Every finding on record at New Hope Retirement & Care Center

Based on observation, record review, and interview, the facility failed to ensure:a. prepared food items were labelled with the preparation and use-by dates,b. food items were discarded after the expiration dates,c. temperature logs were accurate and completed for refrigerators and freezers,d. food temperatures were checked and logged for prepared food items, e. food was prepared in a sanitary environment, andf. food was not stored on the floor in dry storage area. The administrator identified 37 residents received nutrition from the kitchen. Findings:On 12/22/25 at 9:48 a.m., the following observations were made in the double door refrigerator in the kitchen:a. a container of prepared coleslaw with a manufacturer use by date of 12/13/25. b. a container of cottage cheese with a manufacturer use by date of 11/15/25. c. two plastic pitchers with lids with juice type liquid contents without label, preparation or use by datesOn 12/22/25 at 9:59 a.m., a log sheet titled Daily Refrigerator and Freezer Temperature Log, dated December 2025, was reviewed. There was no documentation of temperatures for December 22 and December 23. On 12/22/25 at 10:20 a.m., six chest type freezers with frozen food items were observed. There were not visible thermometers inside.On 12/22/25 at 10:30 a.m., the food preparation area between stove, steam table and counters was observed to have missing floor tiles. The floor in the dry food storge area was observed to have rough surfaces with debris and buildup of a dark matter.On 12/22/25 at 10:32 a.m., two cardboard boxes of apple juice drink blend were observed stored on the floor of the dry storage room under shelving.On 12/23/25 at 11:30 a.m., cook #1 was observed to prepare food for lunch service without checking temperatures of the prepared foods. A facility policy titled Sanitation and Infection Control, dated 2005, read in part, refrigerate food in small, shallow, covered, dated and labelled containers.A facility policy titled Food Cookery, dated 2005, read in part, use a meat thermometer to check internal temperatures.On 12/23/25 at 11:30 a.m., cook #1 stated they did not know they were supposed to check the temperatures of food when it was finished cooking.On 12/23/25 at 11:35 a.m., the dietary manager stated they did not have a process in place or a log for food that was cooked and served. On 12/23/25 at 12:00 p.m., the dietary manager stated they knew food items in the refrigerator were supposed to be labeled and dated and expired food items have been discarded. The dietary manager stated thermometers had been ordered for the freezers and the staff had not been checking them since there were not any thermometers in the freezers. The dietary manager stated the floors had been a problem for several months and were scheduled to be repaired. The dietary manager stated they had been very difficult to clean with the missing tiles and rough floor surface.

Based on observation, record review, and interview, the facility failed to follow the menu for 1 of 1 meal services observed.The administrator identified 37 residents received nutrition from the kitchen.Findings:On 12/22/25 at 12:30 p.m., chicken fried steak, mashed potatoes and gravy, cream corn, dinner roll and pineapple crisp was observed to be served for the noon meal. The menu for week five showed crumb crusted chicken, savory rice, Brussel sprouts, dinner roll and pineapple crisp.An undated policy titled, Menu Substitution, read in part, menu substitutions will be recorded on a substitution record form. The reason for the change will also be noted. On 12/22/25 at 12:30 p.m., the dietary manager stated they were working off of the week five menu this week and had to substitute items due to not having the menu items available. The dietary manager stated they did not document substitutions or specific reasons for substitutions and did not have a form that they were aware of.

Based on record review and interview, the facility failed to ensure dietary staff received training in safe food handling practices for the prevention of foodborne illness for 2 (Cook #3 and Dietary Aide #3) of 7 dietary staff reviewed for staff training. The administrator identified 37 residents received meals from the dietary department. Findings:On 12/22/25 at 11:10 a.m., the dietary manager was asked for verification of food handlers training for all dietary staff.On 12/30/25 at 3:00 p.m., the administrator submitted copies of food handlers training certificates for five of the seven dietary staff. The administrator stated cook #1 and dietary aide #3 had not received the required training.

