Every finding on record at Okemah Care Center

Based on observation, record review, and interview the facility failed to: a. Discard gloves and gown after exiting and returning to the resident room after catheter care. b. Ensure staff changed gloves and wore a gown during wound care for 2 (#2 and #35) of 2 sampled residents reviewed for enhanced barrier precautions. The administrator identified nine residents with enhanced barrier precautions. Findings: 1. On 02/25/26 at 11:50 a.m., LPN #1 obtained supplies to complete catheter care for Resident #2. LPN #1 donned a gown and a pair of gloves. Catheter care was completed. The LPN #1 exited the room with the soiled washcloths and emesis basin of soapy water still wearing the gown and gloves used when care was provided. LPN #1 discarded the soapy water, five rooms down the hall, in a resident common bathroom. LPN #1 continued further down the hall to place the dirty linen in the dirty linen hopper. As LPN #1 walked down the hall to return to the resident room, they removed their gown and gloves and placed them in the trash can in the room of Resident #2. An ENHANCED BARRIER PRECAUTIONS POLICY AND PROCEDURE policy, dated 04/01/24, read in part, EBP WILL BE USED FOR RESIDENTS WITH INDWELLING MEDICAL DEVICES, WOUNDS, OR THOSE WHO ARE COLONIZED BY OR INFECTED WITH A MULTIDRUG - RESISTANT ORGANISM .3. CORRECTLY PUT ON A GOWN AND GLOVES 4. AFTER CARE, THROW AWAY GOWN AND GLOVES 5. CLEAN HANDS AGAIN. An annual assessment, dated 12/08/25, showed Resident #2 had diagnoses which included renal insufficiency, diabetes, and depression. The assessment showed Resident #2 had an indwelling catheter. The care plan, dated 01/09/26, showed Resident #2 had a supra-pubic catheter related to a neurogenic bladder and received catheter care every shift. The care plan showed Resident #2 was placed on enhanced barrier precautions related to the resident having a catheter. On 02/25/26 at 12:14 p.m., the administrator stated LPN #1 should not have entered the hall wearing the gown and gloves worn when catheter care was provided for Resident #2. On 02/26/26 at 10:04 a.m., the infection preventionist stated LPN #1 should not have exited the room wearing the PPE worn during resident care. The infection preventionist stated LPN #1 did not follow enhanced barrier precautions. 2. On 02/26/26 at 10:05 a.m., LPN #1 was observed to provide wound care to Resident #35. LPN #1 was not observed to change gloves between removal of soiled dressings, wound care, and application of clean dressings. They were not observed to don a gown prior to completing wound care. On 02/26/26 at 10:23 a.m., LPN #1 stated they should have changed gloves and performed hand hygiene in-between removing the soiled dressings and doing wound care, and they should have worn a gown for enhanced barrier precautions. On 02/26/26 at 10:37 a.m., the infection preventionist stated enhanced barrier precautions were not followed during the wound care observation. They stated this included glove changes, hand hygiene and wearing a gown.

Based on observation, record review, and interview, the facility failed to ensure the temperature log was maintained for one of one medication refrigerators observed for proper temperature controls for medication storage. The administrator identified 42 residents resided in the facility. Findings:On 02/24/26 at 1:50 p.m., a tour of the medication room was conducted with CMA #1. The temperature log sheet for the month of February 2026, located on the front of the medication refrigerator, showed no documentation for 02/20/26, 02/21/26, 02/22/26, and 02/23/26. The refrigerator was observed to be 42 degrees Fahrenheit.A Medication Storage in the Facility policy, dated 5/2025, read in part, Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept on a refrigerator with a thermometer to allow daily temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.On 02/25/2026 at 9:45 a.m., the DON stated the night shift is assigned to complete the temperature checks and documentation. They stated have had issues with the log sheet being completed in the past. The DON stated it should be done daily.

Based on observation, record review and interview, the facility failed to ensure oxygen (O2) tubing was labeled and dated for two, (26, and #36) of four residents sampled for respiratory care.The DON identified four residents that received oxygen therapy.Findings : On 02/23/26 at 12:35 p.m., Resident #26 was observed using oxygen tubing with a label dated 02/13/26. On 02/24/26 at 2:16 p.m., Resident #36 was observed using oxygen tubing with no label and without a date. An undated, Oxygen Concentrator Maintenance, read in part, All tubing will be changed weekly and PRN as needed for soiling. Tubing will be dated and initialed when completed.On 02/23/26 at 1:20 p.m., LPN #1 confirmed Resident #26 did use the oxygen and the label on the tubing was dated 02/13/26. They stated they thought it was to be changed out weekly.On 02/25/26 at 11:06 a.m., LPN #1 confirmed Resident #36 did use oxygen and there was not a label on the oxygen tubing. They stated they did not know when it had been changed.On 02/25/26 at 1:30 p.m., the DON stated the oxygen tubing should be changed out weekly, and it should be labelled and dated.

Based on record review and interview, the facility failed to update the care plan related to elopement for one (#2) of two residents sampled for elopement. The corporate nurse reported 44 residents resided in the facility. Findings: Res #2 had diagnoses which included bipolar, mood disorder, and schizoaffective disorder. An incident report, dated 10/30/24, documented the resident had eloped the day before and interventions were put in place. There was no documentation related to the new interventions on the care plan. On 12/27/24 at 8:30 a.m., the administrator reported the care plan should have been updated.

Based on observation, record review, and interview, the facility failed to ensure Braden skin assessments, and weekly skin assessments were completed for two (#21 and #13) of two sampled residents reviewed for wound care. The Administrator identified 43 residents resided in the facility. The Resident Matrix documented three residents had pressure ulcers that were not present on admission. Findings: An undated, Skin Assessments policy, read in part .It is the policy of this facility that skin assessment will be completed on every resident every week . An undated, Braden Skin Evaluation policy, read in part .A Braden scale skin evaluation will be completed no less than quarterly. This will be most likely completed with the MDS that comes due whether a quarterly, annual, significant change or admission . 1. Resident #21 had diagnoses which included, pressure ulcer of right buttock Stage 4, dementia, and depressive disorder. A Braden Scale for Predicting Pressure Ulcer Risk dated 12/29/2023, documented the resident was at high risk for pressure ulcers. The clinical health record did not contain documentation weekly skin assessments had been completed since 04/19/24. On 06/06/24 at 11:52 am LPN #1 was asked if they did skin weekly skin assessments, They stated they did the assessments but had been off, and if there was no documentation they did not get completed. On 06/06/24 at 1:38 p.m., LPN #1 was asked if any skin assessments had been completed for Resident #21 after 04/19/24. They stated they did not complete weekly skin assessments if the Resident #21 had outside wound care visits, unless another issue was identified. On 06/06/24 at 1:42 p.m., the DON was asked who is responsible to complete weekly skin assessments. They stated LPN #1. They were asked where the assessments should be documented. They stated the skin assessments should be in the computer. On 06/06/24 1:44 p.m., LPN #1 was asked how often Braden assessments are completed. They stated quarterly. They were asked when the last assessment had been completed on Resident #21. They stated in December 2023. On 06/06/24 at 1:47 p.m., Corp. Nurse Consultant #1 was asked who was responsible for completing weekly assessments. They stated LPN #1. They were asked where the assessments should be documented. They stated the assessments should be documented in the computer unless outside wound care see's the resident. 2. Resident #13 had diagnoses which included Alzheimer's disease and cognitive impairment. A Braden Scale For Predicting Pressure Sore Risk, dated 12/29/23, documented to completed on admission for four weeks then quarterly. The assessment documented Resident #21 was at risk. An annual assessment, dated 03/01/24, documented the resident needed partial to moderate assistance with toileting, upper body dressing. On 06/05/24 at 12:01 p.m., LPN #2 was asked if Resident #13 currently had a wound. They stated no, the wound had healed. . On 06/06/24 at 2:05 p.m., LPN #1 provided paper copies for Braden assessments for Resident #21 and Resident #13. Resident #21's paper assessment Braden Scale For Predicting Pressure Sore Risk, dated 12/1, 3/1, and 6/3, did not have a year, was unsigned by who completed the assessments, and 6/3 contained blanks on assessment. Resident #13's paper assessment Braden Scale For Predicting Pressure Sore Risk, dated 12/30, 3/1, and 6/1 did not have a year, was unsigned by who completed the assessments, and 6/1 contained blanks on assessment. On 06/06/24 at 2:05 p.m., Corp Nurse Consultant #1 reviewed Resident #21 and #13's Braden assessments and stated These were done last year and they are not completed. On 06/06/24 at 2:07 p.m., Corp. Nurse Consultant #1 was asked if outside wound care assessed other areas of the Resident's skin. They stated, Usually not. They were asked if the weekly skin assessments should be completed by facility staff for residents at risk. They stated every resident should have a weekly skin assessment. On 06/06/24 at 2:16 p.m., Resident # 13's heels were observed with Corp Nurse Consultant #1. They stated the left heel had dry flaky skin and a scabbed area and could use skin prep for treatment. Resident #1 was asked if they had any sores on their bottom, they stated no but their foot was. They were asked which one and they stated the left one. On 06/06/24 at 2:22 p.m., Corp. Nurse Consultant #1 was asked what had they observed. They stated the area was healed over with a small scab left and dry peeling tissue. They were asked if the resident had anything in place for prevention. They stated Those shoes. They were asked if any nurse note documented a description of the residents left foot. They reviewed the skin assessments and stated no skin assessments had been completed since April 2024. On 06/06/24 at 2:35 p.m., Corp. Nurse Consultant #1 was asked when Resident #13's wound had healed. They stated on 03/28/24. They were asked why the weekly skin assessments had not been completed. They were not sure why they had not been completed since 04/19/24. On 06/06/24 at 2:37 p.m., LPN #1 was asked when was the last time they had assessed Resident #13's skin. They stated they only document if there is an issue with the skin. On 06/06/24 at 2:42 p.m., Corp Nurse Consultant #1 was asked was the policy followed for weekly skin assessments and Braden assessments. They stated no. They were asked if Resident #13's heel was something the wound care doctor would assess. They stated, Yes. On 06/07/24 at 11:09 a.m., LPN #2 was asked if Resident #1 had been seen by the wound care doctor. They stated they had texted pics to the doctor and described the area as rough feeling and mushy. The physician ordered to skin prep the heel two times per day and offload.

