05 p.m., the DON was asked why the oxygen tank level had dropped to the red area level indicating low/almost empty before staff checked the oxygen level. The DON stated, I am just beside myself, I am not sure. At 1:10 p.m., the DON was asked what process was in place in order to ensure resident's that were 02 dependent had oxygen in their tank. The DON stated, The nurse on the hall should be checking, anyone should be checking, but it isn't happening. At 3:20 p.m., the Medical Director was asked about the prn oxygen orders for the resident. The medical director stated he was going to have to fix the as needed oxygen orders for the long term care residents in this facility. He stated as needed oxygen orders are not for these residents that are end stage [CONDITION(S)] and in [CONDITION(S)], the resident should have been administered continuous oxygen. The director stated an as needed oxygen order was for someone that was crashing, this resident should have been on continuous oxygen at all times. There was no documentation in the resident's medical record from 06/04/21 through 06/23/21 of an assessment by qualified, competent staff of the resident's need for continuous oxygen.

Based on observations, record reviews and interviews, it was determined the facility failed to ensure: ~ policies regarding [MEDICAL CONDITION] (a surgical opening made from the throat to windpipe through which a person can receive air to breathe) care had been developed prior to the admission of residents with tracheostomies; ~ staff were sufficiently trained and competent in [MEDICAL CONDITION] care and emergency interventions prior to the assignment of residents with tracheotomies for two (#1 and #2) of four sampled residents who required [MEDICAL CONDITION] care; ~ residents requiring respiratory care were assessed timely and assessments were completed by qualified staff for one (#1) of 4 sampled residents; and ~ equipment for routine and emergency [MEDICAL CONDITION] care was functional and available at the bedside for one (#2) of four sampled residents. The administrator identified one resident in the facility who had a [MEDICAL CONDITION]. Findings: A facility policy titled, Suctioning the Lower Airway (Endotracheal (ET) or [MEDICAL CONDITION]), documented: .Preparation .Obtain baseline vital signs and oxygen saturation from the resident's medical record .Assemble the equipment and supplies as needed .Test equipment before use .Hyperinflate the resident .before and after suctioning .and hyperoxygenate the resident by increasing the oxygen flow .before the procedure and between suctioning .Monitor the resident's pulse and oxygen saturation .during suctioning. If pulse decreases more than 20 beats per minute (BPM) .or increases more than 40 BPM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re-ventilate and re-oxygenate the resident . Documentation .The following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed 2. The type and size of catheter used 3. Amount of negative pressure .used to suction 4. Amount, color and characteristics of secretions (color, odor, thickness, etc.). 5. The resident's response to the procedure. 6. Cardio-pulmonary status, including lung sounds, during the procedure. 7. Assessment data before and after the procedure . 9. The signature and title of the person performing the procedure . 1. On [DATE], the interim DON (director of nurses) was asked to provide all facility policies related to the care of a resident with a [MEDICAL CONDITION]. On [DATE] at 8:30 a.m., the DON provided the policy titled, Suctioning the Lower Airway (Endotracheal (ET} or [MEDICAL CONDITION]. The policy was reviewed and did not contain guidelines related to the provision of [MEDICAL CONDITION] care/dressing changes, emergency care and interventions and a policy which identified who was supposed to complete respiratory assessments, when they should be completed and the required documentation of the assessments. The DON was asked if the facility had policies for the issues listed above. She stated the facility had no other policies developed related to [MEDICAL CONDITION] respiratory care. 2. Resident #1 had [DIAGNOSES REDACTED]. A census form documented the resident was admitted to the facility on [DATE] at 2:22 p.m. physician's orders [REDACTED].[MEDICAL CONDITION] stoma with O2 (oxygen) concentrator, O2 at 35% liters to keep O2 sats (saturation) greater than 90 % (percent) .O2 sats every shift .[MEDICAL CONDITION] .[MEDICAL CONDITION] needed for excessive secretions .Change inner cannula daily on ,[DATE] (6:00 a.m. to 2:00 p.m.) shift .[MEDICAL CONDITION] NSS (normal saline solution), pat dry and place split gauze every shift [MEDICAL CONDITION] .Change concentrator tubing once a week on ,[DATE] (10:00 p.m. to 6:00 a.m.) shift .[MEDICAL CONDITION]/ties once a week and PRN (as needed) on day shift . A vital summary record, dated [DATE] at 6:38 p.m., documented she had a respiratory rate of 20 breaths per minute. There was no other documentation which included the resident's lung sounds, respiratory effort, oxygen saturation, or if she had sputum. A facility admission assessment, dated [DATE] at 10:38 p.m., documented the assessment was completed by LPN #1. This was the first documented assessment for the resident since admission. This assessment documented several concerns for residents's safety and airway including the resident had an occasional cough with yellow/green sputum and breath sounds of rhonchi in both lungs. The assessment documented the resident experienced shortness of breath while lying down and was using her accessory muscles. During the eight hours prior to the assessment there was scant documenting of the resident's condition. A progress note, dated [DATE] at 11:00 p.m., documented, .Patient requested to be suctioned. Patient tolerated suctioning well . There was no documentation of the characteristics of the sputum, if the resident tolerated the procedure, and her lungs sounds before and after. A nurse progress note, dated [DATE] at 12:45 a.m., documented, .Patient appeared to be resting with her eyes open, patients breathing started slowing down, this nurse went to check on patient and sat her up more. This nurse went to get pulse ox (oximetry) to check her oxygen level, and called another nurse on staff in room. Unable to get oxygen reading on patient, patient then went unresponsive on this nurse, but was still breathing, this nurse suctioned patient, while other nurse called for crash cart and called 911 .This nurse got a small amt of phlegm out [MEDICAL CONDITION] suctioning. Patient checked for breathing and pulse and no pulse noted, CPR (cardiopulmonary resuscitation) started .Firefighters arrived, took over CPR, very faint pulse noted by Firefighters .ambulance arrived shortly after that, they continued to work on patient. Patient left facility via ambulance aprox 0100. (1:00 a.m.) MD (medical doctor) notified . An emergency services report, dated [DATE], documented emergency services arrived at the facility at 12:58 a.m. They left the facility at 1:22 a.m. and arrived at the hospital at 1:24 a.m. The report further documented the resident had a partially obstructed airway with poor exchange and excessive secretions. The report documented the following narrative: .arrived to find pt (patient) in [MEDICAL CONDITION]. Staff on scene states that pt's breathing was slowly decreasing till pt stopped breathing and went into [MEDICAL CONDITION] .EMS (emergency services) did ask why pt was not be (being) ventilated thru (through) trach. Staff states [MEDICAL CONDITION] clogged and unable to ventilate thru it. FD (fire department) is performing CPR at this time . An emergency room report, dated [DATE], documented, .1:28 (1:28 a.m.) .in full arrest on arrival to facility. pt (patient) has a trachea that had liquid coming out per asystole on arrival cpr is in progress .1:39 (1:39 a.m.) .EMS states that patient trachea was suspected to be obstructed and EMS proceeded to suction patient's trachea .Patient was in full respiratory arrest and Vfib (ventricular fibrillation, an abnormal heart rhythm) on arrival to this facility .2:07 (2:07 a.m.) .Family had seen the patient 30 minutes prior to the arrest and she was doing relatively well. They did notice that she was needing suction which they did . A hospital report, dated [DATE] at 12:48 p.m., documented the resident was transferred to another acute care hospital around 5:00 a.m. on [DATE]. The report documented when the resident arrived she was starting to get febrile. She was not responsive and her pupils were pin point. The report documented chest x-ray evidence was [MEDICAL CONDITIONS] versus aspiration. A hospital report, dated [DATE] at 8:23 p.m., documented, .Patient was transferred to .nursing home where she had CODE BLUE ([MEDICAL CONDITION]), was resuscitated and had CPR for 20 minutes prior to transferring to another hospital. From there patient was transferred to our hospital for higher level of care. She continued to decline, requiring more and more pressor support (medications to control her blood pressure), EEG (electroencephalogram, a brain activity study) showed minimal activity, clinically brain dead as per neurologist. This was discussed with the family by .intensivist, after looking at her poor prognosis, the family decided to make her a DNR (do not resuscitate) and subsequently comfort care only. Patient passed away peacefully . On [DATE] at 11:28 a.m., a family member, was asked to describe the events of the resident's admittance to the facility. The family member stated, shortly after arriving at the facility, the nurse assigned to the resident stated she had only been employed there a couple of months and the nurse apologized to the family as she was not very familiar with the [MEDICAL CONDITION] equipment. The family member stated the nurse said she did not complete [MEDICAL CONDITION] training because the trainer left before she could complete the training. At 3:02 p.m., LPN #1 (licensed practical nurse) was asked if she had received [MEDICAL CONDITION] training from the facility prior to the admission of the resident. She stated she had not completed [MEDICAL CONDITION] training prior to the resident's admission because the person teaching the class was no longer at the facility. She stated she had apologized to the family about the lack of training. She stated she had not been familiar with the oxygen set up the resident wanted, and she had not known where [MEDICAL CONDITION] supplies were stored prior to the resident's arrival at the facility. She stated she had not had a chance to set up the resident's room prior to her arrival. She stated LPN #6 and a respiratory therapist helped set up the resident's oxygen equipment because she did not know how to. LPN #1 stated she was assigned care of the resident from admission to 8:00 p.m. She was asked if she had provided suctioning for the resident. She stated when the respiratory therapist arrived she provided education on how to suction the resident to herself and three other nurses (unknown names). She stated she did not know how to suction prior to the training and had not tried to suction the resident. She stated the training was provided between 3:00 and 3:20 p.m. She stated after the training she suctioned the resident twice. She was asked if she documented the characteristics of the sputum, if the resident tolerated the procedure, and what her lung sounds were before and after. She stated she did not document the information. On [DATE] at 10:13 a.m., LPN #5, was asked if she had taken care of residents with tracheotomies at the facility. She said, Yes. She stated she was currently taking care of a resident with a [MEDICAL CONDITION]. She was asked what she would do if the resident's cannula came out. She stated she would apply oxygen and call for assistance, but she was unsure if she would replace the cannula. She stated she was not familiar with the facility policy and would ask in an upcoming class that had been scheduled. At 10:56 a.m., the ADON (assistant director of nurses) was asked who had been doing the respiratory and [MEDICAL CONDITION] care in-services for the nursing staff. She stated the last DON (director of nurses) had planned to do some in-services for [MEDICAL CONDITION] care and suctioning, but she was no longer with the facility. She stated she was not sure how much progress had been made with the training. She stated the interim DON might have access to the training logs. At 11:05 a.m., the interim DON was asked if she had records of respiratory/[MEDICAL CONDITION] care in-services or trainings. She stated she had looked but could not find anything like that. She said, I wish I could .but I have found nothing about respiratory training. At 1:17 p.m., LPN #6 was asked if she had taken care of residents with tracheotomies at the facility. She said, Yes. She was asked if she had received [MEDICAL CONDITION] training from the facility prior to caring for residents with a [MEDICAL CONDITION]. She said, No. She stated she had been assigned residents with a [MEDICAL CONDITION] prior to being in-serviced. She stated she had been a nurse for [AGE] years and had prior experience caring for residents with tracheotomies. She then stated she had relied on her previous experience. At 2:02 p.m., LPN #7 was asked if she had cared for residents with tracheotomies at the facility. She said, Yes. She was asked if she had received [MEDICAL CONDITION] training from the facility prior to caring for those residents. She said, No. She stated she had several years of experience with residents with tracheotomies. She further stated she had relied on her previous experience. At 5:38 p.m., LPN #8 was asked if she received [MEDICAL CONDITION] training from the facility prior to caring for residents with tracheotomies. She said, No. She stated she had been employed at the facility about one month and had taken care of a resident with a [MEDICAL CONDITION]. She was asked if she had suctioned that resident. She said, Yes. She stated she was not familiar with the facility's policy for [MEDICAL CONDITION] care or the documentation the policy required. On [DATE] at 11:00 a.m., RN #1 (registered nurse) stated she had opened the admission assessment screener for the resident. She stated it was routine for her to open the assessments for newly admitted residents and any nurse assigned to the resident could complete them during their shift. She stated it was routine for an LPN to then complete the assessment in it's entirety. Nursing staff who cared for the resident during her stay were interviewed and all nursing staff stated they suctioned the resident at least once during their shift; however, there was not complete documenting of suctioning in the medical record. Documentation was not found to support the resident's pulse and oxygen saturation being monitored during suctioning. Documentation was not found concerning: 1. The date and time that the procedure was performed 2. The type and size of catheter used 3. Amount of negative pressure .used to suction 4. Amount, color and characteristics of secretions (color, odor, thickness, etc.). 5. The resident's response to the procedure. 6. Cardio-pulmonary status, including lung sounds, during the procedure. 7. Assessment data before and after the procedure . 9. The signature and title of the person performing the procedure as required by the facility policy. 3. Resident #2 had [DIAGNOSES REDACTED]. A nurse progress note, dated [DATE] at 3:00 p.m., documented the resident arrived at the facility via personal car with family members from another nursing facility. An admission assessment, dated [DATE] at 4:00 p.m., documented the resident was transferred to the facility at the family's request. She had a [MEDICAL CONDITION]. She was assessed with [REDACTED]. Her respirations were regular. She had an occasional cough with frothy white sputum. She was alert and oriented to person, place, and time. A nurse progress note, dated [DATE] at 5:21 p.m., documented the resident performed [MEDICAL CONDITION] and demonstrated proper/safe technique. The physician was notified and provided an order the resident may self [MEDICAL CONDITION]. physician's orders [REDACTED].[MEDICAL CONDITION] with NSS (normal saline solution), pat dry and place split gauze every shift [MEDICAL CONDITION]. Resident may perform [MEDICAL CONDITION] .[MEDICAL CONDITION] needed for excessive secretions as needed [MEDICAL CONDITION] .Trach size: 6 change as needed for displacement as needed [MEDICAL CONDITION] . A baseline care plan, dated [DATE], documented the resident was receiving [MEDICAL CONDITION] care. She had a size 6 inner cannula and had demonstrated competency with self care of [MEDICAL CONDITION] ability to change and replace the inner cannula as needed. The resident required suctioning and had demonstrated self competency with suctioning. On [DATE] at 9:31 a.m., the resident was observed in her room lying in her bed. She had a [MEDICAL CONDITION] with a #6 shiley inner cannula.[MEDICAL CONDITION] were tied. Split gauze was around the site. There was no drainage observed or dried debris at the site. There was no sputum observed at the opening of the inner cannula. The resident breath sounds could be heard and were clear. The resident was not coughing and appeared in no distress. She communicated with a pen and pad of paper. An ambu bag was observed at the resident's bedside. There was no oxygen concentrator or suction machine and equipment observed at the resident's bedside. There was no replacement inner cannula or obturator observed in plain site. At 9:34 a.m., LPN #5 stated she was assigned to care for the resident. She was asked to observe the resident's room. She acknowledged there was no suction machine and supplies in the resident's room. She then stated there was no oxygen set up in the resident's room. She was asked where the resident's replacement inner cannula and obturator was located. She stated the resident had several supplies in her room. She was a new admit and she was not sure where the supplies were located. She walked down the hall about 50 feet and was able to locate the correct sized inner cannula with an obturator for the resident. She also located suction supplies and oxygen supplies. She stated oxygen concentrators were located on a different hall in the facility. She was asked what action she would take if the resident decannulated. She stated she would call 911, alert staff she needed assistance, and provide the resident with oxygen and ventilation via an ambu bag. She stated she would continue to ventilate the resident until emergency services responded. A physician's orders [REDACTED].Oxygen 3L (liters) [MEDICAL CONDITION] 02 stat sic (saturation) is below 90 % (percent) as needed . At 11:30 a.m., the resident was observed in her room in her bed. She was awake and was not exhibiting any signs or symptoms of distress. An oxygen concentrator was at her bedside with oxygen tubing. A suction machine with supplies was behind the resident's television on a dresser. At 11:33 a.m., LPN #5 was asked if she had received any training at the facility related to care of a resident with a [MEDICAL CONDITION]. She stated a respiratory therapist had provided training on different types of suctioning for residents with tracheotomies. She was asked if the resident had a suction machine and supplies and an oxygen concentrator in her room this morning. She stated she did not. She was asked if her suction machine was currently accessible and if all equipment was hooked up. She stated it was not. She stated she had moved the suction equipment and oxygen equipment in the room after the resident's equipment was reviewed with the surveyor earlier in the morning. She was then asked if a replacement inner cannula and obturator were in the resident's room. She stated she had not put one in her room yet. She stated she wasn't sure what an obturator was. She was then informed what an obturator was and she then stated she was familiar with what it was but did not know what the name was. At 11:45 a.m., the DON was asked what emergency supplies should be at the resident's bedside and easily accessible for a resident with a [MEDICAL CONDITION]. She stated suction machine and supplies, and inner cannula and obturator, an ambu bag, gloves, and oxygen. She was asked why these items should be readily accessible. She stated for easy access. She was asked what action should the staff take if a resident accidentally decannulated. She stated they should call 911 and ventilate the resident with oxygen and an ambu bag until the resident arrived. She was asked how they should ventilate the resident. She stated cover the stoma and ventilate the mouth and nose. She was then notified the resident's room did not have a set up suction machine. There was no oxygen concentrator during earlier morning observations and an inner cannula and obturator had not been located in the resident's room. At 11:50 a.m., LPN #9 was asked if she had received training at the facility related to care of a resident with a [MEDICAL CONDITION] and emergency care. She stated she received an in-service two weeks ago which addressed how to suction a [MEDICAL CONDITION] and general care. She stated she had not received training for emergency care related to tracheotomies. She stated she was very familiar with tracheotomies and had taken care of many residents with tracheotomies at another facility. She stated she relied on her previous experience when caring for residents there. She was asked what emergency supplies should be kept at the resident's bedside. She stated an extra cannula, suction equipment and an oxygen concentrator. She was asked what action she would take if the resident decannulated. She stated she would call 911 and ventilate the resident with oxygen and an ambu bag via mouth and nose and cover the resident's stoma. At 12:00 p.m., the resident's room was observed. LPN #5 was present in the resident's room. She stated the resident's inner cannula and obturator were located and had been taped at the head of the resident's bed, but had not been visible. At 3:34 p.m., LPN #1 was asked if she had received any training at the facility related to care of a resident with a [MEDICAL CONDITION]. She stated it had been awhile since she cared for a resident with a trach. She stated last week she received training from a respiratory therapist on how to suction and how to hook up equipment. She was asked if the facility had provided training on emergences related to care of a resident with a [MEDICAL CONDITION] and what supplies should be kept at beside. She stated they had not. She was asked what action she would take if a resident accidentally decannulated. She stated she would call 911, cover the resident's stoma and provide ventilation, including oxygen, via the mouth and nose until emergency services arrived. She was asked what emergency equipment should be kept at the resident's bedside. She stated an ambu bag and inner cannula. She stated she could not think of anything else. At 3:51 p.m., the resident wrote out responses to questions with a pen on a pad of paper. She was asked if she had experienced any breathing difficulties since her admission. She stated she had not. She was asked if the facility had provided her [MEDICAL CONDITION] care every day. She stated they had but she was able to do her own care and had started doing that. She was asked if she had a need for suctioning since her admission. She stated she had not. She then stated her suction machine was not hooked up and was behind her television. LPN #1 then entered the resident's room. She was asked if the resident was able to provide her own suctioning. She stated she was. She stated the DON had assessed the resident and determined she was able to do her own suctioning. She was asked how the resident was assessed if her suction equipment was still not accessible and not hooked up. She said, I don't know. The resident then stated she had told staff she had done her own suctioning at the previous facility. She stated she didn't like to do it though. She stated she preferred for the staff to do it if she needed it. LPN #5 stated the staff would provide her suctioning. LPN #5 then connected the equipment to the suction machine and tested the settings on the machine. She then moved the equipment to an accessible location.