Based on observation, record review, and interview, the facility failed to ensure a physician's order was followed for 1 (#42) of 1 sampled resident reviewed for respiratory care.The administrator identified one resident used a BIPAP machine.Findings: On 12/29/25 at 2:53 p.m., Res #42 was observed resting in bed, stated they were taking a nap. Res #42's BIPAP machine was not turned on, and the mask was sitting on the resident's bedside table. On 12/30/25 at 2:04 p.m., Res #42 was observed resting in bed with their eyes closed. Res #42's BIPAP machine was not turned on. The mask was observed sitting on the resident's bedside table.On 12/31/25 at 8:52 a.m., Res #42 was observed resting in bed with their eyes closed. Res #42's BIPAP machine was not turned on. The mask was observed sitting on the bedside resident's bedside table.A physician order, dated 07/14/25, showed BIPAP oxygen at 3 LPM at HS and while taking naps.On 12/31/25 at 2:21 p.m., RN #1 stated the resident should have had the BIPAP on during naps.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2-hour required time frame for 1 (#25) of 3 sampled residents reviewed for abuse. The administrator identified 37 residents resided in the facility. Findings:An undated facility policy titled Abuse Prohibition, read in part, the facility shall report all alleged violations and all substantial incidents to the state agency.An admission assessment, dated 12/21/24, showed Resident #25 had diagnoses which included unspecified dementia with behavioral disturbances, hyperlipidemia, anxiety disorder, and migraines.An allegation of abuse, reported to the facility administrator on 12/17/25, showed a facility staff member was observed to be rough while assisting Res #25 to a chair and spoke loudly to the resident. This allegation of abuse was not reported to the OSDH.On 12/31/25 at 12:10 p.m., the administrator stated the abuse allegation incident was reported to them and it was immediately investigated, including camera review by the cooperate office. The administrator stated they did not feel it was a reportable incident after the investigation and did not submit an incident report.

Based on observation and interview, the facility failed to ensure the removal of expired medications and supplies from 1 of 1 medication rooms observed.The administrator reported 37 residents resided in the facility.Findings: On 12/31/25 at 1:15 p.m., the medication storage room was observed with RN #1. The following medications/supplies were observed to be expired:One box of 25-gauge needles with 3 ml syringe with an expiration date of 08/31/25,One box of 21-gauge needles with 3 ml syringe with an expiration date of 12/02/25,Four packets of Dyna Lube (a lubricating jelly) with an expiration date of 03/20/20,Eight tubes of lubricating jelly with an expiration date of 11/24/22,Eleven bisacodyl suppositories with an expiration date of 08/05/25,Six bisacodyl suppositories with an expiration date of 03/24/25.On 12/31/25 at 1:30 p.m., RN #1 stated the expired medications and supplies should have already been removed.

Based on record review and interview, the facility failed to ensure the water management plan to prevent waterborne pathogens had the participation of the infection preventionist. The administrator identified 37 residents resided in the facility.Findings:A facility policy titled Legionella Water Management Program, dated 1/2022, read in part, As part of the infection prevention control program, our facility has a water management program, which is overseen by the water management team. The document also showed:a. there was a water management team consisting of the infection preventionist, the administrator, the medical director or their designee, the director of maintenance, and the director of environmental services,b. a detailed description and diagram of the water system in the facility, including receiving, cold water distribution, heating, hot water distribution and waste, andc. the identification of areas in the water system that could encourage growth and spread waterborne bacteria.A facility cleaning schedule attached to the Legionella water management program for 2025, showed shower heads and quarterly cleaning schedule completed for January, April and July 2025. There was no documentation located for the month of October 2025.On 12/30/25 at 2:24 p.m., the infection preventionist stated they did not know they were on the water management team.On 12/30/25 at 2:24 p.m. the administrator stated they did not have a diagram for a water management program and there was no documentation for the month of October 2025 in the logbook.

Based on record review and interview, the facility failed to ensure assessments were accurate for anticoagulation therapy for 1 (#25) of 4 sampled residents reviewed for resident assessments.The administrator identified 37 residents resided in the facility. Findings:A quarterly assessment, dated11/05/25, showed Resident #25 received anticoagulant therapy.Resident #25's medication administration record, dated November 2025, did not show an anticoagulant medication.On 12/31/25 at 12:42 p.m., the minimum data set coordinator stated Resident #25 did not take an anticoagulant medication. They stated the assessment was coded in error and would be modified.

