Every finding on record at Montevista Rehabilitation and Skilled Care

Based on record review and interview, the facility failed to: a. verify and obtain clarification from the physician to determine how often to flush the cholecystostomy drain and to measure and record the drain output for 1 (#1) of one sampled resident with a cholecystostomy drain; and b. administer medications as physician ordered for 1 (#1) of 1 sampled resident reviewed for new admissions to the facility. The administrator reported 88 residents resided in the facility and had 47 new admits to the facility in the last 30 days. The administrator reported they currently had no cholecystostomy drains in the facility. Findings: 1. A performance checklist skill Managing Wound Drainage Evacuation policy, dated 2018, read in part, Recording and Reporting, 1. Recorded all pertinent information in the appropriate log. 2. Recorded amount of drainage on I&O record. 3. Documented evaluation of patient learning. 4. Reported sudden change in amount of drainage, pungent odor of drainage or new signs of purulence, severe pain, or dislodgement of tube to health care provider immediately. A H&P for Resident #1, dated 01/20/25, showed per IR patient's cholescystostomy tube needed to be flushed and drained twice daily with 5-10ml normal saline flushes. Per GS, patient will need to follow up outpatient with GS and IR in 4-6 weeks for drain removal. The physician order packet (physicians order), dated 01/29/25, read part, Septic shock 12/31/24 - 01/29/25, return visit 02/04/25 with gastrointestinal cancer clinic .Other instructions an IR appointment has been made for you to remove the cholecystostomy tube. If you do not hear from them in 1 week regarding your appointment, would recommend calling [number removed] to schedule appointment. Cholecystostomy drain .Keep a daily record of output for your provider .Flush your drain daily. The physician packet order consisted of 30 pages and contained the flush procedure for a cholecystostomy drain. On 02/25/25 at 10:48 a.m., the ADON provided the physician order packet (admitting physician orders) they received for Resident #1's admission intake. Inside the packet were instructions to flush a cholecystostomy drain. They stated they did not actually see the resident's drain. They stated the order documented it was a cholecystostomy drain. They were asked if these instructions included how many times a day to flush Resident #1's drain. They stated the flushing instructions related to how many times a day the drain was to be flushed were not included in the physician order packet [admitting physician orders], but were located on the H&P dated 01/20/25. The ADON was asked who received the instructions on how to flush the cholecystostomy drain. They stated they passed the cholecystostomy drain procedure to the staff member who was admitting the resident and they passed it on to the next nurse in report. On 2/25/25 at 11:37 a.m., the ADON stated they received the flush orders for Resident #1's drain from the H&P dated 01/20/25, not from the physician order packet (admitting physicians orders). They were asked if the H&P was a physicians order. They stated that it was the plan to take care of them. The ADON was asked if they obtained clarification from the physician. They stated typically they did, but they had cleared everything out of their phone. They were asked if they contacted the physician. The ADON stated it was not charted that anybody was contacted. They were asked if they documented communication with the physician's case manager. They stated there was no clarification from anyone related to the flushes. The ADON determined LPN #6 admitted Resident #1. They stated they made a copy of the instructions and gave that to the nurse that received the resident and then hoped it would become part of their care and passed on in report. On 02/25/25 at 3:12 p.m., the administrator was asked for a policy specifically for drains (cholecystostomy drain/IR drain). The administrator submitted a performance checklist skill document titled, Managing Wound Drainage Evaluation. They stated that was the guide they followed. They were asked if they had a standard facility policy. They stated they have nothing that looked like the other policies submitted. The policy did not mention a cholecystostomy drain. On 02/25/25 at 3:49 p.m., the drain policy and procedure was presented to RN #1. They stated it looked like a checklist. They were asked if they followed the policy. They stated obviously not. RN #1 was asked if drain output should be recorded. They stated the output from drains should be recorded. They stated they would have included the specific instructions for the drain into the actual physician's orders. On 02/26/25 at 6:43 a.m., LPN #6 was asked about the way they flushed the cholecystostomy drain. They stated they would flush it with 10 ml's and go back and see if it drained into the bag and if it did not they would go back and flush it again. They were asked if the physician order stated to record the drain output. They stated it did not, just to flush it with 10 ml's of normal saline. They stated this was the first cholecystostomy tube they had seen. They were asked to review the physician order packet and was asked what the order documented related to measuring output. They stated to keep a daily record of output for your provider. They were asked about the facility policy to record output from a drain. They stated for JP drains it would have been included on the physicians order to measure and record the output from the drain. On 03/04/25 at 12:13 p.m., ADON was asked to review the physician order packet for Resident #1's admission. They stated they transcribed the drain to be flushed twice daily, but the physician order did state to flush it daily. They were asked if it would be acceptable to take physician orders from the H&P dated 01/20/25 dated prior to the residents admission. They stated they agreed it would not be. 2. A Physician Orders Admission policy, dated 03/19/22, read in part, It is the policy of our facility that all treatments and medications be ordered by the resident's physician, advanced practice nurse, physician assistant, or Dentist. The physician order packet, printed on 01/29/25, for Resident #1's admission to the facility showed the following medication list: a. continue loratadine (an antihistamine) 10 mg tablet take 1 tablet by mouth in the morning, b. continue magnesium glycinate (a supplement) 100 mg capsule take 100 mg by mouth at bed time, last time this was given: ask your nurse or doctor, c. continue vitamin C (an antioxidant) take by mouth, d. continue garlic (a supplement) take by mouth, and e. continue zinc (a supplement) take by mouth, last time this was given: ask your nurse or doctor. On 02/25/25 at 8:40 a.m., the physician orders were reviewed with the ADON. They identified the following medications were not transcribed upon admission. The ADON reported it was the facility policy for another nurse to verify the physician orders and they would both initial the physician order, and if they needed to they would notify the physician. a. loratadine 10 mg in the morning, b. magnesium glycinate 100 mg capsule at bedtime, and c. vitamin C, garlic, and zinc. On 02/25/25 at 4:30 p.m., RN #1 reviewed admission orders and verified the following medications were not transcribed. a. loratadine 10 mg in the morning, b. magnesium glycinate 100 mg capsule at bedtime, and c. vitamin C, garlic, and zinc. On 03/04/25 at 12:20 p.m., the physician orders were reviewed with LPN #1. They stated they had entered the physician orders into the eMAR. They stated if they had any questions they would reach out to the liaison. They stated the following medications were not transcribed and should have been. They reported they did not have another nurse verify the physician order. a. loratadine 10 mg in the morning, b. magnesium glycinate 100 mg capsule at bedtime, and c. vitamin C, garlic, and zinc.

Based on record review and interview, the facility failed to implement a baseline care plan to include a IR drain/cholecystostomy drain within 48 hours of admission to the facility for 1 (#1) of 1 sampled resident reviewed for an IR drain. The administrator reported 47 new admissions in the past 30 days. Findings: A Care Plan - Process policy, dated 03/27/23, read in part, Initiate a Baseline Care Plan and complete within forty-eight (48) hours of admission based on the physician's orders and nursing evaluation. Resident #1's diagnoses included intrahepatic bile duct carcinoma, perforation of gallbladder in cholecystitis, and acute kidney failure. Resident #1's admission assessment, dated 01/29/25, showed renal/urinary history-other (describe below)-IR drain. Current bladder/urine status-urinal at bedside. A Baseline Care Plan, dated 02/07/25, showed Physician Orders/Medications/Treatments. The IR drain was not listed under physician orders/treatment or listed under the nursing evaluation on the baseline care plan. On 02/24/25 at 5:52 p.m., the DON was asked about specific information on the baseline care plan related to the IR drain. They stated they did not see it on the baseline care plan. On 02/25/25 at 3:12 p.m., the administrator was asked when the baseline care plan had been completed. They stated it was completed on 02/07/25. They were asked if they followed the facility policy. They stated they did not follow the policy. The baseline care plan was completed by LPN #3, nine days after Resident #1's admission.

Based on record review and interview, the facility failed to document a a skin assessment for 1 (#1) of 2 sampled residents reviewed for physician ordered wound treatments. The administrator identified 88 residents resided in the facility and the facility matrix showed seven residents had wounds in the facility. Findings: A policy titled An Overview of Wound Care, dated July 2018, read in part, It is important that existing PU/PI be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential of additional PU/PIs or the deterioration of the PU/PIs be recognized, assessed and addressed. Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident's care plan. A policy titled Documentation and Measurement of Wounds, revised July 2018, read in part, Wounds are measured and documented within professional practice guidelines. Resident #1's diagnoses included, type 2 diabetes mellitus without complications, intrahepatic bile duct carcinoma, and perforation of gallbladder in cholecystitis. An admission assessment, dated 01/29/25, showed skin intact, fair turgor, pressure redistribution mattress, other describe below surgical incision right upper abdomen IR drainage bag placed. A skin assessment, dated 01/29/25, showed Rash/Redness/Denuded (Includes MASD/IAD)- Yes. Location of Rash/Redness- Buttocks blanchable redness. Surgical wound - Yes. Location of surgical wound-abdomen upper right side of abdomen. A skin assessment, dated 02/05/25, showed Rash/Redness/Denuded (Includes MASD/IAD) - No. Surgical wound - No. A pressure ulcer risk assessment, dated 02/05/25, showed a pressure ulcer risk, mild risk (21): total score 15-24. A care plan, dated 02/05/25, showed skin breakdown: at risk for/actual. Measures will be taken to prevent skin breakdown over the next 90 days, inspect skin complete body head to toe every week and document results, off load heels, treatment and dressings as ordered per physician, dietitian referral 02/07/25, position resident properly; use pressure-reducing or pressure-relieving devices (For example: pillows, positioning wedges, and alternating pressure mattress) if indicated 02/07/25. A physician order, dated 02/07/25, showed to cleanse the wound to the buttocks/ coccyx area with cleanser, pat dry, apply xeroform and cover with bordered gauze daily. Dx: pressure ulcer of specified site, unspecified stage. Entered by LPN #8. D/C by RN #2 on 02/09/25. A baseline care plan, dated 02/07/25, showed pressure ulcer risk, moderate risk: total score 13/14, preventive measures, and education will be provided. Interventions include pressure reducing mattress. On 02/25/25 at 8:40 a.m., LPN #8 reviewed eMAR record. They reported the resident admitted with red buttocks and was starting to get an open area. They stated they notified the physician and received a new order on 02/07/25 and they did not perform a skin assessment, or make a nurse's note related to the description of the wound in the eMAR. They reported the resident was added to the list to be seen by wound care doctor the following Monday on 02/10/25, but the resident left the facility against medical advise on 02/09/25. They reported the left side of the resident's buttocks was redder and it was not blanchable, they believed it was the left side that was worse with purple reddish color, and the skin was starting to flake off and they were concerned about that.

Based on record review and interview, the facility failed to develop and implement a policy for cholecystostomy drain care for 1 (#1) of 1 sampled resident with a cholecystostomy drain and ensure the nursing staff were properly trained and determined competent for 3 (LPN #3, 5 and #6) of 4 sampled LPNs interviewed for drain care. The administrator reported 88 residents resided in the facility and had no cholecystostomy drains in the facility. Findings: A performance checklist skill Managing Wound Drainage Evacuation policy, dated 2018, read in part, Recording and Reporting 1. Recorded all pertinent information in the appropriate log. 2. Recorded amount of drainage on I&O record. 3. Documented evaluation of patient learning. 4. Reported sudden change in amount of drainage, pungent odor of drainage or new signs of purulence, severe pain, or dislodgement of tube to health care provider immediately. The physician order packet (physicians order), dated 01/29/25, read in part, Septic shock 12/31/24 - 01/29/25, return visit 02/04/25 with gastrointestinal cancer clinic .Other instructions an IR appointment has been made for you to remove the cholecystostomy tube. If you do not hear from them in 1 week regarding your appointment, would recommend calling [number removed] to schedule appointment. Cholecystostomy drain .Keep a daily record of output for your provider .Flush your drain daily. The physician packet order consisted of 30 pages and contained the flush procedure for a cholecystostomy drain. Resident #1's eTAR, dated 02/02/25-02/24/24, showed treatment every 12 hours flush cholecysystomy tube twie a day with 10 ml normal saline. LPN #3 documented flushes on 02/01/25, 02/02/25, and 02/03/25. LPN #5 documented flushes on 02/07/24 and 02/08/25. LPN #6 documented flushes on 02/01/25, 02/06/25, and 02/07/25. The eTAR did not document to measure the output. On 02/24/25 at 4:02 p.m., LPN #5 was asked about Resident #1's cholecystostomy drain. They stated they just came back to work on February 7, 2025, and they did not remember the resident. On 02/24/25 at 5:14 p.m., LPN #5 was asked about flushing Resident #1's drain on 02/07/25 and 02/08/25. They were asked to review the eTAR related to the flushing of the drain. They stated it was documented, so they guessed they did. They were asked if they had received training related to a cholecystostomy drain. They stated, No, ma'am, they were a new admit. They were asked if they disconnected it or just flushed it with normal saline. They stated honestly, they could not remember. They were asked if they remembered if it had an opened/closed position. They stated they did not remember. They stated they only worked over on the skilled side for three hours. They were asked if they emptied the drain, would they chart the drain output. They stated they believed you were supposed to. They reported they were informed it was a bile drain. On 02/25/25 at 6:43 a.m., LPN #6 was asked about the way they flushed the cholecystostomy drain. They reported they would flush it with 10 ml's and go back and see if it drained into the bag and if it did not, they would go back and flush it again. They stated the treatment order stated to just flush it. They were asked if the treatment order stated to record the drain output. They stated it did not, just to flush it with 10 ml's of normal saline. They reported this was the first cholecystostomy tube they had seen. They were asked about the facility policy to record output from a drain. They stated for JP drains it would have been included on the physicians order to measure and record the output from the drain. On 02/25/25 at 9:48 a.m., LPN #3 reported they did not flush the drain (which they thought was a nephrostomy tube), and reported they did not flush the drain they only emptied the drain bag. They did not document the output in the nurse's notes or in the output record. Reported they were only familiar with JP drains, indwelling catheter, and a nephrostomy tube. They were asked if that was the facility policy to chart drain output. They stated it was the facility policy. On 02/25/25 at 3:12 p.m., the administrator was asked for a policy specifically for drains (cholecystostomy drain/IR drain). The administrator submitted a document titled, performance checklist skill, managing wound drainage evaluation and stated, this was the guide they followed. They were asked if they had a standard facility policy. They stated they have nothing that looked like the other policies submitted. The policy did not mention a cholecystostomy drain. On 03/04/25 at 10:20 a.m., the DON was asked if the staff received training for a cholecystostomy drain. They reported they had no documentation related to training for the drain and were not aware the staff did not understand it. The DON reported if the staff required training the ADON would provide it.

Based on record review and interview, the facility failed to ensure the resident's representative was notified of changes in skin condition for 1 (#1) of 3 sampled residents reviewed for notifications. The administrator identified 88 residents resided in the facility. Findings: A Change of Condition policy, dated 02/13/23, read in part, Examples of circumstances of when it is appropriate to communicate information to these parties may include, but are not limited to .unexpected deterioration in condition or status. Resident #1's had diagnoses which included Type 2 diabetes mellitus without complications, intrahepatic bile duct carcinoma, and perforation of gallbladder in cholecystitis. An admission assessment, dated 01/29/25, read in part, Does resident wish to have a representative involved in care decision-yes (enter name in text box)- [Family member name withheld]. A skin assessment, dated 01/29/25, showed Rash/Redness/Denuded (Includes MASD/IAD)- Yes. Location of Rash/Redness- Buttocks blanchable redness. Surgical wound - Yes. Location of surgical wound-abdomen upper right side of abdomen. A skin assessment, dated 02/05/25, showed Rash/Redness/Denuded (Includes MASD/IAD) - No. Surgical wound - No. A physician order, dated 02/07/25, showed to cleanse the wound to the buttocks/ coccyx area with cleanser, pat dry, apply xeroform and cover with bordered gauze daily. Dx: pressure ulcer of specified site, unspecified stage. Entered by LPN #8. D/C by RN #2 on 02/09/25. A baseline care plan, dated 02/07/25, showed resident wanted to be involved in care decisions - Yes, wishes to have a representative involved. On 02/05/25 at 8:40 a.m., LPN #8 reviewed the eMAR record. They reported the resident admitted with red buttocks and was starting to get an open area. They stated they notified the physician and received a new order on 02/07/25. They were asked if they contacted the representative listed on the admission assessment. They stated no. They reported a family member was in the room at this time of the treatment and was listed on the contact list in the eMAR. They were asked if they charted the name of the person contacted related to the new wound order. They stated they did not. They were asked if that was the facility policy to chart the person contacted. They stated that was the facility policy to chart the name of person contacted. 03/04/25 at 10:19 a.m., the DON was asked who the staff would notify with a new order for Resident #1. They reported whoever performed the admission assessment should make sure it matched the face sheet in the eMAR. They were asked who the contact person for Resident #1 would be. They stated the name listed on the admission assessment.

Based on observation, record review, and interview, the facility failed to provide staff supervision while smoking for 1 (#1) of 3 residents sampled for smoking supervision. The administrator reported 14 smokers resided in the facility. Findings: A Resident Smoking Policy, dated 01/2024, read in part, Residents who wish to smoke will be evaluated for the level of assistance required while smoking. All residents will be supervised while smoking for their personal safety. Resident #1's care plan, dated 09/05/24, showed the resident smoked and was at risk for injury. The care plan showed the resident would not have any injury while smoking and would smoke in designated areas at all times. The care plan showed cigarettes and lighter would be kept at the nurse's station/designated area. The annual assessment for Resident #1, dated 11/10/24, showed the resident's cognition was intact and required partial/moderate assistance with activities of daily living. On 02/06/25 at 11:10 a.m., the administrator reported they implemented smoking in the facility in June 2024 and stated they had designated smoking times and supervised smoking. The administrator reported they had a resident (Resident #1) who was noncompliant at times and smoked outside of the designated times and without supervision. On 02/06/25 at 1:00 p.m., Resident #1 was observed outside smoking in the enclosed courtyard without staff supervision. Resident #1 was asked about smoking in the facility. They stated they have designated smoking times and the next one was at 2:00 p.m. The resident stated they just wanted to take a couple of puffs after lunch. They stated they would get two cigarettes in the morning and save one of them for times like this when they wanted an extra.

Based on observation, record review, and interview the facility failed to ensure care plans were updated with smoking interventions for 2 (#2 and #3) of 3 residents sampled for smoking safety. The administrator reported 14 smokers resided in the facility. Findings: A policy titled Resident Smoking Policy, dated 01/01/24, read in part, The resident's care plan will include the amount of assistance the resident is to receive during smoking. The care plan will be updated quarter and as necessary to document changes in the resident's need for assistance. 1. Resident #2 had diagnoses which included seizure disorder and bilateral below knee amputation. A Smoking Risk assessment, dated 06/09/24, showed Resident #2 agreed to keep smoking paraphernalia at the nurse's station. A care plan, dated 09/23/24, read in part, Resident has been informed that this is a non smoking facility and continues too smoke at times. The care plan failed to show the facility's change to allow smoking in the courtyard and interventions to prevent the resident from smoking unsupervised. Resident #2's quarterly assessment, dated 01/16/25, showed the resident had moderate cognitive impairment and tobacco use. On 02/05/25 at 4:53 p.m., Resident #2 was observed being wheeled outside to the courtyard by an unknown staff member. The resident was observed outside in the courtyard without supervision. The resident was observed to light and smoke a cigarette. On 02/06/25 at 11:33 a.m., Resident #2 reported being allowed to go outside to the courtyard at anytime requested. The resident reported staff stored all smoking supplies and residents were to be supervised when smoking. On 02/06/25 at 12:26 p.m., the administrator reported Resident #2 had a history of being noncompliant with supervised smoking. On 02/06/25 at 1:17 p.m., the corporate registered nurse reported all residents were supervised smokers and it was the facility policy. On 02/06/25 at 1:35 p.m., the DON reported smoking activity should be included on resident care plans and revised with updated smoking interventions. 2. Resident #3 was admitted on [DATE] with diagnoses which included metabolic encephalopathy. A quarterly assessment, dated 10/07/24, showed the resident's cognition was intact. The assessment showed Resident #3 required assistance with activities of daily living. A care plan, dated 11/06/24, showed no smoking activity or interventions. On 02/06/25 at 9:35 a.m., Resident #3 was observed outside smoking with staff supervision. On 02/06/25 at 9:42 a.m., Resident #3 reported smokers were allowed to go out to smoke with staff. The resident reported not being able to open the door to the smoking area alone. A Smoking Risk assessment for Resident #3, dated 02/06/25, read in part, Staff supervised smoking will be designated at specific times. On 02/06/25 at 1:35 p.m., the DON reported smoking activity should be included on resident care plans and revised with updated smoking interventions. The DON reported Resident #3's smoking assessment had been missed on admission.

Based on observation, record review, and interview, the facility failed to investigate an allegation of abuse and determine when to report the allegation for one (#3) of three sampled residents reviewed for abuse. The administrator identified 92 residents resided in the facility. The administrator reported six allegations of abuse in the past ninety days. Findings: An Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 06/23/27, read in part, The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. The policy also read, All residents, family members, visitors, and others are encouraged to report actual or suspected incidents of resident abuse, neglect, exploitation, and/or misappropriation of resident property without fear of retaliation. On 12/09/24 at 6:49 a.m., CNA #2 was observed working the front half of the 500 hall. CNA #2 was asked if there had been a problem on the 600 hall. They reported there was with Resident #3. They reported they were told not to go to the resident's room because they had made a complaint against them. They reported they were told when they made rounds in Resident #3's room they would need to ask for assistance from another staff member. On 12/09/24 at 7:00 a.m., Resident #3 returned from hospital on hospice services. On 12/09/24 at 7:30 a.m., the DON reported a meeting was held with the ombudsman and Resident #3 about the lights shining through their room at night and they discussed darkening curtains. On 12/09/24 at 8:05 a.m., LPN #1 was asked about CNA #2 working on the 600 hall. They reported they heard last week CNA #2 was not allowed on the 600 hall. On 12/09/24 at 9:19 a.m., the ombudsman was asked if they had informed the DON about a complaint regarding rough treatment of Resident #3. They reported they had met with the DON on 11/05/24 and informed them of the complaint of rough and rude treatment. They reported they were informed by the DON they would speak with night shift and investigate. On 12/09/24 at 10:18 a.m., LPN #3 was asked if they were aware CNA #2 was not to provide care for Resident #3. They reported they had heard that from the night shift nurses. They were asked why CNA #2 was not to provide care. They stated because of a family complaint. On 12/09/24 at 11:49 a.m., CNA #1 was asked if they were aware of a staff member that was not allowed to provide care for Resident #3. They identified CNA #2. They were asked if they knew why. They reported Resident #3 had several complaints about CNA #2 being rough and hateful. They were asked who they reported those complaints to. They reported it to several nurses. On 12/09/24 at 12:37 p.m., the administrator was asked how abuse allegations were reported. They reported they typically called them directly or reported to the DON or ADON. They reported they had not received an abuse allegation regarding Resident #3 and CNA #2. On 12/09/24 at 2:28 p.m., the DON reported they had discussed with Resident #3 if anyone had upset them, but they were unaware of an actual allegation. An initial Incident Report Form, dated 12/09/24, read in part, [Resident #3] and [CNA #2]. During a complaint survey it was notified to the facility that there may be an allegation of abuse by the resident &/or family. CNA suspended. Investigation initiated.