Based on observation, record review, and staff and resident interviews, it was determined the facility failed to: ~ measure pressure wounds weekly for one (#42) of five sampled residents reviewed for pressure ulcers and ~ provide wound care treatment as ordered for three (#15, 42 and #49) of five sampled residents reviewed for pressure ulcers. This resulted in harm when resident #42's pressure ulcer to the right and left ischium increased in size. The Resident Census and Conditions of Residents report, dated 04/16/18, documented 10 pressure ulcers. Findings: A pressure ulcer treatment policy, undated, documented, .The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers . 1. Resident #42 had [DIAGNOSES REDACTED]. A quarterly resident assessment, dated 02/13/18, documented the resident was at risk of pressure ulcer development and had two stage four pressure ulcers. It documented the pressure ulcer with the largest surface area in centimeters (cm) had a length of 8.3, width of 4.1 and depth of 0.2. It documented the most severe tissue type was granulation tissue. The wound physician note, dated 02/27/18, documented the resident had a stage four pressure ulcer of the left ischium which measured 3.5 x 2.1 x 0.1 cm. It documented the recommended treatment was skin prep to peri wound, calcium alginate, leptospermum honey and foam dressing once daily. The wound physician note, dated 03/06/18, documented the resident had a stage four pressure ulcer of the left ischium which measured 3.8 x 2.5 x 0.1 cm. It documented the resident had a stage four pressure ulcer of the right ischium which measured 7.8 x 3.8 x 0.2 cm. The facility weekly pressure ulcer log for the week of 03/08/18 through 03/15/18, documented the right ischium measured 8.3 x 4.1 x 0.2 cm and the left ischium measured 3.5 x 1.2 x 0.1 cm. A care plan, last revised on 03/14/18, documented, .SKIN: (Resident) has actual impairment to skin integrity stage 4 pressure injury to right and left ischium .She is not compliant with pressure reducing efforts and is unable to tolerate repositioning on either side and will frequently change her position back to supine after staff have repositioned .check dressing to left and right ischium for clean dry and intact may change prn (as needed) to reapply per MD (medical doctor) treatment order .Monitor/document location, size and treatment of [REDACTED].(resident) frequently will go back to lying on her back please notify nurse/wound care of her compliance . There were no facility weekly pressure ulcer measurements for the right or left ischium for the week of 03/18/18 through 03/24/18. The wound physician note, dated 03/27/18, documented the resident had a stage four pressure ulcer of the left ischium which measured 9.4 x 3.8 x 0.1 cm, exudate: moderate serous, granulation tissue: 60%, Skin 40%, wound progress: deteriorated. The note documented the recommended treatment plan was for skin prep to be applied to peri wound, calcium alginate, leptospermum honey and dry protective dressing once daily for thirty days. It documented the resident had a stage four pressure ulcer of the right ischium which measured 7.5 x 6.0 x 0.3 cm. It documented the wound progress was deteriorated. A physician order, dated 03/27/18, documented, .LEFT ISCHIUM-Cleanse with [MEDICATION NAME] X (times) 5 minutes-Apply skin prep to periwound area-Apply Leptospermum honey-Apply Ca (calcium) Alginate-Cover with Bordered NADH (nonadherent) Dressing .every day shift for Pressure Ulcers AND as needed for Pressure Ulcer . The (MONTH) (YEAR) treatment administration record (TAR) documented the above order with a start date of 02/21/18 and discontinue (D/C) date of 03/27/18. The same order was repeated again with a start date of 03/28/18 and D/C date of 04/11/18. The treatment was not documented as completed on the 2nd, 11th, 13th, 17th, 24th, 25th or 31st on the (MONTH) (YEAR) treatment administration records (TARs). ~ Right Ischium- Cleanse with NS (normal saline) with gauze- Apply skin prep periwound- Apply Leptospermum Honey- Apply Calcium Alginate- Cover with bordered foam dressing every day shift every Tue, Thu, Sat for pressure ulcers- Start Date 01/18/18 D/C date 03/27/18. The treatment was not documented as completed on the 13th, 17th or 24th. ~ Right Ischium- Cleanse with [MEDICATION NAME] on gauze- Apply skin prep periwound- Apply Calcium Alginate- Cover with bordered NADH dressing every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for pressure ulcers- Start date 03/28/18 D/C date 04/11/18. The treatment was not documented as completed on the 31st. The wound physician note, dated 04/03/18, documented the resident had a stage four pressure ulcer of the left ischium which measured 2.5 x 2.0 x 0.1 cm. It documented the resident had a stage four pressure ulcer of the right ischium which measured 9.0 x 7.5 x 0.2 cm. It documented the wound progress was deteriorated. It documented the resident had a stage two pressure ulcer of the right upper medial thigh which measured 1.1 x 0.5 x 0.1 cm. It documented the duration of the wound was greater than two days. It documented the recommended treatment plan was silver [MEDICATION NAME] and dry protective dressing once daily for 30 days. This was the first documented assessment of this wound. The wound physician note, dated 04/10/18, documented the resident had a stage four pressure ulcer of the left ischium which measured 3.1 x 2.5 x 0.1. It documented the 100% granulation tissue and the wound progress was deteriorated. It documented the recommended treatment was to apply skin prep to peri wound, and apply silver [MEDICATION NAME], calcium alginate, and a dry protective dressing once daily for 30 days. It documented the resident had a stage two pressure ulcer of the right posterior upper medial thigh which measured 1.0 x 0.4 x 0.1. It documented the recommended treatment plan was silver [MEDICATION NAME], calcium alginate and dry protective dressing once daily for 30 days. The wound physician note, dated 04/17/18, documented the resident had a stage four pressure ulcer of the left ischium which measured 4.8 x 3.2 x 0.1 with 100% granulation tissue. It documented the wound progress as deteriorated. It documented staff were unable to keep urine away from wounds. It documented foam dressing with skin prep for adhesion should help secure primary dressings. A physician order, dated 04/18/18, documented, cleanse rt (right) Ischium with ns pat dry, skin prep to edge of wounds, apply silver [MEDICATION NAME] to center of wound and cover with dry non adherent bordered foam dressing daily every day shift for wound care. The (MONTH) (YEAR) TAR documented: ~ Right Ischium- Cleanse with [MEDICATION NAME] on gauze- Apply skin prep periwound- Apply Leptospermum honey- Apply Calcium Alginate- Cover with bordered NADH dressing every day shift every Tue, Thu, Sat for pressure ulcers- Start Date- 03/28/18 D/C date 04/11/18. There was no documentation wound care was provided to this wound between 04/11/18 and 04/19/18. ~ Cleanse right ischium with ns pat dry, skin prep to edge of wounds, apply silver [MEDICATION NAME] to center of wound and cover with dry nonadherent bordered foam dressing daily every day shift for wound care - Start Date - 04/19/18. ~ Cleanse rt posterior upper medial thigh (number 1) with ns, pat dry, wipe peri wound with skin prep apply silver sulfadiazadine cover with foam dressing daily every day shift for wounds -Start date- 04/12/18 D/C date 04/18/18. The TAR did not document treatment was provided to this wound site prior to (MONTH) 12th. ~ Left Ischium-Cleanse with [MEDICATION NAME] x5 minutes- Apply skin prep to periwound area- Apply Leptospermum honey- Apply Ca Alginate- Cover with bordered NADH dressing every day shift for pressure ulcers-Start Date- 03/28/18 D/C date 04/11/18. The treatment was not documented as completed on the 6th. A visitor sign in/out sheet documented on 04/06/18 the resident's time out was 7:00 and time in was 6:30. The record did not document if it was a.m. or p.m. On 04/16/18 at 9:57 a.m., the resident was asked if the facility provided wound care as ordered. She stated she did receive wound care, but it was not provided every day as ordered for the wounds on her buttocks. On 04/24/18 at 10:40 a.m., the wound nurse was observed providing wound care treatment to the resident's pressure ulcers. She was observed using proper infection control measures and provided wound care as ordered except she failed to apply skin prep to the edge of the right ischium pressure ulcer. On 04/25/18 at 10:45 a.m., the wound nurse was asked if the resident's right ischium wound care order documented to apply skin prep to the edge of the wound. She stated, Yes, there is. She was asked if she had provided the treatment as ordered during the wound care observation since she was not observed using skin prep. She stated, No. She was asked what days of the week she worked. She stated she worked Monday through Friday. She was asked who was responsible for providing wound care when she was not working. She stated, The charge nurses. On 04/30/18 at 7:45 a.m., the director of nursing (DON) and the wound nurse were asked how staff determined what treatment was appropriate for residents with wounds. The DON stated once staff identified skin integrity alterations, the nurse would evaluate the wound and notify the primary physician for treatment orders. She stated the wound care nurse would also evaluate the wound and would consult the wound physician as needed. They were asked if the wound physician wrote a wound care treatment recommendation during his visit, did staff follow the recommendation. The DON stated, Yes, we should. They were asked if the 02/27/18 wound physician note for the left ischium documented a dressing of skin prep to peri wound area, calcium alginate, leptospermum honey and foam dressing once daily. The wound nurse stated, That's what is says. She was asked if the facility acted on this recommendation when the (MONTH) (YEAR) TAR documented staff cleansed the wound with [MEDICATION NAME] x 5 min. She stated, We didn't clarify. They were asked if the 03/06/18 wound physician note documented the same dressing. The wound nurse stated, Right. She was asked if the TAR documented the staff cleansed the wound with [MEDICATION NAME] for five minutes. She stated, Yes, they did. They were asked to acknowledge the wound physician did not see the resident between 03/06/18 and 03/27/18. The DON stated, Yes. They were asked if the 03/27/18 wound physician note documented skin prep to peri wound and calcium alginate, leptospermum honey and dry protective dressing once daily for 30 days. The wound nurse stated, Yes. She was asked if she could explain the reason the order, dated 03/28/18, continued to document to cleanse the wound with [MEDICATION NAME] for five minutes. The wound care nurse shook her head no. She was asked if this treatment continued through 04/11/18. She stated, That's what it looks like. She stated, That's the d/c date. She stated if the wound physician did not clarify, it was usually normal saline. They were asked if the note documented the wound had deteriorated with measurements of 9.4 x 3.8 x 0.1. The wound nurse stated, Yes. She was asked if the wound physician note documented the wound measured 3.8 x 2.5 x 0.1 on 03/06/18. She stated, Yes. They were asked if the resident missed five wound care treatments during this time. The wound care nurse stated, Yes. They were asked if not completing wound care treatments as ordered could have contributed to the increase in the resident's wound size. The DON stated, Yes. They were asked if the wound increased in size from the wound physician note on 04/03/18 and 04/10/18. The wound nurse stated, Yes. They were asked if wound care was provided to the resident's wound on 04/06/18. The DON stated, Doesn't look like it. She was asked if the missed wound care could have contributed to the increase in the wound size. She stated, It could have. They were asked what skin prep was used for. They stated it protected the skin and assisted in adhering the dressing to the wound. They were asked if the 04/10/18 wound physician note documented the treatment recommendation included to apply skin prep to the peri wound once daily for 30 days. The wound nurse nodded her head yes. They were asked if the facility acted on this when the TAR did not document skin prep was applied. The wound nurse stated, No. They were asked if the wound physician note, dated 04/17/18, documented the wound had increased in size and the wound had deteriorated. The wound care nurse stated, Yes. The DON and the wound nurse were asked if the wound physician assessed the resident's right ischium pressure ulcer between 03/06/18 and 03/27/18. They stated he did not. They were asked if the facility had any measurements of the wound during that time. They stated, yes, the wound was measured during the week of 03/08/18 through 03/15/18. They were asked if the resident's wound had increased in size. They stated it had. They were asked if the resident missed three wound care treatments between 03/06 and 03/27/18. The wound nurse stated, Yes. They were asked if the 03/27/18 wound physician note documented the wound had deteriorated. The wound nurse stated, Yes. They were asked if the missed wound treatments could have contributed to the deterioration of the wound. The wound nurse stated, Yes. They were asked if the resident missed her wound care treatment on 03/31/18. The wound care nurse stated, Yes. The DON and the wound care nurse were asked if the wound physician's 04/03/18 note documented the right ischium wound had deteriorated with a size increase to 9.0 x 7.5 x 0.2. The wound nurse stated, Yes. They were asked if the (MONTH) TAR documented the treatment to the resident's right ischium was discontinued on 04/11/18. The wound nurse stated, Yes. They were asked if the TAR documented the new wound treatment started on 04/19/18, was there any documentation wound care treatment was provided to the resident's right ischium between the discontinue order on 04/11 and the new order with a start date of 04/19/18. The wound nurse stated, No, it doesn't show it. The DON stated, Nope. The DON and the wound nurse were asked if the 04/03/18 wound physician's note documented the resident had a stage two pressure ulcer to the right posterior upper medial thigh which measured 1.1 x 0.5 x 0.1 cm. The wound nurse stated, Yes. They were asked if the note documented a treatment recommendation of silver [MEDICATION NAME] and dry protected dressing once daily for 30 days. The wound nurse stated it did. They were asked if the facility acted on this recommendation when the (MONTH) TAR documented wound care did not start until 04/12/18. The wound nurse stated, No. The DON and wound nurse were asked if the 04/10/18 wound physician note documented the wound had improved. The wound nurse stated, Yes. They were asked if the note documented the recommended treatment was silver [MEDICATION NAME], calcium alginate and dry protective dressing. The wound nurse stated, Yes. She was asked if she could explain the reason skin prep was added to the order dated 04/12/18. The wound care nurse stated, No, I can't. She stated, Sorry. At 9:23 a.m., the wound physician was asked if he provided services to the resident. He stated, I have. He was asked how often he observed the resident's wounds. He stated one time a week. He was asked if staff should provide the wound care treatments he recommended. He stated, Yes. He stated sometimes there were issues and staff would get ahold of him to deal with the issues. The wound physician was asked what skin prep was used for. He stated it was typically used for monitoring eschar or deep tissue injuries. He stated it also enhanced adhesion for a dry protective dressing. He was asked what staff should do if he did not specify what to cleanse the wound with. He stated, Get ahold of me. The wound physician was asked if he discontinued [MEDICATION NAME] solution on one of the resident's wounds and the facility continued to use it, would this have had any negative affect on the resident's wound. He stated due to the resident having a suprapubic catheter, It all depends on whether or not urine was collecting in the drainage system. The wound care physician was asked if he was aware the resident did not receive wound care treatment to her left ischium on (MONTH) 2nd, 11th, 13th, 17th, 24th, 25th and 31st. He stated, I cant speak to that. He stated, It's not ringing any bells. He was asked if he was aware the resident did not receive wound care treatment to her right ischium on (MONTH) 13th, 17th, 24th and 31st. He stated he would have to review the notes. He stated the facility should have a note of them contacting him if treatment was not provided. He was asked if the missed wound care treatments could have contributed to the deterioration of the resident's wounds. He stated, Yes. At 11:10 a.m., the DON and the wound nurse were asked what time the resident returned to the facility on [DATE]. The DON stated the social worker would know that information. The DON was asked what staff were instructed to do when they identify an alteration in skin integrity. She stated staff were to describe the wound in a progress note and contact the physician, DON and wound nurse. The DON stated, as part of the orientation process, she instructed staff they would describe and measure the wound but could not stage the wound. The wound care nurse was asked when she started working at the facility. She stated she started working on (MONTH) 2nd. She was asked what she did when staff notified her. She stated she would have the staff describe the wound over the phone. She stated if they called on a Sunday, she would instruct them to clean the wound with normal saline and cover with a dry dressing until she could assess it on Monday. She was asked if she took her own measurements of the wound. She stated she did if it was new. At 11:20 a.m., the social worker was asked the time the resident was out of the facility on 04/06/18. She reviewed the resident's electronic record and stated the resident was picked up at 10:30 a.m. She stated she was gone most of the day. She stated the resident should be signed back in at the front desk. At 11:25 a.m., the receptionist was asked to identify the time the resident returned to the facility on [DATE]. She reviewed the sign in/out logs and stated it looked like the form was filled out wrong. She stated she left at 6:30 and came back at 7:00. She was unable to determine if it was a.m. or p.m. At 11:26 a.m., the DON was asked if the resident returned to the facility at 6:30 or 7:00 on the 6th, should wound care have been provided to her. She stated the resident was gone for so long that day, they thought they might have admitted her. She stated she could have written a note instructing staff to provide the wound care when she returned. She stated, So yes, we have 24 hour nursing care and it should have been done. 2. Resident #15 had [DIAGNOSES REDACTED]. A quarterly resident assessment, dated 01/01/18, documented one unhealed stage four pressure ulcer. A physician's orders [REDACTED]. Dressing-Cover with Bordered Foam Dressing. as needed for Pressure Ulcer Replace as needed if dressing becomes soiled, wet, has excessive drainage or comes off . A physician's orders [REDACTED]. every day shift every Tue, Thu, Sat for Pressure Ulcer related to PRESSURE ULCER OF SACRAL REGION, STAGE 4 . A careplan, last reviewed on 04/01/18, documented, .Skin Integrity at risk for potential/actual skin alteration r/t (related to) Hx (history) of ulcers, Immobility, incontinence .Will evidence healing to pressure ulcer of Coccyx through next review date .C[NAME]CYX-Cleanse with NS-Apply Silver Alginate Dressing-Cover with Bordered Foam Dressing .Notify nurse if dressing becomes soiled, wet,has excessive drainage or comes off .Charge nurse to perform when Woundcare Nurse is not available/on duty on this scheduled day .Encourage good nutrition and hydration in order to promote healthier skin . Follow facility protocols for treatment of [REDACTED].to MD . The (MONTH) (YEAR) TAR for the pressure ulcer treatment was blank on 03/17/18. The as needed order for pressure ulcer treatment was blank for the entire month. The (MONTH) (YEAR) TAR for the pressure ulcer treatment was blank on 04/14/18. The as needed order for pressure ulcer treatment was blank for the entire month. A wound care specialist evaluation, dated 04/03/18, documented, .Assessment and Plan Of Care Recommendations .STAGE 4 PRESSURE WOUND SACRUM .Primary Dressing .Silver alginate apply twice daily for 30 days .Secondary Dressing .Foam apply twice daily for 30 days . The wound care specialist evaluation was signed by the physician 04/03/18. There was no documentation on the TAR showing this order was implemented. A wound care specialist evaluation, dated 04/10/18, documented, .Assessment and Plan Of Care Recommendations .STAGE 4 PRESSURE WOUND SACRUM .Primary Dressing .Silver alginate apply once daily for 30 days .Secondary Dressing .Foam apply once daily for 30 days . There was no documentation on the TAR showing this order had been implemented. On 04/15/18 at 11:52 a.m., certified nurse aides (CNA) #4 and #5 entered the resident's room to provide incontinent care. The resident was observed in bed on her right side. When staff turned the resident to her left side, the stage four pressure ulcer was observed to the sacral area without a dressing in place. On 04/25/18 at 7:45 a.m., the DON was asked what the policy was for pressure ulcers. She stated the wound care physician would see them weekly. She stated both primary care physicians wanted the wound care physician consulted for wounds. She stated the wound care nurse would follow the wound care physician's orders [REDACTED]. She stated the wound care physician would determine whether or not healing had occurred and completed measurements weekly. She was asked how staff determined what treatment was appropriate for wounds. She stated the wound care physician would make recommendations. She was asked what the policy was when the wound care physician made recommendations. She stated staff would follow the recommendation and use it as an order. The DON was asked who was responsible for following through with wound care recommendations. She stated the wound care nurse was responsible. She was asked what blanks on the TARs indicated. She stated staff did not document the treatment. She was shown the (MONTH) and (MONTH) (YEAR) TARs with blanks and informed of the observation on 04/15/18 at 11:52 a.m. of the pressure ulcer without a dressing in place. She was shown the (MONTH) 3rd and (MONTH) 10th wound care specialist evaluations and asked if treatment recommendations/orders had been followed. She stated they had not. She was asked if physician's orders [REDACTED]. She stated, No. 3. Resident #49 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A wound care specialist initial evaluation, dated 04/10/18, documented an unstageable sacral wound with measurements of 1.7 x 1.5 x not measurable centimeters with orders for a dressing treatment plan of apply Santyl and Calcium Alginate once daily with a dry protective dressing for 30 days. A telephone order, dated 04/11/18, documented cleanse wound to sacrum with normal saline, pat dry, apply Santyl, Calcium Alginate and cover with dry protective dressing daily every day shift for wound care. The (MONTH) (YEAR) TARs documented gaps in treatment on the 14th and the 15th. A wound care specialist evaluation, dated 04/17/18, documented a stage three sacral wound with measurements of 1.0 x 0.5 x not measurable centimeters with orders for a dressing treatment plan of apply Santyl and Calcium Alginate three times per week with a dry protective dressing for 30 days. A wound care specialist evaluation, dated 04/24/18, documented a stage three sacral wound with measurements of 0.9 x 0.5 x not measurable centimeters with orders for a dressing treatment plan of apply Calcium Alginate three times per week with a dry protective dressing for 30 days. A telephone order, dated 04/27/18, documented to cleanse stage three pressure wound to sacrum with normal saline, pat dry, apply Calcium Alginate and cover with dry protective dressing three times weekly on Monday, Wednesday and Friday. The (MONTH) (YEAR) TARs documented a gap in treatment on the 27th. The TARs documented the treatment ordered on [DATE] of Santyl and Calcium Alginate three times a week was not implemented until 04/27/18. The TARs also documented the Calcium Alginate treatment, minus the Santyl, which was changed on 04/24/18 to three times a week on Monday, Wednesday and Friday, was not started until Monday, 04/30/18. On 05/01/18 at 1:16 p.m., the DON and the wound care nurse were asked the reason the order from the wound care physician was not implemented on 04/10/18. The wound care nurse stated it was late in the afternoon and she wrote the order the next morning. She was asked what the reason was for obtaining the same order from the resident's attending physician the next day on 04/11/18. The wound care nurse stated that was the way the system worked. When the order was put in, it populated with the attending physician. The wound care nurse was asked the reason for waiting until 04/12, two days after the the wound physician saw the resident, to implement the wound care order. She stated she had no idea why the treatment was started on the 12th, it should have started on the 11th. The wound care nurse was asked if she had worked on 04/14/18 and 04/15/18. She stated she worked Monday through Friday and the charge nurses were responsible for doing the treatments on the weekends. The DON stated the charge nurses were responsible on weekends. The wound care nurse was asked the reason the new treatment ordered on [DATE] was not implemented until 04/27/18. She stated, I just didn't get the order input in a timely manner. The wound care nurse was asked about the gap on the TARs on Friday, 04/27 and if she had worked that day. She stated, Yes. She was asked if wound care was provided as ordered. She stated, Yes, I don't know why it is not documented.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to provide wound care as ordered for non pressure wounds for two (#42 and #45) of two sampled residents reviewed with non pressure wounds. This resulted in harm for resident #42 when the resident's left posterior inferior groin wound deteriorated and increased in size. The facility identified three residents with non pressure wounds. Findings: A facility wound care policy, undated, documented, .Purpose .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Documentation .The following information should be recorded in the resident's medical record .The type of wound care given .The date and time the wound care was given .All assessment data .obtained when inspecting the wound .Notify the supervisor if the resident refuses the wound care . 1. Resident #42 had [DIAGNOSES REDACTED]. A quarterly resident assessment, dated 02/13/18, documented the resident had no venous or arterial ulcers, had moisture associated skin damage, and had treatments which included a pressure reducing device for the bed and chair, nutrition and hydration intervention, application of nonsurgical dressing and application of ointments/medications. It documented the resident had an indwelling catheter. The wound physician note, dated 02/27/18, documented the resident had a shear wound of the left posterior inferior groin with a duration of greater than four days which measured 2.8 x 1.2 x 0.1 cm (centimeters). It documented 100% (percent) of granulation tissue was present and the recommended dressing was calcium alginate, leptospermum honey, and dry protective dressing three times per week and as needed. The note documented the resident had a wound of the right dorsal second toe which measured 2.4 x 1.6 x 0.2 cm. It documented the wound had no change and a chemical cauterization was performed. It documented the recommended treatment was iodosorb and a dry protective dressing every three days. It documented a referral to the foot surgeon was pending. There was no documentation the resident's left posterior inferior groin wound was assessed by the facility staff prior to the wound physician's visit on 02/27/18. The wound physician note, dated 03/06/18, documented the resident had a shear wound of the left posterior inferior groin which measured 2.5 x 1.0 x 0.1 cm with 100% granulation tissue present. The wound progress was documented as no change. The recommended dressing was calcium alginate, leptospermum honey and a dry protective dressing three times per week. It documented the resident had a wound of the right dorsal second toe which measured 2.5 x 1.8 x 0.2 cm with 100% of granulation tissue present. It documented the wound had improved with the recommended treatment of [REDACTED]. There was no documentation the facility acted on these recommendations. A care plan, last revised on 03/14/18, documented, .SKIN: (Resident) has actual impairment to skin integrity stage 4 pressure injury to right and left ischium .She is not compliant with pressure reducing efforts and is unable to tolerate repositioning on either side and will frequently change her position back to supine after staff have repositioned .Right 2nd toe-cleanse with [MEDICATION NAME]-apply Iodosorb ointment-apply Ca (calcium) alginate and secure with dressing retention tape .Administer bacterium (sic) DS (double strength) per MD (medical doctor) order .Educate resident/family/caregivers of causative factors and measures to prevent skin injury .Monitor/document location, size and treatment of [REDACTED].Turn and reposition to reduce pressure on wounds to ischium .(resident) frequently will go back to lying on her back please notify nurse/wound care of her compliance . There were no measurements of either wound between the wound physician visit on 03/06/18 and 03/27/18. The wound physician note, dated 03/27/18, documented the resident had a shear wound of the left posterior inferior groin which measured 2.8 x 1.3 x 0.1 cm. It documented 100% granulation tissue was present. The wound progress was documented as deteriorated. The recommended treatment was Dakins solution, leptospermum honey, calcium alginate and dry protective dressing once daily. It documented the resident had a wound of the right dorsal second toe with measured 2.5 x 1.8 x 0.2 cm with 100% granulation tissue present. It documented the wound progress was deteriorated with an evaluation for digital amputation underway. It documented chemical cauterization was performed. It documented the recommended treatment was Dakins solution, sterile packing gauze and dry protective dressing twice daily. The (MONTH) (YEAR) treatment administration record (TAR) documented: ~ right second toe- cleanse with [MEDICATION NAME]- apply iodosorb ointment- apply CA alginate and secure with dressing retention tape- NO BANDAIDS every day shift for wound- Start date 02/07/18- D/C (discontinue) date- 03/27/18. The treatment was not documented as provided on the 2nd, 11th, 13th, 17th, 24th, or 25th. ~ right 2nd toe- Dakins Solution- apply iodosorb ointment- sterile gauze- bordered NADH dressing- no bandainds every day and night shift for severe PAD (peripheral artery disease)- ulcer- Start date 03/28/18- D/C date 04/04/18. The treatment was not documented as completed on the day shift of the 31st. ~ Left posterior, inferior groin/fold- Cleanse with Dakins solution- apply leptospermum honey- Ca Alginate- Bordered NADH dressing every day shift for shear- Start Date- 03/28/18- D/C date- 04/11/18. There was no documentation wound care treatment was provided on 03/31/18. There was no documentation on the TAR any other treatment was provided to the resident's left posterior inferior groin shear wound prior to 03/28/18. The wound physician note, dated 04/03/18, documented the resident had a shear wound of the left posterior inferior groin which measured 1.1 x 0.5 x 0.1 cm. It documented 100% granulation tissue was present. It documented the recommended treatment was Dakins solution, leptospermum honey, calcium alginate and dry protective dressing once daily. It documented the resident had a wound of the right dorsal second toe which measured 2.5 x 2.3 x 0.2 cm with 100% granulation tissue. It documented the wound progress was deteriorated. It documented Dakins solution was to be discontinued and the recommended treatment was iodosorb, sterile packing gauze and dry protective dressing three times a week. The wound physician note, dated 04/10/18, documented the resident had a shear wound of the left posterior inferior groin which measured 2.0 x 0.3 x 0.1 cm. It documented 100% granulation tissue was present. It documented the wound progress as no change. It documented the resident had a wound of the right dorsal second toe which measured 2.5 x 2.4 x 0.2 cm. It documented 100% granulation tissue was present and the wound progress was documented as no change. It documented the recommended treatment was iodosorb, sterile packing gauze and a dry protective dressing three times a week. The wound culture result of the resident's right second dorsal toe, dated 04/13/18, [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) was identified. The physician was notified and an order was obtained to treat the resident with Bactrim DS (double strength) 800-160 milligrams one tablet by mouth twice daily for seven days. The (MONTH) (YEAR) TAR documented: ~ right 2nd toe- Dakins solution- apply iodosorb ointment- sterile gauze- bordered NADH dressing- no bandaids every day and night shift for severe PAD- ulcer- Start date- 03/28/18- D/C date 04/04/18. ~ Left posterior inferior groin/fold- Cleanse with Dakins Solution- apply leptospermum honey- Ca Alginate- bordered NADH dressing every day shift for shear- Start Date- 03/28/18. There was no documentation the wound care was provided on 04/06/18. ~ right 2nd toe- Dakins solution- apply iodosorb ointment- sterile gauze- bordered NADH dressing, no Band-Aid every day shift every Monday, Wednesday and Friday for severe PAD-Ulcer-Start date- 04/06/18. The treatment was not documented as completed on 04/06/18. On 04/16/18 at 9:57 a.m., the resident was asked if wound care was provided as ordered. She stated the staff did provide wound care, but it was not completed every day for her toe. On 04/24/18 at 10:40 a.m., the wound nurse was observed providing wound care to the resident. The wound nurse explained the area of the left posterior inferior groin was healed as of 04/24/18 when the wound physician assessed the resident. This was not a scheduled wound care day for the resident's 2nd toe. On 04/25/18 at 10:45 a.m., the wound nurse was asked what days of the week she worked. She stated she worked Monday through Friday. She was asked who was responsible for providing wound care when she was not at the facility. She stated, The charge nurses. On 04/30/18 at 7:45 a.m., the director of nursing (DON) and the wound nurse were asked how staff determined what treatment was appropriate for residents with wounds. The DON stated once staff identified skin integrity alterations, the nurse would evaluate the wound and notify the primary physician for treatment orders. She stated the wound care nurse would also evaluate the wound and would consult the wound physician as needed. They were asked if the wound physician wrote a wound care treatment recommendation during his visit, did staff follow the recommendation. The DON stated, Yes, we should. They were asked to acknowledge the wound physician did not see the resident between 03/06/18 and 03/27/18. The DON stated, Yes. The DON and wound nurse were asked if the 02/27/18 wound physician note for the resident's right dorsal 2nd toe documented the treatment iodosorb and dry protective dressing every three days and as needed. The wound nurse stated it did. They were asked if the facility acted on this recommendation when the (MONTH) (YEAR) TAR documented the treatment of [REDACTED]. The wound nurse stated, Nope, this doesn't. She stated, His doesn't have calcium alginate. She was asked if it said to change every day. She stated, No. She stated it said to change every three days and as needed. They were asked if the facility measured this wound between 03/06/18 and 03/27/18. The DON stated they did have a non pressure wound sheet, but it did not contain measurements. They were asked if the (MONTH) (YEAR) TAR documented no wound care was provided to the wound on the 2nd, 11th, 17th, 24th and 25th. The wound nurse stated, Yes. They were asked if the wound physician's note, dated 03/27/18, documented the wound progress was deteriorated with an evaluation for digital amputation underway. The wound nurse stated, Yes. The DON and the wound nurse were asked if the missed wound care could have contributed to the deterioration of the wound. The wound nurse stated, The measurements are the same. They were asked if the 04/03/18 wound physician note documented the Dakins solution was to be discontinued. The wound nurse stated it did. She was asked if the facility had acted on this recommendation. She stated, No. They were asked if the note documented the wound had deteriorated and the width had increased to 2.3 cm. The wound nurse stated, Yes. The DON and the wound nurse were asked if the wound physician note, dated 04/10/18 documented Dakins solution was not part of the recommended treatment. The wound nurse stated, Right. They were asked if the facility continued to use the Dakins solution on the wound each treatment throughout April. The wound care nurse shook her head and stated, Yes. They were asked if the 04/17/18 wound physician note documented the resident and her power of attorney refused surgical intervention. The wound nurse stated, Yes. The DON and the wound nurse were asked if the 03/06/18 wound physician note documented the resident had a shear wound to the left posterior inferior groin which measured 2.5 x 1 x 0.1 with a treatment recommendation of calcium alginate, leptospermum honey and dry protective dressing three times a week. The wound nurse stated, Yes, and as needed. They were asked if the (MONTH) (YEAR) TAR documented wound care treatment did not start on this area until the 28th. The wound nurse stated, Right. The DON reviewed the TAR and stated there was nothing until 03/28. The DON and the wound nurse were asked if the facility acted on the physician recommendation. The wound nurse stated, No, I don't see a treatment order. They were asked if the facility had any measurements of this wound between 03/06/18 and 03/27/18. The DON stated, No, she didn't measure non pressure. They were asked if the 03/27/18 wound physician note documented the wound had deteriorated and had increased to 2.8 x 1.3 x 0.1cm. The wound nurse stated, Yes. They were asked if the lack of wound care contributed to the wound deteriorating. The wound nurse stated, It could have. She was asked if the facility provided wound care to this area on 04/06/18. She stated, No. The DON stated the resident had left the facility at 10:30 for physician visits and oral surgery. The DON and the wound nurse were asked if the 04/10/18 wound physician note documented the wound had no change and the recommended wound care was calcium alginate, silver [MEDICATION NAME] and dry protective dressing once daily for thirty days. The wound nurse stated it did. On 04/30/18 at 9:23 a.m., the wound physician was asked if he provided services to the resident. He stated, I have. He was asked how often he observed the resident's wounds. He stated one time a week. He was asked if staff should provide the wound care treatments he recommended. He stated, Yes. He stated sometimes there were issues and staff would get ahold of him to deal with the issues. The wound physician was asked if Dakins solution could harm healthy tissue. He stated, Yeah, it inhibits granulocyte function. He stated it was typically used for constant soiling related to a suprapubic catheter. He was asked if he was aware staff continued to use the Dakins solution after he had discontinued it. He stated he would have to review the resident's record. He was asked if he did not specify what to cleanse a wound with, what should staff do. He stated, Get ahold of me to clarify. The wound physician was asked if he discontinued [MEDICATION NAME] solution on one of the resident's wounds and the facility continued to use it, would this have had any negative affect on the resident's wound. He stated due to the resident having a suprapubic catheter, It all depends on whether or not urine was collecting in the drainage system. The wound care physician was asked if he was aware the resident did not receive wound care treatment to her right second toe on (MONTH) 2nd, 11th, 13th, 17th, 24th and 25th. He stated the most reliable way to figure out was to look at the notes and see if there was a note of the staff contacting him. He stated he would have to review the notes. He stated the facility should have a note of them contacting him if treatment was not provided. The wound physician was asked if he was aware the wound care treatment order to the resident's left posterior inferior groin, dated 03/06/18, was never acted on and the resident did not receive wound care treatment to this area until (MONTH) 28th. He stated he could remember removing a dressing to the area. He stated the area was close to another wound and could have been covered by another dressing. He was asked if the missed wound care treatments could have contributed to the deterioration of the resident's wounds. He stated, Yes. At 11:10 a.m., the DON and the wound nurse were asked what time the resident returned to the facility on [DATE]. The DON stated the social worker would know that information. The DON was asked what staff were instructed to do when they identify an alteration in skin integrity. She stated staff were to describe the wound in a progress note and contact the physician, DON and wound nurse. The DON stated, as part of the orientation process, she instructed staff they would describe and measure the wound but could not stage the wound. The wound care nurse was asked when she started working at the facility. She stated she started working on (MONTH) 2nd. She was asked what she did when staff notified her of new wounds. She stated she would have the staff describe the wound over the phone. She stated if they called on a Sunday, she would instruct them to clean the wound with normal saline and cover with a dry dressing until she could assess it on Monday. She was asked if she took her own measurements of the wound. She stated she did if it was new. She was asked if she had measurements of all non pressure wounds. She stated she did have some measurements. The DON stated for (MONTH) (YEAR), so far, they had measurements of all wounds. At 11:20 a.m., the social worker was asked the time the resident was out of the facility on 04/06/18. She reviewed the resident's electronic record and stated the resident was picked up at 10:30 a.m. She stated she was gone most of the day. She stated the resident should be signed back in at the front desk. At 11:25 a.m., the receptionist was asked to identify the time the resident returned to the facility on [DATE]. She reviewed the sign in/out logs and stated it looked like the form was filled out wrong. She stated she left at 6:30 and came back at 7:00. She was unable to identify if it was a.m. or p.m. At 11:26 a.m., the DON was asked if the resident returned to the facility at 6:30 or 7:00 on the 6th, should wound care have been provided to her. She stated the resident was gone for so long that day, they thought they might have admitted her. She stated she could have written a note instructing staff to provide the wound care when she returned. She stated, So yes, we have 24 hour nursing care and it should have been done. 2. Resident #45 had [DIAGNOSES REDACTED]. A care plan, initiated 03/25/17, documented, .Focus .SKIN: I have Venous Stasis Ulcer to my left lower leg r/t (related to) [MEDICAL CONDITIONS] .Interventions .Wound care MD to eval (evaluate) and treat as ordered Date Initiated: 03/25/2017 Wound care: cleanse BLE (bilateral lower extremity) with NS (normal saline). Gently blot dry. Apply Dimethicone skin cream to BLE. Apply Xeroform to wounds on RLE (right lower extremity). wrap with [MEDICATION NAME] (sic). Leave LLE (left lower extremity) open to air. Change Q (every) day Date initiated: 03/30/2018 . An admission assessment, dated 02/12/18, documented the resident had modified independence for daily decision making and was at risk for developing pressure ulcers. It documented the resident had two venous and arterial ulcers present. It documented pressure reducing device for bed, application of nonsurgical dressings and applications of ointments/medications as skin and ulcer treatments. A care plan, initiated 03/18/18, documented .Focus .SKIN: I have Venous Stasis Ulcer to my right lower leg r/t [MEDICAL CONDITION] .Interventions .Wound care MD to eval and treat as ordered Date Initiated: 03/18/2018 . A physician's orders [REDACTED]. Wound care: cleanse BLE with NS. Gently blot dry. Apply Dimethicone skin cream to BLE. Apply Xeroform to wounds on RLE and lle wrap with [MEDICATION NAME] (sic). Leave LLE open to air. Change Q day. every day shift for wound to RLE .Start Date: 4/12/18 . An order audit report documented an order was created on 04/16/18 at 11:48 a.m. to discontinue the wound care order effective 04/15/18 at 11:48 a.m. There were blanks for 04/14 and 04/15 on the (MONTH) (YEAR) TAR, indicating the above treatment was not completed. On 04/16/18 at 7:53 a.m., the resident was observed in her bed in her room with her lower extremities uncovered. Both of her lower legs were wrapped with kerlix. Each leg had a piece of tape secured to the kerlix dated 04/13/18 with staff initials. She was asked if she had any skin issues. She stated she had venous stasis ulcers on both of her legs. She stated she was supposed to receive treatment to her legs everyday but she didn't this past weekend. On 04/24/18 at 8:40 a.m., the DON was asked to review and clarify the above order. She stated cleanse bilateral lower extremity with normal saline, gently blot dry, apply Dimethicone skin cream to bilateral lower extremities, apply Xeroform to wounds on right lower extremity and left lower extremity, wrap with Kerlix. She stated were to leave left lower extremity open to air and change right lower extremity dressing every day on the day shift. She stated the left lower leg should have been open to air. The DON was asked where staff documented treatments had been provided. She stated the TARs. She was asked what blanks indicated on the TARs. She stated the blanks indicated the treatment was not completed. She was asked to review the (MONTH) (YEAR) TARs and was asked if it was documented the treatment was provided on 04/14 and 04/15. She stated, No. She was made aware of the above observation. She was asked if the physician's orders [REDACTED]. She stated, No.

Based on record review and staff interviews, it was determined the facility failed to ensure wound care was provided as ordered by the physician for one (#1) of three sampled residents reviewed for physician's orders [REDACTED]. The facility identified six residents with non pressure skin alterations. Findings: A policy and procedure for the treatment and prevention of skin breakdown policy, dated 04/11, documented, .POLICY .It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcers according industry standards of care . Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An admission assessment, dated 10/02/17, documented the resident had 11 wounds upon admission to the facility. It documented the wounds resulted from exposure to hypothermia. An admission resident assessment, dated 10/06/17, documented the resident's cognition was moderately impaired. It documented the resident had open [MEDICAL CONDITION] other than ulcers, rashes and cuts. It documented the resident received a pressure reducing device for her chair and bed, was on a turning and repositioning program, had nutrition or hydration intervention to manage skin problems and had applications of nonsurgical dressings and ointments/medications other than to her feet in place for skin treatments. A physician's orders [REDACTED]. Pat dry. Apply xeroform. Cover with dry dressing and wrap with coban. Change dressing every day unless soiled every evening shift for wound care . A physician's orders [REDACTED]. Document on weekly skin assessment in (electronic medical record) . A physician's orders [REDACTED]. Pat dry. Apply xeroform. Cover with dry dressing and wrap with coban. Change dressing every day unless soiled every evening shift for wound care . A physician's orders [REDACTED]. Pat dry. Apply silver alginate to wound bed. Cover with bordered gauze. Change dressing every other day every evening shift every other day for wound care . Care conference notes, dated 10/17/17, documented, .Daughter with multiple concerns regarding wound care frequency and thoroughness. Discussed with Director of Nurses (DON) and daughter reports satisfaction with current wound care orders and interventions . The (MONTH) (YEAR) treatment administered record (TAR), documented: ~ Clean open areas to BLE with NSS. Pat dry. Apply xeroform. Cover with dry dressing and wrap with coban. Change dressing every day unless soiled every evening shift for wound care. The order had a start date of 10/06/17. There was no documentation the treatment was administered on the 10th, 11th, 12th, 13th, 15th, 16th, 17th, 18th, 19th, 20th or 21st. ~ Clean open area to Right heel with NSS. Pat dry. Apply silver alginate to wound bed. Cover with bordered gauze. Change dressing every other day every evening shift every other day for wound care. The order had a start date of 10/06/17. There was no documentation the treatment was administered on the 10th, 12th, 16th, 18th or 20th. ~ Clean open areas to BUE with NSS. Pat dry. Apply xeroform. Cover with dry dressing and wrap with coban. Change dressing every day unless soiled every evening shift for wound care. The order had a start date of 10/06/17. There was no documentation the treatment was administered on the 6th, 10th, 11th, 12th, 13th, 15th, 16th, 17th, 18th, 19th, 20th or 21st. ~ [MEDICATION NAME] to buttocks every day and evening shift. The order had a start date of 09/30/17. There was no documentation the treatment was administered on the evening shift on the 2nd, 3rd, 5th, 6th, 10th, 12th, 13th, 15th, 16th, 17th, 18th, 19th, 20th or 21st. There was no documentation the treatment was administered on the day shift on the 21st. ~ Weekly skin evaluation every Sunday evening. Document on weekly skin assessment in (electronic medical record). The order had a start date of 10/08/17. The skin evaluation was initialed as completed on the 8th, however there was no documentation of the skin assessment in the resident's clinical record. There was no documentation the skin assessment was completed on the 15th. A care plan, last revised 11/13/17, documented, .(Resident) is at increased risk for alteration in skin integrity .Interventions .Actual impairment: Left lower arm (upper section/middle section/lower section): Cleanse area with NSS per Physician orders. Pat dry. Apply Xeroform gauze to wound bed. Cover with coban. Change dressing every day . Actual impairment: Right hand middle knuckle: Cleanse area with NSS per Physician orders. Pat dry. Apply Xeroform gauze to wound bed. Cover with coban. Change dressing every day . Actual impairment: Right heel: Cleanse area with NSS per Physici8an (sic) orders. Pat dry. Apply calcium alginate to wound bed. Cover with bordered gauze. Change dressing every other day . Actual impairment: Right lower arm: Cleanse area with NSS per Physician orders. Pat dry. Apply Xeroform gauze to wound bed. Cover with coban. Change dressing every day . Actual impairment: Right lower leg: Cleanse area with NSS per Physician orders. Pat dry. Apply Xeroform gauze to wound bed. Cover with coban. Change dressing every day . Monitor for S/S (signs/symptoms) of infection and report to MD (medical doctor) as indicated .Administer Wound Care (Treatments) per MD orders . On 01/04/18 at 11:43 a.m., the director of nursing (DON) and assistant director of nursing (ADON) #1 were asked what the policy was for providing wound care to residents in the facility. The administrator (ADM) was present during the interview. ADON #1 stated they would obtain physician's orders [REDACTED]. They were asked where staff documented wound care had been provided. ADON #1 stated, On the TAR. She stated staff might document the treatment twice by putting it in a skilled note also. She stated the TAR documented they completed the treatment, and the skilled note or progress note would document the description. They were asked what the policy was for completing skin assessments. ADON #1 stated, They are done weekly. She stated the aides would also complete shower sheets and report any changes in the resident to the nurse. The DON stated the facility had been completing weekly skin assessments. She stated an assessment would be completed on admission and if there were any issues with the skin, the skin would be assessed weekly. She stated an evaluation would also be completed if a resident had any changes in their skin condition. They were asked to review the assessment dated [DATE] and identify what the resident's wounds were. ADON #1 stated the residents wounds were from exposure with hypothermia. She stated the resident had admitted to the facility from the hospital and upon hospital report, it was from hypothermia. ADON #1 stated all of the skin/wound reports were in conjunction with the admission assessment. She stated, at the time, staff had to complete an assessment for each wound area and should not put all of them on one assessment form. They were asked to explain the blanks on the (MONTH) (YEAR) TAR for the treatment of [REDACTED]. ADON #1 stated, No. They were asked to explain the blanks on the TAR for the treatment of [REDACTED]. ADON #1 was observed shaking her head no. They were asked if they could explain the blanks on the TAR for the treatment of [REDACTED]. ADON #1 stated she could not. They were asked to explain the blanks on the TAR for the treatment of [REDACTED]. ADON #1 stated, No. They were asked to locate a weekly skin assessment dated [DATE]. The DON reviewed the clinical record and stated, I don't see anything in here for 10/08/17. They were asked if the TAR documented a weekly skin assessment was completed on that day. ADON #1 stated, It says one was done on the 8th. She stated they were her initials on the TAR and the only explanation she had was it could have been during the time their computerized charting system was being changed. They were asked if they would explain the blank on the weekly skin assessment for the 15th. ADON #1 stated, No. They were asked with all of the blanks related to the care of the resident's wounds, were physician's orders [REDACTED].#1 stated, Not documented, not done. The DON stated, They didn't document it. They were asked if the care conference notes for the resident, dated 10/17/17, documented the daughter had multiple concerns regarding the wound care frequency and thoroughness. ADON #1 and the ADM acknowledged that was what was documented.

