Every finding on record at Seminole Care and Rehabilitation Center

Based on interview, record review, facility document review, and facility policy review, the facility failed to maintain grievances for 16 of 22 months reviewed for grievances. Additionally, the facility failed to ensure a grievance form was initiated for a resident's missing personal property for 1 (Resident #3) of 2 residents reviewed for personal property.Findings included: 1. A facility policy titled, Grievance, revised 01/28/2026, revealed, If requested, a copy of the grievance form will be provided to the person who reported the grievance. During an interview on 07/16/2026 at 8:46 AM, Social Services Director (SSD) stated she started in January of 2026 as the SSD. She stated she was responsible for grievances. She stated residents would come to her and express their concern. She stated that she would initiate a grievance for the resident and start the process of trying to resolve the concern. She stated that she documented on the grievance form if the concern was resolved and put the grievance form in the grievance binder. She stated that when she started in January, she took over for Former SSD. She stated that she was told the grievance book was in the conference room, but she could not locate the grievance binder at that time and had to start a new grievance binder. She stated that she had been unable to locate the previous grievance binder to this date. The SSD stated that the only grievances she had were from February of 2026 to present. She stated she thought the facility was supposed to maintain grievances for five to 10 years, just like medical records. During an interview on 07/16/2026 at 8:58 AM, the Director of Nursing (DON) stated that grievance forms were placed in the grievance binder, and the grievance binder was kept in the Social Services office. She stated she was aware that the facility did not have any grievance forms prior to February of 2026. She stated they had been unable to find the previous grievance binder and had no idea what happened to the previous grievance binder after the former SSD left. She stated that she expected them to keep the grievance forms for three years. During an interview on 07/16/2026 at 9:23 AM, the Administrator stated that grievance forms should be kept in the grievance log or binder and that the grievance binder was normally kept in the Social Services office. The Administrator stated that the grievances should be kept according to federal regulations. He stated that he did not know how long grievances were to be kept. He stated they had not been able to locate their grievance binder, and the only grievances they had were from February of 2026 to present. He stated that he expected the facility to follow federal regulations. During an interview on 07/16/2026 at 9:45 AM, the Administrator in Training (AIT) stated the staff logged grievances and kept them. The AIT stated that grievances were to be kept in the Social Services office. She stated the facility was required by regulations to keep grievances for three years. The AIT stated that they had only been able to find grievances from February of 2026 to present. The AIT stated that they had not been able to locate any grievances prior to February of 2026. She stated that she expected grievances to be kept for three years per regulations. During an interview on 07/16/2026 at 10:05 AM, the Former SSD stated she was responsible for grievances when she worked at the facility. She stated they had grievance instructions they followed. The Former SSD stated that grievance forms were placed in a grievance binder and the grievance binder was kept in the Social Services office. She stated that she had no idea where the grievance binder was at that time since she had not worked at the facility since January of 2026. She stated she thought grievances were supposed to be kept in the facility for two to three years.2. A facility policy titled, Grievance, revised 01/28/2026, indicated, Residents and Resident Representatives have the right to voice concerns and/or report missing items/property which affect their lives at this Facility, without fear of discrimination or reprisal. The policy also indicated, A. Concerns may be presented to any staff member, if able, shall resolve the concern immediately and document the concern and resolution on the grievance form and turn into the Grievance Official. B. If unable to resolve immediately, staff shall document the concern on the grievance form and turn the form into the Grievance Official. C. Grievance Official shall review the concern and assign to the appropriate department leader for investigation and follow up within 3 business days.An admission Record revealed the facility admitted Resident #3 on 05/20/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease with (acute) exacerbation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Care Plan Report did not include a focus area for maintaining personal items. The facility's Grievance Monthly Tracking Log, for the timeframe from 06/03/2026 through 07/08/2026 did not indicate Resident #3 had a grievance initiated. During an interview on 07/13/2026 at 2:28 PM, Resident #3 stated that a couple of weeks prior, they sent pajama pants to the laundry and did not get them back. Resident #3 stated the pants had a red and black square pattern. Resident #3 stated they told laundry staff the pants were missing, and the staff member said they could not find the pants. Resident #3 stated that the facility did not initiate a grievance form. During an interview on 07/14/2026 at 2:40 PM, Laundry Assistant (LA) #3 stated Resident #3 reported missing red and black pants to him. LA #3 stated the resident reported it to him a week or two prior. LA #3 stated Resident #3 asked if they could look in the laundry room for the pants, and he said there was no personal clothing back in the laundry for Resident #3 to look at. LA #3 stated he did not report to anyone that the resident reported that their red and black pants were missing. During an interview on 07/14/2026 at 2:51 PM, the Housekeeping Supervisor (HS) stated Social Services initiated grievances for missing clothing. The HS stated he was not aware Resident #3 was missing clothing. The HS stated that missing clothing should be found as soon as possible. During an interview on 07/14/2026 at 3:08 PM, the Social Services Director (SSD) stated that if a personal item was missing then the facility staff filled out a grievance form before they began searching. The SSD stated she was responsible for completing grievances. The SSD stated she expected a grievance to be completed in two days from when it was reported. The SSD stated she was not aware Resident #3 was missing laundry. During an interview on 07/14/2026 at 3:14 PM, the Administrator in Training (AIT) stated she was not aware Resident #3 was missing pants. The AIT stated she expected a grievance for missing clothing to be started immediately. During an interview on 07/15/2026 at 1:43 PM, the Director of Nursing (DON) stated she was not notified prior to that day that Resident #3 was missing pants. The DON stated her expectation was that certified nursing assistants (CNAs) would search for the missing item first, and if they could not find it, they were to report to the laundry supervisor. The DON stated if the missing clothing was not found within an hour, then whoever the employee was that took the grievance from the resident was to write it down and take it to Social Services staff. The DON stated that anyone in the building could initiate a grievance form for a resident. The DON stated her expectation was the grievance to be written within an hour of not finding the missing item. During an interview on 07/16/2026 at 12:59 PM, the Administrator stated he expected staff to follow the facility's policy and regulations.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBPs) for 1 (Resident #104) of 3 sampled residents reviewed for indwelling urinary catheters.Findings included: A facility policy titled, Enhanced Barrier Precautions, last reviewed by the facility on 05/15/2024, indicated, The use of gown & gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of MDRO [multi-drug resistant organism] colonization as well as for residents with MDRO infection/colonization. The policy revealed the section titled, Steps, included, - Post signage on the door/wall outside of the resident's room indicating the use of Enhanced Barrier Precautions. - Post signage in the resident room with information on use of Enhanced Barrier Precautions & required PPE [personal protective equipment] (e.g. [exempli gratia, for example], Gown & Gloves). Enhanced Barrier Precautions signage should include information on high contact resident care activities that require the use of gown & gloves. - PPE should be available inside of the resident's room. The policy revealed that High-Contact Resident Care Activities, included, Device Care; Central Line, Urinary Catheter, Enteral Tube, Tracheostomy/Ventilator. An admission Record indicated the facility admitted Resident #104 on 07/09/2026. According to the admission Record, the resident had a medical history that included diagnoses of severe chronic kidney disease and obstructive and reflux uropathy. During an observation on 07/14/2026 at 10:55 AM, Resident #104 was asleep in bed, and their urinary catheter bag was hanging on the side of the bed. There were no available PPE and EBP signs posted on the door of the resident's room. During a concurrent interview, Certified Nursing Assistant (CNA) #1 verified there was no EBP sign or PPE on the resident's door and stated there should be a sign on the door indicating the resident was on EBP and to use PPE. CNA #1 stated she did not think about it and did not use PPE when she provided catheter care to Resident #104 every two hours and after the resident had a bowel movement earlier that morning. During an interview on 07/14/2026 at 10:28 AM, CNA #1 stated she was the assigned CNA for Resident #104. CNA #1 stated she cleaned Resident #104 that morning when the resident had a bowel movement. CNA #1 stated she was also responsible for emptying the contents of Resident #104's urinary catheter bag at the end of her shift, measuring how much was inside it, and providing that information to the licensed nurse to document. During an interview on 07/16/2026 at 10:56 AM, CNA #1 stated she was assigned to Resident #104 on 07/13/2026. CNA #1 stated that on 07/13/2026 she assisted Resident #104 with personal care, going to the bathroom, and catheter care. CNA #1 stated there was no EBP sign or PPE on Resident #104's door on 07/13/2026. A facility document titled, Educational In-Service Record, dated 06/18/2026, indicated that CNA #1 received training on enhanced barrier precautions. During an interview on 07/14/2026 at 10:43 AM, Licensed Practical Nurse (LPN) #2 stated she was the assigned licensed nurse for Resident #104. LPN #2 stated she was responsible for providing catheter care to Resident #104, changing the catheter as needed, and monitoring the amount of urine output. During an interview on 07/14/2026 at 12:09 PM, LPN #2 stated the Infection Preventionist (IP) was primarily responsible for determining which residents would be placed on EBP; however, all staff had been trained on EBP, so all staff were responsible for ensuring that residents requiring EBP were placed on EBP. LPN #2 stated that if she identified a resident who needed to be placed on EBP, she would put up the EBP sign and the PPE and notify the DON. LPN #2 stated that Resident #104 should have been placed on EBP because the resident had an indwelling catheter, and she should wear a gown when providing catheter care to the resident. During an interview on 07/14/2026 at 11:39 AM, the IP stated that any resident with an indwelling urinary catheter would need to be placed on EBP. The IP stated that for residents who required EBP, it was her responsibility to ensure they had orders in place, EBP signs were posted, and the PPE was in place. The IP stated that all staff were trained and in-serviced on EBP, so if she was not available, then the nurses on the floor were able to post the signs themselves. The IP stated that the EBP signs and PPE were readily available to all staff. The IP stated it was her first day back from leave, so she had not reviewed Resident #104's medical record yet. The IP stated she was not aware that Resident #104 had an indwelling urinary catheter and had no EBP signs up. During an interview on 07/15/2026 at 2:56 PM, the Director of Nursing (DON) stated that for newly admitted residents, the admitting nurse was responsible for doing a full head-to-toe assessment and determining the resident's needs, including if the resident needed to be placed on EBP. The DON stated that residents with indwelling catheters needed to be placed on EBP. The DON stated that if a resident who was required to be on EBP did not have an EBP sign up on their door, then the CNA should notify the charge nurse, and the charge nurse should put up the EBP sign and PPE. The DON stated that the IP should verify if the signs were up. During an interview on 07/15/2026 at 3:41 PM, the Administrator (ADM) stated that the IP and nurses were responsible for ensuring that transmission-based precautions were implemented for any resident requiring it. The ADM stated that, even on weekends when the DON and IP were not available, he would expect the nursing staff to follow facility policies and federal guidelines.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident representative was notified when a resident had a change in condition and was diagnosed with scabies for 1 (Resident #80) of 21 sampled residents.Findings included:A facility policy titled, Notification of a Change in Condition, revised 01/20/2026, indicated, The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, according to Standards of Practice and Federal and/or State Regulations. The policy revealed the section titled, Procedure, included, 1. Guideline for Notification of Physician/Resident Representative (not all inclusive): - Significant Change in Medical Cognitive baseline.An admission Record revealed the facility admitted Resident #80 on 03/05/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia and Alzheimer's disease. The admission Record revealed that Family Representative (FR) #4 was Resident #80's responsible party and resident representative. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2026, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident did not have skin problems. Resident #80's Care Plan Report, included a focus area initiated 03/18/2024, that indicated the resident had impaired cognitive function and impaired thought processes related to dementia. Interventions directed staff to communicate with the resident's family regarding the resident's capabilities and needs. The Care Plan Report also included a focus area initiated 03/18/2024, that indicated the resident was at risk for impaired skin integrity related to incontinence and limited mobility and needed one to two staff to assist with care. Interventions directed staff to educate the resident's family of causative factors and measures to prevent skin injury. Resident #80's dermatologist Progress Notes, dated 12/26 (no year) and noted by a licensed practical nurse (LPN) on 12/26/2024, revealed a recommendation to treat scabies with permethrin 5 percent (%) cream. During a telephone interview on 07/14/2026 at 1:03 PM, FR #4 stated that they were notified of Resident #80's dermatology appointment but was not notified that the resident had scabies. During an interview on 07/15/2026 at 3:01 PM, Registered Nurse (RN) #5 stated she remembered Resident #80 having scabies. RN #5 stated the resident's representative should have been notified of any changes, including a diagnosis of scabies. RN #5 reviewed Resident #80's chart and stated the family was not notified of the scabies after the resident returned from the dermatologist. During an interview on 07/16/2026 at 11:46 AM, the Director of Nursing (DON) stated there was no documentation that the representative for Resident #80 was notified of the scabies when the resident returned from the dermatologist appointment. The DON stated her expectation for notification of a scabies diagnosis was that the representative would be notified. During an interview on 07/16/2026 at 1:03 PM, the Administrator stated his expectation was that facility policies and regulations were followed for notification to representatives for scabies.