Based on observation, record review, and interview, the facility failed to ensure staff served prepared food with clean tongs and restrained all hair with beard guards as indicated. Findings: A facility policy, Employee Infection Control, dated 08/01/18, read in part, Anyone who enters the kitchen will have all hair restrained using bouffant caps, mesh or net, beard guard and clothing which covers body hair. A facility policy, General Food Preparation and Handling, dated 02/06/24, read in part, Food is prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. On 09/03/24 at 07:30 a.m., an initial tour was conducted of the kitchen. [NAME] #1 was preparing the morning meal and was observed without a beard guard in place. They reported they were running late this morning. On 09/03/24 at 11:40 a.m., the dietary supervisor was asked about the staff not wearing a beard guard. They reported it was their policy for them to wear beard guards when preparing meals. On 09/03/24 at 12:00 p.m., cook #1 donned gloves and was observed preparing lunch trays. They were observed plating food touching the plates, bowls, and menu slips with their gloved hands and then placed the dinner rolls on the plates with their gloved hands. Another staff member donned gloves and assisted the cook in preparing the lunch trays. They were observed touching the plates, bowls, and menu slips with their gloved hands and placed the dinner rolls on the plates with their gloved hands. The dietary supervisor reported the staff should use tongs when handling dinner rolls.

Based on record review and interview, the facility failed to ensure a registered nurse was on duty for at least eight consecutive hours a day, seven days a week. Findings: A Position Description, documented, position title: Registered Nurse, essential duties to evaluate staffing pattern needed to meet the needs of the residents in conjunction with the Director of Resident Care Services. Organizes/coordinators subordinates, job tasks and time allotments. Oversees/monitors function and activities of subordinate staff. On 09/06/24 at 8:45 a.m., the administrator reported the DON was hired in June 2024 and the ADON was hired on 02/21/24. They reported they were short during the month of April/May 2024. On 09/06/24 at 9:30 a.m., the administrator reported they were short RN coverage for every Saturday and Sunday in May 2024 and two weekends in April 2024.

Based on record review and interview, the facility failed to complete a discharge summary to include a recapitulation of the resident's stay for one (#42) of three residents reviewed for discharge. The DON reported there had been 33 discharges in the previous 30 days. Findings: A Discharge Plan policy, dated 04/26/24, documented in part, .when a resident is discharged , a post-discharge plan shall be provided to the resident, and/or his or her representative .The resident or representative should provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure than an adequate discharge plan can be developed .The medical record must be documented as to the reason why a discharge plan was not developed .As a minimum, the post-discharge plan will include .The identity of specific residents needs after discharge .appropriate referrals .a description of how the resident and family need to prepare for the discharge .Social services will review the plan with the resident and family before the discharge is to take place .A copy of the post-discharge plan will be provided to the resident . Resident #42 was admitted with diagnoses which included anemia, coronary artery disease, hypertension, non-Alzheimer's dementia, multiple sclerosis, depression, and chronic obstructive pulmonary disease. A baseline care plan, dated 07/23/24, documented resident #42 was independent in decision making skills and independent with activities of daily living. The care plan documented the resident planned to discharge home with an anticipated length of stay as 15 to 30 days. The care plan documented the resident was a low elopement risk. An MDS assessment, dated 07/24/24, documented the resident was cognitively intact. A nurse note for resident #42, dated 08/01/24 at 8:00 p.m., documented a CNA notified the charge nurse they could not locate the resident. The note documented the nurse called the resident's contact and was told by the contact they had picked up the resident from the facility earlier in the day. The contact stated the resident had signed a form and thought they were discharged . The note documented the DON and ADON were notified and the resident would be placed out of facility until the following day when administration could follow up with the resident. An incomplete Interdisciplinary Discharge Summary, dated 08/02/24, documented resident #42 was independent with supervision, was continent of bowel and bladder, and documented medications were not sent home with the resident. The summary did not include a recapitulation of the resident's stay, a final summary of the resident's status, or a reconciliation of all pre and post-discharge medications. On 09/06/24 at 11:34 a.m., the DON provided a partially completed discharge summary for resident #42. She stated the resident was given his NOMNC, which he signed and dated on 07/30/24, and apparently thought he was discharged . The DON reported the dayshift nurse on duty on 08/01/24 did not make any notes, complete the discharge summary for the resident, or pass the information on to the nightshift nurse. The DON reported the nurse responsible was no longer employed at the facility. On 09/06/24 at 12:20 p.m., the administrator reported they tried to call the resident the following day after his contact had picked him up but the resident's phone number had been disconnected. The administrator reported the social services director had been in touch with the resident's [Name Deleted] social worker about discharge plans but they thought the resident got confused when the NOMNC paperwork was provided to him and he thought he had been discharged . The administrator reported this information had not been documented anywhere in the resident's record. On 09/06/24 at 2:15 p.m., the administrator reported they had called the [Name Deleted] social worker and confirmed there had been communication from the facility but stated they could not get a copy of that documentation.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 04/04/24 related to the facility's failure to provide adequate supervision to ensure a resident remained safe and free from elopement. The facility failed to provide adequate supervision and interventions to prevent the resident from exiting the facility and leaving the premises unsupervised. On 05/01/24 at 9:57 a.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to provide adequate supervision to protect the resident and prevent elopement. Based on record review and interview, the facility failed to ensure a resident received adequate supervision to prevent elopement for one (#3) of four sampled residents reviewed for elopement. The Administrator reported a resident census of 80. Findings: The facility's Elopement Risk Assessment policy, dated 01/12/20, read in part, The licensed nurse completes the Elopement Risk Assessment in the electronic health record and presents the information to the interdisciplinary team for further interventions .The care plan is updated with the initiation of the interventions and changes in interventions, as needed .The licensed nurse documents in the nurse's notes and behavior monitoring in the electronic health record; any exit seeking behavior on an on-going basis and interventions are adjusted as needed . Resident #3 had diagnoses which included dementia, diabetes mellitus, Parkinsonism, and anxiety. A nurse's Admission Data report, dated 03/22/24, documented Resident #3 was a moderate risk for elopement. A nurse's note, dated 03/22/24 at 6:14 p.m., documented Resident #3 was being combative and refusing. The nurse's note documented the resident was cursing and yelling, stating staff were holding him against his will, and he was leaving the building now. A care plan, dated 03/22/24, read in part Care area: behavioral changes related to elopement risk score 11-20, moderate risk .Goal: Resident #3 will remain safe within the facility .Interventions: analyze key times, places, circumstances, triggers, and what de-escalates behavior . The admission assessment, dated 03/28/24, documented the resident's cognition was severely impaired and the Resident #3 required partial to moderate assistance with transfers and supervision with ambulation in a wheelchair. A nurse's note, dated 04/04/24, documented at approximately 4:20 p.m. during routine rounds, Resident #3 was not found to be in his room. The note documented staff began looking throughout the facility and the Resident #3 was located right outside the front entrance on the porch. The note documented the resident was redirected inside the facility and the Resident #3 stated, I cannot stay another night here. The note documented the Resident #3 was provided emotional support and agreed to go back inside the facility. The note documented staff would continue with frequent rounds, redirection, and education. An Elopement Risk assessment, dated 04/04/24 at 4:51 p.m., documented Resident #3 to be above high risk for elopement. The assessment documented in part, .the resident self-propels wheelchair, verbalizes anger and frustration regarding placement, mental status was highly confused or demented, and previous attempts to leave the facility one or more times in the last week . An OSDH Form 283 incident report, dated 04/04/24, documented at 10:30 p.m. the facility was unable to locate Resident #3 and elopement procedures were initiated. The incident report documented the Resident #3 was located at 12:30 a.m. on 04/05/24, was taken to the emergency room for evaluation, and returned to the facility. The incident report documented the facility investigation identified that the front door of the facility was unlocked. The incident report documented the facility implemented a QAPI plan, Resident #3 was placed on one-on-one supervision, and education was provided related to elopement. A police case report, dated 04/04/24, documented, on 04/04/24 at approximately 11:05 p.m., Officer [name removed] and Officer [name removed] were dispatched to the facility [name removed] for a missing and at-risk person. The report documented the facility Administrator informed the officer that Resident #3 went missing at approximately 9:30 p.m. - 10:30 p.m. The report documented the Administrator reported the Resident #3 had dementia and wanted to return to their residence, and it was all they talked about. The report documented Officer [name removed] went to the facility next door and asked if they had video footage of the facility. The report documented the lead administrator of the facility next door reported they had seen Resident #3 outside [name removed] doors unattended at approximately 7:30 p.m. when leaving work. The report documented Officer [name removed] found Resident #3 at the [name removed] dealership parking lot at 12:30 a.m. on 04/05/24. The report documented the Resident #3 required medical care due to his blood pressure and mental capacity and was transported to [name removed] medical center. A nurse's note, dated 04/05/24, documented Resident #3 returned from the ER at 2:35 p.m. with no new orders or injuries documented. A care plan, updated 04/08/24, read in part, .Care Area: Resident #3 is at risk for elopement .The resident has diagnoses of dementia, Parkinson's, and cognitive ability varies throughout the day .Interventions: : Analyze key times, places, circumstances, triggers, and what de-escalates behavior .Notify physician and family/responsible party .Offer activities of interest .Offer foods or snacks .Remove resident from immediate situation to assure safety .Staff to monitor his whereabouts at all times . On 04/29/24 at 11:35 a.m., CNA #1 reported when Resident #3 had admitted to the facility he had been aggressive and verbalizing that he wanted to leave the facility and go home. The CNA #1 reported resident #3 had started verbalizing about going home and stating, I'm ready to get out of here about a week before his elopement. The CNA #1 reported on 04/04/24 during the afternoon, the Resident #3 was found outside the front door by the CNA #1 and ADON. The CNA #1 reported Resident #3 was asking someone from transportation to take him home. On 04/29/24 at 3:12 p.m., the Regional Nurse Consultant reported the incident when Resident #3 was found outside the front door on 04/04/24 had not been considered an elopement by the facility due to the resident still being on the facility's premises. The Regional Nurse Consultant reported after that incident, the ADON and Administrator made the decision to lock the front door and require a passcode to open to prevent the resident from leaving the facility. On 04/29/24 at 2:18 p.m., family member #1 reported two days before Resident #3 eloped from the facility, the ADON had called to inform family member #1 that Resident #3 had been found outside the facility and they were going to put interventions in place to prevent him from getting outside the facility. The family member reported that on the afternoon of 04/04/24, the ADON called to inform family member #1 the Resident #3 was found outside the facility, they were going to lock the door front door, and require a passcode to exit. The family member #1 reported they had been informed after Resident #3's elopement on 04/04/24 that the front door was found unlocked. On 04/30/24 at 12:56 p.m., LPN #1 reported Resident #3 was usually in their wheelchair near the nurse's station if they were not in their room. The LPN #1 reported the resident would talk about leaving the facility and was confused on and off. On 04/30/24 at 1:05 p.m., CNA #2 reported Resident #3 would wheel up to the nurse's station from their room and stated they was going to leave and needed to get out the door. On 05/01/24 at 9:21 a.m., the Administrator reported that Resident #3 had made comments that they was going to leave the facility, but the facility had no indication that they would leave the facility's property. The Administrator was unaware of any reports that the Resident #3 had gotten out the front door of the facility two days prior to elopement. The Administrator reported the front door was supposed to be locked after the Resident #3 exited the facility the afternoon of 04/04/24 but for unknown reasons, was found unlocked when Resident #3 was found missing on 04/04/24. The Administrator reported if the front door had been locked it may have prevented the Resident #3 from eloping. The Administrator reported the elopement incident had the potential for serious injury or harm to the resident. On 05/01/24 at 9:57 a.m., the Administrator was presented with the IJ template and notified of the past non-compliance IJ situation for the elopement incident on 04/04/24 for resident #3. On 05/01/24 at 10:18 a.m., the regional nurse consultant reported that they were not aware of Resident #3 going outside the facility on 04/02/24 as documented on the IJ template. The regional nurse consultant reported they agreed with the rest of the documentation on the IJ template. On 05/01/24 at 10:23 a.m., per phone call, the ADON reported the resident had not been found outside the facility prior to 04/04/24. The facility's investigation of the elopement incident, dated 04/05/24, and provided by the Administrator, documented the need for immediate action had been resolved on 04/05/24. The investigation documented the following: Resident #3 was placed on one-on-one supervision when Resident #3 returned from theER on [DATE] until Resident #3 was discharged on [DATE]. On 04/05/24, the facility reassessed Resident #3's elopement risk and updated the care plan. The facility completed a headcount of all residents, reviewed all resident's elopement risk assessments and updated care plans as needed. The elopement risk book kept at the nurse's station was reviewed and updated. The facility locked all the coded doors, changed the door codes to make them harder to figure out, and placed signage on all doors to not let residents out. Daily checks of doors were implemented for 4 weeks. Staff members were in-serviced on elopement and keeping the doors locked 24/7. The facility conducted a root cause analysis exercise to determine the reason the elopement occurred. Throughout the survey, staff members were interviewed regarding the education and in-services provided on 04/05/24 and 04/08/24. All staff were knowledgeable on the topics covered during the in-service.

Based on record review and interview, the facility failed to ensure a resident received food prepared to meet the resident's needs, which resulted in hospitalization , for one (#1) of four residents reviewed for therapeutic diets. The administrator reported a census of 84 residents. Findings: A Menu Planning policy, dated 11/01/17, documented in part, .Nutrition Services will be responsible to prepare and serve the diet as ordered .Nursing staff will notify the NSM of needed consistency changes .Resident response to special and modified diets will be evaluated. Ineffective or inappropriate diets, including texture modifications, will be referred .to the attending physician, dietitian, and/or therapy department for evaluation . Resident #1 had diagnoses which included traumatic brain injury, hemiplegia, hemiparesis, and muscle spasms. A physician order, dated 11/29/23, documented a diet order for puree level 4. An MDS assessment, dated 02/17/24, documented the resident required a mechanically altered diet. The assessment documented the resident was severely cognitively impaired. A care plan, dated 02/19/24, documented resident #1 required a pureed level 4 diet. The care plan documented the resident required extensive to total assistance with activities of daily living. A nurse note, dated 03/19/24, documented in part, .Dietician reviewed resident recently. Awaiting call back from physician with decisions related to referral for peg tube or dietary changes . There was no documentation related to a choking incident on this day. A nurse note, dated 03/23/24, documented a focus assessment related to report of respiratory distress and initial O2 reading of 64%. The note documented the resident was placed on O2, EMS was called for transport to the ER, and the resident left the facility at 1:38 p.m. An emergency department note, dated 03/23/24 at 2:31 p.m., documented the resident was diagnosed with pneumonia and likely aspiration pneumonia. The note documented the resident was intubated related to respiratory distress. Hospital records documented the resident remained in the intensive care unit as of 04/01/24. On 04/01/24 at 1:12 p.m. the DM reported the facility currently had three residents with pureed diet orders. The DM reported these residents were normally fed in the assisted dining room. The DM reported dietary staff had meal cards they referred to for each resident, and stated she would be implementing color-coded cards the following week to assist in identifying special diets. On 04/01/24 at 1:30 p.m., LPN #2 reported she assessed Resident #1 the day the resident was sent to the hospital for respiratory distress. The LPN #2 stated one of the CNAs had gotten the resident up for lunch and reported the resident was short of breath and appeared to be struggling with his breathing. The LPN #2 reported the resident had not started eating lunch at that time and they informed the CNA #1 not to feed the resident since Resident #1 wasn't feeling good. The LPN #2 reported the resident had only had fluids for breakfast that morning, a thickened mighty shake and juice, but to their knowledge had not been fed any food on that day. On 04/01/24 at 1:40 p.m., LPN #2 reported after Resident #1 was admitted to the hospital, an unidentified staff member was told by a family member that the resident was diagnosed with aspiration pneumonia related to the resident being fed corn. The LPN #2 stated during a conversation between nursing staff, CNA #1 reported to LPN #2 that they had fed the resident corn, and informed the LPN #2 that the tray had the resident's name on it. The LPN #2 stated they normally didn't have problems getting the wrong diets for residents and they did not report the incident to anyone. On 04/01/24 at 2:20 p.m., the administrator reported they had not been informed of any resident choking or being fed the wrong diet. On 04/01/24 at 3:14 p.m., CNA #1 reported they were new to the facility and still getting to know the residents. The CNA #1 stated during the previous week, possibly their 2nd day to work, another CNA asked CNA# 1 to feed resident #1. CNA #1 stated the resident had mashed potatoes, pureed corn, and what looked like ground or chopped beef. The CNA #1 stated there were whole chunks of fruit on the tray and they knew not to feed the fruit to the resident since the other food was either pureed or chopped. The CNA #1 confirmed the corn was pureed but they could still tell it was corn. The CNA #1 stated the resident normally made grunting sounds and they noticed the resident was quieter. The CNA #1 called for the nurse and the nurse told her to sit the resident up straighter. The CNA #1 stated they pulled the resident up and the resident coughed up some liquid and seemed better. The CNA #1 reported the nurse assessed the resident and they seemed okay after that. The CNA #1 was uncertain of the exact date of the incident, but stated the resident did not go to the hospital that day. On 04/01/24 at 4:00 p.m., RN #1 provided diets and menus which showed cream-style corn and hamburger meat had been served on Tuesday, 03/19/24, prior to the resident being sent to the hospital on Saturday, 03/23/24. The RN confirmed the resident had a choking episode a few days before being sent out to the hospital which, by the nurse note, would have been on 03/19/24. On 04/02/24 at 11:50 a.m., the restorative aide reported they normally worked Monday through Friday and usually fed resident #1. The aide stated they had been out for surgery so they was not working on the days leading up to resident #1 being sent to the hospital. The aide reported they had observed the resident to have choking episodes in the past, which resulted in them requesting the resident be changed to the current pureed diet. The restorative aide stated because of the choking episodes, they always fed resident #1 in the unit dining room so they would be close to a nurse if the resident had any issues. The aide stated they had observed the resident get the wrong tray before, but they would return the tray to the kitchen and request a pureed tray. The restorative aide stated they thought it was just a mistake with kitchen staff being in a hurry to fill trays, but ultimately it was the responsibility of nursing staff to ensure the resident received the correct diet as ordered.

Based on record review and interview, the facility failed to ensure a medication sent home with a resident was their medication for one (#2) of eight residents whose records were reviewed for medications. The Resident Census and Conditions of Residents, dated 09/12/23, documented 88 residents resided in the facility. Findings: A facility policy titled, .Discharge Medications, read in part, .Procedures 2. The labels of discharge medications are verified for completeness and accuracy by checking them against the most recent prescriber's orders. Res #2 was admitted on [DATE] and discharged on [DATE]. They had diagnoses which included Parkinson's, hemiplegia, DM, and CVA. Res #2's physician order, dated 07/25/23, documented to administer atorvastatin 40 mg every evening. A Discharge Instructions For Care document was reviewed, it documented the resident was sent home with atorvastatin 40 mg every evening. On 09/12/23 at 1:46 p.m., via a phone call, a resident's family member reported the resident had been sent home with another resident's atorvastatin medication. The atorvastatin sent home with the resident was only 20 mg, not 40 mg as her family member had been prescribed. On 09/12/23 at 2:25 p.m., RN #2 reported the med aide gathered the medication and brought it to me. Then they count them and documented on the discharge instructions. They reported they guessed they didn't look at the name on the medication card. They reported they thought they always looked at the name but apparently they didn't on that one. On 09/12/23 at 2:30 p.m., the DON reported the medication for the other resident had been discontinued and should have been destroyed.

Based on record review and interview, the facility failed to ensure a resident's pain was controlled for one (#95) of two sample residents were reviewed for pain. The facility failed to have a physician ordered pain medication available for the resident when they requested two separate doses at six hour intervals. The resident requested to go to the hospital due to uncontrolled pain. The Resident Census and Conditions of Residents form, dated 07/09/23, documented 91 residents resided in the facility. Findings: Res #95 had diagnoses which included CAD, HTN, MDRO, CVA, hemiplegia, diabetes mellitus, and MS. The resident's Pain Risk Assessment read in part, .Does the resident have a diagnosis or condition likely to cause pain? Cutaneous abscess of right foot, Other chronic pain, .Onset of Pain - (Chronic) over 3 months .What improves the pain? - Pain medication . The care plan read in part, .Care Area/Problem *Pain [05/25/23] Goal-Chronic pain will be managed effectively at a level that is tolerable to the resident over the next 90 days .Give pain medications before pain becomes severe .Notify physician of any changes in level or frequency of pain . The May 2023 Physicians order documented the resident had an order for oxycodone 20 mg one tablet by mouth every six hours as needed for pain. A Controlled Drug Record documented the resident had 12 oxycodone 20 mg tablets. The first pill was administered on 05/25/23 and the last pill was administered on 05/29/23 at 12:30 a.m. A nurse note, dated 05/28/23 at 6:15 a.m., read in part, 0606 [6:06 a.m.] pain medication given resident states her pain is constant, states pain is 10/10 i told her we.d (sic) wait till 7a-715a se (sic) what her pain is, if no improvement then we.ll (sic) have to send her out due to no pain relief. On 05/28/23 at 7:40 a.m., the MAR documented the resident's follow up pain level was at a nine. There was no documentation the physician was notified of uncontrolled pain. A nurse note, dated 05/29/23 at 1:40 p.m., read in part, .Therapy came and reported to this writer that patient wanted to be sent to [hospital name withheld] for incontrollable (sic) pain .Report called and given at 1300 [1:00 p.m.] to [hospital name withheld] emergency room .ambulance called to transport patient to [hospital name withheld] for further evaluation. DR .notified . There was no documentation the resident's pain level was checked on 05/29/23. A pharmacy report, dated 05/29/23, documented the oxycodone 20 mg IR tablet was ordered on 05/29/23 at 11:45 a.m. An emergency department note, dated 05/29/23 at 2:08 p.m., documented, She is simply here for uncontrolled pain. A facility Interdisciplinary Discharge Summary, dated 06/21/23, read in part, .the resident was sent to the hospital for uncontrolled pain . On 07/13/23 at 12:35 p.m., the corporate nurse stated, We notified the pharmacy on the 29th at 11:45 a.m. that she was out and they sent more that day at 6:28 p.m. On 07/13/23 at 1:05 p.m. the resident was interviewed via a phone call. The resident reported their foot was hurting and the facility had ran out of their medication, so the resident left to go to the hospital because of the pain. The resident reported they asked for the pain medication every six hours but were told they had ran out of the medication. The resident stated their pain intensity was severe enough they requested to go to the hospital. On 07/13/23 at 3:25 p.m., LPN #2 reported that on 05/28/23, when she did the follow-up on the pain medication, the resident's pain was at a nine. The LPN reported the doctor was in the building and was told the resident's pain was not controlled. The LPN was asked if they had charted the physician was informed and they stated it was not charted. The LPN was asked when a medication was typically re-ordered and she stated, I would reorder it when I have 10 pills left. On 07/14/23 at 10:04 a.m., a nurse consultant reported via email, The staff all reported they talked to the Dr. on the 29th but the Dr. stated he did not have any notes from that day.