Based on observation, record review, and interview, the facility failed to ensure the physical environment was maintained in good repair.The administrator identified 39 residents resided in the facility.Findings:On 07/15/25 at 7:55 a.m., during a tour of the dining room, the ceiling was observed to have multiple ceiling tiles with large brown watermark stains.On 07/17/25 at 3:30 p.m., during a tour of the facility, resident rooms #2, #4, #17, and #28 were observed to have sagging white ceiling tiles. The ceiling tiles had brown watermark stains around and near the air vents.A policy titled Homelike Environment, revised February 2021, read in part, Residents are provided with a safe, clean, comfortable and homelike environment.On 07/17/25 at 3:42 p.m., the maintenance supervisor stated the sagging tiles with brown watermark stains were caused by water leaks from the roof. They stated the facility's roof leaked every time it rained. The maintenance supervisor stated they tried to change out the stained and sagging ceiling tiles often, but the roof needed to be permanently repaired.On 07/17/25 at 4:01 p.m., the administrator stated the facility's roof had leaked since they began employment in February 2024. They stated management was aware, but had not permanently addressed the concern. The administrator stated the physical environment of the facility had not been maintained in good repair.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for indwelling urinary catheter care and maintenance for 1 (#2) of 2 residents sampled for indwelling urinary catheters.The administrator identified one resident with an indwelling urinary catheter.Findings:An undated medical diagnosis list showed Res #2 had diagnoses which included retention of urine and congenital bladder neck obstruction.A physician order, dated 08/07/24, showed to change the indwelling urinary catheter every 30 days and as needed and to perform catheter care every shift and as needed.A quarterly assessment, dated 08/21/24, showed Res #2 had a BIMS score of 12 and was cognitively intact. The assessment showed Res #2 had an indwelling urinary catheter.Res #2's care plan was reviewed. There was no documentation for indwelling urinary catheter care and maintenance shown on the care plan.On 07/15/25 at 4:35 p.m., the MDS coordinator stated a comprehensive care plan for urinary catheter care and maintenance had not been developed for Res #2, but should have been.

Based on record review and interview, the facility failed to update a resident's care plan after abusive behavior was observed for 1 (#3) of 3 sampled residents reviewed for abuse.The administrator identified 39 residents resided in the facility.A care plan policy, revised March 2022, showed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The policy showed when possible, interventions addressed the underlying sources of the problem areas, not just symptoms or triggers. The policy showed assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change.A facility reported incident, dated 04/27/25, showed an allegation of abuse/mistreatment involving Resident #3 and Resident #6. The reported incident showed resident to resident abuse by staff. Immediate separation of residents. Alleged abuser had one on one provided while arrangements being made for behavioral placement.There were no updates to Resident #3's care plan regarding the above incident.A nursing note, dated 04/27/25 at 11:00 a.m., read in part, Resident approached another resident and was seen pushing [them] up to the table and trying to lock the wheelchair and was instructed to move on and leave resident alone. [Resident #2] approached [Resident #6] again and was seen criss [sic] crossing the strings on a neck pillow that was on the residents neck and was stopped by kitchen staff and reported it appropriately.[Name withheld] PD [police department] contacted and out to make a report and [report number withheld].DHS [Department of Human Services] LTC [long term care] notified and APS [Adult Protective Services], DON [director of nursing], ADM [administrator], Dr. [doctor] [name withheld] and contacted family [name withheld] .One on one at all times since incident and until [they] leave the facility, pending admission acceptance to a behavioral health center.An annual resident assessment, dated 06/16/25, showed Resident #3's cognition was intact (BIMS 13). The assessment showed Resident #3 had diagnosis which included non-Alzheimer's dementia.Resident #3's care plan, revised 07/08/25, did not show behaviors or interventions had been added to the care plan.On 7/15/25 at 12:42 p.m., MDS coordinator stated the care plan was not updated with new interventions after the incident. They stated care plans were to be updated with any MDS changes, hospital stays, and any changes in health.