Based on record review and interview, the facility failed to revise a care plan to reflect the resident's current status for one (#2) of three sampled residents whose care plans were reviewed. The admission coordinator identified 95 residents resided in the facility. Findings: Res #2 had diagnoses which included right lower leg fracture, left shin fracture, chronic pain syndrome, and osteoarthritis. A care plan, dated 10/10/24, documented the resident had limited physical mobility and was non-weight bearing. A resident admission assessment, dated 10/14/24, documented the resident's cognition was intact, required substantial assistance with most ADLs, had impairment to both sides of their lower extremities, and reported their pain was almost constantly. A care plan, dated 10/18/24, documented the resident had pain. A physician order, dated 11/19/24 at 3:00 p.m., documented the resident was weight bearing as tolerated. There was no documentation the care plan was revised to reflect the change to weight bearing as tolerated. A physician order, dated 12/20/24 at 9:00 p.m., documented to administer two tramadol (pain medication) 50 mg tablets by mouth every six hours as needed. A physician order, dated 12/20/24 at 10:15 p.m., documented to administer one tramadol 50 mg by mouth every six hours as needed. A December 2024 narcotic count sheet documented on 12/22/24 at 8:30 a.m. and 9:23 p.m. the resident refused their tramadol. There was no documentation the care plan was revised to reflect the resident's refusal of their pain medication. On 01/08/25 at 2:38 p.m., the MDS coordinator was asked if the resident's pain medication refusals and their weight bearing status change from non-weight bearing to weight bearing as tolerated should have been updated on their care plan. They stated it should have been updated, but it was not.

Based on observation, record review, and interview, the facility failed to ensure the removal of expired medications and supplies from two of three medication storage rooms observed. The assistant administrator in training reported 93 residents resided in the facility. Findings: On 09/18/24 at 9:40 a.m., the medication storage room on the skilled hall was observed with CMA #1. The following medications/supplies were observed to be expired. 6- boxes lubricant eye drops with an expiration date of 4/24, 1- V.A.C. Granufoam dressing package opened with and expiration date of 11/30/24. On 09/18/24 at 9:45 a.m., CMA #1 reported the expired medications and supplies should have been removed. On 09/18/24 at 9:54 a.m., the medication room for halls 1 and 2 were observed with CMA #2. The following medications were observd to be expired. 1- Box Ipratropium Bromide & Albuterol Sulfate 0.5mg/3mg per 3ml with a use by date of 3/10/24, 1- Box Ipratropium Bromide & Albuterol Sulfate 0.5mg/3mg per 3ml with a use by date of 5/9/24, 1- Box Ipratropium Bromide & Albuterol Sulfate 0.5mg/3mg per 3ml with a use by date of 9/11/24, 1- Box Ipratropium Bromide & Albuterol Sulfate 0.5mg/3mg per 3ml with a use by date of 7/26/4, 1- Box Ipratropium Bromide & Albuterol Sulfate 0.5mg/3mg per 3ml with a use by date of 6/1/24. On 09/18/24 at 9:59 a.m., CMA #2 reported the medications should have been removed.

Based on record review and interview, the facility failed to ensure side effect monitoring was conducted for the use of a psychotropic medication for one (#37) of five sampled residents reviewed for medications. The DON identified 44 residents received psychoactive medications. Findings: Res #37 had diagnoses which included depression. Physicians orders, dated 06/13/24, documented bupropion hydrobromide (antidepressant medication) 150 mg tablet by mouth one time a day; and Lexapro (antidepressant medication) 10 mg tablet one time a day. A care plan, revised 06/24/24, documented the resident used antidepressant medication. It documented to monitor and documented side effects every shift. There was no documentation side effects were monitored. On 09/17/24 at 11:36 a.m., the administrator, ADON, and DON were asked to locate documentation side effects were monitored for the resident. On 09/17/24 at 11:57 a.m., the DON stated side effects were not monitored. They stated the order to monitor had been discontinued.

Based on observation, record review, and interview, the facility failed to perform an entrapment risk assessment and to ensure informed consent was obtained prior to the use of bed rails for one (#49) of one resident sampled for bed rails. The administrator identified 33 residents whose beds were equipped with a bed rail of any type. Findings: A Side Rail Policy - Quarter/Assist Rail policy, dated October 2016, read in parts, .The facility will assess and input proper interventions to protect resident from injury .On admission, quarterly and with significant change of condition; the resident will have a side rail assessment completed .Licensed nurse will review the risks with resident and/or responsible party . Res #49 had diagnoses which included congestive heart failure, respiratory failure, and history of falls. A physician order, dated 08/11/22, documented the resident may have U-Rails to both sides of bed for mobility when entering and exiting for 90 days and then review. An annual assessment, dated 05/15/24, documented the resident was moderately impaired in cognition, required supervision to partial assistance with bed mobility, and had no falls. There was no documentation of an entrapment risk assessment or informed consent for bed rails found in the medical record. There was no documentation of the use of bed rails found in the care plan. On 09/15/24 at 11:49 a.m., Res #49 was observed sitting on the side of the bed. Bilateral bed rails were observed on the upper half of the bed in the up position. Res #49 stated they used the rails for positioning. On 09/17/24 at 8:08 a.m., the DON stated there was no documentation of a current entrapment risk assessment or informed consent prior to use of the bed rails for Res #49. On 09/17/24 at 8:15 a.m., the administrator stated the entrapment risk assessment should have been completed quarterly but it had not been completed in a while. They stated the use of bed rails should have been documented in the care plan.

Based on record review and interview, the facility failed to code MDS assessments accurately for two (#30 and #57) of two sampled residents reviewed for MDS accuracy. The assistant administrator identified 93 residents resided in the facility. Findings: 1. Res #30 had diagnoses which included suicidal ideations, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. A physician order, dated 12/24/21, documented zolpidem tartrate (hypnotic medication) 10 mg tablet by mouth at bedtime for sleep. Physician orders, dated 03/23/24, documented Seroquel (antipsychotic medication) 200 mg tablet one time a day; and Seroquel 200 mg tablet at bedtime. An annual assessment, dated 09/11/24, documented the resident did not receive an antipsychotic or hypnotic medication while a resident. On 09/17/24 at 12:46 a.m., MDS Coordinator #2 was asked if the resident's annual assessment was coded for the use of an antipsychotic or hypnotic medication. They stated they missed it. 2. Res #57 had diagnoses which included muscle wasting and atrophy, GERD, HTN, aphasia, anxiety, dementia, depression, and protein calorie malnutrition. A quarterly assessment, dated 07/31/24, documented the resident received an anticoagulant while a resident. There was no documentation the resident received an anticoagulant. On 09/17/24 at 12:43 p.m., MDS Coordinator #1 was made aware the resident's quarterly assessment documented the resident had received an anticoagulant. They were asked if there was documentation the resident received an anticoagulant. They stated they did not see the resident received an anticoagulant. They stated the assessment was coded incorrectly.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed, a care plan was completed, and a physician order was obtained for the use of a physical restraint for one (#13) of one sampled resident reviewed for physical restraints. The DON identified there were no residents with restraints Findings: A Physical Restraint policy, dated 07/26/23, documented prior to using a restraint an evaluation of the resident should be completed. It was documented a physician order for a restraint was to include the medical symptom for which the restraint was being used and the circumstance in which the restraint was applied. It was documented a comprehensive care plan should address the goal for the use of the restraint. Res #13 had diagnoses which included muscle weakness, cognitive communication, lack of coordination, difficulty in walking, and a history of falling. An inventory sheet of personal items, dated 03/26/24, documented the resident had an electric wheelchair. A safety device tool, dated 06/26/24, documented the resident had no safety device present or in use. A quarterly assessment , dated 07/03/24, documented the resident's cognition was severly impaired. It documented the resident used a wheelchair for mobility and was dependent on staff for transfers. It was documented the resident had no restraints. On 09/15/24 at 12:58 p.m., the resident was observed in their electric wheelchair with a seat belt attached and in place. CNA #1 was asked to have the resident demonstrate they were able to release their seat belt. They resident stated they knew how to do it, but stated their fingers were too fat to release the belt. On 09/16/24 at 9:55 a.m., the resident was observed in their electric wheelchair with a seat belt attached and in place. RN #1 was asked to have the resident demonstrate they were able to release their seat belt. The resident was observed attempting to release the belt, but was not strong enough to release it. On 09/16/24 at 10:03 a.m., RN #1 stated they did not see a physician's order for the use of the seat belt or where it had been care planned. They stated they did not know if an assessment had been completed. On 09/16/24 at 11:44 am., the administrator stated they knew the resident had a seat belt attached to their electric wheelchair. They stated they did not see where it had been care planned. They were asked to provide documentation the resident had been assessed for the use of the seat belt. On 09/17/24 at 9:13 a.m., the administrator stated there was no assessment completed for the use of the resident's seat belt.