Based on observation, record review, and interview, the facility failed to ensure and maintain a sanitary kitchen. The facility failed to ensure: a. food products were properly stored, b. food service equipment was kept clean, and c. sanitary hand hygiene practices were implemented while handling food. The Resident Census and Conditions of Residents report, dated 07/09/23, documented 91 residents resided in the facility and three residents received tube feeding. Findings: The facility's Food Storage Nutrition Services policy, read in part, .air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened .food is stored a minimum of 6 inches above the floor .all foods are covered, labeled and dated . Use of Leftovers, policy, read in part, .leftovers should be covered, labeled, dated and stored appropriately .leftover food is used within 72 hours or discarded . Nutrition Services Use of Disposable Gloves, policy, read in part, .gloves will be changed as soon as they become soiled .before beginning a different task . General Food Preparation and Handling, policy read in part, .food is prepared and served with clean tongs . A weekly facility Cleaning Schedule, read in part, . All kitchen equipment that is used to prepare food is to be cleaned after each use .paper supply and storeroom is to be swept and mopped daily .as well as grease trap on grill .microwave is to be cleaned after each use .clean and organize refrigerators, clean all sinks, clean all silver carts, clean trash can, sweep and mop .wipe down reach in refrigerator .wipe down ice machine .trash can inside and out . On 07/09/23 at 2:15 p.m., a tour of the kitchen and dining room was conducted. The following was observed: a. Dietary staff #1 and #2 were observed to not have hairnets in place. b. Hand sinks had film and grimy buildup on surfaces and faucets. c. Microwave had plastic to inside of door separated from frame and the finish on inside surfaces with gray colored, uneven surface. At that time the staff reported there had been a fire on the inside of the microwave and it was still being used. d. Spice rack above microwave was dusty and food crumbs were on the surface. e. Table stand mixer had white flaky substance and buildup of debris on motor, handle and bowl. f. A portable dish rack for clean dish storage had dried cereal pieces and food debris on sides and bottom surfaces. g. Toaster on tray with accumulation of crumbs. h. Hall carts and service carts with spills and food stains on surfaces. i. A large area on side of range with dried on food and greasy surface. j. A utensil drawer with water collected in scoops, bottom of drawer surface covered in a film, and rusted looking area. k. Bulk storage bins with debris buildup on lids and outside surfaces, scoop stored in the sugar. l. Trash containers without lids and surfaces inside and out had heavy buildup of grim and dirt. m. A laundry only container located at the door to the dishwashing area was dirty and stained inside and out. n. The walk in cooler was observed to have a container of onions, cream of chicken soup, potato salad, and four bags of meat products undated and not labeled. Sliced cheese was not properly sealed or dated. o. Four cardboard boxes were on the floor of cooler containing food products. p. The ice machine was observed to have black/brown and pink slimy substance on the ice guard and the outside surface was smudged and not clean. q. Dining room had condiments left on tables and counters, scattered and unorganized packages of jelly, salt, pepper, sugar, butter, and unlabeled containers of yellow and white substances. Tables and shelving dusty with dried beverage spills in areas. Dining room floor observed with dried spills, trash, and food debris. On 07/09/23 at 4:46 p.m., dietary staff #1 was observed to use gloved hands to remove buns and place them on the resident plates for the meal. Then was observed to return a plate to the dishwashing area, open a drawer, handle the food surface areas of the plates, and continued to place buns on plates without performing hand hygiene or removing gloves. On 07/10/23 at 8:22 a.m., the administrator was made aware of the observations and reported a recently hired CDM will start on July 24th. They reported they had problems retaining kitchen staff and the few staff that remain have worked extra hours to get the food out to the residents. They reported awareness of issues in the kitchen to be addressed and hopeful for the new hires to stay and get things in order. On 07/12/23 at 10:18 a.m., the resident nutrition room on the skilled unit was observed. Signage posted on the door, Frig-Residents Refridgerator (sic) items must be marked with name and date, all other items will be thrown away. A sign posted on the refrigerator, Guidelines for Refrigerator Use, .read in parts, refrigerator is for RESIDENT use only .MUST be labeled .and date . The nutrition room was observed to have four unsealed and undated bowls of food in the refrigerator, personal staff items undated and not labeled, resident snacks on tray, shelving with dried, crusty, debris buildup, brown substances of foods and beverage spills on all surfaces. Cabinets and counters with dried spills, food debris, and crumbs on surfaces. One loaf of bread with a Best by Jun 01 2023, one unsealed bag of vanilla wafers with 5/19 written on the bag, one bag of unsealed marshmallows with 4/21 written on the bag, was observed in cabinets. One coffee maker with a buildup of water stains. The microwave was observed to have dried, splattered eggs on all surfaces. The sink was stained and unclean. On 07/12/23 at 10:20 a.m., the ADON was interviewed and reported the kitchen staff deliver snacks for residents and nursing staff store them in the nutrition room. They reported the kitchen staff are responsible for cleaning and removing outdated products from the room. They were asked if the policy was for staff and resident to share the space and reported they would have to check on that. 07/12/23 at 10:33 a.m., RN consultant #1 was shown the above findings. An Ice Machine Cleaning and Sanitation record documented monthly scheduled cleaning for the year 2023. The last cleaning was documented on 06/08/23. On 07/12/23 at 10:47 a.m., the maintenance supervisor reported monthly cleaning and sanitizing schedule for the ice machine was due.

Based on observations, record review, and interview, the facility failed to ensure the inside of the facility was kept clean. The Resident Census and Conditions of Residents report, dated 07/13/23, documented a census of 91 residents. Findings: The facility's Cleaning policy and procedure, read in part, .Department: Environmental Services .Purpose: To provide a clean, orderly, and attractive public area for residents, visitors and staff that enhance the image of the facility . On 07/09/23 at 2:30 p.m., a tour of the facility was conducted. The floors were observed to be dirty with numerous stains on the floors throughout the building. The flooring had a musky/mildew odor. There was trash on the floors throughout the whole facility. There were dead bugs/insects on the floors, window sills, and on the inside of the hand rails. The dining room and snack room floors were sticky with trash on the floor and spilled beverages on the floor. There was a damaged baseboard with a hole cut out of the wall in the dining room. Some of the resident rooms were not clean and had trash on the floors and food items splattered on some of the walls. On 07/09/23 at 4:45 p.m., the DON toured the facility with the surveyor and was in agreement the floors were dirty, needed to be vacuumed and cleaned, and the facility was overall not clean.

Based on record review and interview, the facility failed to ensure a medication was available to administer as ordered by the physician for one (#95) of two residents whose records were reviewed for pain. The Resident Census and Conditions of Residents, dated 07/09/23, documented 91 residents resided in the facility. Findings: The resident had diagnoses which included CAD, HTN, MDRO, CVA, Hemiplegia, DM, and MS. The facility Ordering and Receiving Controlled Substances, dated 02/12/2020, read in part, .G. Controlled substances are reordered when a 4 day supply remains to allow for transmittal of the required written prescription to the pharmacist. A Controlled Drug Record documented the resident had 12 oxycodone 20 mg tablet 1 tablet by mouth every six hours as needed for pain. The first pill was administered at 8:04 p.m., on 05/25/23 and the last pill was administered on 05/29/23 at 12:30 a.m. A nurse note, dated 05/29/23 at 1:40 p.m., read in part, Therapy came and reported to this writer that patient wanted to be sent to [hospital name withheld] for uncontrollable pain .Report called and given at 1300 [1:00 p.m.] to [hospital name withheld] emergency room . ambulance called to transport patient to [hospital name withheld] for further evaluation. DR .notified . A pharmacy report, dated 05/29/23, documented the oxycodone 20 mg IR tablet was ordered on 05/29/2023 at 11:45 a.m. On 07/13/23 at 12:35 p.m., the corporate nurse reported we notified the pharmacy on the 29th at 11:45 a.m. that she was out and they sent more that day at 6:28 p.m. She reported, they had not ordered it earlier because the physician would not reorder it until he came out to see the resident. On 07/13/23 at 1:05 p.m. the resident was interviewed via a phone call. They reported their foot was hurting and they had ran out of medication so they left to the hospital because of the pain. The resident stated they asked for it every six hours but they told me they ran out of it. On 07/13/23 at 4:45 p.m., the administrator was informed of the above findings.

Based on record review and interview, the facility failed to obtain a written consent for Telemedicine communication for one (#97) of three residents reviewed for privacy and confidentiality. The Resident Census and Conditions of Residents form documented 87 residents resided in the facility. Findings: A facility policy, Telehealth Registered Nurse Assessment Services, dated 09-01-19, documented in parts .The NF must obtain informed consent from the resident, resident's representative, or the resident's legal guardian using the Consent for Telehealth Registered Nurse Assessment form prior to rendering services via telehealth RN assessment services. A facility policy, Resident Rights, dated 02/12/20, documented in part .The staff will abide by and protect resident rights in accordance to state and federal guidelines. Resident #97 was admitted to the facility on [DATE] with diagnoses which included COVID-19, pneumonia, and acute kidney failure. A Grievance Form, dated 03/14/22, documented the Administrator met with the resident's spouse who was upset after walking into the resident's room and seeing therapy staff with a cell phone doing a Telemedicine (Telemed) assessment. The form documented the resident was upset in the process and had been asking for his spouse during the evaluation. The form documented the Administrator educated therapy staff regarding providing more details to residents on the Telemed assessment procedure. A Minimum Data Set Assessment, dated 03/17/22, documented the resident was cognitively intact. An Informed Consent For Your Telemedicine Visit form, dated 03/21/22 at 3:00 p.m, documented the business manager had received a verbal consent, per conversation. The document did not contain the resident's name or a name for the person who provided consent. An Acknowledgment of Receipt of the Notice of Privacy Practices of Sound Inpatient Physicians, Inc. form, dated 03/21/22, documented the resident's spouse had signed the form related to privacy practices. A Physician Note, dated 03/30/22, documented the resident was admitted to the facility secondary to deficits in mobility and activities of daily living (ADLs). The note documented the resident's plan and progress was discussed with nursing staff and therapy, and the patient was seen at the bedside in no acute distress. The note documented the resident's pain was controlled. On 05/04/22 at 1:09 p.m., the DON reported at the time Resident #97 was admitted , the facility was without an Admissions Coordinator. The DON stated the consents should have been signed upon admission but were missed. The Administrator and Director of Nursing reported the facility did not have a separate Telehealth/Telemedicine policy related to the Physical Therapy department.

Based on observation, interview, and record review the facility failed to prepare food which was palatable and served at an appetizing temperature for three (#1, #2, and #3) of three residents sampled for palatable food. The Resident Census and Conditions of Residents report documented 98 residents resided at the facility. Findings: 1. A Minimum Data Set (MDS) assessment, dated 01/17/22, documented Resident (Res) #1 had a diagnosis of [CONDITION(S)]. The assessment documented Res #1 was cognitively intact and independent with eating. On 03/01/22 at 10:00 a.m., Res #1 reported the food was, mushy, low quality, and not cooked properly. Res #1 had taken pictures of numerous meals, which were shown to this surveyor. The meals were noted to be unappetizing. 2. A Care Plan, dated 12/09/21, for Res #2, read in parts .At risk for altered nutrition status related to her need for a therapeutic diet .provide favorite foods and beverages .provide menu alternates and snacks. An MDS assessment, dated 12/12/21, for Res #2 documented the resident had a diagnosis of diabetes mellitus. The assessment documented the resident was cognitively intact. On 03/01/22 at 11:20 a.m., Res #2 reported the facility had previously had good food when the resident was admitted in 2019. The resident stated the only good meal now was breakfast. The resident reported the food was undercooked, overcooked, no variety, with very limited options for alternate meals. The resident reported an alternate choice was usually a grilled cheese sandwich or a hot dog, and stated the grilled cheese sandwiches were always burnt. 3. An MDS assessment, dated 01/09/22, for Res #3 documented the resident had diagnoses which included diabetes mellitus and [CONDITION(S)] of the liver. The assessment documented the resident was moderately impaired with cognition. A Care Plan for Res #3, dated 02/28/22, read in parts .At risk for altered nutritional status related to malnutrition, being on a therapeutic diet, and missing teeth. On 03/01/22 at 11:30 a.m., Res #3 reported he usually ate in the dining room but the food was still cold at times. The resident reported the vegetables and chicken were usually overcooked, and the grits and oatmeal were always cold. On 03/01/22 at 11:50 a.m., a sample tray was received. The tray consisted of pork roast with gravy, brussel sprouts, green beans, macaroni and cheese, and cornbread. The pork roast with gravy was found to be cold. The brussel sprouts and green beans were overcooked, with a mushy consistency, and found to have very little flavor. The cornbread was extremely dry and difficult for surveyors to eat. Multiple residents, in addition to sampled residents, were interviewed throughout the survey and reported meals were tasteless, sometimes burnt, often cold, and not palatable in general. Several staff members were interviewed and reported they no longer ordered meals from the facility kitchen due to the quality of the food. Resident council minutes were requested but never provided by facility staff. On 03/01/22 at 3:00 p.m., the Administrator was informed of the findings. He reported he would speak with kitchen staff to work on providing more palatable food.

On 02/02/15, an immediate jeopardy (IJ) was determined to exist due to the facility's failure to notify the physician and family member in a timely manner concerning the resident's increased pain and increased bleeding from his Foley catheter. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 2:45 p.m., the administrator and the director of nurses (DON) were notified of the above IJ situation. At 5:08 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal documented: "1. All residents with foley catheters will be assessed by an RN (registered nurse) by 9:00 p.m. 02/02/15 2. Licensed nurses will be checked for competency in providing catheter care, to include, insertion, removing, the changing of a catheter, when to call the MD (medical doctor). When to pull the catheter and when not to pull the catheter. Licensed nurses to be completed by 02/02/15 at midnight. If they cannot come in, they will not work any shift until they are checked off. 3. In-service will be done regarding catheter care, physician notification, monitoring of residents on anticoagulant therapy for signs, and symptoms of bleeding, and pain management to be completed by 02/02/15 at midnight. 4. The Director of Nursing/Designee will monitor during daily clinical stand up to ensure policy is followed. 5. Catheter care and physician notification will be reported to the QA&A (quality assurance) committee for follow up and recommendation." On 02/04/15 at 1:15 p.m. thru 4:30 p.m., the nursing staff from the day and afternoon shifts who attended the in-service were interviewed. They were knowledgeable in regard to guidelines for notifying physicians and family members of clinical problems. The IJ was removed effective 02/02/15 at 10:00 p.m., although the deficient practice remained at actual harm, at a patten. Based on Interview and record review it was determined the facility failed to ensure the physician and a family member was notified in a timely manner concerning the increased pain and increased bleeding from a Foley catheter for one (#1) of 6 residents reviewed for Foley catheter care. Resident #1 was on anticoagulant therapy. This resulted in actual harm when the resident was admitted to the hospital and required surgery. This had the potential to affect all 8 residents with Foley catheters. Findings: The 5-day assessment, dated 01/07/15, documented the resident's cognition was intact. Ambulation had not occurred: he was totally dependent upon staff for transfers. He required extensive assistance for dressing, limited assistance for hygiene and supervision for eating. His range of motion was impaired on one side. The resident had a suprapubic catheter. His [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident had received the [MEDICATION NAME] from 10/10/14 thru 12/31/14. The facility's policy for notifying physicians of clinical problems documented, "...Immediate notification (Acute) Problems, The following symptoms, signs ... should prompt immediate notification of the physician, after an appropriate nursing evaluation... #3 (a) Sudden onset or a marked change compared...to usual status and are (b) unrelieved by measures which have already been prescribed..." A nurse's note dated 12/23/14, (late entry without a time) documented, " 12/22/14 - Pt. (patient) c/o (complains of) f/c (Foley catheter) leaking @ 1600 (4:00 p.m.). Urine and scant amt blood noted on underwear. F/C re-positioned and cath guard applied. Pt c/o the same issue again @ 1800 (6:00 p.m.). F/C changed with 16FR (french) with immediate return of bloody urine. Pt with severe muscle cramps BLE (bilateral lower extremities). Medicated with [MEDICATION NAME] per prn orders and muscle rub applied BLE. Re-checked F/C @ 1840 (6:40 p.m.) with bloody urine in bag and clear yellow urine in tubing." A nurse's note, dated 12/22/14 at 7:56 p.m., documented [MEDICATION NAME] was not given until this time and not at 6:00 p.m. The administration of this [MEDICATION NAME] was 1 hour and 56 minutes later than documented it had been given. A nurse's note, dated 12/22/14 at 9:34 p.m., documented Tylenol 325 mg tablet, 2 tablets were given. A nurse's note, dated 12/22/14 at 11:40 p.m., documented, "Residents Foley catheter was changed earlier today on day shift. Dark red blood noted draining from Foley and coming from groin area. Resident complaining of pain. PRN (as needed) [MEDICATION NAME] was given about 1800 (6:00 p.m.), asked resident would he like his Tylenol, resident refused on more than one occasion. Called another nurse for assistance. Resident agreed to take Tylenol to ease the pain. Resident was taken back to his room where his foley was flushed but continued to have dark red blood. Patient urinated just a small amount. Bladder scan showed he still had more than 500 ccs (cubic centimeters) of urine retention. Attempted to change and insert catheter once again, but he continued to bleed. MD called and notified, with an order to send resident to (local hospital) ER (emergency room ). Daughter (name deleted) called and notified. ADON notified. (name deleted ambulance service) called. Report given to ER Nurse." The resident's operative report from the local hospital, dated 12/24/14, documented: "...Preoperative Diagnoses: [REDACTED]. On 01/23/15, at 10:25 a.m., resident #1 stated "After (name withheld) changed out my catheter, it started bleeding, I told (name withheld) I was hurting. She told me she would leave a note for the next shift. It started hurting real bad, I told (name withheld) it was hurting real bad. She said I already had my pain medication and I couldn't have any more for 6 hours. She offered me Tylenol, I told her I was hurting too bad that Tylenol wouldn't help it, so a little bit later I went and told her again I was hurting really really bad and my clothes were soaked in blood. The nurses just ignored me and didn't pay any attention to me when I kept telling them about all the pain. (Name withheld) asked me if I wanted to go to the ER. She told me I had to decide that. I told her that was not my decision to make. She stated she was not making that decision, she didn't want to do all that paperwork." The surveyor asked the resident if his pain had resolved before he went to the ER. He stated, "No it wasn't, I was still in a lot of pain." On 02/02/15 at 10:30 a.m., licensed practical nurse (LPN) #1 was asked, what she had done for the resident's pain. She stated, "I gave him a muscle relaxer, I worked on his legs, he was frogging up with muscle spasms, I'm not sure if pain meds were given at this time or not." She was asked if after seeing the blood and knowing he was in pain, had she called the physician? She stated, "No, I wasn't concerned at that time about the blood." On 01/23/15 at 4:10 p.m., LPN #2 was interviewed and stated, When I was in report they said (resident #1's) catheter was changed earlier that day. The nurse I was relieving said it was bleeding after she changed the catheter. She said she tried to flush it but it wouldn't flush. I started working on the EMAR (electronic medication administration system). Then I was told by the certified nurses aides (CNA's) (resident #1) wanted to talk to me. The CNA told me his Foley bag was clotted off with blood. I don't remember what time I went into his room. I got the blood from the tube to go down in to the bag, then I went back to doing what I was doing before. Every time he was bleeding we changed him. He kept sitting in different positions to help with the pain. So I got (LPN #3) and then he took some Tylenol, then (LPN #3) took him back to his room. She tried to change his Foley again, but it only kept bleeding. He kept saying he had to pee, so he peed a small amount and then would bleed again. Then (LPN #3) tried to put the Foley back in but kept getting resistance. On 01/23/15 at 3:20 p.m., LPN #3 was interviewed and stated, LPN #2 had called her around 10:00 p.m. I was working on the skilled nursing side. I went over to the long term care side. The resident was sitting at the nurse's station in his wheel chair, his Foley was almost completely full of blood, no urine, all blood. We took him to his room, he complained it was hurting really bad. I used the bladder scan and it showed he had a little over 900 cc's of urine, so I removed the catheter and turned him on his side and massaged his bladder, he would void a small amount, and then blood would come out, then void a small amount then blood again, he complained of burning and pain. The CNA ran and got a new Foley. I tried to put a new Foley in and only got blood clots out, no urine. They were really huge blood clots, not little ones. I decided because of the large amount of blood, we should send him out. I massaged his bladder again and he voided some more before he left. I used the bladder scan again before he left and it was showing around 500 cc's urine. He left to the ER without a Foley in. This had been going on for almost 5 hours before he was sent out. At 3:45 p.m. CNA #1 was interviewed and stated, Around 6:00 p.m. I noticed his Foley bag only had blood in it, it was about half full. I went and told (LPN #1) that the bag was full of blood. She replied, 'I know it's full of blood, it just has to drain thru before the urine comes out.' She didn't seemed concerned. After supper he said he was in a lot of pain. We went and told (LPN #1) again. She said the same thing, the blood just has to pass thru before the urine gets in the catheter. The resident kept calling us back into his room because he was in so much pain and blood kept getting on his sheets. By this time, (LPN #1) had given repot to (LPN #2). Me and the other CNA were freaking out because of all the blood, we changed his sheets 4 or 5 times, this went on almost my entire shift. We got him up to the chair, we put a brief and a sheet over him. He kept complaining about pain. He told us something's not right. So we reported to (LPN #2) that he was in a lot of pain. I told her the catheter is not working, the resident said he feels like he has to pee. (LPN #2) said, 'Ok, I'll check him in a little while' and she kept passing medication. he called me and the other CNA in to his room [ROOM NUMBER] or 3 more times before (LPN#2) responded. By this time (resident #1) started getting upset because no licensed nurse was responding to him. It was around 9 by the time (LPN #2) went in and checked on him. There was so much blood. After (LPN#2) checked on him, she kept saying she didn't know what to do. So we put him back in bed. He kept complaining of a ton of pain and the need to urinate. I just kept reporting to (LPN #2, then around 10:00 p.m., (LPN #3) came over. She used the bladder scanner, it showed around 900 cc's. She took the catheter out and tried to recath him. but only big blood clots were coming out. Blood was everywhere, he was still in a lot of pain and shaking, I thought he was going to pass out or go into shock. (LPN #3) said something's not right cause she couldn't put the catheter back in. So (LPN #3) told (LPN#2) to send him to the ER. This went on almost my entire shift, (LPN #1 and #2) would not make a decision. They both just passed it off, finally (LPN #3) made the decision to send him out." On 02/02/15, at 10:58 a.m., the ADON was asked if she was called at any time on the night of 12/22/14 concerning resident #1's pain and bleeding related to his foley catheter. She stated, "No, I did not get a call from staff, but only received a text at 11:24 p.m. that stated "Sent (resident #1) to (local hospital) Fyi." She was asked if the nurse's should have called her. She stated, "Yes, but they wouldn't call me to insert a catheter." She was asked if any training had been done with the licensed staff regarding catheter care, insertion. She stated, "No. She hadn't had time to." She stated, she had spoke to the staff about it, but had no documentation regarding the incident. She was asked if the potential still existed for problems related to Foley catheters to re-occur. She stated "Yes." The residents's physician was interviewed and stated he was not notified of the resident's condition until sometime between 10:00 p.m. and 11:00 p.m. on 12/22/14. The resident's family member stated she was not notified of the resident's condition until 11:15 p.m. on 12/22/14. On 02/05/15 at 10:00 p.m. the DON was in agreement staff should have notified the physician and the family immediately with any change of condition.