Based on record review and interview, the facility failed to monitor for side effects related to the use of antidepressants for four (#1, #3, #32 and #40) of five sampled residents reviewed for unnecessary medications. The Administrator identified 43 residents resided in the facility. The Resident Matrix, dated 06/03/24 documented 31 residents received antidepressants. Findings: An undated Monitoring of Antidepressants policy, read in part .Resident receive antidepressant medication routinely only when medically necessary. Every effort is made to ensure that resident who use antidepressants receive the intended benefit if [sic] the medication and to minimize the unwanted effects of the antidepressant medications . 1. Resident #1 had diagnoses which included depressive disorder and depression. A physician order, dated 07/06/23, documented to administer Trazadone 100 mg one time at bedtime. A physician order dated 06/25/23 documented to administer Escitalopram Oxalate 20 milligrams by mouth one time a day. An undated Monitoring of Antidepressants policy, read in part . There was no documentation for March, April, may June 2024 the resident had been monitored for the use of antidepressants: Lexapro and Trazadone. On 06/06/24 at 11:23 a.m., Corp Nurse Consultant #1 was asked if Resident #1 had been monitored for side effects related to the use of Trazadone and Lexapro. They stated there was no documentation side effects had been monitored. They were asked what the policy was to monitor. They stated side effects should have been monitored. 2. Resident #3 had diagnoses which included recurrent depressive disorder. A physician order, dated 12/18/23, documented to administer Pristiq 50 milligrams one time a day. A physician order, dated 06/27/23, documented to administer Trintellix 20 milligrams one time a day. Resident #3's treatment administration records for April, May and June 2024, did not contain documentation side effects had been monitored for the use of Pristiq and Trintellix. Resident #3's care plan, dated 02/07/24, read in part, .The resident has depression .Pristiq as ordered: side effects may include Blistering, peeling or loosening of the skin .bloating .blood in the stool or urine .chest tightness, discomfort, or pain .cough .dark urine .Trintellix as ordered: mood swings, headache, muscle stiffness, and runny nose . On 06/06/24 at 10:34 a.m., Corp. Nurse Consultant #1 was asked if Resident #3 had been monitored for side effects related to Pristiq and Trintellix. They stated they had not been monitoring for side effect for Pristiq or Tarantella. The care plan stated to monitor for specific side effects but that had not been done. 3. Resident #32 had diagnoses which included unspecified mood (affective) disorder and anxiety. A physicians order, dated 11/02/23, documented to administer Lexapro 10 milligrams one time a day. A physicians order, dated 11/9/23, documented to administer Lamotrigine 25 milligrams two times a day. Resident #32's treatment administration records for April, May and June 2024 did not contain documentation side effect monitoring for the use of Lexapro. Resident #32's care plan, dated 06/03/24, read in part, The resident has a mood disorder .Lomotrigine as ordered: side effects may include dizziness, light headedness, blurred vision. The care plan also read, Lexapro as ordered: side effects may include diarrhea, drowsiness, headache. On 06/06/24 at 11:26 a.m., the Corporate Nurse Consultant #1 stated there was no side effect monitoring. 4. Resident #40 had diagnoses which included Bipolar disorder. A physicians order, dated 06/26/23, documented to administer Bupropion 150 milligrams two times a day. A physicians order, dated 07/06/23 , documented to administer Trazodone 50 milligrams at bedtime. On 06/06/24 at 2:34 p.m., LPN #2 stated side effect monitoring was documented on the treatment administration record. They stated they should do side effect monitoring on depression, psychotropic and anxiety medications. LPN #2 stated there was no side effect monitoring for the Trazodone or the Wellbutrin (Bupropion.) 45583

Based on record review and interview, the facility failed to ensure the person designated to serve as the dietary manager had met the state requirement for dietary management. The Director of Nursing stated 42 residents received food from the kitchen and 43 residents resided in the facility. Findings: There was no documentation the DM was certified as a dietary manager. A Office of Professional and Workforce Development Receipt dated 11/03/22, documented a transaction basket number dated for 03/11/22 for enrollment in the course. A document titled Grades for {name withheld}, documented the grades for the modules. The introduction was dated for 12/20/22. There was no final test score. There was no documentation the dietary manager had taken the test to become a certified dietary manager. On 06/05/24 at 11:22 a.m., the administrator stated the dietary manager had not taken the certification exam. They stated the dietary manager started around 03/11/22.

Based on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The Director of Nursing identified 42 residents who received services from the kitchen. Findings: A Sanitization policy dated 10/08, read in part, The food service area shall be maintained in a clean and sanitary manner. All .kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodent, roaches, flies and other insects. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. The policy also read, Dishwashing machines must operate using the following specifications: .Low-Temperature Dishwasher (Chemical Sanitization) a. wash temperature (120 degree F); b. Final rinse with 50 parts per million(ppm) hypochlorite (chlorine) for at least 10 seconds. The policy also read, The Food Service Manager will be responsible for scheduling staff for regular cleaning of the kitchen .Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. A Food Receiving and Storage policy, dated 07/14, read in part, Foods shall be received and stored in a manner that complies with safe food handling practices. Food services, or other designated staff, will maintain clean food storage areas at all times. The policy also read, Dry foods that are stored in bins will be removed from the original packaging, labeled and dated (use by date). The policy also read, Other opened containers must be dated and sealed or covered during storage. On 06/03/24 at 10:02 a.m., initial tour of the kitchen was conducted, and the following observations were made: a. Black substance along the back trim of the sink with the sprayer and the handwashing sink, b. Black wet substance on the floor under the sink and dishwasher, c. Rusty metal box overflow with suds/bubbles and two metal knives and a blue handled wrench on the floor next to the canned goods as well as debris under the shelf with cans, d. Two trays of the dessert for the day in cups/bowls with no label or date, e. Three bags of opened bread (one sandwich bread and two hot dog buns) with no date when opened and not sealed, f. Three more desserts in cups and two bowls with no label or date, g. One gallon of milk was almost empty with no opening date, h. One gallon of milk was almost full of no opening date, i. A three-tiered cart located next to the prep table across from the oven had food debris on all corners and on each shelf as well as debris on top of the items in a cup on the top, j. The dishwasher temp did not get above 112 degrees, k. No dishwashing wash and no dishwasher sanitation fluid. Both were empty and there had been dishes washed. On 06/03/24 at 10:21 a.m., [NAME] #1 stated there was a chore list for weekly and monthly so cleaning was done every day. They stated under the sink was stained then stated it was dirty after saw what was wiped with a paper towel. [NAME] #1 stated the floor in the dry storage room where the cans were was clean and stated it flooded the floor in that area, and also stated under the cans was not clean. On 06/03/24 at 110:35 a.m., the dietary manager stated they did not date the bread because it came in weekly. There were blanks throughout the cleaning schedule. The dietary manager was unaware of the need to date the bread when opened. On 06/03/24 at 10:43 a.m., the dietary manager stated the black substance at the sink was maybe mold. On 06/03/24 at 10:45 a.m., the dietary manager stated under the dishwasher was not clean after seeing debris from paper towel when wiped. On 06/03/24 at 10:54 a.m., the dietary manager stated they did not know when the desserts or the milk were prepared or opened because there was no date. On 06/03/24 at 11:21 a.m., the dietary manager stated they had tried to clean the three-tiered cart weekly, it just got back like that. On 06/03/24 at 11:36 a.m., the dietary manager stated the dishwasher was to be at 120 degrees to wash. On 06/03/24 at 11:36 a.m., there was no sanitization detected on the test strip. On 06/03/24 at 11:37 a.m., the dishwasher was restarted and tested again with no sanitization detected on the strip. On 06/03/24 at 11:40 a.m. observed the sanitizer and wash buckets for the dishwasher were both empty. On 06/03/24 at 11:42 a.m., the dietary manager stated they were told to order from the dishwasher company instead of their other delivery service they used prior. They stated thy requested the assistant administrator to order them. On 06/03/24 at 12:25 a.m., the dietary manager stated the process for reordering dishwasher and sanitizer for the dishwasher was that they ordered at least once a week and they had requested on Wednesday of last week to be there on Thursday. They stated they had no problem when they ordered from the food service but when they ordered from the machine company they were always on back order.