Based on record review and interview, the facility failed to notify the physician of signs and/or symptoms of a potential infection at a urinary catheter's entry site for 1 (#2) of 2 residents sampled for indwelling urinary catheters.The administrator identified one resident with an indwelling urinary catheter.Findings:An undated policy titled Communication of Resident Condition and Treatment with Antimicrobial Orders, read in part, When facility staff suspects a resident has an infection, the nurse should appropriately document a comprehensive assessment of the resident using established and accepted assessment protocols. This assessment will determine if the resident's status meets minimum criteria for initiating antibiotics. When contacting a physician to communicate to discuss a resident's change in condition and a suspected infection, a nurse should have the medical record available and should communicate the following: written results of the written resident assessment, signs and symptoms, and time symptoms first observed.An undated medical diagnosis list showed Res #2 had diagnoses which included retention of urine and congenital bladder neck obstruction.A physician order, dated 08/07/24, showed to monitor Res #2's catheter's insertion site for signs and/or symptoms of infection and report to the physician if present.A quarterly assessment, dated 08/21/24, showed Res #2 had a BIMS score of 12 and their cognition was moderately impaired. The assessment showed Res #2 had an indwelling urinary catheter.A physician order, dated 09/03/24, showed Res #2 was scheduled for suprapubic catheter placement on 09/11/24.A nurse note, dated 09/05/24 at 7:44 p.m., showed odorous brownish drainage was observed on the penile area during catheter care.A nurse note, dated 09/07/24 dated at 10:19 a.m., showed brown drainage was observed during catheter care.A nurse note, dated 09/08/24 at 10:36 a.m., showed tannish brown drainage was observed coming from the urethra during catheter care.A nurse note, dated 09/08/24 at 7:18 p.m., showed brown drainage continued from the urethra during catheter care.A nurse note, dated 09/10/24 at 7:32 p.m., showed the resident was scheduled to have a suprapubic catheter placed at the hospital on [DATE] at 8:00 a.m.A nurse note, dated 09/11/24 at 2:28 p.m., showed Res #2 had been admitted to the hospital for a urinary tract infection and hypotension. The note showed the suprapubic catheter procedure was not performed.A hospital physician report, dated 09/11/24 at 4:04 p.m., showed Res #2 was admitted to the medical surgical floor for treatment of a complicated urinary tract infection with antibiotics.A nurse note, dated 09/12/24 at 6:46 p.m., showed Res #2 returned to the facility from the hospital. The note showed the suprapubic catheter had not been placed.On 07/15/25 at 2:47 p.m., RN #1 stated it was the nurse's responsibility to monitor catheter insertion sites for signs and/or symptoms of infection such as redness, irritation, and drainage. They stated if any signs and/or symptoms of infection were observed the physician should have been notified.On 07/15/25 at 4:00 p.m., RN #2 stated Res #2 had a history of recurrent urinary tract infections and discharge from the catheter entry site. They stated Res #2 had not been feverish or complained of pain. RN #2 stated they could not remember if the physician had been notified of the brown discharge at the catheter entry site. They denied documentation of the physician having been notified or their response.On 07/16/25 at 8:00 a.m., the infection preventionist stated the physician should have been notified after the staff observed discharge with odor from Res #2's penile area. They stated the discharge could have been an indication of an infection.

Based on observation and interview, the facility failed to post the required staffing information. The administrator identified 39 residents who resided in the facility. Findings: On 11/05/24 at 11:00 a.m., posted staffing was observed to be documented on a white board at the nursing station. The date, census, and staff/title were documented. The facility name and projected and actual staffing hours were not documented. On 11/07/24 at 9:02 a.m., posted staffing was observed to be documented on a white board at the nursing station. The date, census, and staff/tile were documented. The facility name and projected and actual staffing hours were not documented. On 11/07/24 at 9:52 a.m., the DON reported they were unaware of what staffing information was required to be documented on the staffing board.