On 02/02/15, an immediate jeopardy (IJ) was determined to exist due to the facility's failure to thoroughly assess, monitor and appropriately intervene in a timely manner, after resident #1 experienced increased bleeding and increased pain following the replacement of his Foley catheter. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 2:45 p.m., the administrator and the director of nurses (DON) were notified of the above IJ situation. At 5:08 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal documented: "1. All residents with foley catheters will be assessed by an RN (registered nurse) by 9:00 p.m. 02/02/15 2. Licensed nurses will be checked for competency in providing catheter care, to include, insertion, removing, the changing of a catheter, when to call the MD (medical doctor). When to pull the catheter and when not to pull the catheter. Licensed nurses to be completed by 02/02/15 at midnight. If they cannot come in, they will not work any shift until they are checked off. 3. In-service will be done regarding catheter care, physician notification, monitoring of residents on anticoagulant therapy for signs, and symptoms of bleeding, and pain management to be completed by 02/02/15 at midnight. 4. The Director of Nursing/Designee will monitor during daily clinical stand up to ensure policy is followed. 5. Catheter care and physician notification will be reported to the QA&A (quality assurance) committee for follow up and recommendation." On 02/04/15 at 1:15 p.m. thru 4:30 p.m., the nursing staff from the day and afternoon shifts who attended the in-service were interviewed. They were knowledgeable in regard to guidelines for notifying physicians and family members of clinical problems. The IJ was removed effective 02/02/15 at 10:00 p.m., although the deficient practice remained at actual harm, at a patten. Based on interview and record review, it was determined the facility failed to ensure one (#1) of six residents was thoroughly assessed, monitored and provided appropriate care in a timely manner, after he experienced increased bleeding (was receiving anticoagulant therapy) and increased pain following the replacement of his Foley catheter. This resulted in actual harm when the resident was admitted to the hospital and required surgery. This had the potential to affect all 8 residents with Foley catheters. Findings: The 5-day assessment, dated 01/07/15, documented the resident's cognition was intact. Ambulation had not occurred: he was totally dependent upon staff for transfers. He required extensive assistance for dressing, limited assistance for hygiene and supervision for eating. His range of motion was impaired on one side. The resident had a suprapubic catheter. His [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident had received the [MEDICATION NAME] from 10/10/14 thru 12/31/14. The facility's policy for notifying physicians of clinical problems documented, "...Immediate notification (Acute) Problems, The following symptoms, signs ... should prompt immediate notification of the physician, after an appropriate nursing evaluation... #3 (a) Sudden onset or a marked change compared...to usual status and are (b) unrelieved by measures which have already been prescribed..." A nurse's note dated 12/23/14, (late entry without a time) documented, " 12/22/14 - Pt. (patient) c/o (complains of) f/c (Foley catheter) leaking @ 1600 (4:00 p.m.). Urine and scant amt blood noted on underwear. F/C re-positioned and cath guard applied. Pt c/o the same issue again @ 1800 (6:00 p.m.). F/C changed with 16FR (french) with immediate return of bloody urine. Pt with severe muscle cramps BLE (bilateral lower extremities). Medicated with [MEDICATION NAME] per prn orders and muscle rub applied BLE. Re-checked F/C @ 1840 (6:40 p.m.) with bloody urine in bag and clear yellow urine in tubing." A nurse's note, dated 12/22/14 at 7:56 p.m., documented [MEDICATION NAME] was not given until this time and not at 6:00 p.m. The administration of this [MEDICATION NAME] was 1 hour and 56 minutes later than documented it had been given. A nurse's note, dated 12/22/14 at 9:34 p.m., documented Tylenol 325 mg tablet, 2 tablets were given. A nurse's note, dated 12/22/14 at 11:40 p.m., documented, "Residents Foley catheter was changed earlier today on day shift. Dark red blood noted draining from Foley and coming from groin area. Resident complaining of pain. PRN (as needed) [MEDICATION NAME] was given about 1800 (6:00 p.m.), asked resident would he like his Tylenol, resident refused on more than one occasion. Called another nurse for assistance. Resident agreed to take Tylenol to ease the pain. Resident was taken back to his room where his foley was flushed but continued to have dark red blood. Patient urinated just a small amount. Bladder scan showed he still had more than 500 ccs (cubic centimeters) of urine retention. Attempted to change and insert catheter once again, but he continued to bleed. MD called and notified, with an order to send resident to (local hospital) ER (emergency room ). Daughter (name deleted) called and notified. ADON notified. (name deleted ambulance service) called. Report given to ER Nurse." The resident's operative report from the local hospital, dated 12/24/14, documented: "...Preoperative Diagnoses: [REDACTED]. On 01/23/15, at 10:25 a.m., resident #1 stated "After (name withheld) changed out my catheter, it started bleeding, I told (name withheld) I was hurting. She told me she would leave a note for the next shift. It started hurting real bad, I told (name withheld) it was hurting real bad. She said I already had my pain medication and I couldn't have any more for 6 hours. She offered me Tylenol, I told her I was hurting too bad that Tylenol wouldn't help it, so a little bit later I went and told her again I was hurting really really bad and my clothes were soaked in blood. The nurses just ignored me and didn't pay any attention to me when I kept telling them about all the pain. (Name withheld) asked me if I wanted to go to the ER. She told me I had to decide that. I told her that was not my decision to make. She stated she was not making that decision, she didn't want to do all that paperwork." The surveyor asked the resident if his pain had resolved before he went to the ER. He stated, "No it wasn't, I was still in a lot of pain." On 02/02/15 at 10:30 a.m., licensed practical nurse (LPN) #1 was asked, what she had done for the resident's pain. She stated, "I gave him a muscle relaxer, I worked on his legs, he was frogging up with muscle spasms, I'm not sure if pain meds were given at this time or not." She was asked if after seeing the blood and knowing he was in pain, had she called the physician? She stated, "No, I wasn't concerned at that time about the blood." On 01/23/15 at 4:10 p.m., LPN #2 was interviewed and stated, When I was in report they said (resident #1's) catheter was changed earlier that day. The nurse I was relieving said it was bleeding after she changed the catheter. She said she tried to flush it but it wouldn't flush. I started working on the EMAR (electronic medication administration system). Then I was told by the certified nurses aides (CNA's) (resident #1) wanted to talk to me. The CNA told me his Foley bag was clotted off with blood. I don't remember what time I went into his room. I got the blood from the tube to go down in to the bag, then I went back to doing what I was doing before. Every time he was bleeding we changed him. He kept sitting in different positions to help with the pain. So I got (LPN #3) and then he took some Tylenol, then (LPN #3) took him back to his room. She tried to change his Foley again, but it only kept bleeding. He kept saying he had to pee, so he peed a small amount and then would bleed again. Then (LPN #3) tried to put the Foley back in but kept getting resistance. On 01/23/15 at 3:20 p.m., LPN #3 was interviewed and stated, LPN #2 had called her around 10:00 p.m. I was working on the skilled nursing side. I went over to the long term care side. The resident was sitting at the nurse's station in his wheel chair, his Foley was almost completely full of blood, no urine, all blood. We took him to his room, he complained it was hurting really bad. I used the bladder scan and it showed he had a little over 900 cc's of urine, so I removed the catheter and turned him on his side and massaged his bladder, he would void a small amount, and then blood would come out, then void a small amount then blood again, he complained of burning and pain. The CNA ran and got a new Foley. I tried to put a new Foley in and only got blood clots out, no urine. They were really huge blood clots, not little ones. I decided because of the large amount of blood, we should send him out. I massaged his bladder again and he voided some more before he left. I used the bladder scan again before he left and it was showing around 500 cc's urine. He left to the ER without a Foley in. This had been going on for almost 5 hours before he was sent out. At 3:45 p.m. CNA #1 was interviewed and stated, Around 6:00 p.m. I noticed his Foley bag only had blood in it, it was about half full. I went and told (LPN #1) that the bag was full of blood. She replied, 'I know it's full of blood, it just has to drain thru before the urine comes out.' She didn't seemed concerned. After supper he said he was in a lot of pain. We went and told (LPN #1) again. She said the same thing, the blood just has to pass thru before the urine gets in the catheter. The resident kept calling us back into his room because he was in so much pain and blood kept getting on his sheets. By this time, (LPN #1) had given repot to (LPN #2). Me and the other CNA were freaking out because of all the blood, we changed his sheets 4 or 5 times, this went on almost my entire shift. We got him up to the chair, we put a brief and a sheet over him. He kept complaining about pain. He told us something's not right. So we reported to (LPN #2) that he was in a lot of pain. I told her the catheter is not working, the resident said he feels like he has to pee. (LPN #2) said, 'Ok, I'll check him in a little while' and she kept passing medication. he called me and the other CNA in to his room [ROOM NUMBER] or 3 more times before (LPN#2) responded. By this time (resident #1) started getting upset because no licensed nurse was responding to him. It was around 9 by the time (LPN #2) went in and checked on him. There was so much blood. After (LPN#2) checked on him, she kept saying she didn't know what to do. So we put him back in bed. He kept complaining of a ton of pain and the need to urinate. I just kept reporting to (LPN #2, then around 10:00 p.m., (LPN #3) came over. She used the bladder scanner, it showed around 900 cc's. She took the catheter out and tried to recath him. but only big blood clots were coming out. Blood was everywhere, he was still in a lot of pain and shaking, I thought he was going to pass out or go into shock. (LPN #3) said something's not right cause she couldn't put the catheter back in. So (LPN #3) told (LPN#2) to send him to the ER. This went on almost my entire shift, (LPN #1 and #2) would not make a decision. They both just passed it off, finally (LPN #3) made the decision to send him out." On 02/02/15, at 10:58 a.m., the ADON was asked if she was called at any time on the night of 12/22/14 concerning resident #1's pain and bleeding related to his foley catheter. She stated, "No, I did not get a call from staff, but only received a text at 11:24 p.m. that stated "Sent (resident #1) to (local hospital) Fyi." She was asked if the nurse's should have called her. She stated, "Yes, but they wouldn't call me to insert a catheter." She was asked if any training had been done with the licensed staff regarding catheter care, insertion. She stated, "No. She hadn't had time to." She stated, she had spoke to the staff about it, but had no documentation regarding the incident. She was asked if the potential still existed for problems related to Foley catheters to re-occur. She stated "Yes." The residents's physician was interviewed and stated he was not notified of the resident's condition until sometime between 10:00 p.m. and 11:00 p.m. on 12/22/14. On 02/05/15 at 10:00 p.m. the DON was in agreement staff should have notified the physician and the family immediately with any change of condition.

On 05/15/13 at 4:30 p.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to protect all residents after a resident made an allegation of a certified nurse aide (CNA #1) being abusive. The facility failed to have an effective plan in place to supervise and monitor the CNA to ensure all the residents were safe from abuse. At 4:35 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:45 p.m., the facility administrator and director of nursing (DON) were notified of the existence of an IJ pertaining to the failure to protect all residents from abuse. At 5:30 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "The facility will follow its policy on Abuse and Neglect. Specifically the suspension of an alleged perpetrator (staff), conduct an complete investigation, and provide retraining as deemed necessary prior to the alleged perpetrator returning to assigned duties. The administrator was removed as the Abuse Coordinator. The Director of Nursing was appointed Interim Abuse Coordinator. The Management Company's Director of Clinical Services and Regional Director of Operations conducted an in-service on May 15, 2013 at 5:30 p.m. on the facility Abuse Policy to all facility management team." At 5:40 p.m., the administrator and DON were informed the IJ was removed. The deficient practice remained at a level of actual harm that was not immediate jeopardy, at a pattern. On 05/17/13 at 9:35 a.m., the OSDH was called and verified the need to reinstitute the IJ due to the facility's failure to protect all residents and follow their abuse policy as documented on their plan of removal, received on 05/15/13 at 5:30 p.m. At 9:45 a.m., the DON and the regional consultant were informed the IJ was reinstituted and why. At 10:30 a.m., the plan of removal for the reinstituted IJ was received and accepted. The Plan of Removal documented the CNA (#1) was terminated from the facility. The IJ was removed effective 05/17/13 at 10:30 a.m. The deficient practice remained at a level of no actual harm with a potential for more than minimal harm, at a pattern. Based on observations, record review and interviews, it was determined the facility failed to protect all residents after one (#3) of twelve sampled residents made an allegation of a CNA (#1) being abusive. The facility failed to have an effective plan in place to supervise and monitor the CNA to ensure all the residents were safe from abuse. This had the potential to affect all 81 residents. Findings: The facility's policy, 'Abuse Prohibition Management Program-Identification, Investigation and Reporting Policy', documented, "All personnel, residents, family members, visitors, etc., are encouraged to report actual or suspected incidents of Resident Abuse or inappropriate behavior that may lead to resident abuse. Such reports may be made without fear of retaliation from the facility or its staff. The facility will provide feedback to residents and family members and others regarding concerns that have been expressed to facility staff, in a timely manner. Procedures: Identification: 1. To assist our facility's staff members, residents, families and visitors to our facility in recognizing incidents of Resident Abuse, the following definitions are provided: a. Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... b. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families... c. Sexual abuse... d. Physical abuse... e. Mental or psychological abuse includes, but not limited to, humiliation, harassment and threats of punishment or deprivation... Investigation: 3. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident... 5. The individual conducting the investigation will, at a minimum (and as appropriate): a. Review the completed Resident Abuse Report Form: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's attending physician to determine the resident's current mental status, if appropriate; g. Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members and visitors; i. Interview other residents to whom the accused employee provides care or services; j. Review all events leading up to the alleged incident; and... 26. Social Services follow-up: a. As part of the investigation, the Social Worker will conduct a "Safe Survey." The Social Worker will interview all other cognitive residents possible affected by this incident. b. this action is to evaluate their perspective or their feeling of being safe and if they are aware of how to report an incident... Protection of Residents During Abuse Investigations Policy: Our facility will protect residents from harm during investigations of abuse allegations. Procedures: 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participation in the alleged abuse will be immediately suspended until the administrator has reviewed the findings of the investigation..." Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/13/12, documented his cognition was moderately impaired. He was dependant on the staff with transfers, dressing and personal hygiene. He required extensive assistance with eating and bathing. An Incident Report Form reported to the OSDH by the administrator, dated 05/01/13, documented, "Resident alleged that a CNA fed him roughly. He stated that she 'fed me like a dog.' Reported to ADON (assistant director of nurses) that CNA informed him that his door had to be closed while he was being fed, when he did not want the door closed. Resident also reported that CNA was watching TV while feeding him. Resident does have cognitive impairment. Investigation complete. Resident interviewed confirmed CNA (name withheld) was feeding him in an angry manner making him feel as he put it, 'like a dog' CNA terminated. resident informed of investigation result. He stated he was satisfied." A typed letter by the administrator, dated 05/01/13, documented the administrator and the assistant administrator went to visit with the resident. "...He (the resident) was very pleasant and when asked about his meal, he became agitated. He stated (name withheld) made him feel like a dog when she was 'shoving' food in his mouth. He stated she was mad when she came in and wanted to watch television more than help me eat. He stated he did not want her in his room again. I apologized that this had happened and that this was not they (the) way we treat people. I informed him that (name withheld) was sent home. He stated he was glad. I also informed him that I was making a report to the State health department. He stated he did not understand why she was treating him (this) way and that she should not be helping people. I thanked him for his time and advised him I would let him know when I concluded the investigation." The CNA's (CNA #1) employee file contained A Notice of Warning form, dated 05/07/13. It documented the CNA was given a written warning for unsatisfactory performance for "...assisting feeding a resident in an angry manner Resident felt he was being treated like a 'dog'." She would return to work with education. The corrective plan of action was for her to complete training on sensitivity, resident dignity and proper feeding procedures. The file contained five certificates of completion: proper feeding procedures, making a positive difference every day, resident rights: the right thing to do, the professional CNA and resident rights, dated 05/08/13. The Employee Time Sheet Report for CNA #1, documented she worked on 05/07/13, 05/08/13, 05/11/13, 05/12/13, 05/13/13 and 05/14/13, after the incident had occurred. On 05/14/13 at 6:05 p.m., the surveyor observed CNA #1 assisting the resident with his dinner meal in his room. On 05/15/13 at 3:45 p.m., the resident's clinical record was reviewed by the surveyor. At 4:12 p.m. resident #3 was interviewed. He stated he was a little bit afraid of the CNA that had fed him angrily and that he would prefer her to not take care of him anymore. "She forces me to eat." At 4:45 p.m., the administrator was asked why CNA #1 was assisting the resident. She stated she did not know the CNA was assisting the resident. "I had no idea she was working on the other side (of the building), I had no clue." The surveyor asked the administrator why the incident report sent to the OSDH documented CNA #1 was terminated. She stated she had talked to corporate and they had encouraged her not to terminate the CNA. She stated the CNA was sent home immediately pending the investigation and was suspended for three days. The CNA was required to complete training and was only to work on the opposite side of the building from the resident's room. The surveyor asked the administrator who she assigned to monitor the CNA's work performance. She stated the Assistant Director of Nursing (ADON). The administrator was asked if other residents had been interviewed pertaining to CNA #1. She stated social services should have done a 'Safe Survey.' There was no documentation provided to show a 'Safe Survey' had been conducted during the investigation. On 05/16/13 at 2:00 p.m., the ADON was asked if she had been monitoring the CNA's work performance after her suspension. She stated she did not know the CNA had been suspended and did not know she was supposed to be monitoring her. On 05/17/13 at 8:30 a.m., a hand written letter signed by the DON, CNA #1, the administrator and the Regional Director of Operations was presented to the survey team. It documented a meeting they had together that morning at 7:00 a.m. It documented the CNA had assisted the resident because she "...was afraid just to leave his tray outside or just leave it in his room, since state was here. I didn't want to just leave his food & not assist as I didn't want to get into trouble for that..." The letter documented the CNA was re-educated that when she had been informed she was unable to work with a specific resident then she would not be able to do so for absolutely any reason. "Also explained that when we spoke with resident upon completion of that investigation that he was informed that you would not be working with him ever again and that is what he agreed to." The documentation did not contain who would monitor the CNA's work performance to ensure the safety of other residents. There was no documentation other residents had been interviewed concerning the performance of CNA #1.

On 05/15/13 at 4:30 p.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to fully investigate an allegation of abuse reported by a resident in regard to certified nurse aide (CNA #1), and the failure to take appropriate actions to protect all residents. At 4:35 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:45 p.m., the facility administrator and director of nursing (DON) were notified of the existence of an IJ pertaining to the failure to fully investigate and protect all residents from abuse. At 5:30 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "The facility will follow its policy on Abuse and Neglect. Specifically the suspension of an alleged perpetrator (staff), conduct an complete investigation, and provide retraining as deemed necessary prior to the alleged perpetrator returning to assigned duties. The administrator was removed as the Abuse Coordinator. The Director of Nursing was appointed Interim Abuse Coordinator. The Management Company's Director of Clinical Services and Regional Director of Operations conducted an in-service on May 15, 2013 at 5:30 p.m. on the facility Abuse Policy to all facility management team." At 5:40 p.m., the administrator and DON were informed the IJ was removed. The deficient practice remained at a level of actual harm that was not immediate jeopardy, at a pattern. On 05/17/13 at 9:35 a.m., the OSDH was called and verified the need to reinstitute the IJ due to the facility's failure to protect all residents and follow their abuse policy as documented on their plan of removal, received on 05/15/13 at 5:30 p.m. At 9:45 a.m., the DON and the regional consultant were informed the IJ was reinstituted and why. At 10:30 a.m., the plan of removal for the reinstituted IJ was received and accepted. The Plan of Removal documented the CNA (#1) was terminated from the facility. The IJ was removed effective 05/17/13 at 10:30 a.m. The deficient practice remained at a level of no actual harm with a potential for more than minimal harm, at a pattern. Based on observations, record review and interviews, it was determined the facility failed to fully investigate an allegation of abuse reported by one (#3) of twelve sampled residents in regard to CNA (#1), and take appropriate actions to protect all residents. This had the potential to affect all 81 residents. Findings: The facility's policy, 'Abuse Prohibition Management Program-Identification, Investigation and Reporting Policy', documented, "All personnel, residents, family members, visitors, etc., are encouraged to report actual or suspected incidents of Resident Abuse or inappropriate behavior that may lead to resident abuse. Such reports may be made without fear of retaliation from the facility or its staff. The facility will provide feedback to residents and family members and others regarding concerns that have been expressed to facility staff, in a timely manner. Procedures: Identification: 1. To assist our facility's staff members, residents, families and visitors to our facility in recognizing incidents of Resident Abuse, the following definitions are provided: a. Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... b. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families... c. Sexual abuse... d. Physical abuse... e. Mental or psychological abuse includes, but not limited to, humiliation, harassment and threats of punishment or deprivation... Investigation: 3. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident... 5. The individual conducting the investigation will, at a minimum (and as appropriate): a. Review the completed Resident Abuse Report Form: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's attending physician to determine the resident's current mental status, if appropriate; g. Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members and visitors; i. Interview other residents to whom the accused employee provides care or services; j. Review all events leading up to the alleged incident; and... 26. Social Services follow-up: a. As part of the investigation, the Social Worker will conduct a "Safe Survey." The Social Worker will interview all other cognitive residents possible affected by this incident. b. this action is to evaluate their perspective or their feeling of being safe and if they are aware of how to report an incident... Protection of Residents During Abuse Investigations Policy: Our facility will protect residents from harm during investigations of abuse allegations. Procedures: 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participation in the alleged abuse will be immediately suspended until the administrator has reviewed the findings of the investigation..." Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/13/12, documented his cognition was moderately impaired. He was dependant on the staff with transfers, dressing and personal hygiene. He required extensive assistance with eating and bathing. An Incident Report Form reported to the OSDH by the administrator, dated 05/01/13, documented, "Resident alleged that a CNA fed him roughly. He stated that she 'fed me like a dog.' Reported to ADON (assistant director of nurses) that CNA informed him that his door had to be closed while he was being fed, when he did not want the door closed. Resident also reported that CNA was watching TV while feeding him. Resident does have cognitive impairment. Investigation complete. Resident interviewed confirmed CNA (name withheld) was feeding him in an angry manner making him feel as he put it, 'like a dog' CNA terminated. resident informed of investigation result. He stated he was satisfied." A typed letter by the administrator, dated 05/01/13, documented the administrator and the assistant administrator went to visit with the resident. "...He (the resident) was very pleasant and when asked about his meal, he became agitated. He stated (name withheld) made him feel like a dog when she was 'shoving' food in his mouth. He stated she was mad when she came in and wanted to watch television more than help me eat. He stated he did not want her in his room again. I apologized that this had happened and that this was not they (the) way we treat people. I informed him that (name withheld) was sent home. He stated he was glad. I also informed him that I was making a report to the State health department. He stated he did not understand why she was treating him (this) way and that she should not be helping people. I thanked him for his time and advised him I would let him know when I concluded the investigation." The CNA's (CNA #1) employee file contained A Notice of Warning form, dated 05/07/13. It documented the CNA was given a written warning for unsatisfactory performance for "...assisting feeding a resident in an angry manner Resident felt he was being treated like a 'dog'." She would return to work with education. The corrective plan of action was for her to complete training on sensitivity, resident dignity and proper feeding procedures. The file contained five certificates of completion: proper feeding procedures, making a positive difference every day, resident rights: the right thing to do, the professional CNA and resident rights, dated 05/08/13. The Employee Time Sheet Report for CNA #1, documented she worked on 05/07/13, 05/08/13, 05/11/13, 05/12/13, 05/13/13 and 05/14/13, after the incident had occurred. On 05/14/13 at 6:05 p.m., the surveyor observed CNA #1 assisting the resident with his dinner meal in his room. On 05/15/13 at 3:45 p.m., the resident's clinical record was reviewed by the surveyor. At 4:12 p.m. resident #3 was interviewed. He stated he was a little bit afraid of the CNA that had fed him angrily and that he would prefer her to not take care of him anymore. "She forces me to eat." At 4:45 p.m., the administrator was asked why CNA #1 was assisting the resident. She stated she did not know the CNA was assisting the resident. "I had no idea she was working on the other side (of the building), I had no clue." The surveyor asked the administrator why the incident report sent to the OSDH documented CNA #1 was terminated. She stated she had talked to corporate and they had encouraged her not to terminate the CNA. She stated the CNA was sent home immediately pending the investigation and was suspended for three days. The CNA was required to complete training and was only to work on the opposite side of the building from the resident's room. The surveyor asked the administrator who she assigned to monitor the CNA's work performance. She stated the Assistant Director of Nursing (ADON). The administrator was asked if other residents had been interviewed pertaining to CNA #1. She stated social services should have done a 'Safe Survey.' There was no documentation provided to show a 'Safe Survey' had been conducted during the investigation. On 05/16/13 at 2:00 p.m., the ADON was asked if she had been monitoring the CNA's work performance after her suspension. She stated she did not know the CNA had been suspended and did not know she was supposed to be monitoring her. On 05/17/13 at 8:30 a.m., a hand written letter signed by the DON, CNA #1, the administrator and the Regional Director of Operations was presented to the survey team. It documented a meeting they had together that morning at 7:00 a.m. It documented the CNA had assisted the resident because she "...was afraid just to leave his tray outside or just leave it in his room, since state was here. I didn't want to just leave his food & not assist as I didn't want to get into trouble for that..." The letter documented the CNA was re-educated that when she had been informed she was unable to work with a specific resident then she would not be able to do so for absolutely any reason. "Also explained that when we spoke with resident upon completion of that investigation that he was informed that you would not be working with him ever again and that is what he agreed to." The documentation did not contain who would monitor the CNA's work performance to ensure the safety of other residents. The facility's abuse policy was not followed in regard to all of the interviews that should have been conducted as the policy directed. The only interviews conducted were with the resident, CNA #1 and two other residents. Also, the abuse policy was not followed in regard to Social Services not conducting a 'Safe Survey.'

