Every finding on record at Rainbow Terrace Care Center

Based on observation, record review, and interview, the facility failed to follow infection control practices during a mediation pass and failed to ensure EBP was followed during wound care for one (#11) of one sampled resident observed during wound care. The DON identified 29 residents who resided in the facility and four residents who were on enhanced barrier precautions. Findings: A document titled Medical Glove Policy and Procedure, read in parts The purpose of this policy is to establish guidelines for the proper use of medical gloves in order to prevent the transmission of infections and ensure the safety of residents and healthcare workers .Change gloves between tasks and procedures on the same patient to prevent cross-contamination. A document titled Policy and Procedure: Enhanced Barrier Precautions, read in parts Enhanced Barrier Precautions (EBPs) is a Centers for Disease Control and Prevention (CDC) recommendation to provide guidance for use of personal protective equipment (PPE) in facilities for preventing the spread of multi-drug resistant organisms (MDROs) .The facility may choose to implement enhanced barrier precautions to include any resident with an indwelling medical device or wound .appropriate signage for type of precaution will be posted on room door .Isolation cart containing appropriate PPE and hand sanitizer will be readily accessible for use .The IP/Designee will provide staff, residents and/or resident representatives with education regarding the purpose of enhanced barrier precautions. 1. On 01/07/25 at 7:10 a.m., LPN #1 was observed preparing a medication administration for a resident. The LPN donned a pair of gloves, opened cart drawers, obtained medication from different medication bottles and packages, and turned pages on the paper MAR. Using the same gloved hands the LPN prepared to crush the medications by placing the tablet/capsule each time in their gloved hand, then placed the medication in a plastic envelop to crush. On 01/07/25 at 7:23 a.m., the LPN #1 stated they should not have placed the tablet/capsule in their unclean gloved hand. The LPN stated they should have changed their gloves and washed their hands between tasks and touching unclean surfaces. On 01/08/25 at 1:13 p.m., the DON stated LPN #1 should have washed their hands and changed gloves between tasks. 46703 2. On 1/08/25 at 8:00 a.m., LPN #1 washed their hands and donned gloves, but did not wear a gown. Resident #11's covers were removed and they were rolled onto their right side revealing a dime sized open area on the left buttocks. LPN #1 cleansed the open area with wound cleanser and applied lanolin. On 1/08/25 at 8:10 a.m., LPN #1 stated they had never worn a gown to perform wound care only gloves. They stated they were not aware of an enhanced barrier precautions policy.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The administrator identified 29 residents resided in the facility. Findings: The work schedule for July 2024 through August 2024 documented no RN coverage for 7/12, 8/6, 8/16, 8/17, 8/18, 8/23, 8/24, 8/25, 8/29, and 8/30. On 01/08/25 at 12:46 p.m., the DON stated in July and August they were short staffed on RNs and did not have RN coverage every day.

Based on record review and interview, the facility failed to have an antibiotic stewardship program with a system to monitor antibiotic use for the residents. The DON identified five residents who were currently receiving an antibiotic medication. Findings: A policy titled Antibiotic Stewardship, read in part The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. On 01/07/25 at 2:53 p.m., the DON stated there had been no documented infection control monitoring completed since November 2023. The DON stated they were not aware they were responsible for infection control or antibiotic stewardship monitoring. The DON stated there was no tracking/ monitoring for the use of antibiotics in the facility.

Based on record review and interview, the facility failed to ensure a referral was made to the LOCEU for one (#18) of three sampled residents reviewed for PASSARs. The DON identified five residents with a PASSAR level ll after a referral to the LOCEU. Findings: Resident #18 had diagnoses which included delusional disorderes and major depressive disorders. A PASSAR level l, dated 05/25/21, documented the resident had a diagnosis of a serious mental illness. The form documented a referral was to be made to the LOCEU for consultation. On 01/07/25 at 12:08 p.m., the DON reviewed the resident's PASSAR level l and stated per the documentation a PASSAR level ll referral should have been made to the LOCEU. The DON stated per documentation a referral had not been completed.

Based on record review and interview the facility failed to provide pressure ulcer treatment as directed for one (#2) of three residents reviewed for pressure ulcers/wounds. The DON reported the facility had one resident in the facility with a wound. Findings: A facility policy, revised January 2002, titled Wound Care, read in part .The purpose of this procedure is to provide guidelines for the care of wound to promote healing. 1. Verify there is a physician's order for this procedure .If the resident refuses the care, inform your supervisor .The following information should be recorded in the resident's medical record: .If the resident refused the treatment and the reason(s) why .Report other information in accordance with facility policy and professional standards of practice. Res #2 had diagnoses which included edema, paraplegia,and dementia with behaviors, A quarterly assessment documented the resident was at risk for pressure ulcers and had MASD. A physician order, dated 10/09/23, documented Santyl external ointment to apply to affected area every 72 hours for open areas related to paraplegia. The TAR for February and March 2024 were reviewed and 10 treatments were not completed according to the documentation. The resident's clinical records, including the TARs) were reviewed and did not document a reason the treatments had not been carried out. On 03/27/24 at 2:40 p.m., RN #1 stated the resident often refused wound care. RN #1 stated according to the TAR for February and March the wound care was not completed as ordered and confirmed there was no documentation of the resident refusing the treatment. On 03/27/24 at 3:37 p.m., the DON stated the wound care for the resident had not been completed as ordered by the physician. The DON stated there was no documentation why the wound care was not completed in the resident's clinical records.

On 08/17/23 at 5:45 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure background screenings were completed for four of 29 employees hired between 2022 and 2023. The facility failed to ensure residents were not at risk for abuse related to staff background screening and finger printing not being completed. On 08/17/23 at 5:50 p.m., the charge nurse on duty was informed of an Immediate Jeopardy situation and the IJ template was emailed to the DON at that time. The administrator, assistant administrator, and DON were not in the facility at that time. On 08/21/23 at 4:38 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health by the assistant administrator. The facility plan of removal, read in entirety, Immediate Jeopardy Plan of Removal 8/18/2023 On 8/17/2023 at 5:50 PM, an Immediate Jeopardy situation was announced to the ADON, [name withheld]. The Immediate Jeopardy was due to the facility not having up to date background checks on 4 out of 29 employees hired between 2022 and 2023. On March 20, 2023, the Administrator that was in charge of background checks suffered a stroke, and he was the one that had access to OkScreen. On 8/17/2023, an email was sent to OkScreen to regain access to the site. Access was granted on 8/18/2023 and at 0800 [8:00 a.m.], the payment was submitted. According to the OkScreen site, full access to the background check site will not be fully functioning until one business day after the payment is rendered. Copies of the background checks for [NA #1 name withheld] and [NA #3 name withheld] were obtained and they will remain in the employee charts until the facility gains access to the OkScreen site. At this time, the employees will be verified through the site. The remaining two employees that do not have background checks do not work directly with residents. They have been checked by ODCR and do not hold any criminal records. As soon as access is granted to the site, these individuals will be set up for a fingerprint screening. Until they have their fingerprints, these individuals that work in the kitchen will not have any interaction with residents that reside in the facility. Both kitchen workers have been contacted, and informed that they are not to have any contact with the residents. The cook in the kitchen has been notified that they are to watch for contact with residents, and the charge nurse will be notified if contact is made. Both the cooks and charge nurses have been notified to watch for any contact, and if contact is made, those without a background check will be asked to leave the facility. The charge nurses and kitchen cooks have been notified by telephone of these changes. Notifications have been finished by 11:45 AM on 8/18/2023. Since the facility will soon have access to the OkScreen site, a list of all employees will be run and compared to the employees that are listed on the facility profile. Any employee that is missing a background check will be verified, and if no previous check has been completed, the employee will be scheduled for fingerprinting. To continue to remain in compliance, once compliance is reached, a new system will be created to ensure that background checks are completed in a timely manner. Any future employees will have to be submitted for a background check as soon as it is determined that they are of hiring potential. The Office Manager will assist the RN Consult with monthly auditing of employees to ensure that no background checks are missed. In-service has been given to the people that are in charge of hiring to ensure that they initiate a background check before someone is placed on the schedule. The office assistant has been in-serviced on overlooking employee files monthly. In-services have been completed as of 11:45AM on 8/18/2023. Access was regained to OkScreen site, and background checks were completed for: [Cook #3, DA #3, Cook #1, DA #2, NA #1, NA #3, NA #4, NA #5, DA #1, and Maintenance Worker #1, names withheld]. According to a search of the SOM, there is no Federal Regulation that states how long an employee leaving on good terms must be terminated before getting rehired. That was thoroughly checked and the facilities policy was reviewed to ensure that employees were rehire able [sic]. Per the documentation that has already been sent, in-service was provided to those in charge of hiring, in-service was provided to the office assistant that reviews charts and in-service was held with the employees that were awaiting checks, the charge nurses and the supervisors that were in the kitchen, as they would be watching to ensure those needing background checks were not around the residents. It is still believed that the facility completed all steps necessary to ensure safety, as you can't schedule fingerprints until ALL background checks have been run. The IJ was lifted, effective 08/29/23, when all components of the plan of removal had been completed and the employees who did not have background checks and fingerprinting were completed. The deficiency remained at a widespread level with potential for more than minimal harm. Based on interview and record review, the facility failed to ensure background screenings were completed prior to employment for 13 of 33 employees reviewed for background screening. The Resident Census and Conditions of Residents form documented 27 residents resided at the facility. Findings: A Background Screening Investigation policy, revised November 2015, read in part, .1. The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by stated law) on all potential employees and contract personnel who meet the criteria for direct access employee, as stated above. Such investigation will be initiated within two days of an offer of employment or contract agreement . On 08/17/23 at 2:01 p.m., the SS director/BOM stated they had done all the hiring in the last two years and no one had been screened. The SS director stated the new hires could not be ran through OK screen because they could not get into the system. SS director stated the administrator could not remember the password and they would have to get it reset. On 08/17/2023 at 3:18 p.m., a staff list was provided with the date of hire and the list documented whether the staff had or did not have a background screening. The list documented 11 staff did not have background checks. On 08/22/23 at 10:06 a.m., the program manager for the Oklahoma National Background Check Program was contacted and a report was obtained which listed six of 17 staff who the facility recently registered with OK screen. On 09/12/23 at 11:06 a.m., the program manager for the Oklahoma National Background Check Program was contacted and they sent a report which documented 19 of 19 total staff who had background checks and finger printing completed. The report documented the facility had two staff eligible on 08/20/23, two staff eligible on 08/21/23, five staff eligible on 08/27/23, and three staff eligible on 08/29/23.