Based on observation, record review, and interview, the facility failed to provide meals in a timely manner. The DON identified 90 residents who received meals from the kitchen. Findings: A Meals and Snacks policy, dated 03/31/21, documented meals shall be scheduled to ensure a maximum of 14 hours from dinner to breakfast on the following day. A schedule of meal times, updated 01/15/24, documented the following meal service times: 8:00 a.m. breakfast, 12:00 p.m. lunch, and 5:00 p.m. dinner. On 01/23/24 at 8:58 a.m., Res # 5 was observed sitting in their room eating breakfast. Res #5 stated meals are often served late which have resulted in food being colder than they preferred. On 01/23/24 at 9:06 a.m., Res #4 was observed lying in bed eating breakfast. Res #4 stated they ate some meals in their room and went to the dining room for other meals. They stated most meals are served at least an hour or longer past the scheduled meal times. Res #4 stated the meals were often cold by the time they received their meal tray. On 01/23/24 from 12:00 p.m. through 1:15 p.m., the lunch meal service was observed. At 12:05 p.m., nine residents were observed in the main dining room waiting for their noon meal. No food had been observed being served from the kitchen. The residents remained without meals until 12:25 p.m. when the first meal tray was served. At 1:15 p.m., the last meal tray was observed having been delivered to the resident in room [ROOM NUMBER] on the north hall of the facility. At 1:45 p.m., the administrator stated noon meal service should begin at 12:00 p.m. and all residents should have their meal within an hour. They stated the noon meal was delivered slightly late for the residents who preferred to eat meals in their rooms. On 01/24/24 from 8:00 a.m. through 9:12 a.m., the breakfast meal service was observed. At 9:12 a.m., the last meal tray was observed having been delivered to the resident in room [ROOM NUMBER] on the north hall of the facility. At 10:30 a.m., the dietary manager stated the breakfast meal was not served to all residents within an hour of the scheduled meal time. They stated dietary services had enough staff to prepare the food but would benefit from additional staff to improve the timeliness of meals being served.

Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#3) of one sampled resident reviewed for discharge. The DON identified 21 residents who had discharged home in the last three months. Findings: Res #3 was admitted [DATE] with diagnoses which included chronic heart failure, cerebral infarction, and dementia. A discharge assessment, dated 12/22/23, documented an unplanned discharge with return not anticipated. A nurse note, dated 12/22/23 at 2:58 p.m., read in part, .Resident discharge to home with home health, all medications and belongings sent home with wife, PCP notified of discharge . There was no documentation a discharge summary had been completed. On 01/24/24 at 11:50 a.m., the social services director stated they completed most of the discharge summaries for discharged residents. They stated they had not completed the discharge summary for Res #3. On 01/25/24 at 8:45 a.m., the DON stated the discharge summary for Res #3 had not been completed within thirty days but should have been.

Based on record review and interview, the facility failed to develop a comprehensive care plan related to pressure ulcers for one (#3) of three residents reviewed for pressure ulcers. The DON identified three residents with pressure ulcers. Findings: Resident #3 had diagnoses which included cerebral infarction, hemiplegia, hemiparesis, and chronic heart failure. A pressure ulcer risk assessment, dated 11/11/23, documented the resident was at moderate risk for development of a pressure ulcer. An admission assessment, dated 11/18/23, documented the resident was moderately cognitively impaired and required substantial to maximum assistance with walking and most activities of daily living. The assessment documented the resident did not have a pressure ulcer/injury upon admission. A nurse note, dated 11/22/23, documented a fluid filled purple discoloration to the left heel and purple/red discoloration to the right heel. The note documented the physician was notified and treatment orders were received. A physician order, dated 11/22/23, documented heel protectors in place at all times and float bilateral heels while in bed. A comprehensive care plan, initiated 11/24/23, did not document Res #3 was at risk for pressure ulcers. The care plan did not document the active pressure ulcers, treatment, monitoring, or preventive measures. A wound physician summary, dated 12/05/23, documented new unstageable deep tissue injuries to the right and left heels. On 01/24/24 at 11:40 a.m., MDS coordinator #1 stated they did not care plan Res #3's pressure ulcers, treatments, monitoring, or preventive measures. On 01/25/24 at 8:54 a.m., the DON stated Res #3 received pressure ulcer preventive measures and treatments but the pressure ulcer treatments, monitoring, and preventive measures were not documented in the comprehensive care plan.

Based on record review and interview, the facility failed to update a care plan with fall interventions for one (#59) of six sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 93 residents resided in the facility. Findings: 1. Res #59 had diagnoses which included dementia, history of falling, and muscle weakness. A fall care plan, last updated 11/18/22, documented the following interventions: a. on 03/30/20 anticipate and meet the resident's needs, encourage the resident to call for assistance, encourage resident to wear non-skid footwear, and follow therapy recommendations for transfers and mobility, b. on 05/21/20 therapy evaluated and provided a walker to resident and removed the wheelchair, c. on 07/30/20 room to remain clutter free, d. on 08/03/20 staff to assist resident with toileting before bed, e. on 08/31/20 staff to keep resident's room clutter free, f. on 11/18/20 staff to perform frequent non-invasive rounds to identify motion inside room and to meet unmet needs, g. on 11/18/20 staff to toilet before and after meals and activities, before laying down, and upon rising from bed, h. on 08/11/21 move resident to a common area for increased assistance during periods of increased agitation, i. on 08/11/21 staff to encourage resident to allow staff to assist to dining room table for meal, j. on 11/09/21 anti-rollback on wheelchair and staff to dress and assist to bed after dinner, k. on 03/09/22 do not park medication carts in front of resident's door, l. on 05/23/22 staff to attempt frequent toileting with resident as they allow due to agitation and combativeness, m. on 09/06/22 staff to perform frequent non-invasive rounds to identify motion inside room and to meet unmet needs, n. on 09/07/22 non-skid strips to be placed in restroom floor in front of toilet, and o. on 11/18/22 the resident will wear a soft helmet to prevent head trauma. A nurse's progress note, dated 03/06/23 at 1:15 a.m., documented the resident had a witnessed fall at the nurses station from their wheelchair. The intervention recommended was to slip on shoes. The care plan was not updated with the intervention A nurse's progress note, dated 04/05/23 at 7:00 p.m., documented the resident had an unwitnessed fall in the doorway of another resident's room. The intervention was to assist the resident to bed after meals. A nurse's progress note, dated 07/22/23 at 6:44 p.m., documented the resident had a witnessed fall in the hallway from their wheelchair. The note documented to ask the resident if they wanted to lay down after meals. The intervention was used on the prior fall and was not documented on the care plan. On 08/30/23 at 10:04 a.m., the resident was observed lying in their bed with eyes closed. The bed was observed in the lowest position with a fall mat at bedside. On 08/31/23 at 2:31 p.m., MDS Coordinator #1 was asked to review the resident's falls and care plan. They stated they did not see the interventions from the falls in 2023 on the care plan. They stated the care plan should be updated after each fall.

Based on observation, record review, and interview, the facility failed to ensure MDS assessments accurately reflected the use of physical restraints for two (#4 and #21) of two sampled residents reviewed for restraints. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 93 residents resided in the facility. It was documented there were no residents who were physically restrained. Findings: 1. Res #4 had diagnoses which include traumatic brain injury. A physician order, dated 02/23/22, documented U-rail on both sides of the bed for mobility assistance. A quarterly assessment, dated 07/12/23, documented the resident required extensive assistance with bed mobility and transfers. It was documented a bed rail was used daily as a restraint. On 08/30/23 at 10:14 a.m., their was one U-rail observed on the resident's bed. On 08/31/23 at 8:33 a.m., the DON was asked if there were any residents who had bed rails as physical restraints in the facility. They stated, No. On 08/31/23 at 9:32 a.m., LPN #4 was asked about the resident's mobility. They stated the resident was not able to get out of bed without help from staff. They were asked if the resident had U-rails on their bed and if the rail restrained the resident. They stated they had one rail and they used it for positioning. 2. Res #21's physician order, dated 02/23/22, documented U-rail on both sides of the bed for mobility assistance. An annual assessment, dated 08/03/23, documented the resident required limited assistance with bed mobility and tranfers. It was documented a bed rail was used daily as a restraint. On 08/30/23 at 12:53 p.m., there were no U-rails observed on the resident's bed. On 08/31/23 at 9:40 a.m., LPN #4 was asked if there were U-rails on the resident's bed. They stated they had worked at the facility since April and had not observed rails in the resident's bed. On 08/31/23 at 11:14 a.m., MDS Coordinator #1 and #2 were asked if there were any residents who were physically restrained in the facility. MDS Coordinator #1 stated, No. They were asked to review Res #4 and Res ##21's assessment for restraints. They were made aware Res #21 did not have rails on their bed. They stated the assessments were not marked correctly. They stated the rails were not restraints.

Based on observation, record review, and interview, the facility failed to assess a resident for self administration of medications for one (#30) of 19 sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 93 residents resided in the facility. Findings: Res #30 had diagnoses which included glaucoma, osteoarthritis, HTN, CAD, muscle weakness, and COPD. A physician order, dated 07/05/23, documented to administer diclofenac sodium external gel 1 % topically to affected areas twice per day for pain. A 5-day MDS, dated [DATE], documented the resident's cognition was moderately impaired and they required limited assistance of one staff with activities of daily living. On 08/30/23 at 09:33 a.m., the resident was observed in their room seated on their bed. There was a 30 ml cup with a small amount of ointment observed on top of the bedside table. There was a blue prescription pump bottle observed in the drawer of the bedside table. The resident was asked about the bottle and they stated it was a cream for their arthritis. They stated they applied it to their foot and legs. They stated a doctor in town had prescribed it. The label read diclofenac gel and had the resident's name and information. The resident's physician orders, assessments, and care plan did not document an assessment for self-administration of medications. On 08/31/23 at 10:39 a.m., the DON was asked to observe the resident's room for medications. There were two pill cups containing ointment observed on the bedside table. There was a blue pump bottle observed in the drawer of the bedside table. The DON stated the medication was filled at a pharmacy not used by the facility. They stated they were unsure when or where the resident obtained the medication. They stated the resident had not been assessed for self administration of medications.