On 05/15/13 at 4:30 p.m., an immediate jeopardy (IJ) situation was identified related to the failure of the facility to follow their abuse policy after a resident made an allegation of a certified nurse aide (CNA #1) being abusive. At 4:35 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:45 p.m., the facility administrator and director of nursing (DON) were notified of the existence of an IJ pertaining to the failure to protect all residents from abuse. At 5:30 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "The facility will follow its policy on Abuse and Neglect. Specifically the suspension of an alleged perpetrator (staff), conduct an complete investigation, and provide retraining as deemed necessary prior to the alleged perpetrator returning to assigned duties. The administrator was removed as the Abuse Coordinator. The Director of Nursing was appointed Interim Abuse Coordinator. The Management Company's Director of Clinical Services and Regional Director of Operations conducted an in-service on May 15, 2013 at 5:30 p.m. on the facility Abuse Policy to all facility management team." At 5:40 p.m., the administrator and DON were informed the IJ was removed. The deficient practice remained at a level of actual harm that was not immediate jeopardy, at a pattern. On 05/17/13 at 9:35 a.m., the OSDH was called and verified the need to reinstitute the IJ due to the facility's failure to protect all residents and follow their abuse policy as documented on their plan of removal, received on 05/15/13 at 5:30 p.m. At 9:45 a.m., the DON and the regional consultant were informed the IJ was reinstituted and why. At 10:30 a.m., the plan of removal for the reinstituted IJ was received and accepted. The Plan of Removal documented the CNA (#1) was terminated from the facility. The IJ was removed effective 05/17/13 at 10:30 a.m. The deficient practice remained at a level of no actual harm with a potential for more than minimal harm, at a pattern. Based on observations, record review and interviews, it was determined the facility failed to follow their abuse policy after one (#3) of twelve sampled residents made an allegation of a CNA (#1) being abusive. This had the potential to affect all 81 residents. Findings: The facility's policy, 'Abuse Prohibition Management Program-Identification, Investigation and Reporting Policy', documented, "All personnel, residents, family members, visitors, etc., are encouraged to report actual or suspected incidents of Resident Abuse or inappropriate behavior that may lead to resident abuse. Such reports may be made without fear of retaliation from the facility or its staff. The facility will provide feedback to residents and family members and others regarding concerns that have been expressed to facility staff, in a timely manner. Procedures: Identification: 1. To assist our facility's staff members, residents, families and visitors to our facility in recognizing incidents of Resident Abuse, the following definitions are provided: a. Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... b. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families... c. Sexual abuse... d. Physical abuse... e. Mental or psychological abuse includes, but not limited to, humiliation, harassment and threats of punishment or deprivation... Investigation: 3. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident... 5. The individual conducting the investigation will, at a minimum (and as appropriate): a. Review the completed Resident Abuse Report Form: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's attending physician to determine the resident's current mental status, if appropriate; g. Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members and visitors; i. Interview other residents to whom the accused employee provides care or services; j. Review all events leading up to the alleged incident; and... 26. Social Services follow-up: a. As part of the investigation, the Social Worker will conduct a "Safe Survey." The Social Worker will interview all other cognitive residents possible affected by this incident. b. this action is to evaluate their perspective or their feeling of being safe and if they are aware of how to report an incident... Protection of Residents During Abuse Investigations Policy: Our facility will protect residents from harm during investigations of abuse allegations. Procedures: 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participation in the alleged abuse will be immediately suspended until the administrator has reviewed the findings of the investigation..." Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/13/12, documented his cognition was moderately impaired. He was dependant on the staff with transfers, dressing and personal hygiene. He required extensive assistance with eating and bathing. An Incident Report Form reported to OSDH by the administrator, dated 05/01/13, documented, "Resident alleged that a CNA fed him roughly. He stated that she 'fed me like a dog.' Reported to ADON (assistant director of nurses) that CNA informed him that his door had to be closed while he was being fed, when he did not want the door closed. Resident also reported that CNA was watching TV while feeding him. Resident does have cognitive impairment. Investigation complete. Resident interviewed confirmed CNA (name withheld) was feeding him in an angry manner making him feel as he put it, 'like a dog' CNA terminated. resident informed of investigation result. He stated he was satisfied." A typed letter by the administrator, dated 05/01/13, documented the administrator and the assistant administrator went to visit with the resident. "...He (the resident) was very pleasant and when asked about his meal, he became agitated. He stated (name withheld) made him feel like a dog when she was 'shoving' food in his mouth. He stated she was mad when she came in and wanted to watch television more than help me eat. He stated he did not want her in his room again. I apologized that this had happened and that this was not they (the) way we treat people. I informed him that (name withheld) was sent home. He stated he was glad. I also informed him that I was making a report to the State health department. He stated he did not understand why she was treating him (this) way and that she should not be helping people. I thanked him for his time and advised him I would let him know when I concluded the investigation." The CNA's (CNA #1) employee file contained A Notice of Warning form, dated 05/07/13. It documented the CNA was given a written warning for unsatisfactory performance for "...assisting feeding a resident in an angry manner Resident felt he was being treated like a 'dog'." She would return to work with education. The corrective plan of action was for her to complete training on sensitivity, resident dignity and proper feeding procedures. The file contained five certificates of completion: proper feeding procedures, making a positive difference every day, resident rights: the right thing to do, the professional CNA and resident rights, dated 05/08/13. The Employee Time Sheet Report for CNA #1, documented she worked on 05/07/13, 05/08/13, 05/11/13, 05/12/13, 05/13/13 and 05/14/13, after the incident had occurred. On 05/14/13 at 6:05 p.m., the surveyor observed CNA #1 assisting the resident with his dinner meal in his room. On 05/15/13 at 3:45 p.m., the resident's clinical record was reviewed by the surveyor. At 4:12 p.m. resident #3 was interviewed. He stated he was a little bit afraid of the CNA that had fed him angrily and that he would prefer her to not take care of him anymore. "She forces me to eat." At 4:45 p.m., the administrator was asked why CNA #1 was assisting the resident. She stated she did not know the CNA was assisting the resident. "I had no idea she was working on the other side (of the building), I had no clue." The surveyor asked the administrator why the incident report sent to the OSDH documented CNA #1 was terminated. She stated she had talked to corporate and they had encouraged her not to terminate the CNA. She stated the CNA was sent home immediately pending the investigation and was suspended for three days. The CNA was required to complete training and was only to work on the opposite side of the building from the resident's room. The surveyor asked the administrator who she assigned to monitor the CNA's work performance. She stated the Assistant Director of Nursing (ADON). The administrator was asked if other residents had been interviewed pertaining to CNA #1. She stated social services should have done a 'Safe Survey.' There was no documentation provided to show a 'Safe Survey' had been conducted during the investigation. On 05/16/13 at 2:00 p.m., the ADON was asked if she had been monitoring the CNA's work performance after her suspension. She stated she did not know the CNA had been suspended and did not know she was supposed to be monitoring her. On 05/17/13 at 8:30 a.m., a hand written letter signed by the DON, CNA #1, the administrator and the Regional Director of Operations was presented to the survey team. It documented a meeting they had together that morning at 7:00 a.m. It documented the CNA had assisted the resident because she "...was afraid just to leave his tray outside or just leave it in his room, since state was here. I didn't want to just leave his food & not assist as I didn't want to get into trouble for that..." The letter documented the CNA was re-educated that when she had been informed she was unable to work with a specific resident then she would not be able to do so for absolutely any reason. "Also explained that when we spoke with resident upon completion of that investigation that he was informed that you would not be working with him ever again and that is what he agreed to." The documentation did not contain who would monitor the CNA's work performance to ensure the safety of other residents. The facility's abuse policy was not followed in regard to all of the interviews that should have been conducted as the policy directed. The only interviews conducted were with the resident, CNA #1 and two other residents. Also, the abuse policy was not followed in regard to Social Services not conducting a 'Safe Survey.'

On [DATE] at 9:40 a.m., an Immediate Jeopardy (IJ) situation was identified related to the facility's failure to provide immediate cardiopulmonary resuscitation (CPR) to a resident who had requested to be a full code status. At 9:50 a.m., the existence of the IJ situation was verified with the Oklahoma State Department of Health. At 9:55 a.m., the administrator was notified of the existence of an IJ situation pertaining to the failure to provide CPR to an unresponsive resident with a full code status. At 1:55 p.m., the Plan of Removal was received and accepted. The Plan of Removal documented: "1. [DATE]. A record review was completed on all residents. Appropriate identification was on 100% of reviewed records - green colored sheet for FULL CODE, red colored for sheet for DNR (do not resuscitate). 2. [DATE]. 100% chart audit was completed on [DATE] to ensure appropriate physician orders [REDACTED]. 3. [DATE], (2013), 11:30 am. All Direct Care currently on duty ,[DATE] shift on have been educated on the RED-GREEN identification system. No later than 11:00pm, [DATE], unless not available, all Direct Care Staff not currently on duty will be educated prior to accepting their assignment a. RED Sleeve contains the OOHDNR (out of hospital do not resuscitate) that will indicate to all staff resident is a DNR. b. GREEN Sleeve contains the advanced directive acknowledgement that the resident wishes to be a FULL CODE. c. Both are located in the front on the medical record. 4. [DATE]. All new Admissions will be reviewed within 24 hours to ensure code status has been addressed and medical record identified appropriately. 5. Licensed Staff will be retrained when their CPR certification has expired with a current CPR card on file. 6. [DATE]. An Off cycle QA (quality assurance) was held regarding the concerns identified and plans to address and correct identified issues. Medical Director was in attendance via telephone. 7. [DATE]. An update to the Facility's Code Status Identifying System Policy occurred to include: A. a RED dot identifier on the resident's name plaque if the resident has elected a DNR code status (12:44 pm); B. if a Certified Nursing Assistant, Certified Medication Aide, or Licensed Nurse discovers a resident with no pulse and no respiration who does NOT have a RED DOT identifier on their name plaque, Assistance will be called for, and CPR initiated at that time. 8. [DATE]; 1:00 pm. All nursing staff currently on duty ,[DATE] shift has been inserviced by the DON (director of nursing) and / or Designee on the modification to the code status identifying system. 9. [DATE]; 11:00 pm. Any nursing staff employee currently not on duty will be educated to the modification prior to accepting their assignment until all nursing staff is inserviced." On [DATE] at 12:45 p.m., the surveyor asked the administrator for all documentation the facility had to confirm the Plan of Removal had been completed. At 2:33 p.m., the surveyor asked certified nurse aide (CNA) #1 which staff members could initiate CPR when a resident was found unresponsive. She stated the "head nurse" initiated CPR. This response indicated she had either not been inserviced regarding the facility's DNR/CPR policy/procedure changes and/or she did not understand the new policy/procedure. At 2:37 p.m., the surveyor asked licensed practical nurse #1 which staff members could initiate CPR when a resident was found unresponsive. She stated the "head nurse" initiated CPR. This response indicated she had either not been inserviced regarding the facility's DNR/CPR policy/procedure changes and/or she did not understand the new policy/procedure. At 3:10 p.m., the administrator was informed the IJ situation remained due to the facility's failure to ensure staff were aware of the facility's DNR/CPR policy/procedure changes. On [DATE] at 8:30 a.m., surveyors returned to the facility and asked for any information/documentation pertaining to the IJ Plan of Removal. The surveyors verified all the steps of the facility's Plan of Removal, as well as the directed Plan of Removal from the Center for Medicare/Medicaid Services (CMS) in Dallas, Texas, had been completed. Inservices and the facility's new policy/procedure for DNR/full code status identification and initiation of CPR were reviewed. Clinical records and residents' name plaques were checked against the facility's list of residents who had DNR status. Interviews were conducted with 21 staff to verify they had attended and understood the content of the inservice. The surveyor confirmed, per CMS direction, the facility had retained the services of a physician who was not associated with the facility to conduct mandatory inservices on the current standards of practice pertaining to CPR and DNR situations. The physician conducted the inservices for the staff on [DATE]. During a review of the chart of resident #40, an empty green sleeve was found in the front of his chart. The facility had identified the resident to be a full code. Documentation in the clinical record and a telephone interview with the resident's wife/power of attorney (POA) revealed the resident wanted to have a DNR status. The facility confirmed the error and corrected it. This delayed the removal of the IJ until the resident's code status had been corrected and the chart and the resident's name plaque had been properly labeled according to the facility's new policy/procedure. On [DATE] at 11:32 a.m., the surveyor notified the administrator and the director of nurses (DON) the IJ was removed as of [DATE] at 1:30 p.m. They were informed a partial extended survey had been initiated. The deficient practice remained at a level of actual harm, isolated. * * * * * * * * * * * * * * * * * * * * * * * * On [DATE] at 1:40 p.m., an IJ situation was identified regarding the facility's failure to assess and manage a resident's [MEDICAL TREATMENT] catheter, which resulted in an infection and an abscess for which the resident had to be hospitalized . At 1:50 p.m., the existence of an IJ was verified with the OSDH. The IJ situation began on the date of the resident's admission to the facility, [DATE], and remained in existence through [DATE], when the resident was admitted to the hospital with [REDACTED]. a. obtain physician's orders [REDACTED]. b. obtain physician's orders [REDACTED]. c. ensure a follow-up appointment was made with a physician in one week's time from admission, per the hospital discharge instructions, to determine the resident's continuing need for the [MEDICAL TREATMENT] catheter. The IJ situation was verified to be ongoing [DATE], when the facility's noncompliance in regard to the care/management of the resident's [MEDICAL TREATMENT] catheter was discovered by the surveyor. The IJ remained in effect until [DATE] at 3 p.m. At 1:55 p.m., the administrator and the DON were notified of the existence of the IJ. At 3:45 p.m., a plan of removal for the IJ was received and accepted. The facility's Plan of Removal documented: "PROCESS: All residents will be assessed upon admission for any Perma-A-Cath ([MEDICAL TREATMENT] catheter). IF RECEIVING [MEDICAL TREATMENT]: If present, the dressing will remain in place, until admission orders [REDACTED]. The staff will be educated to this fact. The nurses will be instructed to not change the dressing unless orders are provided by [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] Center will manage the dressing the majority of the time. However, ...if the resident is not receiving [MEDICAL TREATMENT], an immediate plan will be requested from the physician for discontinuation of Perm-a-Cath. IF NO ORDER FOR [MEDICAL TREATMENT]: If the resident is not receiving [MEDICAL TREATMENT], an immediate plan regarding the removal of the Perm-a-Cath will be requested from the physician. If the site care of the Perm-A-Cath is to be the responsibility of the skilled nursing facility and until the Perm-A-Cath is removed, findings will be documented in the chart to include: insertion site and skin surrounding Port-A-Cath site for signs and symptoms of infection, (i.e., redness, swelling). The specific orders for the Port-a-Cath will be transcribed onto the resident's Treatment Administration Record (TAR). Site will be checked at least daily with dressing change and assessment of insertion site and surrounding area or will state DO NOT REMOVE if [MEDICAL TREATMENT] Center is managing. QAPI (Quality Assurance Performance Improvement)/Oversight: A communication form will be forwarded to the wound care nurse for assessment of the dressing or site (according to orders) the next business day. The site will then be monitored by the wound care nurse or designee on a daily basis. All physician order [REDACTED]. Infection Control report to include incident of infection in Port-A-Cath sites will be track, trended and reported on a monthly basis to the QAPI Committee. EDUCATION: Licensed nursing staff will be re-educated on [DATE] by midnight on: (attempts to have all current licensed nurses attend inservices by this time. If such events occur that prevent their attendance, detailed summary of attempts and reasons for absence will be documented.) 1. Perm-A-Cath device insertion, use and functionality of Perm-a-Cath. 2. Adverse reactions as a result of Perm-A-Cath, i.e., infection [MEDICAL CONDITION]. 3. The facility Policy and Procedure on the care, assessment, and treatment of [REDACTED]. Daily documentation requirements for Perm-A-Cath to include signs and symptoms of infection." On [DATE] at 8:35 a.m., at 8:40 a.m., the Vice President for Clinical Operations presented the surveyors with a binder containing signed sheets by licensed staff and education material relating to [MEDICAL TREATMENT] catheter care. She stated that all but three currently employed licensed nurses were inserviced as of midnight on [DATE]. Two of these nurses were on medical leave and the other nurse was inserviced upon arrival for her shift on Sunday [DATE]. Documentation of the inservices was presented. Eight licensed nurses were interviewed to verify the inservices had taken place and that they understood the information presented. On [DATE] at 1:10 p.m., the regional nurse consultant stated he had inserviced the last nurse on [DATE] at 3:00 p.m. On [DATE] at 3:05 p.m., the administrator and DON were informed the IJ was removed as of [DATE] at 3:00 p.m. The deficient practice remained at a pattern level of actual harm. Based on record review and interview, it was determined the facility failed to ensure: 1. a. CPR was immediately initiated for residents who were found unresponsive and with no pulse/respirations. This affected 1 (#3) of 1 sampled residents who were found unresponsive and with no pulse/respirations and was a full code status. This had the potential to affect 54 residents in the facility who were a full code status; the facility had provided a list of 31 residents who had a DNR status. b. a system was in place to ensure CPR was initiated without delay for residents who were a full code status. The facility's policy was that only licensed staff could initiate CPR. Also, there was no way to identify a residents code status in a timely manner. The staff had to retrieve the resident's chart in order to verify the code status. This had the potential to delay the initiation of CPR by several minutes. Eighty-five residents resided in the facility. These deficient practices resulted in an IJ situation. 2. a [MEDICAL TREATMENT] catheter was assessed and managed for one (#27) of two sampled residents who had a [MEDICAL TREATMENT] catheter. The facility's failure to assess and manage the [MEDICAL TREATMENT] catheter for 24 days following admission resulted in an abscess,[MEDICAL CONDITION] and an 8-day hospitalization . The facility identified no additional residents with a [MEDICAL TREATMENT] catheter. This deficient practice resulted in an IJ situation. 3. the code status of 1 (#40) of 26 sampled residents who currently resided in the facility was correct. The facility had not discussed the resident's code status with him and/or his wife/POA and documented he was to be a full code. The resident wished to be a DNR. Seventy-eight residents resided in the facility. 4. wound treatments were performed for 1 (#41) of 5 sampled residents whose clinical records were reviewed for the provision of wound care. The Resident Census and Conditions of Residents documented 7 residents had a pressure ulcer. Findings: 1. Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment, dated [DATE], documented the resident had moderate cognitive impairment; required extensive assistance with transfers, dressing, hygiene and bathing; required supervision with eating; and was always incontinent of bowel and bladder. The "Acknowledgement of Oklahoma Advance Directive Forms," dated [DATE], which was located in a clear green sleeve in the front of the resident's clinical record, documented the resident did not initially have a DNR consent. The form documented, at some point in time, the resident did have a DNR consent. The form documented the resident's DNR consent had been "revoked [DATE]." The care plan, dated [DATE], and most recently reviewed on [DATE], documented the resident/power of attorney "has chosen code status to be DNR." The goal was "staff will adhere to residents and resident family request for DNR and selected level status." An intervention was to "establish DNR status." A social service progress note, dated [DATE], documented: "MSW (Master's in social work) visited (with) resident about code status after she informed BSW(bachelor's in social work) that she wished to be a full code. Resident confirmed that she does wish to have CPR if she stops breathing and her heart stops. She informed MSW that she has considered this for ,[DATE] weeks. MSW informed resident that her son signed her DNR before she was admitted to facility. She relays that at the time her children thought that she was going to die. She relays that things are different now and she wants staff to try. MSW informed resident of the risks while performing CPR and possibly the need for a (ventilator) following CPR. She relays that she understands this, but she is positive that she wants staff to perform CPR if need arises. MSW contacted resident son to inform him that the DNR would be revoked. Residents son relayed that he signed the DNR because his mother had completed an Advance Directive stating that she wanted no life sustaining treatment. MSW educated (resident's) son about the difference between DNR & Advance Directive..." A nurse's note, dated [DATE] at 2:30 p.m., documented: "Resident was found to be unresponsive (with no) pulse at (2:20 p.m.) by (name withheld, certified nurse aide and name withheld, licensed practical nurse (LPN) #3). 911 notified. DNR form found. Son notified. Physician on call, (name withheld) notified..." The record of death documented the resident had expired on [DATE] at 2:25 p.m. The record of death documented the physician had been notified on [DATE] at 2:45 p.m. Remarks were: "Aid notified this nurse that resident's lips were blue and she was unresponsive. Pulse was checked. Resident found to be unresponsive (with no) pulse." On [DATE] at 3:05 p.m., the surveyor asked the social services director how staff knew whether a resident was a DNR or a full code. She stated residents who had a DNR had "papers" in red sheet protectors and residents who were to be coded had "papers" in green sheet protectors. She stated the red or green sheet protectors were in the front of the residents' clinical records. On [DATE] at 3:25 p.m., the surveyor asked LPN #3 how she knew if a resident had a DNR or was a full code. She stated she knew when a resident had a DNR, papers were in a red sleeve and when a resident was a full code, papers were in a green sleeve. On [DATE] at 3:57 p.m., the surveyor showed resident #3's care plan, the social services note, dated [DATE], and the "Acknowledgement of Oklahoma Advance Directive Forms," dated [DATE], to minimum data set (MDS) coordinator #1. The surveyor asked if the care plan had been revised to reflect the resident's full code status. She stated, "No." On [DATE] at 12:55 a.m., the surveyor asked LPN #4 if she was aware of the red/green sheet protectors in the front of the clinical record to designate a resident's code status. She stated she was not aware of that system. The surveyor asked who determined a resident's code status if the resident was found unresponsive. She stated, "I have an aide look at the chart or bring it to me in the room." The surveyor asked at what point CPR would be started. The LPN stated, "If they are full code, immediately." The surveyor asked how long it took to get a chart to look for the resident's code status. She stated, "It shouldn't take very long." On [DATE] at 1:30 a.m., the surveyor asked CNA #2 what the facility's policy was if a resident was found unresponsive. She stated she would "yell for help" or use her head piece to summon help. The surveyor asked how she knew if a resident was a DNR. She stated the residents wore a wrist band which tells if they were a DNR. The surveyor asked if she knew where the DNR information was in a resident's clinical record. She stated, "No, I don't." On [DATE] at 1:32 a.m., the surveyor asked CNA #3 what the facility's policy was if a resident was found unresponsive. She stated she would check for vital signs and "holler" for help. She stated if the resident was unresponsive, she would start CPR. The surveyor asked how she knew if a resident was a DNR. She stated, "I don't know because we don't have it posted anywhere. It's not posted in rooms like some facilities have." The CNA stated she worked different halls and did not know the residents' DNR status. The surveyor asked if she knew where to find a resident's DNR status. She stated, "I could look in the chart, but I really don't know where in the chart." On [DATE] at 1:38 a.m., the surveyor asked LPN #5 what the facility's policy was if a resident was found unresponsive. She stated she would "check for a DNR and proceed from there." The surveyor asked when CPR would be initiated. She stated CPR would be initiated immediately and a staff would be sent for the chart. She stated she preferred to get the chart herself "because CNAs aren't supposed to get in the charts." On [DATE] at 1:55 a.m., the surveyor asked CNA #4 if she knew the color coding system in the chart to determine if a resident is a DNR or a full code. She stated, "I think there is supposed to be, but I'm not sure what it is." On [DATE] at 8:50 a.m., the surveyor asked LPN #3, if at the time the resident was found, she believed the resident was a DNR. She stated, "I don't usually work that hall and I didn't know." The surveyor asked why she originally called 911. She stated, "That was my first response before I even thought about it." The surveyor asked which DNR form she was referring to in the nurse's note. She found the "Acknowledgement of Oklahoma Advance Directive Forms," dated [DATE], which was in a clear green sleeve in the closed clinical record, and stated she believed resident was a DNR. As she looked at the form, the LPN stated the form was confusing because the resident's DNR status had changed 2 times since it was initially completed. The surveyor asked if the resident's DNR status was clear by what was written on the form. She stated, "No." The surveyor showed the resident's "Acknowledgement of Oklahoma Advance Directive Forms," dated [DATE], which was in a green sheet protector in the front of the chart, to LPN #3 and asked if she was aware of the red/green color coding system. She stated she was not aware of the system at the time resident #3 was found unresponsive, but had learned since then. On [DATE] at 9:35 a.m., the surveyor informed the director of nurses (DON) that interviews with nursing staff revealed the staff did not know which residents were DNRs and which were to have a full code. The surveyor asked if the facility had conducted any inservices since resident #3's death to educate staff about that protocol. She stated, "No, ma'am, we have not." The surveyor reported that LPN #3 did not know about the red/green system on [DATE] and that LPN #3 had acknowledged the "Acknowledgement of Oklahoma Advance Directive Forms," dated [DATE], was confusing. The surveyor asked the DON if the facility's procedure had changed since [DATE]. She stated, "No." On [DATE] at 9:57 a.m., when the administrator was informed of the IJ situation, she stated QA had been initiated on [DATE]. The surveyor asked if the facility's QA committee had identified the problem with the DNR/full code policy/procedure prior to the surveyor bringing it to their attention on [DATE]. She stated, "No." On [DATE] at 10:05 a.m., the administrator reported to the surveyor that all LPNs had been inserviced. The surveyor asked if the CNAs had been inserviced. The administrator stated CNAs had not been inserviced. She stated CNAs did not have access to the charts. On [DATE] at 10:37 a.m., the surveyor asked the administrator if staff had any way to identify residents with a DNR from the resident's room. She stated, "We don't use the dot system. CNAs do not initiate CPR, the charge nurses do." On [DATE] at 11:15 a.m., the surveyor asked the administrator if it was possible that it may take ,[DATE] minutes to find an LPN and for that LPN to get to a resident's room to begin CPR. The administrator did not respond. The surveyor asked if the initiation of CPR could be delayed that long, when seconds count, while an LPN was being located. The administrator did not respond. 2. Resident #27 was admitted with [DIAGNOSES REDACTED]. A discharge summary, dated [DATE], from a local hospital, documented the resident received [MEDICAL TREATMENT] three times a week during his hospital stay and his renal function slowly improved. His renal function was felt to be stable. He was being transferred to the facility for ongoing physical and occupational therapy. The discharge summary documented the resident's "[MEDICAL TREATMENT] catheter" would be left in place, but he was to be seen in a follow-up appointment with a physician in one week's time to evaluate for possible further need for [MEDICAL TREATMENT]. The facility's admission nurse's note, dated [DATE] at 1:10 p.m., documented the resident had a "...med port to R (right) chest wall. Drsg (dressing) intact, will mont (monitor)..." There was no documentation to indicate the facility had assessed the resident for the type of device and/or the appearance/condition of the skin around the site. A Resident-Data Collection sheet, dated [DATE] at 1:10 p.m., documented the resident had a right chest dressing. There was no documentation to indicate the facility had assessed the resident for the type of device and/or the appearance/condition of the skin around the site. The care plan, dated [DATE], documented the resident had the need of a "[MEDICAL TREATMENT] shunt." The goal for 90 days was for the shunt to have no signs of problems. The site was to be monitored to ensure there was a brute and thrill noted. The care plan did not address the resident's [MEDICAL TREATMENT] catheter. The resident's admission assessment, dated [DATE], documented he was cognitively intact. He required extensive assistance from the staff with transfers, dressing, eating, personal hygiene and bathing. He was always continent of bowel and had a urinary catheter. The physician's admission orders [REDACTED]. There was no physician's telephone order which documented the care/management to be provided for the [MEDICAL TREATMENT] catheter from the resident's admission to the facility on [DATE] until his discharge to the hospital on [DATE]. Nurses' notes had entries for the resident on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The [MEDICAL TREATMENT] catheter and/or the dressing over the [MEDICAL TREATMENT] was not mentioned except in the admission note on [DATE] and on [DATE]. A nurse's note, dated [DATE] (no time), documented the "resident up for a.m. care to the shower room-res (resident's) port (word unreadable) had been previously placed (secondary) to his possible need for [MEDICAL TREATMENT] had fallen out. res (resident) alert (and) ort (oriented) x3 said he did not feel it come out-area has 0 (zero) redness or swelling noted did have some scant amount of purulent drainage @ site. Dr made aware n.o.(new order) for a.m. labs and will f-u (follow-up) @ (word unreadable)...port was intact when found on res (resident's) (word unreadable) after his a.m. care. A nurse's note, dated [DATE] at 9:50 a.m., documented the resident complained of pain to his right arm and his inability to lift his arm as normal to raise his spoon to eat. He complained of chills. He had a temperature of 104.8 axillary. The physician was notified and the resident was sent to a local hospital were he was admitted . A history and physical, dated [DATE], from the hospital admission, documented the resident was admitted with fever and [MEDICAL CONDITION]. An operative report, dated [DATE], from a local hospital, documented the resident's pre-operative and postoperative [DIAGNOSES REDACTED]." It documented the procedure was: "Incision, drainage and debridement, width of wound is 15 cm (centimeters), length 2.5 cm, depth 2 cm." The report documented the resident "came in with fever, chills, and multiple decubiti all over the body including this pus-filled tract from where the catheter was removed with drainage just pushing, culturing, [MEDICAL CONDITION] out of it." The report documented the abscess was "debrided of all the necrotic tissue that was within the crater..." The resident was discharged from the hospital and returned to the facility on [DATE]. On [DATE] at 10:40 a.m., the surveyor asked the DON if, prior to resident #27's admission to the facility or while he was a resident, any licensed staff was inserviced regarding the management of a [MEDICAL TREATMENT] catheter. She stated, "No, it had not been done house wide." The surveyor asked if licensed staff were skilled in [MEDICAL TREATMENT] catheter care. She stated there was no documentation to prove that. The surveyor asked if there is documentation in the clinical record to indicate resident #27's [MEDICAL TREATMENT] catheter was managed and/or the dressing had been changed during his stay from [DATE] - [DATE]. She stated there is no documentation to indicate the [MEDICAL TREATMENT] catheter had been managed or that the dressing had been changed. The surveyor asked the DON if the facility obtained a physician's orders [REDACTED]. She stated, "No." The surveyor asked if there was any reference to the chest dressing over the [MEDICAL TREATMENT] catheter other than on the resident-data collection sheet, dated [DATE], and in the nurses' notes dated [DATE] and [DATE]. She stated she could not find anything. The surveyor asked if the facility had any central venous catheter dressing change kits required to change a [MEDICAL TREATMENT] catheter dressing. She stated there were no supplies at the time. The surveyor asked the DON if there were instructions in the hospital discharge summary, dated [DATE], for the resident to be seen by Dr. (name withheld) in one week to determine if [MEDICAL TREATMENT] was necessary. She stated this was not noticed when the resident was admitted . She was asked if the facility made a follow-up appointment with Dr. (name withheld). She stated, "No." The surveyor asked if the [MEDICAL TREATMENT] catheter was examined by a physician at any point during the resident's stay. The DON stated, "No." The surveyor asked if the [MEDICAL TREATMENT] catheter was addressed in the resident's care plan. She reviewed the care plan and stated, "No." On [DATE] at 12:43 p.m., an interview was conducted with LPN #6. The surveyor asked if he had taken care of resident #27. He stated he had. The surveyor asked if he had done a dressing change on resident #27. He stated, "No." The facility's policy, '[MEDICAL TREATMENT]/Apheresis Catheter Management', documented, "To be Performed By: [MEDICAL TREATMENT] or Apheresis nurses, unless emergency circumstances dictate otherwise. Emergency care may be performed by licensed nurses according to state law and facility policy. The nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice. The nurse shall be accountable for attaining and maintaining competence with infusion therapy within her or his scope of practice... ...Any bleeding or drainage at catheter site must be reported to the nephrologist, hematologist, oncologist or [MEDICAL TREATMENT] center immediately..." The facility's policy, '[MEDICAL TREATMENT]/Apheresis Catheter Dressing Change', documented, "...Licensed nurses skilled in central venous catheter care may change dressings if [MEDICAL TREATMENT] nurses are not available... ...The [MEDICAL TREATMENT]/apheresis catheter insertion site is a potential entry site for bacteria that could produce a catheter-related bloodstream infection... ...A physician/licensed independent practitioner order is required for antibacterial ointment... ...Integrity of the dressing is to be assessed every shift... ...If the dressing is changed by the facility nurse, the site assessment includes, but is not limited to: Absence or presence of [DIAGNOSES REDACTED], drainage, swelling, induration, skin temperature at site, complaint of tenderness at the site... Central Venous Catheter Dressing Change Kit..." 3. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital history and physical, dated [DATE], dictated by a physician, documented: "The patient is NOT RESUSCITATE and DO NOT INTUBATE. I spoke with the wife and son at the bedside. His wife has power of attorney. She wanted to follow the patient's wishes." An admission assessment, dated [DATE], documented the resident had moderate cognitive impairment and required limited to extensive assistance with activities of daily living. The care plan, dated [DATE], documented the resident was a full code. The goal was for the resident's and family's wishes to be respected. Interventions included to explain the CPR process to the family and resident and to respect the resident's wishes and provide CPR as needed. On [DATE] at 9:40 a.m., while verifying that the Plan of Removal for the IJ regarding the facility's DNR/full code policy/procedure had been completed, the surveyor observed the clinical record of resident #40 to have an empty green sleeve in the front of his chart. The green sleeve indicated the resident was a full code. At 10:05 a.m., in a telephone interview, the surveyor asked the resident's wife/POA what she wanted the facility to do regarding resuscitation measures if her husband was found with no pulse and no respirations. She stated her husband should be a DNR. The wife stated she and her husband had discussed the matter and he had told her he did not want CPR. The surveyor asked if anyone at the facility had talked with her about her husband's DNR/fu