Based on observation, record review, and interview, the facility failed to: a. complete pressure ulcer assessments which included measurements and description for one (#128); b. notify the physician of a wound area and unstageable pressure ulcer timely for one (#128); and c. have a care plan in place and/or updated to prevent pressure ulcers for residents at risk for ulcers for two (#128 and #115) of two residents reviewed for pressure ulcers. Res #128's medical records documented a scabbed area to the resident's coccyx that continued through June and July 2023 without assessment or physician notification. On 07/28/23 the unstageable ulcer was assessed and measured at 3.0 x 5.0 x 1.0 cm. The physician was notified on 07/31/23 and an order for treatment was obtained. The Resident Census and Conditions of Residents report, dated 08/15/23, documented no with resident pressure ulcers. Findings: A facility policy and procedure titled, Pressure Ulcer Treatment, documented a stage I pressure ulcer was a persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. The policy documented interventions/care strategies were to evaluate until redness was no longer persistent; notify physician, family and appropriate facility personnel; and initiate a skin grid and care plan. A Pressure Ulcer Risk Assessment Policy, revised 03/2005, read in part, .10. Routinely assess and document condition of the resident's skin per facility wound and skin program for any signs and symptoms of skin irritation or skin breakdown. Immediately report any signs of a developing pressure ulcer to supervisor .assess for the presence of developing of pressure ulcers on a weekly basis or more frequently if indicated . 1. Resident #128 was admitted to the facility on [DATE] with diagnoses which included non-traumatic intracerebral hemorrhage in the brain stem and encephalopathy. An admission assessment, dated 05/11/23, documented the resident was not impaired for daily decision making, was total dependent for ADLs, and had a catheter. The assessment documented the resident did not have a pressure ulcer or skin issues. The assessment documented the resident was at risk for pressure ulcers. The CAA triggered for pressure ulcers to be care planned. A weekly skin assessment log, for the weeks 05/01/23 through 07/31/23, documented a P each week on Monday to the coccyx area. The log defined a documented P as representing an area with a newly noted problem. The log documented more detail would be provided on a separate, detailed sheet. The log documented clear skin would be indicated with the letter C. A Skin Note, dated 05/01/23, documented the resident had an area to the coccyx, with rolled up skin, and no redness or open area noted. A Skin Note, dated 05/08/23, documented the resident continued to have an unopened area to the coccyx. The note documented the resident had an order for barrier cream through hospice services. The physician orders and TAR did not document an order for barrier cream. There was no assessment or notification of the physician documented in the record. A Skin Note, dated 05/15/23, documented the resident continued to have an area to the coccyx with no open areas noted. An assessment was not documented or physician notified. A Skin Note, dated 05/29/23, documented the resident had a scratch to the coccyx area. The note documented no erosion seen or further breakdown noted. A Skin Note, dated 06/05/23, documented a scabbed area to the coccyx with barrier cream continued to be used. An assessment and physician notification was not documented. A Skin Note, dated 06/12/23, documented a scabbed area on coccyx with no open areas noted. There was no documentation of a wound assessment or notification to the physician regarding the unstageable wound. A Skin Note, dated 06/19/23, documented a calloused area to the coccyx with no open areas and applied barrier cream on coccyx to protect. No assessment was documented or physician notification. A Skin Note, dated 07/03/23, documented an area to the coccyx remained closed with no redness noted. The note documented CNA to use barrier cream for protection. No assessment or notification was recorded. A Skin Note, dated 07/10/23, documented the resident continued to have a calloused, unopened area to the coccyx. No assessment or notification to the physician was documented. A care plan, initiation date of 07/19/23, documented the resident had little or no activity involvement related to physical limitations and physical mobility related to stroke. The care plan documented the resident had an ADL self-care performance deficit related to a brain stem injury. The care plan documented the resident had potential/actual impairment to skin integrity of the coccyx related to fragile skin. The care plan documented the following interventions: a. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. b. Encourage good nutrition and hydration in order to promote healthier skin. c. Follow facility protocols for treatment of injury. d. Monitor/document location, size and treatment of skin injury. e. Report abnormalities, failure to heal, sign and symptom of infection, maceration, etc. to physician. The MDS triggered for care planning for pressure ulcers on 05/11/23. The care plan was not created until 07/19/23. A Skin Note, dated 07/25/23, documented the resident had a rash under the left arm. The note documented the physician was notified for orders. The note documented the area on the coccyx was red with a callous and not open. There was no wound assessment or mention of the coccyx wound if reported to the physician. A physician note, dated 07/26/23, documented the chief complaint was the resident was being seen for gurgling. The note stated a chest x-ray was ordered. The note documented in the skin section of the document to see the detailed report in the patient record. There was no detailed skin report at that time. A Skin Check assessment, dated 07/28/23, documented a stage II/unstageable 3.0 cm x 5.0 cm x 1.0 cm pressure ulcer to the coccyx. No notification to the physician and no order was obtained. A Skin Note, dated 07/28/23, documented scratches noted to coccyx area and cream was applied. This documentation did not coincide with the previous assessment. A Skin Check assessment, dated 07/31/23, documented a stage II to coccyx and dressing orders received. A Skin Note, dated 07/31/23, documented area to coccyx noted to be open, approximately 3.0 cm x 5.0 cm x 1.0 cm. Physician notified for wound orders and dressing applied to coccyx. A physician order, dated 07/31/23, documented to apply a Santyl and Alginate pad with an island dressing. The order documented to change the dressing every 72 hours and as needed for soiling or dislodgement. The TAR or resident record did not document a dressing change was performed at any time before the resident left the faciity on [DATE]. A nurse note, dated 08/02/23, documented the resident had hematuria (blood in urine) and an elevated temperature, 101.1-degree Fahrenheit. The note documented a new ulcer to the coccyx area 3.0 cm x 5.0 cm x 1.0 cm that was previously a calloused area. The note documented the resident was sent to the hospital for evaluation. A significant change assessment, dated 08/04/23, documented the resident was modified independent for daily decision making, was total dependent for ADLs, and had a catheter. The assessment documented the resident had one stage II pressure ulcer. On 08/14/23 at 11:09 a.m., a family member was interviewed regarding the resident. The family stated the hospital advised surgery was needed for the wound. On 08/21/23 at 11:41 a.m. the DON reviewed the resident's records. The DON stated the resident had an unstageable pressure ulcer on the 07/28/23. The DON stated the physician was not notified on the 07/28/23 of the unstageable pressure ulcer. On 08/21/23 at 12:25 p.m., LPN #1 was observed sitting at the nurse station completing August 2023 TARs for the resident. The LPN did not provide the TAR for August 2023. On 09/12/23 at 1:10 p.m., the DON provided the resident's MARs and TARs for July 2023 and August 2023. The documents did not document the physician order received for Santyl and Alginate 07/31/23. The DON stated the order must not have printed to the TAR, but was documented in a Skin Note as completed. The DON stated there was not an order for barrier cream because the facility had standing orders for the use of barrier cream. The DON provided a document titled Rainbow Terrace Care Center Standing Orders. The document did not have a physician signature. The DON was unsure about a physician signed copy of the standing orders. 46909 2. Res #115 was admitted to the facility on [DATE] with diagnoses of intracranial hemorrhage, chronic pancreatitis, pain in unspecified limb, diabetes mellitus, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, and vitamin D deficiency. The care plan, initiation date of 09/12/17 and last revised on 09/12/17, documented the resident had potential impairment to skin integrity related to fragile skin and poor mobility. The goal was the resident would maintain or develop clean and intact skin by the review date with a target date of 09/20/21. The interventions included the following: a. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. b. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. c. Encourage good nutrition and hydration in order to promote healthier skin. d. Follow facility protocols for treatment of injury. e. Identify/document potential causative factors and eliminate/resolve where possible. A quarterly assessment, dated 06/04/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had no pressure ulcers but was at risk for pressure ulcers. An annual assessment, dated 06/17/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had no pressure ulcers but was at risk for pressure ulcers. On 08/15/23 at 11:58 a.m., CNA #1 was observed rolling the resident on their right side and an observation was made of a scar with an open nickel size pressure ulcer on it on their left hip. The CNA stated she would let the nurse know about the wound. A weekly skin assessment, dated 08/15/23, documented the resident had a P for problem on the left hip. A pressure ulcer report, dated 08/15/23, documented the resident had a stage II pressure ulcer measuring 3.0 x 2.5 cm on their left hip and an order was obtained to treat with barrier cream. On 08/17/23 at 10:47 a.m., an observation was made of the wound while CNA #1 repositioned the resident. The pressure ulcer was observed open and had a scant amount serosanguinous fluid on it. Res #115 reported the wound had been on his left hip for more than two months. On 08/17/23 at 11:50 a.m., an interview was conducted with LPN #1 and they stated CNA #1 had reported the wound to them on 08/15/23 and an order was obtained to treat the wound with barrier cream. The LPN stated the physician did examine the resident on 08/17/23 and stated to continue the previous order of barrier cream.

Based on record review and interview, the facility failed to electronically submit direct care staffing data based on the facility payroll to CMS. The Resident Census and Conditions of Residents form documented 27 residents reside in the facility. Findings: The Quality Improvement and Evaluation System was reviewed and did not reveal PBJ data for the facility during the previous two quarters. On 08/21/23 at 9:46 a.m., an interview was conducted with the BOM, and they were not aware of a staffing report needing to be submitted to CMS for direct care for residents. They also stated the only care report they needed to complete was the quality of care for the state. The BOM stated the administrator was probably doing these reports, but he has been out of the facility with health issues. On 08/21/23 at 9:50 a.m., the acting administrator was not currently available for an interview. On 08/22/23 at 10:27 a.m., the acting administrator was not currently available for an interview. On 08/22/23 at 10:29 a.m., an interview was conducted with the DON and they stated the administrator, nurse consultant, or the administrator's wife would normally report payroll staffing. They also stated they had no idea about a PBJ report.

Based on record review and staff interview, it was determined the facility failed to provide staff training over behavioral health issues. The Resident Census and Conditions of Residents form documented 27 residents reside in the facility. Findings: An Abuse Prevention Program policy read in part, .Required staff training/orientation programs that includes such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior .Handling verbally and physically aggressive residents behavior. On 09/12 23 at 12:50 p.m. an observation was made of Cook #1's employee file and the file only had an application for employment in it. a. LPN #2; hire date 07/16/23, b. Cook #1; hire date 08/08/23, c. Cook #2; hire date 08/26/21, d. DA #1; hire date 04/28/23, and e. DA #2; hire date 09/17/20. On 09/12/23 at 9:55 a.m.,an interview was conducted with the SS/BOM, they stated they did not provide training/orientation for verbally and physically aggressive resident behaviors for the five employees upon hire. They also state if it is not in the employee file then it was not done. Education and orientation was a complete oversight.

Based on observation and interview the facility failed to ensure medications were stored in locked compartments. The Resident Census and Conditions of Residents form dated 08/15/23 documented 27 residents resided in the facility. Findings: On 08/16/23 at 10:10 a.m., an observation was made of two cabinets storing medications behind the nursing station was opened and unlocked. On 08/16/23 at 10:11 a.m., an interview was conducted with LPN #1 and they stated the cabinet draws should be closed and locked to prevent any resident from getting into the medications.

Based on record review and interview, the facility failed to ensure OHCA was contacted when residents had serious mental illnesses for two (#101 and #111) of two residents reviewed for PASRR assessments. The Resident Census and Conditions of Residents form documented 27 residents had documented psychiatric diagnoses. Findings: 1. Res #101 was admitted to the facility on [DATE] and had diagnoses which included vascular dementia, major depressive disorder, and psychotic disorder. A PASRR level I, dated 07/27/23, did not document the resident had a serious mental illness and OHCA was not contacted. A physician order, dated 07/27/23, prescribed Zyprexa (an antipsychotic medication) for the resident. On 08/16/23 at 3:13 p.m., an interview was conducted with the DON and they stated the hospital informed them a PASRR II was not required for vascular dementia and they had not spoken with anyone from DHS. 2. Res #111 was admitted to the facility on [DATE] and had diagnoses of schizophrenia and recurrent depressive disorder. A PASRR level I, dated 01/31/23, documented the resident had a serious mental illness and there was no documentation the OHCA was notified. On 08/17/23 at 4:26 p.m., an interview was conducted with the DON and she stated they did not call OHCA for resident being diagnosed with a serious mental illness.