Based on observation, record review, and interview, the facility failed to date and cover urinary catheter bags for two (#11 and #35) of two sampled residents reviewed for urinary catheters. The DON identified four residents with urinary catheters. Findings: 1. Res #11 had diagnoses which included overactive bladder, paraplegia, and a stage 4 sacral pressure ulcer. A physician order, dated 05/29/23, documented catheter care per facility guidelines. A discharge return anticipated assessment, dated 10/24/24, documented the resident was modified independent for daily decision making and had a urinary catheter. On 11/05/24 at 11:00 a.m., the resident was lying in bed with a urinary catheter bag hanging from the bedside. The bag was not dated or covered. On 11/07/24 at 2:23 p.m., the DON stated the resident's urinary catheter bag should have been dated and covered. 2. Res #35 had diagnoses which included retention of urine and congenital bladder neck obstruction. A physician order, dated 08/07/24, documented catheter care per facility guidelines. On 11/05/24 at 11:21 a.m., the resident was sitting in a recliner in their room. The resident's urinary catheter bag was hanging from the side of the chair. The catheter bag was not dated or covered. On 11/06/24 at 8:33 a.m., the resident was sitting in a chair in their room. The resident's catheter bag was hanging from the chair. The catheter bag was no dated or covered. On 11/07/24 at 10:20 a.m, the resident was sitting in their room in a recliner. The resident's catheter bag was hanging from the chair. The catheter bag was not dated or covered. On 11/07/24 at 2:23 p.m., the DON stated the resident's urinary catheter bag should be dated and covered.

Based on record review and interview, the facility failed to ensure DNR orders were in place for three (#4, 7 and #10) of 14 sampled residents whose advance directives were reviewed. The administrator identified 12 residents who were DNR's. Findings: A Do Not Resuscitate Order policy, dated [DATE], read in part, 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. 1. Res #4 had diagnoses which included type 2 diabetes mellitus and cerebral infarction. A Do Not Resuscitate care plan, dated [DATE], documented Res #4 did not want CPR performed if their heart/respirations should stop. Res #4 signed an Oklahoma Do Not Resuscitate (DNR) Consent Form was signed on [DATE]. Res #4 did not have a physician's order for a DNR. 2. Res #7 had diagnoses which included Parkinson's, dementia, behavioral disturbance, and anxiety. A Do Not Resuscitate care plan, dated [DATE], documented Res #7 did not want CPR performed if their heart/respirations should stop. The POA for Res #7 signed an Oklahoma Do Not Resuscitate (DNR) Consent Form on [DATE]. Res #7 did not have a physician's order for a DNR. 3. Res #10 had diagnoses which included chronic kidney disease stage 3, type 2 diabetes mellitus, and congestive heart failure. A Do Not Resuscitate care plan, dated [DATE], documented Res #10 did not want CPR performed if their heart/respirations should stop. Res #10 signed an Oklahoma Do Not Resuscitate (DNR) Consent Form was signed on [DATE]. Res #10 did not have a physician's order for a DNR. On [DATE] at 10:58 a.m., the MDS coordinator reported the residents did not have an order for a DNR and was not aware an order needed to be written for DNR residents.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#21 and #28) of 14 sampled residents whose resident assessments were reviewed. The administrator identified 39 residents who resided in the facility. 1. Res #21 had diagnoses which included heart failure, cerebral infarction, and history of pulmonary embolism. A physician's order, dated 09/24/22, documented the resident was taking aspirin (antiplatelet mecication) 81 mg daily. A 5 day resident assessment, dated 09/24/24, documented the resident was taking an anticoagulant. The resident assessment did not document the resident was taking an antiplatelet. On 11/07/24 at 10:55 a.m., the MDS coordinator reported the medication section of the resident assessment is auto-populated and they did not catch the error of an anticoagulant being documented. The MDS coordinator reported antiplatelet should have been documented. 33097 2. Res #28 had diagnoses which included atrial fibrillation and chronic obstructive pulmonary disease. A physician's order, dated 08/21/24, documented the resident was admitted to hospice services for a diagnosis of chronic obstructive pulmonary disease. The admission assessment, dated 08/27/24, did not document the resident was receiving hospice services. On 11/07/24 at 3:29 p.m., the MDS coordinator reviewed the admission assessment for the resident. They stated the assessment did not document the resident was receiving hospice services.