Based on observation, record review and interviews, it was determined the facility failed to assess, monitor and intervene in a timely manner for a resident who's oxygen saturation levels dropped to 54% for one (#7) of seven sampled residents. This caused the resident harm and he was sent to the emergency room at a local hospital. This had the potential to affect fourteen residents who were on oxygen therapy, identified by the charge nurses on halls 100 through 600. Findings: Resident #7 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. He was admitted for physical and occupational therapy. He had fallen at home and fractured his hip. His comprehensive assessment, dated 05/06/12, documented the resident's cognition was independent. He could make reasonable decisions consistently. His assessment documented he was totally dependent on the staff for transfers and all activities of daily living. He was incontinent of bowel and bladder. His assessment documented he was on oxygen therapy. The resident's initial care plan was not completed to include oxygen therapy. The resident was in the facility from 10:00 a.m. on 05/05/12 through 3:30 a.m. on 05/06/12, when he was taken to the emergency room at a local hospital. The physician's admission orders 730A (7:30 a.m.) - ...O2 at 2L/min/NC." The MAR indicated [REDACTED]. They were scheduled at "0600, 1200, 1800 and 0000." He arrived on the morning of 05/05/12. He missed his updraft treatment scheduled for 12:00 noon. The 6:00 p.m. treatment was not initialed on the MAR indicated [REDACTED]. She pointed to the note that documented, "...updrafts as ordered..." The vital signs and weight record, dated 05/05/12 (evening shift) documented his oxygen saturation (O2 Sats) was 96%. A daily skilled nurse's note, dated 05/05/12, documented, "2200 (10:00 p.m.) - SpO2 96% (with) O2 @ 2LPM NC. Updrafts as ordered. LS CTAB..." The vital signs and weight record, dated 05/06/12 (night shift) documented his oxygen Sats were "75% - 82% @ 2300 (11:00 p.m.)." A daily skilled nurse's note, dated 05/06/12, documented, "0100 (1:00 a.m.) - Was notified by CNA that his O2 Sat (was) 75% - went and check him, his O2 Sat was 54% - O2 @ 3L/NC - he was very diaphoretic - cool - clammy - not responding. Very labored. Resp/Pulse 128, 130 - BS done 270 - worked with him - gave him [MEDICATION NAME] tx (after) tx started to open his eyes and move his arm some - very weak hand grip - unable to maintain his Sats (above) 80%." The next entry documented, "0230 (2:30 a.m.) - Called (physician) and said to send him to (local hospital) ER for evaluation. His son was called but no answer." The next entry documented, "0300 (3:00 a.m.) - Called report to (local hospital) ER nurse and ambulance requested." The next entry documented, "0315 (3:15 a.m.) - Transported to (local hospital). Wife was notified of his transfer." The resident transfer form, dated 05/06/12, documented under reason for transfer, "Non-responsive - low O2 Sat." The physician's note, dictated 05/06/12 at 7:30 a.m., after the resident was taken to the hospital, documented, "...a resident of [MEDICATION NAME] skilled nursing facility and was transferred to the emergency room after he was found to be hypoxic on room air." The physician's progress note, dated 05/06/12 at 7:40 a.m., documented, "ICU admission - ...Pt started having SOB & started dropping his O2 Sats in 70's. Pt was somewhat anxious and confused...Signs of (elevated) WBC, acidosis & resp failure. Pt was intubated..." On 06/12/12 at 11:18 a.m., a family member was asked about the resident. The family member stated, "He was able to talk to the nurses. He could make his needs known if he was ok. He knew how important that oxygen was to him. He wouldn't take it off for nothing. If it fell off, he would be yelling for the nurses. He could use the call light and he did use it." At 4:47 p.m., RN #3 was interviewed by telephone. She was asked about the resident. She stated, "The CNA was making rounds. She told me the resident's Sats were low and he was unresponsive. I went to assess him and they were low. I tried to rouse him. We was just making rounds and taking vital signs." She was asked if she called the doctor. She stated, "Yes, I called the doctor and he said to send him out." She was asked why she waited until 2:30 a.m., to call the doctor when the CNA took the O2 Sat at 11:00 p.m., and the CNA documented the resident's O2 Sat's were 75% - 82%. She stated, "It takes time to get him ready and fill out the paperwork." She was asked if she listened to the resident's lungs. She stated she didn't remember. The resident arrived at the emergency room at 3:30 a.m. with a [DIAGNOSES REDACTED]. On 06/13/12 at 11:15 a.m., the treating physician was called and asked about his progress note on 05/06/12 when the resident was admitted to the hospital. He stated, "He was found with his oxygen off. That's what the nurse told me or I wouldn't have dictated that in my notes. He was a chronic O2 patient since '05. There's no way he could have been without oxygen for even 30 minutes." At 11:45 a.m., the director of nurses was asked about the resident and informed what the physician had said. She stated, "I know about that incident. The staff told me about it. It was on a weekend and I wasn't here. I think (the physician) was misinformed."

Based on observation, record review and interviews, it was determined the facility failed to notify the physician in a timely manner for a resident who's oxygen saturation levels dropped to 54% for one (#7) of seven sampled residents. This caused the resident harm and he was sent to the emergency room at a local hospital. This had the potential to affect fourteen residents who were on oxygen therapy, identified by the charge nurses on halls 100 through 600. Findings: Resident #7 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. He was admitted for physical and occupational therapy. He had fallen at home and fractured his hip. His comprehensive assessment, dated 05/06/12, documented the resident's cognition was independent. He could make reasonable decisions consistently. His assessment documented he was totally dependent on the staff for transfers and all activities of daily living. He was incontinent of bowel and bladder. His assessment documented he was on oxygen therapy. The resident's initial care plan was not completed to include oxygen therapy. The resident was in the facility from 10:00 a.m. on 05/05/12 through 3:30 a.m. on 05/06/12, when he was taken to the emergency room at a local hospital. The physician's admission orders 730A (7:30 a.m.) - ...O2 at 2L/min/NC." The MAR indicated [REDACTED]. They were scheduled at "0600, 1200, 1800 and 0000." He arrived on the morning of 05/05/12. He missed his updraft treatment scheduled for 12:00 noon. The 6:00 p.m. treatment was not initialed on the MAR indicated [REDACTED]. She pointed to the note that documented, "...updrafts as ordered..." The vital signs and weight record, dated 05/05/12 (evening shift) documented his oxygen saturation (O2 Sats) was 96%. A daily skilled nurse's note, dated 05/05/12, documented, "2200 (10:00 p.m.) - SpO2 96% (with) O2 @ 2LPM NC. Updrafts as ordered. LS CTAB..." The vital signs and weight record, dated 05/06/12 (night shift) documented his oxygen Sats were "75% - 82% @ 2300 (11:00 p.m.)." A daily skilled nurse's note, dated 05/06/12, documented, "0100 (1:00 a.m.) - Was notified by CNA that his O2 Sat (was) 75% - went and check him, his O2 Sat was 54% - O2 @ 3L/NC - he was very diaphoretic - cool - clammy - not responding. Very labored. Resp/Pulse 128, 130 - BS done 270 - worked with him - gave him [MEDICATION NAME] tx (after) tx started to open his eyes and move his arm some - very weak hand grip - unable to maintain his Sats (above) 80%." The next entry documented, "0230 (2:30 a.m.) - Called (physician) and said to send him to (local hospital) ER for evaluation. His son was called but no answer." The next entry documented, "0300 (3:00 a.m.) - Called report to (local hospital) ER nurse and ambulance requested." The next entry documented, "0315 (3:15 a.m.) - Transported to (local hospital). Wife was notified of his transfer." The resident transfer form, dated 05/06/12, documented under reason for transfer, "Non-responsive - low O2 Sat." The physician's note, dictated 05/06/12 at 7:30 a.m., after the resident was taken to the hospital, documented, "...a resident of [MEDICATION NAME] skilled nursing facility and was transferred to the emergency room after he was found to be hypoxic on room air." The physician's progress note, dated 05/06/12 at 7:40 a.m., documented, "ICU admission - ...Pt started having SOB & started dropping his O2 Sats in 70's. Pt was somewhat anxious and confused...Signs of (elevated) WBC, acidosis & resp failure. Pt was intubated..." On 06/12/12 at 11:18 a.m., a family member was asked about the resident. The family member stated, "He was able to talk to the nurses. He could make his needs known if he was ok. He knew how important that oxygen was to him. He wouldn't take it off for nothing. If it fell off, he would be yelling for the nurses. He could use the call light and he did use it." At 4:47 p.m., RN #3 was interviewed by telephone. She was asked about the resident. She stated, "The CNA was making rounds. She told me the resident's Sats were low and he was unresponsive. I went to assess him and they were low. I tried to rouse him. We was just making rounds and taking vital signs." She was asked if she called the doctor. She stated, "Yes, I called the doctor and he said to send him out." She was asked why she waited until 2:30 a.m., to call the doctor when the CNA took the O2 Sat at 11:00 p.m., and the CNA documented the resident's O2 Sat's were 75% - 82%. She stated, "It takes time to get him ready and fill out the paperwork." She was asked if she listened to the resident's lungs. She stated she didn't remember. The resident arrived at the emergency room at 3:30 a.m. with a [DIAGNOSES REDACTED]. On 06/13/12 at 11:15 a.m., the treating physician was called and asked about his progress note on 05/06/12 when the resident was admitted to the hospital. He stated, "He was found with his oxygen off. That's what the nurse told me or I wouldn't have dictated that in my notes. He was a chronic O2 patient since '05. There's no way he could have been without oxygen for even 30 minutes." At 11:45 a.m., the director of nurses was asked about the resident and informed what the physician had said. She stated, "I know about that incident. The staff told me about it. It was on a weekend and I wasn't here. I think (the physician) was misinformed."

Based on observations, interviews and record review, it was determined the facility failed to provide pain medication for effective pain management per the physicians' orders for one (#5) of three sampled residents who had physician ordered pain medication. This had the potential to affect 30 residents who triggered for pain management according to the facility's census and condition report. Findings: Resident #5 was admitted with [DIAGNOSES REDACTED]. Her comprehensive assessment, dated 01/26/12, documented her cognitive status was intact. She was dependent on the staff for transfers, dressing and bathing. She required extensive assistance from the staff with eating. It documented she was usually incontinent of bowel. She had an indwelling foley catheter. On 4/23/12 at 8:30 a.m., the resident and her roommate were asked if they had problems receiving their pain medication. They stated that it took forty-five minutes or longer to receive their pain medication. At 10:35 a.m., RN #1 was observed performing a treatment to the resident's coccyx area. During the treatment, the resident moaned with pain. RN #1 stated the resident had been medicated for pain about 9:00 a.m. per the physician's orders [REDACTED]. At 10:50 a.m., the treatments were completed. The certified medication aide (CMA) for hall 500 was walking by the resident's room. She stated the resident did have a pain medication order for breakthrough pain but could not receive it until 2:00 p.m. At 11:00 a.m., the resident continued to complain of pain. The CMA entered the room and stated she had confirmed with the nurse, the resident could receive the pain medication ordered for breakthrough pain now. At 11:15 a.m., the resident received her narcotic pain medication.