Based on record review and staff interviews, it was determined the facility failed to ensure wound care was provided as ordered for a resident with a pressure ulcer for one (#5) of three sampled residents reviewed for physician's orders [REDACTED]. The facility identified eight residents with pressure ulcers. Findings: A policy and procedure for the treatment and prevention of skin breakdown policy, dated 04/11, documented, .POLICY .It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcers according industry standards of care . Resident #5 had [DIAGNOSES REDACTED]. An admission resident assessment, dated 05/09/17, documented the resident's cognition was intact and he had a stage two pressure ulcer which was present upon his admission to the facility with [MEDICATION NAME] tissue as the most severe tissue type observed. It documented pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care and applications of ointments/medications other than to feet were in place. A quarterly resident assessment, dated 11/09/17, documented the resident's cognition was intact. It documented the resident had one stage three pressure ulcer with granulation tissue as the most severe tissue type observed. It documented the dimensions of 5.5 cm (centimetes) x (by) 6.0 cm x 0.2 cm. It documented pressure reducing device for bed and chair, nutrition or hydration intervention to manage skin problems, pressure ulcer care and applications of ointments/medications other than to feet were in place. A physician's visit report, dated 11/14/17, documented, .Wound (number one) Right Heel has a Primary Etiology of diabetic wound of the lower extremity, neuropathic .Subsequent wound encounter measurements are 5.5cm length x 7cm width x 0.2cm depth .There is a moderate amount of serous drainage noted. Wound bed has 51-75 (percent) adherent, yellow slough, 1-25 (percent) non-granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal .Wound Orders .Cleanse wound with Saline Apply Alginate w (with)/ Silver to wound bed Cover wound with Bordered Gauze Change daily . The record documented a surgical debridement was conducted and the post debridement measurements were: 5.5 cm length x 7cm width x 0.3 cm depth. The note was electronically signed by wound care physician #1. A physician's orders [REDACTED]. A skin/wound note, dated 11/15/17, documented, .Xray obtained on right heel and results received. Negative for osteo[DIAGNOSES REDACTED] Dr. (doctor) notified. Wants to place resident on antibiotic due to infection in right heel. Contact nephrologist to see what antibiotic is safe to start resident on related to his kidney function. Left message with (physician's) office to return my call . A physician's orders [REDACTED].[MEDICATION NAME] Tablet 100 MG (milligrams) Give 1 (one) tablet by mouth one time a day for skin infection for 10 days . The final laboratory microbiology results, dated 11/19/17, documented the resident was positive for multiple organisms. It documented the resident was placed on [MEDICATION NAME] 100 mg 1 tablet by mouth times ten days on 11/16/17. The next wound documentation in the clinical record with measurements was a nurse skin review note, dated 11/27/17, which documented, .Right Heel p/u (pressure ulcer) measures at 7cmx8cmx0.2cmdepth(of edges)Heavy amount of Purulent drainage-Odor noted-it is evident that previous (wound care physician #1) had mechanically debrided part of the wound during previous visit-90 (percent) green/yellow stringy slough .(primary care physician) updated to wound status with new md (medical doctor) orders recvd (received), noted and applied. Continuing po ABT (antibiotic) [MEDICATION NAME] for wound infection . A care plan focus, last revised 12/03/17, documented, .Skin Alteration of Skin Integrity r/t (related/to) limited mobility and incontinence .Interventions .Right heel cleanse with NS (normal saline) and gauze pat dry with gauze apply Santyl apply ABD (abdominal) pad apply foam heel cup wrap with roll gauze secure with tape every day shift for pressure ulcer .Date Initiated: 12/12/2017 . RIGHT HEEL-Cleanse with NS and Gauze-Pat Dry with Gauze-Apply Santyl-Apply Abd pad-Apply Foam Heel Cup Wrap with roll gauze-Secure with tape .Date Initiated: 12/03/17 .Vitamin c Tablet ([MEDICATION NAME] Acid)-Give 1 (one) tablet by mouth one time a day for wound care supplement .Zinc Tablet Give 1 tablet by mouth one time a day for wound care supplement . A skin/wound note, dated 12/08/17, documented, .Right Heel p/u measures at 7cmx8cmx0.2cmdepth(of edge) Heavy amount of Purulent drainage- Odor is still present- 50 (percent) green/yellow slough .(primary care physician) updated to wound status with new md orders to extend ABT (antibiotic) [MEDICATION NAME] x7 days . A physician's orders [REDACTED]. A care plan, last revised 12/10/17, documented, .(Resident) is at risk for ongoing infectio0n (sic) of pressure ulcer .Interventions .Observed/assess and s/s (signs/symptoms) of infection: fever, chills, sweating .Administer ointments, treatments (and) other medications as ordered by the MD . A skin/wound note, dated 12/12/17, documented, .Right Heel p/u measures at 7cmx8cmx1.5Depth Moderate amount of drainage is more serosanguineous and less purulent-Odor is mild in comparison to last Friday assessment-Resident continues on [MEDICATION NAME] for wound infection and is expected to end on 12/15/17 . A physician's orders [REDACTED]. A wound care specialist initial evaluation form, dated 12/15/17, documented, .Unstageable (Due To Necrosis) Of The Right, Posterior Heel .ETIOLOGY .Pressure .WOUND SIZE (L (length) x W (width) x D (depth)): 5.7 x 4.5 x Not Measurable cm .EXUDATE: Moderate Sero-sanguinous .THICK ADHERENT DEVITALIZED NECROTIC TISSUE: 100 (percent) . patient on [MEDICATION NAME] per previous culture result. There is calcaneus in the lateral aspect of wound. Loose bone spicules removed and culture taken from clean specimen underneath while completing [MEDICATION NAME]. Previous culture result 11/14/17 used to guide empiric selection, results from current culture pending. Continue current regimen of [MEDICATION NAME] to end with cipro. Renal doseage (sic) [MEDICATION NAME] last 4 (four) weeks . DRESSING: Calcium Alginate - Once Daily, Dry Protective Dressing - Once Daily, Santyl - Once Daily .RECOMMENDATION: Antibiotic: [MEDICATION NAME] 400 mg tabs (tablets) 1 (one) PO Q (every) 24H (hours) x 4 weeks, send bone specimen for culture . The record documented a surgical debridement was completed the same day, hemostatsis was achieved and a clean dressing was applied. The record was electronically signed by wound care physician #2. A physician's orders [REDACTED]. A wound care specialist evaluation form, dated 12/22/17, documented the resident had a stage four pressure ulcer which measured 6.2 cm x 4.8 cm x not measureable with 80 percent of thick adherent devitalized necrotic tissue present. It documented the wound progress as No Change. The note was electronically signed by wound care physician #2. The (MONTH) (YEAR) treatment administration record (TAR), documented: ~ RIGHT HEEL-Cleanse with NS and Gauze-Pat Dry with Gauze-Apply Santyl-Apply Calcium Alginate-Wrap with roll gauze-Secure with tape every day shift for Pressure Ulcer. There was no documentation the treatment had been provided on the 18th, 20th, 21st or 27th. ~ RIGHT HEEL-Cleanse with NS and Gauze-Pat Dry with Gauze-Apply Santyl-Apply ABD pad-Apply foam heel cup-Wrap with roll gauze-Secure with tape every day shift for Pressure Ulcer. There was no documentation the treatment had been provided on the 14th. On 01/04/18 at 11:43 a.m., the director of nursing (DON) and assistant director of nursing (ADON) #1 were asked what the policy was for providing wound care to residents in the facility. The administrator (ADM) was present during the interview. ADON #1 stated they would obtain physician orders, put them into the computer and put them on the Medication Administration Record [REDACTED]. They were asked where staff documented wound care had been provided. ADON #1 stated, On the TAR. She stated staff might document the treatment twice by putting it in a skilled note also. She stated the TAR documented they completed the treatment, and the skilled note or progress note would document the description. They were asked what the policy was for completing skin assessments. ADON #1 stated, They are done weekly. She stated the aides would also complete shower sheets and report any changes in the resident to the nurse. The DON stated the facility had been completing weekly skin assessments. She stated an assessment would be completed on admission and if there were any issues with the skin, the skin would be assessed weekly. She stated an evaluation would also be completed if a resident had any changes in their skin condition. At 3:52 p.m., the wound care nurse and the DON were asked if the 11/14/17 note from wound care physician #1 documented a right heel wound with a primary etiology of diabetic wound measuring 5.5 cm x 7 cm x 0.2 cm with the base of the ulcer slough/necrotic and an excisional debridement was preformed. The wound care nurse stated, That's what I'm reading. They were asked if the laboratory results for the wound culture dated 11/19/17 documented the wound was infected and the resident was started on [MEDICATION NAME] 100 mg one tablet by mouth times ten days. Both the DON and the wound care nurse stated, Yes. They were asked if the next skin note with measurements of the resident's wound was dated 11/28/17. The DON reviewed the resident's clinical record and stated the next wound care note with measurements since was on a weekly skin evaluation dated 11/27/17. They were asked if the note documented the resident had purulent drainage with odor noted and 90 percent green/yellow stringy slough was present and the primary care physician was notified and a new order was received. The wound care nurse stated, Yes. The wound care nurse was asked if the 12/08/17 skin/wound note documented the right heel wound measured 7 cm x 8 cm x 0.2 cm with a heavy amount of purulent drainage and an odor still present with 50 percent green/yellow slough and the primary care physician was updated and a new order was received to extend the [MEDICATION NAME] for seven more days. The wound care nurse stated, Yes. She stated the resident had just completed antibiotics, and she was concerned because there was still an odor and green/yellow slough. She stated she contacted the physician and obtained an order to continue the antibiotics. They were asked to explain the reason the primary care physician was notified and to explain his role in the resident's care. The wound care nurse stated he was the attending physician at the time. She stated when she noticed all of the above findings, she reported it to him and he instructed her to extend the antibiotics for seven more days. The DON stated there was a time lapse between wound care physicians when the staff utilized the primary care physician for oversight. She stated he was who staff consulted with during the time they were changing wound care physicians. They were asked if the 12/12/17 skin note documented the resident had a pressure ulcer to their heel which measured 7 cm x 8 cm x 1.5 cm with a moderate amount of drainage which was more serosanguenous and less purulent and the odor was mild in comparison to last Friday. The wound care nurse stated, Yes. They were asked if it documented the primary care physician was notified and staff were to continue current orders. She stated, Yes. She was asked the reason the primary care physician was notified of the wound. She stated, I update him every time. They were asked if wound care physician #2's note dated 12/15/17, documented an unstageable pressure ulcer to the resident's right posterior heel with a duration of greater than 228 days. The wound care nurse stated, This is his estimation. She was asked if he documented the measurements of the wound as 5.7 cm x 4.5 cm x not measurable with 100 percent of thick adherent devitalized necrotic tissue present. The wound care nurse stated, Yes. The DON was observed asking the wound care nurse if the order changed from diabetic to pressure. The wound care nurse stated, Yes. She stated wound care physician #2 stated it was not diabetic, it was a pressure ulcer on his heel. They were asked if the note documented the wound was surgically debrided on 12/15/17 and a portion of the removed bone was preserved and sent for pathologic examination. The wound care nurse stated, Yes. The DON stated, Yes, it was. They were asked if the note documented to continue the [MEDICATION NAME] to the end and to add ciproflaxacin 400 mg one tablet by mouth every 24 hours times four weeks and to send the bone specimen for culture. The wound care nurse stated, Yes. They were asked if this was wound care physician #2's first time to see the resident. The DON stated, I would say yes. They were asked if wound care physician #2's note dated 12/22/17 documented the wound was a stage four pressure ulcer to the right posterior heel which measured 6.2 cm x 4.8 cm x not measurable and there was 80 percent of thick adherent devitalized necrotic tissue. The wound care nurse stated, Yes. She was asked if the wound progress documented no change. She stated, Yes. She was asked to explain the blank on the TAR on 12/14/17 TAR for the treatment of [REDACTED]. The wound care nurse stated, No. She stated sometimes when staff would start a new order before the would care had been completed for the day, the order would be discontinued in the program. The DON was asked if the resident received any wound care on 12/14/17. She stated, There isn't anything documented on the 14th. They were asked if they could explain the blanks on the (MONTH) (YEAR) TAR for the treatment of [REDACTED]. The wound care nurse stated she believed that was when she went to the hospital. She stated another staff member had gone behind her an put some orders into the computer. She was asked if she could explain the blanks and if wound care was provided. She stated, I wasn't here. The DON was asked if she could explain the blanks for wound care. She stated, No ma'am. The DON was asked if wound care had been provided per physician's orders [REDACTED]. They were asked if the resident was being treated for [REDACTED]. She was asked if the wound had increased in size. She stated wound care physician #2 did excise on the 15th and he only conducted measurements before the surgical excision so it would be bigger the next visit.

Based on observation, clinical record review and staff, resident and family interviews, it was determined the facility failed to have an effective quality assessment and assurance (QA &A)committee which effectively monitored problems and put effective plans in place. The following areas were found to be deficient: the care of pressure ulcers, supervision to prevent falls, the care of surgical wounds, coordination of care for [MEDICAL TREATMENT] and hospice, care plan implementation and notification of the physician and family for changes in condition. The Resident Census and Conditions report, dated 12/01/15, documented 75 residents resident in the facility. Findings: 1. The facility failed to provide necessary care and services to prevent and/or promote healing of pressure ulcers for three (#49, 69 and #116) of five sampled residents who were reviewed for pressure ulcers. This resulted in actual harm for resident #69 when interventions were not implemented and the resident developed a new stage II pressure ulcer. See F314. 2. The facility failed to provide supervision to prevent falls for two (#85 and #131) of two sampled residents who were reviewed for falls. This resulted in actual harm of a head injury for resident #131, who received an anticoagulant medication, when she experienced three falls and no interventions were identified or implemented to aid in the prevention of falls. See F323. 3. The facility failed to ensure there was sufficient staff to meet the needs of residents. See F353. 4. The facility failed to: ~ Assess, monitor, and intervene for two (#85 and #131) residents who received anti-coagulant medications and experienced falls; and ~ Turn and reposition and provide incontinent care for one (#69) resident who was reviewed for the care of surgical wounds; and ~ Turn and reposition and provide surgical wound care in a manner to prevent cross-contamination for one (#116) of two sampled residents reviewed for the care of surgical wounds; and ~ Coordinate care with the [MEDICAL TREATMENT] center for one (#150) of one sampled resident who was reviewed for [MEDICAL TREATMENT]; and ~ Coordinate care with hospice for one (#64) of one sampled resident who was reviewed for hospice services. See F309. 5. The facility failed to ensure care plans were implemented related to: ~ failing to assess and monitor residents after falls for two (#85 and #131) sampled residents; and ~ failing to transport a dependent resident to and from activities for one (#116) sampled resident; and ~ failing to brush a resident's natural teeth with toothpaste and a toothbrush for one (#116) sampled resident; and ~ failing to turn and reposition a dependent resident at least every two hours for one (#116) resident; and ~ failing to assess and monitor for side effects and adverse consequences for the medication [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) for one (#150) resident and ~ failing to increase the protein in a resident's diet for one (#150) resident. See F282. 6. The facility failed to notify the physician and/or family of falls and/or changes in condition following a fall for two (#85 and #131) residents who had falls and received [MEDICATION NAME], an anticoagulant medication. See F157. On 12/08/15 at 4:15 p.m., an interview was conducted with the administrator (ADM). She was asked if prior to this survey had the quality assessment and assurance (QA&A) committee identified any of the following issues: pressure ulcers, falls, assessing and monitoring, implementing resident care plans and physician notification. The ADM stated yes, we put a plan in place. We treated the plan like a survey, reviewed it monthly and if the monitoring was not effective we changed it. If it (the issue) looked like it was doing good we would cancel the monitoring and start monitoring something else. We would go over the monitoring with the medical director since we can call him any time. The ADM was asked what type of procedures were in place to make sure the nursing needs of the residents were met. She asked for clarification of the question. The ADM was asked was the monitoring working. She stated on some things it was working, but not others. The ADM was asked if the morning stand up meetings were a part of QA&A. She stated any issues brought up, yes and if resolved before the QA meeting the issues were discussed anyway. The ADM was asked if she monitored the director of nursing (DON). She stated, By her willingness to provide support to the staff and work together as a team to provide care to the residents. Making sure she is monitoring her staff. The ADM was asked how she monitored staff to ensure the systems in place were monitored. She stated we have a standards of care meeting every week with dietary, nursing and therapy. We have a morning stand up meeting every morning to discuss issues, go over incident reports. She also stated the DON and assistant director of nursing (ADON) go over things with the nurses. The ADM was asked how she thought the harm situation came about with the pressure ulcers. She stated the facility needed an effective wound nurse who would document and do the job. The ADM was asked how she thought the harm situation came about with the falls. She stated the DON would have been called. That was the protocol or if the ADON had been told, she would have done the monitoring. The ADM was asked what resources were available to her. She stated they did not have a sister facility here in Oklahoma. She stated all of the sister homes were in Texas. The ADM stated they did have QA nurses. The nurses were doing everything they could to help and get things lined out. She also stated they had been working with a local consulting firm to get off the special focus list. At 4:30 p.m., an interview was conducted with the DON. She was asked what training did she ensure the nursing staff had to care for residents with pressure ulcers, falls and those residents who received anticoagulant medications. She stated the director of education and quality (DEQ) did the competency checks on the nurses and other staff. The DON was asked how she ensured the nurses were competent in their skills for assessing and monitoring. She stated the DEQ is responsible and did all of the competency checks. The DON was asked how she thought the harm situation came about with the pressure ulcers. She stated between the wound nurse calling in and not coming in to work, hopefully the new wound nurse the facility has hired will work out. The DON was asked how she thought the harm situation came about with the falls. She stated she didn't know. She stated it was frustrating she didn't know about falls. I am only as good as my nurses and we failed.

3. Hospital records for resident #49, dated 11/03/15, documented the resident had the following ulcers: ~ a stage four pressure ulcer to both buttocks, ~ a stage three pressure ulcer to the right heel, ~ a stage four pressure ulcer to the right medial leg, ~ a necrotic right medial knee wound base, ~ a right medial distal thigh wound base with necrotic slough, ~ a right medial proximal wound base with 100% granulation, ~ a left lateral foot wound and ~ a left lateral knee wound. The resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The wound physician saw the resident on Thursday, 11/12/15, and measured each wound. The progress note of the same date documented the resident had the following ulcers: ~ a stage two pressure ulcer to the left medial ankle, ~ a stage three pressure ulcer to the left lateral lower leg, ~ a stage three pressure ulcer to the left lateral knee, ~ a stage three pressure ulcer to the right heel-resolved, ~ a stage four pressure ulcer to the right medial knee, ~ an unstageable pressure ulcer to the right medial upper leg, ~ a stage four pressure ulcer to an unspecified buttock, ~ an unstageable pressure ulcer to the left distal lateral foot and ~ a chronic stage four pressure ulcer to the right heel. The wound physician saw the resident on Thursday, 11/19/15, and measured each wound. The progress note of the same date documented the resident continued with the same pressure ulcers as the previous week. There was no documentation to show the pressure ulcer measurements were completed for the week of 11/22/15 through 11/28/15. On 12/03/15 at 2:15 p.m., the ADON was asked to locate any other wound measurements for resident #49 besides the two wound physician progress notes [REDACTED]. At 3:00 p.m., the ADON was asked if she had located any other wound measurements. She stated she had asked RN #1 to look for the measurements. The ADON stated RN (registered nurse) #1 was calling the charge nurse to see where she had put the measurements. At 3:30 p.m., the ADON provided pressure ulcer measurements for resident #49, dated 12/02/15. The measurements had been completed by RN #1 for the following pressure ulcers: ~ a stage three to the right heel, ~ a stage three to the left lateral leg, ~ a stage three to the left ankle, ~ a stage three to the sacrum, ~ a stage three to the right posterior, ~ a stage three to the left knee and ~ a stage three to the right foot. On 12/08/2015 at 11:54 a.m., LPN #5 was asked how often she measured the residents pressure ulcers. She stated normally she would measure wounds once a week but didn't know what the facility protocol was since she had only worked at the facility for about a week. She stated the wound physician was here every week on Tuesday or Wednesday and he measured all wounds. At 11:57 a.m., LPN # 4 was asked how often she measured the residents' pressure ulcers. She stated the facility had a wound physician who came on a weekly basis. The LPN stated if the wound physician was not seeing the resident then she would measure the pressure ulcers. At 12:02 p.m., the DON was asked how often did the nurses measure the pressure ulcers or wounds. She stated weekly and the wound physician measured them weekly. The DON was asked to print all nurses' notes and any wound measurements in the computer for resident #49. No other documentation of pressure ulcer measurements was provided for resident #49 prior to survey exit on 12/09/15. Based on observation, record review, staff and resident interviews, it was determined the facility failed to provide necessary care and services to prevent and/or promote healing of pressure ulcers for three (#49, 69 and #116) of five sampled residents who were reviewed for pressure ulcers. The facility failed to: ~ Identify, assess, monitor, obtain orders for and provide treatment for one resident (#69). This resulted in actual harm for resident #69 when interventions were not implemented and the resident developed a new (facility acquired) stage II pressure ulcer; and ~ Implement the intervention of turning and repositioning for one resident (#116) which resulted in actual harm when the status [REDACTED]. Both of these were facility acquired; and ~ Provide consistent measurements for one (#49) of five sampled residents who were reviewed for pressure ulcers. The assistant director of nursing (ADON) identified 11 residents with pressure ulcers. Findings: A facility policy for prevention of pressure ulcers, updated 09/2013, documented, .The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practioner, physician, and family, and addressed. Interventions and Preventive Measures: General .For a person in bed: .Change position at least every two hours or more frequently if needed .Encourage the resident to participate in active range of motion exercises to improve circulation .Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms or irritation or breakdown .Report any signs of a developing pressure ulcer to the physician . Interventions and Preventive Measures: Residents with Risk Factors Risk factor - Moisture .Place resident on a minimum of a q (every) 2 hour check and change program. Provide personal hygiene care/bath to remove perspiration, bacteria and promote comfort .Address causes of moisture .scheduled toileting . A Pressure Ulcer Risk Assessment policy, updated 9/13, documented, .Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated . Assessment . Monitoring: staff will perform routine skin inspections (with daily care). Nurses are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin assessments at least weekly to identify changes . A repositioning policy, last revised May 2013, documented, .The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents . Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief .Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning .Notify the supervisor if the resident refuses the care . 1. Resident # 69 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The INDIVIDUAL RESIDENT CARE PLAN-A, dated 09/21/15, documented the resident was alert and oriented and required assistance with repositioning every two hours. Nurses' notes, dated 09/21/15 to 12/08/15, did not document when the weekly skin assessments were completed. An admission assessment, dated 09/28/15, documented the resident was cognitively intact and did not exhibit rejection of care. The assessment documented the resident required two person extensive assistance with bed mobility, dressing and bathing and required one person extensive assistance with toilet use and personal hygiene. The assessment documented the resident had lower extremity impairment on both sides. The assessment documented the resident had an ostomy and was not on a toileting program. The assessment documented the resident had pain frequently rated at a 7, the pain limited the daily activities and frequently made it hard to sleep. The assessment documented the resident had one unhealed stage II pressure ulcer. The assessment documented the resident had moisture associated skin damage, received pressure ulcer care and had application of non surgical dressings. The care plan, dated 09/22/15, documented the resident had altered skin integrity at bilateral glutes, superior and inferior trochanter, right ischium and right hip. The care plan documented a goal for the resident would be to have no complications related to skin alteration with goal date of 12/22/15. The care plan documented the following approaches: provide treatment as ordered, notify responsible party of wound status/changes. Provide turning and repositioning frequently. Keep clean and dry. The SKIN GRID - OTHER SKIN PROBLEMS sheet, dated 09/22/15, did not include weekly documentation of observation of the resident's buttocks. The sheet documented observations of the left lower medial thigh, the right shin and the left hip. The last day observation of the wounds were documented on 09/28/15. The sheet documented skin observations for the month of October were made on 10/02/15, 10/09/15, 10/14/15, 10/29/15 and 10/29/15. The October 2015 treatment sheet documented the resident did not receive magic butt paste as ordered or wound care as ordered on [DATE]. The October 2015 functional performance sheet documented the resident received incontinent care two times on the day shift for a total of 11 times and no incontinent care one time during the day shift. The evening shift documented the resident received incontinent care three times during the shift on six days. The sheet documented the resident received incontinent care two times during the shift for a total of six days. The night shift documented 11 times incontinent care was performed three times during the shift for 11 days, and was performed two times during the shift for two of the days. The other days did not document incontinent care had been performed. Incontinent care was provided three times a shift for 14 of the 16 days, and performed two times on one day and there was no documentation of incontinent care for 10/31/15. Bathing was documented to have occurred five times on the 7th, 9th,16th, 23rd and 26th of October 2015. There was no November 2015 documentation of a SKIN GRID-OTHER SKIN PROBLEMS sheet in the clinical record. The November 2015 treatment sheet documented the resident did not receive wound care as ordered on the 11/12/15, 11/ 23/15, 11/ 25/15, 11/ 27/15 and 11/30/15. November 2015 functional performance sheet documented the resident received incontinent care three times during the day shift for all days except on the 28th, 29th and 31st. The functional performance sheet documented incontinent care occurred two - three times during the evening shift, and two - three times during the night shift. Bathing was documented to have occurred seven times in November. On 11/30/15 at 4:58 p.m., the resident stated she had no control over her bladder and had pads under her. The December 2015 SKIN GRID - OTHER SKIN PROBLEMS sheet documented a skin tear on the resident's left upper thigh on 12/03/15. The sheet documented measurements for a surgical wound at the left lower medial thigh, the right shin and the left hip on 12/04/15. There was no documentation of observation of the resident's buttocks for December 2015. The December 2015 treatment sheet documented the resident did not receive wound care as ordered on [DATE], and the magic butt paste was not applied as ordered on [DATE]. December 2015 functional performance sheet documented the resident received incontinent care three times on the day shift. Two days had no documentation of incontinent care provided. The evening shift documented the resident received incontinent care two times during the shift for a total of four days. The night shift documented the resident received incontinent care three times during the shift for a total of six times. The December 2015 physician's orders did not include an order for [REDACTED]. Additional orders: Follow facility pressure ulcer prevention policy/protocol, offload heels per policy and pressure relief/off loading. A physician wound progress note, dated 11/24/15, documented the resident's right lower leg stage IV pressure ulcer was not healed. The measurements were 3 centimeter (cm) x 2 cm x 0.1 cm. The Left superior trochanter stage III pressure ulcer was not healed and measured 9 cm x 3 cm x 0.1 cm. There was no documentation of an assessment of the resident's buttocks in the progress note. On 12/02/2015 at 1:01 p.m., the resident was asked how many times each shift the staff assist her with incontinent care. The resident stated she often had to wait to be changed because the staff would say they need two people. The resident stated, I am able to roll myself over and they can do it with out the other person. The resident stated the staff tell her it is the policy. The resident stated when the staff start the incontinent care, they usually saw my gown was also wet. The staff would leave and go find a gown and come back later, sometimes an hour later, to finish the incontinent care. The resident stated at lunch time, the staff would be getting residents up, then help them eat, then put them back to bed, So I am left until the end of the shift. The resident stated, I am changed one time every shift. I have just quit asking because they do not come and help. I had always been changed at the end of the shift because the oncoming staff will get mad if residents were wet when they come to work. The resident was asked if she had been assisted with incontinent care today. She stated, No one had been in the room to offer incontinent care yet. The 10:00 p.m. to 6:00 a.m. shift did it right before they went home. At 1:28 p.m., certified nurse aide (CNA) #7 was interviewed regarding how often the resident received incontinent care. The CNA stated the resident was provided incontinent care at least twice a shift. The CNA was asked how often a resident who required assistance with toileting was toileted. The CNA reported residents who require assistance should be toileted every two hours. At 4:08 p.m., the resident was noted to have a very strong odor of urine about her person. There was no observed discoloration on the sheet covering the resident. The resident was asked if she had received incontinent care since the change of shift. The resident stated, No, I have not been changed yet. At 5:25 p.m., the resident was observed with her dinner tray. The resident reported the staff provided incontinent care for her 15 minutes earlier. On 12/03/2015 at 9:35 a.m., the resident stated she had been provided incontinent care by CNA #7. The resident stated she had not received a bed bath. On 12/07/15 at 8:10 a.m., the resident's dressings were observed with LPN #3. The dressings on the left upper hip and left lower hip were dated 12/05/15. The dressings had not been changed in two days. The dressing on the right lower extremity was dated 12/04/15. This dressing had not been changed in three days. At 8:34 a.m., CNA #12 was observed on hall 200. The CNA entered the residents room, asked if she was finished eating breakfast, and left the resident's room. The CNA did not offer or provide incontinent care. At 9:10 a.m., two CNAs were standing at the end of the hall talking. CNA #12 told CNA #10 she was clocking out to take her break and would be back. CNA #10 was observed walking up and down the hall, speaking to the residents but did not enter any residents room. At 9:06 a.m., an unidentified CNA entered the resident's room to offer ice to her. The CNA did not offer to assist the resident with any care. At 9:25 a.m., CNA #14 was observed walking up and down the hallway. The CNA did not offer to provide any incontinent care to the resident. At 9:40 a.m., CNA #12 reported she was back from break and was walking down hallway with CNA # 14. At 9:45 a.m., CNA #13 reported she was the bath aide today. CNA #13 entered the resident's room and asked the resident's room mate if she wanted a shower today. The CNA did not ask the resident if she wanted a bed bath or shower. At 9:54 a.m., CNA #12 was asked when incontinent care for the resident was last provided. The CNA stated this would be the first time it would be done today, since we were giving her a bed bath we will do it then. The CNA stated the 10:00 p.m. to 6:00 a.m. shift changed her before they left this morning. The resident's incontinent pads were observed to have large discolored dark yellow areas where the residents thighs were laying and at the lower area of the resident's back. At 10:05 a.m., the resident's buttocks were observed with LPN #3 and CNA #12. The resident was rolled over to the left side. The resident was observed to have three pads under her which were saturated with dark yellow urine. The incontinent pads were noted to have a very strong urine odor. The resident was observed to have an open area at her right buttock. The open area was observed to be bleeding. LPN #3 was asked what the area was. The LPN stated it looked like an abrasion to her. She stated there was currently an order for [REDACTED]. The LPN reported there was a wound care nurse who is no longer at the facility who provided all wound care. The LPN reported each charge nurse started performing wound care on their residents last week because the wound care nurse was no longer working for the facility. The skin around the open area on the right buttock was observed to be bright pink. The surrounding skin on the buttock was white in color and macerated. When the LPN left the room to obtain a measuring tape, CNA #12 stated the open area on her buttock had been there for a couple of weeks. The CNA stated, I reported this area to the wound care nurse when I had first observed the open area. The resident stated, That is right, she told the wound care nurse the day she found the area. She stated, The wound care nurse (Name deleted) came to see me that day and put some kind of gauze dressing on the open area, but it would not stay on my skin. The LPN came back into the room and measured the open area. The LPN stated the open area was 4 cm x 2 cm. The CNA was asked about the odor and color of the resident's urine. The CNA stated, It was normally that odor and color. The LPN was then asked about the odor of the resident's urine. She stated it was very strong and was discolored on the incontinent pad. The LPN was asked if she was aware of the color and odor of the urine. She stated she was not aware of the odor or color. At 10:34 a.m., the DON was interviewed regarding who was responsible for providing wound care in the facility. The DON stated, We had a wound care nurse up until last Monday on 11/30/15 when she skipped out on us. At 1:38 p.m., the resident stated she was changed by the CNA. The resident was observed to be dry and had a clean, dry pad in place. CNA #12 was asked what time she changed the resident. The CNA stated she changed her at 1:10 pm. The CNA was asked how many times she had changed the resident today. The CNA stated she had changed the resident two times today, this morning and just now at 1:10 pm. The CNA was asked how often the resident should be changed. The CNA stated she should be changed every two hours. The CNA stated, We tell the nurses she will not let us change her. The nurses would tell us it is her right to refuse to turn or be changed, so we don't do anything. The nurses told us they just document she is refusing the care. The CNA was asked about inservices on how to turn and reposition a resident or about incontinent care and how often they should be done. The CNA stated, We always get inservices on those things. At 1:43 p.m., LPN #3 was asked what was ordered for the resident's right buttock. The LPN stated the wound care order was initially for the resident's bottom, it was magic butt paste. The LPN stated the nurses were to apply as ordered. At 2:08 p.m., the director of nursing (DON) was asked how long the resident had the open area on the right buttock. She stated there was no documentation in the record regarding how long the wound had been there. The DON stated there was an order written [REDACTED]. She was asked if there was any other treatment ordered for this open area prior to today. The DON stated, No, I can not say there were any other wound care orders. The DON was interviewed regarding how often a resident should have incontinent care provided. She stated it should be provided every two hours and as needed. The DON was asked if incontinent care was being provided twice on a shift would it be sufficient for a resident who was dependent with incontinent care. The DON stated No, it is not. On 12/08/15 at 7:30 a.m., the DON was asked for all skin assessment reports for the resident beginning on 09/21/15 to present. At 9:00 a.m., the DON provided copies a Wound Healing Progress report, dated 09/21/15, and copies of Wound Assessment Reports, dated 04/24/15 to 08/07/15. The DON did not provide copies of assessments for the 09/21/15 to present day. At 9:08 a.m., the MDS (minimum data set)/care plan nurse #1 was interviewed regarding where the information for a new open wound would be documented. The MDS nurse stated the previous wound care nurse did that section and the assessments. She was asked where would the information be documented. The MDS nurse stated it would be in the chart. The nurse stated the documentation should be in the wound care section. She did not know what the wound care nurse's process was for documenting new open wounds. At 10:00 a.m., the DON was interviewed regarding what the policy was for performing skin checks for residents. The DON stated the nurses would do a skin check on admission, and the wound care nurse would complete the skin assessment the next day worked. The DON was asked when the physician was notified. She stated, I can not tell you the date. The DON was asked if the physician should have been notified of the new area when it was first reported to the wound care nurse. She stated, Yes, it should have been reported. The DON was asked what the facility had been doing to care for the pressure ulcer on the resident's right buttock. She stated, Whatever is in the chart. The DON was asked what the policy was for staff to report open areas. She stated, Anytime an area is observed, it would be reported to any nurse. The DON was asked when CNA #12 reported the open area to the wound care nurse. She stated, I do not know if the CNA informed anyone, I have not talked to her. The DON was asked where a nurse would document a new open area. She stated, In the nurse notes. The DON was asked if the resident was resistive to care. The DON stated, She is often resistive, the nurses were supposed to document every time she refused care. The DON was asked if the staff had inservices on caring for residents who are resistive to care. She stated, Yes there have been inservices, the staff know what to do. 2. Resident #116 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 04/27/15, documented, .CONTRACTURES resident has contractures of U&L (upper and lower) EXT (extremities) Bil (bilateral) Knees- Severe had AKA (above the knee amputation) (bilateral) with potential for further contractures R/T (related/to) M.S. ([MEDICAL CONDITION]) .Passive ROM (range of motion) to joints during care and as needed .Reposition at least every 2 hours .Provide activities which don't depend on dexterity: music, parties, movies . P/F (potential for) SKIN BREAKDOWN Related to .(decreased) mobility Skin Risk Assessment Score of .Contributing [DIAGNOSES REDACTED].Other contributing factors of .Contractures Bil (bilateral) Amputation .Approaches .Turn and reposition at least q (every) 2 hrs (hours) and as needed . .Alteration in Skin Integrity .Resident has the following skin breakdown .S/P (status/post) muscle flap .sig(significant) (change) new pressure ulcer areas .With potential for further skin breakdown R/T .(decreased) mobility .Other contributing factors of .MS .Severe Contractures .U&L EXT .Turn and reposition at least every 2 hrs . SELF-CARE DEFICIT .Resident needs the following assistance with ADLS (activities of daily living) .Extensive to total assist .Bed mobility .Transfers .Locomotion .Dressing .Eating .Toilet Use .Personal Hygiene .Bathing .Related to M.S .Give .assistance to resident when bathing/dressing/transferring . A nurses' note, dated 04/28/15, documented, .Surgical Incision//Right Buttock .Resident admitted on ,[DATE] with multiple wounds . A wound assessment report, dated 04/27/15, documented resident #116 had a surgical incision to her right buttock; hip, a surgical incision to her right buttock; sacral, and a surgical incision to her right buttock; medial ischium. A wound assessment report, dated 05/04/15, documented the resident had a surgical incision to her right buttock; sacral and a surgical incision to her right buttock; medial ischium. It documented the surgical incision to the right buttock; ischium resolved on 05/20/15. A wound assessment report, dated 05/06/15, documented the resident had a surgical incision to her right buttock; hip. A wound assessment report, dated 05/13/15, documented resident #116 had a surgical incision to the right buttock; medial ischium, a surgical incision to the right buttock; sacral, and a surgical incision to the right buttock; hip. It documented the surgical incision to the right buttock; hip resolved on 06/04/15. A wound assessment report, dated 06/04/15, documented the resident had a surgical incision to her right buttock; sacral. It documented the wound resolved on 06/12/15. A care plan, dated 5/24/15, documented, .Alteration in skin integrity (left) buttock (left) ischium .provide turning and repositioning frequently .tx (treatment) as ordered . A care plan, dated 07/06/15, documented, .Resident has sheering to right and left ischiums .8-20-15- wedge use for positioning . A skin grid- other skin problems sheet, dated 7/6/15, documented the resident had a right ischium failed flap. A skin grid- other skin problems sheet, dated 07/06/15, documented the resident had a left ischium failed flap. A wound assessment report, dated 07/06/15 documented the resident had a stage two pressure ulcer to the right buttock, ischium and a stage two pressure ulcer to the left buttock; ischium. A nurses' note, dated 07/09/15, documented, .Focus R/T (related to) PA (physician's assistant) here to assess wounds. Residents (sic) wounds to left and right ischium that resident was admitted with have reopened . No documentation was provided to reflect resident #116 had ever had a surgical wound to the left ischium. A significant change resident assessment, dated 07/22/15, documented resident #116 required extensive one person assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. It documented the resident required total dependence of two person assistance for locomotion on and off the unit. It documented none of the above on the dental section of the assessment. It documented the resident had three stage three pressure ulcers. It documented two of these pressure ulcers were present on admission. It documented the resident did not have any current pressure ulcers. A physician's order, dated 09/03/15, documented, .CLEANSE RIGHT ISCHIUM WITH NORMAL SALINE, PAT DRY APPLY SANTYL NICKEL THICK AND COVER WITH DRY DRESSING FOAM CHANGE DAILY AND AS NEEDED FOR SOILAGE OR LOSS OF OCCLUSION . A physician's order, dated 09/03/15, documented, .CLEANSE LEFT ISCHIUM WITH NORMAL SALINE, PAT DRY, APPLY COLLAGEN TO WOUND BED AND COVER WITH FOAM/DRY DRESSING, CHANGE EVERY MON. (MONDAY), WED. (WEDNESDAY), & FRI (FRIDAY) AND AS NEEDED FOR SOILAGE OR LOSS OF OCCLUSION . A wound assessment report, dated 09/25/15, documented the resident had a stage two pressure ulcer to her right buttock; right ischium and a stage two pressure ulcer to her left buttock; left ischium. This was the most recent wound assessment report provided to the surveyor. A weekly report for all other skin problems, dated 10-02-15, documented the resident had a non in house acquired surgical wound to the left ischium which measured 1.5 x 8.5. It documented the wound was identified on 04/27/15, and was improving. It documented the care plan for this wound was current. It documented the resident had a non in house acquired surgical wound to the right ischium which measured 6 x 5 x 0.2. It documented the wound was identified on 04/27/15, and was improving. It documented the care plan for this wound was current. A weekly report for all other skin problems, dated 10-09-15 documented the resident had a non in house acquired surgical wound to the left ischium which measured 0.7 x 11.5. It documented the wound was identified on 04/27/15, and was healing. It documented the care plan for this wound was current. It documented the resident had a non in house acquired surgical wound to the right ischium which measured 4.5 x 2.5. It documented the wound was identified on 04/27/15, and was improving. It documented the care plan for this wound was current. A weekly report for all other skin problems, dated 10/23/15, documented the resident had a non in house acquired surgical wound to right ischium buttock which measured 4 x 2 x 0.2. It documented the wound was identified on 04/27/15, and was improving. It documented the care plan for this wound was up to date. It documented the resident had a non in house acquired surgical wound to the right ischium buttock which measured 9.5x1.5x0.2. It documented the wound was improving. A quarterly resident assessment, dated 10/21/15, documented the resident required extensive two person assist for bed mobility. It documented the resident required total assistance of two people for transfers, dressing, toilet use, and bathing. It documented the resident required total one person assistance for locomotion on and off the unit and for personal hygiene. The November 2015 treatment administration record (TAR) documented blanks on the 23rd, 25th, and the 30th for the left ischium wound care completion. A skin grid/pressure sheet, dated 12/02/15, documented the resident had a right ischium stage two. A skin grid/pressure sheet, dated 12/02/15, documented the resident had a left ischium stage two. On 12/01/15 at 7:34 a.m., LPN #6 was interviewed and asked if resident #116 currently had one or more pressure ulcers. She stated the resident had two stage two pressure ulcers, one to the left ischium and one to the right ischium. At 9:30 a.m