Based on observation, record review, and interview, the facility failed to ensure privacy curtains were used for two (#9 and #21) of three sampled residents reviewed for privacy. The Administrator identified 43 residents resided in the facility. Findings: An undated Privacy Curtains policy, read in part . It is the policy of this facility that each resident will have a privacy curtain in room to maintain him/her privacy from someone entering the room . Resident #9 had diagnoses which included cerebral palsy and severe intellectual disabilities. A quarterly assessment, dated 05/16/24, documented Resident #9 was dependent on staff for all ADL's. On 06/03/24 at 10:04 a.m., Resident #9 was observed from the hallway. They were lying uncovered with a t-shirt on, and their legs folded up. There was no sheet on the resident's lower body. On 06/03/24 at 2:53 p.m., Resident #9 was observed in bed from the hallway. The privacy curtain was not pulled and the resident was not covered from the waist down. On 06/03/24 at 03:10 p.m., CNA #1 was asked to observe Resident #9. They stated the resident's curtain should be pulled, but the curtain only goes halfway in the room. On 06/03/24 at 3:31 p.m., the Administrator was asked to observe the Resident lying in their bed from the hallway. Resident #9 was observed lying in their bed bilateral legs folded up towards their abdomen, with a blanket bunched up on the side of their right hip. They were asked if the curtain provided privacy for the resident. They stated, No. There was no curtain observed to be hanging to provide privacy for the resident. The curtain did not extend to the right side of the room. They were asked if the resident was exposed. They stated yes. 2. Resident #21 had diagnoses which included, pressure ulcer of right buttock Stage 4, dementia, and depressive disorder. On 06/05/24 at 10:57 a.m., upon entry to the room, the resident was lying in the bed with their shorts pulled down with their buttocks exposed to the hallway. The privacy curtain was not pulled. Two staff CNA were observed in the room CNA #2 was on the side of the bed assisting with positioning of resident. They were not wearing PPE. The other staff member left the room and donned PPE. They returned and provided incontinent care. Wound care was performed by the LPN wearing PPE . After completion of wound care CNA #2 was observed to assist with changing the Resident #21's shorts. The privacy curtain was not pulled at any time during provision of pericare or wound care. On 06/05/24 11:21 a.m., LPN #2 was asked if Resident #21 had a room mate. They stated Resident #21 did have a roommate. They were asked why the privacy curtain had not been pulled during the provision of pericare and wound care. They stated, Because the room mate was not in the room. On 06/05/24 at 1:42 Corp. Nurse Consult. #1 was asked when the privacy curtain should be used. They stated during treatment or care for the resident. They were asked if the curtain should be used during wound care on the buttocks or peri care. They stated, Definitely.

Based on record review and interview, the facility failed to have a process in place to identify resident's code status for one (#33) of ten residents reviewed for code status. The Administrator identified 43 residents resided in the facility. Findings: An Advanced Directivespolicy, revised April 2008, read in part, .Changes or revocations of a directive must be submitted in writing to the Administrator .The Care plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment .and care plan . Resident #33 had diagnoses which included type two diabetes mellitus, anemia and malaise. An undated form titled Full Code was observed on the inside of a cabinet door at the nurse's station. The form documented Resident #33 was a full code. Resident #33 had a signed DNR, dated 05/13/22, in their hard chart. On 06/04/24 at 12:03 p.m., LPN #2 was asked what was the list of full code and DNR. They stated To let everyone know the DNR code status, if someone is down they will come up here and check it. They were asked how often the list is updated. They stated they though it was every month or every other month. They were asked who is responsible to update the list. They stated LPN #1. On 06/04/24 at 12:09 p.m., the DON was asked if the resident is a full code or DNR. They stated Resident #33 had a signed a DNR on 05/13/22. They were asked to review the form kept at the nurse's desk and asked how it identified Resident #33. They stated as a full code. They were asked if that was correct. They stated it was not correct. On 06/05/24 at 1:37 p.m., Corp. Nurse Consult. #1 was asked if the list full code that had been kept at the nurse's desk was accurate. They stated they did not think it was. They were asked how often the list should be updated. They stated with a change in the care plan or anytime it changes. Corp. Nurse Consult. #1 was asked if Resident #33 had signed and dated their DNR on 05/13/22, why wasn't the list updated and accurate. They stated the list had been updated last year. They were asked if their process in place correctly identified the resident's code status. They stated No, it was not.

Based on observation, record review, and interview, the facility failed to maintain a clean homelike environment for: a. residents who ate their meals in the dining room and who watched TV in the television room, and b. prevent lingering urine odors for two (#9 and #33) of all residents who resided in the facility. The Administrator identified 43 residents resided in the facility. Findings: An undated Housekeeping policy, read in part .It is the policy of this facility that housekeeping services will be provided every day. Housekeeping will be responsible to clean the residents area Housekeeping will also be responsible for cleaning the .halls .dining room . A. Dining Room On 06/03/24 at 11:54 a.m., Resident #3 was observed entering the television room and sitting near the coke machine. A puddle of water was observed on the floor near the resident and coke machine. On 06/03/24 at 12:05 p.m., the windows in the dining room were observed to have noted to have dust/dirt and dead flies lying on the window ledges. There was a dead fly in the southwest window, two dead flies and dirt and dust in the north west window and seven dead flies in the northwest window. The windows in the TV room were observed to have multiple dead flies and dirt in the southeast window and multiple dead bugs, flies and mouse droppings in the northeast window. The area of waster remained on the floor near the coke machine. On 06/03/24 at 12:33 p.m., CNA #3 was asked to observe the water on the floor. CNA #1 asked dietary manager what the water was, they were unsure. CNA #3 instructed Resident #3 to not walk through the water, but did not attempt to clean the area or notify housekeeping. On 06/03/24 at 12:45 p.m., water was still on the floor in the TV room. A resident was observed sitting nearby on a couch. On 06/03/24 at 12:52 p.m., a Resident #3 sitting in a wheel chair came into the TV room near the water spill. On 06/03/24 at 12:56 p.m., CNA #3 left the TV room and went into the dining room. They were not observed to attempt to clean the area or notify housekeeping. On 06/03/24 at 1:07 p.m., the DON was asked to observe the dining room. They stated there were dead flies and debris in the west windows and north windows. They were asked who was responsible to clean the windows. They stated kitchen or housekeeping. The DON observed the windows in the TV room and stated it looked like numerous flies and mouse pills. The DON was notified of the water on the floor in the TV room. The DON asked the dietary manager if they were aware of the water on the floor. They stated yes, but was unsure what it was from. The DON was asked what the staff should have done about the water. They stated the staff should have gotten someone (housekeeping) right away or got some towels and cleaned it themselves. The DON asked Maintenance 31 if they had been notified of the water near the coke machine. They stated, No. B. Lingering Oders On 06/03/24 at 2:53 p.m., there was a strong odor of urine in the hallway and in Resident #9's room. On 06/03/24 11:23 a.m., Resident #33's room was noted to have a strong smell of urine. On 06/04/24 at 2:13 p.m., Corp Nurse Consult. #1 was asked what was the odor in Resident #9's room. They stated they smelled bleach. On 06/04/24 at 2:16 p.m., Corp Nurse Consult. #1 was to observe Resident #33's room. They were asked what was the odor in Resident #33's room. They stated the room smelled like pee and there was a wet brief in the trash. On 06/05/24 at 8:10 am a strong odor of urine was noted in Resident #33's room during medication observation. On 06/05/24 at 8:23 a.m., CMA #1 was asked what the odor was in Resident #33's room. They stated, it smelled like urine to them.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for activities for one (#38) of one sampled residents reviewed for activities. The Administrator identified 43 residents resided in the facilty. Findings: A Goals and Objectives, Care Plans policy, dated 8/2006, read in part, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The policy also read, Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and area able to report whether or not the desired outcomes are being achieved. Goals and objectives are reviewed and/or revised . at least quarterly. A Care Plans-Comprehensive policy, dated 10/2009, read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. The policy also read, The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. A Care Planning-Interdisciplinary Team policy, dated 12/2008, read in part, .The care plan is based on the resident's comprehensive assessment and is developed by a Care Panning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: .The activity Director/Coordinator . Resident #38 admitted with diagnoses which included unspecified psychosis, paranoid personality disorder, dementia, and insomnia. Resident #38's annual assessment dated [DATE] documented their favorite activity was somewhat important and group activities was somewhat important and choosing their bedtime was very important. On 06/03/24 at 2:38 p.m. an activities calendar was observed in a resident room and it had no times or location on it. On 06/03/24 at 2:51 p.m., two residents were observed sitting in front of the front entrance sitting area watching t.v. On 06/04/24 at 9:02 a.m., Resident #38 stated there was nothing to do but sit there all day, sleep, go to the bathroom, watch Tv, sit around and watch everybody. They stated they have bingo once a month. They had told everyone about the activities and they will listen but not do anything. The resident stated they couldn't complain too much. They stated they play on their phone for entertainment. Resident #38 stated they will every once in a while will go out and ride in the van and did so last Friday. It is only done twice a year. On 06/04/24 at 9:33 a.m., a June 2024 activities calendar was observed on the door of room [ROOM NUMBER] with no times of the activities on it. On 06/05/24 at 10:16 a.m., there were no observations of activities occuring. On 06/05/24 at 10:49 a.m., Resident #38 stated they don't do what was on the calendar. They stated the movies and bowling were interesting but did not know what time or when they were. There was no time or location listed next to the activities on the June 2024 calendar provided to the residents. On 06/05/24 at 10:58 a.m., CNA #4 stated the activities they knew of where movies the day before and that activities were done maybe once a week. They stated the resident sometimes would go to bingo. On 06/05/24 at 11:02 a.m., the activity director stated the new admission and yearly screening was to find out what hobbies were prior, activities they like to do, and if they like music or t.v. and would provide if available. They stated Resident #38 declined activities and watched t.v. westerns or sports and bingo sometimes depending on their mood. They stated the resident participated about 2-3 times a month if there was bingo. The activity director also stated they ensure activities of choice were available by asking during resident council what kind of activities they would like to see and try a new one each month. On 06/05/24 at 11:04 a.m., the activity director stated they forgot to put the time on the June 2024 calendar and that there was a 10:00 a.m. and 2:00 p.m. activity. On 06/05/24 at 11:08 a.m., the MDS coordinator stated they stated Resident #38 did not have an activities care plan and they did not do them for everyone. They stated they had not care planned activities individually. They stated they would only care plan activities for level 2 PASRR, bed ridden, or when in covid isolation. They further stated that staff would know resident activity preferences from the activities coordinator that plans and gathers the residents. On 06/06/24 9:22 a.m., Resident #38 was observed sitting in their wheelchair in the hall outside of their room looking at their cell phone with earbuds in their ears. On 06/06/24 at 11:20 a.m., the Corporate Nurse Consultant #1 stated they would expect each resident to have an activity care plan. On 06/04/24 at 2:39 p.m. the Administrator stated, after looking at the June 2024 activities calendar, that they did not know what time the activities were done by looking at the calendar and they they just knew when they were and would have to ask. The administrator also stated the Podiatrist was not an activity as it was listed for Wednesday the 12th. They stated that the movies were also able to be shown on the resident individual t.v. as well as on the public t.v The administrator stated there had not been any residents to complain about activities. There was no activities care plan located in the medical record. A monthly summary 2024 documented the resident did not participate in activities. An Activity participation note dated 2/29/24 at 1:39 p.m., documented the resident participated in some activities, resident council, sitting outside when the weather permits, and enjoys visiting with staff and residents. An Activity participation note dated 3/29/24 at 2:00 p.m., documented the resident enjoyed watching t.v. in the family room, sitting outside when the weather permits, and visiting with staff and residents.