Based on record review, and interview, the facility failed to ensure a resident's code status was documented for one (#91) of 24 sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 93 residents resided in the facility. Findings: Res #91 was admitted to the facility on [DATE] with diagnoses which included dementia, chronic pain syndrome, open wound to right lower leg, history of falling, and protein calorie malnutrition. There was no documented code status for the resident. On 08/31/23 at 12:04 p.m., LPN #1 was asked how staff determined what was a residents' code status. They stated they would look the code status up in the computer. They were asked what was Res #91's code status. LPN #1 stated Res #91 did not have a code status documented in the EHR. They stated there was no physician order.

Based on observation, record review, and interview, the facility failed to administer oxygen therapy according to physician orders for one (#192) of two sampled residents reviewed for respiratory therapy. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 93 residents resided in the facility. Findings: Res #192 admitted to the facility on [DATE] with diagnoses which include pleural effusion, emphysema, and shortness of breath. A physician order, dated 08/28/23, documented to administer oxygen at 3 liters per minute via mask. On 08/30/23 at 10:19 a.m., the resident was observed in bed wearing a nasal cannula. The oxygen concentrator was set at 3.5 liters. On 08/31/23 at 10:04 a.m., the resident was observed in bed wearing a nasal cannula. The oxygen concentrator was observed with the top of the floating ball touching the line indicating 4 liters. On 08/31/23 at 10:11 a.m., LPN #4 was asked to observe the oxygen concentrator. They stated it was set at 4 liters. The LPN was asked to review the resident's physician orders and stated the resident was supposed to receive 3 liters per minute via mask.

Based on record review and interview, the facility failed to ensure physician orders were followed for the treatment of hypoglycemia and failed to ensure facility policy was followed for a glucometer reading below 70 for one (#1) of one resident whose medical record was reviewed. The DON identified 20 residents who were diabetic. Findings: A Notification of a Change in a Resident's Condition policy, dated 04/28/21, documented the attending physician will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations when there is a glucometer reading below 70 or above 200 unless specific parameters given by physician for reporting. The policy documented the physician was to be notified if a resident had a significant change of condition or unstable vital signs. Res #1 had diagnoses which included type II diabetes mellitus with diabetic chronic kidney disease. A care plan, dated 06/22/22, documented the resident had a diagnosis of diabetes mellitus which placed them at risk for hypoglycemic episodes. The care plan documented an intervention to administer diabetic medications as ordered and to monitor and document for side effects and effectiveness. A physician order, dated 07/21/22, documented to administer Glucagon solution 1 mg subcutaneous injection every 2 hours as needed for a FSBS less than 70. A care plan, dated 09/20/22, documented the resident had hypoglycemia related to the disease process with an intervention to monitor/document/report to the physician signs and/or symptoms of hypoglycemia such as sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait. A nurse note, dated 09/22/22 at 7:35 a.m., documented a FSBS was checked and noted at 35. The note documented the resident was taken to the dining room and administered glucose gel. There was no documentation in the nurse's notes the physician was notified of a FSBS below 70. There was no documentation of a physician order in the medical record to administer oral glucose gel. There was no documentation in the medical record of Glucagon subcutaneous injection having been administered after a FSBS of less than 70. A nurse note, dated 09/22/22 at 8:10 a.m., documented a FSBS was re-checked and noted at 31. The note documented the resident remained leaning to the left side of the wheelchair while staff feeding resident while food continued to run out of mouth. The note documented 30cc of glucose gel administered. There was no documentation in the nurse's notes the physician was notified of a FSBS below 70. There was no documentation of a physician order in the medical record to administer oral glucose gel. There was no documentation in the medical record of Glucagon subcutaneous injection having been administered after a FSBS of less than 70. A nurse noted, dated 09/22/22 at 8:20 a.m., documented the staff continued trying to feed the resident. The resident started dry heaving and staff took the resident out of the dining area. The resident vomited on self in front of nurses' station. The note documented the resident was leaning more to the left side with lips purple in color with oxygen in place. There was no documentation the physician was notified of the resident's condition. A nurse note, dated 09/22/22 at 8:25 a.m., documented the resident was transferred back to bed absent of respiration. No pulse could be obtained and the resident was absent of vital signs. The note documented hospice was notified of the resident's condition. There was no documentation of the physician having been notified of the resident's condition until 09/22/22 at 8:48 a.m. On 04/13/23 at 1:05 p.m., the DON stated the facility does not have a hypoglycemic protocol. She stated the nurses are to follow the Notification of a Change in a Resident's Condition policy if a resident experienced hypoglycemia and did not have specific physician orders to follow. At 1:30 p.m., the DON stated the nurse should have administered Glucagon by subcutaneous injection to the resident after a FSBS of 35 was obtained. She stated the nurse should have notified the physician and EMS of the resident's condition immediately. At 2:52 p.m., the DON stated the nurse did not handle the situation appropriately. She stated the correct medication should have been administered and the policy to notify the physician of a significant change should have been followed. On 04/13/23 at 3:10 p.m., the Administrator stated the nurse did not follow physician orders and administer the correct medication but should have. She stated the nurse did not notify the physician of the resident's change of condition according to policy. She stated the nurse was terminated due to not following physician orders and facility policy related to hypoglycemia.

Based on record review and interview, the facility failed to ensure the physician was notified of a low blood sugar for one (#1) of three residents whose medical records were reviewed. The DON identified 20 residents who were diabetic. Findings: A Notification of a Change in a Resident's Condition policy, dated 04/28/21, documented the attending physician will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations when there is a glucometer reading below 70 or above 200 unless specific parameters given by physician for reporting. Res #1 had diagnoses which included type II diabetes mellitus with diabetic chronic kidney disease. A care plan, dated 09/20/22, documented the resident had hypoglycemia related to the disease process with an intervention to monitor/document/report to the physician signs and/or symptoms of hypoglycemia such as sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait. A nurse note, dated 09/22/22 at 7:35 a.m., documented a FSBS was checked and noted at 35. The note documented the resident was taken to the dining room and administered glucose gel. There was no documentation in the nurse's notes the physician was notified of a FSBS below 70. A nurse note, dated 09/22/22 at 8:10 a.m., documented a FSBS was re-checked and noted at 31. The note documented the resident remained leaning to the left side of the wheelchair with staff feeding resident while food continued to run out of mouth. The note documented 30cc of glucose gel administered. There was no documentation in the nurse's notes the physician was notified of a FSBS below 70. A nurse noted, dated 09/22/22 at 8:20 a.m., documented the staff continued trying to feed the resident. The resident started dry heaving and staff took the resident out of the dining area. The resident vomited on self in front of nurses' station. The note documented the resident was leaning more to the left side with lips purple in color with oxygen in place. There was no documentation the physician was notified of the resident's condition. On 04/13/23 at 2:52 p.m., the DON stated the nurse should have called the physician after the first FSBS reading of 35. She stated the physician and EMS should have been called after the second FSBS reading of 31 because the result was lower than the first reading and the resident's condition had declined. She stated policy was not followed but should have been. On 04/13/23 at 3:11 p.m., the Administrator stated the nurse did not notify the physician but should have according to policy. She stated the nurse was terminated due to not following facility policy and standards of practice.

Based on record review and interview, the facility failed to administer medication as ordered for one (#1) of three residents whose medical records were reviewed. The Resident Census and Conditions of Resident report documented 86 residents resided in the facility. Findings: Res #1 had diagnoses which included type II diabetes mellitus with diabetic chronic kidney disease. A care plan, dated 06/22/22, documented the resident had a diagnosis of diabetes mellitus which placed them at risk for hypoglycemic episodes. The care plan documented an intervention to administer diabetic medications as ordered and to monitor and document for side effects and effectiveness. A physician order, dated 07/21/22, documented to administer Glucagon solution 1 mg subcutaneous injection every 2 hours as needed for a FSBS less than 70. A nurse note, dated 09/22/22 at 7:35 a.m., documented a FSBS was checked and noted at 35. The note documented the resident was taken to the dining room and administered glucose gel orally. There was no documentation of a physician order in the medical record to administer oral glucose gel. There was no documentation in the medical record of Glucagon subcutaneous injection having been administered after a FSBS of less than 70. A nurse note, dated 09/22/22 at 8:10 a.m., documented a FSBS was re-checked and noted at 31. The note documented the resident remained leaning to the left side of the wheelchair while staff feeding resident while food continued to run out of mouth. The note documented 30cc of glucose gel administered orally. There was no documentation of a physician order in the medical record to administer oral glucose gel. There was no documentation in the medical record of Glucagon subcutaneous injection having been administered after a FSBS of less than 70. On 04/13/23 at 1:27 p.m., the DON stated every diabetic resident should have the specific hypoglycemic medication that had been ordered by the physician available for use at any time. She stated an additional supply of these types of medications are kept in the facility's emergency kit and are available at all times in cases of hypoglycemic episodes. On 04/13/23 at 2:53 p.m., the DON stated the resident did not have a physician order to administer glucose gel orally. She stated the nurse should have administered Glucagon by subcutaneous injection and re-checked the FSBS within 15 minutes. On 04/13/23 at 3:10 p.m., the Administrator stated the nurse did not follow physician orders and administer the correct medication but should have. She stated the nurse was terminated due to not following physician orders for a resident's care.