Based on interview and record review, it was determined the facility failed to provide supervision to prevent falls for two (#85 and #131) of two sampled residents who were reviewed for falls. This resulted in actual harm of a head injury for resident #131, who received an anticoagulant medication, when she experienced three falls and no interventions were identified or implemented to aid in the prevention of falls. The facility identified 26 residents who had experienced falls in the last three months. Findings: The facility's policy on falls, dated 09/2012, documented, .The staff will evaluate and document falls that occur while the individual is in the facility .For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall . 1. Resident #131 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. admission orders [REDACTED]. An incident report, dated 08/11/15, documented, .was admitted on [DATE] from .next door. She was nonresponsive to stimuli including a sternal rub on admission. A rapid response was called and she was administered Narcan. She then became somewhat responsive. After a few minutes the nurse left the room. A few minutes later (resident #131) was noted to be on the floor. She had a knot forming on the top of her forehead. After assessment, the physician was notified and ordered (resident #131) to be sent to (hospital name deleted) to have a computed tomography (CT) of the head .The CT of the head was negative and (resident #131) was sent back to us. Her assessments were completed. Interventions put in place are bed in lowest position and fall mats to the side of bed .She was evaluated by and picked up on PT, OT and ST (physical, occupational, and speech therapies) . An individual resident care plan, dated 08/11/15, documented the resident was at risk for falling due to a history of falls, altered mental status and medications. It was documented a low bed with fall mats was in place. A nurse's note, dated 8/15/15 at 2:00 a.m., documented, .Resident noted on floor mat next to bed. Incont (incontinent) of loose BM (bowel movement). Cleaned (and) assisted back to bed. No (complaint of) pain It was documented the resident's vital signs were obtained, and they were within normal limits for the resident. It was documented that frequent checks would be completed. There was no documentation any new interventions had been identified or implemented to aid in the prevention of falls or that the facility had attempted to identify the root cause of the fall. There was no incident report of the fall. A nurse's note, dated 08/15/15 at 5:00 a.m., documented frequent rounds were made after the resident fell . There was no documentation of the resident's condition during those rounds. An admission assessment, dated 08/18/15, documented the resident had long and short term memory problems and was moderately impaired in cognitive skills for daily decision making. It was documented the resident required extensive assistance for bed mobility, transfers, and dressing. It was documented she was totally dependent for locomotion, eating, personal hygiene, and bathing. It was documented the resident was always incontinent of bowel and bladder, and had one fall without major injury since admission. The resident's care plan, dated 08/19/15, documented a problem related to being at risk for falls. The goal was the resident would have no falls with or without injury through the next review date. Approaches included to place on fall program, assist with transfers, ambulation, and bed mobility; to keep the call light within reach; assure proper footwear was used; and to observe for side effects from medications. The care plan was updated on 08/20/15 with an intervention to use a low bed and fall mats. A nurse's note, dated 08/23/15 at 6:25 a.m., documented, .Pt (patient) found on mat left side of bedside. Pt awake, resp (respirations) even (and) unlabored .No new bruise seen or skin tears on pt. Incont care given . It was documented the resident's vital signs were obtained, and they were within normal limits for the resident. There was no documentation any new interventions had been identified or implemented to aid in the prevention of falls or that the facility had attempted to identify the root cause of the fall. There was no incident report of the fall. A nurse's note, dated 08/29/15 at 10:30 a.m., documented, .this nurse was notified by CNA (certified nurse aide) stating resident was lying bedside bed on floor mats. Upon entering room nurse notes resident lying on left side of bed into floor mat c (with) head handing (sic) off lying on pedals of the peg tube pole. Nurse and CNA assisted resident on to back. Notes discoloration to middle of forehead. (No) skin openings, swelling or any other discolorations noted @ this time. Resident alert c some confusion noted .Resident c/o pain unable to describe locations and rate pain .Noted resident was dirty (large) BM noted in brief .Nurse educated staff that resident needs to changed (sic) (every) 2 (hours) . A progress note, dated 08/29/15 and untimed, documented, .Nurse notes discoloration to middle of forehead. Resident c/o general pain moaning when assisting c care of getting back into bed . An incident report, dated 08/29/15, documented, .nurse was notified by staff regarding resident on floor. Upon entering nurse noted resident lying on (left) side of bed on floor mats c head hanging off mats on to pedals of peg tube pole. Alert c some confusion . On 12/07/15 at 1:56 p.m., LPN #3, who was the nurse for the resident on 08/29/15, was asked if the resident could walk. She stated she could help with assistance. She was asked if the resident could reposition herself in bed. She stated the resident moved around a lot in bed. She was asked if the resident was at risk for falls. She stated, Yes. LPN #3 was asked what happened when the resident fell on [DATE]. She stated, They told me she was on the floor. She was asked what caused the resident's fall. She stated, I couldn't say exactly what caused the fall. LPN #3 was asked who identified interventions to aid in the prevention of falls. She stated, We try to do something right then and there, and then the DON (director of nursing) follows up. She was asked how staff was made aware of any interventions identified by the DON. She stated, They come back and tell us or you can go back and look at the care plan. She was asked how the aides were informed of the interventions. She stated they tried to get the aides right at the time of the incident. LPN #3 was asked if the resident was being monitored for anything in particular. She stated the resident was at risk for bleeding, so they would have been monitoring for signs and symptoms of bleeding. She was asked if she had monitored the resident for bleeding after the fall on 08/29/15. She stated, No. She was asked which physician she notified. She stated she notified physician #3 because he was on call for physician #1. She was asked if she informed physician #3 the resident was receiving Lovenox. She stated, I can't remember if I said that or not. She was asked if she documented that she informed the physician. She stated, No, I didn't. On 12/07/15 at 2:11 p.m., the DON was asked if the resident was at risk for falls. She stated, Yes. She was asked if the resident had falls while at the facility. She stated, Yes. She stated the resident had experienced a fall within the first few minutes of being at the facility. The DON was asked what interventions were implemented at that time. She stated a fall mat and low bed were implemented. The DON was asked what the root cause of the fall was. She stated the resident had received emergency care and she woke up and tried to get up and fell . The DON was asked how many falls the resident had at the facility. She reviewed the clinical record and stated the resident had three falls. She was asked when the resident fell . She reviewed the record and stated 08/11/15, 08/15/15, 08/23/15, and 08/29/15. The DON was asked where the incident reports were for the falls on 08/15/15 and 08/23/15. She reviewed the incident reports and stated she could not find one for those falls. The DON was asked what the root cause was for the resident's falls. She stated, I don't know right off. I knew about the first fall. That's the only one that sticks in my head. She stated, As far as the others, I don't know. The DON was asked what the facility's policy was on determining root causes of falls. She stated falls were reviewed in clinical meetings and they tried to figure out what happened and why. She was asked if the resident's falls were reviewed. She stated, The first one, yes. The DON was asked when the fall mat and low bed were implemented. She stated it was when the resident returned to the facility after the first fall. She was asked what interventions were identified and implemented after the fall on 08/15/15. She stated, I didn't know about that. That wasn't told to me. She stated the nurse had documented she implemented frequent checks but there was no documentation of the checks. The DON was asked what caused the resident's falls. She stated, I can't tell you. A lot of residents roll out of bed onto their floor mats. 2. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. It was documented the resident was to be monitored for signs and symptoms of bleeding every shift. An admission assessment, dated 10/30/15, documented the resident was cognitively impaired and had no behaviors or psychosis. It was documented the resident required extensive assistance of two people for bed mobility; transfers; locomotion on and off the unit; and dressing, eating, toileting, and personal hygiene. It was documented the resident was not steady when moving from a sitting to standing position or with surface to surface transfers. It was also documented the resident had an indwelling urinary catheter and was always incontinent of bowel. It was documented the resident had received an anticoagulant medication on seven of the previous seven days. It was also documented it could not be determined whether the resident had falls prior to admission to the facility. The resident's care plan, dated 11/02/15, documented a problem related to the resident being at risk for falls due to [DIAGNOSES REDACTED]. The goal was the resident would have no falls, with or without injury, through the next review date. Approaches included to assist with transfers and bed mobility; keep the call light within reach; use proper footwear; observe for side effects from medications; remind to utilize assistive devices; provide adequate lighting; keep pathways free and clear of any objects; monitor for wet/slippery floors; therapy to evaluate and treat as ordered; use a wheelchair for mobility; and medications as ordered for Parkinson's disease. A departmental note, dated 11/12/15 at 6:24 a.m., documented, .Patient observed this am on floor at his bedside, bed in low position, awake and alert, ROM (range of motion) done to all extremities, all WNL (within normal limits) at this time, no S/S (signs or symptoms) of pain or discomfort, patient assisted to bed x (times) 2 assist, call light in reach and operable. Family and doctor aware . Review of the clinical record revealed no documentation the facility attempted to determine the root cause of the resident's fall. An incident report, dated 11/13/15 at 9:45 p.m., documented, .staff reported patient on the floor, went to room patient laying on left side propped up by left elbow, alert oriented to person, skin tear to left elbow patient denies pain or discomfort assisted to bed cleansed skin tear with normal saline, covered with island dressing neuros started, range of motion within normal limits grasp equal, pupils equal and reactive to light . On 12/03/15 at 8:26 a.m., LPN #7 was asked if the resident could walk. He stated he did not think so. He was asked if the resident could reposition himself in bed. LPN #7 stated the resident moved around a lot and he would have to be repositioned. He stated the resident would get his legs off the bed. He was asked if the resident was at risk for falls. He stated yes, because of the Parkinson's diagnosis. LPN #7 was asked what happened when the resident experienced his first fall. He stated, His bed was in the low position. I just remember him. He didn't have any open areas or hematomas like he had bumped his head or anything like that. He was asked what caused the resident's fall. He stated he thought it was because the resident was trying to get out of bed. On 12/03/15 at 9:18 a.m., the DON was asked who the nurse was when the resident experienced his second fall. She stated the nurse was no longer employed at the facility. On 12/03/15 at 9:22 a.m., CNA #6 was asked if the resident had been at risk for falls. He stated he thought so. He was asked how he would have known. He stated when a resident arrived at the facility, he would check to see if there was a fall risk bracelet in place from the hospital, or he would ask the nurse if the resident was at risk. He stated if he thought they were at risk for falls, he would put fall mats in place and make sure the bed was in the low position. He was asked if the nurses told the CNAs that residents were at risk for falls. He stated they figured it out on their own mostly. CNA #6 stated he would get a bed alarm as well and let the nurses know so they could get an order. CNA #6 was asked if the resident had experienced any falls. He stated, I came in one time and found him sitting in the floor by the bed. He stated he found the resident at shift change, at approximately 5:45 or 5:50 a.m. He was asked what caused the resident's fall. He stated he did not know. He was asked what he did when he found the resident. He stated he notified the nurse, they obtained vital signs, and put the resident back in bed. CNA #6 was asked if he was informed of any new interventions after the fall. He stated, no. On 12/03/15 at 10:09 a.m., the DON was asked if the resident had been at risk for falls. She reviewed the clinical record and stated, Yes, I would say that he was. She stated it was not documented the resident had a previous fall, but it was documented he had confusion. She stated the family member had reported the resident was able to ambulate prior to being hospitalized . She was asked if the resident had experienced falls while at the facility. She stated she thought he had two or three falls, occurring on 11/12/15 and 11/13/15. The DON was asked what had been determined to be the root cause of the resident's falls. She stated, I am not really sure what the root cause was. I was not here. I was on vacation when this occurred. She was asked who had been responsible during her absence. She stated both ADON #1 and #2. The DON was asked what the facility's policy and procedure was for determining root causes of falls. She stated that whenever a fall occurred, the facility tried to drill down and figure how what caused the falls. She stated with resident #85, there were several reasons for the resident to fall, including confusion and the ability to walk prior to hospitalization . She was asked where the investigation into the root causes of the resident's falls was documented. She stated, There wasn't one on these forms (incident reports). She was asked if that was where root cause investigations were documented. She stated, Yes, and what interventions were put into place. The DON was asked what interventions were put into place after the resident's first fall. She stated, According to this, it doesn't show anything. She reviewed the clinical record and stated a fall mat and low bed had been initiated on admission. She was asked if any new intervention had been identified and implemented. She stated, It does not appear to (be). It says something about frequent monitoring. She stated the incident report had documented frequent monitoring would occur. The DON was asked where the documentation of frequent monitoring was. She reviewed the clinical record and stated, I don't know. I don't see it.

On 08/29/14 at 1:50 p.m., an IJ (immediate jeopardy) situation was determined to exist due to the facility's failure to assess, monitor and intervene for one (#117) sampled resident with [DIAGNOSES REDACTED]. The Oklahoma State Department of Health was notified and the IJ situation was verified. At 2:05 p.m., the administrator, the DON (director of nursing) and the corporate nurse were informed of the IJ and the extended survey. At 3:01 p.m., a plan of removal was received from the facility. The plan of removal was rejected because the plan contained no documentation of a plan to educate/inservice nurses before being allowed to pass medications. At 3:15 p.m., the facility was informed the plan had not been accepted. At 3:35 p.m., a second plan was presented. This plan was rejected due to the plan contained no documentation the agency nurses would be educated/inserviced before being allowed to pass medications. At 3:47 p.m., a third plan was presented, this plan was accepted. The plan of removal documented: "Problem Statement. At approximately 2:20 p.m., on August 29, 2014, the facility was notified of an immediate jeopardy. Facility failed to have a system in place to prevent significant med (medication) errors and facility failed to thoroughly assess and monitor residents with chronic [MEDICAL CONDITION]. Plan of Removal: ? Facility will review residents with physician orders [REDACTED]. ? Facility will assess residents with orders for lovonox and [MEDICATION NAME] for signs and symptoms of bleeding and pain. Any negative outcomes will be reported to physician and responsible party by 5:00 PM on 8/29/14. ? Facility will educate all licensed staff on medication administration, specifically lovonox and [MEDICATION NAME] by 5:00 PM on 8/29/14 for staff currently working in the building, nurses will be educated before being allowed to pass medications, including agency staff. ? Facility will review any changes to lovonox and [MEDICATION NAME] via (by) the daily clinical meeting to ensure appropriate notification and interventions were complete. Additionally, the 24 hour report record will be reviewed through this same process for pain and bleeding. ? Future Monitoring: Nursing management or designee will review Medication Administration Record [REDACTED]. In addition, lab orders will be reviewed in the same fashion and values communicated to the physician and responsible party. ? Residents with [MEDICAL CONDITION] will be assessed for pain and complications associated with [MEDICAL CONDITION]. Negative observations results will be communicated to the physician and treated according to physician orders [REDACTED]. ? Facility will educate licensed staff on signs and symptoms, treatment and interventions for chronic [MEDICAL CONDITION] by 5:00 PM for staff currently working in the building, nurses will be educated before being able to provide resident care, including agency staff. ? Residents with [MEDICAL CONDITION] will be assessed each scheduled shift. Negative observation will be communicated to the physician and treated according to physician orders. ? Future Monitoring: Facility will review the 24 hour report record through the daily clinical meeting process to ensure appropriate notification and interventions were complete for residents with signs and symptoms of chronic [MEDICAL CONDITION]. Facility will review the results of this monitoring process through the quality assurance performance improvement process for consideration, root cause analysis and resolution." On 09/02/14 at 1:30 p.m., the facility presented documentation of two (#139 and #115) additional residents' clinical record, which the facility had reviewed for the administration of [MEDICATION NAME]. Resident #139's clinical record documented the resident had been on [MEDICATION NAME] for two months without a justification for the use of [MEDICATION NAME]. The facility was advised the IJ could not be lifted due to the lack of a facility investigation for the administration of Lovonox for resident #139. At 3:45 p.m., the facility provided documentation the physician had been contacted and he had ordered the [MEDICATION NAME] to be discontinued due the lack of a valid medical justification for the use of [MEDICATION NAME]. At that time the IJ was removed. The deficiency remained at a level K. Based on observation, record review and interview, it was determined the facility failed to monitor, assess and intervene for one (#117) of one sampled resident with [DIAGNOSES REDACTED]. The facility identified no other residents with a [DIAGNOSES REDACTED]. The facility census and conditions, dated 08/25/14, documented the resident census was 74. Findings: 1. Resident #117 had [DIAGNOSES REDACTED]. A physician's admission order, dated 07/17/14, documented the resident was to be administered [MEDICATION NAME] 2 mgs (milligrams) daily for a [DIAGNOSES REDACTED]. The resident's care plan, dated 07/17/14, documented: "7/17 HX (history) [MEDICAL CONDITION], PE 1) meds as ordered 2) labs as ordered" The resident's admission assessment, dated 07/24/14, documented the resident was cognitively intact, understood others and made himself understood. He was able to make his needs known. The clinical record contained no documentation of the need for the staff to conduct regular and routine monitoring of the resident's left leg. The clinical record contained no description of what signs and symptoms the staff was to monitor for the resident's [DIAGNOSES REDACTED]. The clinical record contained no assessment documentation of the size, color, pedal pulses or temperature of the resident's left leg since his admission on 07/17/14. A physician's orders [REDACTED]. (This test is used to determined the blood's ability to clot). The order provided a [DIAGNOSES REDACTED]. On 08/19/14 at 4:00 p.m., a physician's orders [REDACTED]. SENT STAT (immediately). The clinical record contained no documentation of an assessment or monitoring having been performed. There was no documentation of the occurrences or circumstances that required the immediate increase of the resident's dose of [MEDICATION NAME]. The record contained no documentation describing the resident's condition. A physician's orders [REDACTED]. On 08/22/14, the ultra sound report documented the resident had a diffuse blood clot of his lower left leg. A physician's orders [REDACTED]. The clinical record contained no documentation of an assessment and/or monitoring having been performed. There was no documentation of the occurrences or circumstances that required the need to obtain an immediate US and/or Doppler of the resident's lower left leg. The record contained no documentation describing the resident's condition. A physician's orders [REDACTED]. The order provided a [DIAGNOSES REDACTED]. The resident's August 2014, MARs (medication administration records) documented the resident missed both of his doses of [MEDICATION NAME] on Sunday the 24th., and the evening dose on the 28th. The report also documented the resident missed his doses of [MEDICATION NAME] on the 19th., 25th., and the 27th. On 08/26/14 at 8:26 a.m., resident #117 was interviewed. He stated he had missed some of the doses of his medications this weekend (Sunday the 24th). He said he had not told anyone because one of the nurses confirmed to him he had not been given all of his medications on Sunday. He stated they were already aware of his missed doses. On 08/28/14 at 4:00 p.m., the resident was interviewed again. The resident was observed to be seated in his wheelchair with his left leg hanging down. The left leg and ankle were observed to be very swollen. He stated he had a blood clot in his left leg. He was asked if staff had spoken with him about the advisability of not hanging his leg down. He stated someone had told him to keep his leg propped up. He added that he couldn't keep it up when he was seated in his wheelchair. He was asked why. He said, "I'll show you." He elevated the leg rest of his wheelchair and placed his left leg on the calf support attachment of the leg rest. His leg immediately slid off of the calf rest. The resident stated the calf support was too small. He was asked if the staff had ever evaluated the wheelchair or offered to place a pillow under his leg. He said no one had attempted anything. He stated, "I just let it hang down when I'm in my wheelchair." On 08/29/14 at 10:00 a.m., the DON was asked if the physician had been notified of the resident's missed doses of [MEDICATION NAME] and [MEDICATION NAME]. She stated she didn't think so. The DON was asked if the facility ever monitored the resident's MARs to see if he was receiving his blood thinners as ordered. She stated she thought the pharmacist did that when he was here. She was asked why the resident's dose of [MEDICATION NAME] had been increased and the stat (immediate) PT/INR had been ordered on the 19th of August. She stated she thought the resident had approached someone and told them he felt like he had another clot in his leg. She was asked if there was documentation of the conversation. She stated she didn't see any. She was asked if a resident assessment had been performed on the 19th of August. She stated she wasn't sure. She was asked if there was documentation of an assessment having been conducted, and she stated she didn't think so. The DON was asked if monitoring of the resident's leg had been carried out after the resident had complained of the possibility he had another clot in his leg. She stated she couldn't find documentation of assessments and/or monitoring having been conducted. She was asked what was going on with the resident on the 22nd of August when a stat PT/INR, ultra sound and Doppler were ordered by the physician. She stated she thought the resident had told someone he felt like he had another clot. The DON added the resident had chronic clots, so he was able to tell them when he felt like he was getting another one. The DON was asked if there was documentation of the conversation and she stated she didn't see any. She was asked if an assessment of the resident's leg had been performed following the incident on the 22nd of August. She stated she wasn't sure. She was asked if there was documentation of an assessment having been conducted and again she stated she didn't think so. She was asked if monitoring of the resident's leg had been carried out after the resident had complained of the possibility he had another clot in his leg. She stated she couldn't find documentation of assessments and/or monitoring having been conducted. On 08/29/14 at 11:06 a.m., a nurse's note documented: Anticoagulant Therapy Note, "Resident with concerns regarding [MEDICATION NAME] and [MEDICATION NAME] bil (bilateral) lower extremities with [MEDICAL CONDITION] 3+ pitting. Notified Dr. (Name withheld) with symptoms and concerns. received new order for Stat (immediately) PT/INR and Stat bil venous doppler. PT/INR done results PT 23.5 (normal - 10.2-13.4) INR 2.0 (normal-2.0-3.5)." At 1:05 p.m., the physician was interviewed. He was asked if he had been informed the resident had missed three doses of [MEDICATION NAME] and three doses of [MEDICATION NAME]. He stated he had not. He was asked if the missed doses would have affected the lab results. He stated it could have. The physician was asked if he titrated the resident's dose of medications to the lab values and he stated he, Yes," he did. He added he liked to keep resident's on [MEDICATION NAME] until they were above a two. The physician stated the results of the testing done earlier in the morning revealed the resident did not have a new clot. He added the resident still had the clot in his left leg, it ran down his entire lower leg and it would probable not go away. At 2:00 p.m., the DON was interviewed. She was asked if it would have been normal precautions to keep the lower leg elevated when a resident had a [DIAGNOSES REDACTED]. She stated the leg should have been elevated. She was asked if the resident's leg had been kept elevated while he was in the wheelchair. She stated she didn't think so. The DON was asked if the facility had attempted to elevate the resident's leg while he was in the wheelchair. She said she wasn't sure. She was asked if a staff member had attempted an assessment or determined why the resident's leg had been hanging down when he was positioned in his wheelchair. She stated she didn't know if anyone had assessed or determined why the resident's leg was not elevated.

On 08/29/14 at 1:50 p.m., an IJ (immediate jeopardy) situation was determined to exist due to the facility's failure to administer three doses of [MEDICATION NAME] (a blood thinner to prevent blood clots) and three doses of [MEDICATION NAME] (a blood thinner to prevent blood clots) to one (#117) sampled resident with [DIAGNOSES REDACTED]. The Oklahoma State Department of Health was notified and the IJ situation was verified. At 2:05 p.m., the administrator, the DON (director of nursing) and the corporate nurse were informed of the IJ and the extended survey. At 3:01 p.m., a plan of removal was received from the facility. The plan of removal was rejected because the plan contained no documentation of a plan to educate/inservice nurses before being allowed to pass medications. At 3:15 p.m., the facility was informed the plan had not been accepted. At 3:35 p.m., a second plan was presented. This plan was rejected due to the plan contained no documentation the agency nurses would be educated/inserviced before being allowed to pass medications. At 3:47 p.m., a third plan was presented, this plan was accepted. The plan of removal documented: "Problem Statement. At approximately 2:20 p.m., on August 29, 2014, the facility was notified of an immediate jeopardy. Facility failed to have a system in place to prevent significant med (medication) errors and facility failed to thoroughly assess and monitor residents with chronic [MEDICAL CONDITION]. Plan of Removal: ? Facility will review residents with physician orders [REDACTED]. ? Facility will assess residents with orders for lovonox and [MEDICATION NAME] for signs and symptoms of bleeding and pain. Any negative outcomes will be reported to physician and responsible party by 5:00 PM on 8/29/14. ? Facility will educate all licensed staff on medication administration, specifically lovonox and [MEDICATION NAME] by 5:00 PM on 8/29/14 for staff currently working in the building, nurses will be educated before being allowed to pass medications, including agency staff. ? Facility will review any changes to lovonox and [MEDICATION NAME] via (by) the daily clinical meeting to ensure appropriate notification and interventions were complete. Additionally, the 24 hour report record will be reviewed through this same process for pain and bleeding. ? Future Monitoring: Nursing management or designee will review medication administration record prior to the end of each scheduled shift to ensure all doses of lovonox and [MEDICATION NAME] have been administered according to physician order. In addition, lab orders will be reviewed in the same fashion and values communicated to the physician and responsible party. ? Residents with [MEDICAL CONDITION] will be assessed for pain and complications associated with [MEDICAL CONDITION]. Negative observations results will be communicated to the physician and treated according to physician orders [REDACTED]. ? Facility will educate licensed staff on signs and symptoms, treatment and interventions for chronic [MEDICAL CONDITION] by 5:00 PM for staff currently working in the building, nurses will be educated before being able to provide resident care, including agency staff. ? Residents with [MEDICAL CONDITION] will be assessed each scheduled shift. Negative observation will be communicated to the physician and treated according to physician orders. ? Future Monitoring: Facility will review the 24 hour report record through the daily clinical meeting process to ensure appropriate notification and interventions were complete for residents with signs and symptoms of chronic [MEDICAL CONDITION]. Facility will review the results of this monitoring process through the quality assurance performance improvement process for consideration, root cause analysis and resolution." On 09/02/14 at 1:30 p.m., the facility presented documentation of two (#139 and #115) additional residents' clinical record, which the facility had reviewed for the administration of [MEDICATION NAME]. Resident #139's clinical record documented the resident had been on [MEDICATION NAME] for two months without a justification for the use of [MEDICATION NAME]. The facility was advised the IJ could not be lifted due to the lack of a facility investigation for the administration of [MEDICATION NAME] for resident #139. At 3:45 p.m., the facility provided documentation the physician had been contacted and he had ordered the [MEDICATION NAME] to be discontinued due the lack of a valid medical justification for the use of [MEDICATION NAME]. At that time the IJ was removed. The deficiency remained at a level of actual harm that is not an immediate jeopardy. Based on observation, record review and interview, it was determined the facility failed to ensure: a. Resident #117 was administered [MEDICATION NAME] per physician orders. The facility identified two additional residents who had physician orders [REDACTED]. b. Resident #117 was administered [MEDICATION NAME] per physician orders. The facility identified ten additional residents who had a physician order [REDACTED]. c. Resident #139 had medical justification for the need of [MEDICATION NAME] before administering the drug to the resident for 60 plus days. The facility identified two additional residents who had physicians' orders for [MEDICATION NAME]. d. Resident #73 had a pulse obtained prior to the planned administration of [MEDICATION NAME]. The facility identified five additional residents who had physicians' orders for [MEDICATION NAME]. The facility census and conditions report, dated 08/25/14, documented the resident census was 74. 1. Resident #117 had [DIAGNOSES REDACTED]. The resident's admission assessment, dated 07/24/14, documented the resident was cognitively intact, understood others and made himself understood. A physician's orders [REDACTED]. On 08/26/14 at 8:26 a.m., resident #117 was interviewed. He stated he had missed some of the doses of his medications this last weekend (Sunday) (08/24/14). He said he had not told anyone because one of the nurse's confirmed to him he had not been given all of his medications on Sunday. He stated they were already aware of his missed doses. On 08/28/14 at 4:00 p.m., the resident was interviewed again. The resident was observed to be seated in his wheelchair with his left leg hanging down. The left leg and ankle were observed to be very swollen. He stated he had a blood clot in his left leg. He was asked if he had been receiving all of his medications. He stated he had not been given some of his medications last Sunday. He was asked if he knew which medicines had been missed. He stated he didn't know the name. On 08/29/14 at 8:25 a.m., LPN #4 was observed administering [MEDICATION NAME] injection to resident #117. At that time the resident told the nurse he had not been given his medicine last night. The resident was interviewed privately. He stated the nurse told him she could not find some of his medication. He added she never came back to give him his medicine. At 9:15 a.m., the resident's MARs was reviewed in the presence of LPN #4. The record documented agency LPN #6 had signed the MARs indicating the dose of [MEDICATION NAME] had been administered to the resident on the evening of the 08/28/14. The MARs also documented the resident had missed both of his [MEDICATION NAME] injections on Sunday (08/24/14). At 9:30 a.m., LPN #1 and LPN #4 were asked to conduct a count of the remaining doses of [MEDICATION NAME] on the medication cart. The count of remaining doses was compared to the documented administered doses of [MEDICATION NAME]. The tabulation indicated the count of [MEDICATION NAME] was long by three doses. LPN #4 provided documentation 10 doses of [MEDICATION NAME] had been ordered and received on the 08/22/14 and 10 doses of [MEDICATION NAME] had been ordered and received on the 08/27/14. The documentation indicated the medication was available for use on the 08/24/14 and on 08/28/14. At 10:00 a.m., the DON was asked to review the count of the remaining doses of [MEDICATION NAME] and compare the count to the documented doses which had been administered since August 22 ND. She stated three doses of [MEDICATION NAME] had been missed. She was asked to contact LPN #6 to obtain verification she had administered the dose of [MEDICATION NAME] to the resident the night before. The DON contacted LPN #6 and asked her if she had documented the dose of [MEDICATION NAME] as having been given last night. The LPN stated she had. The DON asked the LPN if she had administered the [MEDICATION NAME]. The LPN admitted she had not given the [MEDICATION NAME] to the resident. She said she had intended to give it but she couldn't find it. The DON asked the LPN if she had asked anyone where the medication was. She stated she had not asked anyone. The DON was asked if the physician had been notified on the 24th of the missed doses of [MEDICATION NAME]. She stated she didn't think so. On 08/29/14 at 10:45 a.m., a time line was created, it documented: On 08/19/14 a PT ([MEDICATION NAME] time)/INR (international normalized ratio) laboratory test obtained at 4:35 a.m., by the facility. (the lab tests were used to determine the clotting ability of the resident's blood). A physician's orders [REDACTED]. The resident had not been administered his dose of [MEDICATION NAME] on the evening of the 08/19/14. On 08/22/14 (no time documented), a physician's telephone order documented to obtain a US (ultra sound) of the left lower leg, arterial. The ultra sound report, dated 08/22/14, documented the resident had a diffuse (extensive) left leg blood clot. A telephone order at 1:00 p.m., documented to obtain a Doppler to the left leg immediately to rule out a [MEDICAL CONDITION]. A physician's telephone order documented to administer [MEDICATION NAME] 60 mgs every 12 hours for 14 days for severe [MEDICAL CONDITION]. On 08/24/14, the resident missed both of his [MEDICATION NAME] injections. On 08/25/14, the resident missed his dose of [MEDICATION NAME]. On 08/26/14, a PT/INR lab test was obtained. The report documented the PT was 18.9 H (high), normal range was 10.2 to 13.4. The INR was 1.6 L (low), normal range was 2.0 to 3.5. On 08/27/14, the resident missed his dose of [MEDICATION NAME]. On 08/28/14, the resident missed his evening dose of [MEDICATION NAME]. On 08/29/14, at 11:06 a.m., a nurse's note documented: "Anticoagulant Therapy Note, Resident with concerns regarding [MEDICATION NAME] and [MEDICATION NAME] bil (bilateral) lower extremities with [MEDICAL CONDITION] 3+ pitting. Notified Dr. (Name withheld) with symptoms and concerns. received new order for Stat (immediately) PT/INR and Stat bil venous doppler. PT/INR done results PT 23.5 INR 2.0" On 08/29/14 at 12:45 p.m., the resident's primary care physician was interviewed. He was asked if he had been notified of the resident's missed doses of [MEDICATION NAME] and [MEDICATION NAME]. He stated he was notified this morning about last nights missed dose of [MEDICATION NAME]. He added he had not been notified of the other missed doses. The physician was asked if the missed doses could have affected the lab results. He said, "Yes, it could." He was asked if he used the lab results to titrate the required therapeutic dose of [MEDICATION NAME] and [MEDICATION NAME]. He stated he did depend on the lab results to determine the dose necessary to prevent blood clots for the resident. The physician said, "I'm more concerned about the missed doses of [MEDICATION NAME] than the missed doses of [MEDICATION NAME]. The [MEDICATION NAME] is a problem." The physician said, "There is no reason why he should have missed the doses." The physician was asked about the dose of [MEDICATION NAME] that was documented as given but had not been given. He said, "Do they realize you can't do that. You could lose your license." The physician said, "Todays ultra sound revealed no clot to the resident's right leg. The left leg still had a clot that extended down his entire lower leg. It is not going to go away." 2. Resident #139 was admitted to the facility with [DIAGNOSES REDACTED]. A 30 day comprehensive assessment dated [DATE], documented the resident was cognitively intact without behaviors, required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. The assessment further documented the resident received anti-coagulant injections for 7 days during the seven day look back period. A care plan dated 6/30/14 documented, "Problem/Need; I am at risk for bleeding secondary to the use of anticoagulant therapy. Goal; I will be free of signs and symptoms of complication related to my use of anticoagulant medication Approach's; Please give my medication as per orders. observe my labs and report my lab results to my MD or as ordered. Observe me for signs or symptoms of bleeding and report to my MD as needed. (Bleeding gums, Hematuria, Joint pain, Increased bruising, Abdominal pain, Swelling, Epistaxis..." An admission order form dated 06/30/14, documented "[MEDICATION NAME] 40 mg, 0.4 ml (milliter) SQ, Q (every) 24 hr (hour) DX; [MEDICAL CONDITION]. A monthly physician's orders [REDACTED]. A MAR dated July 2014, documented [MEDICATION NAME] was administered as ordered except on the following days; 7/04/14, 07/05/14, 07/06/14, 07/19/14, 07/20/14, and 07/27/14. A MAR dated August 2014, documented the anticoagulant medication was administered as ordered every day except on 08/18/14. A MAR dated [DATE], documented the medication was administered on 9/01/14 and 09/02/14, as ordered. On 9/2/14 at 1:50 p.m., LPN #4 was asked if she knew why the resident was receiving the medication. She stated she did not. She stated she did not administer the injections, the day shift nurse administered the injections. At 1:55 p.m., LPN #1 was interviewed and asked if she administered the medication daily. She stated she did and the injections were administered every morning at 8:00 am. She was asked if she knew why the resident was receiving the medication. She stated, "Because she was a fresh surgery and has had a [MEDICAL CONDITION]." She was asked if she knew when the resident experienced a [MEDICAL CONDITION]. She stated she did not. She was asked how long had it been since her peri-[MEDICAL CONDITION] surgery. She stated, "She came here shortly after surgery." The LPN was then asked how long the resident had been on the anti-coagulant. She stated, "Since she was admitted ." She was then asked if she thought this practice was appropriate. She stated,"No, they don't usually stay on it that long." At 2:35 p.m., the clinical wound nurse was interviewed and asked if she had ever taken care of the resident. She stated she had. She was asked if she knew of any reason the resident would still be on [MEDICATION NAME] daily. She stated, "Possible due to her [MEDICAL CONDITION]." She was asked if [MEDICAL CONDITION] recently or is it the fact she had a [MEDICAL CONDITION]. The nurse then stated, "Maybe she had a [MEDICAL CONDITION]." After reviewing the medical record the wound care nurse stated, "No, she hasn't had a [MEDICAL CONDITION] or a recent [MEDICAL CONDITION]." At 2:45 p.m., the resident was interviewed and asked when she last had a [MEDICAL CONDITION]. Her spouse answered for her and stated, "She's only had one, that was in 2010." The wound care nurse was asked to review the residents MAR and current physician's orders [REDACTED]. She stated, "I'm not sure why it's still being given. They usually write an order for [REDACTED]." The staff member was asked again if there was any medical indication which would dictate the need for the anticoagulant for 60 plus days. She stated, "No. Not unless I'm missing something." She then added, "The medication was ordered on admission from the hospital, partially because of her abdominal surgery. At 2:55 p.m., physician #1 was interviewed regarding the prolonged use of the anti-coagulant [MEDICATION NAME]. After briefly discussing the resident with the physician he was asked if he was aware of any reason for which the resident would remain on the anti-coagulant for the past 60 days. After a brief pause the physician stated, "There's no stop date on that order is it." He was asked if he was aware of any [DIAGNOSES REDACTED]. He stated, "No, not unless the oncologist (cancer doctor) ordered it for her." The wound nurse contacted the resident's oncologist who quickly denied ordering the prolonged doses of [MEDICATION NAME] and suggested the facilty contact the resident's cardiologist (heart doctor). She then contacted the resident's hospitalist/hospital physician who advised her the [MEDICATION NAME] was specifically ordered due to the abdominal surgery during the hospitalization . At 3:15 p.m., the DON was interviewed. She was asked how often the pharmacist conducted medical regime reviews (MRR). She stated he comes every month and reviews each record. She was asked if she knew if the pharmacist had reviewed the MRR for resident #139. She stated she thought he had. She was asked to review the MAR and advise why the resident would continue to receive the drug which is an acute anti-coagulant. She stated she wasn't sure and didn't see a reason or [DIAGNOSES REDACTED]. The DON was asked to explain the admission process for ordering medications, when a resident was admitted . She stated the receiving nurse was suppose to make sure this type of medication had a stop date. "If it didn't, they should call the doctor and get one." She further stated, "If the nurse misses applying the stop date, the pharmacist should catch it." The DON was asked if there were any MRR notes from the pharmacist visit for this resident. She stated, "I will have to look. I have some for August in my office." The DON failed to provide any MRR reports to the surveyors prior to the end of the survey. At 3:45 p.m., the wound nurse advised the physician had been contacted and ordered the [MEDICATION NAME] injections be discontinued due to a lack of a valid medical justification for it's use. The resident had received a total of 64 doses of [MEDICATION NAME] during her stay in the facility. An online drug web site at Drugs.com documented the suggested us for [MEDICATION NAME]. "Usual Adult Dose for [MEDICAL CONDITION] after Abdominal Surgery: 40 mg subcutaneously once a day with the initial dose given 2 hours prior to surgery. The usual duration of administration is 7 to 10 days; up to 12 days administration has been well tolerated in clinical trials." 3. Resident #73 had a [DIAGNOSES REDACTED]. The resident was cognitively intact. She understood others and made herself understood. She was able to make her needs known. The resident had a physician's orders [REDACTED]. The order documented the drug to be withheld if the resident's pulse was below 60 beats per minute. On 08/27/14 at 8:55 a.m., LPN #7 was observed passing medications to the resident. The resident's pulse was not obtained. The LPN was stopped before she administered the medication to the resident. She was asked if the pulse should have been taken before giving the [MEDICATION NAME] to the resident. The LPN stated she didn't know. She was asked to read the physician's orders [REDACTED]. At 11:05 a.m., the DON was interviewed about the LPN not taking the resident's pulse per the physician's orders [REDACTED]. She stated the LPN should have informed her, filled out an incident report and notified the physician, if necessary.