Based on record review and interview, the facility failed to administer tube feeding bolus according to physician order for one (#32) of one sampled resident reviewed for tube feeding. The administrator identified two residents received tube feeding resided in the facility. Findings: A Intake, Measuring and Recording policy, dated 9/2005, read in part, The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. The policy also read, Record the fluid intake as soon as possible after the resident has consumed the fluids. At the end of you shift total the amounts of all liquids the resident consumed . The policy also read, The following should be recorded in the resident's medical record per facility guidelines: .The amount (in mls) of liquid consumed .notify the supervisor if the resident refuses the procedure. Res #32 had diagnoses which included anorexia, cachexia. A physicians order dated 09/02/23 documented mighty shake one time a day for weight loss. A physicians order dated 10/19/23 documented regular diet mechanical soft texture, regular/thin consistency, give drink every 3 bites. Drink from cup side (no straws) sips only. Up 90 degrees in chair for all po intakes. A physician order dated 02/01/24 documented Osmolite give 1(240ml) 4 times a day-hold at meals if eats more than 50% as needed. On 06/06/24 at 9:26 a.m., LPN #2 stated Resident #32's tube feeding order was if they ate less than 50% they get a supplement of Osmolyte 270 ml's and to flush with 100 ml's of water each bolus and every shift. LPN #2 stated they also received a shake because of weight loss before. On 06/06/24 at 9:28 a.m., LPN #2 stated their should not be blanks on the medical record and if there were then it was not done or they were late. They stated there were seven blanks for the task of eating, six blanks for the task of amount eaten, and six blanks for the fluids. The LPN stated there was another sheet used for documenting intake that the CNA's document the meal percentages. On 06/06/24 at 9:49 a.m., the Corporate Nurse Consultant #1 reviewed the meal percentages on paper and documentation in the electronic medical record and stated there was no documentation of meal percentages for May 2024 on the 6th, 9th, 10th, 24th, or 26th. They stated there should be documentation. The Corporate Nurse Consultant #1 stated the resident needed to be fed regardless because the order was confusing.

Based on observation, record review, and interview, the facility failed to ensure medication error rate was not greater than 5% for two (#6 and #12) of three sampled residents observed during medication observation The Administrator identified 43 residents resided in the facility. Findings: An undated Medication Administration and General Guidelines policy, read in part .Medications are administered in accordance with written orders of the attending physician . 1. Resident #6 had diagnoses which included hypertension and mood disorder. A physician order, dated 02/06/24, documented to administer aspirin 81 milligram chewable tablet one time a day. On 06/05/24 7:58 a.m., CMA #1 was observed to prepare and administer Resident #6's medications. CMA #1 did not instruct Resident #6 to chew the Aspirin tablet when administered. 2. Resident #12 had diagnoses which included Atherosclerosis of native arteries of extremities. A physician order, dated 06/27/2, documented to administer aspirin 81 milligrams chewable tablet one time a day. On 06/05/24 at 8:17 a.m., CMA #1 was observed to prepare and administer Resident #12's medications. They did not instruct Resident #12 to chew the Aspirin tablet when administered. On 06/05/24 at 9:27 a.m., Corp. Nurse Consultant #1 was asked if the medication card documents the medication is a chewable aspirin how should it be administered. They stated it should be chewed, unless the doctor stated otherwise.

Based on observation, record review, and interview, the facility failed to ensure: a. staff wore PPE during provision of care for one (#21) of one sampled residents reviewed for EBP and b. failed to ensure a syringe used for tube feeding administration was stored in a manner to prevent cross contamination for one (#32) of one sampled resident reviewed for tube feeding. The Administrator identified 43 residents resided in the facility. The Director of Nursing identified two residents received tube feeding. Findings: An Enhanced Barrier Precautions Policy and Procedure, dated 04/01/24, read in part .EBP will be used for resident with indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug - resistant organism .procedure to use EBP when .other high-contact resident care activities . 1. Resident #21 had diagnoses which included, pressure ulcer of right buttock Stage 4, dementia, and depressive disorder. On 06/05/24 at 10:57 a.m., upon entry to the room, the resident was lying in the bed with their shorts pulled down with their buttocks exposed to the hallway. The privacy curtain was not pulled. Two staff CNA were observed in the room CNA #2 was on the side of the bed assisting with positioning of resident. They were not wearing PPE. One staff member left the room and donned PPE. They returned and incontinent care was provided. Wound care was performed by the LPN wearing PPE. After completion of wound care, CNA #2 was observed to assist with changing Resident #21's shorts. CNA #2 was not wearing PPE. On 06/05/24 at 11:21 a.m., LPN #2 was asked why did one staff DON PPE and one did not. They stated they did not know. They were asked if they were providing contact assistance should PPE be worn. They stated it should have been worn. On 06/05/24 1:44 p.m., Corp. Nurse Consultant #1 was informed of the wound care and assistance provided for Resident #21. They were asked would one staff provide care without PPE for enhanced barrier. They stated, I am not sure both staff should have worn PPE. On 06/06/24 at 9:05 a.m., CNA #2 was asked if they assisted on 06/05/24 when wound care was completed for Resident #21. They stated, Yes. They were asked what care was provided for Resident #21. They stated We helped [the Resident #21] change [their] shorts and got [the Resident #21] up for lunch. They were asked what they understood about enhanced barrier precautions. They stated they thought they only had to use PPE if it was on the door. They were asked if they had training on when to use PPE for EBP. They stated they had at their other job but had not had training here. 2. Resident #32 had diagnoses which included unspecified congestive heart failure. A quarterly assessment, dated 04/04/24, documented assist needed for eating. On 06/05/24 at 10:54 a.m., an observation was made of a tube feeding syringe on the small dresser next to Resident #32's bed without a protective barrier. On 06/06/24 at 9:04 a.m., an observation was made of a tube feeding syringe on the small dresser next to Resident #32's bed with the plunger end on the table and not in a protective barrier with an undated open container of apple sauce next to it. On 06/06/24 at 9:26 a.m., LPN #2 stated the resident received osmolyte tube feeding. They stated Resident #32 should be assisted with everything and had to be fed and staff were to stay with resident to feed them. LPN #2 stated there should not be food left in the room, suppose to pick up the trays. They stated the tube feeding syringe was usually put the sack back over the top of the syringe and should be clean and put on a napkin to let dry. On 06/06/24 at 9:28 a.m., LPN #2 stated the applesauce should have been thrown away if they did not eat it. They stated the concern was the syringe was left open. 45583

Based on record review and interviews, the facility failed to ensure physician ordered scheduled appointments were not canceled for one of (#1) of 5 sampled residents reviewed for outside appointments. Findings: Resident #1 was admitted on [DATE] and had diagnoses of chronic pain, dry eye syndrome, and carcinoma of the face. Resident #1 had a consult appointment scheduled for 08/02/23 with a specialty physician for carcinoma of the face. Resident #1 had been rescheduled for the consult appointment to 08/27/23 without notifying Res #1 or their representative. A grievance form, dated 08/02/23 at 2:00 p.m., documented the administration had received a complaint from the resident's representative regarding the canceled appointment. The grievance form documented an in-service with the social service director on 08/02/23. The grievance form documented monitoring of the appointment schedule was conducted in the daily stand up meeting and was ongoing at the time of the survey. On 08/14/23 at 08:42 a.m., an interview was conducted with Res #1 and they stated their consult appointment for 08/02/23 had been rescheduled without notifying either the resident or their representative. On 08/14/23 at 11:00 a.m., an interview was conducted with the administrative assistant and they stated the facility did a full investigation and a one-on-one in-service related to rescheduling any appointment was conducted with the family member, medical staff, and social services to prevent any rescheduling problems again. On 08/14/23 at 11:30 a.m., an interview was conducted with the social service director and they stated they was in-serviced on rescheduling appointments and notifying the resident, their representative, medical staff members, and any person involved with the care of a resident.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 38 residents resided at the facility. The form documented one resident with tube feeding. Findings: On 05/01/23 at 9:30 a.m., an initial tour of the kitchen and food storage areas was conducted. In the refrigerator macaroni salad was observed, which had been opened and served out of and was dated 04/22/23. A bag of shredded lettuce in a re-sealable bag was observed and was not dated. A thick amber liquid, labeled caramel and out of the original container was dated 04/23/22. A container labeled chili was observed with a date 04/19/23. In the first chest freezer a large bag of bread sticks were observed to be open to air. In the small refrigerator a container of prune juice was observed to have been opened and not dated. The floor in the kitchen and storage areas were observed to not have been thoroughly cleaned around the edges and debris was observed on the floor. The lid to the sugar bin was observed to not have been secured properly. On 05/01/23 at 9:40 a.m., the DM stated the items opened in the refrigerated should have been dated when opened. On 05/01/23 at 9:50 a.m., the ice machine was observed to have pink slime was visible on the ice shield. A white clean cloth was used to wipe the ice drop of the ice machine and the cloth revealed a pink and black substance on the cloth after the shield was wiped. At that time the DM stated she did not know what the substances were on the cloth. She stated the company which came to the facility to clean the ice machine last cleaned it about four months ago. On 05/01/23 at 9:54 a.m. the DM stated the stored food in the freezer should not have been open to air. She stated left overs were normally kept seven days in the refrigerator and then discarded. On 05/03/23 at 7:25 a.m., during the second tour of the kitchen, a partially frozen turkey breast was observed thawing in warm water in the sink. At that time cook #1 stated the turkey breast should have been thawed in the refrigerator over night and not in the standing water. On 05/03/23 at 7:35 a.m., Cook #1 was observed to receive a call on his cell phone he stepped out of the kitchen to answer the phone. The cook was not observed to not wash his hands when he re-entered the kitchen. He was then observed to used the facility phone. He was then observed to move two pitchers of drinks from the counter. On 05/03/23 at 8:12 a.m., wet serving trays and lid covers were observed stacked together and used during meal service. On 05/03/23 at 12:03 p.m., the DM stated all items should have been dated and labeled when in the refrigerator. She stated she had a weekly deep cleaning schedule for the kitchen and the staff should have made sure the kitchen was cleaned daily. The DM stated the lids on all containers should have been sealed when in storage. She stated the staff should always wash their hands when entering the kitchen. The DM stated the meat should have been placed in a tub and on the bottom shelf of the refrigerator to thaw out the day before it was to be served and the dishes should not have been put up wet.