Based on observation, record review and interview, it was determined the facility failed to provide sufficient nursing staff to meet the needs of the residents. This had the potential to affect 91 of 91 residents in the facility. Findings: 1. The facility failed to: ~ assess, monitor and intervene to provide care and services for one (#1) of one sampled residents with [MEDICAL CONDITION]. There were no other residents identified by the facility with [MEDICAL CONDITION]. ~ perform fingerstick blood sugars and administer correct dosages of sliding scale insulin for one (#2) of ten sampled residents who received fingerstick blood sugar testing and sliding scale insulin. The DON identified 31 residents who were diabetics. ~ provide care and services for redness and excoriation per physician's orders [REDACTED]. ~ ensure residents with indwelling urinary catheters had a medical [DIAGNOSES REDACTED].#9) of five sampled residents with indwelling urinary catheters. This had the potential to affect four additional residents in the facility with catheters, according to the resident census and condition report provided by the facility. ~ failed to assess the [MEDICAL CONDITION] status on an ongoing basis and with the administration of breathing treatments for one (#18) of one sampled residents who had [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The resident developed pneumonia and required antibiotics. ~ assess, monitor and intervene for five (#1, 6, 13, 18 and #23) of five sampled residents who experienced a change in condition. This resulted in actual harm for : ~ Resident #1 who attempted to cut his wrists, was not provided with mental health services and continued to verbalize [MEDICAL CONDITION]. ~ Resident #13 who had a known history of severe [MEDICAL CONDITION] and was awaiting stent placement for a vascular blockage. Ongoing assessment and monitoring of his vascular status was not provided to include checking peripheral pulses and monitoring the color and temperature of his right foot. The resident was hospitalized and his right foot was purple and cold with no pulses either palpable or by Doppler. He required amputation of his right foot. The resident also had a [MEDICAL CONDITION] infection with diarrhea for four days, while the facility continued to administer stool softeners. ~ Resident #6 who had an indwelling urinary catheter and had a urinary tract infection. The facility failed to assess the resident when he experienced an episode of no urinary output and exhibited increasing signs of infection. The resident had to be hospitalized with urosepsis. ~ Resident #23 who had a change in status and thorough assessment and monitoring were not provided. The resident was later sent to the hospital with an exacerbation of [MEDICAL CONDITION] and placed in the intensive care unit. This had the potential to affect 91 of 91 residents who resided in the facility, who may experience a change in condition. See F309 for details. 2. The facility failed to provide services to promote healing of existing pressure sores and to prevent new pressure sores from developing for two (#2 and #35) of four sampled residents with pressure ulcers. The facility failed to routinely assess pressure ulcers and failed to provide care in a manner to prevent cross-contamination of wounds for resident #2. The resident developed two additional stage II pressure ulcers on her buttocks. The facility failed to ensure wound care was provided, heel protectors were available and used to alleviate pressure on the resident's heels, the resident's heels were floated to relieve pressure and the resident was not being required to stand and pivot on the Stage IV pressure ulcer to his heel for resident #35. The resident developed a wound infection. This had the potential to affect eleven additional residents with pressure sores, identified on the residents' census and condition provided by the facility. See F314 for details. 3. The facility failed to assist the residents with activities of daily living (ADL's) for twelve (#2, 3, 6, 7, 10, 11, 15, 18 and #23-26) of eighteen sampled residents. This had the potential to affect 61 additional residents in the facility who required assistance with ADL's according to the resident census and condition provided by the facility. See F312 for details. 4. The facility failed to provide services to ensure: ~ [MEDICAL CONDITION] care was performed routinely for one (#18) of one sampled residents with a [MEDICAL CONDITION]; and failed to ensure ~ residents' lung sounds and a baseline pulse were assessed before and after breathing treatments for three (#20-22) of three sampled residents who self-administered breathing treatments. This had the potential to affect 22 additional residents who received respiratory treatments according to the resident census and condition report provided by the facility. See F328 for details. 5. The facility failed to investigate and resolve grievances in a timely manner for thirteen of thirteen (#4, 11, 12, 16 and #31-40) sampled residents who voiced grievances to the facility. This had the potential to affect all residents with a grievance. The facility's census was 91. See F166 for details. 6. The facility failed to offer a bedtime snack to all residents in the facility. The resident census and condition report provided by the facility documented a census of 91 residents. See F368 for details. On 08/11/11 at 9:10 a.m., the DON and administrator were interviewed. They were informed the facility staffing patterns were not sufficient to meet the residents' needs. The DON stated, "I don't understand. We always have enough to meet the numbers (staff to resident required ratios)." The administrator stated, "I understand. We need to staff according to acuity and not according to numbers." On 08/25/11 at 12:40 p.m., CNA #13 was asked about the documentation of the residents' I&O's. She stated, "That is the last thing we do before we leave our shift, but there is not enough time to get it all done, much less document everything. We are always short-handed and now they are saying they are cutting out the overtime. Baths don't get done, beds don't get changed, residents don't get turned and cleaned up like they need to be. Everyone works hard, but there just is not enough time to get it all done."

Based on observation, record review and interview, it was determined the facility failed to provide services to promote healing of existing pressure sores and to prevent new pressure sores from developing for two (#2 and #35) of four sampled residents with pressure ulcers. The facility failed to routinely assess pressure ulcers and failed to provide care in a manner to prevent cross-contamination of wounds for resident #2. The resident developed two additional stage II pressure ulcers on her buttocks. The facility failed to ensure wound care was provided, heel protectors were available and used to alleviate pressure on the resident's heels, the resident's heels were floated to relieve pressure and the resident was not being required to stand and pivot on the Stage IV pressure ulcer to his heel for resident #35. The resident developed a wound infection. This had the potential to affect eleven additional residents with pressure sores, identified on the residents' census and condition provided by the facility. Findings: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's care plan, dated 05/10/11, documented, "Problems: (Resident #2) has a pressure area to her buttocks X 2. Goals: Skin will remain clean and dry and area will heal over the next 90 days. Interventions: Turn and reposition resident routinely and prn... Examine skin during bathing for signs/symptoms of irritation and/or breakdown.... Perform treatment per Dr's orders, report progress to Dr. in 14 days... Problems: (Resident #2) has a pressure area to left foot. Goals: Skin will remain clean and dry and area will heal over the next 90 days. Interventions: Turn and reposition resident routinely and prn... Examine skin during bathing for signs/symptoms of irritation and/or breakdown... Perform treatment per Dr's orders, report progress to Dr. 14 days... Problems: (Resident #2) has a pressure area right heel. Goals: Skin will remain clean and dry and area will heal over the next 90 days. Interventions: Turn and reposition resident routinely and prn... Examine skin during bathing for signs/symptoms of irritation and/or breakdown... Perform treatment per Dr's orders, report progress to Dr. in 14 days." The resident's comprehensive assessment, dated 05/30/11, documented her cognition was modified independence. She required extensive assistance from the staff for bed mobility, transfers and ADLs. She required total assistance from the staff for toileting. She was frequently incontinent of bowel and bladder. It documented the resident had one Stage I and one Stage III pressure sores. The weekly body assessment form for July 2011 documented, "7/2 (07/02/11) - Open areas to bilateral heels, (L) great toe (and) (L) second toe. Open area to coccyx. 7/9 (07/09/11) - Open areas to bil heels, (L) toe X 2, open area to coccyx." The form contained dates of 07/16/11, 07/23/11 and 07/30/11. These dates were blank and did not contain documentation of a skin assessment. Five pressure ulcers were identified. One on each heel, the left great toe, the left second toe and the coccyx. The resident's care plan update by the wound care nurse, dated 07/08/11, documented, "Healing. Cont current tx." The same was documented on all three care plans for the resident's pressure sores. The resident's comprehensive assessment, dated 07/15/11, documented she had two Stage II and one Stage III pressure sores. A physician's orders [REDACTED]. (Change) daily." The treatment sheet for August 2011, included a physician's orders [REDACTED]. (Change) dly (daily)." The weekly body assessment form for August 2011 documented, "8/6 (08/06/11) - (R) heel decub. buttock decubs. Tx being done." A "Step by Step Wound Care Directions" for the resident, hand-written by the wound care nurse, (not dated), documented, "... L (and) R buttocks - apply Santyl, cover c Calcium Alginate + gauze. Apply skin prep before securing c tape. (Change) daily... This documented the resident now had two pressure ulcers on her buttocks. A Braden Scale for predicting pressure sore risk, dated 08/06/11, documented a total score of "14" (moderate risk). On 08/09/11 at 7:55 a.m., LPN #1 (facility wound care nurse) was observed as she performed wound care for the resident's pressure sores. CNA #6 assisted the LPN. The LPN set the wound care supplies up on the resident's overbed table without a barrier. She donned a pair of gloves. She did not wash her hands before gloving. The LPN removed the soiled dressing from the resident's left foot. She cleaned the tops of the resident's left toes with normal saline (NS) on a 4x4 gauze, patted them dry with a dry 4x4 gauze pad, applied [MEDICATION NAME] (antibiotic)/Santyl (debridement) ointment, covered them with Calcium Alginate and gauze, wrapped her foot with Kerlix (rolled gauze) and secured it with tape. Without changing her gloves or washing her hands, the LPN removed the soiled dressing from the resident's right foot. She cleaned the right heel necrotic/eschar (dead, black, leather-like tissue) area with NS on a 4x4 gauze and patted it dry with a 4x4 gauze. She cleaned the tops of the resident's toes with NS on a 4x4 gauze and patted it dry with a 4x4 gauze. She applied [MEDICATION NAME]/Santyl ointment to the heel and the tops of the toes, covered the toes with Calcium Alginate and gauze, covered the area on the heel with Calcium Alginate and gauze and an Allevyn pad (thick absorbent dressing), wrapped it all with Kerlix and secured it with tape. CNA #6 turned the resident onto her right side and unfastened the resident's adult brief. The LPN rolled the brief down under the resident's buttocks. Without washing her hands or changing her gloves, the LPN used her gloved hand to apply [MEDICATION NAME] cream (anti-fungal) to the red, excoriated rash on the resident's upper thighs and lower buttocks. The LPN did not wash the area or clean the area or the residual cream off before she applied the new cream. As the LPN turned around, the large piece of tape she had prepared for the next dressing became dislodged and stuck to itself. The LPN attempted to straighten it, threw it in the trash, removed her gloves and left the room. She returned with a new piece of tape and donned clean gloves. She did not wash her hands before gloving. The LPN removed the soiled dressing from the resident's buttocks. She cleaned the area with NS on a 4x4 gauze. She stated, "There are two here." The surveyor asked to look at the wounds more closely. There were three open areas. The LPN stated, "Oh. There are three. That one is new (pointing to the third open area)." Without washing her hands or changing her gloves, the LPN applied Santyl and calcium alginate, covered the area with gauze and tape. She did not use skin prep before she applied the tape. The base of the dressing did not seal. The base of the dressing was open across the divide in the resident's buttocks. The LPN stated, "Okay, we're done." She started to pull the resident's brief back up to refasten it. The surveyor asked the LPN if the resident was wet. She checked the line on the outside of the brief and stated, "A little." The LPN and CNA removed the wet brief from the resident. The CNA went to the resident's dresser, retrieved a clean brief. She and the LPN placed it on the resident. As the LPN started to pull up the brief, the CNA stated to the LPN, "Peri-wash." The LPN used her foot to open and close two drawers in the resident's bedside table. There was peri-wash in the top drawer. The LPN retrieved the peri-wash, looked around the room and stated, "We will just have to improvise." She opened a packet of 4x4 gauze, sprayed three sprays of peri-wash on the 4x4s and handed them to the CNA. The CNA used the 4x4s and wiped the resident's vaginal cleft with them twice. The resident cried out with each wipe by the CNA. The insides and front of both of the resident's thighs were red and excoriated. The CNA and LPN pulled the brief up, fastened it, and pulled the resident up in her bed. They did not use soap and water. They did not apply the cream to the resident's thighs, groin or perineal area. The resident's care plan was not updated to include all of the resident's pressure sores, treatment changes, intervention additions or changes. On 08/09/11 at 8:35 a.m., the resident was interviewed regarding her care in the facility. She was asked about receiving her medications. She stated, "They seem to have a hard time getting all the medicine that I need. Sometimes I don't get my insulin like I am supposed to. That makes me kind of nervous, because my (blood) sugars get out of control if I don't get my insulin. These sores (pressure sores on both feet and buttocks) won't ever heal if I don't keep my sugars under control." On 08/11/11 at 9:10 a.m., the administrator and DON were informed of the above observations. The administrator stated they would check into it. 2. Resident #35 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's care plan, dated 05/20/11, documented, "(Resident #35) has a pressure area to right heel with [DEVICE] Skin will remain clean and dry and area will heal over next 90 days... Turn and reposition resident routinely and prn... Position with pillows, cushion, elevate feet, footrests... Perform treatment per (doctor's) orders..." (Resident #35) is in need for limited to extensive care of staff R/T immobility, lack of coordination and abnormality of gait... Resident will have all needs met..." The resident's comprehensive assessment, dated 06/17/11, documented his cognition was intact. He required limited assistance from the staff for personal hygiene. He required extensive assistance from the staff for bed mobility, transfers and toilet use. He required total assistance from the staff for eating and bathing. He was incontinent of bowel and bladder. He had one Stage III pressure sore (full thickness tissue loss) on admission to the facility. The bed of the pressure sore contained slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps). The resident's care plan was updated 07/08/11. It documented, "Hold wound vac. Cont new drsg order." A physician's orders [REDACTED]. A non-pressure skin condition report for August 2011, documented the resident's wound measurements as follows: "08/04/11 - R heel... 8 (cm) X 8 (cm) X 1.1 (cm)... 08/09/11 - R heel... 7.2 X 6.8 X 0.4..." A physician's orders [REDACTED]. A wound culture report for the resident's right heel wound, dated 08/11/11, documented the organism identified was Proteus mirabilis (a bacteria found in the bowel)..." A physician's orders [REDACTED]. STAT. Indication - Dx: wound (infection)." The resident's skin condition report, dated 08/16/11, documented the pressure sore on his right heel measured 9 cm in length by 8 cm in width and was 1.7 cm deep. The pressure sore contained slough and eschar (dead, brown/black tissue) and the progress of healing had deteriorated. The resident was being seen weekly at the local wound care center. The physician at the wound care center performed debridement on the resident's pressure sore on a regular basis, according to the facility's wound care nurse. The resident received [MEDICAL TREATMENT] three times a week for his end stage [MEDICAL CONDITION]. A physician's orders [REDACTED]. The resident's skin condition report, dated 08/23/1, documented, "... R heel... 8.9 X 7.7 X 1.6 (cm)... undermining 11-12 (11:00-12:00) 1.2 (cm) 2-3 (2:00-3:00) 2.5 (cm)..." A physician's orders [REDACTED]. Off loading..." On 08/24/11 at 10:45 a.m., the resident was observed in his bed. His right foot was on the bed with a dressing on it. The resident did not have heel protectors on and his heels were not floated. The resident's wife was in the room with him. She was asked about his care. She stated, "They do not come check on him. I come every day, because they do not take good care of him. (LPN #1 - wound care nurse) takes good care of him. She changes his bandage on Monday through Friday, but the nurses on the weekends do not change it." She was asked about his heels being floated. She stated, "Sometimes I put pillows under his feet, because I know they need to be up. The aides (CNA's) don't do it. When they get him up, they make him stand on that foot. I tell them he can not stand on that foot. It hurts him, but they do it anyway." At 12:00 p.m., his right foot was on the bed with a dressing on it. The resident did not have heel protectors on and his heels were not floated. At 12:05 p.m., the facility's wound care nurse was observed as she provided wound care to the resident's pressure sore. When the dressing was removed, a foul odor was noted. She stated he had been on antibiotics for an infection and was to see a surgeon on 08/25/11 for possible deep debridement of the wound or possible amputation. She was asked what happened if she did not have time to change his dressing before he went to [MEDICAL TREATMENT]. She stated, "I try to get to him in the mornings, because I am gone by the time he gets back from [MEDICAL TREATMENT]. If I don't get to him, I let the nurses know they are to change it on the evening shift." (The resident is at [MEDICAL TREATMENT] from 12:30 p.m. until approximately 6:00 p.m. on Mondays, Wednesdays and Fridays.) The resident's treatment sheet for wound care for August 2011, documented the following: 08/12/11 - OOF (out of facility) 08/13/11 - blank 08/19/11 - OOF (circled - indicated the treatment was not done). 08/20/11 - circled 08/22/11 - blank. When the wound care was completed, the wound care nurse was asked if the resident's heels should be floated on pillows to alleviate the pressure to the area. She stated, "Yes, and he is supposed to have heel protectors on at all times. He has a doctor's order for it." She looked around the resident's room, but was unable to locate the heel protectors. She stated, "I will make sure the staff knows to keep his heels floated and I will get him some new heel protectors." She was informed of the resident's wife stating the CNA's make him stand and pivot on his right foot during transfers. She stated, "That should not happen. I will make sure they know he is to be non-weight bearing on that foot." She was asked about the resident's wound. She stated, "He was admitted with the pressure sore with a wound vac on it. I was not working here when he was admitted and by the time I came, the wound was too far gone. I got the wound vac held and we started daily treatments." She was asked if she did the dressing changes every day. She stated, "No, I only work Monday through Friday, but I have trained the nurses to do the dressings on the weekends when I am not here." She was asked if when she comes in on Mondays, have the dressings been changed. She stated, "Yes." She was asked if there were ever old dressings on his foot that had not been changed. She stated, "Not lately." All five of the resident's toes contained necrotic areas on them. The tip of his little toe contained a dime-sized necrotic area. The tip of the second toe contained a pea-sized area. The other three toes had small necrotic areas. The wound care nurse was asked about the necrotic areas on the resident's toes. She stated, "The doctor is aware, but is not worried about those areas. There is not a treatment order for them." She was asked if the areas were documented. She stated, "No, but I will do that as soon as we get finished here. I was trained by (the wound care doctor), so they (the physicians) trust me. I write the wound care orders and they sign them." On 08/25/11 at 1:20 p.m., the facility's CEO and corporate RN were informed of the observations. The RN stated they understood the deficient practice, would talk to the wound care nurse and inservice the staff.