Based on observation, record review and interviews, it was determined the facility failed to ensure a resident with limited range of motion of bilateral extremities received range of motion, handrolls, splints or contracture devices for two (#44 and #132) of three sampled residents reviewed for receiving range of motion services. This resulted in an actual harm to resident #44. The resident census and condition report dated 08/25/14, documented eleven residents resided in the facility with contractures. Findings: 1. Resident #44 was admitted to the facility with [DIAGNOSES REDACTED]. On 08/25/14 at 4:03 p.m., the resident was observed in bed with evidence of contractures to the right and left hands and right and left feet. No braces or splints were in use for her hands or feet. The current physician's orders [REDACTED]. The resident's care plan did not address the resident's contractures and her limited range of motion. An admission assessment dated [DATE], documented the resident sometimes understood and understands and had a BIMS (brief interview of mental status) of 7 (severly impaired). The resident's total mood severity of seven indicated mild depression and the resident had a [DIAGNOSES REDACTED]. The resident had limited range of motion to the upper and lower extremities on both sides and was only able to stabilize with staff assistance when transferring from a surface to surface. The admission assessment did not document the resident received any range of motion services. A quarterly assessment dated [DATE], documented the resident's cognition skills for daily decisions had increased to a score of 11 (moderately impaired). The rest of the assessment had not changed. The quarterly assessment did not document the resident received any range of motion services. There was no documentation in the clinical record the resident had been assessed for the need of range of motion and/or restorative services. There was no documentation the resident had been evaluated for a splint or other device to prevent further contractures. An interview was conducted on 08/25/14 at 11:21 a.m., with LPN #3. She was asked if the resident had contractures. She stated the resident had contractures of both hands and feet. She then added, "The hands are the most contracted." The nurse was asked if the resident received range of motion services or had a splint or device in place. She stated, "The resident does not receive range of motion services and does not have a splint for her hands." She then stated the resident wore heel protectors while in bed and while up for meals. An interview was conducted on 08/29/14 at 9:38 a.m., with the resident. She was asked if she had splints, braces or anything for the contractures. She stated, "NO." The resident was in bed and observed with no splints or equipment to aide in the prevention of further contraction. She was asked if the facility had ever exercised her arms or legs. She stated they never had done any type of exercise. At 9:45 a.m., when LPN #3 entered the resident's room, she was asked to see the resident's hands. When the LPN attempted to open the resident's fingers, the resident screamed and said, "Ouch." An interview was conducted on 08/29/14 at 9:58 a.m., with restorative aide #1. She was asked what the criteria was for a resident to receive range of motion and/or restorative services. She stated, "My nurse (RN #2) will have therapy screen, if it triggers." She stated they had patients they worked with; opened and placed towels in their hands. She stated sometimes therapy would order hand rolls. The restorative aide stated, "Our goal is to catch one before it gets bad and they are contracted bad." The restorative aide was asked if a resident care plan should be developed for contractures and limited range of motion. She stated, "We can not do anything unless it's on the care plan." She was asked if the resident currently received range of motion or restorative services. She stated, "It has been a long time." The restorative aide was asked what the resident's program contained. She stated, "Cueing on feeding but not sure about anything else." She was asked how resident's were evaluated and added to a range of motion or restorative program. She stated, "When therapy gets done, they refer them with a program." The restorative aide was asked if the resident had any hand rolls or splints for her contractures. She stated, "Not now. I am not sure why she doesn't have hand rolls or splints. She can open one (hand) but I don't know why she doesn't." She was asked if the resident was a candidate and would benefit from restorative care, splints, braces or other equipment to aide in the prevention of decline of range of motion. She stated, "A hand roll would not hurt her at all." The restorative aide was asked if the resident had a decline in her upper and lower extremities. She stated, "Yes, she has been able to help us and now she tightens up and not able to help us. There has been a decline and it's harder to get her dressed and do things with her." She was asked how long ago the resident had a decline in her range of motion. She stated, "The decline has been in the last year after she went to the hospital for wounds. When she got back she had a big decline." She then added it had been the first part of the year. The restorative aide stated the resident had gone to the hospital, and when she got back her program had ended. She was asked why the resident did not continue with a program when she got back from the hospital. She stated therapy would have to pick them up first and if they felt it would benefit the resident then the resident was referred to them. She stated, "(RN #2) has a note from therapy from when she got back from the hospital." She stated, "We tell (RN #2) once a week how well a resident is doing. When the resident reaches their goal we write a summary." She then stated the resident will say, "ouch" when you try to clean her hand. On 08/29/14 at 11:00 a.m., an interview was conducted with RN #2. She was asked who was responsible for overseeing the range of motion and/or restorative services. She stated she was responsible and that she also completed the minimum data set and care plans for the residents. She was asked what the criteria was for residents being placed on range of motion services. She stated, "Usually I initiate it because we have noticed a decline on the the MDS. Other times when the resident comes off therapy, they will initiate it." RN #2 stated, "She was discharged to the hospital and came off (restorative). I will say she is going to be a candidate for the rest of her life. She has contractures in her arms and legs--so they don't get worse." She was asked if the resident received range of motion or restorative services other then the two weeks prior to going to the hospital. She stated she would have to check the medical record. After looking through the medical record she stated, "That's all that was in the chart so that's what I understand. There should be no more." RN #2 was asked when the resident had received skilled services. She stated, "01/21/14, and was discharged on [DATE] to restorative." She was asked if the resident had received any skilled nursing services when she returned from the hospital in March. She stated the resident was not on skilled services. She was asked who was responsible for ensuring range of motion was completed for the resident and placing splints or handrolls. She stated, "The aides can do range of motion and hand rolls." The nurse was asked if the resident's care plan should be developed to address the contractures and limited range of motion. She stated, "I probably didn't think the contractures where a problem, because she is dependent on staff for eating." She was asked if the resident had any pain associated with her contractures. She stated, "Yes, she has pain. She can tell you where the pain is." RN #2 was asked about when aides were working with the resident, was the resident's pain associated with the contractures? She stated, "It has never been brought to my attention. There probably is pain." She was asked if the aides were able to work with the resident and clean the resident's hands. She stated, "I am sure her hands would hurt to open them." The nurse was asked if the resident's care plan was developed for care of contractures and limited range of motion. She stated, "No, there is not one in the care plan specifically for contractures." She was asked if the resident had been assessed and/or utilized hand rolls or splints to aide in the prevention of a further decline in range of motion. She stated, "None that I know of." RN #2 was asked to describe the resident's ability to use her hands before going to the hospital. She stated, "Not able to grasp much, total assist with feeding. I have not known her to assist with any of her meals." She was asked where the documentation was located when range of motion was competed by the nurse aides. She stated, "It should be somewhere in the ADL sheets." She was asked what interventions were in place for the care and exercise of the resident's hand and feet contractures. She stated, "The care plan says range of motion exercise as needed." The nurse was asked to define, "as needed." She stated, "It should be at least once a day." She was asked why range of motion services did not get picked back up then the resident returned from the hospital in March. She stated, "It was probably my oversight because there were no orders to pick her back up on restorative." On 08/29/14 at 12:20 p.m., the resident was observed at the dining room table, her drink and supplement on the table. The resident was being assisted by staff for the meal. The resident was observed with handrolls in both hands. 09/01/14 at 8:35 a.m., the resident was observed in the common area near the dining room. The resident had a hand roll in the left hand. No hand roll had been placed in the right hand. 09/01/14 at 9:10 a.m., an interview was conducted with the director of nursing (DON). She was asked to describe the resident's ability to assist with her meals and use her hands. She stated the resident required a lot of assistance and to her knowledge could not assist with her own meals. She was asked how long ago the resident had a decline in range of motion. She stated since coming back in March from the hospital, but added she was not completely sure of the resident's ability prior to the hospital, because she had not worked at the facility. The DON was asked if the resident had handrolls and or splints. She stated, "Not that I can recall." She was asked what the criteria was for for restorative and who would benefit from range of motion or restorative services. She stated, "Physical and occupational therapy can recommend restorative. It's all what physical therapy recommends." The DON was asked if residents with contractures would benefit from range of motion services. She stated, "Yes. To relieve the muscles and prevent further contractures or skin breakdown. If they can not follow commands therapy will turn them over to restorative." She was asked if this resident was a candidate for range of motion or restorative services. She stated, "Yes she is." She was asked if the resident was receiving the services. She stated, "She should be." A request was made for any documentation to verify the resident was on range of motion or restorative services. The DON provided a restorative care plan and stated, " It's from March, when she went to the hospital. They did not pick her back up." An interview was conducted on 09/01/14 at 9:35 a.m., with CNA #3. She was asked if resident #44 could assist with her meals. She stated, "She needs a lot of assistance. No she is not able to." She was asked when the resident had lost the ability to hold food and assist with part of the meal. She stated, "Not since I have been working here, two months." She was asked if the resident had any splints, braces or devices for the contractures. She stated, "She has boots for pressure, nothing for contractures." The aide then added, "I think she is working with (Restorative Aide #1). On 09/01/14 at 9:44 a.m., an interview was conducted with CNA #4. He was asked what level of assistance the resident required with her meals. He stated, "Sometimes I will give her bread and she could hold it and eat it. She was able to grab the bread and eat it on her own." He was asked if the resident had lost the ability to hold bread and food. He stated the resident is not able to hold the food but will try (making a fist with one finger out like a hook) to get. He stated it was like the resident was digging to eat the food with one finger. He was asked if the resident was more contracted or had a decline in range of motion. He stated, "She is a little more contracted, then she use to be." The aide was asked if the resident had any range of motion or restorative services. The aide stated, "They are suppose to put a wedge in her hands to open the hands to help prevent further contractures." 2. Resident #132 had [DIAGNOSES REDACTED]. A physical therapy plan of care dated 04/09/14 documented, "...Long term goals will educate and train restorative care nursing on proper ROM (range of motion), positioning techniques and transfers for OOB (out of bed) mobility..." A telephone order dated 04/09/14, documented, "P.T. (physical therapy) clarification order: Evaluation & assessment complete, pt (patient) to be see 3X/wk ( times a week) X 2 wks & transition to restorative care nursing." There was no documentation to verify the resident had been transitioned to restorative nursing after the two weeks of therapy. A quarterly assessment dated [DATE], documented the resident made himself understood, usually understood others, had cognition that was intact, required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. The resident had impairment, upper and lower extremity of both sides and did not have any restorative or range of motion services being provided. An annual assessment dated [DATE], documented the resident made himself understood, usually understood others, cognition was intact, required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. The resident had impairment, upper and lower extremity of both sides and could only stabilize on surface to surface transfers with staff assistance. The resident did not have any restorative or range of motion services being provided. A care plan dated 08/07/14, documented, "Problem resident expresses pain related to chronic pai[DIAGNOSES REDACTED], contractures. Goal resident will state/demonstrate relief/reduction in pain intensity within one hour after receiving interventions. Approach notify MD if resident does not express relief, decrease of pain within one hour of intervention...administer/monitor for effectiveness and for possible side effects from routine and or PRN pain meds...encourage resident to report onset of pain immediately...assess for breakthrough pain when on routine meds....monitor resident for non-verbal S/S of pain facial grimacing, crying, moaning, guarding, agitation/restlessness, cognitive changes." A care plan dated 08/07/14, documented the resident had a problem with refusing personal care and refusing to eat. There was no documentation on the care plan to indicate the resident refused range of motion services. The care plan did not address the resident's contractures and limited range of motion. A review of the restorative book contained no documentation the resident had received range of motion and/or any restorative services. There was no documentation in the clinical record the resident had been assessed for a range of motion and/or a restorative program. A care plan dated 09/02/14, documented, "Problem: Resident has contractures and is at risk for skin break down, increased pain from affected areas and injuries. Contractures located: Right upper right lower, left upper, left lower hand and foot. Goal contractures will not increase skin break down will not occur. Increased pain will be relieved with in hour of intervention and no injuries will occur.. Approach...provide relieving devices on bed and chair...Monitor for increased pain/stiffness-provide meds/ tx's (medications/treatments) asses for relief...assist with repositioning q (every) 2 hrs (hours) using positioning devices to maintain proper body alignment provide comfort measures as need..keep contractured areas clean and dry provide PROM (passive range of motion) -do not force contractured areas...rag in (R) (right) hand....wedge cushion at FOB (foot of bed) to elevate feet." Prior to 09/02/14, there was no care plan developed to address the resident's contractures and or range of motion services. On 09/02/14 at 2:10 p.m., the resident was observed in his room in bed. Both hands were contracted and a wedge cushion was at the foot of the bed. There was no handroll in either hand. The resident was asked if he had handrolls placed or any other device to help with the contractures. He stated, "I use to have a ball that I could squeeze, but its gone." He was asked how long it had been missing. He stated, "It's been a couple of months since I last had it." He stated, "What I need is therapy. They don't have enough here. I need more therapy." He was asked if the facility had provided any services for his contractures. He stated, "They use to come in and they stopped coming in and I am not getting it anymore. It has been almost two months since that happened." He was asked who provided the services to him When he received them. He stated restorative aide #1 and #2. An interview was conducted on 09/02/14 at 2:21 p.m., with CNA #1. She was asked how long she had been employed at the facility. She stated, "I have been here four months." She stated hall 300, the hall the resident resided on, was her permanent assignment for work. She was asked if the resident had contractures. She stated, "Yes." The CNA was asked what interventions were provided for the resident's contractures. She stated, "You are suppose to put a roll in his hand and turn him every two hours." She was asked if rolls were for both hands. She stated, " I would have to ask the nurse. I know it is usually the right hand." She was asked if the resident received any range of motion services. She stated, "I don't know. I would have to ask the nurse or physical therapy." She was asked if the resident received services from the restorative aides. She stated, "I don't know. I would have to ask." The CNA was asked if she had received any range of motion training for resident's on her hall. She stated, "Not since I have been here." She was asked whose responsibility it was to provide range of motion services to residents. She stated, "The restorative aides." An interview was conducted on 09/02/14 at 3:05 p.m., with CNA #2. She was asked what hall she was assigned to work on. She stated, "Hall 300 since the second week in April." She was asked if the resident had contractures. She stated the resident had right hand contractures,some left hand and leg contractures. The CNA was asked what interventions were in place to prevent a further decline in the resident's range of motion. She stated they move them around (hands and legs) and can place a rag in the right hand. She then stated, "The roll is just something I do, not everyone does the roll." She was asked if the resident had a squeeze ball for his hand. She stated, "I don't know about a squeeze ball." She was asked if the resident received restorative or range of motion services. She stated, "I don't know what therapy does. We have restorative aides. There is nothing in the ADL's for us to do." The CNA was asked if the resident had a decline in his range of motion. She stated, "I really don't know about loss of ability. That was the way he was when I started here in April." She was asked who was responsible for range of motion services. She stated, "The restorative aides are responsible for providing the service." 09/03/14 at 8:30 a.m., the resident was observed in his room in bed. The resident did not have a hand roll in his right or left hand. A wedge cushion was at the food of the bed. The resident was asked if he had removed his hand rolls. He stated, "I'm not able to remove a handroll when there is one in place." He was asked if he had lost any ability in the use of his hands. He stated they had always been the way they currently are. An interview was conducted on 09/03/14 at 8:41 a.m., restorative aide #2. She was asked if the resident was receiving any range of motion or restorative services. She stated, "No he is not." She was asked if there were any interventions in place to prevent a further decline in range of motion. She stated, "We just put things (handrolls) in his hand." The aide was asked if the resident had been assessed for restorative services. She stated, "I think he had been on there but not sure of the time and date." She was asked where the documentation was located for the previous range of motion or restorative services and/or assessment. She stated, "If the documentation is not in the chart, medical records will have it. An interview was conducted on 09/03/14 at 8:52 .M., with restorative aide #1. She was asked if the resident received range of motion services or restorative care. She stated, "He is not on restorative at this time, he had been." When asked how long it had been since the service had been received and if he participated in the services when it was offered. She stated, "He did good and looked forward to us coming in and working with him. He enjoyed it and participated and did not refuse the service. " She did not comment on how long it had been since the resident had been on range of motion or restorative services. She was asked what services the resident currently received. She stated, "Right now the biggest thing is when he gets dressed. He can preform some on his own, but not much. He is not currently working range of motion with us. The girls are suppose to do something." On 09/03/14 at 9:05 a.m., an interview was conducted with RN #2, who was the minimum data set and care plan coordinator. She was asked if a care plan had been developed to address the resident's contractures and limited range of motion. She stated, "Prior to yesterday, it was not a separate care plan. It was not developed." She was asked who oversaw the range of motion and or restorative program. She stated, " I have been for over a year but I have not really been instructed." The nurse was asked when the resident last had range of motion and/or restorative services. She stated, "I don't see anything since back in February. He had gone out to the hospital and returned in February." She was asked if the resident was a candidate for range of motion and/or restorative services. She shook her head up and down indicating, "Yes." She was asked if the resident had been evaluated and had a program implemented. She stated, "No, not that I know of." The nurse was asked why the resident had not been evaluated and had a program implemented. She stated, "I don't know. I really don't know the answer to that." She stated, "Yes, (Resident) has fallen through the cracks and I did not realize that." An interview was conducted on 09/03/14 at 9:27 a.m., with the director of nursing. She was asked about the range of motion services and contractures of the resident. She stated, "I can only say what should be happening, not what is happening." She then looked through the care plan and chart and stated she did not see anything on range of motion activities for the resident. She stated, "I don't see any documentation of anything being done." She added the resident had been dropped through the cracks.

Based on observation, record review and interviews, it was determined the facility failed to assess a resident's falls and implement interventions to aide in the prevention of recurrent falls with injuries for one (#7) of seven sampled residents reviewed for falls. This resulted in an actual harm. The director of nursing identified 17 residents who had recurrent falls with injuries. Findings: A policy titled, "Falls Management" documented the following: "...Protocol The facility strives to reduce the risk for falls and injuries by promoting and implementation of the Risk Reduction: Falls and injury program...Residents/patients are assessed for the fall risk factor... ...Procedure...Assess and review risk factors for falls and injuries...Complete the fall risk assessment.....implement the plan of care -Fall Risk Reduction based on individual resident/patient needs..." Resident #7 had [DIAGNOSES REDACTED]. A care plan last updated 02/13, documented, "Problem: Potential for injury: Falls...related to cognitive deficits with poor safety awareness, history of previous falls...antidepressant... Goal: minimize the risk of resident falls during stay... Interventions: lock all moveable equipment before transferring resident...transfer with assist X 1-2...remind/ encourage to use call light for assistance...utilize W/C alarm...utilize bed alarm when in bed...encourage my participation.... Problem: alteration in comfort- Pain....hx of hip fracture..." An incident report dated 02/12/13 at 11:00 p.m., documented, "Upon entering resident room during rounds, this nurse noticed resident in fetal position on rt side head by the bed. resident stated that she fell oob, cna and this nurse assisted resident into bed and complaints of rt rib pain, no bruising or redness noted...no injury just complains of pain to rt rib area...pain scale 4...immediate action taken: assessed for injury and pain, initiated neuro checks, assisted resident into bed and will continue to monitor...medical risk factors possibly related to incident: fall history...confusion/disorientation...." A physician's telephone order dated 02/12, documented, "Obtain rib series chest x-ray." A telephone order dated 02/13/13, documented, "Send to ER for xray of CXR, ribs & (R) hip..." A telephone order dated 02/20/13, documented, "Xray (L) hips s/p fall /c c/o pain." A physician's progress note dated 02/14/13, documented, "...c/o of pain (R) rib...xray negative..." An incident report dated 02/20/13 at 12:20 a.m., documented, "Upon entry to room noted resident lying in floor on lt side by the B bed. No injury noted. c/o 7/10 (pain) to lt hip. neuros started. when resident questioned about what happened she state, "I don't know what I'm doing up. Is my brother asleep?" assisted up to chair with X 2 assist. noted bed in low position, call light in reach and fall mat in place at bedside...immediate action taken: assessment, vitals, neuro checks and family and md notifies...pain scale 7...medical risk factors possibly related to incident: fall history, inability to understand directions, fracture...confusion/disorientation...." A "Radiology Report" dated 02/20/13 documented, "...conclusion: Mild osteoarthritis of the left hip. If symptoms persist, F/U is recommended." An incident report dated 02/22/13 at 6:40 p.m., documented, "Upon entry to room nurse observed resident on rt side in floor by the sink. noted resident in small pool of blood, face and hands bloody. upon assessment noted laceration to rt brow. resident with c/o pain to bilat hips 5/10...pressure applied laceration on forehead which was bleeding by this nurse...md on call n/o to sent to ER for eval and tx. family notified of transfer to er. laceration to rt brow approx 1 inch in length and 1/4 inch wide...immediate action taken: assessment for injury, neuro checks, pressure to head wound and cleaned up blood on face and hands...pain scale 5....medical risk factors possibly related to incident: fall history, inability to understand directions, fracture, confusion/disorientation....incontinence..." A physician's telephone order dated 02/22/13, documented, "Send to ER to eval & treat..." A report to the Oklahoma State Department of Health dated 02/22/13, documented, "...6:40 pm resident found on floor in room by sink, laceration to (R) brow C/O pain to bil hips...87 yo female with [DIAGNOSES REDACTED]. Resident is redirected without difficulty...fall prevention care plan is in place and reviewed/ updated with each incident...02/23/13 returned to facility...sutured on (R) brow, X-rays negative, also requested CT scan, negative. Staff instructed on increased fall risks, care plan updated for further preventive measures..." A care plan dated 03/04/13, documented, "Problem: Resident is at risk for falls r/t medications, impaired cognition, hx of falls... Goal: Resident will not sustain an injury related to fall through next review period... Approaches: evaluate meds to determine possibility to discontinue, discuss w/ MD...provide verbal cueing for safety awareness...report fall to MD and responsible party...monitor for side effects of psychotherapeutic medications...enlist family/ caregiver support and participation...provide close supervision...if resident is on cardiovascular meds: observe for hypotension, dehydration, vertigo, orthostatic hypotension, or dizziness...refer to restorative nursing as needed...bed sensor alarm/bed alarm...side rails 1/2 X 2....bolsters to bed...bed in lowest position with fall mats....toilet and provide incontinent care frequently...." An incident report dated 04/14/13 at 5:45 p.m., documented, "...was found on floor on her back in TV room pt stated she did not hit her head...pt was put in w/c. PSA was attached but did not sound. Pt was given PRN pain meds for leg and hip (L) pain. Dr...called and informed and ordered -x-ray for (L) hip, femur and knee..." A report to the Oklahoma State Department of Health, documented, "...2140 (9:40 p.m.) x-ray results received. Fracture proximal femur and femoral neck of (L) hip. Transferred to hospital for direct admit...87 yo female with [DIAGNOSES REDACTED]. Current preventative interventions have been effective...resident will be evaluated for fall risk and prevention upon return to facility from hospital...resident will be on special focus for fall prevention..." A physician's telephone order dated 04/14/13, documented, "Xray (L) hip and (L) leg (thigh & knee) S/P fall..." A "Radiology Report" dated 04/14/13 documented, "Exam: Hip...Results: There is a fracture involving the left femoral neck with modest displacement. The joint shows no dislocation...There is osteopenia. The fracture is new from 2/20/13. Conclusion: Acute appearing left hip fracture as described above. Exam: Femur...Results: There is a fracture involving the proximal femur with modest displacement. The remainder of the femur is intact. Conclusion: Acute appearing left femur fracture as described..." A physician's progress note dated 04/18/13, documented, "...current dx: recently hospitalized for [REDACTED]." A "Nursing Comprehensive Admission Data" dated 04/18/13, documented, "...admitting DX: (L) ORIF....medical history: Alzheimers/ dementia, osteoporosis, (L) & (R) ORIF..." A care plan dated 04/22/13, documented, "Problem: (arrow up) risk for falls R/T end stage dementia, past hx of falls to include ORIF 04/14/13, and psych and NARC medications... Goal...will not have any further falls /c injury...." There were no additional interventions added to the care plan. A physician's telephone order dated 04/28/13 at 4:45 a.m., documented, "xray Lt hip s/p fall..." There was no facility incident report or documentation in the clinical record for the fall that occurred on 04/28/13. A fall risk assessment dated [DATE], 02/12/13, 03/04/13, 04/18/13 and 04/29/13, documented the resident was a high risk for falls with a score of 75. A score of 45 or greater indicated the resident was a high risk for falls. An incident report dated 04/29/13 at 5:00 a.m., documented, "...found resident laying on Lt side on the floor next to her bed. 0 injuries or bruising, surgical site intact....physician statement...xray of (L) hip...." An incident report dated 04/30/13 at 7:55 p.m., documented, "...describe what happened: see attached note...location of injury: skull / scalp....date of transfer 04/30/13 2105 (9:15 p.m.)...physician statement..send to ER for eval and tx..." A daily skilled nurse's note at the same time documented, "Was informed by staff that resident was in the floor. Upon entry to room observed the resident laying on her lt side by the side of the bed. Noted large pool of blood around the head...when asked about her head she stated it hurt a little...questioned about neck pain and she stated it hurt a little. Upon assessment of head noted laceration approx 2 cm in length X 0.5 cm in width....n/o received to send to ER for eval & Tx..." A report to the Oklahoma State Department of Health, documented, "...Dementia, S/P (L) ORIF, requires total care with all aspects . Condition has declined with progression of Dementia, care plan for fall prevention, special focus through QA fall prevention program. Resident is unaware of her limitations and safety R/T cognitive deficits...resident has a h/o agitation, R/T her Dementia and trends toward sundowners. Behaviors are easily managed. High fall risks are identified through the fall risk assessment with preventive measures in place as well as care plan..." A physician's telephone order dated 04/30/13, documented, "Send to ER for eval & tx..." A care plan update dated 04/30/13, documented, "Fall /c injury." There were no additional interventions added to the care plan after the resident sustained [REDACTED]. A care plan dated 05/02/13, documented, "Problem: fractured hip S/P (L) hip ORIF... Problem: pain and comfort alteration in pain and comfort R/T: S/P (L) hip ORIF. (arrow down) mobility.... Problem: Self care deficit...related to S/P (L) hip ORIF.... Problem: Osteoporosis: Bone demineralization caused by mineral absorption that exceeds bone formation resulting in brittle porous thinning bones..." A physician's progress note dated 06/06/13, documented, "...history of present illness: monthly follow up for recent re-admission after hospitalization for hip surgery...surgical history: Rt hip ORIF, Lft hip ORIF 04/18/13..." An incident report dated 07/10/13 at 4:31 a.m., documented, "Pt found sitting on buttocks on safety mat with back against bed. Unable to tell what happen. Assessed resident and ROM within normal limits. Neuros initiated. Assisted to w/c by CNAs. Fall assessment updated. IDT meet and came to the conclusion that incident maybe related to toileting due to res. was incont of bowel when found...res brought out to hall with nurse to continue monitoring. Immediate Post incident action: reassure safety alarm in place and check function. Immediate action taken: resident assessed, neuros initiated, and continue to observe during remainder of shift...medical risk factors...fall history and fracture..." A care plan approach dated 07/10/13, documented, "Reinforce safety alarm & function..." A care plan approach dated 07/14/13, documented, "Falling star program. Educate staff require frequent toilet and anticipate needs..." The care plan did not define how often the resident would be toileted. There were no changes in any of the care plan interventions to aide in the prevention of recurrence of falls with injuries. A significant change assessment dated [DATE], documented the resident rarely understands others, rarely is understood, has short term memory problems, long term memory problems and was moderately impaired in cognitive skills for daily decision making. The resident did not walk during the seven day look back period, required extensive assistance with bed mobility, transfers, locomotion on and off the unit. dressing, toilet use, hygiene and bathing. The resident was not on a toileting program or schedule, and the resident had two falls without injury since the last assessment. The assessment also documented the resident did not have any therapy or restorative services. An incident report dated 07/24/13 at 2:30 p.m., documented, "Heard resident psa sounding and entered room and saw resident sliding out of bed onto knees onto mat by side of bed. Bed in low position. No injuries...immediate action taken: assessment for pain...medical risk factors...fall history, inability to understand direction, arthritis/ osteoporosis, fracture, confusion, incontinent...Narrative of investigation: (Resident) was noted to have a soiled brief. intervention added were to continue to provide toileting q 2 hours and change mat to decrease slippage..." A nurse's note dated 07/24/13 at 10:41 p.m., documented, "Entered resident room at 1430 (2:30 p.m.) psa alarm sounding. observed resident sliding out of bed onto knees onto floor mat. No injury noted and no s/s of pain noted...noted that resident brief dirty and assisted back to bed...educated staff to check resident at beginning of shift to make sure that (resident) was clean and dry..." An incident report dated 08/07/13 at 12:00 a.m., documented, "Resident was observed by cna on floor mat cna immediately reported event to this nurse nurse went to assess the resident no s/s of new injury bruise cuts or skin tears......medical risk factors fall history, dementia, arthritis/ osteoporosis, confusion/ disorientation...incontinency...immediate post incident action: will check on resident more frequently throughout the night instead of the standard two hours have nursing staff check on resident q 1..." An incident report dated 08/17/13 at 9:21 a.m., documented, "This nurse was called to room of res by CNA. Upon entering room res noted on floor with blood coming from nose and mouth. Bruise noted to right inferior orbit and right medial jaw. The nurse obtained 4 x 4 gauze sponges and applied pressure to bridge of nose and lifted head to side to prevent aspiration. Although pressure was applied res continued to have epistaxis (nose bleed) so this nurse called EMS to send res to the hospital for evaluation and tx. Epistaxis without apparent external trauma to nose...immediate action taken: first aide and sent to (hospital) for evaluation and tx....immediate post incident action: PSA and fall mat to be in place..." A report to the Oklahoma State Department of Health, documented, "...08-21-13 resident returned from the hospital. Large amount of bruising to (R) side of face and neck. Extensive bruising R/T plavix (blood thinner) use. Care plan meeting held with family and hospice for fall prevention. reclining G/C is use, mattress changed to bolster mattress and 3/4 side rails to bed...resident cont at high risk for recurrent falls, all previous interventions have not prevented injury r/t falls..." A care plan approach dated 08/17/13, documented, "Send to ER." A care plan approach dated 08/21/13, documented, "Geri-chair /c tray." The new interventions did not address the residents continued falls from her bed. There was no documentation the facility completed a review of the resident's medication in relation to the recurrence of falls with injuries; nor provided restorative services to strengthen the resident; as were addressed in previous care plan approaches. A social service note dated 08/21/13 at 3:06 p.m., documented, "Care plan conference...social services and administrator present to discuss some type of restraint that will benefit their mother to keep her from falling...family wants to use a geri chair..." A care plan dated 08/22/13, documented, "Resident requires physical restraint s/t multiple falls, decreased cognition and poor safety awareness. Other attempts (sic) to keep resident safe have been unsuccessful. Goal: resident will remain free of injury..." Approaches...educate resident/family of any risks associated with use of restraint...falls/ injury...." A quarterly assessment dated [DATE], documented sometimes understood, sometimes understands, had long and short term memory problems and modified independence in cognitive skills for daily decision making. The resident required two person extensive assistance with transfers, bed mobility, dressing, eating, toilet use, hygiene and bathing. She required staff assistance with stabilizing self while moving from a seated to a standing position and surface to surface transfers. The assessment also documented the resident was incontinent of bowel and bladder, was not on toileting program or schedule and had two falls without injury and one with a minor injury since the last assessment. A care plan approach dated 10/10/13, documented, "W/C /c lap buddy." On 10/28/13 at 10:05 a.m., the resident was observed resting in her bed. The bed was in the lowest position, but the mat was not next to the bed. The mat was under the bed. On 10/30/13 at 9:00 a.m., the resident was observed resting in bed. The bed was in the lowest position. The safety mat was under the bed. The resident remained that way until 9:35 a.m., when an aide went in and saw the mat was not out. On 10/30/13 at 1:45 p.m., the resident was observed up in her wheel chair at the nurses station. Staff was observed taking the resident to the dining room for the cake and ice cream social. At 2:00 p.m., 2:15 p.m., 2:25 p.m., 2:45 p.m., and 3:10 p.m., the resident remained in the dining room where the cake and ice cream social was observed. At 3:10 p.m., the resident was observed being taken from the dining room to the television area. The resident was observed in the television area at the following times: 3:30 p.m., 3:45 p.m. and 4:25 p.m. At 4:25 p.m., the resident was observed wheeling herself from the television area to hall 400 were she stopped and was looking around. The resident remained up in her wheel chair from 1:45 p.m. to 4:25 p.m., when a request was made to observe the condition of the resident's skin. Staff had not toileted nor checked the resident for incontinence during the three and half hour observation. When the resident's skin was checked at 4:25 p.m., the resident's brief was found to be saturated with urine. An interview was conducted on 10/31/13 at 10:05 a.m., with the director of nursing and the unit manager. They were asked what interventions had been implemented to aide in the prevention of recurrence of falls with injuries. The director of nursing stated, "Low bed, personal safety alarm, fall mat, frequent checks, toileting schedule and lap buddy." She was asked if the interventions between February 2013 and August 2013 had been evaluated and changed. She stated, "They are all the same. There are no changes." The unit manager looked through the clinical record and stated, "She has had a lot of injuries." He then added, "I agree there had been no changes in interventions between February and August." They were asked what the resident's toileting schedule was. The director of nursing stated, "Every two hours." She was asked if this was resident specific. She stated, "Everyone gets checked every two hours." On 10/31/13 at 11:53 a.m., the administrator was made aware of the recurrence of falls with injuries between 02/13 and 08/22/13, and the failure to evaluate and implement interventions to aide in the prevention of falls with injuries. She acknowledged the problem and stated, "We will improve."