Based on observation, interview, and record review, the facility failed to assess, notify the physician, and provide treatment after pressure ulcers were observed for one (#3) of three residents reviewed for pressure ulcers. Res #3 was admitted with two stage II pressure ulcers on 01/11/22 at 12:30 a.m. Two days and 21 hours later the pressure ulcers were assessed as two unstageable ulcers and the physician was notified for treatment orders. Three days and 20 hours after admit the pressure ulcers were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Census and Conditions of Residents report documented two residents had pressure ulcers who resided in the facility. Findings: 1. Resident (Res) #3 was admitted to the the facility on 01/11/22 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note, dated 01/11/22 at 12:30 a.m., read in part, .Noted 2 stage 2 to right buttock and sacrum area with dressing over the top of areas . The base-line care plan, dated 01/11/22, documented the resident had current skin integrity issues to the left knee. The care plan did not document the resident had any pressure ulcers. An admission assessment, dated 01/18/22, documented the resident was moderately impaired with cognition and required limited to extensive assistance with ADLs. The assessment documented the resident had an unstageable pressure ulcer. The resident's comprehensive care plan did not document the resident had any pressure ulcers or was at risk for pressure ulcers. A nurse note, dated 01/13/22 at 9:12 p.m., read in part, .[named omitted] NP was notified of wounds to sacrum and right buttocks, wound to the sacrum is 3.2 x 3.0 x 2.0, 90% slough, 10% pink granulation noted to wound bed, wound edges are attached to wound bed, wound to right buttocks is 2.8 x 3.4 x 1.0 with 50% slough and 50% pink granulation, wound edges are attached to wound bed, new treatment orders noted . A physician order, dated 01/14/22 at 3:00 p.m., documented to cleanse with wound cleanser, pat dry, apply [MEDICATION(S)], cover with border dressing at bedtime for stage II ulcer on right buttock and stage II ulcer on sacrum. The TAR for January 2022, documented wound care for the pressure ulcers was started on 01/14/22 at 8:00 p.m. A VOHRA Wound Physicians Initial Wound Evaluation, dated 01/19/22, documented a full thickness pressure ulcer on the sacrum which was unstageable due to necrosis. The evaluation documented the pressure ulcer was 3.0 x 5.0 x not measurable cm. The evaluation documented 40% of thick adherent devitalized necrotic tissue and 60% other viable tissue. The procedure note documented a curette was used to surgically remove 6.0 cm square of devitalized tissue, necrotic muscle, and surrounding fascial fibers at a depth of 0.5 cm. The note documented the pressure ulcer as a stage IV after debridement. A VOHRA Wound Physician Wound Evaluation, dated 01/25/22, documented a sacrum stage IV pressure ulcer measuring 3.0 x 5.0 x not measurable cm with light serous exudate, 20% thick adherent necrotic tissue, 20% slough, and 60% other viable tissue. A VOHRA Wound Physician Wound Evaluation, dated 02/01/22, documented a stage IV pressure wound to sacrum measuring 6.0 x 4.0 x 1.2 cm with moderate sero-sanquinous exudate, 10% thick adherent necrotic tissue, 20% slough, 10% granulation tissue, and 60% other viable tissue. On 02/07/22 at 5:09 p.m., LPN #3 was observed providing wound care to the resident's pressure ulcers. The resident had a stage IV pressure ulcer to his sacrum and and a stage III ulcer on his right buttock. The wounds were in close proximity. On 02/09/22 at 8:30 a.m., the resident's primary physician was interviewed. He stated he had not observed the resident's wounds. He stated he expected the facility to continue with the orders from the hospital until the wound physician evaluated the wounds. He stated if there were no orders from the hospital then he would expect the nurse to call and obtain orders upon admit. On 02/09/22 at 10:23 a.m., RN #1 stated when she admitted a resident she would assess the resident for any skin breakdown or bruising. She stated if the resident had any wounds she would measure them and describe the wounds in the resident's chart. She stated she would then notify the physician and the wound nurse. On 02/09/22/at 10:36 a.m., LPN #2/Wound Nurse stated during the time the resident was admitted she was off from work. She stated she did make rounds with the wound physician. She stated the wound physician clustered the two wounds when measuring and assessing them. On 02/09/22 at 11:35 a.m., LPN #1 stated she admitted the resident and performed a head to toe assessment on the resident. She stated she removed the dressing and saw two stage II pressure ulcers. She was asked how she knew they were stage II ulcers. She stated they had one layer of skin off. She stated she did not measure them. The LPN stated there were no hospital orders for the ulcers and she did not call the physician to obtain orders. She stated she usually would call the physician to get orders and did not know why she did not at that time.