Based on record review and interview, the facility failed to ensure there was documentation of the coordination of care between hospice and the facility for one (#28) of one sampled resident reviewed for hospice care. The DON identified three residents who received hospice services. Findings: Res #28 had diagnoses which included atrial fibrillation and chronic obstructive pulmonary disease. A physician's order, dated 08/21/24, documented the resident was admitted to hospice services for a diagnosis of chronic obstructive pulmonary disease. The admission assessment, dated 08/27/24, did not document the resident was receiving hospice services. On 11/06/24 at 2:41 p.m., the administrator could not provide hospice documentation regarding the resident's hospice services, including the plan of care.

Based on record review and interview, the facility failed to ensure a resident who received psychotropic medication had an acceptable diagnosis/indication for the use of an antipsychotic medication for one (#33) of five sampled residents reviewed for unnecessary medications. The DON identified 10 residents who received antipsychotic medications. Findings: Res #33 had diagnoses which included dementia without behavioral or psychotic disturbances, anxiety disorders, and unspecified mood affective disorder. A physician order, dated 10/21/24, documented the resident was to receive Risperidone (an antipsychotic medication) 0.5 mg two times a day. The admission assessment, dated 10/28/24, documented the resident was cognitively intact and was receiving a antipsychotic and a antianxiety medication. The care plan, dated 11/01/24, documented the resident received psychotropic medication. The care plan documented staff were to monitor for behaviors, verbal and non-verbal, for which the medication was being given. On 11/06/24 at 4:01 p.m., the DON reviewed the resident's clinical record. The DON was unsure if the resident had an appropriate diagnosis for the use of the antipsychotic medication. On 11/06/24 at 4:06 p.m., the facility pharmacist reviewed the resident's medication and diagnoses list. The pharmacist stated the resident was receiving an antipsychotic medication and did not have a diagnosis for the use of the medication.

Based on record review and interview, the facility failed to ensure a resident experiencing pain was monitored for pain for one (#39) of one sampled resident reviewed for pain. The administrator identified 39 residents who resided in the facility. Findings: Res #39 had diagnoses which included muscle spasm, pain, and anxiety disorders. A physician order, dated 09/27/24, documented the resident was to receive Tramadol (a narcotic medication) 50 mg two tablets by mouth every eight hours as needed for pain. The resident did not have a physician order for scheduled pain medication. An admission assessment, dated 10/01/24, documented the resident was cognitively intact and had occasional pain rated six on a pain scale from 0 to 10. The care plan, dated 10/04/24, documented the resident had pain. The care plan documented the resident was to have pain relieved or controlled as evident by facial expression and verbalization of pain relief. A physician order, dated 10/15/24, documented staff was to monitor the resident's pain daily every morning, evening, and night shift. The staff was to document a Y for yes if the resident had pain and a N for no pain. On 11/05/24 at 2:53 p.m., the resident stated they always had pain to their left arm and leg. They stated the pain medication given provided some relief. On 11/07/24 at 1:49 p.m., the DON stated monitoring for pain was not completed as ordered by the physician for the resident.