Based on observation, record review and interviews, it was determined the facility failed to ensure a resident who was a new admit and was in severe pain was assessed and had their pain management program implemented for one (#12) of four sampled residents reviewed for pain management and medication administration. This deficient practice resulted in an actual harm. The director of nursing identified 19 residents who were newly admitted and on a pain management program since 10/09/13. Findings: The "Pain Management" policy documented, "...The facility recognizes that a resident/patient's response to pain is subjective and individual. All residents/patients are initially screened for pain upon admission, quarterly, and/or with a significant change in condition that may cause an onset or increase in pain...the facility promotes resident/ patient self reporting as the most reliable indicator of pain...determine the appropriate interventions to manage pain and aide effects. Appropriate interventions may include pharmacologic as well as non-pharmacologic interventions...notify physician if interventions are not effective achieving resident/patient comfort....re-assess resident/patient status as indicated.." A facility policy titled " Medication Errors" documented the following...Procedure...Check the medication against the prescription or order before they are given..." 1. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission/ Start Up orders documented the following pain medication orders [REDACTED] Neurotone 300 milligrams twice a day for pain; [MEDICATION NAME] 500 milligrams twice a day for pain; [MEDICATION NAME] 10 milligrams three times a day for muscle spasms; [MEDICATION NAME] 10 milligrams three times a day for muscle spasms; [MEDICATION NAME] 10 milligrams every twelve hours for pain; [MEDICATION NAME] IR (intermediate release) 5 milligrams every four hours as needed (PRN) for breakthrough pain. A review of the nursing comprehensive admission assessment dated [DATE], documented the resident arrived at the facility at 6:20 p.m. The assessment also documented the resident had pain at a level of four (moderate) on a scale of one to ten. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A pharmacy form "Prescription Delivered to Midwest City N.C. (nursing center)" documented the pharmacy received the medication orders and filled them between 9:30 p.m. and 10:00 p.m. There was no documentation of the time the facility received the delivery of the medication. The individual patient narcotic record documented the medications were received at 11:00 p.m., three hours after the scheduled doses were to be administered. There was no documentation the facility administered any pain medication until 10/29/13 at 1:20 a.m., when the first PRN medication of [MEDICATION NAME] was provided. This was two hours and twenty minutes after the medication was received by the facility. There was no documentation the facility evaluated the resident's pain, notified the physician and/or provided interventions to aide in alleviating the resident's pain. An "Individual Resident Care Plan" dated 10/30/13, documented, "Problem: manipulative behaviors 2 (secondary) to loss of independent pain management control... Goal: resident will cope /c (with) loss of independence to self moderate for pain over the next 21 days... maintain acceptable level of pain (0-4) as stated by resident on a scale of 0-10 .... Interventions...pain medication A/O (as ordered)..." The skilled nursing documentation dated 10/29/13, for the first shift (6:00 a.m. through 2:00 p.m.), documented the resident had pain at a level of eight (severe pain) and was located in the resident's legs, head and throat. An interview was conducted on 10/30/13 at 3:00 p.m., with the resident. He was asked the date and time he was admitted to the facility. He stated, "10/28/13 around 6:00 p.m." He was asked if he received the medications as listed above. He stated he had not received them. He then stated, "I asked for pain medications and was told they are waiting on paperwork from the hospital." The resident was asked about his ability to sleep the first night he was admitted . He stated, "I had pain and stayed up due to the pain." He was asked to rate his pain on a scale of 0 to 10. He stated, "Eight." The resident was asked when he first received pain medications. He stated after midnight. He then stated his other medications were given the next morning. He was asked what he first received and stated [MEDICATION NAME]. The resident was asked how long it took for the pain medication to work. He stated he liked his pain level to be between 0 and 4 and it took almost a full day to get it back down. An interview was conducted on 10/31/13 at 9:49 a.m., with the administrator, director of nursing and unit manager. They were asked why the medications were not provided to the resident at 8:00 p.m. The director of nursing stated, "They weren't here." She was asked if this was a significant error. She stated, "Yes. It's a significant medication error." They were asked if the doctor was notified of the medications not being provided. The unit manager stated, "If it's not documented, it didn't happen." They were asked what time the medications arrived in the facility. All three agreed the medication was received at 11:00 p.m. The administrator, director of nursing and unit manager were asked if the resident's pain management program was being followed upon admission. The director of nursing stated it wasn't. A request was made for documentation the facility notified the physician of the pain management program not being followed; documentation an evaluation of the resident's pain was done and interventions to alleviate the pain were instituted. No further documentation was provided. An interview was conducted on 10/31/13 at 11:25 a.m., with physician #1. He was asked if he was the attending physician for resident #12. He stated, "Yes." The physician was asked if the facility notified him the resident did not receive his 8:00 p.m. medications and/or about the resident having severe pain. He stated, "Without notes I can not say. I don't see anything they notified me of the pain or missing medications." He was asked about the missed doses of medication. He stated, "If it's ordered they need to give it."

Based on observation, record review and interviews, it was determined the facility failed to ensure a newly admitted resident received his prescribed medications which included pain medications, muscle relaxers and antibiotics for one (#12) of four sampled residents who was newly admitted since 10/09/13. This resulted in an actual harm. The director of nursing identified 19 residents who had been admitted since 10/09/13. Findings: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission/Start Up orders documented the following medication orders [REDACTED] [MEDICATION NAME] DR 250 milligrams twice a day for depression; [MEDICATION NAME] 300 milligrams twice a day for pain; [MEDICATION NAME] 500 milligrams twice a day for pain; [MEDICATION NAME] 10 milligrams three times a day for muscle spasms; [MEDICATION NAME] 10 milligrams three times a day for muscle spasms; [MEDICATION NAME] 10 milligrams every twelve hours for pain; [MEDICATION NAME] 100 milligrams at bedtime for [MEDICAL CONDITION]; [MEDICATION NAME] 875 milligrams twice a day for infection; Cipro 500 milligrams twice a day for infection; A review of the nursing comprehensive admission assessment dated [DATE], documented the resident arrived at the facility at 6:20 p.m. The assessment also documented the resident had pain at a level of four on a scale of one to ten. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A pharmacy form, "Prescription Delivered to Midwest City N.C. (nursing center)" documented the pharmacy received the medication orders and filled them between 9:30 p.m. and 10:00 p.m. There was no documentation of the time the facility received the delivery of the medication on that form. The individual patient narcotic record documented the medications were received at 11:00 p.m., three hours after the scheduled doses were to be administered. An "Individual Resident Care Plan" dated 10/29/13, documented, "Problem: Antibiotics resident requires antibiotic therapy for s/[MEDICAL CONDITION] Goals: resident will not experience or show any signs of and symptoms of infections... Intervention...meds as ordered... Problem: 10-29-13 Resident is currently taking [MEDICAL CONDITION] medication(s) as evidenced by: depression, anxiety, [MEDICAL CONDITION] currently takes [MEDICATION NAME], Ambien, [MEDICATION NAME] Problem: Resident has a Dx of [MEDICAL CONDITION] and is at risk for...injuries due to increased weakness... Goal: Residents dignity...will be maintained and no occurrence of injury will occur... Intervention...give meds per order... Problem: [MEDICAL CONDITION] as ordered... Problem: 10-30-13 manipulative behaviors 2 (secondary) to loss of independent pain management control... Goal: resident will cope /c loss of independence to self moderate for pain over the next 21 days... maintain acceptable level of pain (0-4) as stated by resident on a scale of 0-10 .... Interventions...pain medication A/O (as ordered)..." The skilled nursing documentation dated 10/29/13, for the first shift (6:00 a.m. through 2:00 p.m.), documented the resident had pain at a level of eight (severe pain) located in the resident's legs, head and throat. An interview was conducted on 10/30/13 at 3:00 p.m., with the resident. He was asked the date and time he was admitted to the facility. He stated, "10/28/13 around 6:00 p.m." He was asked if he received the medications listed above. He stated he had not received them. He then stated, "I asked for pain medications and was told they are waiting on paperwork from the hospital." The resident was asked about his ability to sleep the first night he was admitted . He stated, "I had pain and stayed up due to the pain." He was asked to rate his pain on a scale of 0 to 10. He stated, "Eight." The resident was asked when he first received pain medications and he stated after midnight. He then stated his other medications were given the next morning. He was asked how long it took for the pain medication to work. He stated he liked his pain between 0 and 4 and it took almost a full day to get it back down. An interview was conducted on 10/31/13 at 9:49 a.m., with the administrator, director of nursing and the unit manager. They were asked why the medications were not provided to the resident at 8:00 p.m. The director of nursing stated, "They weren't here." She was asked if this was a significant medication error. She stated, "Yes. It's a significant medication error." They were asked if the doctor was notified of the medications not being provided. The unit manager stated, "If it's not documented, it didn't happen." They were asked what time the medications arrived in the facility. All three agreed the medication was received at 11:00 p.m. An interview was conducted on 10/31/13 at 11:25 a.m., with physician #1. He was asked if he was the attending physician for resident #12. He stated, "Yes." He was asked if the facility notified him the resident did not receive his 8:00 p.m. medications and about the resident having severe pain. He stated, "Without notes I can not say. I don't see anything they notified me of the pain or missing medications." He was asked about the missed doses of medications. He stated, "If it's ordered they need to give it."

Based on observation, record review and interviews, it was determined the facility failed to ensure a resident received his routine pain medications as part of his pain management program for one (#3) of three sampled residents who received routine and as needed (PRN) medication for pain management. This resulted in an actual harm. The director of nursing identified 58 residents who were currently on a pain management program with routine pain medications. Findings: Resident #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The admission start up orders, dated 09/26/13, documented the following pain medication orders [REDACTED] "[MEDICATION NAME] 10 mg (milligrams) PO (by mouth Q (every) 12 (hours) DX (diagnoses) pain 0800 and 2000 (8:00 a.m. and 8:00 p.m.)... [MEDICATION NAME] 10 mg PO TID (three times a day) PRN (as needed) muscle spasms... [MEDICATION NAME] 300 mg PO TID DX pain 0800, 1400 2100 (8:00 a.m., 4:00 p.m. and 9:00 p.m.)... [MEDICATION NAME] 2 mg PO Q 3 (hours) PRN severe pain... [MEDICATION NAME] 10/325 mg (two tablets) PO q 4 (hours) PRN severe pain... [MEDICATION NAME] 10/325 mg (one tablets) PO q 4 (hours) PRN severe pain..." A nursing admission assessment dated [DATE], documented the resident arrived at 7:00 p.m. at The Midwest City Nursing Center from the (Name deleted) Hospital. It also documented the resident had pain of six on a level of one to ten, and had grimacing, non-verbal signs of pain. The Medication Administration Record [REDACTED]. There was no documentation on the back of the Medication Administration Record [REDACTED]. The "Controlled Drug Administration Record" documented 19 tablets of [MEDICATION NAME] 300 mg were delivered to the facility on [DATE]. A review of the pharmacy order history for the resident documented the resident received 15 tablets of [MEDICATION NAME] 10 mg on 09/27/13. There was no documentation of the time the facility received the residents medications from the pharmacy. On 10/03/13 at 11:30 a.m., the resident was observed in his room grimacing. He stated he was in a lot of pain, but had a pain management program that helped. An interview was conducted with the resident at that time. He was asked what time of day he arrived and was admitted to the facility. He stated he had arrived at 6:30 p.m. on the date of admission (09/26/13). He was asked if he had received [MEDICATION NAME] 10 mg at 8:00 p.m. or [MEDICATION NAME] 300 mg at 9:00 p.m. on 09/26/13. He stated, "No, I didn't receive them." An interview was conducted on 09/23/13 at 12:05 p.m., with the director of nursing (DON). She was asked if the resident received his routine medications on 09/26/13. She stated, " No medications on 09/26/13." The DON was asked if the resident was in pain during this time. She stated, "He (the resident) stated he was in a lot of pain during that time." A second interview was conducted at 1:15 p.m., with the resident. He was asked if he was able to sleep the night he was admitted . He stated, "I never slept that night." The resident was asked to rate the pain that night on a scale of 1:10, with ten being the worst. He stated, "Low ten, it was very bad pain." He was asked how long it took for the pain to be relieved once medication was available. He stated, "It took three doses to start getting the pain down." An interview was conducted on 10/03/13 at 2:07 p.m., with licensed practical nurse (LPN) #1. She was asked if resident #3 was in pain the night he was admitted . She stated, "I talked to him hourly and he was in a lot of pain." She was asked what shift she worked the night the resident was admitted . She stated, "10:00 p.m. through 6:00 a.m." The nurse then stated, "It aggravates me. We can not get the pain medications residents need." She was asked if the resident was able to sleep the night he was admitted . She stated, 'He didn't sleep at all that night." An interview was conducted on 10/03/13 at 2:20 p.m., with LPN #2 regarding medication acquisition. She was asked if resident #3 had been given his 8:00 p.m. and 9:00 p.m. routine pain medication. She stated, "No. I didn't have pain medications." She stated the medications had not been delivered and the resident had not received any pain medication. She was asked what shift she had worked the night the resident was admitted . She stated she had worked 2:00 p.m. through 10:00 p.m. An interview was conducted on 10/03/13 at 2:30 p.m., with certified nurse aide (CNA) #2. She was asked what shift she worked the night resident #3 was admitted . She stated, "10 to 6 shift." She was asked what she remembered about the resident's first night. She stated, "He would call every hour wondering about his pain medications." The CNA also stated, "He said he didn't understand why the medications were not here." When asked if the resident had any pain, she stated, "He was hurting. That's why he called." An interview was conducted on 10/03/13 at 2:55 p.m., with CNA #4. He was asked what shift he worked the night resident #3 was admitted . He stated, "Two to ten shift." He was asked if he remembered anything about the night the resident had been admitted . He stated, "He kept putting the light on wanting pain medication." He then stated he told the nurse about the resident's pain but was not sure if the resident ever received any pain medication. An interview was conducted on 10/03/13 at 3:43 p.m., with LPN #3 regarding medication acquisition. She was asked about the pain medications for resident #3 on the night he was admitted . She stated, "I got off at 11:30 p.m. and (Name deleted/in state pharmacy) still had not filled the medications because there was no authorization from (Name deleted/out of state pharmacy)." When asked if the resident exhibited signs or voiced complaints of pain she stated, "He complained of pain all over; back, necks, hips, all over pain." An interview was conducted on 10/08/13 at 2:37 p.m., with the director of nursing. She was asked if the missed doses of pain medication was a significant medication error. She stated, "Yes. They are medication errors."

Based on observation, record review and interviews, it was determined the facility failed to ensure a newly admitted resident received his prescribed medications which included pain medications, muscle relaxers and antibiotics for one (#12) of four sampled residents who was newly admitted since 10/09/13. This resulted in an actual harm. The director of nursing identified 19 residents who had been admitted since 10/09/13. Findings: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission/Start Up orders documented the following medication orders [REDACTED] [MEDICATION NAME] DR 250 milligrams twice a day for depression; [MEDICATION NAME] 300 milligrams twice a day for pain; [MEDICATION NAME] 500 milligrams twice a day for pain; [MEDICATION NAME] 10 milligrams three times a day for muscle spasms; [MEDICATION NAME] 10 milligrams three times a day for muscle spasms; [MEDICATION NAME] 10 milligrams every twelve hours for pain; [MEDICATION NAME] 100 milligrams at bedtime for [MEDICAL CONDITION]; [MEDICATION NAME] 875 milligrams twice a day for infection; Cipro 500 milligrams twice a day for infection; A review of the nursing comprehensive admission assessment dated [DATE], documented the resident arrived at the facility at 6:20 p.m. The assessment also documented the resident had pain at a level of four on a scale of one to ten. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A pharmacy form, "Prescription Delivered to Midwest City N.C. (nursing center)" documented the pharmacy received the medication orders and filled them between 9:30 p.m. and 10:00 p.m. There was no documentation of the time the facility received the delivery of the medication on that form. The individual patient narcotic record documented the medications were received at 11:00 p.m., three hours after the scheduled doses were to be administered. An "Individual Resident Care Plan" dated 10/29/13, documented, "Problem: Antibiotics resident requires antibiotic therapy for s/[MEDICAL CONDITION] Goals: resident will not experience or show any signs of and symptoms of infections... Intervention...meds as ordered... Problem: 10-29-13 Resident is currently taking [MEDICAL CONDITION] medication(s) as evidenced by: depression, anxiety, [MEDICAL CONDITION] currently takes [MEDICATION NAME], Ambien, [MEDICATION NAME] Problem: Resident has a Dx of [MEDICAL CONDITION] and is at risk for...injuries due to increased weakness... Goal: Residents dignity...will be maintained and no occurrence of injury will occur... Intervention...give meds per order... Problem: [MEDICAL CONDITION] as ordered... Problem: 10-30-13 manipulative behaviors 2 (secondary) to loss of independent pain management control... Goal: resident will cope /c loss of independence to self moderate for pain over the next 21 days... maintain acceptable level of pain (0-4) as stated by resident on a scale of 0-10 .... Interventions...pain medication A/O (as ordered)..." The skilled nursing documentation dated 10/29/13, for the first shift (6:00 a.m. through 2:00 p.m.), documented the resident had pain at a level of eight (severe pain) located in the resident's legs, head and throat. An interview was conducted on 10/30/13 at 3:00 p.m., with the resident. He was asked the date and time he was admitted to the facility. He stated, "10/28/13 around 6:00 p.m." He was asked if he received the medications listed above. He stated he had not received them. He then stated, "I asked for pain medications and was told they are waiting on paperwork from the hospital." The resident was asked about his ability to sleep the first night he was admitted . He stated, "I had pain and stayed up due to the pain." He was asked to rate his pain on a scale of 0 to 10. He stated, "Eight." The resident was asked when he first received pain medications and he stated after midnight. He then stated his other medications were given the next morning. He was asked how long it took for the pain medication to work. He stated he liked his pain between 0 and 4 and it took almost a full day to get it back down. An interview was conducted on 10/31/13 at 9:49 a.m., with the administrator, director of nursing and the unit manager. They were asked why the medications were not provided to the resident at 8:00 p.m. The director of nursing stated, "They weren't here." She was asked if this was a significant medication error. She stated, "Yes. It's a significant medication error." They were asked if the doctor was notified of the medications not being provided. The unit manager stated, "If it's not documented, it didn't happen." They were asked what time the medications arrived in the facility. All three agreed the medication was received at 11:00 p.m. An interview was conducted on 10/31/13 at 11:25 a.m., with physician #1. He was asked if he was the attending physician for resident #12. He stated, "Yes." He was asked if the facility notified him the resident did not receive his 8:00 p.m. medications and about the resident having severe pain. He stated, "Without notes I can not say. I don't see anything they notified me of the pain or missing medications." He was asked about the missed doses of medications. He stated, "If it's ordered they need to give it."

On 10/03/13, an immediate jeopardy situation was determined to exist due to the facility's failure to have an effective system in place to assess and address newly admitted residents pain. The facility also failed to implement existing pain management programs. Resident #3 was admitted to the facility from the hospital and had an existing pain management program in place. The facility failed to ensure the resident received pain medication for over ten hours to address the excruciating pain the resident exhibited. At 12:35 p.m., the Oklahoma State Department of Health was notified and confirmed the existence of the immediate jeopardy. At 1:00 p.m., the administrator and director of nursing were notified of the existence of the immediate jeopardy. On 10/07/13 at 5:00 p.m., the administrator provided an acceptable plan of removal. The plan of removal was as followed: "10-03-13 Plan of Removal- Pharmacy Services and pain management Pain evaluations will be completed on every resident by 9 pm to validate that pain goals are met. Staff education will be completed for pain management and documentation of pain with effectiveness of management program by 10-04-13, 9 a.m.. New admissions will have pain evaluation completed at time of admission. Pain evaluations are completed quarterly, with increase or new onset of pain and with significant change in resident status. The pain evaluation program will be monitored by the DON or designee, daily until compliant, then weekly thereafter. Monitoring results will be presented by the director of nursing or designee at the Quality Assurance Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team with subsequent plans of corrections developed and implemented as deemed necessary. Pain medication availability for residents has been verified by completion of MAR indicated [REDACTED] A contract has been acquired with an instate pharmacy service, effective 10-04-13. Licensed staff has received re-education on pain medication availability and pain medication ordering procedures, which includes documentation of medication ordering and receipt. In-Service training will be scheduled quarterly pain assessment and procedures for ordering medications. Pain medication for new admissions and stat orders will be delivered to the facility as soon as possible, after receipt of physician's orders [REDACTED]. A follow up call will be made to pharmacy from the facility to validate receipt of prescription. During the interim for delivery, nonpharmacologic interventions and house stock [MEDICATION NAME] may be administered with physician's orders [REDACTED]. The DON or designee is monitoring medication availability daily until compliance is achieved, then 3 X week there after. New admission medications are being validated by the DON or designee, with focus on ordering and timely receipt of medications. Monitoring results will be presented by the Director of Nursing or designee at the Quality Assurance Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team with subsequent plans of corrections developed and implemented as deemed necessary." On 10/08/13 at 3:05 p.m., after reviewing all in-services, audits and interviews with staff, the administrator and director of nursing was notified the immediacy had been lifted effective 10/07/13 at 5:00 p.m., when the facility had submitted their acceptable plan of removal. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from recurring. Based on observation, record review and interviews, it was determined the facility failed to ensure a resident who was in excruciating pain was assessed and had their pain management program implemented for one (#3) of three sampled residents reviewed for pain management and medication administration. This deficient practice resulted in an actual harm. The director of nursing identified 40 residents who had been admitted since 08/01/13, fifteen who were on a pain management program. She also identified 58 residents who currently resided in the facility were on a pain management program. Findings: The "Pain Management" policy documented, "...The facility recognizes that a resident/patient's response to pain is subjective and individual. All residents/patients are initially screened for pain upon admission, quarterly, and/ or with a significant change in condition that may cause an onset or increase in pain...the facility promotes resident/ patient self reporting as the most reliable indicator of pain...determine the appropriate interventions to manage pain and aide effects. Appropriate interventions may include pharmacologic as well as non-pharmacologic interventions...notify physician if interventions are not effective achieving resident/ patient comfort....re-assess resident /patient status as indicated..." Resident #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The admission start up orders, dated 09/26/13, documented the following pain medication orders [REDACTED] "[MEDICATION NAME] 10 mg (milligrams) PO (by mouth Q (every) 12 (hours) DX (diagnoses) pain 0800 and 2000 (8:00 a.m. and 8:00 p.m.)... [MEDICATION NAME] 10 mg PO TID (three times a day) PRN (as needed) muscle spasms... [MEDICATION NAME] 300 mg PO TID DX pain 0800, 1400 2100 (8:00 a.m., 4:00 p.m. and 9:00 p.m.)... [MEDICATION NAME] 2 mg PO Q 3 (hours) PRN severe pain... [MEDICATION NAME] 10/325 mg (two tablets) PO q 4 (hours) PRN severe pain... [MEDICATION NAME] 10/325 mg (one tablets) PO q 4 (hours) PRN severe pain..." A nursing admission assessment dated [DATE], documented the resident arrived at the facility at 7:00 p.m. from the (Name deleted) Hospital. It also documented the resident had pain of six on a level of one to ten, and had grimacing, non-verbal signs of pain. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation the facility administered any pain medication until 09/27/13, when the first PRN medication, [MEDICATION NAME] two tablets was administered. The time the medication was administered was not documented. There was no documentation in the clinical record to show the facility evaluated the resident's pain, notified the physician and/or provided interventions to aide in alleviating the resident's pain. The "Controlled Drug Administration Record" documented 19 tablets of [MEDICATION NAME] 300 mg and 30 tablets of [MEDICATION NAME] 2 mg were delivered to the facility on [DATE]. A review of the personal prescription information sheet from (Name deleted) pharmacy documented nine tablets of [MEDICATION NAME] ([MEDICATION NAME]) 10 mg and 30 tablets of [MEDICATION NAME] 10/325 mg were delivered to the facility on [DATE]. A review of the pharmacy order history for the resident documented the facility received 15 tablets of [MEDICATION NAME] 10 mg on 09/27/13. There was no documentation of the time the facility received the residents medications from the pharmacy. On 10/03/13 at 11:30 a.m., the resident was observed in his room grimacing. He stated he was in a lot of pain, but had a pain management program that helped. An interview was conducted with the resident at that time. He was asked what time of day he arrived and was admitted to the facility. He stated he had arrived at 6:30 p.m. on the date of admission (09/26/13). He was asked if he had received [MEDICATION NAME] 10 mg at 8:00 p.m. and [MEDICATION NAME] 300 mg at 9:00 p.m. on 09/26/13. He stated, "No. I didn't receive them." The resident was asked when he had received any pain medications. He stated, "5:00 a.m. the next morning." He was asked what he received at 5:00 a.m., and he stated he had received two tablets of [MEDICATION NAME]. The resident was asked how long he had to wait before receiving any pain medications. He stated, "First night over ten hours because they didn't get the medication from the pharmacy." An interview was conducted on 10/03/13 at 12:05 p.m., with the director of nursing (DON). She was asked if the resident received his routine medications on 09/26/13. She stated, " No medications on 09/26/13." The DON was asked how many medications the resident received for pain, including routine and PRN. She stated, "Five: [MEDICATION NAME] and [MEDICATION NAME]." The DON was asked why the resident didn't receive his routine pain medications on 09/26/13. She stated, "Medications didn't get here until 4:10 a.m." The DON was asked why the medications took nine and half hours to get to the facility. She stated, "The pharmacy was waiting on an authorization from (Name deleted/out of state pharmacy) so they were paid for." The DON was asked if the resident was in pain during this time. She stated, "He (the resident), stated he was in a lot of pain during that time." She then stated the facility had been having problems with the backup pharmacy receiving authorizations for payments. She was asked how long this had been going on. She stated, "Since I've been here for two months, probably longer." She was asked if the facility had done anything different since identifying there was a problem. She stated there had been no changes in their procedures. A second interview was conducted at 1:15 p.m., with the resident. He was asked if he was able to sleep the night he was admitted . He stated, 'I never slept that night." The resident was asked to rate the pain that night on a scale of 1:10, with ten being the worst. He stated, "Low ten, it was very bad pain." The resident was asked how long it took for the pain to be relieved once the medication was available. He stated, "It took three doses to start getting the pain down." He was asked how the facility addressed the pain he was experiencing. He stated, "They didn't do anything, just tried to get the medications." An interview was conducted on 10/03/13 at 2:07 p.m., with licensed practical nurse (LPN) #1, regarding medication acquisition and pain management. She was asked to describe the facility procedure for medication acquisition for newly admitted residents. She stated the facility had faxed the information to the out of state pharmacy and they would call and confirm the fax was received. The LPN was asked how long it would take to get medications for the resident, such as routine pain medication and/or other medications. She stated a local backup pharmacy was used but they would not release the medication until there was an authorization from the out of state pharmacy. The LPN was asked if resident #3 was in pain the night he was admitted . She stated, "I talked to him hourly and he was in a lot of pain." She was asked what shift she worked the night the resident was admitted . She stated, "10:00 p.m. through 6:00 a.m." The LPN then stated, "It aggravates me. We can not get the pain medications residents need." She was asked if resident #3 was able to sleep the night he was admitted . She stated, 'He didn't sleep at all that night." The LPN was asked what time the medications arrived at the facility. She stated, "The pharmacy never called back until after 4:00 a.m." She was asked when the resident received his first dose of PRN and/or routine pain medication. She stated, "Close to 5:00 a.m. (09/27/13)." When asked what the facility did to address the resident's pain, the LPN stated, "Nothing but kept trying to get medications." An interview was conducted on 10/03/13 at 2:20 p.m., with LPN #2 regarding medication acquisition. She was asked if resident #3 had his 8:00 p.m. and 9:00 p.m. routine pain medication. She stated, "No. I didn't have pain medications." She stated the medications were not delivered and the resident had not received them. The LPN was asked if she had any concerns the medications were not at the facility. She stated, "No. I didn't have concerns." She was asked what shift she had worked on the night the resident was admitted . She stated she had worked 2:00 p.m. through 10:00 p.m. An interview was conducted on 10/03/13 at 2:30 p.m., with certified nurse aide (CNA) #2. She was asked what shift she worked on the night resident #3 was admitted . She stated, "10 to 6 shift." She was asked what she remembered about the resident's first night. She stated, "He would call every hour wondering about his pain medications." The CNA also stated, "He said he didn't understand why the medications were not here." When asked if the resident had any pain, she stated, "He was hurting. That's why he called at 3:30 a.m." She then added she continued to tell the nurse about the resident's condition but the medications were not there yet. The CNA was asked if she knew when the medications arrived in the facility. She stated, "After 4:00 a.m." An interview was conducted on 10/03/13 at 2:55 p.m., with CNA #4. He was asked what shift he worked the night resident #3 was admitted . He stated, "Two to ten shift." The CNA was asked if he remembered anything about the night the resident had been admitted . He stated, "He kept putting the light on wanting pain medication." He then stated he told the nurse about the resident's pain but was not sure if the resident received any pain medication. An interview was conducted on 10/03/13 at 3:06 p.m., with the administrator. She was asked if the quality assurance committee identified a problem with new admissions receiving their medication timely. She stated, "It was discussed in quality assurance." She was asked when the facility first identified the problem. She stated, "We first identified it in May, actually April 2013." An interview was conducted on 10/03/13 at 3:43 p.m., with LPN #3 regarding medication acquisition. She was asked to describe how medication was acquired for new admissions. She stated the pharmacy had been faxed and for immediate medications a back up pharmacy was used. The LPN was asked how long it took for pain and other medications to be received if they were ordered to be administered the same day as admission. She stated the back up required an authorization of payment from the contracted pharmacy before they could be delivered and received at the facility. She also stated the facility could only pick them up after the authorization for payment was made. She was asked about the pain medications for resident #3 on the night he was admitted . She stated, "I got off at 11:30 p.m. and (Name deleted/in state pharmacy) still had not filled the medications because there was no authorization from (Name deleted/out of state pharmacy)." When asked if the resident exhibited signs or voiced complaints of pain she stated, "He complained of pain all over: back, necks, hips, all over pain." She was asked if she notified the physician of the problem with the resident being in pain and no pain medications available in the facility. She stated, "I didn't call the physician." When asked how the facility addressed the resident's pain, she stated, "Kept trying to get the medications." An interview was conducted on 10/08/13 at 2:37 p.m., with the DON. She was asked if the facility had notified the physician the resident was in excruciating pain and had no pain medications available in the facility. She stated, "He should have been, but there is no documentation the physician was notified." She was asked how the facility assessed and addressed the resident's pain. She stated, "We didn't assess and address the the pain. We waited until the medications were at the facility."