Based on observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for five (#2, 5, 9, 10 and #30) of twenty residents whose assessments were reviewed. The facility failed to accurately code for: a. the presence of the state level II PASRR process to have serious mental illness for Res #2, 5, 10, and #30. b. the use of insulin for Res #5. c. falls for Res #9. The Resident Census and Conditions of Resident form documented 38 residents resided in the facility. Findings: 1. Res #2's PASRR level II evaluation, dated 06/04/19, documented the resident had a major mental illness as defined by CMS. The resident was admitted , on 06/05/19, and had diagnoses which included schizophrenia, obsessive-compulsive disorder, and other recurrent depressive disorders. An annual assessment, dated 03/02/23, revealed the facility documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 05/02/23 at 1:03 p.m., the corporate nurse consultant, who had been asked to provide a copy of the level II PASRR, stated it had not been in the facility. She stated she had to contact OHCA and obtain a copy and it had just arrived. On 05/03/23 at 9:33 a.m., MDS coordinator stated Res #2's name was not on a list provided to her to complete the section on the level II PASRR question in the MDS assessment. She stated she should have coded the resident as having a level II PASRR. 2. Res #5 was admitted , on 10/25/10, and had diagnoses which included severe intellectual disability, recurrent depressive disorder, and unspecified psychosis. The resident's PASRR level II evaluation, date 09/16/15, documented the resident had severe intellectual disabilities. A care plan, dated 05/23/22, revealed documentation Res #5 required specialized services related to intellectual disabilities. An annual assessment, dated 08/25/22, documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 05/01/23 at 3:45 p.m., Res #5 was observed in the dining room sitting at at table, awaiting his meal, and reported he was happy at the facility but was worried about his wife. On 05/03/23 at 9:20 a.m., MDS coordinator confirmed Res #5's PASRR II was not documented on the section of the assessment which contained the level II PASRR evaluation question. 3. Res #5 had diagnoses which included type 2 diabetes mellitus without complications. A physician order, dated 09/21/21, documented the facility was to administer Tresiba (a type of insulin) daily to the resident for a diagnosis of diabetes. A care plan, dated 05/23/22, documented Res #5 had a diagnosis of diabetes and to administer Tresiba as ordered by the physician and monitor for side effects. An annual assessment, dated 08/25/22, documented Res #5 did not receive insulin. A quarterly assessment, dated 02/21/23, documented Res #5 did not receive insulin. On 05/03/23 at 10:11 a.m., the MDS coordinator confirmed she had missed coding insulin on the assessment. 4. Res #10 was admitted , on 12/08/10, and had diagnoses which included cerebral palsy, unspecified psychosis, and severe intellectual disabilities. The resident's PASRR level II evaluation, dated 11/06/20, documented the resident had severe intellectual disabilities. A care plan, dated 05/27/22, documented Res #10 had diagnosis of intellectual disability. An admission assessment, dated 08/17/22, revealed the facility documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 05/01/23 at 9:55 a.m., Res #10 was observed in his room in a geri chair. He was unable to be interviewed. On 05/03/23 at 9:36 a.m., the MDS coordinator stated the admission assessment did not capture the presence of the PASRR II. 5. Res #30's PASRR level II evaluation, dated 06/13/19, documented the resident had a major mental illness as defined by CMS. The resident was admitted , on 06/27/19, and had diagnoses which included recurrent depressive disorders, bipolar disorder, and obsessive-compulsive disorder. An annual assessment, dated 07/07/22, revealed the facility documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 05/01/23 at 1:34 p.m., Res #30 was observed in her room and was coloring. She stated she had a diagnosis of bi-polar. On 05/03/22 at 9:22 a.m., the MDS coordinator stated the corporate nurse was responsible to update the PASRR book. The MDS coordinator reviewed the PASRR I and stated the form documented the resident was bi-polar on admission and should have had a level II evaluation documented on the MDS assessments. 46909 6. Resident #9 had diagnoses which included rheumatoid arthritis, edema, and pain. A care plan, dated 07/13/22, documented potential for falls. An incident report dated 02/22/23, documented Res #9 had a fall and the intervention was to check on resident more frequently. A quarterly assessment, date 04/05/23, documented the resident had no falls. On 05/02/23 at 9:10 a.m., an observation was made of the resident sitting in a wheelchair in his room. An interview was conducted with Res #9 at that time and he stated he fell a couple of months ago. On 05/04/23 at 8:10 a.m., the MDS coordinator and she stated she did not capture the fall on the assessment dated [DATE].

Based on interview and record review, the facility failed to ensure assessments were encoded and transmitted to CMS in the required time frame for two (#28 and #36) of twenty residents whose assessments were reviewed. The Resident Census and Conditions of Resident form documented 38 residents resided in the facility. Findings: 1. Res #28 had diagnoses which included congestive heart failure and diabetes. A quarterly assessment, dated [DATE], was completed and transmitted to CMS. A nurse note, dated [DATE], documented the resident had expired. A discharge, death in the facility, assessment was not located in the resident's records. On [DATE] at 11:07 a.m., the corporate nurse confirmed the discharge, death in the facility, assessment had not been completed in the required time frame. 38495 2. Res #36 had diagnoses which included COPD, end stage renal disease, anxiety, and dementia. An admission assessment, dated [DATE], was completed and transmitted to CMS. The resident's clinical records documented a discharge assessment, dated [DATE], was in process. The discharge assessment had been encoded in the seven day time frame but had not been transmitted at as of [DATE]. On [DATE] at 1:45 p.m., MDS coordinator stated she completed the MDS assessments and the corporate nurse consultant #1 transmitted the assessments. On [DATE] at 1:48 p.m., corporate nurse consultant stated the discharge assessment had not been transmitted.