Based on record review and interview, the facility failed to ensure the physician was notified of out of parameter blood sugars for two (#21 and #31) of three sampled residents whose diabetic records were reviewed. The administrator identified 12 residents whose blood sugars were monitored. Findings: 1. Res #21 had diagnoses which included type 2 diabetes with autonomic polyneuropathy. A physician's order, dated 04/26/24, read in part, Obtain and record FSBS (finger stick blood sugar) .ac and hs. Notify physician if FSBS <70 or >400. On 10/02/24 at 4:30 p.m., Res #21's blood sugar was 458. There was no documentation in the narrative note or blood glucose MAR the physician was notified of the out of parameter blood sugar. 2. Res #31 had diagnoses which included type 2 diabetes mellitus. A physician's order, dated 08/12/23, read in part, Obtain and record FSBS .ac and hs .Notify physician if FSBS <60 or >400. There was no documentation in the narrative note or blood glucose MAR the physician was notified of the following out of parameter blood sugars: a. on 09/20/24 at 10:10 p.m., blood sugar was 403, b. on 09/24/24 at 10:15 p.m., blood sugar was 475, c. on 09/27/24 at 8:30 p.m., blood sugar was 404, d. on 09/30/24 at 9:00 p.m., blood sugar was 431, and e. on 10/14/24 at 4:18 p.m., blood sugar was 429. On 11/07/24 at 1:20 p.m., RN #1 reported the physician should be notified of an out of parameter blood sugar. On 11/07/24 at 1:25 p.m., the DON reported physician notification of an out of parameter blood sugar would be documented in the narrative note or the blood glucose MAR. If there was no documentation the physician was not notified and should have been. 45913