Based on observation, record review and interview, it was determined the facility failed to ensure one (#2) of three sampled resident's received a pacemaker check per physicians orders. The facility identified three residents who resided in the facility who had pacemakers. Findings: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A history and physical, dated 10/10/12, documented the chief complaint was a pacemaker replacement and a fall. Discharge instructions, dated 10/10/12, documented, "...the pacemaker department will send you a schedule for quarterly pacemaker checks. You will receive a monitor from the manufacturer that will allow you to perform checks from home. Please follow recommended pacemaker follow-up for your safety to ensure device is functioning appropriately." The care plan, updated on 05/13/13, documented on 10/10/12, the resident was at risk for pacemaker malfunction and irregular heart beat, shortness of breath and possible chest pain. A handwritten note, dated 10/09/12, documented a pacemaker was placed. A goal was for the resident's pacemaker to be checked as ordered. A handwritten date of 02/13, 05/13 and 08/13, was documented and had a line drawn through them. Approaches were to check pacemaker as ordered by the physician. The quarterly assessment, dated 08/13/13, documented the resident's cognition was intact. She required supervision with transfers, bed mobility, walking in room. She required limited assistance with dressing. She was independent with toilet use and personal hygiene. There were no physician's order to monitor the pacemaker. A letter from (name deleted hospital) documented they had not received the last three scheduled reports for the pacemaker checks. A transmission time had been scheduled on 08/22/13. On 08/27/13 at 11:08, LPN #1 was asked if the resident has had a pacemaker check since the insertion in October 2012. He stated he would call the heart hospital and find out. After talking with (name deleted nurse) in the pacemaker department, he stated that yesterday was the first one to be completed. The nurse stated that it was standard protocol to have the pacemaker checked every three months. He was asked whose responsibility it was to follow up on the admission orders [REDACTED].

Based on record review and interviews, it was determined the facility failed to notify the physician of a change in condition for one (#2) of six sampled residents reviewed for changes in conditions. Resident #2 began having brown emesis on [DATE] and was found unresponsive in a large pool of black emesis on [DATE]. The physician had not been notified of the change of condition. This had the potential to affect 80 of 80 residents who resided in the facility. Findings: A policy for notification of resident/patient change in condition documented, "...The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association..." Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 5:00 p.m., documented the resident stated she didn't want to eat. It also documented she stated she wasn't feeling good. A nurse's note, dated [DATE] at 7:43 p.m., documented, "...Was notified by (name deleted) CNA while in room [ROOM NUMBER] that I needed to come check (name deleted) in room [ROOM NUMBER] B. This nurse immediately went to residents room and found resident in bed c (with) eyes open, o (no) respirations, o (no) pulse and unresponsive. Resident was in large black pool of emesis c (with) black emesis coming from open mouth..." Cardiopulmonary resuscitation was provided. The resident was transported to the hospital at 8:05 p.m. An EMS report, dated [DATE], documented, "...Scene: On scene to find pt. (patient) in Cardiopulmonary arrest, CPR/BLS in progress. Unwitnessed arrest, per staff, pt. in Arrest x 10 min. Pt. cold to touch, pupils fixed and dilated. Pt. c black substance coming from oropharynx and rectum...ABD: Distended o masses palpated..." The physician's notes from the emergency room , dated [DATE] at 8:31 p.m., documented, "...CPR assessment: unresponsive, pupils fixed T dilated, no respiratory effort, intubated, Ambu ventilation, cyanotic. Cardiac rhythm is asystole. General: Appears unresponsive. Behavior is black fluid around face and neck. Neuro: Level of Consciousness is unresponsive. Cardiovascular: Rhythm is asystole. Respiratory: Respiratory effort is no effort. GI: other dark black fluid around mouth. GI: Abdomen is distended...Outcome Patient expired. Patient expired: Time of death 20:23 Pronounced by (name deleted) MD..." The physician's notes from the emergency room further documented, "...Diagnosis: [REDACTED]. On [DATE] at 1:45 p.m., an interview was conducted with CNA #4 regarding changes in the resident's condition. She was asked if she noted any changes in resident #2's behavior on [DATE] or [DATE]. She stated on the evening of [DATE], she notified the charge nurse the resident was spitting up brown emesis. She stated the resident had spit up the brown emesis three or four times that evening and each time she informed the charge nurse. She stated the charge nurse told her to catch the brown emesis in a cup. On [DATE] at 2:30 p.m., LPN #3, identified as caring for resident #2 on the evening of [DATE], was interviewed. LPN #3 was asked if he was informed resident #2 was spitting up brown emesis by the CNA on duty that same night. He stated, "Yes." He was asked if he assessed the resident and documented the assessment. He stated, "I guess I did not write it down." He also stated that he did not call the doctor until the resident coded. On [DATE] at 3:50 p.m., an interview was conducted with CNA #3. She was asked how resident # 2 was doing on the date of her death. CNA #3 stated she worked on [DATE] on the ,[DATE] shift. She stated resident #2 appeared ill and she was lying down. She also stated resident #2 threw up black stuff around 2:00 p.m. on [DATE]. She stated she told the charge nurse and the nurse gave the resident [MEDICATION NAME]. On [DATE] at 5:30 p.m., an interview was conducted with the resident's primary physician. He was asked if he was notified on [DATE] of the resident spitting up brown emesis. The physician stated he was never made aware the resident ever spit up brown emesis. There was no documentation on [DATE] to show the physician was notified of the resident spitting up brown emesis.

Based on record review and interview, it was determined the facility failed to assess, monitor and intervene for one (#2) of six sampled residents who had experienced a change in condition. The resident began having brown emesis on [DATE]. The physician was not contacted, an assessment and monitoring was not documented, and no intervention was provided until [DATE] at 7:43 p.m., when the resident was found in a large pool of black emesis and unresponsive without a pulse or respirations. This had the potential to affect 80 of 80 residents who resided in the facility. Findings: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 5:00 p.m., documented the resident stated she didn't want to eat. It also documented she stated she wasn't feeling good. A nurse's note, dated [DATE] at 7:43 p.m., documented, "...Was notified by (name deleted) CNA while in room [ROOM NUMBER] that I needed to come check (name deleted) in room [ROOM NUMBER] B. This nurse immediately went to residents room and found resident in bed c (with) eyes open, o (no) respirations, o (no) pulse and unresponsive. Resident was in large black pool of emesis c (with) black emesis coming from open mouth..." Cardiopulmonary resuscitation was provided. The resident was transported to the hospital at 8:05 p.m. An EMS report, dated [DATE], documented, "...Scene: On scene to find pt. (patient) in Cardiopulmonary arrest, CPR/BLS in progress. Unwitnessed arrest, per staff, pt. in Arrest x 10 min. Pt. cold to touch, pupils fixed and dilated. Pt. c black substance coming from oropharynx and rectum...ABD: Distended o masses palpated..." The physician's notes from the emergency room , dated [DATE] at 8:31 p.m., documented, "...CPR assessment: unresponsive, pupils fixed T dilated, no respiratory effort, intubated, Ambu ventilation, cyanotic. Cardiac rhythm is asystole. General: Appears unresponsive. Behavior is black fluid around face and neck. Neuro: Level of Consciousness is unresponsive. Cardiovascular: Rhythm is asystole. Respiratory: Respiratory effort is no effort. GI: other dark black fluid around mouth. GI: Abdomen is distended...Outcome Patient expired. Patient expired: Time of death 20:23 Pronounced by (name deleted) MD..." The physician's notes from the emergency room further documented, "...Diagnosis: [REDACTED]. On [DATE] at 1:45 p.m., an interview was conducted with CNA #4 regarding changes in the resident's condition. She was asked if she noted any changes in resident #2's behavior on [DATE] or [DATE]. She stated on the evening of [DATE], she notified the charge nurse the resident was spitting up brown emesis. She stated the resident had spit up the brown emesis three or four times that evening and each time she informed the charge nurse. She stated the charge nurse told her to catch the brown emesis in a cup. There was no documentation on [DATE] to show the physician was notified of the resident spitting up brown emesis. There was no documentation to show an assessment had been completed on [DATE] at 5:00 p.m., when the resident stated she wasn't feeling good. On [DATE] at 2:30 p.m., LPN #3, identified as caring for resident #2 on the evening of [DATE], was interviewed. He was asked if he was informed resident #2 was spitting up brown emesis by the CNA on duty that same night. He stated, "Yes." He was asked if he assessed the resident and documented it. He stated, "I guess I did not write it down." He also stated that he did not call the doctor until the resident coded. On [DATE] at 3:50 p.m., an interview was conducted with CNA #3. She was asked how resident # 2 was doing on the date of her death. CNA #3 stated she worked on [DATE] on the ,[DATE] shift. She stated resident #2 appeared ill and she was lying down. She also stated resident #2 threw up black stuff around 2:00 p.m. on [DATE]. She stated she told the charge nurse and the nurse gave the resident [MEDICATION NAME]. On [DATE] at 5:30 p.m., resident #2's primary physician was asked if he was notified on [DATE] of the resident spitting up brown emesis. The physician stated he was never made aware the resident ever spit up brown emesis.

Based on record review and interviews, it was determined the facility failed to ensure the resident's change in condition was documented in the clinical records for one (#2) of six sampled residents whose clinical records were reviewed for documentation. This had the potential to affect 80 of 80 residents who resided in the facility. Findings: A policy for notification of resident/patient change in condition documented, "...The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association...Document in the Nurses' Notes the time of notification was made and the names of the person(s) to whom you spoke. Sign entry..." Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 12/04/12 at 5:00 p.m., documented the resident stated she didn't want to eat. It also documented she stated she wasn't feeling good. A nurse's note, dated 12/04/12 at 7:43 p.m., documented, "...Was notified by (name deleted) CNA while in room [ROOM NUMBER] that I needed to come check (name deleted) in room [ROOM NUMBER] B. This nurse immediately went to residents room and found resident in bed c (with) eyes open, o (no) respirations, o (no) pulse and unresponsive. Resident was in large black pool of emesis c (with) black emesis coming from open mouth..." On 01/04/12 at 1:45 p.m., an interview was conducted with CNA #4. She was asked if she noted any changes in resident #2's behavior on 12/03/12 or 12/04/12. CNA #4 stated on the evening of 12/03/12, she notified the charge nurse the resident was spitting up brown emesis. She stated the resident had spit up the brown emesis three or four times that evening and each time she informed the charge nurse. She stated the charge nurse told her to catch the brown emesis in a cup. There was no documentation regarding the resident having brown emesis on 12/03/12 or 12/04/12 until 12/04/12 at 7:43 p.m. when the resident was found unresponsive in a large pool of black emesis. On 01/04/13 at 2:30 p.m., LPN #3, identified as caring for resident #2 on the evening of 12/03/12, was interviewed. He was asked if he was informed resident #2 was spitting up brown emesis by the CNA on duty that same night. He stated, "Yes." He was asked if he assessed the resident and documented it. He stated, "I guess I did not write it down." On 01/04/12 at 3:50 p.m., an interview was conducted with CNA #3. She was asked how resident #2 was doing on the date of her death. CNA #3 stated she worked on 12/03/12 on the 2-10 shift. She stated resident #2 appeared ill and she was lying down. She also stated resident #2 threw up black stuff around 2:00 p.m. on 12/03/12. She stated she told the charge nurse and the nurse gave the resident [MEDICATION NAME]. On 01/04/12 at 5:00 p.m., the DON was asked about nursing documentation. The DON stated, "I can not get the nurses to document." On 01/04/13 at 5:30 p.m., an interview was conducted with the resident's primary physician. He was asked if he was notified on 12/03/12 of the resident spitting up brown emesis. The physician stated he was never made aware the resident ever spit up brown emesis.

Based on observation, record review, and interview, it was determined the facility failed to complete an assessment for one (#2) of six sampled residents who had a change in condition. The resident began having brown emesis on [DATE]. No assessment was completed. The resident was found unresponsive in a large pool of black emesis on the evening of [DATE]. This had the potential to affect 80 of 80 residents who resided in the facility. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 5:00 p.m., documented the resident stated she didn't want to eat. It also documented she stated she wasn't feeling good. A nurse's note, dated [DATE] at 7:43 p.m., documented, "...Was notified by (name deleted) CNA while in room [ROOM NUMBER] that I needed to come check (name deleted) in room [ROOM NUMBER] B. This nurse immediately went to residents room and found resident in bed c (with) eyes open, o (no) respirations, o (no) pulse and unresponsive. Resident was in large black pool of emesis c (with) black emesis coming from open mouth..." Cardiopulmonary resuscitation was provided. The resident was transported to the hospital at 8:05 p.m. An EMS report, dated [DATE], documented, "...Scene: On scene to find pt. (patient) in Cardiopulmonary arrest, CPR/BLS in progress. Unwitnessed arrest, per staff, pt. in Arrest x 10 min. Pt. cold to touch, pupils fixed and dilated. Pt. c black substance coming from oropharynx and rectum...ABD: Distended o masses palpated..." The physician's notes from the emergency room , dated [DATE] at 8:31 p.m., documented, "...CPR assessment: unresponsive, pupils fixed T dilated, no respiratory effort, intubated, Ambu ventilation, cyanotic. Cardiac rhythm is asystole. General: Appears unresponsive. Behavior is black fluid around face and neck. Neuro: Level of Consciousness is unresponsive. Cardiovascular: Rhythm is asystole. Respiratory: Respiratory effort is no effort. GI: other dark black fluid around mouth. GI: Abdomen is distended...Outcome Patient expired. Patient expired: Time of death 20:23 Pronounced by (name deleted) MD..." The physician's notes from the emergency room further documented, "...Diagnosis: [REDACTED]. On [DATE] at 1:45 p.m., an interview was conducted with CNA #4 regarding changes in the resident's condition. She was asked if she noted any changes in resident #2's behavior on [DATE] or [DATE]. She stated on the evening of [DATE], she notified the charge nurse the resident was spitting up brown emesis. She stated the resident had spit up the brown emesis three or four times that evening and each time she informed the charge nurse. She stated the charge nurse told her to catch the brown emesis in a cup. There was no documentation on [DATE] to show the physician was notified of the resident spitting up brown emesis. There was no documentation to show an assessment had been completed on [DATE] at 5:00 p.m., when the resident stated she wasn't feeling good. On [DATE] at 2:30 p.m., LPN #3, identified as caring for resident #2 on the evening of [DATE], was interviewed. He was asked if he was informed resident #2 was spitting up brown emesis by the CNA on duty that same night. He stated, "Yes." He was asked if he assessed the resident and documented it. He stated, "I guess I did not write it down." He also stated that he did not call the doctor until the resident coded. On [DATE] at 3:50 p.m., an interview was conducted with CNA #3. She was asked how resident # 2 was doing on the date of her death. CNA #3 stated she worked on [DATE] on the ,[DATE] shift. She stated resident #2 appeared ill and she was lying down. She also stated resident #2 threw up black stuff around 2:00 p.m. on [DATE]. She stated she told the charge nurse and the nurse gave the resident [MEDICATION NAME]. On [DATE] at 5:30 p.m., resident #2's primary physician was asked if he was notified on [DATE] of the resident spitting up brown emesis. The physician stated he was never made aware the resident ever spit up brown emesis.

On 05/13/12, an Immediate Jeopardy (IJ) situation was determined to exist due to failures in multiple areas of pressure ulcer care, treatment and prevention. The facility failed to provide treatment for [REDACTED]. to assess the resident and/or to complete accurate assessments of their pressure ulcers, and failed to care plan for pressure ulcers. The facility also failed to monitor fluid and nutritional intake for residents with pressure ulcers to ensure adequate nutrition and fluid was provided to aid in healing. Residents developed new and/or worsening pressure ulcers, including unstageable pressure ulcers. The IJ situation was verified with the Oklahoma State Department of Health . At 1:10 p.m., the administrator and the DON were notified of the IJ situation related to failures in multiple areas of pressure ulcer care, treatment and prevention. On 05/13/12 at 3:52 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: "Subject: Plan of Removal for Immediate Jeopardy 1. All nurses will be re-educated on Admission process (highlighting Temporary Care Plan, MDS inputs, Nutritional referral and any special equipment that may be needed - low air loss mattress), proper procedures for performing wound care to include but not limited to dressing changes, proper medication to be applied, proper glove use and hand washing. Re-education will include re-positioning of patient for pressure relief and I&O sheets. Dietician will assess resident for weight loss and the need for additional protein. The re-education for all nurses will be completed by midnight 13May2012. Dietician will complete her actions by midnight 13May2012. 2. DON will audit all other residents with wounds to ensure that current orders are being followed and will monitor all dressing changes remaining for 13May2012 to ensure proper technique is being followed per facility policy. 3. In addition to re-educating all nurses in #1 above, Re-education will include all CNA's to ensure residents are repositioned as ordered. Re-education for all CNA's will be completed by midnight 13May2012. 4. Results of re-education, Dietician assessment and audit will be reported to Ad-Hoc Performance improvement Committee meeting 13May2012 for further recommendation(s). This Plan of Removal/Correction is submitted as Midwest City Nursing Center's willingness and ability to achieve and maintain compliance and to provide residents the care and services they need. Corrections will have been completed by May 13, 2012..." An Inservice record, dated 05/13/12 from 2:30 p.m. to 8:00 p.m., documented, "Repositioning & turning Q 2 h, repositioning, skin and peri care, assisting wound care nurse, specialty bed, ADL documentation, baths." This inservice was for CNA's. Thirteen CNA's, who were listed on the facility's schedule, did not sign the inservice sheets. An Inservice record, dated 05/13/12 from 7:30 p.m. to 9:30 p.m., documented, "Initial Temporary Care Plan, Document on I&O sheets, Dressing Change Technique, Return demonstration, infection control during dressing changes, as appropriate pre-medicate before dressing changes, admission process, items that trigger dietary consult, CNA re-educated repositioning." This inservice was for the licensed nurse's. An additional inservice record for licensed nurses was dated 05/14/12 from 5:30 p.m. to 6:30 p.m. Four LPN's and three RN's, who were listed on the facility's schedule, did not sign the inservice sheets. RN #3's name was written in on the first form. To the side of her name was written, "Telecon (teleconference)." On 05/15/12, interviews were conducted with staff regarding the inservices that were to be provided. The following information was obtained: On 05/15/12 at 4:10 p.m., RN #3 stated she attended an inservice today about peri care. When asked if she attended an inservice on Sunday 05/13/12, she stated she was off on the weekend. She was asked if she attended an inservice on 05/14/12. She stated she had not. At 4:15 p.m. CNA #1 was asked if she had attended an inservice on Sunday, Monday or today. She stated she was off on Sunday. She stated on Monday they were supposed to have training but they were too busy. She said they told them they would do it today, but she came in one hour late. She stated she had not received any training today. At 4:28 p.m., RN #3 was asked if she had been called by the DON or staff on Sunday. (The inservice sheet documented she had been contacted per phone.) She stated she was called by the DON on Sunday evening and told that State was in the building and there were some issues on the 300 and 400 halls, regarding infection control and peri care. She said the DON told her that they would be having some inservices over it. She stated she was told nothing else and nothing specific. At 4:34 p.m., CNA #2 stated she was off on the weekend. She stated she had worked yesterday (Monday) and today. She stated today she had training regarding peri care and hand washing. "That was it." At 4:40 p.m., LPN #1 stated she only worked Monday through Friday. She stated she was not called on the weekend. She stated yesterday she attended an inservice about wound care, the steps you use when it is done and following doctor's orders. She stated today, she attended an inservice about peri care. She did not recall them talking about anything else. She wasn't there the whole time because she had to leave due to an issue she had on the hall. At 4:45 p.m., CNA #3 stated she normally worked doubles on the weekend, but she was off on Saturday and Sunday (05/12/12 and 05/13/12). She stated she was called on Sunday and asked to see the DON when she came in . She stated she went to see the DON when she came in today. She was told that she (the DON) was busy and she would call her back later. At 4:50 p.m., the DON was asked for the documentation of the wound audits she had performed. She did not provide documentation of wound audits. At 5:00 p.m., the administrator and the DON were informed that the IJ could not be removed because the staff did not indicate that they had been trained as outlined in the plan of removal. They were also informed that all staff were not included on the inservice forms provided by the facility. In addition the DON had not provided documentation of the wound audits. The DON stated, "I don't know how to get them to understand." At 5:30 p.m., the administrator was asked for a new time frame of when they would have the plan of removal completed. He stated he thought it might be Friday (05/18/12). On 05/19/12 the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. Based on observations, review of clinical records and interviews, it was determined the facility failed to provide care and/or treatment to prevent or promote healing of pressure sores for four (residents #1, 2, 3 and #4) of five sampled residents who had pressure ulcers or who were at risk for pressure ulcers. The facility failed to: ~ provide wound care treatments; ~ provide the correct wound care treatment; ~ provide pressure ulcer care in a manner to prevent cross contamination; ~ provide pressure relieving devices in a timely manner; ~ ensure residents with pressure ulcers were repositioned; ~ identify and address severe weight loss for residents with pressure ulcers; ~ provide protein supplementation for residents with pressure ulcers; ~ obtain dietary consults for residents with pressure ulcers; ~ complete accurate assessments of resident's pressure ulcer status; ~ develop a care plan to address the resident's needs related to pressure ulcers; and/or ~ failed to monitor fluid and nutritional intake for residents with pressure ulcers to ensure adequate nutrition and fluid was provided to aid in healing. Resident #1 and #3 developed new and/or worsening pressure ulcers, including unstageable pressure ulcers. This resulted in an Immediate Jeopardy situation. The facility identified four current residents with pressure ulcers. Findings: The facility's policy titled, Nutrition Referral, Screening, Assessment, and Care Planning for SNF Facilities, documented, "The DTR and/or dietician will complete a comprehensive assessment of each patient/resident who is determined to be at nutritional risk. The patient's/resident's nutrition status and requirements will be assessed in a timely manner to assist in maintaining or achieving optimal nutrition status and to decrease complications related to specific conditions or disease states...Procedure 1. Nursing will initiate an automatic referral for high risk admissions within 24-48 hours of admission, including the following: ~ Clear liquid or NPO > 3 days ~ Stage II - IV pressure wounds ~ Tube feeding or [MEDICATION NAME] nutrition ~ Physician consults ~ Significant weight loss of 2% in one week or 5% in 30 days... 12. Nursing will monitor patients/residents for any change in nutritional status and refer to the dietician or DTR as needed...Change in nutritional status includes any of those in No. 1 above and :.. ~ Development or worsening of pressure wounds... ~ Patients/residents on tube feeding or [MEDICATION NAME] nutrition with weight loss of 5 lb or more..." A facility policy titled, "Recording weights in the American Healthtech System, documented, "...Nursing will obtain the initial height and weight for each patient/resident on admission and document ...on the admission assessment. The current weight will be recorded in the...system...by nursing within 48 hours of admission. Subsequent weights will also be documented in the (system) by nursing. Nursing will provide the Dietary Department with a weight report produced from the (system) each week on Wednesday. The Dietary Manager will analyze the weight report and identify any significant weight losses. The Dietary Manager will update the plan of care to address any significant weight losses...The Dietary Manager will add any resident with significant weight loss to the Dietitian Referral Form for evaluation by the dietitian on the next visit..." 1. Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Admission physician's orders [REDACTED]. "[MEDICATION NAME] 1 scoop daily per tube mix c H2O... Air Mattress 4/27/12 ... Skin prep to ulcer on buttock daily ... Skin prep to L post (posterior) (lower) leg daily ... Weekly skin assessment Thursdays ... Glucerna 1.2 @ 50ml/hr Free H2O flush 200ml q 4 (hours) ..." A nurse's note, dated 04/26/12 at 8:30 p.m., documented, "Skin assessment completed; resident has a stage II wound to her R buttocks measuring about 2cm x 1.5cm and a healed scar to her L buttocks ...has a wound to her L (lower) leg measuring about 7cm x 10cm ...Bilateral heels are tender, soft and starting to form a blister, skin prep applied and both heels lifted on a pillow ...Grimacing noted upon palpation of BLE... " A nurse's note, dated 04/27/12 at 10:00 a.m., documented, "...wound to LLE ...measures 3 in x 3.5 in, (no) open areas. Small reddened spot on R buttock ? inch W (wide) x ? L (long), (no) open areas ... " An Intake & Output record, which recorded results for 04/27/12 through 05/02/12, documented the resident received 450 cc of tube feeding for the night shift on 04/28/12. The resident was to receive 600 cc of tube feeding for each 12 hour shift. The resident was to have received 600cc of water flushes for each 12 hour shift. The record documented the following amounts of flushes were administered to the resident: 04/27/12 - 240cc for the night shift 04/27/12 - 240cc for the evening shift 04/28/12 - 240cc for the night shift 04/28/12 - 480cc for the day shift 04/29/12 - 240cc for the night shift 05/01/12 - 300cc for the night shift 05/01/12 - 400cc for the day shift 05/02/12 - 300cc for the night shift 05/02/12 - 300cc for the day shift There were no documented recordings of intake and output for three of the 12 shifts which were to be recorded on the form. The May 2012 MAR indicated [REDACTED]." This was documented as given twice daily for May 1-3. A physician's progress note, dated 05/01/12, documented, "concern for worsening of wound...Stage III -IV sacral wound ...Unstageable L back leg ...A/P (assessment/plan) Stage III - IV sacral wound Unstageable L leg wound Air mattress every 4 hours turning if keep getting worse send to wound care center." A physician's orders [REDACTED]." A wound care note, dated 05/02/12, documented, "L posterior leg - 6.4 x 4cm black tissue (no) drainage noted. Res sitting up in neuro chair, unable to assess other bony prominences. Recommend foam boots to offload bilateral heels pressure as preventive measure, (no) skin breakdown noted." A nurse's note, dated 05/02/12 at 2:00 a.m., documented, "...Order per (physician) noted for an Air mattress STAT..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. An entry on the Medication Administration Record, (Increase) water flush by 50cc/shift " Written in for the hour to be administered was, "Note." There were no entries to show the flush was increased by 50cc each shift. An entry on the May 2012 MAR indicated [REDACTED]." From 05/04/12 through 05/12/12, there were nine times it was not documented as given. An Intake & Output Record for May 2012, documented the resident received 400 cc of tube feeding on 05/05/12 for the day shift (12 hours) and 250 cc of tube feeding on 05/11/12 for the day shift. The resident was to receive 600cc of tube feeding per each 12 hour shift. There was no documentation of the amount of tube feeding provided for seven of 18 shifts to be documented on the record, which recorded from 05/03/12 through 05/11/12. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Cleanse wound to L outer leg c NS pat dry c 4 x 4 gauze apply [MEDICATION NAME] and leave open to air daily until healed and prn." There was no documentation to show the wound care was provided on 05/08/12. The record also documented, "Cleanse wound to R butt c NS pat dry c 4 x 4 gauze apply hydrogel and cover c border drsg daily until healed." There was no documentation to show the wound care was provided on 05/04/12, 05/08/12 and 05/10/12. The record also documented, "Skin prep to both heels q shift." This was scheduled to be provided twice daily during the day shift and the night shift (12 hour shifts).There was no documentation to show the care was provided on the day shift on 05/08/12 or on the night shift on 05/10/12. Weight records documented the resident weighed 164 pounds on 04/27/12 and 153 pounds on 05/10/12. This represented a severe weight loss of 11 pounds or 6.7% in 13 days. A wound care note, dated 05/10/12 at 2:00 p.m., documented: " L posterior leg - unstageable 6.5cm x 4.5cm 95% slough, 5% pink granulation, moderate serosanguinous drainage. Will DC vasalex, start Santyl and [MEDICATION NAME] 1:1 daily. L lateral leg - 1.5 x 0.5cm Stage II. 50% slough, 50% red granulation. Will start santyl & [MEDICATION NAME] R Buttock - 2.5 x 1.5cm Stage II, 20% yellow tissue, 80% red granulation, moderate serosanguinous drainage, (no) odor. Will DC hydrogel and start Santyl & [MEDICATION NAME] 1:1 daily & prn soiling..." A physician's orders [REDACTED]. "DC [MEDICATION NAME] to L leg and hydrogel to R buttock. L posterior and lateral leg - clean c NSS, pat dry, apply Santyl and [MEDICATION NAME] 1:1, cover c bordered gauze, change daily & prn soiling. Buttock - clean c NSS, pat dry, apply Santyl and [MEDICATION NAME] 1:1, cover c bordered gauze. Change daily & prn soiling." A nurse's note, dated 05/11/12 at 1:00 p.m., documented, "Removed drsg to LLE, mod amt of green drainage noted. Using aseptic tech cleansed wound to LLE c NS, applied [MEDICATION NAME], covered c nonstick drsg, secured c mepiplex. Wound measures appx (approximately) 3 in x 5 cm. (No) depth, wound bed green c reddened edges. Left communication for (physician), wound not improving, poss consult c wound clinic might be beneficial. Cleansed wound to R buttock. Wound improving, closed c small scab noted. Applied hydrogel and left OTA ..." The May 2012 MAR indicated [REDACTED]. On 05/12/12 at 11:35 a.m., the resident was observed in her bed, positioned on her back. On 05/12/12 at 12:27 p.m., RN #4 was observed to provide wound care for the resident with CNA #4. The RN had assembled supplies on the resident's overbed table. The resident was positioned on her back. The RN donned gloves. The RN removed the resident's incontinent brief. The resident was soiled with BM. The RN cleansed the resident with wipes down the left side of the labia, the right side, and down the middle of the labia, multiple times. The resident was turned to her left side. The RN cleaned feces by wiping from the front to the back of the anal area and the buttocks multiple times. She then removed the dressing to the wound on the resident's buttocks with her soiled gloves. She continued the incontinent care by wiping the resident's anal and buttocks area from front to back multiple times with a new cloth. She then changed her gloves without washing her hands. She patted the wound to the right buttock with a 4 x 4 moistened with normal saline and then cleaned around the wound with the 4 x 4. She measured the wound to be 4cm long x 2cm wide. She also identified a reddened area to the coccyx as 2 cm x 0.5cm. She removed some Santyl/[MEDICATION NAME] (She identified a substance that had been placed in a cup on the resident's bedside table with the wound care supplies as Santyl and [MEDICATION NAME].) from a cup on the bedside table with her fingertips and applied it to the wound to the right buttocks and the coccyx area with her fingertips. She covered the wound with a dressing and placed a new brief on the resident. She removed her gloves and repositioned the resident higher in the bed, pulled up the side rail, picked up the resident's neck pillow, moved her bed pillow, moved the bedside table and moved the trash can. She then removed a new pair of gloves from a box on the wall, without washing her hands, and donned a new pair of gloves. She cut the dressing on the resident's left lower leg. She placed the scissors on the overbed table. She obtained paper towels from the dispenser on the wall and placed them under the resident's left leg. She used the scissors from the overbed table to cut more of the dressing on the left lower leg. She removed the dressing. She cleaned the wound with a 4 x 4 gauze moistened with normal saline. She reported there was a little odor to the wound. She measured the wound to be 7 cm x 4.5 cm. She changed gloves without washing her hands. She obtained Santyl/[MEDICATION NAME] from the cup on the bedside table with her fingertips. She applied the mixture to the wound with her fingertips. She covered the wound with a bordered dressing and then removed her gloves. She placed a heel protector on the resident's foot, touched the resident's shoulders, placed a pillow under the resident's knees, moved a suction catheter to the resident's bedside table, adjusted the resident's pillow to her left side, moved the ventilator tubes, and turned the feeding pump on. She then washed her hands. The resident was positioned on her back. The wound to the lateral side of the left lower extremity was not observed and wound care was not provided to the area. A nurse's note, dated 05/12/12 at 2:30 p.m., documented, "Dc'd drsg to R buttock, (no) drainage. Small reddened area measures 2cm x 0.5cm, (no) depth ...Dc'd drsg to LLE. Small amt lt (light) green drainage on drsg. Wound on LLE measures 7cm x 4 cm. Wound bed is green c mild odor ... " The new wound care orders (received on 05/10/12) were added to the May 2012 MAR for the wound to the buttocks and the left outer leg to begin on 05/12/12. The entry for wound care to the left leg only addressed the outer area and not the wound to the posterior area. The May 2012 Medication Administration Record, [REDACTED]. The record was blank for 5/1, 5/2, 5/3. 5/4, 5/8, 5/9 and 5/10. The entries for 5/5, 5/11 and 5/12, were circled to indicate they were not given. The back of the record documented for 05/05/12, 05/09/12, 05/11/12 and 05/12/12, that the [MEDICATION NAME] was not given because it was not on the cart. On 05/12/12 at 3:16 p.m., the resident was in bed, positioned on her back. On 05/12/12 at 4:12 p.m., RN #4 was asked if the resident had any [MEDICATION NAME] in the medication cart. She looked in the cart and did not find [MEDICATION NAME]. She was asked if the resident had ever had the [MEDICATION NAME]. She stated she had not seen it. At 4:15 p.m., the resident was in bed, positioned on her back. At 4:22 p.m., the DON was asked for the admission comprehensive assessment for the resident and the resident's care plan. On 05/12/12 at 4:54 p.m., the DON stated the nurse who admitted the resident on 04/26/12, had been in a car accident and they couldn't talk to her. She stated she (the admitting nurse) may have taken papers including the initial care plan and put them somewhere. She stated she could not find the initial care plan. She also stated the MDS Coordinator was not available. She stated she could not find the MDS. She stated she did not think it was done yet because it was not 14 days. The days were counted with the DON and it was verified that this was the 16th day since admission. She stated she would call the second MDS nurse to see if she could help locate the MDS. The DON was asked if there was a delay in obtaining the low air loss mattress for the resident. She was shown there was an order for [REDACTED]. A t 5:10 p.m., the DON provided a comprehensive assessment, completed on 05/08/12. It documented the resident had no stage 1 or greater pressure ulcers, a scar over a bony prominence or a non-removable dressing or device. The assessment documented the resident did not have one or more unhealed pressure ulcers at Stage 1 or higher. The areas to describe the number of unhealed pressure ulcers at each stage; the dimensions of unhealed Stage 3 or 4 pressure ulcers or eschar; the most severe tissue type for any pressure ulcer, worsening in pressure ulcer status and healed pressure ulcers was blank. No care plan was provided for the resident. At 5:55 p.m., the resident was observed in her bed positioned on her back. On 05/13/12 at 9:00 a.m., the resident was observed in bed, lying on her back. At 9:18 a.m., RN #4 was asked about a wound to the resident's left lateral lower leg. She stated there wasn't one. She stated there was just the one wound on the lower leg to the back of the resident's leg. She was informed of the information in the record that indicated there was also a wound to the resident's lateral leg. She was asked to observe the resident's left lower leg. On 05/13/12 at 9:55 a.m., the resident was in bed, lying on her back. RN #4 removed the dressing to the left lower leg and an open wound was observed to the lateral side of the leg. The wound measured approximately 1 x 2 cm. There was slough present in the wound bed. A nurse's note, dated 05/13/12 at 10:00 a.m., documented, ...Dc'd drsg to LLE, moderate amt green drainage on drsg. Cleansed c NSS. Wound to posterior LLE measures 7cm x 4 cm ...Cleansed wound to lateral side of LLE c NSS. Measures 2cm x 1 cm, applied Santyl c [MEDICATION NAME], covered c bordered gauze ... " At 10:05 a.m., the resident was observed in bed lying on her back. At 11:27 a.m., the resident was observed in bed lying on her back. On 05/13/12 at 11:40 a.m., the DON stated the admitting nurse did not order the pressure relief mattress. The DON was informed of the severe weight loss and was asked how they monitor for weight loss. She stated the restorative aide weighed the residents and notified staff of residents with weight loss with a note that was put in their boxes. She stated they have a registered dietician who works for the nursing home. She stated that today, she (the DON) sent the registered dietician a note that they needed to meet about this resident. She was asked about the [MEDICATION NAME] and why it had not been administered. She stated the [MEDICATION NAME] was kept in the kitchen. She stated the admitting nurse did not send the kitchen a communication form regarding the [MEDICATION NAME] or notify the registered dietician of the need for a dietary consult. She stated that because she was a high risk admission due to her tube feeding and her pressure ulcers, a dietary consult should have been ordered on admission. On 05/13/12 at 3:15 p.m., a family member of the resident, was asked about the low air loss mattress on the resident's bed. She stated the physician came in once and felt the mattress and said she (the resident) needed a specialty mattress. She stated the physician came a second time and said she needed one and he was upset. She stated a nurse was with him writing notes. She stated then they got the resident a specialty mattress. She stated the previous mattress was a regular bed mattress. She stated there were no controls at the end of the bed for the mattress, like there was now. The resident was lying on her back, turned partially to her left side with a pillow behind her right hip and back. The family member stated they had repositioned the resident about one hour ago. A nutritional assessment, dated 05/13/12 at 3:30 p.m., documented, " Supplement: (was blank) ...family states pt has recently gained wait (sic) while in the hospital. Nursing weights indicate weight loss in last 3 wks ...skin condition: Pressure ulcer (no was checked) comments: wound on lower extremity ...5/13/12 3:30 pm Pt is an 84 yo (illegible) female. admitted for [MEDICAL CONDITION]. Pt is currently on the vent with a trach. Pt is NPO and receiving TF of Glucerna 1.2 @ 50ml/hr. This TF provides 1440 Kcal and 72 gram protein per day. This TF meets 92 - 124% estimated Kcal needs. Estimated needs were calculated above using ABW. [MEDICATION NAME] lab value has been ordered (5/10/12). Will reassess protein needs when [MEDICATION NAME] lab value is available. Recommend increase TF to 55 ml/hr (arrow to the right) 1584 Kcal and 79 gram protein per day..." The assessment did not identify the three pressure ulcers present, or the significant weight loss the resident had experienced. On 05/13/12 at 4:25 p.m., RN #4, was asked how much water in flushes the resident was getting. She looked at the medication administration records and stated it was 200cc every four hours. She was shown the initial physician's orders [REDACTED]. She was asked what every shift meant, since some of the staff worked 8 hour shifts and some of them worked 12 hour shifts. She was then shown the physician's orders [REDACTED]. She stated the MAR indicated [REDACTED]. She stated she would request clarification of the flush orders. On 05/13/12 at 5:00 p.m., the physician stated there was not a specialty mattress on the bed and that he requested it when he made rounds. When asked if he was aware of the resident's weight loss, he stated he was not. He stated they need to notify him when there are weight losses. He stated in the past they had notified him of losses of three pounds or greater, so he could assess the situation. A nutritional assessment, dated 05/18/12, documented, "...Supplement [MEDICATION NAME] 1 scoop ...Comments: family denies any recent wt. changes. Nursing records report a recent weight loss upon last admission ...Skin condition: pressure ulcer (no was checked) comments: wound L posterior leg unstageable." 2. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A one page, undated, Individual Resident Care Plan -A, documented the resident was weight bearing as tolerated; required assistance with transfers; positioned her self and required assistance with positioning; was to shower Monday, Wednesday and Friday on the 6-2 shift; required assistance with dressing; set-up help for oral care; was incontinent of bladder and continent of bowel; her vision and hearing were adequate; she was able to make her needs known; she was alert and oriented; went to bed after the 10 p.m. news and was on a regular diet. It indicated she required adaptive equipment. AF was documented. For comments and special needs, it documented, "AFO Boots to BLE @ all times. Skin Care was marked and described as, "A&D ointment prn incontinence." The back of the care plan was blank. The care plan did not address the care needs related to the resident's three pressure ulcers. The May 2012 treatment administration record documented, "Cleanse L lat knee c NSS, pat dry, apply Santyl/[MEDICATION NAME] 1:1 to wound bed, fill c 1/4 inch packing strip. Cover c Bordered Gauze daily & prn." There was no documentation to show this wound care was provided on 05/04/12 or 05/06/12. The treatment record also documented, "Cleanse L posterior calf c NSS, pat dry, apply Santyl/[MEDICATION NAME] 1:1 to wound bed cover c Bordered gauze daily & prn." There was no documentation to show the wound care was provided on 05/06/12. The treatment record also documented, "Cleanse L achilles wound c NSS, pat dry, apply Santyl/[MEDICATION NAME] 1:1 to wound bed, cover c bordered foam daily & prn." There was no documentation to show the wound care was provided on 05/06/12. On 05/13/12 at 10:33 a.m., RN #2 was observed to provide wound care for the resident. The nurse had assembled supplies on the resident's bedside table. The nurse asked the resident if it hurt. She stated, "no, it's still." After washing her hands and donning gloves, the nurse removed dressings from the resident's left posterior ankle wound, left lateral knee wound and removed the packing from the knee wound. She changed her gloves, and without washing her hands, removed the dressing from the left lower posterior leg. The RN changed gloves, without washing her hands, and opened a package of sterile applicators. She had a container that held gauze that had been moistened with normal saline. She removed one of the gauze pads from the container and cleaned the wound to the lateral knee with one of the gauze pads and a sterile applicator, she cleaned around the wound with another gauze and normal saline. She changed her gloves and then applied Santyl and [MEDICATION NAME] to the wound bed with an applicator. She changed her gloves and opened a bottle of packing strip. With a sterile applicator she packed the wound to the knee. She changed her gloves and cut the gauze. The lid to the bottle of packing fell on the floor. She removed a pen from her pocket and wrote on a dressing. She put the pen back in her pocket. She placed the bordered dressing to the wound. She removed her gloves and opened anothe