On 03/09/17 at 4:20 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to provide supervision and/or assistance devices to prevent accidents for resident #2. The facility failed to: a) Identify the appropriate transfer device (lift); b) Provide appropriate transfer assistance; c) Complete a head to toe assessment after a fall; and d) Assess, monitor, and intervene in a timely manner for resident #2. A nurse's note for resident #2 documented, Received call from hospital (name deleted) ER, resident has a midline fracture to left femur and will be transferred to another hospital . On 03/09/17 at 4:45 p.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide supervision and/or appropriate transfer assistance to prevent accidents for residents. On 03/09/17 at 4:54 p.m., the administrator (ADM), the director of nursing (DON), and the regional nurse were informed of the IJ situation which constituted substandard quality of care. The ADM, DON, and the regional nurse verbalized understanding. On 03/09/17 at 6:10 p.m., the ADM provided a plan of removal for the immediate jeopardy. The plan of removal was accepted and documented the following: Plan of Removal Immediate Jeopardy All residents who use lifts will be considered at risk for alleged deficient practice these residents, will be assessed for appropriateness of lift devices by therapy. Plan of care will be updated to reflect transfer device. All nursing staff will be in-serviced on safe transfers and lift use. Any staff not available to receive in-service will be removed from schedule and not be allowed to work until education completed. Director of Nursing or Designee will monitor the implementation of the plan and if need to make changes. Random audits of lift transfers to be done daily for 4 weeks, then if compliance noted, then random audits done weekly for 90 days, until substantial compliance noted. The quality assurance committee will review IDT (interdisciplinary team) findings for a period of 3 months then quarterly for 9 months to ensure continued compliance with state and federal regulations. On 03/10/17, the survey team interviewed staff to verify their knowledge related to mechanical lift transfer procedures. The staff verbalized understanding of the facility's policy in relation to the mechanical lift procedures. On 03/10/17 at 12:15 p.m., the facility was informed the IJ was removed, effective 03/09/17 at 11:59 p.m., when all components of the plan of removal had been implemented. The deficiency remained at actual harm level at a pattern. Based on observation, record review, and interview, it was determined the facility failed to ensure two (#2 and #3) of four residents reviewed received adequate supervision and assistance with mechanical devices for transfers to prevent accidents. The facility failed to: a. Identify the appropriate transfer assistance device, failed to complete a head to toe assessment after a fall, and failed to assess, monitor, and intervene in a timely manner for resident #2. A nurse's note for resident #2 documented, Received call from hospital (name deleted) ER, resident has a midline fracture to left femur and will be transferred to another hospital . b. Ensure a mechanical lift transfer was conducted safely for resident #3. The DON reported 10 of 61 residents utilized a mechanical lift for transfers. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A revised care plan, dated 04/30/16, documented the resident had an ADL self care performance deficit related to limited mobility, impaired balance, contracture to her right hand, and right sided paralysis, as a focus area. One intervention listed was for the staff to transfer the resident utilizing a Hoyer lift with two staff members assisting. Another intervention listed was for the staff to transfer the resident utilizing a sit to stand lift with two staff member assistance. A revised care plan, dated 06/21/16, documented the resident had impaired mobility related to impaired ROM and a contractured right hand. A quarterly assessment, dated 09/18/16, documented the resident was cognitively intact, required extensive assistance of two or more staff members for bed mobility, transfer, dressing, and hygiene. The assessment documented the resident had impairment on one side of her upper extremities and impairment on both sides of her lower extremities. The assessment documented the resident was frequently incontinent of bowel and bladder. A physical therapy plan of care (Evaluation Only) form, dated 10/25/16, documented, .Reason For Referral: Pt (patient) referred to PT (physical therapy) services to assess ability to use sit to stand lift .Therapy Necessity: Pt (patient) was assessed and noted to be unable to properly utilize the sit to stand lift secondary decreased UE (upper extremity) ROM (range of motion) with pain issues . A quarterly assessment, dated 12/19/16, documented the resident was cognitively intact, required total assistance of two or more staff members for transfers, total assistance of one staff member for bed mobility, dressing, bathing, and hygiene. The assessment documented the resident had impairment on one side of her upper extremities and impairment on both sides of her lower extremities. The assessment documented the resident was always incontinent of bowel and bladder. A revised care plan, dated 02/24/17, documented the resident was at risk for falls related to unaware of safety needs, paralysis, poor communication/comprehension, and incontinence. The care plan documented the resident required a sit to stand mechanical lift for all transfers. An intervention listed was for the staff to utilize a Hoyer lift with two staff members for transfers. A nurse's note, dated 02/24/17 at 18:30 (6:30 p.m.), documented, LATE ENTRY Note Text: Clarification: Resident being transferred with x2 CNA using sit to stand. Resident had completed use of BSC (bedside commode) and CNA had pulled pants up and was lowering her to W/C. CNA's reported that resident was agitated. Resident was holding on to bar of sit to stand while lowering to W/C and let go of bar. Resident then became fearful as legs were giving out. Gait belt was applied to resident as CNA (name deleted) summoned nurse to room while CNA (name deleted) stayed with resident. CNA (name deleted) lowered device to assist resident to floor. On arrival to room, nurse noted res (resident) standing on her knees with sling across back, and under arms, with resident holding onto top of device. CNA (name deleted) lowered her to floor. Resident was then sitting on knees on sit to stand device. Assisted to semi standing on knees position to allow release of sling and resident assisted to sitting position on buttocks with legs outstretched. Resident assisted with 5 staff, including this nurse 3 CNA's and CMA, assist with use of gait belt to standing position and placed in w/c. Res (resident) c/o (complained of) pain, decreased ROM (range of motion) to lateral left knee and was rubbing it. Assessment completed as allowed with limited cooperation from resident as she was tearful and agitated and kept pushing my hand away. Reassured and redirected prn (as needed) and was able to effectively calm resident. Resident wearing pants and refused to take them off and was unable to get leg of pants up completely over top of knee to view thigh. Palpation of hip, thigh, knee, ankle with no crepitus, tenderness, swelling bruising, or pain noted or reported at this time. CNA's remain in room. Resident had rec'd (received) prn medication for pain prior to occurrence at 1800 (6:00 p.m.) per CMA. Resident denies further pain at present. Ice pack placed to Left knee with towel as barrier. Resident in W/C with call light in reach. PCP (primary care provider) notified at 1840 (6:40 p.m.). Advised PCP of Res c/o pain to lateral left knee with Decreased ROM and slight edema noted. Assert if wants to obtain Xray of site. PCP declined X Ray at this time. V/O (verbal order) obtained for ice pack to site. Cont (continue) to monitor. A nurse's note, dated 02/24/17 at 19:30 (7:30 p.m.), documented, Resident resting with eyes closed. Resp (respirations) E/U (even and unlabored). Skin W/D (warm and dry). Took PM meds for CMA without difficulty. Voices no complaints. A nurse's note, dated 02/24/17 at 22:20 (10:20 p.m.), documented, CNA to room to answer call light. Resident remains up in W/C and states she is ready for bed. CNA states 'she won't let us do anything. Can you come look at her' On arrival to room, I spoke with resident and she c/o pain with movement to Left leg. Requested to get add'l (additional) CNA's to help transfer resident to bed. 4 CNA's in room plus this nurse. Mechanical lift sling placed behind resident and positioned under legs as tolerated and secured to mech lift with 3 staff securing mech lift sling around resident and guiding resident to bed. Resident grimacing and yelling out during transfer. Once in bed we Removed pants and noted left thigh firm, very tender to palpation, warm to touch. No open areas or bruises noted. PCP notified and order obtained to transport to ER for Eval. (evaluation) EMS notified at 2250 (10:50 p.m.) . A compliance interview written statement which was attached to the OSDH incident report, dated 02/24/17, documented CNA #7's statement: Mrs. (name deleted) needed to use the restroom and got adigitated (sic) because I had to finish with trays being picked up. CNA (name deleted) and I took the sit to stand in to help her use the potty. We were lifting to put her back in her wheelchair and she was still adgitated (sic) and started to slip out of the harness. We lowered it as fast as we could and got the harness off, lowered her to the floor. CNA (name deleted) went and got help. (Three other staff members names deleted) came and helped us get her situated and back in her chair. Got her some ice for her knee. She said was hurting. A compliance interview written statement which was attached to the OSDH incident report, dated 02/24/17, documented CNA #8's statement: CNA (name deleted) and myself were using the sit-to-stand to take the resident from the commode to her wheelchair. As we were trying to pull up her pants, she started slipping. CNA (name deleted) lowered the sit-to-stand a little bit so we could pull them up then the (resident' name deleted) started slipping more. I tried pulling her up by her pants and the gait belt but she was still slipping. I ran to get the nurse then came back and we lowered her to the ground. She did not fall. All three CNA's the CMA and the nurse all picked her back up. A nurse's note, dated 02/25/17 at 12:30 a.m., documented, Received call from hospital (name deleted) ER, resident has a midline fracture to left femur and will be transferred to another hospital . On 03/09/17 at 10:10 a.m., the DON reported the resident had transferred to another facility for rehabilitation. On 03/09/17 at 11:10 a.m., the regional nurse was asked for their policy for utilizing a sit to stand lift. The regional nurse reported they had no specific policy regarding the sit to stand lift. The regional nurse was asked how the staff knew how to use the sit to stand lift. The regional nurse stated, We provide routine education. On 03/09/17 at 2:35 p.m., CNA #6 was asked if she had ever taken care of the resident. The CNA stated, Yes. The CNA was then asked how the resident was to be transferred. The CNA reported with a sit to stand lift and two staff members present. The CNA was asked if the resident was able to bear weight. The CNA stated, No, she wasn't able to stand on her own. The CNA was then asked if the resident was able to hold onto the bar of the sit to stand lift with both hands. The CNA stated, She couldn't with her left hand. On 03/09/17 at 2:45 p.m., CNA #4 was asked if she had ever taken care of the resident. The CNA stated, Yes. The CNA was then asked how the resident was to be transferred. The CNA stated, Either sit to stand or Hoyer with two staff. The CNA was asked if the resident was able to bear weight. The CNA stated, No, she would say she could but she couldn't. The CNA was then asked if the resident could hold onto the bar of the sit to stand lift with both hands. The CNA reported the resident could not hold on with one hand. The CNA was unsure which hand was contractured. On 03/09/17 at 2:50 p.m., LPN #1 was asked if she had ever taken care of the resident. The LPN reported she had taken care of the resident. The LPN was asked if the resident was able to bear weight. The LPN reported she was unsure. The LPN was then asked if the resident could use both hands to hold onto the bar of the sit to stand lift. The LPN reported one side was limited but was unsure which side. On 03/09/17 at 3:03 p.m., the DON was asked how the resident was to be transferred. The DON stated, Using sit to stand. The DON was asked if the resident had been assessed by physical therapy to use a sit to stand lift. The DON reported she was unsure. The DON was asked if the resident could bear weight. The DON stated, I don't know. The DON was then shown the resident's last assessment and asked if the sit to stand lift was appropriate for the resident. The DON stated, Probably not. The DON was shown the nurse's note, dated 02/24/17 at 6:30 p.m The DON was asked if she thought the resident should have been assessed more thoroughly before having her stand or be moved after her fall. The DON stated, Yes. The DON was asked when the staff had assessed the resident with her complaint of pain, should the resident have bore weight after the fall. The DON stated, No. The DON was asked if there had been an in-service regarding the use of the sit to stand lift. The DON stated, We did mechanical lift but not specific sit to stand. The DON was asked if an in-service had been completed regarding assessing a resident prior to moving them after a fall. The DON stated, No. On 03/09/17 at 3:44 p.m., the ADM was asked who determined which residents were appropriate for the use of a sit to stand lift. The ADM reported the facility had a team which included nursing and therapy. On 03/09/17 at 3:55 p.m., the DON was shown the nurses' notes and asked if the resident should have been re-assessed by a nurse between 7:30 p.m. and 10:20 p.m. after the fall. The DON stated, Yes, she should have. On 03/09/17 at 4:10 p.m., the COTA reported PT would evaluate residents prior to the use of a sit to stand lift. The COTA was asked where the evaluation would be located. The COTA reported the report would be placed in a pink binder for the nursing staff to review. 2. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/23/16, documented the resident was cognitively intact with minimal depression. The assessment documented the resident required one to two persons total assistance with all ADLs. The assessment documented the resident had range of motion impairment to both his upper and lower extremities. The assessment documented the resident was at risk for falls. A care plan, dated 01/04/17, documented the resident was at risk for falls related to paralysis, quadriplegia, and muscular wasting. The goal documented was for the resident to be free of falls through the review date. The care plan documented the resident had an ADL self care performance deficit related to quadriplegia, limited mobility, and paralysis. An intervention listed was for total assistance from staff to transfer the resident in a mechanical lift. A nurse's note, dated 01/31/17 at 12:03 p.m., documented, Resident reports on 3 to 11 shift on 1-30-2017, he was up in the hoyer lift and almost fell out of the hoyer lift while being put to bed. He hit his legs on the side of the bed but did not actually fall out. They regained balance and was able to place him in bed. Head to toe assessment completed with no open areas, no discolorations, and no complaints of pain . An incident report, dated 01/31/17, documented an entry on 02/01/17, .IDT (interdisciplinary team) Team Note: Wheels of lift will be cleaned weekly, per cleaning schedule, to ensure proper mobility . A facility in-service was conducted on the use of the Hoyer lifts on 02/10/17. An inservice training report, dated 03/07/17, documented an in-service was conducted on the policy & procedure of using a mechanical lift. On 03/09/17 at 10:15 a.m., the resident was observed to be transferred from his bed to a shower chair by CNAs #1 and #2. The CNAs were observed to position the Hoyer lift sling under the resident while he was in bed. CNA #2 then raised the sling via the lift to transfer the resident toward the shower chair. CNA #1 moved the shower chair away to accommodate the lift movement. The CNA was observed to not apply the wheel brake on the shower chair after the chair was moved. CNA #1 placed one of her feet behind one back wheel of the shower chair. The CNA then tilted the shower chair backward so that both front wheels of the shower chair were off the floor. The CNA had the top back bar of the shower chair against her upper torso with the chair tilted back. The surveyor commented twice to the CNAs the front wheels of the shower chair were off the floor. CNA #1 stated, I tilt the chair so he can sit up better. The CNA was observed to hold one hand on the top bar of the shower chair and one hand to guide the sling. CNA #2 lowered the resident into the tilted shower chair while CNA #1 guided the resident in the sling apparatus. After the transfer and while the CNAs were out of the room, the resident was asked if he felt safe during the transfer and he reported yes. The resident was asked if the CNAs usually tilted the shower chair backward as observed that day. The resident reported yes. On 03/09/17 at 1:35 p.m., CNA #3 was interviewed and asked how a shower chair was to be positioned when transferring a resident from bed with the Hoyer lift. The CNA reported the legs of the lift were to be open and the shower chair wheels should be locked with the wheels remaining on the ground. On 03/09/17 at 1:38 p.m., CNA #4 was asked about transferring a resident from bed to the shower chair with the Hoyer lift. The CNA reported the shower chair with the wheels locked should be positioned between the legs of the lift. The CNA was asked if the shower chair was to be tilted back during the transfer. The CNA reported no. On 03/09/17 at 2:25 p.m., the DON was interviewed in regard to transferring a resident from bed to a shower chair with a Hoyer lift. The DON reported the shower chair with the brakes locked should be positioned under a resident's buttocks. The DON was asked if the shower chair should be tilted back to transfer the resident into the chair. The DON reported no. On 03/09/17 at 3:50 p.m., CNA #5 was asked about transferring a resident with a Hoyer lift from the bed to a shower chair. The CNA reported he would lock the brakes of the chair and hold the lift sling to lower a resident. The CNA reported the shower chair should not be tilted to transfer a resident. On 03/09/17 at 4:00 p.m., the resident was asked could he tell the surveyor what had happened about 5-6 weeks ago when he almost had fallen from the Hoyer lift while being placed in bed. The resident reported the legs of the lift closed and the lift tilted. The resident reported the lift lost balance and he reported the staff were in a hurry at the time of the transfer. The resident reported he was over the bed when the incident occurred. The resident reported he thought the staff put the particular lift away somewhere. The resident reported the lifts were since working properly. The resident reported he would make sure an experienced staff member was working with a new staff member using the Hoyer lift for his transfers.