Based on record review, observation, and interview, the facility failed to ensure colostomy care was provided by professional standards of practice for two (#109 and #117) of two residents reviewed for colostomy care. The Resident Census and Conditions of Residents report, dated 08/15/23, documented two residents with an ostomy. Findings: The facility Colostomy/Ileostomy Care Policy documented the staff were to document the date and time the colostomy/ileostomy care was provided. The policy documented the staff were to document the name and title of the individual who provided the colostomy/ileostomy care and any breaks in the resident's skin, signs of infection, or excoriation of skin. 1. Resident #109 was admitted to the facility on [DATE] with diagnoses which included colostomy status and local infections of the skin and subcutaneous tissue. A skills checklist, dated 07/03/23, for CNA #2 did not document competency for colostomy care or colostomy bag changes. The annual assessment, dated 07/07/23, documented the resident was moderately impaired for daily decision making, was independent with ADLs, and had a ostomy. The assessment documented the resident had no pressure ulcers, wounds, or skin damage. The care plan, dated 08/14/22, documented the resident had a alteration in gastro-intestinal status (colostomy). The care plan documented the resident had learned how to empty the colostomy bag on their own and the staff were to provide the resident with a new bag that was cut to fit around their stoma and monitor to ensure no complications with the colostomy bag. On 08/11/23 at 11:50 a.m., CNA #2 was observed changing the colostomy bag for resident. The bag was leaking a large amount of loose stool from around side of the colostomy bag. CNA #2 pulled the bag off and cleaned the skin area around the stoma. An area of skin close to the stoma was cracked and bleeding. The CNA stated the resident pulls off the bag frequently and requires the bag to be changed. The CNA stated the colostomy was changed at least once a day, which irritated the skin. The CNA started to put a new bag over the irritated skin when the surveyor asked about the irritated skin. The CNA stated she would let the nurse know. The August 2023 ADL sheet for the resident documented to change the colostomy bag every 72 hours and as needed. The ADL sheet documented check marks and zeros for day, evening, and night shifts since 08/01/23. The ADL sheet did not document the condition of the skin, any skin breakdown, signs of infection, or excoriation of skin. On 08/17/23 at 2:25 p.m., the DON was asked for skill checks for staff. The DON stated they had not personally conducted skill checks, because everyone was already hired before before taking the DON position. The DON stated they had been employed by the facility since last July 2022, but stated as a charge nurse. On 08/22/23 at 8:25 a.m., LPN #1 reviewed the TARs for the resident and stated the CNAs have always changed the colostomy bag for the resident. The LPN stated the resident usually required a colostomy bag change daily due to leakage and the resident pulling the bag off. The LPN reviewed the ADL sheet and was unsure what the zeros and check marks represented regarding colostomy bag changes. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses which included impulse disorder, DM, and urinary incontinence. The MDS assessment, dated 06/04/23, documented the resident was moderately impaired for daily decision making, was independent with most ADLs , and had a ostomy. The care plan, dated 08/14/23, documented the resident had a colostomy bag due to intestinal issues and the colostomy area would remain clean, dry, and odor free, with no signs of infection. The care plan documented the colostomy bag would be emptied every 72 hours and as needed and colostomy care every shift and as needed. On 08/17/23 at 10:20 a.m., the resident was observed in the lobby area of the facility. The resident stated the staff changed and maintain his ostomy bag. On 08/18/23 at 11:00 a.m., NA #3 reviewed the resident's ADL sheet for August 2023. The NA stated they changed the resident's colostomy the day before. The NA stated they had changed the resident's colostomy bag four times this week. There was no documentation regarding skills checks for NA #3 providing care.

Based on observation and interview, the facility failed to provide privacy for seven (#101, 103, 110, 111, 115, 125, and #127) of seven resident reviewed for privacy. The Resident Census and Condition of Residents, documented a census of 27 residents. Findings: 1. Res #101 was admitted to the facility and had diagnoses which included major depressive disorder and dementia. An admission assessment, dated 08/09/23, documented the resident was moderately impaired with cognition and was independent with most ADLs. On 08/16/23 at 9:05 a.m., there were no curtains or covering of any kind on the window in the resident's room. Res #101 stated they would like to have a window covering but could not afford one. The resident's room was on the west hall facing the parking lot and street. On 08/16/23 at 9:50 a.m., maintenance staff #1 stated they were waiting for new curtain rods to come in and then would put the curtains up. On 08/18/23 at 8:47 a.m. the DON stated we cannot provide privacy at this time for the residents. We are in the process of buying and installing new curtains rods and we just bought a new washer and dryer to wash the curtains. Once we have started washing the curtains and as soon as we get the curtain rods up the residents will have their privacy back. 2. Res # 103 admitted to the facility and had diagnoses which included major depressive disorder, HTN and Dementia. An admission assessment, dated 11/09/22, documented the resident was moderately impaired with cognition and required extensive to total assistance with ADLs. On 08/15/23 at 10:58 a.m., the window was observed in the resident's room to not have any window covering. The resident's room was on the front of the building facility facing the street. On 08/15/23 at 11:05 a.m., Res #103 stated they did not like the window not being covered but what were they supposed to do about it. 3. Res #110 admitted to the facility and had diagnoses which included schizoaffective disorder and anxiety disorder. A quarterly assessment, dated 06/04/23, documented the resident was intact with cognition and was independent with ADLs. On 08/15/23 at 4:36 p.m., the resident's room was observed to not have a curtain or blind, view from the residents room was of the parking lot and the street. On 08/15/23 at 4:39 p.m., Res #110 stated staff told him they would be putting up curtains, but have not done it yet. Res #110 stated they should put something over the window so people can't see in the room. 4. Res #111 admitted to the facility and had diagnoses which included myocardial infarction, depressive disorder, and schizophrenia. A quarterly assessment, dated 05/15/23, documented the resident was intact with cognition and required limited to extensive assistance with ADLs. On 08/15/23 at 4:22 p.m., the resident's room was observed to not have a curtain or blind, view from the resident's room was of the parking lot and the street. At this time the resident stated the staff hung the privacy curtain between the beds yesterday but the resident did not know when a window curtain would be put up and it bothered him not to have anything over the window. 5. Res #115 was admitted to the facility and had diagnoses which included non-traumatic intracranial hemorrhage, hemiplegia and hemiparesis, and DM. An annual assessment, dated 16/17/23, documented the resident was independent with cognitive skills and daily decision making. The assessment documented the resident was total care with most ADLs. On 08/15/23 at 11:41 a.m., the resident's room was observed to not have a curtain or blind, view from the resident's room was of the parking lot and the street. The resident was asked what happened to the window covering. Res #115 shook their head and shrugged their shoulders they did not know. Res #115 was asked if it bothered them to not have a window covering and the resident shook their head yes. 6. Res #125 was admitted to the facility and had diagnoses which included traumatic brain injury, major depressive disorder, and diabetes mellitus. A quarterly assessment, dated 06/04/23, documented the resident moderately impaired with cognition and was independent with ADLs. On 08/16/23 at 9:34 a.m., there were not any kind of window covering observed in the resident's room. At this time the resident stated somebody took the curtains. Res #125 stated they missed having them for privacy and didn't want anyone peeking in on them. 7. Res #127 was admitted the facility and had diagnoses which included anxiety disorder, hallucinations, and osteoarthritis. An admission assessment, dated 07/20/23, documented the resident was intact with cognition and was independent with ADLs. On 08/15/23 at 2:48 p.m., the resident's room window was observed to not have curtains or blinds. Res #127 stated the window should have a curtain or blind. On 08/15/23 at 2:49 p.m., the east hall was observed with one resident room having a window covering. The other seven occupied rooms on the east hall did not have any kind of window covering. On 08/15/23 at 3:20 p.m., Res #127 stated the facility did have curtains on the window prior to cleaning the rooms. The resident stated the sun shines through the window and there is a glare and the facility should put curtains up.

Based on record review and interview, the facility failed to assess a resident for an infection using standardized tools and criteria for the initiation of an antibiotic for one (#105) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/15/23, documented no residents were currently receiving antibiotics. Findings: The care plan, dated 08/14/22, documented the resident was a high risk for UTI's due to catheter and urine backflow. The care plan documented to monitor/document/report to the physician as needed for signs and symptoms of UTI such as frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea , vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. The most recent assessment, dated 08/29/22, documented the resident was not impaired for daily decision making, was independent with most ADLs, and had not received an antibiotic the past seven days. A physician order, dated 07/20/23, documented Bactrim DS BID for 14 days for diagnosis of UTI. On 08/17/23 at 5:05 p.m., the facility provided a binder titled Antibiotic Stewardship for review. The most recent resident McGreer criteria for infection surveillance checklist was completed 04/26/22. There was no policy or guidance regarding the antibiotic stewardship program. On 08/17/23 at 5:10 p.m., the charge nurse/LPN #1 stated the assistant administrator stated the only antibiotic stewardship program documentation was provided in the binder. The charge nurse was unaware of a policy for antibiotic stewardship. On 08/18/23 at 8:17 a.m., the DON stated she was informed yesterday she was responsible for the antibiotic stewardship program as of yesterday. The DON stated they had not been keeping up with the documentation and was unaware of a policy. On 08/18/23 at 8:20 a.m., the charge nurse/LPN #1 stated the hospice staff was in the facility on 07/20/23 and verbally stated the resident's urine had a strong foul order and would talk to the physician about an antibiotic for the resident. The LPN stated there was no documentation regarding the need for an antibiotic for the resident. The LPN stated sometimes the facility does not know a medication has been ordered for a resident until it arrives from the pharmacy.

Based on record review and staff interview, it was determined the facility failed to complete a facility assessment. The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: On 08/15/23 at 8:09 a.m., an entrance conference was conducted with the administrator and the entrance conference worksheet was reviewed. They were made aware of the information required to be submitted from the facility to the survey team. They were provided a copy of a facility assessment template for review. On 09/12/23 at 3:41 p.m., the DON was asked if she had located the facility assessment. They stated they could not find it anywhere and they had looked all over for the facility assessment form but didn't find it. They also stated the administrator may have the facility assessment form.

Based on observation, record review, and interview, the facility failed to provide an advance directive acknowledgment for one (#101) of four residents reviewed for advance directives. The Resident Census and Condition of Residents, documented a census of 27 residents. Findings: Res #101 admitted to the facility on [DATE] and had diagnoses which included major depressive disorder, psychotic disorder, and dementia. An admission assessment, dated [DATE], documented the resident was moderately impaired with cognition and was independent with most ADLs. The assessment documented the resident had delusions and received antipsychotic and antianxiety medication. On [DATE] at 10:20 a.m., the resident's hard chart was reviewed. The hard chart had a green dot on the outside of the chart. The chart contained a document titled Physician Order which had CPR marked on the form. The chart did not contain documentation of the resident or representative being offered an advanced directive. On [DATE] at 3:09 p.m., the DON stated they did not know what the residents wishes were for an advanced directive and DHS did not sign an advance directive for the resident. The DON stated the advanced directive form offering the resident to decline an advanced directive was not in the admitting paperwork. The DON stated they did not use the advance directive form for new admissions. On [DATE] at 10:28 a.m., Res #101 was observed in the lobby of the facility ambulating without assistance.

Based on observation, record review, and interview the facility failed to have evidence a thorough investigation was conducted related to an allegation of abuse and prevent further potential abuse/mistreatment while the investigation was in progress for one (#111) of two sampled residents for abuse. The Residents Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: Res #111 admitted to the facility and had diagnoses which included myocardial infarction, depressive disorder, and schizophrenia. A quarterly assessment, dated 05/15/23, documented the resident was intact with cognition and required limited to extensive assistance with ADLs. On 08/15/23 at 4:18 p.m., the resident was observed sitting in their room on the bed. Res #111 stated a male aide got mad at them last night because they used the call light to call for ice water. Res #111 stated most of the staff are good. Res #111 stated they threaten them all the time with sending them to room with another resident which the resident did not wish to be around. During the interview a NA #1 entered the room. Res #111 stated NA #1 was the one that threatened the resident for using the call light. The resident was asked if he was afraid at this time. Res #111 stated they were not afraid and nothing had ever happed by the other resident. Res #111 stated that was the first time NA #1 had ever asked the resident if they needed anything. Res #111 stated they had not reported the allegation it to anyone till now. On 08/15/23 at 4:43 p.m., the allegation of abuse related to NA #1 and Res #111 was reported to the DON. The DON went and spoke with the resident at that time. A state incident report form 283, with a fax date of 08/15/23 and an incident date of 08/14/23, was reviewed which documented the resident reported an allegation of [name withheld] CNA saying that the call lights were for emergencies and if the resident did not quit acting out the resident would be moved in with another resident. A nurse aide registry incident form 718, with an incorrect date of 06/07/23, documented the employee was not suspended. The investigation documented the resident's room mate, two other residents on the hall, one NA, one CMA, and one nurse were interviewed. The investigation did not contain a statement by the alleged perpetrator NA #1. On 08/21/23 at approximately 3:40 p.m., the DON stated they did not have the NA in question to clock out and leave the building after an allegation of abuse had been made. The DON stated they did interview NA #1 but must not have written it down.