Based on interviews and record reviews, it was determined the facility failed to prevent severe weight loss resulting in actual harm for two (#1 and #3) of three sampled residents with weight loss. The facility failed to ensure: ~ protein supplementation was provided as ordered; ~ residents at nutritional risk were assessed by the dietician; ~ physician ordered dietician assessments were provided; ~ dietician assessments identified and addressed severe weight loss and pressure ulcers; ~ severe weight loss was identified; ~ physician's were notified of severe weight loss; ~ Wound clinic orders for high protein diets were followed; ~ Dietary recommendations were followed up on; ~ enteral feedings and water flushes were provided as ordered; and/or ~ enteral feedings and water flushes were monitored. Resident #1 had a severe weight loss of 11 pounds or 6.7% in 13 days. Resident #3 had a severe weight loss of 9.5 pound or 5.3 % in 15 days. The residents developed worsening pressure ulcers and/or the emergence of a new pressure ulcers. The facility identified eight residents with significant weight loss in the last three months. Findings: The facility's policy titled, Nutrition Referral, Screening, Assessment, and Care Planning for SNF Facilities, documented, "The DTR and/or dietician will complete a comprehensive assessment of each patient/resident who is determined to be at nutritional risk. The patient's/resident's nutrition status and requirements will be assessed in a timely manner to assist in maintaining or achieving optimal nutrition status and to decrease complications related to specific conditions or disease states...Procedure 1. Nursing will initiate an automatic referral for high risk admissions within 24-48 hours of admission, including the following: ~ Clear liquid or NPO > 3 days ~ Stage II - IV pressure wounds ~ Tube feeding or [MEDICATION NAME] nutrition ~ Physician consults ~ Significant weight loss of 2% in one week or 5% in 30 days... 12. Nursing will monitor patients/residents for any change in nutritional status and refer to the dietician or DTR as needed...Change in nutritional status includes any of those in No. 1 above and :.. ~ Development or worsening of pressure wounds... ~ Patients/residents on tube feeding or [MEDICATION NAME] nutrition with weight loss of 5 lb or more..." A facility policy titled, "Recording weights in the American Healthtech System, documented, "...Nursing will obtain the initial height and weight for each patient/resident on admission and document ...on the admission assessment. The current weight will be recorded in the...system...by nursing within 48 hours of admission. Subsequent weights will also be documented in the (system) by nursing. Nursing will provide the Dietary Department with a weight report produced from the (system) each week on Wednesday. The Dietary Manager will analyze the weight report and identify any significant weight losses. The Dietary Manager will update the plan of care to address any significant weight losses...The Dietary Manager will add any resident with significant weight loss to the Dietitian Referral Form for evaluation by the dietitian on the next visit..." 1. Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Admission physician's orders [REDACTED]. "[MEDICATION NAME] 1 scoop daily per tube mix c H2O... Skin prep to ulcer on buttock daily ... Skin prep to L post (posterior) (lower) leg daily ... Glucerna 1.2 @ 50ml/hr Free H2O flush 200ml q 4 (hours) ..." A nurse's note, dated 04/26/12 at 8:30 p.m., documented, "Skin assessment completed; resident has a stage II wound to her R buttocks measuring about 2cm x 1.5cm and a healed scar to her L buttocks ...has a wound to her L (lower) leg measuring about 7cm x 10cm ...Bilateral heels are tender, soft and starting to form a blister, skin prep applied and both heels lifted on a pillow ...Grimacing noted upon palpation of BLE... " An Intake & Output record, which recorded results for 04/27/12 through 05/02/12, documented the resident received 450 cc of tube feeding for the night shift on 04/28/12. The resident was to receive 600 cc of tube feeding for each 12 hour shift. The resident was to have received 600cc of water flushes for each 12 hour shift. The record documented the following amounts of flushes were administered to the resident: 04/27/12 - 240cc for the night shift 04/27/12 - 240cc for the evening shift 04/28/12 - 240cc for the night shift 04/28/12 - 480cc for the day shift 04/29/12 - 240cc for the night shift 05/01/12 - 300cc for the night shift 05/01/12 - 400cc for the day shift 05/02/12 - 300cc for the night shift 05/02/12 - 300cc for the day shift There were no documented recordings of intake and output for three of the 12 shifts which were to be recorded on the form. The May 2012 MAR indicated [REDACTED]." This was documented as given twice daily for May 1-3. A physician's progress note, dated 05/01/12, documented, "concern for worsening of wound...Stage III -IV sacral wound ...Unstageable L back leg ...A/P (assessment/plan) Stage III - IV sacral wound Unstageable L leg wound Air mattress every 4 hours turning if keep getting worse send to wound care center." A wound care note, dated 05/02/12, documented, "L posterior leg - 6.4 x 4cm black tissue (no) drainage noted. Res sitting up in neuro chair, unable to assess other bony prominences. Recommend foam boots to offload bilateral heels pressure as preventive measure, (no) skin breakdown noted." A physician's orders [REDACTED]. A physician's orders [REDACTED]. An entry on the Medication Administration Record, (Increase) water flush by 50cc/shift " Written in for the hour to be administered was, "Note." There were no entries to show the flush was increased by 50cc each shift. An entry on the May 2012 MAR indicated [REDACTED]." From 05/04/12 through 05/12/12, there were nine times it was not documented as given. An Intake & Output Record for May 2012, documented the resident received 400 cc of tube feeding on 05/05/12 for the day shift (12 hours) and 250 cc of tube feeding on 05/11/12 for the day shift. The resident was to receive 600cc of tube feeding per each 12 hour shift. There was no documentation of the amount of tube feeding provided for seven of 18 shifts on the record, which recorded from 05/03/12 through 05/11/12. Weight records documented the resident weighed 164 pounds on 04/27/12 and 153 pounds on 05/10/12. This represented a severe weight loss of 11 pounds or 6.7% in 13 days. A wound care note, dated 05/10/12 at 2:00 p.m., documented: " L posterior leg - unstageable 6.5cm x 4.5cm 95% slough, 5% pink granulation, moderate serosanguinous drainage. Will DC vasalex, start Santyl and [MEDICATION NAME] 1:1 daily. L lateral leg - 1.5 x 0.5cm Stage II. 50% slough, 50% red granulation. Will start santyl & [MEDICATION NAME] R Buttock - 2.5 x 1.5cm Stage II, 20% yellow tissue, 80% red granulation, moderate serosanguinous drainage, (no) odor. Will DC hydrogel and start Santyl & [MEDICATION NAME] 1:1 daily & prn soiling..." A nurse's note, dated 05/11/12 at 1:00 p.m., documented, "Removed drsg to LLE, mod amt of green drainage noted. Using aseptic tech cleansed wound to LLE c NS, applied [MEDICATION NAME], covered c nonstick drsg, secured c mepiplex. Wound measures appx (approximately) 3 in x 5 cm. (No) depth, wound bed green c reddened edges. Left communication for (physician), wound not improving, poss consult c wound clinic might be beneficial. Cleansed wound to R buttock. Wound improving, closed c small scab noted. Applied hydrogel and left OTA ..." On 05/12/12 at 12:27 p.m., RN #4 was observed to provide wound care for the resident with CNA #4. The resident was observed to have a wound to her right buttock and left lateral posterior lower leg. The May 2012 Medication Administration Record, [REDACTED]. The record was blank for 5/1, 5/2, 5/3. 5/4, 5/8, 5/9 and 5/10. The entries for 5/5, 5/11 and 5/12, were circled to indicate they were not given. The back of the record documented for 05/05/12, 05/11/12 and 05/12/12, that the [MEDICATION NAME] was not given because it was not on the cart. On 05/12/12 at 4:12 p.m., RN #4 was asked if the resident had any [MEDICATION NAME] in the medication cart. She looked in the cart and did not find [MEDICATION NAME]. She was asked if the resident had ever had the [MEDICATION NAME]. She stated she had not seen it. At 4:22 p.m., the DON was asked for the admission comprehensive assessment for the resident and the resident's care plan. On 05/12/12 at 4:54 p.m., the DON stated the nurse who admitted the resident on 04/26/12, had been in a car accident and they couldn't talk to her. She stated she (the admitting nurse) may have taken papers including the initial care plan and put them somewhere. She stated she could not find the initial care plan. She also stated the MDS Coordinator was not available. She stated she could not find the MDS. She stated she did not think it was done yet because it was not 14 days. The days were counted with the DON and it was verified that this was the 16th day since admission. She stated she would call the second MDS nurse to see if she could help locate the MDS. At 5:10 p.m., the DON provided a comprehensive assessment, completed on 05/08/12. It documented the resident had no stage 1 or greater pressure ulcers, a scar over a bony prominence or a non-removable dressing or device. The assessment documented the resident did not have one or more unhealed pressure ulcers at Stage 1 or higher. The areas to describe the number of unhealed pressure ulcers at each stage; the dimensions of unhealed Stage 3 or 4 pressure ulcers or eschar; the most severe tissue type for any pressure ulcer, worsening in pressure ulcer status and healed pressure ulcers was blank. The assessment documented the resident had not had weight loss of 5% or more in the last month or 10% or more in the last six months, had a feeding tube and received 51% or more of their total calories through [MEDICATION NAME] or tube feedings. No care plan was provided for the resident. On 05/13/12 at 9:55 a.m., the resident was in bed, lying on her back. RN #4 removed the dressing to the left lower leg and an open wound was observed to the lateral side of the leg. The wound measured approximately 1 x 2 cm. There was slough present in the wound bed. A nurse's note, dated 05/13/12 at 10:00 a.m., documented, ...Dc'd drsg to LLE, moderate amt green drainage on drsg. Cleansed c NSS. Wound to posterior LLE measures 7cm x 4 cm ...Cleansed wound to lateral side of LLE c NSS. Measures 2cm x 1 cm, applied Santyl c [MEDICATION NAME], covered c bordered gauze ... " On 05/13/12 at 11:40 a.m., the DON was informed of the severe weight loss and asked how they monitor for weight loss. She stated the restorative aide weighed the residents and notified staff of residents with weight loss with a note that was put in their boxes. She stated they have a registered dietician who works for the nursing home. She stated that today, she (the DON) sent the registered dietician a note that they needed to meet about this resident. She was asked about the [MEDICATION NAME] and why it had not been administered. She stated the [MEDICATION NAME] was kept in the kitchen. She stated the admitting nurse did not send the kitchen a communication form regarding the [MEDICATION NAME] or notify the registered dietician of the need for a dietary consult. She stated that because she was a high risk admission due to her tube feeding and her pressure ulcers, a dietary consult should have been ordered on admission. A nutritional assessment, dated 05/13/12 at 3:30 p.m., documented, " Supplement: (was blank) ...family states pt has recently gained wait (sic) while in the hospital. Nursing weights indicate weight loss in last 3 wks ...skin condition: Pressure ulcer (no was checked) comments: wound on lower extremity ...5/13/12 3:30 pm Pt is an 84 yo (illegible) female. admitted for [MEDICAL CONDITION]. Pt is currently on the vent with a trach. Pt is NPO and receiving TF of Glucerna 1.2 @ 50ml/hr. This TF provides 1440 Kcal and 72 gram protein per day. This TF meets 92 - 124% estimated Kcal needs. Estimated needs were calculated above using ABW. [MEDICATION NAME] lab value has been ordered (5/10/12). Will reassess protein needs when [MEDICATION NAME] lab value is available. Recommend increase TF to 55 ml/hr (arrow to the right) 1584 Kcal and 79 gram protein per day..." The assessment did not identify the three pressure ulcers present, or the significant weight loss the resident had experienced. On 05/13/12 at 4:25 p.m., RN #4, was asked how much water in flushes the resident was getting. She looked at the medication administration records and stated it was 200cc every four hours. She was shown the initial physician's orders [REDACTED]. She was asked what every shift meant, since some of the staff worked 8 hour shifts and some of them worked 12 hour shifts. She was then shown the physician's orders [REDACTED]. She stated the MAR indicated [REDACTED]. She stated she would request clarification of the flush orders. On 05/13/12 at 5:00 p.m., the physician was asked if he was aware of the resident's weight loss. He stated he was not. He stated they need to notify him when there are weight losses. He stated in the past they had notified him of losses of three pounds or greater, so he could assess the situation. A laboratory test, completed on 05/14/12, documented the resident's [MEDICATION NAME] was 2.4 (reference range 3.3-4.6). A nutritional assessment, dated 05/18/12, documented , " ...Supplement [MEDICATION NAME] 1 scoop ...Comments: family denies any recent wt. changes. Nursing records report a recent weight loss upon last admission ...Skin condition: pressure ulcer (no was checked) comments: wound L posterior leg unstageable." 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 03/13/12 at 9:30 p.m., documented, "...arrived facility @ 1900 (7:00 p.m.)...Stage III wound noted to coccyx measuring 6cm x 6cm to R coccyx and 4.5cm x 5cm to L coccyx white slough noted in the middle,wound clean c NSS, pat dry, santyl applied to wound bed, covered c [MEDICATION NAME] boarder...Stage III wound to R butt measuring 3cm x 2 100% yellow, wound to coccyx 2.5cm x 1, 100% yellow, L butt 2cm x 1, drsg in place." physician's orders [REDACTED]. "...Santyl apply to dark & yellow slough areas qd... Glucerna 1.2 @ 60ml/hr... Free H2O 6 oz q 6 h (hours) via PEG..." An Individual Resident Care Plan - A, for the date of admission of 03/13/12, documented the resident required a bedbath, needed assist of two for bathing and one for dressing, used the commode for bladder, was alert, non verbal, used no safety devices, required in-room activities, had a tube feeding of Glucerna, required daily weights x 1 week and then weekly on Thursday and was on contact precautions. Nothing else was addressed on this care plan. The care plan did not address his pressure ulcers, or specifics regarding his tube feeding. A March 2012 Resident Weight Record documented the resident weighed 181 pounds on 03/14/12. A progress note for nursing, related to wounds, dated 03/14/12, documented, "New admit...Pt present c wounds to (L) buttocks Stg II 2 x 1 cm, scant serosanguineous drainage, periwound intact, (R) buttocks unstageable due to 100% slough and unable to determine depth, 3 cm x 2 cm, scant SS (serosanguinous) drainage, periwound intact, coccyx 2.5 x 1 cm unable to determine depth due to 100% yellow slough in wound bed, periwound intact, SS scant drainage, no noted s/s of pain or discomfort. Discharge (sic) order for Santyl qd, uses low air loss mattress for wound management & comfort & skin breakdown prevention, on PEG tube Glucerna 1.5 cal @ 60cc/hr per peg tube via pump..." The Intake & Output record for March 2012, documented the resident received the following amounts of enteral feeding: ~ 350cc on the day shift on 03/17/12, ~ 450cc on the night shift on 03/18/12, and ~ 350cc on the day shift on 03/18/12. ( A nurse's note, dated 03/18/12 for the 6 a.m. to 6 p.m. shift, documented, "...Glucerna 1.5 cal infusing 50ml/hr per peg tube...) The physician's orders [REDACTED]. This would equal 720cc in a 12 hour shift. The Intake & Output record for March 2012, documented the resident received the following amounts of water flushes: ~ 200cc on the night shift on 03/17/12 (A nurse's note, dated 03/17/12 for the 6 p.m. to 6 a.m. shift, documented, "Pt's peg tube was flushed with 200cc of water...") ~ 200cc on the night shift on 03/18/12. The physician's orders [REDACTED]. This would equal 360cc in a 12 hour shift. A nursing progress note, dated 03/19/12, documented the resident was sent to the hospital at 9:30 a.m., due to decreased oxygen levels. A Nutrition Assessment Follow-Up completed by the hospital dietician, while the resident was in the hospital on [DATE], documented the resident was receiving [MEDICATION NAME] per tube feeding at 40cc/hr. The form documented: "Inadequate enteral nutrition infusion Low rate for initiation of TF TF meets 74% Kcal + 64% pro (protein) needs... Diagnosis-Related Interventions: ...Rec (recommend) (increase) TF rate to goal of 60cc/hr + [MEDICATION NAME] 1 scoop in 120ml H2O (arrow) will provide...100% est (estimated) Kcal + pro needs..." A nurse's note, dated 03/27/12 at 9:00 p.m., documented the resident was readmitted to the facility at 7:00 p.m. admission orders [MEDICATION NAME] 40ml/hr..." A nursing progress note, dated 03/28/12, documented, "...3/27/12...Re-admit-completed wound assessment to (1) (L) buttocks Stg II 4 x 3 x 0, scant drainage, 70% red/granulation, 30% yellow slough, surrounding wound red, (no) noted s/s of pain, (2) (R) buttocks Stg II 3x2x0, sm amt SS drainage, 80% slough, 20% granulation, periwound red, (no) s/s of pain or discomfort noted, (3) Coccyx unstageable due to 100% yellow slough, 3.0x1.5cm periwound red, scant drainage SS, (no) noted s/s of pain, calazyme cream order upon re-admit, uses low airloss mattress..." A care plan, dated 04/02/12, documented: Problem...P/F (potential for) skin breakdown Related to: (blank) Skin Risk Assessment Score of: (blank) Contributing [DIAGNOSES REDACTED]. Other contributing factors of: (blank). Goals Resident will be free of skin breakdown through NRD (next review date). Target date 6/12 Approaches 1. Dietary to assess diet, for vitamins and supplements... 3. Encourage good meal intake... 6. Monitor labs when available... Problem...P/F Alteration in nutrition and hydration status R/T: NPO Peg, wounds Has [DIAGNOSES REDACTED]. Other indicators of: wounds Goals Nutrition and Hydration status will be maintained without any significant changes (i.e. poor appetite, weight loss or gain, et.) thru next review date. Target date 6/12. Approaches 1. Observe for s/s of dehydration (i.e. dry mucous membranes, poor skin turgor, decreased urinary output, sunken eyes, elevated BUN, etc.) and notify MD. 2. Monitor labs for elevated BUN/Creat., change in Na level, etc. and notify MD. 3. Monitor weights. 5. Monitor skin condition. 6. Honor food preferences... Problem...P/F Alteration in Nutrition and Hydration Status R/T: Alternative Route in Nutrition Has [DIAGNOSES REDACTED]. Other indicators of: (blank) Goals Nutrition and hydration status will be maintained without any significant changes (i.e. poor appetite, weight loss or gain, etc.) through (sic) next review date. Target date 6/12. Approaches 1. Observe for s/s of dehydration (i.e. poor skin turgor, dry mucous membranes, decreased urinary output, sunken eyes, etc.) and notify MD. 2. Monitor labs for elevated BUN/Creatinine, change in NA level, etc. and notify MD. 3. Monitor weights. 4. Provide appropriate tube feeding regimen to meet nutritional needs. 5. Monitor skin condition. 6. Flushes via peg/[DEVICE]. Monitor tolerance to tube feeding... Problem...Alteration in Skin Integrity Resident has the following skin breakdown L & R buttocks *See wound care sheets* With potential for further skin breakdown R/T: (decreased) mobility Skin Risk Assessment Score: (blank) Has [DIAGNOSES REDACTED]. Other contributing factors of: (blank) Goals Skin condition will exhibit evidence of healing as shown on the weekly skin condition report without any further skin breakdown through next review date. Target date 6/12. Approaches 1. Observe effective ness of treatment and notify MD if ineffective... 3. Encourage good meal intake... 7. Monitor labs when available..." A nurse's progress note, dated 04/02/12 at 6:00 a.m., documented, "Assessment complete resident able to move his eyes unable to respond to verbal command, unable to voice wants & needs. FSBS - 451...temp 101.9 ax... [MEDICATION NAME] @ 40cc/hr -pt has wound on coccyx emaciated - slough - noted red & tender to touch...pt was transported to (hospital)..." A Nutrition Assessment Follow-Up completed by the hospital dietician, while the resident was in the hospital on [DATE], documented, "...Diet Order/Supplements/Nutrition support: NPO, TF via PEG: [MEDICATION NAME] @ goal rate of 65ml/(hour) c [MEDICATION NAME] (two) scoops in 120ml water BID...meets 102% kcal, 100% pro needs...Problem: Increased nutrient needs (protein) high demand d/t wounds wounds to buttocks..." A nurse's note, dated 04/10/12, documented the resident was readmitted to the facility at 7:00 p.m. The note documented, "...old wound to coccyx c eschar formation measuring abt (about) 5.5 cm x 6.5 cm and a small area to the side of the big wound abt 1.5cm x 2.5 cm...wound noted to R elbow abt 2cm x 2cm..." physician's orders [REDACTED]. "...Flush peg tube c 240cc H2O q shift (6 a.m. to 6 p.m. and 6 p.m. to 6 a.m. were specified)... [MEDICATION NAME] @ 40cc/hr..." A weekly skin assessment, dated 04/10/12, documented the resident had an unstageable wound to his coccyx which measured 15 x 5.5, a stage II to his right elbow that measured 1.5 x 1.5 and a stage II to his left lateral leg that measured 3 x 1. A comprehensive assessment, completed on 04/11/12, with an assessment reference date of 04/02/12, documented the resident had a stage I or greater pressure sore, or scar over a bony prominence or a non-removable dressing or device; was at risk of developing pressure ulcers; had one or more unhealed pressure ulcers at stage I or greater; had one stage I and two stage II pressure ulcers of which both stage II pressure ulcers were present on admission. There were no dimension of the largest unhealed unstageable pressure ulcer and no identification of the most severe tissue type of any pressure ulcer. Wound assessments on 03/31/12 (related to the assessment reference date of 04/02/12 above) documented the resident had two Stage II pressure ulcers and one unstageable pressure ulcer. Due to the assessment reference date, this was the information to be included in the assessment. A nurse's note, dated 04/14/12 at 12:30 p.m., documented, "...Pt able to communicate c facial expressions and moving lips..." A nurse's note, dated 04/15/12 for the 6 a.m. to 6 p.m. shift, documented, "...Pt awake/alert. Communicates by nodding head yes or no..." A weekly skin assessment, dated 04/17/12, documented a Stage II wound to the left elbow that measured 1.0 x 0.8, a wound to the coccyx that measured 11.6 x 7, and a Stage II wound to the left lateral lower leg which measured 4.5 x 4.5. A Skin Grid/Pressure form assessment, dated 04/17/12, documented the pressure ulcer to the back of the lower left was unstageable due to 90% slough and 10% granulation. The wound measured 4.5 x 1.8 cm with a depth that was unable to be determined. The wound had serosanguinous drainage. The comments section of the form documented, "N.O D/C [MEDICATION NAME] - start Santyl. Wound care clinic." The picture of the wound location indicated the wound was to the right posterior lower leg. A nutritional assessment, dated 04/17/12 at 3:20 p.m., documented it was an initial assessment and that the resident had no pressure ulcers. The narrative part of the assessment documented, "Nutrition initial nutrition assessment. Diet order NPO (arrow to the right) TF [MEDICATION NAME] @ 40 ml/hr. Pt is on the vent and unresponsive. No height could be found. Needs were estimated from available information. recommend that the TF rate be changed to [MEDICATION NAME] @ 60 ml/hr (arrow to the right) This will provide 1440 ml, 2160 Kcal, & 91 grams protein per day. and meet 100% of his calorie needs and 76% of his estimated protein needs." There was no documentation to show the facility had implemented or followed up on the recommendation to increase the tube feeding rate. A wound care order sheet, from the wound care clinic, dated 04/18/12, documented: "Sacral Santyl Apply Nickle thick [MEDICATION NAME] High Protein Diet - consider Juvin & Arginate LLE [MEDICATION NAME] Ag [MEDICATION NAME]." A physician's orders [REDACTED]. "DC santyl to L (lower) back of leg and R elbow. Cleanse wound to L (lower) back of leg c NS pat dry apply [MEDICATION NAME] Ag/[MEDICATION NAME]. Cleanse wound to R elbow c NS pat dry apply [MEDICATION NAME] Ag/[MEDICATION NAME] and foam elbow protector." A nurse's note, dated 04/22/12 at 2:00 p.m., documented, "DC'd drsg to coccyx. Scant amount of SS (serosanguinous) drainage noted. Ulcer to coccyx unstageable. Wound bed black c white edges..." A physician's orders [REDACTED]." A nurse's note, dated 04/25/12 at 4:30 p.m., documented, "Pt seen by (physician) N.O. for dietician to eval for to see if TF meets needs for calories & protein, order noted and faxed to (pharmacy), copy in (name deleted's) box." An April 2012 Resident Weight Record documented the resident weighed 179 pounds on 04/11/12 and 169.5 pounds on 04/26/12. This documented a 9.5 pound or 5.3 % severe weight loss in 15 days. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. NOTE." There was no documentation to show the dietician had evaluated the resident. A nurse's note, dated 04/27/12 at 9:00 a.m., documented, "...Wound care performed. Cleansed wound to sacral area c NS, applied Santyl to yellow wound bed. Strong odor noted. Covered c foam drsg..." A nurse's note, dated 04/29/12 at 2:00 p.m., documented, "[MEDICATION NAME] infusing @ 40cc..." The May 2012 physician's monthly orders documented: "[MEDICATION NAME] @ 40cc/hr... Flush PEG tube w/ 240cc H2O every shift..." A nurse's note, dated 05/01/12 at 3:00 a.m., documented, "[MEDICATION NAME] continues at 40mls/hr..." A wound assessment, dated 05/02/12, documented: "(1) (R) elbow - resolving, 1.3cm x 1 cm reddened area, skin intact, (No) drainage noted. May DC [MEDICATION NAME] Ag and continue foam protector. (2) (L) posterior lower leg - 4.5 cm x 1.5 cm entire area. 3 cm x 0.6 cm yellow tissue, unstageable, scant serosanguinous drainage, Cleansed c NS. Applied santyl then covered c small bordered gauze. (3) R & L buttocks & sacral area - W 14 cm x L 8 cm, unstageable d/t 90% yellow tissue and slough to wound bed. 10% granulation to outer area, loose necrotic tissue noted at the sacral area c opening. Heavy serosanguinous drainage noted, (no) odor. Cleansed c NS, applied Santyl, covered c ABD pad, secured c tape..." The Intake & Output record for 04/10/12 through 05/02/12, documented the resident received the following amounts of enteral feeding: ~ 300cc on the day shift on 04/14/12, ~ 320cc on the day shift on 04/16/12, ~ 370cc on the day shift on 04/17/12, and ~ 335cc on the day shift on 04/25/12. The physician's orders [REDACTED]. This would equal 480cc in a 12 hour shift. The Intake & Output record for 04/10/12 through 05/02/12, documented the resident received the following amounts of water flushes: ~ 200cc on the night shifts on 04/15/12, 04/16/12, 04/21/12, 04/22/12, 04/23/12 ,04/27/12, and 04/28/12. The physician's orders [REDACTED]. Intake and Output were not monitored or recorded for seven of the 42 shifts to be recorded on the sheet. A nurse's note, dated 05/04/12 at 9:00 p.m., documented, "...Pt's wound have started to tunnel. Note written to doctor about it..." A nurse's note, dated 05/05/12 at 12:00 p.m., documented, "...DC'd drsg to LLE. Green drainage on drsg noted. Stage II 3.5cm x 1cm, (no) tunneling. Wound bed green c yell (yellow) drainage...Removed drsg to coccyx. Large amounts of green drainage on dressing. Wound measures 3 in x 2.5 in on L buttock, R buttock 4 inches x 3 inches. Wound bed is green and has purulent odor. Wound edges are red, some undermining and tunneling present in center of both wounds..." A nurse's note, dated 05/05/12 at 6:00 p.m., documented, "Left communication for (physician), request further eval of patients wound and poss getting order for wound vac." A nurse's note, dated 05/07/12 at 9:00 p.m., documented, "...New order per (physician) for wound care to assess, dietary consult..." A physician's orders [REDACTED]." Results for a CMP drawn on 05/08/12 at 12:30 a.m., documented the resident's BUN was 27 (reference range of 6-25), Total Protein was 5.1 (reference range of 6.3-8.4), and [MEDICATION NAME] was 2.4 (reference range of 3.4-4.8). Results of the [MEDICATION NAME] drawn on 05/08/12 12:30 a.m. were 8.1 (reference range of 18.0-45.0). There was no documentation to show the dietary consult was provided. A wound care note, dated 05/09/12, documented: "sacral wound - 7 x 12.5 x 3 cm depth, 95% yellow, black slough necrotic tissue, 5% pink granulation, (+) odor. (L) posterior leg - 3 x 0.6, unstageable, 100% yellow tissue, scant serosanguinous drainage. Continue Santyl daily to both wounds until res. see wound care clinic doctor on 5/15/12... (3:20 p.m.) (R) elbow - 1.2 x 1 cm, 100% yellow, scant serosanguinous drainage. Restart Santyl, covered c bordered gauze daily, continue foam pad...Will recommend vitamins for wound healing and monitor [MEDICATION NAME]." A physician's orders [REDACTED]. "Multivitamin 1 tab per tube daily for general nutrition [MEDICATION NAME] 1 tab per tube daily for general nutrition [MEDICATION NAME] acid 500mg per tube daily for wound healing Zinc 220mg per tube daily for wound healing." The Intake & Output record for 05/03/12 through 05/09/12, documented the resident received the following amounts of water flushes: ~ 200cc on the night shift on 05/05/12, and ~ 150cc on the night shift on 05/07/12. The physician's orders [REDACTED]. Intake and Output were not monitored or recorded for three of the 13 shifts to be recorded on the sheet. An undated and untime