Based on observation and interview, the facility failed to ensure the environment was free of dust and kept the vents and ceiling tiles in good repair. The Resident Census and Conditions of Residents form, documented 38 residents resided at the facility. Findings: On 05/02/23 at 9:30 a.m., an environmental tour of the facility was conducted to look at the vents in the resident rooms. The vents in room [ROOM NUMBER] were observed to have been full of dust, room [ROOM NUMBER] had one vent observed with dust, room [ROOM NUMBER] had one vent which was observed broken with paint chips and one vent with dust. room [ROOM NUMBER] was observed to have ceiling tiles with brown areas on them, tiles which had been taped, and the tape was observed to be peeling. Another ceiling tile was observed to have been cracked across the width of the tile. The vent was observed to have dust and what appeared to have been rust. room [ROOM NUMBER]'s intake vent was observed to be very dusty and room [ROOM NUMBER]'s ceiling tile around the vent was damaged and looked as if parts of the tile had come off. room [ROOM NUMBER]'s intake vent was observed to have been dirty with a black colored substance around the vent. On 05/02/23 at 12:41 p.m., the maintenance person was shown the rooms listed above. They stated housekeeping normally would clean the vents in the resident rooms. They stated he had ceiling tiles ordered and should be in during the upcoming weekend. The maintenance person stated the vents in the resident rooms should not have been full of dust like they were and the vent with cracks and peeling paint, and the vent with rust should have been replaced. They stated the vents had not been cleaned in about five months. On 05/02/23 at 12:51 p.m., the maintenance person stated room [ROOM NUMBER]'s vent had tape over it and when the tape was pulled off part of the ceiling tile came off with it. They stated the light cover in room [ROOM NUMBER] had some of the old ceiling, from above the dropped ceiling, which had fallen and was on the light cover and was blocking some of the light. On 05/02/23 at 12:53 p.m., Res #18 stated the light panels had not been replaced when they were broken. They stated the maintenance man put up the ceiling tile and took out the light cover. Res #18 stated they did not know why the maintenance person did that and they would like the light back. On 05/02/23 at 12:58 p.m., the maintenance person stated he performed checks of the facility once a month for things which needed repair.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and consistently identify and implement interventions to aid in the prevention of falls for two (#18 and #33) of five sampled residents who had experienced falls. Resident #18 had a history of [REDACTED]. The resident had fallen three times in 14 days while living at the facility. After the second fall the resident experienced a head injury. After the third fall the resident experienced experienced a hairline hip fracture. Resident #33 experienced eight falls in 11 weeks while living at the facility. During that period the resident: a) experienced a skin tear to the resident's arm above the elbow; b) experienced lacerations to the resident's hand, eyebrow (which required stitches), elbow, and forearm (which was 11 centimeters in length); and c) hit his head four times and experienced three head injuries. The director of nursing identified 35 residents who had fallen in the facility in the last six months. Findings: The facility's current policy for falls documented the following: .For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall, for example, a balance problem caused by an old or recent stroke. After a first fall, the staff (and physician if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur .After more than one fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing or changing problematic medications .If underlying causes can not be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of the current interventions .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approaches remain relevant . 1. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the past medical and family history, dated 09/26/16, documented a history of falls which resulted in a fractured right arm, fractured right femur, and fractured right knee. An incident report, dated 09/26/16 at 4:45 p.m., documented the resident was found in her room lying on the floor face down in front of her chair. The report documented the resident stated she hit her right hip and right wrist. The report documented the steps to prevent recurrence (STPR) were to continue to orient the resident to the facility, check her frequently, and remind her to use the call light. A care plan, dated 09/26/16, documented the resident was found on the floor face down in front of the chair. The care plan documented to orient the resident to the facility, to check her frequently, to remind her to use the call light, and to initiate neuro checks. An incident report, dated 10/04/16 at 8:30 p.m., documented the resident was found lying on her right side on the floor in her room. The report documented the resident had a small abrasion to her left forehead with minimal bleeding. The report documented the resident had bruising and slight swelling under her left eye. The report documented the STPR were to better anticipate the resident's needs and to check on her more frequently. A care plan, dated 10/04/16, documented the resident was found lying on her right side on the floor in her room. The care plan documented the resident had a small abrasion to her left forehead with minimal bleeding. The care plan documented the resident had bruising and slight swelling under her left eye. The care plan documented the approaches were to check on her more frequently. An admission assessment, dated 10/07/16, documented the resident was severely cognitively impaired, had no behaviors, and required extensive to total assistance with all activities of daily living (ADLs). The assessment documented the resident had no impairment in range of motion, was frequently incontinent of bladder, and was always continent of bowel. The assessment documented the resident had experienced one fall with injury, and one fall without injury since admission. An incident report, dated 10/10/16 at 11:05 a.m., documented the resident was found on the floor in her room sitting upright in front of her recliner. The report documented the resident complained of left hip pain and her left leg was rotated outward. The report documented the STPR was to educate the certified nurse aide (CNA) to stay with the resident while she was on the bedside commode. A care plan, dated 10/10/16, documented the resident was found on the floor in her room sitting upright in front of her recliner. The care plan documented the resident complained of left hip pain and her left leg was rotated outward. The care plan documented the approaches were to educate the CNA to stay with the resident while she was on the bedside commode (BSC) and to notify emergency medical services of the new order to transfer her to the hospital. The state reportable incident report, dated 10/10/16, documented the X-ray at the hospital showed a hairline fracture of her hip. A discharge return not anticipated assessment, dated 10/10/16, was submitted by the facility. On 02/15/17 at 2:45 p.m., the minimum data set (MDS) coordinator was interviewed about the incident report regarding the resident's fall on 10/10/16 and which had her signature. The nurse was asked why she documented to educate the CNA to not leave the resident alone while on the BSC as an intervention to prevent recurrence. The MDS coordinator reported the resident had been placed on the bedside commode by a CNA who then left the room. The MDS coordinator stated the resident had tried to transfer herself from the BSC and fell . The MDS coordinator was asked how the CNAs knew what level of assistance was required for a resident. She reported the facility did not use CNA care plans and would only verbalize the interventions needed. The MDS coordinator was asked about the resident's first fall which was documented on an incident report, dated 09/26/16, which she had signed. The MDS coordinator was asked if the intervention to use the call light was an appropriate intervention considering the resident's cognition. The MDS coordinator reported she would have to check. She reported the resident had sundowners and would be normal during the day time but more confused in the evening. The MDS coordinator was asked to review the admission assessment, dated 10/07/16, which documented the resident was severely cognitively impaired. On 02/15/17 at 5:05 p.m., an attempt was made to notify the CNA who left the resident alone on the BSC. The CNA, who no longer worked at the facility, could not be reached. On 02/16/17 at 7:45 a.m., the DON was interviewed and reported she was in the facility on 10/10/16 when the resident fell and fractured her hip. She reported she had spoken with the CNA who left the resident on the BSC. The DON reported the CNA had placed the resident on the BSC and left the resident unattended while she stepped across the hall to assist another resident. On 02/16/17 at 8:15 a.m., the administrator was interviewed and reported she had received a telephone call when the resident fell on [DATE]. The administrator was asked if the facility investigated falls in an attempt to determine a cause. The administrator reported, No. 2. Resident #33 was admitted to the facility on [DATE] and was [AGE] years old. The resident had [DIAGNOSES REDACTED]. The admission assessment, dated 10/04/16, documented the resident's cognition was intact and he had no rejection of care behaviors. The assessment documented the resident was independent with activities of daily living and required assistance with bathing. The assessment documented the resident's balance was steady at all times and he used a cane/crutch. The assessment documented the resident was always continent of urine and did not receive a diuretic medication. The assessment documented the resident had one fall prior to admission and had not received physical therapy or restorative services. A care plan, dated 10/24/16, documented the resident had a potential for falls related to his unsteady gait and his [DIAGNOSES REDACTED]. The care plan documented to encourage the resident to use non-skid socks or shoes daily. A fall risk assessment, dated 10/26/16, documented the resident was at high risk for falls. An incident report, dated 11/30/16 at 04:50 p.m., documented the resident stated he was walking in his room, lost his balance, fell , and hit his head on the floor. The report documented the resident received lacerations to his middle and index fingers on his right hand which required a dressing. The report documented the steps to prevent recurrence (STPR) was to instruct the resident to use his walker. The care plan, updated 11/30/16, documented the resident had a fall, hit his head, and received lacerations to two of his fingers. The care plan documented to educate the resident to use his walker. A quarterly assessment, dated 01/04/17, documented the resident's cognition was intact and he had no rejection of care behaviors. The assessment documented the resident was independent with activities of daily living and required assistance with bathing. The assessment documented the resident's balance was steady at all times and he used a cane/crutch or walker. The assessment documented the resident was frequently incontinent of urine and received a diuretic medication. The assessment documented the resident had one fall with minor injury since the last assessment. The assessment documented the resident