Based on observation, record review and interview, it was determined the facility failed to: ~ assess, monitor and intervene to provide care and services for one (#1) of one sampled residents with [MEDICAL CONDITION]. There were no other residents identified by the facility with [MEDICAL CONDITION]. ~ perform fingerstick blood sugars and administer correct dosages of sliding scale insulin for one (#2) of ten sampled residents who received fingerstick blood sugar testing and sliding scale insulin. The DON identified 31 residents who were diabetics. ~ provide care and services for redness and excoriation per physician's orders [REDACTED]. ~ ensure residents with indwelling urinary catheters had a medical [DIAGNOSES REDACTED].#9) of five sampled residents with indwelling urinary catheters. This had the potential to affect four additional residents in the facility with catheters, according to the resident census and condition report provided by the facility. ~ failed to assess the [MEDICAL CONDITION] status on an ongoing basis and with the administration of breathing treatments for one (#18) of one sampled residents who had [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The resident developed pneumonia and required antibiotics. ~ assess, monitor and intervene for five (#1, 6, 13, 18 and #23) of five sampled residents who experienced a change in condition. This resulted in actual harm for : ~ Resident #1 who attempted to cut his wrists, was not provided with mental health services and continued to verbalize [MEDICAL CONDITION]. ~ Resident #13 who had a known history of severe [MEDICAL CONDITION] and was awaiting stent placement for a vascular blockage. Ongoing assessment and monitoring of his vascular status was not provided to include checking peripheral pulses and monitoring the color and temperature of his right foot. The resident was hospitalized and his right foot was purple and cold with no pulses either palpable or by Doppler. He required amputation of his right foot. The resident also had a [MEDICAL CONDITION] infection with diarrhea for four days, while the facility continued to administer stool softeners. ~ Resident #6 who had an indwelling urinary catheter and had a urinary tract infection. The facility failed to assess the resident when he experienced an episode of no urinary output and exhibited increasing signs of infection. The resident had to be hospitalized with urosepsis. ~ Resident #23 who had a change in status and thorough assessment and monitoring were not provided. The resident was later sent to the hospital with an exacerbation of [MEDICAL CONDITION] and placed in the intensive care unit. This had the potential to affect 91 of 91 residents who resided in the facility, who may experience a change in condition. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's initial care plan, dated 06/03/11, documented the following: "(X) Behavior Symptoms. Goal: Fewer symptoms. 'Dementia'. (X) [MEDICAL CONDITION] Drug Use: Goal: Benefit without side effects. '[MEDICATION NAME] (anti-depressant) 20 mg daily. (X) Pressure sore/Skin at risk. Goal:Prevent/Heal pressure sores. 'Calmaseptic (skin protection cream) to buttocks. (X) Pain. Goal: Experience less/no pain (X) Fall/Safety Risk. Goal: No injury falls." The rest of the care plan was blank. The resident's comprehensive assessment, dated 06/10/11, documented his cognitive status was independent. His short term and long term memory was intact. He was able to express ideas and wants. He could make his needs known. He did not display any behaviors or psychosocial problems. He required total assistance from the staff for bed mobility, transfers and all ADLs, except eating. He was unable to ambulate due to [MEDICAL CONDITION]. He had an indwelling urinary catheter and was occasionally incontinent of bowel. He had one Stage II pressure sore. A daily skilled nurses note, dated 06/11/11, documented: "(06/10/11) 2315 (11:15 p.m.) - Pt. moaning, mumbling. Able to follow simple command. Unintelligible speech... would not smile. No asymmetry noted in face. Muscles in arms/shoulder spasmodic. Vitals stable - Medicated for pain. Vitals. Close monitoring. Vital signs written at the top of the page of nurse's notes documented: "temp 100.4 pulse 104 resp 24 (O2 saturation) 90 b/p 140/52- 2350 (11:50 p.m.). (O2 saturation) 85 b/p 103/54 - 0130 (1:30 a.m.)" There was no documentation to show the facility had completed a thorough assessment other than vital signs and oxygen saturations. There was no documentation of interventions to address the resident's decreased oxygen saturations or drop in blood pressure, or notification of the physician. There was no further assessment documented for two hours and fifteen minutes. Vital signs written at the top of the page of nurse's note documented, "(O2 saturation) 70 b/p 61/34 - 0345 (3:45 a.m.)" A nurse's note, dated 06/11/11 at 3:45 a.m., documented, "O2 2L started. (Physician) notified of change in condition. Continues to follow commands (simple). Continues moaning and incoherent speech. HOB (down) feet (up). Continue close monitoring. There was no documentation of the physician's instructions. Vital signs written at the top of the page of nurse's notes documented: "pulse 103 (O2 saturation) 93 b/p 91/43 - 0410 (4:10 a.m.) temp 99 pulse 106 0600 (6:00 a.m.)" There was no documentation of an assessment of the resident for two and one half hours. A nurse's note, dated 06/11/11 at 8:30 a.m., documented, "Resident lethargic, confused. Lungs (with) coarse crackles (B). VS obtained. B/P 126/73, P 129, T 103, O2 75% on 4/L NC. Placed on NRB c (no) (change) in O2 sat. Uncontrollable shaking noted. Moaning incoherent words. (Physician) unreachable @ this time. (Medical director) notified of (change) in condition. N/O to send to (Local hospital) ER for eval per family request rec'd. Nephew notified. Incorrect # for daughter. (Local ambulance service) ambulance notified. Report called to (Local hospital) ER. Ambulance here @ 0850 (8:50 a.m.). 3-11 (3:00 p.m. - 11:00 p.m. shift) - Res remains in (Local hospital)." There was no documentation between 11:15 p.m. on 06/10/11 and 3:45 a.m. on 06/11/11, or between 3:45 a.m. and 8:30 a.m. on 06/11/11, to show the resident's condition was monitored. An emergency department report, dated 06/11/11, documented, "History of present illness: The patient is a [AGE] year-old from Monte Vista this morning for respiratory distress. The patient is altered and unable to give any further history. Per Monte Vista he has had three to four hours of fever and altered mental status... Vital Signs: Blood pressure 75/31, heart rate 109, respirations 14, temperature 104 rectal, oxygen saturation 90% on 100% non-rebreather... General: The patient is completely unresponsive. He has audible course rales bilaterally. He appears in mild distress and is very warm to touch... Medical Decision Making: In the emergency department a decision was made to emergently intubate the patient. He was started on intravenous fluids, receiving 4 L immediately... The patient was placed on a ventilator... chest x-ray is obtained which demonstrates pneumonia bilaterally... admit the patient to the Intensive Care Unit. Assessment: 1. Pneumonia. 2.[MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. Plan: In-patient critical care admission [MEDICAL CONDITION] management, as well as antibiotics for pneumonia. Assessment/Primary Admission Diagnosis: [REDACTED]. 2. Septic shock 3. Pneumonia 4. Urinary tract infection 5. Rule out [MEDICAL CONDITION] infarction." The resident was readmitted to the facility on [DATE]. His care plan, dated 07/01/11, documented, "Problems: Infection: (Resident #1) has an infection present,[MEDICAL CONDITIONS] in the lungs...pneumonia. Goals: (Resident #1) will have no s/sx of infection thru next 90 days. Interventions: Monitor disease progression and provide immediate intervention. Monitor and report signs of infection. Encouragement and assistance with eating as needed. Medication as ordered and lab work as ordered and report any abnormal reading to MD. Problems: (Resident #1) is at risk for self isolation R/T the need for isolation r/[MEDICAL CONDITION]. Goals: (Resident #1) will increase personal contact and do increased self started activities by the next 90 days. Interventions: Inform resident of facility events on a regular basis. Identify factors contributing to social isolation. Assess and document ability to speak, hear, write, read and understand. If appropriate, arrange for interaction with others who have similar problems. Inform, invite and escort to activities of choice, respecting resident refusals. Problems: (Resident #1) has the need of extensive to total care from the staff. Goals: (Resident #1) will have all needs met and will be clean, dry, odor free and appropriately dressed thru the next 90 days. Interventions: ... Bathe resident per schedule and PRN... Personal hygiene and grooming daily and prn (wash face, comb hair, apply make-up, etc.). Encourage resident to assist as much as possible and give ample time to do herself with as much assistance as needed..." An accident/incident report, dated 08/05/11 at 6:00 a.m., documented, "... Type of injury: Laceration... Describe incident: Resident in pain. Expressing discomfort by banging wrists on bedrails. Intervention/Treatment at time of Incident: Medicated for pain - comforted (and) reassured. ABT oint (and) dsg to both wrists. Condition of resident IMMEDIATELY AFTER incident: No (change), just medicated. Witness Account of Event (Facts only): Incident directly related to pain/discomfort. Immediate relief (not) possible (with) p/o pain med - Behavior continued despite verbal comfort measures. Supervisor's Investigation of Event and Interventions: Referred to Social Services for psych consult. Physician called to notify of pain. Muscle relaxant ordered." (The report was signed by the DON and administrator on 08/08/11). The nurses' notes, dated 08/05/11, documented, "0700 (7:00 a.m.) - Resident c/o back and 'bottom' pain @ 0500 (5:00 a.m.) - Medicated (with) [MEDICATION NAME] 10/500 mg (narcotic pain reliever) (one) p/o per standing orders - (no) relief obtained immediately (with) resident acting out. Incident - injury to wrists. dsgs to wrists intact." "7-3 (7:00 a.m. - 3:00 p.m. shift) - Resident (up) in w/c @ start of shift. Res showed (bilateral) wrists to me. Wrists (with) multiple abrasions. When asked what happened, res replied, 'I was hurting so much, I was banging them against the rails.' Dsg applied per night shift. (Resident's physician) notified. N/O to (increase) [MEDICATION NAME] (muscle relaxant) (and) [MEDICATION NAME] (anti-anxiety). Medicated (with) [MEDICATION NAME] 10 mg now. Shortly after being medicated, res found outside telling officer that he slit his wrist and wanted to die. Res brought inside to nurses' station. Res then said to me, 'Stay close to me, I might kill myself.' (Resident's physician) notified. N/O to send to (local psychiatric facility) if able. (Social services director) notified. Will cont to monitor." "1400 (2:00 p.m.) - No bed available on (local psychiatric facility). Per (Resident's physician), watch over weekend. If bed becomes available over weekend, then send. Resident calm @ this time. Rec'd [MEDICATION NAME] as ordered. N/O rec'd (increase) [MEDICATION NAME] Q 4 (hours) (and) [MEDICATION NAME] (anti-convulsant/also used for treating neuropathic pain)." A care plan dated 08/05/11 documented, "Problems: (Resident #1) is at risk for behavior problems R/T depression secondary to pain in BLE. Goals: (Resident #1 will not have complications from behaviors thru next 90 days. Interventions: Approach in clam, relaxed manner... Establish eye contact... Don't stand to closely to invade their space... Problems: Mood: (Resident #1) has episodes of making negative statements lately, stating he 'wants to die because his pain is too bad.' Goals: (Resident #1 will not make negative statements thru next 90 days. Interventions: ... One on one monitoring of resident at all times for his safety. Psychiatric consult to mental health facility. The next entry in the resident's nurses' notes was dated 08/06/11 at 2100 (9:00 p.m.). The nurse's note documented, "Res. resting in bed (with) (no) s/s of distress. (No) outbursts this shift. Safety met by staff. Call light in reach." A nurse's note, dated 08/08/11, documented, "7-3... Res (with) noticeable depression..." On 08/09/11 at 7:00 a.m., the resident was observed lying in his bed. He asked the surveyor if he could talk to her. He stated, "I am so depressed I want to die. It's so bad, I even cut my wrists the other day." The resident raised both arms up to show the surveyor both of his wrists, which were wrapped in gauze. He stated, "I didn't cut them bad, because I didn't have anything to cut them with." He was asked what he used to cut his wrists with. He pointed to the metal clip attached to the television remote cord wrapped around his siderail and stated, "That." He was asked why. He stated, "I am so depressed. I don't think I will ever get out of here. No one comes in here except to bring me awful food that I don't want to eat. I've decided I'm going to just quit eating too." The resident was intensely scratching his arms and shoulders and stretching to try to reach his back. His skin was very dry. The surveyor asked him if he had told the staff about the itching. He stated, "Yes, but they don't do anything about it. I even asked for some lotion, but they haven't brought that either. I'm sure it would help if they would get me up in the shower. I haven't had a shower in about two weeks." The resident's ADL sheets documented he had received a bed bath on his scheduled bath days. There was no lotion in the resident's room. At 11:15 a.m., CNA #6 was asked why the resident was given bed baths instead of showers. She stated, "He has to have two people to give him a shower. There usually aren't enough of us (CNA's) to do that." He was asked if the staff assisted him when he was incontinent. He stated, "Yes, but it takes them a long time to answer my (call) light when I turn it on." He was asked how long was a "long time." He stated, "Sometimes, they will come in twenty or thirty minutes, turn it off and tell me they have to go get supplies or someone to help them clean me up. Then, if they come back, it is an hour or so later." He was asked if there was a particular shift that this happened on. He stated, "No, it's all the same. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's ADL sheet, dated June 2011, documented the resident required extensive assistance from the staff for bed mobility, limited to extensive assistance for transfers, dressing and locomotion in room/hall. He required limited to total assistance from the staff for toilet use and personal hygiene. The resident's hospital records which accompanied the resident on admission, documented he had a recent history of [MEDICAL CONDITION] ([MEDICAL CONDITION] - an infection of the bowel which causes jelly-like diarrhea, is contagious, and requires isolation precautions) and had [MEDICAL CONDITION] that he was awaiting stent placement for. The nurse's notes, dated 06/01/11, documented, "7-3 (7:00 a.m. - 3:00 p.m. shift) ... AA & O X 3 (awake, alert and oriented times three). C/O pain to (R) foot. Discoloration to (R) foot noted. Res scheduled for stent placement on June 8. 2 cm x 2 cm eschar area to R outer heel noted. No other places of breakdown noted." The nursing assessment check boxes on the daily skilled nurses notes did not contain check marks regarding cardiovascular assessments of the resident's foot or peripheral pulses for the following shifts: 06/01/11 - evening shift 06/02/11 - day shift and evening shift 06/03/11 - day shift 06/04/11 - night shift 06/08/11 - evening shift. There were no nurse's notes that documented an assessment of the resident's foot or peripheral pulses for these shifts. A nurse's note, dated 06/02/11 on the 7:00 a.m. - 3:00 p.m. shift, documented, "... Resident requesting change in pain meds... " A nurse's note, dated 06/04/11 for the 7 a.m. to 3 p.m. shift documented, "... C/O tenderness to R foot. Some heat noted upon palpation. Res has 2 X 1.9 cm necrotic area to lateral aspect of R heel outer aspect. Oval in shape. (No) other open areas/skin issues... " The nursing assessment check boxes on the daily skilled nurses notes were blank for the day shift. The nurse's notes, dated 06/05/11, documented, "... 0145 (1:45 a.m.) - ... c/o pain to B/L (bilateral) legs. Extreme pain to R foot/heel..." The nurses' notes, dated 06/06/11, documented, "0400 (4:00 a.m.) - Resident presented (with) c/o chills, fever: 102 (degrees Fahrenheit) - Medicated per standing orders c fluid encouraged. Freq. urination (and) jelly like stools. MD to be notified in AM... condition monitored. 7-3 (7:00 a.m. - 3:00 p.m. shift) - Resident ate meals in room this a.m., c/o grogginess and some confusion in a.m. Explained may possibly (be) related to sleeping meds... 3-11 (3:00 p.m. - 11:00 p.m. shift) - ...Cont. (with) diarrhea...." A physician's progress note, dated 06/07/11, documented, "... Also ++ diarrhea since yesterday..." The nurse's notes, dated 06/07/11, documented, "7-3 ... Sample for culture (and) [MEDICAL CONDITION]. Lab notified. Sample sent. All AM meds (and) tx as ordered... 3-11 Rec'd call from (local hospital) lab of + (positive) [MEDICAL CONDITION] results..." The nurses' notes, dated 06/08/11, documented the resident was on isolation precautions due to [MEDICAL CONDITION] and ran a 100.4 degree temperature on the 7-3 shift. The nursing assessment check boxes on the daily skilled nurses notes, dated 06/08/11, did not contain check marks regarding cardiovascular assessments of the resident's foot or peripheral pulses for the evening shift. There were no nurse's notes documented regarding the assessment of the resident's foot or peripheral pulses. The daily skilled nurses notes for 06/09/11 documented the resident's temperature was 99.8 and his b/p was 82/39. The nurses' notes, dated 06/09/11, documented, "Res cont (with) diarrhea. FSBS 86. B/P 91/50. Spouse requesting transport to ER for evaluation. MD notified. EMS notified. ER notified..." The resident's MARs documented the resident was administered his [MEDICATION NAME] 100 mg (stool softener) two times daily from 06/01/11 through 06/09/11, even though he had diarrhea documented from 06/06/11 through 06/09/11. The resident's emergency department report, dated 06/09/11, documented, "... History of Present Illness: The patient is a [AGE] year-old male who presents to the emergency department from [MEDICATION NAME]. The patient has been having low blood pressure, nausea, vomiting, and diarrhea with positive for [MEDICAL CONDITION] over the last two days. Additionally, the right lower foot has become extremely painful and has minimal pulse and is purple. He has had a known femoral blockage in that leg, but this is acutely worse in the last couple of days as well as the patient has been having difficulty with his mental status.. Physical examination... Blood pressure is 88/41... His right foot is purple and is cold. There is no palpable or Doppler pulse in the posterior tibial or dorsalis pedis. It is tender to palpation actually all the way up to his calf..." His hospital admission history and physical, dated 06/09/11, documented, "... having foot pain on the right which he states has been going on since January or February, but has worsened in the last couple of days. It is sharp and burning, 10/10 pain... Positive for fever, chills... Positive for reflux, nausea, vomiting... diarrhea... [MEDICAL CONDITION] toxin A and B was detected... there is none (pulse) on the right (foot). Blue discoloration of the foot. Tender on palpation... Admission diagnoses... Severe peripheral artery disease with occlusion on the right with foot pain... Dehydration... Acute [MEDICAL CONDITION]" On 08/12/11 at 9:20 a.m., the DON was asked if there was any further documentation regarding the assessments of the resident's foot. She stated, "It should be in the nurses' notes or on the weekly skin check sheets." According to the resident's hospital documentation, his right leg required amputation. 3. a. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 06/16/11, documented his cognition was moderately impaired. He required total assistance from the staff for transfers, ADL's and was incontinent of bowel. He had an indwelling urinary catheter (Foley). The resident's care plan, dated 06/16/11, documented to turn and reposition every two hours, Foley cath care every shift and document intake and output every shift. The intake and output records from 07/21/11 through 08/11/11 contained twenty-five blanks where the Foley output should have been documented. There was no intake or output recorded for the night shift on 08/10/11 or 08/11/11. A nurse's note, dated 08/07/11 for the 11 p.m. to 7 a.m. shift documented, "... Foley patent (with) cloudy yellow urine..." A nurse's note, dated 08/10/11 at 10:00 p.m., documented, "Received N/O for [MEDICATION NAME] 500 mg (antibiotic) by PEG (percutaneous endoscopic gastrostomy - feeding tube)... X 10 days..." A nurse's note, dated 08/11/11 for the 11 p.m. to 7 a.m. shift documented, "...conts on ABT VS 98.4 - 110 - 20 - 110/50 sats 95% (with) O2 @ 2L/NC Foley patent..." On 08/11/11 at 10:00 a.m., LPN #5 stated, "(LPN #3) said the resident hadn't had any output from his Foley from 2 a.m. until 7 a.m. I asked her why she didn't check it to see why it wasn't draining. She just shrugged her shoulders. I'm going to check it now." The LPN went to the resident's room and was observed to drain the bulb of the indwelling catheter and remove the catheter. Bright, red blood gushed out of the resident's penis. The LPN stated, "Oh my gosh, I've never seen that before. I have to go get my boss to see if I need to send him out (to the ER) or re-insert the catheter." The resident was diaphoretic (sweating), had a temperature of 100.8 (axillary), was breathing fast with a respiratory rate of 40 breaths per minute. His oxygen saturation was 93% and he was groaning. LPN #5 was asked how long the resident had been displaying symptoms of a UTI. She stated, "He wasn't like this yesterday. He must have gotten worse through the night. I don't know why (LPN #3) didn't do something." There was no documentation to show the LPN on the night shift had assessed the resident when he had a decreased urinary output. At 10:10 a.m., two CNA's entered the room to clean the resident up. The DON and corporate nurse came in to see about the resident. The corporate nurse stated to call the physician and send him to the ER for evaluation and treatment. At 11:00 a.m., the ambulance arrived and took the resident to the ER at a local hospital. At 3:55 p.m., LPN #5 was asked if she had heard how the resident was doing. She stated, "I just heard. He was admitted with urosepsis and [MEDICAL CONDITION]." b. There were no orders for the resident's indwelling urinary catheter, no medical [DIAGNOSES REDACTED]. 4. Resident #23 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note, dated 06/17/11, documented, "11-7 (11:00 p.m.-7:00 a.m. shift, starting 06/16/11 at 11:00 p.m.) - Awake - anxious (and) very needy tonoc (tonight) - constantly ringing call light. No acute distress noted. Med for anxiety X 1. Poor results. Needs met freq." The nursing assessment check off area of the daily skilled nurse's notes documented for the 7 a.m. to 3 p.m. shift on 06/17/11 that the resident was anxious, crying, tearful, confused, short of breath, and weak. There was no narrative nurse's note for the 7 a.m. to 3 p.m. shift. The next nurse's note was dated 06/17/11 and untimed. It documented, "Received resident in a weakened and disoriented state. O2 sat (down) to 79% on rm air. O2 @ 2L/NC placed on. O2 (up) @ 95%. B/P fluctuating. MD notified. Received order to send on to (local hospital) ER for eval (and) tx...ambulance here to transport (at) 1530 (3:30 p.m.)..." A hospital history and physical, dated 06/17/11, documented, "Chief Complaint: Shortness of breath. History of present illness: Patient is a [AGE] year-old female transferred from the rehabilitation unit at [MEDICATION NAME] because of increasing shortness of breath... The patient stated that approximately four days prior to admission, she had noted increasing shortness of breath and on the day of admission, severe shortness of breath and was brought to the emergency room ... Patient appears to be in moderate distress with shortness of breath... Decreased breath sounds throughout... there is a purplish discoloration of the left big toe and the second toe... The patient is lethargic but oriented times three... Investigations: Chest x-ray shows a pleural effusion. Assessment: This is a [AGE] year-old female in [MEDICAL CONDITION]. Plan: The plan is admission in intensive care unit, aggressive diuresis, cardiac echo and a cardiology consult." The current physician's orders [REDACTED]. A care plan, dated 07/06/11, documented, "Problems: (Resident #23) is in need of a fluid restriction... Goals: (Resident #23) will be able to maintain and follow fluid restriction without problems thru the next 90 days. Interventions: ... Fluid restriction as ordered. Teach resident the importance of remaining of diet as ordered and restriction..." The resident's total intake and output record (I&O's) from 07/06/11 through 07/19/11 and 07/26/11 through 07/31/11, contained 25 blanks for intake and 25 blanks for output. There were no records available to review for 07/20/11 through 07/25/11. The weekly intake and output evaluations at the bottom of the form were not completed. The resident's I&O record from 08/01/11 through 08/11/11, contained 11 blanks for intake and 11 blanks for output. The weekly intake and output evaluations at the bottom of the form were not completed. The resident's comprehensive assessment, dated 07/26/11, documented her cognition was intact. She required extensive assistance from the staff for bed mobility, transfers, ambulation, toilet use, dressing, hygiene and bathing. She was incontinent of bowel and bladder. On 08/11/11 at 3:10 p.m., the resident was asked about her care in the facility. She was asked about her illness in June 2011. She stated, "Oh my goodness, I was so sick. I couldn't breathe. I kept telling them something was wrong, but they didn't believe me. The night before I went to the hospital, I thought I was going to suffocate. The nurse gave me a nerve pill and told me just to go to sleep and I would feel better in the morning. It didn't help. I couldn't catch my breath. That is a very scary feeling." At 3:25 p.m., LPN #8 was interviewed about the resident's illness. She stated, "When I came in that morning and got out of report, I went to check on her, she was in bad shape. Her O2 sats were in the 70's, she was crying and couldn't catch her breath. Her lung sounds were decreased. I called her doctor and couldn't reach him, so I called our medical director and got orders to send her out." 5. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's care plan, dated 04/12/11, documented, "Problems: (Resident #18) is at risk for impaired airway clearance R/T [MEDICAL CONDITION]. Goals: Will have no SOB for the next 90 days. Interventions: Monitor lung sounds and congestion prn. Monitor [MEDICAL CONDITION] function by oxygen sat, the respiration rate and any coughing... Medications as ordered. Problems: (Resident #18) is at risk for impaired breathing pattern, shortness of breath on exertion R/T [MEDICAL CONDITION] Goals: Maintain patent airway as evidenced by improved breath sounds and absence of dyspnea thru review period. Interventions: Monitor lung sounds and congestion prn... Note any respiratory distress such as increased respirations, shallow breathing or increased congestion..." The resident's comprehensive assessment, dated 07/11/11, documented her cognition was intact. She required supervision for ADL's. She was on a scheduled pain medication regimen and experienced shortness of breath with exertion. She was occasionally incontinent of urine. A physician's orders [REDACTED]. Chest Xray today (and) report to me. [MEDICATION NAME] 20 mg (steroid) po now (and) daily X 2 more days. Send stat." A chest xray, dated 08/05/11, documented, "... There is an infiltrate in the left lung base... A small left pleural effusion is not fully excluded... Impression: Mild left lower lobe infiltrate. Cannot exclude a small left pleural effusion... [MEDICAL CONDITION]" A physician's telephone order, dated 08/08/11, documented, "[MEDICATION NAME] (antibiotic) 500 mg (one) PO q day X 7 days. Dx: Pneumonia. Send STAT." On 08/10/11 at 12:30 p.m., the resident was observed as she sat on the side of her bed and administered her own breathing treatment through her trach. She was asked about it. She stated, "Honey, I'm lucky if they bring me the medicine to do it with. I have to ring my call bell to get it most of the time. There is no way they have time to stay in here while it's going." She was asked if the nurses listen to her lungs before and after the breathing treatments. She stated, "No and I am on antibiotics for pneumonia right now." At 12:50 p.m., LPN #4 was asked if the resident's lung sounds were assessed. She stated, "Yes. They are supposed to be assessed every shift." She was asked if the resident's lung sounds were assessed before and after her breathing treatments. She stated, "Probably not every time. She takes a lot of breathing treatments. She usually does them herself." 6. a. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 05/30/11, documented her cognition was modified independence. She required extensive assistance from the staff for bed mobility, transfers and ADLs. She required total assistance from the staff for toileting. She was frequently incontinent of bowel and bladder. It documented the resident had one Stage I and one Stage III pressure sores. The resident's treatment sheet for June 2011, documented, "05/10/11 (original date of the physician's orders [REDACTED]." "05/11/11 - [MEDICATION NAME] R (fast acting insulin) 100 u/ml... Use per sliding scale: If FSBS 0-150 Give no insulin If FSBS 151-200 Give 4 units SQ If FSBS 201-250 Give 6 units SQ If FSBS 251-300 Give 8 units SQ If FSBS 301-350 Give 10 units SQ If FSBS >350 Give 12 units SQ The following errors were noted on the resident's treatment sheets: 06/01/11 at 6:30 a.m. - FSBS 160 - no insulin administered 06/13/11 at 6:30 a.m. - FSBS not obtained 06/14/11 at 6:30 a.m. - FSBS not obtained 06/15/11 at 6:30 a.m. - FSBS not obtained 07/03/11 at 9:00 p.m. - FSBS 215 - no insulin administered 07/07/11 at 6:30 a.m. - FSBS not obtained 07/09/11 at 6:30 a.m. - FSBS not obtained 07/11/11 at 11:30 a.m. - FSBS not obtained 07/13/11 at 11:30 a.m. - FSBS 207 -

Based on record review and interviews, it was determined the facility failed to provide supervision to prevent falls for one (#8) of five sampled residents who had experienced falls. One of the falls of resident #8 resulted in an actual harm of a fractured right hip which required surgery. Findings: The facility's fall prevention program, documented, "A Fall Prevention Program will be established and maintained, to assess all residents to determine their risks for falls. A plan of care will be implemented based on the resident's assessed needs." "When Falls Occur: When a fall occurs, staff must immediately: assess the injury, treat the injury; and identify the cause of the fall. Initiate the comprehensive assessment following a fall form. Initiate interdisciplinary assessment/intervention checklist. Document on the checklist the interventions and the date implemented." Resident #8 was admitted on [DATE] with a history of falls. Her initial fall risk assessment, dated 08/17/10, documented her fall score was 11. (A score of 10 or higher is a high fall risk.) On the back of the assessment, documented, "Intervention: Frequent monitoring and call light in use." The resident's care plan, dated 08/17/10, documented she was at risk for falls related to a history of falls. The interventions were: "Add to fall program Assist with transfers, ambulation prn Encourage to ask for assistance Assure proper footwear Assist to bathroom regularly and prn Therapy to screen for falls." The resident had nine documented falls between 08/26/10 through 01/24/11. The resident's care plan update, dated 09/03/10, documented, "New walker ordered, received, works better." An update, dated 09/07/10, documented, "N.O. x-ray R hip/pelvis r/t post fall, hx of fx of hip." The resident had an unwitnessed fall on 09/15/10. She stated she hit her head on the wall. The resident had an unwitnessed fall on 10/02/10 at 7:00 p.m. The incident report, documented she fractured her hip. There were no interventions documented to prevent reoccurrence. The resident's care plan, updated on 10/02/10, documented, "Sent to (local hospital) - Dx: Fx distal femur." The resident's care plan, updated on 10/07/10, documented, "Bed alarm applied. Bed in low position. Call light in reach." The fall risk assessment updated on 10/07/10, documented, "Score - 22. Intervention: Bed, chair alarm applied. Bed in lowest position. Call light in reach. Frequent monitoring." The resident had unwitnessed falls on 12/12/10 at 3:00 p.m., 12/26/10 and 01/02/11 at 8:45 p.m., 01/16/11 at 10:50 p.m. and 01/24/11 at 11:30 a.m. There had been no other updates or evaluations of the interventions since 10/07/10, documented on the resident's fall care plan. There was no documentation that the falls had been investigated to determine the cause of the falls. On 03/02/11 at 3:00 p.m., the ADON #3 was asked about the resident's falls and care plan updates. She stated, "I remember her. We tried a lot of things to keep her from falling but nothing worked."