Based on record review and staff interview, it was determined the facility failed to train/orient new employees on abuse, neglect, and exploitation. The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. An Abuse Prevention Program policy read in part, .Protect our residents abuse by anyone including, but not necessary limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .Required staff training/orientation programs that includes such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior .Abuse, neglect, and exploitation toward residents. On 09/12/23 at 9:10 a.m., the SS/BOM was asked about staff training related to abuse, neglect, and exploitation on hire. On 09/12 23 at 12:50 p.m. an observation was made of Cook #1's employee file and the file only had an application for employment in it. a. LPN #2; hire date 07/16/23, b. Cook #1; hire date 08/08/23, c. Cook #2; hire date 08/26/21. d. Dietary Aide #1; hire date 04/28/23, e. Dietary Aide #2; hire 09/17/20. On 09/12/23 at 12:55 p.m.,an interview was conducted with the SS/BOM, they stated they did not provide training/orientation for verbally and physically aggressive resident behaviors for the five employees upon hire. They also state if it is not in the employee file then it was not done and education and orientation was a complete oversight. On 09/12/23 at 3:02 p.m., an interview was conducted with the DON and they stated in-services were done twice a month on abuse, neglect, exploitation, resident's having aggressive behavior but the new employees had to wait for in-service day to be train/oriented. They also stated they would start training/orientation on abuse, neglect, and exploitation upon hire.

Based on record review and interview, the facility failed to ensure labs were collected for one (#111) of five sampled resident's reviewed for lab service. The Residents Census and Conditions of Residents form, documented 27 residents resided in the facility. Findings: Res #111 admitted to the facility and had diagnoses which included myocardial infarction, depressive disorder, and schizophrenia. A quarterly assessment, dated 05/15/23, documented the resident was intact with cognition and required limited to extensive assistance with ADLs. A physician order, dated 05/31/23, documented to decrease Coumadin (an anticoagulant medication) to 6 mg daily and redraw PT/INR in one week. A physician order, dated 06/01/23, documented Coumadin 6 mg one time a day related to myocardial infarction. A nurse note dated 06/01/23 at 7:15 a.m., documented the resident was sent to the ER. A nurse note, dated 06/01/23 at 5:00 p.m., documented the resident would be monitored overnight related to PT/INR and Coumadin changes. A nurse note, dated 06/02/23 at 2:00 p.m., documented the resident returned to the facility via wheel chair. The nurse note documented the resident had no medication changes and to continue orders as previously written. A PT/INR was not found to be obtained for June after the resident returned from the hospital. A PT/INR was not obtained for the resident in July. On 08/17/23 at 3:27 p.m., the DON stated the resident should have a PT/INR at least once a month. On 08/18/23 at 10:48 a.m., the DON stated if the labs were not in the chart, they did not have them. On 08/18/23 at 11:40 a.m., the DON stated the physician had been in the facility since the resident had returned from the hospital and wrote no new orders. On 08/18/23 at 1:53 p.m., the physician returned a phone call. The physician stated the resident had been in and out of the hospital and returned on the same dose of Coumadin, so for the PT/INR in June the hospital would have done one. The physician stated the facility should have obtained a PT/INR for the resident in July.

Based on observation and interview, the facility failed to ensure an RN worked eight consecutive hours seven days a week. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 27 residents resided in the facility. Findings: On 08/13/23 at 4:04 p.m. an observation was made of all staff working in the facility this date. There was no RN identified working in the facility this day. On 08/13/23 at 4:06 p.m., the charge nurse/LPN #1 was interviewed regarding the RN coverage for the day. The LPN stated she had not seen an RN today since she arrived about 7:00 a.m. this morning. The LPN stated there was an RN scheduled for day shift, but she had not seen an RN and did not know if they would have one today. The LPN stated the facility did not always have RN coverage, usually once or twice a week, especially on the weekend. On 08/13/23 at 4:35 p.m., the DON entered the facility. The DON stated she did not know there was no RN coverage today. The DON stated she received a text message from a staff member advising the state surveyor was in the facility, but not advised there was no RN coverage for the day.

An Immediate Jeopardy (IJ) situation was determined to exist effective [DATE] based upon the facility's failure to immediately contact EMS when CPR was initiated for Res #26 with a full code status who was found not breathing and without a detectable heart beat. On [DATE] at 11:21 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 11:26 a.m., the administrator was notified of the IJ situation. On [DATE] at 1:38 p.m., an acceptable plan of removal was provided. The plan of removal documented: ''Rainbow Terrace Care Center Immediate Jeopardy Plan for Removal [DATE]. On [DATE], a resident was found to not have viable vital signs, resulting in CPR being initiated. Although the Charge Nurse directed for someone to call [DATE], there is no documentation to support a call being made. After 25 minutes of CPR being performed, Dr. [name withheld] called time of death. While it is unknown if EMS would have arrived or transferred the resident to the nearest emergency room , the fact remains that there is no evidence of the call being placed. It is the responsibility of the charge nurse to initiate CPR and all actions of the Police and Procedure be followed. Step 1 of ensuring the Policy and Procedure is followed is ensuring that there is a designated team per shift. The charge nurse is responsible for initiating CPR and leading the code. The Certified Medication Aide on day and evening shifts is responsible for verifying the code status of the resident, reporting to the nurse aid calling [DATE]. On Midnight shift, the East Hall Certified Nurse Aide is responsible for determining the code status based on the red or green dots on the outside of the charts, and calling [DATE] for emergency services. While this action is being completed, the charge nurse will initiate CPR, using the BLS sequences of events. CPR will be performed until EMS arrives and leaves with the resident or receives the official time of death verification. Once the plan of removal has been approved by the State Department of Health, All staff will be immediately in-serviced in person/by telephone and verbally acknowledge the system in place. This is expected to be completed within 4 hours of approval. To further this process, the facility will contact the American Red Cross or the American Heart Association and set up a time for staff to become BLS certified at the cost of the facility. To ensure that new staff are aware of this team-oriented approach, new hires will be educated at the time of hire to ensure understanding. The facility will educate all staff on this process every 3 months from now on. The Director of Nursing will monitor understanding of the process and ensure that it is completed when notified that CPR had been performed.'' This form was signed by the DON and dated [DATE]. A document entitled, IJ Plan of Removal Staff Contacts documented a staff sign-in list with the last staff member in-serviced at 2:42 p.m. On [DATE] interviews were conducted with nursing staff regarding education and in-service information pertaining to the IJ plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On [DATE] at 3:30 p.m., the DON was informed the IJ was lifted at [DATE] at 2:42 p.m. The deficiency remained at the level of actual harm. Based on record review and interview, the facility failed to provide EMS services for one (#26) of four residents sampled for death in facility. The ''Resident Census and Conditions of Residents'' report documented 33 residents resided in the facility. Findings: Res #26 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], documented the resident had a full code status. An advanced directive, dated [DATE], documented the resident wanted hydration, nutrition and life sustaining treatment. A quarterly assessment, dated [DATE], documented the resident was moderately impaired with cognition and required extensive assistance with most activities of daily living. A nurse note, dated [DATE] at 7:00 p.m., documented Res #26 continued sitting in the recliner resting with eyes closed and oxygen at 2 L per NC and responded to stimuli. A nurse note, dated [DATE] at 8:00 p.m., documented Res #26 was in the recliner with oxygen in place at 2 L per NC. The note documented temp 102.8, resp 30, P 59, and SpO2 75%. The note documented the nurse told the resident she was going to call the physician and send Res #26 to the ER. The note documented Res #26 refused and stated, No three times. A nurse note, dated [DATE] at 8:30 p.m., documented in parts .called to R's room the resident was non-responsive, unable to palpate pulse, no breath sounds, R was put on floor CPR initiated, black fluid filling mouth head turned to side, copious amount of dark fluid cont to pour out of mouth and nose CPR continued for 35 min, contacted Dr. [name removed], time of death 2105 .Contacted funeral home [name withheld] for pick-up. Called [name withheld] friend of resident .2215 [name withheld] funeral home left with R. On [DATE] at 4:23 p.m., the DON stated she did not see where 911 was called in the nurse notes. She stated you call 911 anytime CPR is started. On [DATE] at 4:40 p.m., LPN #1 stated she did not call EMS. She stated she thought someone else was calling EMS. She stated when she was relieved by another staff member who continued CPR for the resident, she went up to call the physician and by that time it had been at least 35 minuets and EMS had not shown so she was not sure if EMS had been called. On [DATE] at 9:47 a.m., CNA #4 stated she worked weekend doubles but was not working when the resident passed. She stated last time she worked Res #26 was fine but not eating well. She stated he was talking and he was able to stand with help. She stated the facility had in-services but not a CPR in-service on what to do with a full code. She stated she was not sure what to do and had not had to help with a full code. She stated she was not CPR certified. On [DATE] at 9:58 a.m., CNA #3 stated he was present the night the resident passed away. CNA #3 stated CMA #1 found Res #26 and hollered at the nurse and him. CMA #3 stated they went into full code. CMA #3 stated the nurse started doing CPR and then asked me if I could take over. He stated he was CPR certified. CNA #3 stated he did not think anyone called EMS. ON [DATE] at 10:15 a.m., CMA #1 stated she had worked at the facility at least [AGE] years. She stated she was working the night Res #26 passed away. She stated she was not able to perform CPR. She stated she normally would get the paperwork together and call 911. She stated she honestly could not remember if she called the ambulance but if it had been called it would have been her that called.