had not received physical therapy or restorative services. An incident report, dated 01/27/17 at 10:30 p.m., documented the resident was lying on his back between the wall and the toilet. The report documented the resident stated he slid off the toilet seat when he was using the restroom. The report documented the resident said he hit the back of his head on the toilet. The report documented redness was observed on the back of the resident's head and the left side of his back. The report documented the STPR was to continue to anticipate the resident's needs. The care plan, updated 01/27/17, documented the resident fell in his bathroom and hit his head on the toilet. The care plan documented to encourage the resident to use the call light for assistance with toileting and to check the resident every two hours to see if he was incontinent of urine or needed assistance with toileting. An incident report, dated 02/04/17 at 4:30 p.m., documented the resident was sitting on the floor in front of his bathroom. The report documented the resident said he was going to the bathroom and fell back on the wheelchair and then to the floor. The report stated the resident said he hit on his bottom. The report documented the resident did not receive any injuries from the fall. The report documented the STPR were to have the staff monitor the resident as closely as possible and to encourage him to use the call light. The care plan, updated 02/04/17, documented the resident was sitting on the floor in front of the bathroom. The care plan documented to have the staff monitor the resident as closely as possible and encourage him to use his call light. The care plan documented to encourage staff to check for incontinence every two hours and encourage him to toilet with staff assist. The care plan documented to clear a path to the bathroom. An incident report, dated 02/05/17 at 4:25 a.m., documented the resident walked out of his room into the hallway, lost his balance, fell , and hit his face on the floor. The report documented the resident said he was throwing away some trash. The report documented the resident had a laceration above the right eyebrow. The report documented the resident was sent to the hospital. The report documented the STPR were to encourage the resident to use the call light and have the certified nurse aides (CNAs) check on him more often. The care plan, updated 02/05/17, documented the resident walked out of his room, lost his balance, fell , and hit his face on the floor. The care plan documented the resident received a laceration above his right eyebrow. The care plan documented to encourage the resident to use the call light and encourage CNAs to check on him more often. The care plan documented to monitor the stitches to his eyebrow until resolved. An incident report, dated 02/06/17 at 5:00 a.m., documented the resident was exiting his room into the hallway, lost his balance, fell backward, and slid down the door frame. The report documented the resident received a laceration to his right elbow which required steri-strips. The report documented the STPR was to instruct the resident to use his walker when ambulating. The care plan, updated 02/06/17, documented the resident fell near his doorway and received a skin tear. The care plan documented to encourage the resident to use a walker when ambulating. An incident report, dated 02/10/17 at 8:15 a.m., documented the resident was found lying on the floor between his toilet and wall. The report documented the resident received an 11 x 0.2 x 0.2 centimeter (cm) laceration to his left forearm which required steri-strips. The report documented the STPR were to continue to monitor as closely as possible and to check for a urinary tract infection. The care plan, updated 02/10/17, documented the resident fell in his bathroom and received a large laceration to his left forearm. The care plan documented to encourage the resident to toilet periodically with staff assistance. The care plan documented to educate staff to monitor the resident periodically for toileting and encourage him to toilet with staff assistance. On 02/13/17 at 11:49 a.m., the resident was observed lying on his bed. The resident was observed to have a laceration, which was approximately six inches long, on his forearm. The resident was observed to have several stitches to his right eyebrow. The resident was asked what happened. The resident stated he had a fall. The resident was observed wearing socks which were not non-skid socks. One arm crutch was observed leaning against the wall near the head of the resident's bed. A walker was observed folded and leaning against the wall on the other side of the resident's bedside table out of reach of the resident. An incident report, dated 02/14/17 at 3:40 a.m., documented the resident was laying on his back on the floor in his bathroom. The report documented the resident received a quarter size skin tear to his right elbow. The report documented the STPR were to remove the bilateral arm crutches from the resident's room and to encourage him to allow staff to toilet him frequently. The care plan, updated 02/14/17, documented the resident fell in his bathroom and received a skin tear to his right arm. The care plan documented to encourage the resident to toilet with staff assistance periodically. On 02/14/17 at 08:06 a.m., the resident was observed sitting up on the side of his bed feeding himself breakfast. The resident was wearing socks but not wearing non-skid socks. The resident's armcrutch was observed near the resident's bed. The resident's walker was observed out of reach of the resident on the other side of the resident's bedside table. An incident report, dated 02/14/17 at 8:50 a.m., documented the resident fell in his bathroom during a transfer to the toilet. The report documented the resident had stood up and fell into the wall. The report documented the resident hit his forehead on the wall which resulted in a pinpoint open area on his left forehead. The report documented the STPR were to continue to check on the resident frequently and encourage him to toilet when staff check on him. A physician order, dated 02/14/17 at 10:50 a.m., documented to obtain a urinalysis (UA) using a straight catheter with culture and sensitivity if indicated. A physician order, dated 02/14/17, documented for physical therapy to evaluate and treat as indicated. A physician order, dated 02/15/17, documented to administer Cipro 250 milligrams (mg) two times a day for 14 days for a [DIAGNOSES REDACTED]. On 02/15/17 at 9:08 a.m., the resident was observed sitting up in bed. Certified nurse aide (CNA) #3 was observed offering the resident liquids and she reminded the resident to use his call light. The resident was wearing socks but not the non-skid type. The resident's walker was folded and leaned against the wall on the other side of the resident's bedside table out of reach of the resident. The resident was asked what the staff did to help him to not fall. He said he did not know. He was asked if he used his walker. He said he would use it if he walked in the hallway. He was asked if he ever wore non-skid socks. He said he just wore whatever they put on him. On 02/15/17 at 9:11 a.m., CNA #2 was asked if the resident used his call light. She said the resident never used his call light and would get up without assistance. The CNA stated the resident had been independent until recently. She said the resident wanted to be independent and didn't want to ask for help. The CNA was asked if the resident ever wore non-skid socks. The CNA stated she had not seen the resident wear non-skid socks. On 02/15/17 at 9:17 a.m., CNA #3 was asked if the resident needed help with dressing. She said she helped the resident get dressed almost every morning. The CNA was asked if the resident had been wearing non-skid socks. She said she had not seen the resident wear non-skid socks and had not been dressing him with them. The CNA looked in the resident's sock drawer and found several pairs of socks. She said none of the resident's socks were non-skid socks. The CNA was asked if the resident needed assistance to ambulate to the bathroom. She stated the resident was able to go to the bathroom by himself as long as he held on to something. She was asked if the resident used his crutch or walker for ambulation. She said only if we reminded him. On 02/15/17 at 11:19 a.m., CNA #2 was asked how the CNAs knew the plan of care for a resident. She stated the nurses would verbally tell them. She said the residents have care plans in the chart, but she did not look at them. On 02/15/17 at 11:28 a.m., CNA #3 was asked how the CNAs knew if a resident was at risk for falls. She said the nurses verbalized to them what residents were at risk and what to do with each resident. On 02/15/17 at 11:31 a.m., the resident was observed sleeping in bed. The resident's walker was observed folded and leaning out of reach of the resident. The resident's arm crutch was leaning on the wall next to the head of the bed. The resident was wearing socks which were not non-skid socks. On 02/15/17 at 11:32 a.m., licensed practical nurse (LPN) #1 was asked about the resident's balance around the time the resident was admitted . The LPN stated the resident was not very steady and needed his walker to be safe when ambulating. The LPN was asked about the interventions related to the resident's previous falls. The LPN said the staff had reduced the clutter in the resident's room. She said the resident's arm crutch was more of a hindrance than help and encouraged the resident to use his walker instead. The LPN said the resident would not use his call light. She said they just tried to check on him as often as possible. She was asked if there was any documentation of how often the resident was observed. The LPN said there was not anything documented. The LPN was asked why the intervention to obtain a UA on 02/10/17 was not obtained until 02/14/17. She said the staff tried to get the resident to urinate in the urinal but he would not. She stated an order was obtained for a straight catheter procedure on 02/14/17. The LPN was asked if she filled out the STPR on the incident reports when a resident fell . She said she did the reports. The LPN was asked how she knew what interventions had been previously used and if they were effective or still relevant. She said she was not for sure what the previous interventions were when she filled out the incident reports each time. On 02/15/17 at 2:16 p.m., the DON was interviewed regarding the resident's previous falls and interventions for those falls. The DON said she was unaware the resident was not wearing non-skid socks. She said she was unaware the armcrutch was still in the resident's room because both of them had been taken out of his room along with his cane. She said the resident was more independent when he first came in and had noticed in January he required more assistance. The DON stated the UA should have been obtained on the 10th of February, not four days later. The DON was asked if the facility had analyzed the falls of the resident to evaluate if the interventions were working. She said she had noticed he was getting up to go to the bathroom on some of the falls and had told the CNAs to toilet him every two hours. She said the resident would not cooperate to go to the bathroom when the staff wanted him to go. She was asked if there was any documentation of the times the staff had checked on the resident. She said there was not any documentation except for a week of bladder training. The DON said she had also noticed the falls were happening on the night and evening shifts. She said the staff were told to check on him more often but there was no documentation.