Based on observation, record review, and interview, the facility failed to provide treatment and services to prevent worsening of a pressure ulcer for one (#4) of four sampled residents reviewed for pressure ulcers. The LPN #1 identified two residents with pressure ulcers. Findings: A facility pressure ulcer policy and procedure read in part, the facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility with pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable. The policy also read, aggressive and appropriate preventative measures and care are provided to address a resident's unique risk factors. Res #4 admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, osteoporosis, and fracture of part of the neck of right femur. A care plan, dated 07/15/24, documented to assess skin condition and treat as needed. A nursing note, dated 07/15/24, documented a small pressure area noted to buttocks, zinc oxide applied. No redness noted to surrounding skin. There was no further description or mention of this wound until 07/22/24. A bath sheet, dated 07/19/24, documented the presence of a scratch/tear to right leg. There was no mention of pressure wounds at all. A nursing note, dated 07/22/24, documented the CNA that bathed resident noticed some wounds and notified the nurse. It was documented as noted 3 open areas to buttocks. A 1cm x1cm open area to left lower sacrum. A 3 cm by 4 cm open area with slough noted to sacrum in center of buttocks. A 3 cm by 3 cm open area, black in color, noted to right buttocks. The wounds were not staged only described. A nursing note, dated 07/23/24, documented the physician was notified of the wounds to buttocks and sacrum, and new orders were received to cleanse area with NS or wound wash. pat dry. apply medihoney, cover and secure every shift and as needed until resolved. This was the first notification to the physician of the wound. A physician order, dated 07/24/24, documented to provide a cushion to wheelchair at all times while up. On 07/31/24, at 11:11 a.m., LPN #1 and DON were observed providing wound care to resident #4's buttocks, left of sacrum. The wound was not measured but was approximately the size of a quarter. It was 100% covered in slough. On 07/31/24 at 12:13 p.m., LPN #1 stated they admitted resident #4, and the area to the buttocks was not open at that time. They stated residents are to be turned every 2 hours, but resident #4 wants to sit down in their wheelchair and lay on their back. They stated staff tell each other interventions verbally, but it also will show up in the Treatment record. The Treatment record documented the order for medication to the wounds were initiated on 7/23/24 and the cushion to the wheel chair was initiated on 07/24/24. Repositioning every 2 hours was the only wound care intervention documented prior to 07/22/24. On 07/31/24, at 12:20 p.m., the administrator stated it looks like we haven't done anything. The administrator stated that resident #4 has now seen VOHRA wound care once since the wound was identified, but they were unable to provide those records.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure four newly identified Stage II pressure sores had been completely assessed, reported and a treatment obtained from a physician for one (#6) of one sampled resident identified with pressure sores. b) Ensure pressure sores had been completely assessed and monitored for two (#3 and #4) of two sampled residents with a history of pressure sores. This had the potential to affect 29 of 29 residents at risk for skin breakdown. Findings: The facility's 'Policy and Procedure' for 'Maintaining Skin Integrity', documented, "...Each resident will have their skin assessed for redness, bruising, abrasions, open areas, etc. weekly and PRN by a licensed nurse...The nurse discovering the skin changes is responsible for notifying physician, family and DON or ADON. The nurse on duty at the time the physician returns the phone call is responsible...for charting all measurements (width, height, and depth if possible, location (using correct anatomical terms)). When charting, enter times physician, family, DON or ADON were notified. Place resident in shift charting until area is healed..." 1. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident required extensive assistance of two persons with bed mobility and was at risk of developing pressure sores. On 05/07/13 at 1:00 p.m., the resident was observed lying in bed in her room. A resident's family member was at her bedside visiting. The resident's care plan documented a Stage I to coccyx on 04/01/13, [MEDICATION NAME] applied. Interventions included evaluate skin weekly and report redness, open area, blister etc. to charge nurse. The 'Weekly Skin Assessment', for 04/13/13, 04/20/13, 04/27/13, and 05/04/13, documented skin intact with slight redness on buttocks. On 05/07/13 at 1:15 p.m., observation was made of the resident's skin condition with the ADON. The coccyx was reddened and had four opened areas. The ADON reported the four areas had just opened and she would measure the areas. On 05/07/13 at 3:00 p.m., a copy of the measurements of the four opened areas was received from LPN #1. The areas were documented as: Site 1: (1 cm round, 1 cm long, and 1 cm wide), Site 2: (0.5 round, 0.5 long, and 0.2 width), Site 3: (0.5 round, 0.1 cm. long, and 0.1 cm wide), and Site 4: (0.5 round, 0.1 cm long, and 0.1 cm width). None of the four sites were staged. On 05/08/13 at 9:00 a.m., the DON was interviewed regarding the four opened areas. She reported she had not been informed of the opened areas until earlier that morning. She reported she attempted to call the physician after she had been informed. The DON was asked if the nurse should have staged the opened areas. The DON replied they should have been staged when the skin opened when the nurse measured them. The DON reported the nurse who had observed and measured the opened areas should have informed both herself, the physician and the family of the opened areas yesterday when they had been discovered. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nursing admission assessment, dated 03/06/13, on day shift, documented the resident had two opened areas on the coccyx. The note did not describe the opened areas nor stage the pressure sore. A nurse's note, dated 03/06/13, on evening shift, documented the resident had an open area on the coccyx. The note did not describe the opened area. A physician's orders [REDACTED]. Nurses' notes, dated from 03/06/13 through 03/26/13, documented the resident had a pressure sore. The notes did not describe the sore. The admission assessment, dated 03/13/13, documented the resident was at risk for developing pressure sores. The medical record was reviewed, there was no documentation the pressure sore/sores had been assessed initially and/or weekly or monitored for the two weeks the pressure sores had been documented in the nurses' notes. On 05/06/13 at 10:30 a.m., the resident was observed lying on her bed reading a book. On 05/07/13 at 4:35 p.m., the ADON and the DON were asked if the resident's pressure sore/sores should have been assessed and monitored. They both reported they did not know the resident had a pressure sore. They thought the skin problem was just redness and/or excoriation. 3. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's current quarterly assessment was dated 04/17/13. The 'BIMS' portion of the assessment was blank. The 'Staff Assessment for Mental Status' portion document his cognition was independent, required maximum assistance with transfers, dressing, bathing, was frequently incontinent of bowel and had a Foley catheter, was at risk for pressure sores and at risk for falls. The assessment further documented he had a fall since prior assessment and had a healed 'Stage II pressure ulcer'. A nurse's note, dated 02/06/13, documented the resident had a small opened area to right buttocks. The physician was notified and the nurse received an order for [REDACTED]. No documentation was found as to the size or staging of the opened area in the nurses' notes or the weekly skin assessments. The nurses' notes and weekly skin assessments were reviewed between the dates of 02/06/13 through 04/09/13. No documentation was located describing the size or stage of the opened area. The area was documented as healed on 04/09/13, on the treatment sheet. On 05/06/13 at 3:15 p.m., the resident was observed during indwelling urinary catheter care. The area on his right buttock had healed. On 05/07/13 at 1:25 p.m., the DON was interviewed regarding the pressure sore. She was asked if the nurses should have assessed the opened area, described the area, measured the size and staged the pressure sore. She stated, "Yes."