I. On [DATE] at 1:25 p.m., Oklahoma State Department of Health (OSDH) was notified of two immediate jeopardy (IJ) situations related to the facility's failure to: a) Ensure hazardous chemicals were securely stored out of reach of residents. The hazardous chemicals were in two different bottles labeled liquid Comet Cleanser and labeled to keep out of reach of children. Both bottles were left within reach of the residents. b) Ensure water temperatures were maintained at safe levels. Water temperatures were above 133 degrees Fahrenheit in resident rooms #2 and #4, the east hall shower room, and the east hall residents' bathroom. The water temperature in the sink in resident room #4 registered 133.6 to 140.8 degrees Fahrenheit. The facility identified one cognitively-impaired, wandering resident was at risk for getting burned by hot water. On [DATE] at 1:30 p.m., OSDH verified the existence of the two IJ situations related to the facility's failure to ensure hazardous chemicals were securely stored out of reach of residents and water temperatures were at a safe levels. On [DATE] at 1:35 p.m., the administrator (adm) and the director of nursing (DON) were informed of the IJ situation regarding the unsafe water temperature of 140 degrees Fahrenheit (F) in resident room #4 and hazardous chemicals in a bottle, labeled Comet Cleanser with bleach, left out in reach of residents in resident room #5. They were informed these constituted substandard quality of care. The administrator and the DON verbalized understanding. On [DATE] at 4:30 p.m., the DON presented a plan of removal to the survey team. The plan of removal was accepted and documented the following: On [DATE] at 1:35 PM, an immediate jeopardy was announced in regards to: ~Hazardous Chemicals being left within reach of residents ~Water temperatures being too high At 1:39 PM, the Director of Nursing called all-staff in for an In-Service regarding the chemicals being left out. The staff stated that they had been room to room checking for any chemicals and that they did not see any when they had checked. It was determined that the bottle had cleaner in it that had been mixed. During the in-service, the staff was told that they are not allowed to mix cleaners/chemicals in bottles that are not marked. The staff was informed that no chemicals/anything considered hazardous if ingested, could be left within reach of the patients. Anything considered hazardous must be kept locked up. If it is being used, then a staff member must have eyes on it. The current working staff signed a paper stating that they understood this. The in-service will be continued over to the shifts that are coming on, and they will be required to sign acknowledgement. After the in-service, staff was sent out to once again check the rooms. The bottle that was mentioned was found and taken from the room to be locked up. Staff continued searching each room for hazardous chemicals, including checking the bathrooms and under the sinks. All chemicals have been placed in the janitor's closet and locked up. To ensure that this matter does not continue or reoccur, the Charge Nurse has been assigned the duty of checking the halls to ensure that all chemicals are kept locked up and out of reach of the residents. The Charge Nurse will be required to sign a paper after checking the halls when his/her shift begins. In addition, the Certified Nurse Aides have been directed to keep an eye out in their rooms. The janitor/housekeeper staff has been informed that they are not to set anything down in a patient's room, chemicals must either be on the cart or in their possession. When the OSDH first checked the Hot Water Temp in room 4 it registered at 140.8, upon their re-check it registered 137.5 and steadied at 133. The Administrator immediately went and adjusted the hot/cold tempering valve, waited 5 minutes and checked the temperature again. At this time, the hot water registered between ,[DATE] degrees. The Administrator then made a re-adjustment, waited 5 minutes, and re-checked the temperature, which was at 110 degrees. The temperature was checked every 10 minutes for the next 40 minutes with temperatures ranging from ,[DATE] degrees. The temperature in room 4 will continue to be monitored every 30 minutes to one hour throughout the day and evening. Room 4 is being chosen to check every 30 minutes due to the fact that the water coming out of that room is the hottest that the water will be, considering it is closest to the hot water tank. The Administrator will assume the responsibility of monitoring the temps, will be done every morning at 8:00 AM then again at 11:00 AM. The rooms checked during this time will be a variety of rooms to ensure that temperatures are within guidelines in all rooms. The overall cause of the high temperature was due to someone having turned up the adjustment on the tempering valve. The reason why room 4 was higher than any other room was due to the fact that it is the 1st unit to be serviced after leaving the tank. On [DATE] at 3:00 p.m., the facility was informed the IJ was removed when all components of the plan of removal had been implemented, inservices had been completed, and staff had verbalized an understanding of the safety hazards of the chemicals and the hot water temperatures. The final inservice was conducted on [DATE] at 4:25 p.m. The deficiency remained at the level of no actual harm with the potential for more that minimal harm at a pattern level. II. On [DATE] at 5:10 a.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to provide safety from fire when a non-approved electrical space heater, plugged into a power strip, was being used to heat a room where two residents resided. On [DATE] at 5:10 a.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to protect the residents from fire by the use of a non-approved electrical space heater plugged into a power strip to heat a room where two residents resided. On [DATE] at 5:15 a.m., licensed practical nurse (LPN) #1, who was in charge of the facility at that time, was informed of the immediate jeopardy situation which constituted substandard quality of care. The LPN verbalized understanding and said she would contact the adm and the DON immediately. On [DATE] at 10:30 a.m., the DON presented a plan of removal to the survey team. The plan of removal was accepted and documented the following: On [DATE] at 5:20 AM the Oklahoma State Department of Health announced that an Immediate Jeopardy situation was present in regards to: ~ A space heater was found in Room 11 At approximately 5:35 AM, the Administrator came into the facility, located the heater, and unplugged it from the power strip. The resident was told that a space heater was not allowed to be used in the room under any circumstances. At 7:38 AM, the Director of Nursing began verbally telling each and every resident that space heaters were not allowed in the facility. The residents confirmed it, and the residents that were considered cognitive gave a verbal acknowledgement of this. The last resident was verbally told at 8:10 AM. It will be added into the Resident Rights that they receive during admission that space heaters are prohibited in the facility. Since the resident that had the space heater stated that as soon as state left he would be buying a new heater and putting it in his room. Since this resident chooses to be non-compliant, the conversation will be documented in his Nursing Notes. An update will be made to the care plan stating that the resident is non-compliant. A room monitoring tool will be used to periodically (weekly) check the room for any heaters that might be non-compliant. The DON or Administrator will be in charge of this check. On [DATE], at 9 AM, the Director of Nursing approached the residents that had the heater. The Director of Nursing explained that the heater had to be removed from the room. The resident in Bed A declared that it would not be taken from his presence. The DON explained that it was mandatory to remove it, but if the family of Resident B wanted to come and remove it from the facility, they were more than welcome to and it would be handed over to them. Bed A Resident stated that it wouldn't work and he would talk to the Administrator. At 9:15 AM on [DATE], the Resident in Bed A agreed to let the Director of Nursing remove the heater from the room. The heater was removed and will be locked in the Directors office until the family comes to take it home. The staff will be in-serviced on space heaters and what to do if a space heater is seen in the facility. The staff in the facility will be in-serviced at 9:45 AM. Any staff not present will be contacted by telephone. This will be completed by 10:30 AM. A copy of the inservice and the sign-in sheet will be turned in. On [DATE] at 3:00 p.m., the facility was informed the IJ was removed when all components of the plan of removal had been implemented, and the staff had verbalized an understanding of a fire safety risk of using a space heater in the facility. The final inservice was conducted on [DATE] at 10:30 a.m. The deficiency remained at the level of no actual harm with the potential for more than minimal harm at a pattern. Findings: Based on record review, interview, and observation, it was determined the facility failed to provide an environment free of accident hazards. The facility failed to: a) Ensure a space heater was not used by residents to heat their room for two (#28 and #30) of six sampled residents identified without heat to their rooms. b) Maintain safe water temperatures for four (#9, 10, 12, and #23) of 30 sampled residents whose water was checked. Water temperatures were above 133 degrees Fahrenheit in resident room #2, resident room #4, the east hall shower room, and the east hall residents' bathroom. The water temperature in the sink in resident room #4 registered 133.6 to 140.8 degrees Fahrenheit. The facility identified one cognitively-impaired, wandering resident (resident #10) was at risk for getting burned by hot water. Twenty-three residents used the east shower room and the east hall bathroom per the DON. c) ensure hazardous chemicals found in residents' rooms were securely stored out of reach of residents for two (#10 and #13) of 30 sampled residents. The hazardous chemicals were in two different bottles labeled liquid Comet Cleanser and labeled to keep out of reach of children. Both bottles were left within reach of the residents. The facility identified one cognitively-impaired, wandering resident. The facility administrator identified 14 residents were without heat in their rooms. Findings: 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], for resident #28 documented the resident's cognition was intact and was independent in all activities of daily living. 2. Resident #30 was admitted to the facility on [DATE] with unspecified paralysis, depressed mood, and alcohol dependence. A quarterly assessment, dated [DATE], for resident #30 documented his cognition as intact, and that the resident was dependent for all activities of daily living. On [DATE] at 10:50 a.m., during initial rounds of the facility, an observation was made of a space heater turned on in resident room eleven. The space heater was setting on a towel and plugged into a power strip. Both residents #28 and #30 were in their room and told the surveyor they did not get any heat during the cold months so they had started using a space heater which was purchased by a family member of resident #30. On [DATE] at 11:00 a.m., room eleven was re-entered and the space heater was not observed in the room. The surveyor went to the office of the DON and interviewed the adm who was in the DON's office. The adm was asked who had removed the space heater from room eleven. The adm stated he had the space heater. He reached behind him, picked up the space heater, and showed it to the surveyor. The surveyor asked if she could take the heater to the breakroom to read the labeling on the heater in better lighting. The surveyor then told the adm she would return the heater to his custody later in the day. The space heater remained in the breakroom, not in use, until the survey team left the facility that day at 5:30 p.m., at which time the adm came into the breakroom and was informed he then had custody of the space heater. He stated okay. The breakroom was located across the hall from room eleven. On [DATE] at 5:00 a.m., the surveyor went into resident room eleven, after knocking on the door, to check the temperature of the room. The temperature registered 75.5 degrees Fahrenheit. An observation was made of a space heater turned on, setting on a towel on the floor at the foot of bed A, and facing the foot of bed B. The resident in bed A then told the surveyor to please get out of the room that they (the residents were trying to sleep. The surveyor left the room at that time. Licensed practical nurse (LPN) #1 was asked to notify the adm that the survey team was in the facility. On [DATE] at 5:26 a.m., LPN #1 was interviewed and reported resident #28 in room eleven did not like to have the door open to the room. The LPN said when it got colder, they tried to keep the residents warmer by having their doors open. She reported she had not been aware of the presence of a space heater in room eleven until 7:30 p.m. the previous night when she had been passing medications. LPN #1 then reported the adm had been in the facility the previous night at approximately 9:00 p.m. and again at 11:00 p.m. He had told the staff to give the residents extra blankets and to leave their doors open to allow heat to circulate into their rooms. On [DATE] at 5:23 a.m., an observation was made of LPN #1 and certified nurse aide (CNA) #1 entering room eleven. When they exited the room, LPN #1 reported the resident would not let them take the space heater out of the room but the space heater was now unplugged from the electrical circuit. On [DATE] at 5:55 a.m., the adm was interviewed and asked how the residents in room eleven had the space heater again. He reported he had given the space heater back to them. On [DATE] at 8:05 a.m. the Life Safety surveyor, adm, and DON were seen going into room eleven. They did not bring the space heater back out with them when they left the room. On [DATE] at 9:15 a.m., the DON went back into the residents' room and removed the space heater. The DON put the space heater in her office. 3. Resident #23, who resided in room four, was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated [DATE], documented the resident's cognition was moderately impaired and that the resident was independent in all activities of daily living. On [DATE] at 11:26 a.m., the water temperature from the sink in the resident's room registered 140.8 degrees Fahrenheit (F). At 11:36 a.m., the water temperature in the resident's room was 137.5 degrees F. At 12:35 p.m., the water temperature in the resident's room was 133.6 degrees F. On [DATE] at 1:35 p.m., the administrator (adm) and the director of nursing (DON) were informed of the unsafe water temperature of 140 degrees F in room four. On [DATE] at 2:30 p.m., the adm was asked about the water which was too hot. He said the high temperature was due to someone having turned up the adjustment on the tempering valve. The adm said the reason room four's water was higher than any other room was due to the fact it was the first unit to be serviced after leaving the tank. 4. On [DATE] at 11:42 a.m., the water temperature in the east hall shower room registered 124.1 degrees Fahrenheit (F). On [DATE] at 11:50 a.m., the water temperature in the east hall resident bathroom which contained a toilet and sink registered 120.3 degrees F. 5. Resident #9 and resident #12 resided in room two. Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], for resident #9 documented the resident had severely impaired cognition, was independent with activities of daily living, and required limited assistance with bathing. 6. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident's cognition was intact and that the resident was independent with activities of daily living with limited assistance with hygiene and bathing. On [DATE] at 12:38 p.m., the residents' water temperature from the sink in room two registered 124.4 degrees Fahrenheit. The residents stated they had not noticed their water being too hot. On [DATE] at 2:00 p.m., the adm was asked if he would provide the water temperature log documentation. He said he was not sure where it was but would try to locate it. The facility's water temperature log was not provided to the surveyors before the end of the survey. 7. Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The facility staff had identified the resident as a resident who wandered about the facility. A quarterly assessment, dated [DATE], documented the resident had severely impaired cognition, had hallucinations, delusions, and disorganized thinking. The assessment documented the resident had wandered ,[DATE] days of the seven day look back period, did not require assist with transfers, had no range of motion deficits, and was able to walk without assistance. A care plan, dated [DATE], documented the resident was a wanderer. The care plan documented to distract the resident from wandering, offer him a pleasant diversion, provide structured activities, provide him food, talk to him, turn on the television, or read him books. The care plan documented to monitor the resident's location throughout every shift including times when the resident was believed to be in bed asleep. On [DATE] at 11:00 a.m., the resident was observed walking around in the lobby. He was observed to go in and out of the dining room. On [DATE] at 1:30 p.m., licensed practical nurse (LPN) #2 was asked if the resident ever wandered into other resident's room, would he be able or likely to turn on the water faucets, or pick up a chemical left out. She stated the resident was a wanderer and could go into a room and turn on the water faucet if he took a notion to do so. LPN #2 stated resident #10 was able to pick up anything. LPN #2 stated the resident would pick-up other residents' cups and drink the liquid left in the cups. On [DATE] at 10:30 a.m., resident #10 was observed pushing another resident who was sitting in a wheelchair. On [DATE] at 4:00 p.m., the resident was observed walking aimlessly around in the lobby. 8. Resident #28 and resident #30 shared room eleven. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident's cognition was intact and was independent in all activities of daily living. Resident #30 was admitted to the facility on [DATE] with unspecified paralysis, depressed mood, and alcohol dependence. A quarterly assessment, dated [DATE], documented resident's cognition was intact and needed assistance with activities of daily living. On [DATE] at 10:50 a.m., a full bottle of liquid, labeled Comet cleanser, was observed on the floor behind the bathroom door of the residents' room. The label documented keep out of reach of children. Resident #28 said he liked to keep it available to clean the toilet. On [DATE] at 12:05 p.m., the director of nursing (DON) was informed of the cleanser, labeled Comet, which was in the residents' room. The DON stated the cleaner should not be in the residents' room. She said she would address the situation. 9. Resident #13, who resided in room five, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], for resident #13 documented the resident's cognition was severely impaired and that the resident required assistance with activities of daily living. On [DATE] at 12:43 p.m., a ,[DATE] full, quart-sized spray bottle, labeled Comet cleanser with bleach, was observed setting by the sink in room five. The label documented to keep out of reach of children. There were no residents in the room at that time. At 1:16 p.m., resident #13 was observed being assisted by certified nurse aide (CNA) #1 from the lobby area to his room for incontinent care. At 1:20 p.m., the resident was observed being assisted out of his room by CNA #1 and back to the lobby area. The spray bottle, labeled liquid Comet cleanser, remained setting by the sink. On [DATE] at 1:35 p.m., the administrator (adm) and the director of nursing (DON) were informed of the bottle, labeled Comet cleanser with bleach, located in room five. The DON stated the staff knew better than to leave the cleaner in a resident's room.