§ 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. §483.25(l) [MEDICAL TREATMENT]. The facility must ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Based on record review and interview, it was determined the facility failed to provide care and services to maintain the highest well being for one (#2) of four residents reviewed for well-being. The facility failed to identify appropriate transfer assistance; failed to complete a head to toe assessment after a fall; and failed to assess, monitor, and intervene in a timely manner for resident #2. A nurse's note documented, Received call from hospital (name deleted) ER, resident has a midline fracture to left femur and will be transferred to another hospital . The ADM reported 61 residents lived in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A revised care plan, dated 04/30/16, documented the resident had an ADL self care performance deficit related to limited mobility, impaired balance, contracture to her right hand, and right sided paralysis, as a focus area. One intervention listed was for the staff to transfer the resident utilizing a Hoyer lift with two staff members assisting. Another intervention listed was for the staff to transfer the resident utilizing a sit to stand lift with two staff member assistance. A revised care plan, dated 06/21/16, documented the resident had impaired mobility related to impaired ROM and had a contractured right hand. A quarterly assessment, dated 09/18/16, documented the resident was cognitively intact, required extensive assistance of two or more staff members for bed mobility, transfer, dressing, and hygiene. The assessment documented the resident had impairment on one side of upper extremities and impairment on both sides of lower extremities. The assessment documented the resident was frequently incontinent of bowel and bladder. A physical therapy plan of care (Evaluation Only) form, dated 10/25/16, documented, .Reason For Referral: Pt (patient) referred to PT (physical therapy) services to assess ability to use sit to stand lift .Therapy Necessity: Pt (patient) was assessed and noted to be unable to properly utilize the sit to stand lift secondary decreased UE (upper extremity) ROM (range of motion) with pain issues . A quarterly assessment, dated 12/19/16, documented the resident was cognitively intact, required total assistance of two or more staff members for transfers, total assistance of one staff member for bed mobility, dressing, bathing, and hygiene. The assessment documented the resident had impairment on one side of upper extremities and impairment on both sides of lower extremities. The assessment documented the resident was always incontinent of bowel and bladder. A revised care plan, dated 02/24/17, documented the resident was at risk for falls related to unaware of safety needs, paralysis, poor communication/comprehension, and incontinence. The care plan documented the resident required a sit to stand mechanical lift for all transfers. An intervention listed was for the staff to utilize a Hoyer lift with two staff members for transfers. A nurse's note, dated 02/24/17 at 18:30 (6:30 p.m.), documented, LATE ENTRY Note Text: Clarification: Resident being transferred with x2 CNA using sit to stand. Resident had completed use of BSC (bedside commode) and CNA had pulled pants up and was lowering her to W/C. CNA's reported that resident was agitated. Resident was holding on to bar of sit to stand while lowering to W/C and let go of bar. Resident then became fearful as legs were giving out. Gait belt was applied to resident as CNA (name deleted) summoned nurse to room while CNA (name deleted) stayed with resident. CNA (name deleted) lowered device to assist resident to floor. On arrival to room, nurse noted res (resident) standing on her knees with sling across back, and under arms, with resident holding onto top of device. CNA (name deleted) lowered her to floor. Resident was then sitting on knees on sit to stand device. Assisted to semi standing on knees position to allow release of sling and resident assisted to sitting position on buttocks with legs outstretched. Resident assisted with 5 staff, including this nurse 3 CNA's and CMA, assist with use of gait belt to standing position and placed in w/c. Res (resident) c/o (complained of) pain, decreased ROM (range of motion) to lateral left knee and was rubbing it. Assessment completed as allowed with limited cooperation from resident as she was tearful and agitated and kept pushing my hand away. Reassured and redirected prn (as needed) and was able to effectively calm resident. Resident wearing pants and refused to take them off and was unable to get leg of pants up completely over top of knee to view thigh. Palpation of hip, thigh, knee, ankle with no crepitus, tenderness, swelling bruising, or pain noted or reported at this time. CNA's remain in room. Resident had rec'd (received) prn medication for pain prior to occurrence at 1800 (6:00 p.m.) per CMA. Resident denies further pain at present. Ice pack placed to Left knee with towel as barrier. Resident in W/C with call light in reach. PCP (primary care provider) notified at 1840 (6:40 p.m.). Advised PCP of Res c/o pain to lateral left knee with Decreased ROM and slight [MEDICAL CONDITION] noted. Assert if wants to obtain Xray of site. PCP declined X Ray at this time. V/O (verbal order) obtained for ice pack to site. Cont (continue) to monitor. A nurse's note, dated 02/24/17 at 19:30 (7:30 p.m.), documented, Resident resting with eyes closed. Resp (respirations) E/U (even and unlabored). Skin W/D (warm and dry). Took PM meds for CMA without difficulty. Voices no complaints. A nurse's note, dated 02/24/17 at 22:20 (10:20 p.m.), documented, CNA to room to answer call light. Resident remains up in W/C and states she is ready for bed. CNA states 'she won't let us do anything. Can you come look at her' On arrival to room, I spoke with resident and she c/o pain with movement to Left leg. Requested to get add'l (additional) CNA's to help transfer resident to bed. 4 CNA's in room plus this nurse. Mechanical lift sling placed behind resident and positioned under legs as tolerated and secured to mech lift with 3 staff securing mech lift sling around resident and guiding resident to bed. Resident grimacing and yelling out during transfer. Once in bed we Removed pants and noted left thigh firm, very tender to palpation, warm to touch. No open areas or bruises noted. PCP notified and order obtained to transport to ER for Eval. (evaluation) EMS notified at 2250 (10:50 p.m.) . A compliance interview written statement which was attached to the OSDH incident report, dated 02/24/17, documented CNA #7's statement: Mrs. (name deleted) needed to use the restroom and got adigitated (sic) because I had to finish with trays being picked up. CNA (name deleted) and I took the sit to stand in to help her use the potty. We were lifting to put her back in her wheelchair and she was still adgitated (sic) and started to slip out of the harness. We lowered it as fast as we could and got the harness off, lowered her to the floor. CNA (name deleted) went and got help. (Three other staff members names deleted) came and helped us get her situated and back in her chair. Got her some ice for her knee. She said was hurting. A compliance interview written statement which was attached to the OSDH incident report, dated 02/24/17, documented CNA #8's statement: CNA (name deleted) and myself were using the sit-to-stand to take the resident from the commode to her wheelchair. As we were trying to pull up her pants, she started slipping. CNA (name deleted) lowered the sit-to-stand a little bit so we could pull them up then the (resident' name deleted) started slipping more. I tried pulling her up by her pants and the gait belt but she was still slipping. I ran to get the nurse then came back and we lowered her to the ground. She did not fall. All three CNA's the CMA and the nurse all picked her back up. A nurse's note, dated 02/25/17 at 12:30 a.m., documented, Received call from hospital (name deleted) ER, resident has a midline fracture to left femur and will be transferred to another hospital . On 03/09/17 at 10:10 a.m., the DON reported the resident had transferred to another facility for rehabilitation. On 03/09/17 at 11:10 a.m., the regional nurse was asked for their policy for utilizing a sit to stand lift. The regional nurse reported they had no specific policy regarding the sit to stand lift. The regional nurse was asked how the staff knew how to use the sit to stand lift. The regional nurse stated, We provide routine education. On 03/09/17 at 2:35 p.m., CNA #6 was asked if she had ever taken care of the resident. The CNA stated, Yes. The CNA was then asked how the resident was to be transferred. The CNA reported with a sit to stand lift and two staff members present. The CNA was asked if the resident was able to bear weight. The CNA stated, No, she wasn't able to stand on her own. The CNA was then asked if the resident was able to hold onto the bar of the sit to stand lift with both hands. The CNA stated, She couldn't with her left hand. On 03/09/17 at 2:45 p.m., CNA #4 was asked if she had ever taken care of the resident. The CNA stated, Yes. The CNA was then asked how the resident was to be transferred. The CNA stated, Either sit to stand or Hoyer with two staff. The CNA was asked if the resident was able to bear weight. The CNA stated, No, she would say she could but she couldn't. The CNA was then asked if the resident could hold onto the bar of the sit to stand lift with both hands. The CNA reported the resident could not hold on with one hand. The CNA was unsure which hand was contractured. On 03/09/17 at 2:50 p.m., LPN #1 was asked if she had ever taken care of the resident. The LPN reported she had taken care of the resident. The LPN was asked if the resident was able to bear weight. The LPN reported she was unsure. The LPN was then asked if the resident could use both hands to hold onto the bar of the sit to stand lift. The LPN reported one side was limited but was unsure which side. On 03/09/17 at 3:03 p.m., the DON was asked how the resident was to be transferred. The DON stated, Using sit to stand. The DON was asked if the resident had been assessed by physical therapy to use a sit to stand lift. The DON reported she was unsure. The DON was asked if the resident could bear weight. The DON stated, I don't know. The DON was then shown the resident's last assessment and asked if the sit to stand lift was appropriate for the resident. The DON stated, Probably not. The DON was shown the nurse's note, dated 02/24/17 at 6:30 p.m The DON was asked if she thought the resident should have been assessed more thoroughly before having her stand or be moved after her fall. The DON stated, Yes. The DON was asked when the staff had assessed the resident with her complaint of pain, should the resident have bore weight after the fall. The DON stated, No. The DON was asked if there had been an in-service regarding the use of the sit to stand lift. The DON stated, We did mechanical lift but not specific sit to stand. The DON was asked if an in-service had been completed regarding assessing a resident prior to moving them after a fall. The DON stated, No. On 03/09/17 at 3:44 p.m., the ADM was asked who determined which residents were appropriate for the use of a sit to stand lift. The ADM reported the facility had a team which included nursing and therapy. On 03/09/17 at 3:55 p.m., the DON was shown the nurses' notes and asked if the resident should have been re-assessed by a nurse between 7:30 p.m. and 10:20 p.m. after the fall. The DON stated, Yes, she should have. On 03/09/17 at 4:10 p.m., the COTA reported PT would evaluate residents prior to the use of a sit to stand lift. The COTA was asked where the evaluation would be located. The COTA reported the report would be placed in a pink binder for the nursing staff to review.