On 01/22/13, an immediate jeopardy situation was determined to exist due to the facility's failure to have an effective system in place to ensure a resident at risk of constipation and status [REDACTED]. At 11:35 a.m., the Oklahoma State Department of Health was notified and confirmed the existence of an immediate jeopardy situation. At 12:10 p.m., the administrator and corporate RN (registered nurse) were notified of the existence of the immediate jeopardy. At 3:49 p.m., the administrator provided an acceptable plan of removal. The plan of removal was as follows: "...The current resident's ADL (activity of daily living) sheets will be highlighted on the B.M. (bowel movement) line to call attention to the importance of accurate documentation of all bowel movements, this will be completed by 11:59 p.m. on January 22, 2014. ...An inservice will be created by 3:00 p.m. on January 22, 2014 covering accurate documentation of bowel movements and reporting to the charge nurse when a resident has not had a B.M. within 3 days. Also included will be information for the nurses to ensure the importance of following a treatment plan for constipation. Details: a. On duty Nursing staff will be in-serviced before they leave from their shift January 22, 2014. b. Nursing staff will be in-serviced on January 22, 2014 no later than 11:59 p.m. If unable to be in-serviced by 01/22/2014 by 11:59 p.m. the nursing department staff member will be taken off of the schedule to work until the above listed in-service is completed. c. Nursing staff will not be on duty until fully in-serviced over the above listed issue. d. All other departments will be notified either at the above listed verbal in-service and/or will be given instructions at the time clock before they clock in or clock out in written form to always report any bowel issues that any resident reports to them immediately to the charge nurse. The written in-service will be posted at the time clock by 5:00 p.m. January 22, 2014. ...Dr. (name deleted) was consulted on January 22, 2014 and new orders were given at approximately 12:30 to 1:00 p.m. January 22, 2014 for (name deleted) resident #3 and those orders are currently in process of being followed. ...All resident's ADL's will be reviewed by 11:59 p.m. on January 22, 2014 with particular focus on BM's. If there (are) any other issues of residents not having bowel movements within 3 days, all ordered treatments will be followed if the resident has no current orders the doctor will be contacted for new orders. ...A newly written constipation policy will be executed on January 22, 2014 by 11:59 p.m." On 01/22/14 at 4:20 p.m., the resident's record and newly written physician's orders [REDACTED]. At 4:30 p.m., an interview was conducted with resident #3, regarding the newly written physician's orders [REDACTED]. The resident informed the surveyor that the staff had implemented the above orders and she had good results from the enema and the laxative. At 4:30 p.m., the revised policy for constipation was received and accepted. From 5:00 p.m. to 5:15 p.m. and on 01/23/14 from 8:45 a.m. to 9:15 a.m., interviews were conducted with licensed and unlicensed staff concerning the inservices which were held. Staff verbalized understanding of the inservice content. On 01/23/14 at 9:30 a.m., documentation of staff checking each resident's record for their last bowel movement and interventions implemented as needed was reviewed. At 10:46 a.m., after reviewing the plan of removal and confirming the last inservice had been completed on 01/22/14 at 11:04 p.m., the administrator was informed the immediacy had been removed effective 01/22/14 at 11:04 p.m. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on record review and interviews, it was determined the facility failed to: a. ensure a resident with a [DIAGNOSES REDACTED].#3) of eight sampled residents. This resulted in an immediate jeopardy. The facility identified 35 residents with a [DIAGNOSES REDACTED]. Seventeen of those residents also had prn (as needed) orders for laxatives, b. ensure a resident with a [DIAGNOSES REDACTED].#5) of eight sampled residents. This had the potential to affect 35 residents identified by the facility with a [DIAGNOSES REDACTED]. Seventeen of those residents also had prn orders for laxatives, and c. assess, monitor and provide appropriate interventions related to [MEDICAL CONDITION] for one (#2) of eight sampled residents. This had the potential to affect all 54 residents who resided in the facility. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the November 2013 ADL sheet documented the resident had no bowel movements recorded for six days from 11/23/13 through 11/28/13. There had been no prn laxative given to the resident during that time period. A review of the December 2013 ADL sheet documented the resident had no bowel movements recorded for eight days from 12/9/13 through 12/16/13. There had been no prn laxative given to the resident during that time period. The record documented the resident had complained of abdominal pain on 12/22/13. She again complained of abdominal pain on 12/23/13, and was then transferred to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was discharged from the hospital on [DATE] and returned to the facility. A care plan updated on 12/23/13, documented, ..."Problem - To hospital with bowel obstruction...Goal - will have BM q (every) 3-5 days...Approach - Give lax (laxative) if no BM q 3-5 days..." On 01/21/14 at 8:40 a.m., CNA #3 (certified nurses aide) was asked what he would do if he noticed that a resident had not had a bowel movement. He stated he had been instructed to report to the charge nurses if residents had not had a bowel movement within 3 - 5 days. On 01/21/14 at 8:45 a.m., CNA #1 was asked what she would do if she noticed that a resident had not had a bowel movement. She stated she had been instructed to report to the charge nurses if residents had not had a bowel movement within 3 - 5 days. On 01/21/14 at 8:50 a.m., CNA #2 was asked what she would do if she noticed that a resident had not had a bowel movement. She stated she had been instructed to report to the charge nurses if residents had not had a bowel movement within 3 - 5 days. An interview was conducted on 01/21/14 at 1:20 p.m., with the corporate RN. She was asked about the care plan notation updated on 12/23/13 that referred to the documentation of the problem of the resident's bowel obstruction and the goal of routine bowel movements. She was asked why there had been no intervention to address the resident's lack of bowel movements for eight days in December 2013. She stated the facility policy was to administer a laxative after a three to five day period without a bowel movement. She stated the policy had not been followed. She presented the surveyor with an undated policy for constipation which documented, ..."if a resident does not have a bowel movement in 3-5 days depending on the residents bowel function, the charge nurse will be notified and utilize any prn medications or treatments ordered for the resident...the ADL record will be reviewed on a weekly basis, by nursing staff for indication of constipation." She was asked who reviewed the ADL record on a weekly basis. She stated the charge nurses reviewed them. On 01/22/14 at 3:10 p.m., an interview was conducted with LPN #3 (licensed practical nurse). She was asked if she reviewed the ADL sheets for documentation of bowel movements on a weekly basis. She stated she reviewed them if a CNA (certified nursing assistant) reported that a resident had not had a bowel movement in 3 - 5 days. She was asked if she was aware resident #3 had no bowel movements in over 5 days. She stated she was not aware. On 01/22/14 at 2:20 p.m., LPN #1 was asked if she reviewed the ADL sheets for documentation of bowel movements on a weekly basis. She stated she did not review them. On 01/22/14 at 3:30 p.m., the resident was asked if she had experienced constipation before she went to the hospital. She stated she had stomach pains and she had received a laxative the day before she went to the hospital. She was asked if she had a bowel movement since she came back from the hospital on [DATE]. She stated she had a bowel movement the day after she got back on 01/12/14. She stated she had not had one since. The January 2014 ADL record documented the resident had a medium bowel movement on 01/12/14. There was no documentation of any bowel movements in the nine days from 01/13/14 through 01/21/14. There was no documentation in the clinical record to show the resident had received any prn laxative during this nine day period of time. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The November 2013 ADL Flow Record documented the resident had no bowel movements from 11/24/13 through 11/30/13 (seven days). The November 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] ~ refused his [MEDICATION NAME] which was ordered to be given daily on a routine basis on 11/30/13, and ~ received no prn (as needed) dose of Milk of Magnesia (MOM) for constipation. The December 2013 ADL Flow Record documented the resident had no bowel movements from 12/06/13 through 12/11/13 (six days). The December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] ~ refused his routine daily dose of [MEDICATION NAME] on 12/01/13, 12/07/13, 12/08/13, 12/14/13, 12/15/13, 12/21/13 and 12/22/13, ~ received a prn dose of MOM on 12/26/13 and 12/27/13 for complaints of constipation, and ~ refused his [MEDICATION NAME] and [MEDICATION NAME] on 12/28/13, which were all ordered to be given routinely. The January 2014 monthly physician's orders [REDACTED]. "[MEDICATION NAME] (laxative) 10Gm (grams)/15ml (milliliters) solution give 30 ml by mouth daily (Dx (diagnosis): constipation) [MEDICATION NAME] (laxative)...mix 1 packet (3.4Gm) in 8oz (ounces) of water and give by mouth daily (Dx: constipation) ...Polyethylene [MEDICATION NAME] (laxative) 17Gm/1dose...mix 17Gms in 8 oz of water and give by mouth daily (Dx: constipation) [MEDICATION NAME] Sodium 100mg (milligrams)...1 cap (capsule) by mouth twice daily (Dx: constipation) ...Milk of Magnesia (MOM) 8% oral susp (suspension)...give 30 ml by mouth daily as needed for constipation..." The January 2014 ADL Flow Record documented the resident had no bowel movements from 01/13/14 through 01/21/14 (nine days). The January 2014 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] ~ refused his routine daily dose of [MEDICATION NAME] on 01/18/14 and 01/19/14, and ~ received no prn dose of MOM for constipation. On 01/23/14 at 1:25 p.m., LPN #1 was asked about the resident's refusal to take routine laxatives as ordered, the lack of bowel movements and lack of administration of prn laxatives when the resident had no BM. She stated she was unaware of the resident having refused medications or that he had gone for the extended periods of time without a BM. 3. Resident #2 was admitted to the facility, on 12/23/13, with [DIAGNOSES REDACTED]. An admission nursing evaluation, dated 12/23/13, documented, "...Skin Condition Using the diagrams provided, indicate all body marks such as old/recent scars (surgical and other), bruises, discolorations, abrasions, pressure ulcers, or questionable markings. Indicate size, depth...color and drainage. Comments...cannula still in his (left) AC (antecubital space) removed cannula, still had tracking device pinned on shirt. Has peg tube...Physical [MEDICAL CONDITION] (site, describe) (this section was left blank)..." A skin assessment, dated 12/26/13, documented, "...Left shin 4 x 4 cm dry flaking skin powedery (sic) white skin. An area 5 x 5 cm just below the above dark wrinkled skin -Just Below- 5cm x 4.5 cm salmon color center. Left Great Toe- Fungal @ base of nail. 1.5 x 1 lesion with stacked layers of skin(.) 3 cm below great toe outer edge of foot is 3x2cm layered callous...Rt (right) Sm (small) lesion also on middle & little toes- on Bottom of foot @ base of great toe 1.5 x 1.4 hard thick callous..." A telephone order, dated 01/03/14, documented, "...apply skin prep to Bilat (bilateral) (lower) ext (extremities) q (every) day...apply skin prep to top Bilat toes q day..." The resident's care plan, dated 01/03/14, documented, "...Alteration to skin to Left hand 3rd 4th Digit c (with) [MEDICAL CONDITION] caught hand in w/c (wheel chair)..." The clinical record documented the resident's physician had seen the resident one time, on 01/08/14, during his stay at the facility. A physician's visit note, dated 01/08/14, documented the review of the resident's respiratory and skin systems were negative for symptoms. On 01/21/14 at 1:00 p.m., LPN #1 was asked about the resident's hospitalized from [DATE] to 01/16/14. She stated he was hospitalized for [REDACTED]. She was asked about the condition of his legs at the time of the hospitalization . She stated the resident was admitted with [MEDICAL CONDITION] to bilateral lower extremities. She stated the resident was receiving treatment for [REDACTED]. She stated the resident received a treatment as ordered by the physician to both his legs and toes. She stated the resident had two to three plus non-[MEDICAL CONDITION] to bilateral lower extremities. At 1:10 p.m., the resident was asked about his [MEDICAL CONDITION]. He stated the nurses and the therapist were aware his legs were [MEDICAL CONDITION], and they did not notify his physician. He was asked about his hospitalization . He stated his legs were swollen and he had pneumonia. He stated he had gone to an appointment and while out of the facility for the appointment, his family took him to the hospital because his legs were so swollen. At 2:25 p.m., the DON (director of nursing) was asked about the resident's skin condition when admitted to the facility. She stated the resident was admitted to the facility with a wound on his leg which was pink in the center. At 2:30 p.m., the DON and surveyor observed the resident's skin. The resident was observed to have multiple old scars, scabs and one plus non-[MEDICAL CONDITION] to his bilateral lower extremities. No open areas were observed. Multiple calluses were observed on his bilateral feet and toes. A tattoo was also observed on his upper left arm. At 3:00 p.m., the resident's physician was interviewed via telephone. He stated he had only seen the resident once, was unaware of the resident's hospitalization and could not remember the resident having any open areas or [MEDICAL CONDITION] when he saw the resident. At 3:15 p.m., LPN #2 was asked about the resident's [MEDICAL CONDITION]. She stated the resident was admitted with one plus non-[MEDICAL CONDITION]. She stated it was worse on the day he went to the hospital. When asked how much [MEDICAL CONDITION] the resident had on the day he went to the hospital, she stated the [MEDICAL CONDITION] in his bilateral lower extremities was two plus and non-pitting. LPN #2 was asked at what point the physician should be notified concerning [MEDICAL CONDITION]. She stated if the resident had any complications such as redness, warmth upon touch, wheezing/respiratory problems or complaints of pain. She was asked if she notified the physician of the increased [MEDICAL CONDITION]. She stated no. On 01/22/14 at 9:25 a.m., LPN #1 was asked when the resident's [MEDICAL CONDITION] had increased. She stated she had noticed his [MEDICAL CONDITION] was two to three plus non-pitting a couple of days prior to going to the hospital. She was asked if she had informed the physician of the increased [MEDICAL CONDITION]. She stated, "No..."