On 08/10/15 at 3:20 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to put effective measures into place to prevent unsafe wandering and elopement. On 08/10/15 at 3:20 p.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to put effective measures into place for unsafe wandering and elopement. On 08/10/15 at 3:30 p.m., the administrator (ADM) and the director of nursing (DON) were informed of the IJ situation related to the facility's failure to put effective measures into place for unsafe wandering and elopement. The ADM and DON were informed of the immediate jeopardy situation which constituted substandard quality of care. The ADM and the DON verbalized understanding. On 08/10/15 at 4:30 p.m., the DON presented a plan of removal to the survey team. The plan of removal was accepted and documented the following: On 08/10/15 at approximately 3:30 PM, the facility was notified of an Immediate Jeopardy being in place as follows: Ineffective measures to prevent wandering and elopement. On 07/26/15, a resident walked out the West end door with no shoes on. The staff immediately noticed the resident had left, and began looking for him. While looking for the resident, the police were also informed of the resident that had left. On this day, it was declared that the West side door was not locking when it was closed. The door would close, but did not latch for the security measures to be in place. With this being said, the resident that walked out of the facility was able to put the code in and exit the door at any time. Interventions had been put in to place to know where this resident was at least hourly. The staff had talked to him 5 minutes before he walked out the door. On 08/10/15 at approximately 11 AM, the security system operators came in to the facility to check out the doors. They were able to fix the West side door to ensure that it latched properly. They stated that they had to order a part for it to open from the outside, but at this moment, the door will not open from the inside without the code. All of the main entry/exit doors in the facility will have to be opened from the inside until the missing part has come in, which will most likely be 8/11/2015. An in-service will be held with all-staff as they come in for their next shift regarding the residents that we have that are elopement risks or wanderers in case of a future malfunction of the doors. In the inservice, it will be determined that in the case of this malfunction, the residents that are considered elopement risks will be placed as one to one residents. A staff member will be assigned to these residents until the door is fixed and no longer an issue. If the door continues to be an issue past a shift, the Charge Nurse of each shift will designate a staff member to stay with those residents. To ensure that staff is aware of the functioning of the doors, each Charge Nurse will be responsible for checking the status of the doors at the beginning of the shift. During each set of rounds, all doors are to be again checked by the floor staff. If a problem occurs with the door, the Administrator will be immediately notified, and the plan for elopement risks will go into effect. To ensure that the residents that are wanderers or elopement risk are kept safe, a Care Plan will be created that deems them as such. Interventions will be put in to place to make sure the residents don't leave the facility or harm themselves. The interventions will outline the steps that will be taken to assess the resident and care for the residents. If an event of elopement happens. the care plan will immediately be updated with more interventions in place to keep the residents safe. On 08/11/15 at 10:30 a.m., the facility was informed the IJ was removed when all components of the plan of removal had been implemented, inservices had been completed, and staff had verbalized an understanding of the wandering and elopement residents safety. The deficiency remained at the level of no actual harm with the potential for more than minimal harm at a pattern level. Based on record review and interview, it was determined the facility failed to ensure effective measures were put into place to prevent unsafe wandering and elopement for one (#2) of three residents sampled with wandering behaviors. The facility failed to identify and assess wandering residents for triggers and put effective interventions into place to prevent elopement for resident #2. The facility identified three residents with wandering behaviors and as elopement risks. Findings: On 08/10/15 at 9:15 a.m., the surveyor entered the facility and observed the front door had been propped open with a wet floor sign. Several residents were observed in the main lobby near the propped open door and three residents were observed sitting outside smoking. On 08/10/15 at 10:00 a.m., the director of nursing (DON) was asked why the front door was propped open. The DON said to keep the front door from locking residents outside. The DON was asked if there were wandering residents residing in the facility. She said they had two residents who wandered, but one was at the physician. She pointed out the other wandering resident who was observed sitting in a recliner in the lobby. Resident #2 had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]., and chronic liver disease. An admission assessment, dated 01/25/15, documented the resident had moderately impaired cognition with no behaviors, was independent with bed mobility and transferring between surfaces, had no range of motion limitations, was independent with ambulation, and was occasionally incontinent of bowel and bladder. A care plan, dated 01/25/15, documented the resident had a problem with wandering around the facility. The care plan documented the staff was to monitor the resident's location every hour and to ensure the doors were locked so the resident could not go outside without assistance. A quarterly assessment, dated 04/25/15, documented the resident had moderately impaired cognition with no behaviors, was independent with bed mobility and transferring between surfaces, had no range of motion limitations, was independent with ambulation, and was occasionally incontinent of bowel and bladder. A nurse's note, dated 05/20/15 at 5:30 a.m., documented, CNA (Certified Nurse Aide) notified this nurse resident was missing - all rooms checked no sign of resident - Weleetka PD (Police Department) notified, description of resident taken by officer - DON notified of resident missing - CNA (name deleted) stated resident was on couch at 5 am when she went to laundry - all outside areas checked & Police Dept reported all officers are out looking for resident. A nurse's note, dated 05/20/15 at 7:30 a.m., documented, R (resident) brought back to facility by staff member who had been out looking for him. R wet and dirty. R showered by staff. Police notified. An inservice had been conducted on 05/25/15, five days after the elopement had occurred. The inservice documented, On 5/20/15, resident #2 left the building. We must take steps on ensuring that no resident leaves the building without our knowledge. If a resident wanders, re-direct them away from the doors. A resident stating they want to leave, discuss why they want to leave. If a wanderer goes outside, make sure a staff has eyes on them while out the door. Ensure side doors close properly. The initial incident report, dated 07/26/15, documented the resident was seen and talked to at 8:45 a.m. The report documented a certified medication aide went down the hall to give the resident his medications and the resident could not be found. The report documented the police was contacted and staff began searching the wooded areas and creeks. A nurse's note, dated 07/26/15 at 7:15 a.m., documented, Resident on couch lying down. Staff directed him to dining room for breakfast. A nurse's note, dated 07/26/15 at 8:45 a.m., documented, CMA (Certified Medication Aid) unable to find resident to give him his medication. Building searched, last time staff (Name deleted) seen him approx (approximately) 2 min (minutes) prior to CMA unable to find him. Staff out looking for resident. A nurse's note, dated 07/26/15 at 9:08 a.m., documented, Notified Admin (Administrator) by message. A nurse's note, dated 07/26/15 at 11:16 a.m., documented, Notified DON (director of nursing) reported resident missing for approx 3 hours. A nurse's note, dated 07/26/15 at 12:00 p.m., documented, Staff back at facility, had spoke with Weleetka officer. A follow-up report was sent into OSDH on 07/30/15. The report documented the facility still had not located the resident. A typed report, dated 08/03/15, was presented to the surveyor. The report documented a problem with the facility's doors not working. It documented the doors could not be opened from the outside so the facility was having to prop open the door when residents went outside to smoke so the residents could get back inside the building. On 08/10/15 at 10:35 a.m., CNA #1 was interviewed regarding the broken door locks. She was asked if the door locks had ever been fixed. She said the locks would work off and on for one week. On 08/10/15 at 11:00 a.m., the activity director was asked if she knew anything about the door locks not working. She said they had worked off and on for a week or two. On 08/10/15 at 11:50 a.m., the DON was asked for the incident report of the resident's elopement which had occurred on 05/20/15, per the nurses' notes. She said she did not know anything about an incident report for that date but she would look. On 08/10/15 at 12:15 p.m., the DON said she could not find an incident report for the resident's 05/20/15 elopement. On 08/10/15 at 1:00 p.m., the DON was interviewed. The DON was asked if she had sent in to the state the resident had never been found. She said that she had not sent in a final report because the resident was still missing. She said they had contacted the sheriff and the police. She said they also had to contact his parole officer because he was a sex offender. She said the resident had also been on the news as missing.

On [DATE], an immediate jeopardy situation was determined to exist due to the facility's failure to have an effective system in place for the acquisition of medications for newly admitted residents and ensure residents were free of significant medications errors and routine antihypertensive and anticoagulant mediations were administered as ordered. At 4:35 p.m.,, the Oklahoma State Department of Health was notified and confirmed the existence of an immediate jeopardy situation. At 4:55 p.m., the administrator, registered nurse #1 nurse, director of nursing and administrative assistant were notified of the existence of the immediate jeopardy. At 8:00 p.m., the administrator provided an acceptable plan of removal. The plan of removal was as followed: "On [DATE] at approximately 5:15 p.m., a notification of immediate jeopardy was announced by OSDH. Failure to assess and monitor resident with hypertension and who was status [REDACTED]. As of [DATE], every resident, including current residents, who receive an antihypertensive medication will have their vital signs taken daily. The vital signs will be documented in the nurses Notes, MAR, or on the Treatment sheet for the resident. A visual assessment will be in a narrative form. The visual assessment will be documented by exception. If normal visual assessment, the nurse will document that a visual assessment has been completed and was within normal limits. As of [DATE], any resident, including residents, who receive anticoagulant medications, a complete head-to-toe assessment will be conducted weekly (Sunday being the first day of the week through Saturday, the last day of the week) on a "Head-to-toe Assessment for residents on Anticoagulant" form and placed in each resident's Nurse Notes. See attached. The facility will no longer accept residents who do not have Medicaid approval for the nursing home already and a means to obtaining their medications prior to being admitted to the facility. This will prevent this from recurring. An LPN job orientation will be conducted on the first shift and LPN is hired and will be kept in the employee's personnel record. A one on one in-service will be given on emergency/disaster plans on this first shift. The facility uses a "buddy" system for training and orientation of a newly hired LPN. See attached. For current employees in-service emergency/disaster plans will be completed by [DATE]. For any LPN unavailable [DATE] through [DATE], these LPN's will be in-serviced prior to beginning of their next shift. On-going in services will be conducted as changes are made to emergency/ disaster plans. Bi-monhtly in-services will always include in-service with new hires on emergency/disaster plans, CPR, and [MEDICATION NAME] Maneuver." On [DATE], after observing the facility crash cart with the suction machine, reviewing residents head to toe assessments, daily vital signs and interviewing licensed staff the immediacy was removed. The deficient practice remained at a pattern with the potential for more then minimal harm. On [DATE] at 2:25 p.m., the administrator was informed the immediacy had been removed effective [DATE] at 11:00 p.m. Based on record review and interviews, it was determined the facility failed to ensure a newly admitted resident's antihypertensive and anticoagulant medications were acquired and administered as ordered or one (#1) of three sampled residents. This resulted in an immediate jeopardy. The director of nursing identified five residents that had been admitted to the facility since [DATE]. Based on record review and interviews, it was determined the facility failed to ensure a resident's antihypertensive and anticoagulant medications were acquired and administered for one (#1) of three sampled residents. This resulted in a significant medication error for the resident and an immediate jeopardy. The director of nursing identified twenty seven residents who received antihypertensive medications and three residents who received anticoagulant medications. Findings: The policy, "Administering Medications" documented, "Medications will be administered in a timely manner and as prescribed by the resident's attending physician..." The policy, "Medication Errors and Adverse Reactions" documented, "Medication errors and adverse drug reactions must be reported to the attending physician..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A consultation report from (name deleted) rehabilitation center dated [DATE], documented, "...Diagnoses: [REDACTED]. Patient is on [MEDICATION NAME] and [MEDICATION NAME] for stroke protection..." An admission assessment dated [DATE], documented, "...requires total assistance /c (with) ADL's (activities of daily living), has (R) (right) side weakness D/T (due to) [MEDICAL CONDITION] (diagnoses) diabetes, [MEDICAL CONDITION]" A physcian's physical examination documented, "admitted : [DATE]...general condition good...rehab potential good. [DIAGNOSES REDACTED]. The physical was signed and dated by the attending physician on [DATE]. A physician's telephone order dated [DATE], documented, "[MEDICATION NAME] 75 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 80 mg po daily." [MEDICATION NAME] is an anticoagulant and [MEDICATION NAME] is an antihypertensive medication. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident did not receive his medications on any day he was at the facility. An undated "Social Notes" documented, "November: family contacted after speaking /c (name deleted) about Medicare not being updated...daughter contacted and the facility was told to get in contact /c (Pharmacy). (Pharmacy) was contacted /c orders and daughter was notified to pick up medications. Daughter brought in meds from home and was told he had new orderers. She...stated she would pick them up. When meds (medications) weren't received a worker went to (Pharmacy) which was closed for the holiday." There was no documentation of the date when the pharmacy was contacted with the orders and when the worker went to pick them up. A "Prehospital Care Report" dated [DATE], documented, "...pulse 107, respiration 20..." A physcian's telephone order dated [DATE], documented, "Sent to (hospital) for evaluation." There was no additional documentation in the nurses notes or in the chart of the resident's condition upon transfer to the hospital. A "Prehospital Care Report" dated [DATE], documented, "...1852 (6:2 p.m.) pulse 130, respiration 30...1900 (7:00 p.m.) pulse 127 and respiration 28..." This form was filled out by the transporting ambulance. A nurse's note at 9:30 p.m., documented, "This nurse called (Hospital) to check on resident. (Hospital) stated he had been transferred to (Name deleted) hospital." A nurse's note dated [DATE] at 6:05 a.m., documented, "Medical examiner office called. Resident passed away during the night." An interview was conducted on [DATE] at 1:30 p.m., with certified medication aide #1 regarding the resident's medications. She was asked what medications the resident took routinely. She stated, "He didn't have any medications." When asked why he didn't have the medications, She stated, "We didn't have any to give him. The nurse knew he didn't have medications." She was asked who was responsible for ensuring medications were ordered and received when a resident was admitted to the facility. She stated, "(Certified medication aide #2) does all the ordering." An interview was conducted on [DATE] at 1:40 p.m., with certified medication aide #2. She was asked why the resident did not have medications while he was at the facility. She stated, "Pharmacy wouldn't fill the medications because Medicare wouldn't pay for them." An interview was conducted on [DATE] at 2:05 p.m., with the director of nursing regarding the resident not having medications as ordered. She was asked why the resident did not receive his medications. She stated, "Medicare wouldn't pay for it." She was asked what the medications were for. She stated, "They are important, they are for hypertension and due to his stroke." She was asked if this was a significant medication error. She stated, "Yes, they were for his hypertension and stroke prevention." She was asked if the resident's physician had been notified of he medications not being provided as ordered. She stated, "If notified it would be in the nurses' notes." After looking through the resident's clinical record she stated, "No. He wasn't notified." An interview was conducted on [DATE] at 2:40 p.m., with certified medication aide #3. He was asked what medications the resident had. He stated, "I never went into his room." He then stated the resident didn't have any medications. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A consultation report from (name deleted) rehabilitation center dated [DATE], documented, "...Diagnoses: [REDACTED]. Patient is on [MEDICATION NAME] and [MEDICATION NAME] for stroke protection..." An admission assessment dated [DATE], documented, "...requires total assistance /c (with) ADL's (activities of daily living), has (R) (right) side weakness D/T (due to) [MEDICAL CONDITION] (diagnoses) diabetes, [MEDICAL CONDITION]" A physcian's physical examination documented, "admitted : [DATE]...general condition good...rehab potential good. [DIAGNOSES REDACTED]. The physical was signed and dated by the attending physician on [DATE]. A physician's telephone order dated [DATE], documented, "[MEDICATION NAME] 75 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 80 mg po daily." [MEDICATION NAME] is an anticoagulant and [MEDICATION NAME] is an antihypertensive medication. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An undated "Social Notes" documented, "November: family contacted after speaking /c (name deleted) about Medicare not being updated...daughter contacted and the facility was told to get in contact /c (Pharmacy). (Pharmacy) was contacted /c orders and daughter was notified to pick up medications. Daughter brought in meds from home and was told he had new orders. She...stated she would pick them up. When meds (medications) weren't received a worker went to (Pharmacy) which was closed for the holiday." There was no documentation of the date when the pharmacy was contacted with the orders and when the worker went to pick them up. A "Prehospital Care Report" dated [DATE], documented, "...pulse 107, respiration 20..." A physcian's telephone order dated [DATE], documented, "Sent to (hospital) for evaluation." There was no additional documentation in the nurses notes or in the chart of the resident' condition upon transfer to the hospital. A "Prehospital Care Report" dated [DATE], documented, "..1852 (6:2 p.m.) pulse 130, respiration 30...1900 (7:00 p.m.) pulse 127 and respiration 28..." This form was filled out by the transporting ambulance. A nurse's note at 9:30 p.m., documented, "This nurse called (Hospital) to check on resident. (Hospital) stated he had been transferred to (Name deleted) hospital." A nurse's note dated [DATE] at 6:05 a.m., documented, "Medical examiner office called. Resident passed away during the night."

On [DATE], an immediate jeopardy situation was determined to exist due to the facility's failure to have an effective system in place to ensure staff was knowledgeable of proper operation of the suction machine and acquired medications for a newly admitted resident with [DIAGNOSES REDACTED]. At 4:35 p.m.,, the Oklahoma State Department of Health was notified and confirmed the existence of an immediate jeopardy situation. At 4:55 p.m., the administrator, registered nurse #1, director of nursing (DON) and administrative assistant were notified of the existence of the immediate jeopardy. At 8:00 p.m., the administrator provided an acceptable plan of removal. The plan of removal was as followed: "On [DATE] at approximately 5:15 p.m., a notification of immediate jeopardy was announced by OSDH. Failure to assess and monitor resident with hypertension and who was status [REDACTED]. As of [DATE], every resident, including current residents, who receive an antihypertensive medication will have their vital signs taken daily. The vital signs will be documented in the Nurse (s') Notes, MAR (medication administration record), or on the Treatment sheet for the resident. A visual assessment will be in a narrative form. The visual assessment will be documented by exception. If normal visual assessment, the nurse will document that a visual assessment has been completed and was within normal limits. As of [DATE], any resident, including residents, who receive anticoagulant medications, a complete head-to-toe assessment will be conducted weekly (Sunday being the first day of the week through Saturday, the last day of the week) on a "Head-to-toe Assessment for residents on Anticoagulant" form and placed in each resident's Nurse ('s) Notes. See attached. The facility will no longer accept residents who do not have Medicaid approval for the nursing home already and a means to obtaining their medications prior to being admitted to the facility. This will prevent this from recurring. An LPN job orientation will be conducted on the first shift and LPN is hired and will be kept in the employee's personnel record. A one on one in-service will be given on emergency/disaster plans on this first shift. The facility uses a "buddy" system for training and orientation of a newly hired LPN. See attached. For current employees in-service emergency/disaster plans will be completed by [DATE]. For any LPN unavailable [DATE] through [DATE], these LPN's will be in-serviced prior to beginning of their next shift. On-going in services will be conducted as changes are made to emergency/ disaster plans. Bi-monthly in-services will always include in-service with new hires on emergency/disaster plans, CPR, and [MEDICATION NAME] Maneuver." On [DATE], after observing the facility crash cart with the suction machine, reviewing residents head to toe assessments, daily vital signs and interviewing licensed staff, the immediacy was removed. The deficient practice remained at a pattern with the potential for more then minimal harm. On [DATE] at 2:25 p.m., the administrator was informed the immediacy had been removed effective [DATE] at 11:00 p.m. Based on observation, record review and interviews, it was determined the facility failed to ensure a resident with hypertension and status [REDACTED].#1) of three sampled residents. This resulted in an immediate jeopardy. The DON identified twenty seven residents who received antihypertensive medications and three residents who received anticoagulant medications. Findings: The policy, "Supplies and Equipment, Use of," documented, "...Equipment must be ready for use at all times of the day and night to serve the residents' needs..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A consultation report from (Name deleted) rehabilitation center dated [DATE], documented, "...Diagnoses: [REDACTED]. Patient is on [MEDICATION NAME] and [MEDICATION NAME] for stroke protection..." A physician's telephone order dated [DATE], documented, "V/S (vial signs) q (every week...skin assessment q [MEDICATION NAME] 75 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 80 mg po daily." ([MEDICATION NAME] is an anticoagulant and [MEDICATION NAME] is an antihypertensive medication.) An admission assessment dated [DATE], documented, "Time: 10 AM, T (Temperature) 97.4 P (pulse) 72, R (respiration) 18, B/P (blood pressure) ,[DATE]...requires total assistance /c (with) ADL's (activities of daily living), has (R) (right) side weakness D/T (due to) [MEDICAL CONDITION] (diagnoses) diabetes, [MEDICAL CONDITION]" A physician's physical examination documented, "admitted : [DATE]...T, P,R: 97.4, 72, 18...BP ,[DATE]...general condition good...rehab potential good. [DIAGNOSES REDACTED]. The physical was signed and dated by the attending physician on [DATE]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident went to the hospital on [DATE] at 8:30 a.m. and returned on [DATE] at 5:15 p.m. There was no documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The documentation verified the resident did not receive his medications on any day he was a resident at the facility. A review of the treatment record for [DATE], documented, "Vital signs weekly." The date the order was first written was on [DATE], the date the resident was admitted to the facility. There was no documentation to verify the resident was assessed and monitored in the absences of not receiving his routine antihypertensive and anticoagulant medications as ordered. An undated social note documented, "November: family contacted after speaking /c (family member) about Medicare not being updated...daughter contacted and the facility was told to get in contact /c (Pharmacy). (Pharmacy) was contacted /c orders and daughter was notified to pick up medications. Daughter brought in meds from home and was told he had new orders. She...stated she would pick them up. When meds (medications) weren't received a worker went to (Pharmacy) which was closed for the holiday." There was no documentation of the date when the pharmacy was contacted with the orders and when the worker went to pick them up. A physician's telephone order dated [DATE], documented, "Send to (Hospital) for evaluation." There was no nursing assessment to indicate the resident's condition upon transfer to the hospital. A "Prehospital Care Report" dated [DATE], documented, "...pulse 107, respiration 20..." This form was filled out by the transporting ambulance. A second nurse's note at 2:00 p.m., documented, "...@ 2 pm called (Hospital) for update-states was transferred to (Hospital) possible UTI (urinary tract infection) and pneumonia..." A nurse's note dated [DATE] at 5:15 p.m., documented, "Ambulance here /c /R (with resident)...B/P ,[DATE] P 80, R 20..." A nurse's note dated [DATE] at 6:15 p.m., documented, "Called to residents room slight wheezing noted. Family requesting to be sent to ER (emergency room ). Dr. (name deleted) called N/O (new order) to send to (Hospital) for eval... 6:45 p EMS (emergency medical services) taking resident to (Hospital) @ (at) this time. Family following in personal vehicles." There was no nursing assessment to indicate the resident's condition upon transfer to the hospital. A "Prehospital Care Report," dated [DATE], documented, "..1852 (6:52 p.m.) pulse 130, respiration 30...1900 (7:00 p.m.) pulse 127 and respiration 28..." This form was filled out by the transporting ambulance. A nurse's note dated [DATE] at 9:30 p.m., documented, "This nurse called (Hospital) to check on resident. (Hospital) stated he had been transferred to (Name deleted) hospital." A nurse's note dated [DATE] at 6:05 a.m., documented, "Medical examiner office called. Resident passed away during the night." On [DATE] at 12:15 p.m., the DON was asked to view the emergency cart and suction machine. She stated she didn't know where it was kept. She asked another staff member where the emergency cart and suction machine was kept. The staff member showed the DON the cart was in the hallway next to the nurses' station. The DON was asked to assemble the suction machine and turn it on. She stated there was no tubing on the cart to connect to the suction machine. She stated she was not sure where the tubing was kept. She asked another staff member where the suction tubing was kept. The DON and the other staff member walked away. At 12:30 p.m., the director of nursing returned with suction tubing and stated the tubing was kept in the storage room. The DON connected the tubing to the suction machine and turned the machine on. The DON was asked where the suction tubing was to be kept on the emergency cart next to the suction machine or in the storage room. She stated, "On the cart." An interview was conducted on [DATE] at 1:30 p.m., with certified medication aide (CMA) #1 regarding the resident's medications. She was asked what medications the resident took routinely. She stated, "He didn't have any medications." When asked why the resident didn't have medications, she stated, "We didn't have any to give him. The nurse knew he didn't have medications." CMA #1 was asked who was responsible for ensuring medications were ordered and received when a resident was admitted to the facility. She stated, "(CMA #2) does all the ordering." She was asked if the resident required suctioning on [DATE], prior to being sent out to the hospital. She stated, "Only licensed staff does the suctioning. The nurse got the suction machine. I don't know if he was suctioned." An interview was conducted on [DATE] at 1:40 p.m., with CMA #2. She was asked why the resident did not have medications as ordered while he was at the facility. She stated, "Pharmacy wouldn't fill the medications because Medicare wouldn't pay for them." She was asked if the nurse suctioned the resident on [DATE], prior to being sent to the hospital. She stated, "They got the machine, but I don't think he got suctioned." An interview was conducted on [DATE] at 2:05 p.m., with the DON regarding the resident not having medications as ordered, and about the failure to assess and monitor a resident with hypertension and post [MEDICAL CONDITION]. She was asked why the resident did not receive his medications. She stated, "Medicare wouldn't pay for it." She was asked about the medications. She stated, "They are important. They are for hypertension and due to his stroke." The DON was asked if the resident's physician had been notified of the medications not being administered as ordered. She stated, "If notified it would be in the nurses' notes." After looking through the resident's clinical record she stated, "No. He wasn't notified." She was asked if the resident's vital signs were monitored per facility policy. She stated, "They were taken on admission and when he came back from the hospital." The DON was asked if the vital signs on the physician's physical was from the original admission assessment. She stated, "Yes." She was asked about the condition of the resident on [DATE], when he was sent to the hospital. She stated, "I don't know. There wasn't anything documented." The DON was asked why the resident was sent to the hospital. She stated, "The family requested it." She was asked if the resident was assessed on [DATE], prior to being sent out to the hospital. She stated, "No assessment is documented." She then stated the nurses' note documented he had a slight wheezing. The DON was asked if the resident's vital signs were taken at times other than on admission and when he came back from the hospital on [DATE]. She stated, "No other vitals were taken." She was asked if the resident should have been assessed and monitored in the absence of his antihypertensive and anticoagulant medication not being administered. She stated, "We should have, but nothing is documented." The DON was asked if the resident required suctioning on [DATE], prior to being sent to the hospital. She stated, "No. He wasn't suctioned." She was asked if he needed to be suctioned. She stated, "I was told he could have been." An interview was conducted on [DATE] at 2:40 p.m., with CMA #3. He was asked what medications the resident had. He stated, "I never went into his room." He then stated, "The resident didn't have any medications." He was asked what the resident's condition was prior to being sent out to the hospital on [DATE]. He stated, "He wasn't breathing good." CMA #3 was asked if the charge nurse provided suctioning that night. He stated, "They went down and got the suction machine but didn't use it." He was asked to identify the employee that didn't use the suction machine. He stated, "(Licensed Practical nurse (LPN) #1)." An interview was conducted on [DATE] at 3:55 p.m., with LPN #1. She was asked to describe the resident on [DATE]. She stated, "He was having some wheezing." She was asked if the resident needed suctioning. She stated, "Yes. I could have gotten most of it out." The LPN was asked if the resident was suctioned. She stated, "I couldn't figure out how to use it. I didn't know how to use it. I really should have suctioned." She then stated the tubing was missing from the machine and she didn't know where it was located. She called the doctor and sent him out when she couldn't get the suction machine working. The LPN was asked if the resident had a documented assessment prior to being sent out to the hospital. She stated, "I should have put it all in the nurses' notes." An interview was conducted on [DATE] at 8:00 p.m., with CMA #2. He was asked to describe the resident on [DATE], prior to being sent out to the hospital. He stated, "The family was complaining food was coming out of his mouth." He was asked if the charge nurse provided suctioning to the resident. He stated, "The nurse was going to suction him. She was scrambling around looking for the suction machine and tubing." An interview was conducted on [DATE] at 8:10 p.m., with certified nurse aide (CNA) #1. She was asked if she worked with the resident on [DATE], prior to his going out to the hospital. She stated, "I worked with him right when I got here at 4:30. (p.m.)." She was asked to describe the resident. She stated, "He felt and looked clammy." She then added, "He was more 'gurgly' during his meal." The CNA was asked when he first started having the problems. She stated, "4:45 (p.m.) he started having problems during the meal." She was asked if she notified anyone. She stated, "( LPN #1) came in about 5:00 (p.m.)." The CNA was asked if the resident was suctioned prior to going out to the hospital. She stated, "I recall they found the suction machine and was (were) going to suction him, but was (were) looking for tubing."

Based on record review and interviews, it was determined the facility failed to assess and monitor a resident who was a high risk for pressure ulcers and obtain orders for treatments when the resident experienced a decline in skin condition for one (#1) of three sampled residents who were at risk for and had pressure sores. This resulted in an actual harm. The director of nursing identified one active resident who had a pressure sore. Findings: The policy "Pressure Ulcer Risk Assessment" documented, "...If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times becomes infected...Risk assessment: a pressure ulcer risk assessment will be completed upon admission, with each additional assessment, quarterly, annually and with significant change...skin assessment. Skin will be assessed for the presence of developing ulcers on a weekly basis or more frequently if indicated..." The policy "Prevention of Pressure Ulcers" documented, "...The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated and reported to the practitioner, physician, and family, and addressed..." Resident #1 was admitted to the facility, with [DIAGNOSES REDACTED]. A history and physical dated 10/18/13, documented, "...Skin: he has redness of the buttocks/sacrococcyx area stage I decubitus. He has two 1.5 cm (centimeters) lateral decubiti stage I of the right foot. He has an unstageable bruise or blister at the distal portion of the left great toe..." A 'Discharge/transfer Summary" dated 11/07/13, documented, "...condition of skin: Stage I coccyx..." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] skin protectant apply topically...twice daily to buttocks and heels....[MEDICATION NAME] spray topically twice daily to left great toe and rt ext foot..." A physician's telephone order dated 11/07/13, documented, "[MEDICATION NAME] to buttocks & heels BID (twice a day) for preventive measures..." There was no documentation the order for [MEDICATION NAME] had ben transcribed to the current orders once the resident was admitted to the facility on [DATE]. The treatment record documented the treatment was provided as ordered between 11/07/13 and 11/15/13. The resident went to the hospital on [DATE] at 8:30 a.m. and returned on 11/18/13 at 5:15 p.m. There was no documentation the treatment was provided after the resident returned from the hospital on [DATE]. An admission nurse's note dated 11/07/13 at 10:00 a.m., documented, "....resident has a purplish color to tip of (L) (left) great toe...has stage I (one) decubitis to coccyx area, no drainage or redness noted..." A nurse's node dated 11/15/13 at 8:30 a.m., documented, "Received call from (name deleted doctor) to send resident to (name deleted hospital) for evaluation...." There also was no documentation as to the condition of the resident's skin upon transfer to the hospital. A "Nursing Transition of Care Record", from the hospital, dated 11/18/13, documented, "....skin: pressure ulcers; stage 2 coccyx...(R) abrasions...(R) toe 2n/3rd necrosis..." A nurse's note dated 11/18/13 at 5:15 p.m., documented, "Ambulance here /c /R (with resident)...L-great toe /c 3 cm X 3 cm blood blister on tip of toe, L- heel /c 4cm X 4cm discolored soft area. R-foot 3rd & 4th toe /c abrasions approx 2cm X 2CM, R-outer foot /c (documentation incomplete) L-buttock in butt crack stage II (two) approx 6 cm X .75 cm." There was no documentation in the clinical record the physician had been notified of the resident's decline in skin condition after returning from the hospital on [DATE]. There was no documentation the facility was providing a treatment to the resident's stage two pressure ulcer. The "Treatment Record" for November 2013, documented, "Weekly skin assmt (assessment) QWK (once per week)..." The order was first written on 11/07/13, the date of admission. There was no documentation on the treatment record the skin assessment had been completed between 11/07/13 and 11/15/13. An interview was conducted on 12/10/13 at 12:15 p.m., with the director of nursing. She was asked why the [MEDICATION NAME] spray had not been administered. She looked through the resident's chart and stated, 'There was no physician's order for it." She was asked if the order should have been transcribed from the discharging rehabilitation center. She stated, 'It was at (hospital) but no order at the facility." She then stated, "Yes. It should have an order." The director of nursing was asked what the condition of the resident's skin was when he transferred out to the hospital on [DATE]. She stated, "I could not tell you because there are no skin assessments." She was asked if there had been a decline in the resident's skin condition since being admitted to the facility. She stated, "Yes. There was a decline in the resident's skin condition." She was asked when the decline occurred. She stated, "I don't know when the decline occurred." She was asked if the resident received any treatments for the pressure ulcers after he returned from the hospital on [DATE]. She stated, "We don't have any orders on it." The nurse was asked if the physician had been notified of the decline in the resident's skin condition and a treatment ordered obtained. She stated, "I don't know." She then looked through the nurses' notes and stated, "I don't see he was."