Based on record review, observation and staff interviews, it was determined the facility failed to: a) Assess, monitor and treat shoulder pain for one (#5) of one sampled resident who experienced a torn rotator cuff. This resulted in harm. This had the potential to affect all 71 residents who resided in the facility. b) Ensure a urinary analysis report, indicating a urinary tract infection, was followed up on with the physician, for one (#1) of two sampled residents who had experienced urinary tract infections. This had the potential to affect all 71 residents who resided in the facility. c) Ensure a pain medication was refilled and available for use for one (#1) of six sampled residents who required pain medications. This had the potential to affect 68 residents, identified by the DON, who required pain medications. d) Ensure physician's orders [REDACTED].#1) of one sampled resident, who had physician's orders [REDACTED]. This had the potential to affect all 71 residents who had physician's orders [REDACTED]. Findings: 1. Resident #5 had been admitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. A care plan, revised on 12/17/13, documented the following: "Focus (Resident's name deleted) has a potential for pain R/t [MEDICAL CONDITION], muscular wasting. Interventions Administer...medication as ordered. Assist to reposition for comfort. Encourage...to communicate presence of pain as pain may keep her awake at night or find it difficult to go to sleep. Monitor...pain on scale of 0-10. Pain assessments per protocol..." A nurse's note dated 04/30/14 at 5:30 a.m., documented, "[MEDICATION NAME] 10/325 mg (one) given po for c/o feet/leg/shoulder pain. Rated pain 9/10..." A nurse's note, dated 05/02/14 at 2:47 p.m., documented, "PCP in facility no new orders @ this time, will cont to monitor." A Doctor's orders and Progress Notes, dated 05/05/14, documented, "Order rec'd per Dr. (Name deleted) for: Muscle Rub =May apply to Rt shoulder PRN=muscle soreness." The nurses' notes documented the following: "5/6/14 0515 (5:15 a.m.) [MEDICATION NAME] 10/325 mg (one) given PO per request for c/o feet/legs/R shoulder pain, rates pain 9/10..." "5/6/14 1430 (2:30 p.m.) Resident given [MEDICATION NAME] 10 mg by CMA for pain rated 10/10..." "5/7/14 05:15 (5:15 a.m.) [MEDICATION NAME] 10/325 mg=given PO for C/O pain, 8/10, to Rt shoulder..." "(4:00 pm) Resident C/O Rt shoulder pain and crying. Resident wanting to go to hospital. Phone call to Dr. (Name deleted) @ physician office and reported resident's concern. Phys to call back. RN/DON notified. (4:05 pm) Phone call rec'd from physician c order to Send resident to E/R for Rt shoulder X-Ray...RN/DON notified and informed. Order rec'd & noted. (4:25 pm) Daughter...notified via phone that resident Will go to E/R via ambulance. (4:34 pm)...here and departed facility c resident via stretcher to ...E/R. (7:50 pm) Phone call to (name deleted) E/R regarding resident p call rec'd from daughter that resident had been admitted . Phone call to E/R and was informed that resident was admitted for = (1) LE swelling to L/E [MEDICAL CONDITION], (2) Fx Rt clavicle. Resident to stay in hospital 1-2 days." An X-ray report, dated 05/07/14, documented, "Impression: Features of a severe chronic rotator cuff tear, with severe [MEDICAL CONDITION] changes of the shoulder. There is no evidence of a fracture or dislocation." The nurses' notes, documented the following: "5/08/14 4:15 pm Report rec'd from.... (hospital) Resident due back to facility via ambulance. Dx Rt Rotator cuff tear; F/u c Ortho Surgeon. Resident needs to have an U/S (ultrasound) of LE to R/O [MEDICAL CONDITION]. 435 pm Resident back in N.H. via...EMS ambulance per stretcher and transferred bed..." There was no documentation in the clinical record of the facility staff examining or assessing the condition of the right shoulder before the resident was hospitalized . There was no documentation the muscle rub medication had ever been administered. A quarterly assessment, dated 05/29/14, documented the resident was cognitively intact, required moderate assistance transferring while in bed, extensive assistance with transfer from the bed and did not ambulate. The resident required minimal assistance with eating. The resident required extensive assistance with hygiene/bathing and was incontinent of bowel and bladder. On 07/03/14 at 11:30 a.m., the treatment cart was examined. There was no muscle rub in the treatment cart. At 11:45 a.m., an unopened tube of the muscle rub was shown to the surveyor. The tube had not been opened. On 07/03/14 at 2:30 p.m., the DON was asked if the resident's shoulder had been examined or assessed before the hospitalization . She reported the resident's pain had been assessed, but not the condition of the resident's right shoulder. At that time, the DON was asked to review the treatment sheets for May and June 2014. She was asked if the muscle rub had been used. She stated, "The medication was not used." 2. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, with a revision date of 12/20/12, documented the resident required an indwelling urinary catheter and was at increased risk for recurrent UTIs. One intervention documented was for the staff to notify the licensed nurse if the resident experienced changes in urine clarity, color, decreased output and odor. A quarterly assessment, dated 05/28/14, documented the resident was cognitively intact, exhibited mild depression symptoms and had no behaviors. The resident was totally dependent on two or more staff for assistance with bed mobility, transfers, toileting, personal hygiene and bathing. The resident was incontinent of bowel and required an indwelling urinary catheter. A nurse's note, dated 06/25/14 at 1:15 p.m., documented, "(Laboratory name deleted) was phoned & (received) urine culture results: Multiple organisms isolated. No further testing performed. recollect the urine sample. PCP was phone (sic) & faxed the results. (received) (new order) Obtain UA (with) C & S if indicated on 6-26-14. Family notified." A nurse's note, dated 06/26/14 at 6:00 p.m., documented, "...Waiting for results of UA..." A laboratory report, dated 06/29/14, documented the urine culture identified Escherichia coli, Proteus mirabilis and Group B strep as the isolated organisms. A nurse's note, dated 06/30/14 at 10:00 a.m., documented, "C & S (received). PCP phoned & stated 'fax to my office.' Results were faxed. awaiting response from PCP." A nurse's note, dated 06/30/14 for the 3-11 shift, documented, "Continue to wait for any (new orders) from C & S faxed to PCP..." A nurse's note, dated 07/02/14 for 07/01/14 at 10:30 a.m., documented, "telephone order (received) for tylenol 500 (2)..." There was no documentation the physician was asked about the UA results at that time. On 07/03/14 at 9:30 a.m., the DON was asked if the UA C & S should have been followed-up with the physician. The DON stated, "Yes." 3. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, with a revision date of 12/20/12, documented the resident problem of pain related to immobility and [MEDICAL CONDITION]. One intervention documented for the staff to administer pain medication as ordered. A physician's orders [REDACTED]." The resident's MARs and Controlled Drug Records for June and July 2014 documented the resident received an average of three [MEDICATION NAME] tablets daily. The MAR and Controlled Drug Record documented the resident received [MEDICATION NAME] at 2:00 a.m., 10:00 a.m. and 3:55 p.m. on 06/30/14, leaving the resident one [MEDICATION NAME] tablet. The resident received one [MEDICATION NAME] on 07/01/14, at midnight, which depleted the resident's [MEDICATION NAME] supply. The Controlled Drug Record documented the facility received the refill of the [MEDICATION NAME] on 07/01/14. No time was documented as to when the medication was received. On 07/02/14 at 8:45 a.m., the resident was interviewed regarding the pain medication. He reported he was without pain medication from midnight until 9:00 p.m. on 07/01/14, because they ran out of medication and there was none available. The resident reported the physician had written a refill prescription last week for the [MEDICATION NAME]. At 10:50 a.m., the DON was asked for the narcotic sign records for the resident's [MEDICATION NAME] and the pharmacy refill request for the medication. At that time, the DON was asked if she was aware the resident had run out of pain medication on 07/01/14. The DON reported she was not aware of the problem. On 07/03/14 at 9:50 a.m., the DON was asked again for the pharmacy refill request for the pain medication order for the surveyor to ascertain if the medication had been ordered in a timely manner. The refill request documentation was not provided by the end of the survey. At 10:30 a.m., the DON was asked if the resident's medication should have been reordered before he ran out of pain medication. The DON reported the medication should have been available for the resident. 4. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. WITHOUT EXCUSE!!-Day Shift Everyday." A care plan entry, dated 04/11/14, written on the back page of the care plans, documented, "N.O. (new order) =up daily (without) Excuse!!" On 07/02/14 at 8:45 a.m., the resident reported he was suppose to be gotten up daily per doctor's orders. The resident reported he was gotten out of bed on shower days only when (CNA's name deleted) worked. The resident reported the CNA was on vacation and he would not be gotten up or showered until the CNA returned next week. The resident reported he would like to get out of bed at least five days of the week. He reported he did not care about getting up on the weekends since there was nothing to do. The resident reported he was only turned about once a shift had not been offered to be gotten up out of bed by the CNAs. On 07/03/14 at 10:00 a.m., the DON was asked about the resident not being gotten out of bed per the physician's orders [REDACTED]. At that time, the DON was informed the resident reported he was not offered assistance to get out of bed.

On 03/18/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene when a resident who was on [MEDICATION NAME] had black tarry stools. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 1:55 p.m., the ADM, DON, corporate ADM and corporate RN were notified of the IJ situation. At 3:35 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal documented the following: "Physician notification/Assessment and Monitoring 1. 100% in-service of licensed nurses on the requirement for physician notification requirements, care and care services policy, notification of physician (CALL when abnormal findings are noted). Fax is only appropriate in non-emergent circumstances when no abnormal findings are noted. In-service will include the requirements for assessment and monitoring and reporting changes to the MD. In-service will be completed at 4 p.m. on 03/18/14. Any nurse that does not attend this in-service will not be allowed on the floor until the in-service is complete. 2. 100% in-service of CNA's will be completed regarding reporting changes in condition to licensed nurse as soon as noted. This in-service will be completed on 03/18/14 at 4 p.m. any aide that does not complete the in-service at this time will not be allowed to work until the in-service is complete. 3. An audit by staff and resident interview will be complete at least three times weekly to ensure compliance with nurse notification of changes from the CNA. 4. The resident had previously been admitted to the hospital for treatment. 5. Complete a 100% audit of current residents documentation (January through current date) to ensure that any changes of condition have been communicated to the doctor. This audit will be completed by 1 pm on 03/19/14. 6. Audit of the 24 hour report will be completed and documentation reviewed three times weekly to ensure continued compliance. 7. Any identified non-compliance will result in one on one in-servicing and progressive disciplinary action. 8. Results of the audits will be presented to the facility QA committee monthly for a period of no less than 90 days for further evaluation, review and changes." On 03/19/14 at 9:00 a.m., a copy of the facility's in-service on the subject of physician notification, change of condition, assessment and monitoring of the patient and CNAs' notifying nurse of changes in condition. A copy of the in-service topics included: "03/18/14 4:00-4:45 LPN's/RN Physician Notification of Changes 1. The doctor must be notified with ANY change in the resident condition of abnormal findings. The notification must be completed at the time the change is noted. Example: Fall, Wound, Abnormal Labs etc. How do we notify the Physician? 1. Fax- this method may only be used when the situation is non-emergent and there are no abnormal findings. (Minor skin tear, lab results received are normal etc.) If you are unsure if you should fax or call, notify your DON for guidance. 2. Call-the doctor must be called when abnormal findings are noted or when the situation is emergent. (New complaint of pain level, abnormal labs, falls with injury etc) ANY CHANGE IN CONDITION MUST BE COMMUNICATED TO THE DOCTOR 1. When completing an assessment vital signs should be completed. The change of condition form is used for documentation and should be complete (sic) filled out. When changes are noted follow up documentation and assessment should be completed to monitor the progress of the condition of the resident. CNA YOU ARE THE FIRST LINE OF DEFENSE! You see the resident more than any other staff. You will be the first to notice small changes and big changes. It is your responsibility to report any and all changes to the nurse! Examples: Walking to the dining room and want a wheelchair, dressing self and now are unable, discolored or stinky urine, not drinking, not eating, skin issue, etc. any change that is not the norm for the resident must be report to the nurse for further evaluation. No matter how small you think the change is, always report." The names on the in-service form were compared to the staffing roster. Staff members from various shifts of the nursing department were interviewed in regard to the in-service. The staff members reported they received information including reporting, assessment, monitoring and intervening for change in condition. The staff answered questions appropriately in regard to the in-service. The IJ was removed on 03/19/14 at 1:00 p.m. The deficiency remained at the level of actual harm that was not immediate jeopardy, at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to: a) Assess and monitor a resident with black tarry stools for one (#2) of one sampled resident who experienced black tarry stools. This had the potential to affect two residents, identified by the DON, who had black tarry stools in the past three months. b) Have FSBS elevated parameters in which to notify the physician for one (#6) of three sampled residents who had FSBS ordered. This had the potential to affect 26 residents, identified by the DON, who had FSBS ordered. c) Follow up on a laboratory analysis with the physician for one (#8) of 10 sampled residents who required laboratory analysis. This had the potential to affect all 75 residents who resided in the facility. d) Have blood pressure parameters in which to notify the physician for three (#3, 7 and #9) of three sampled residents who required blood pressure readings. This had the potential to affect 19 residents, identified by the DON, who required blood pressure readings. e) Assess and monitor a burn for one (#13) of one sampled resident who experienced a burn. This had the potential to affect two residents, identified by the DON, who had a burn in the past three months. Findings: A facility policy, dated 02/05/13, documented, "Care and Services- POLICY: It is the center's policy to provide residents with the necessary care and services to maintain his/her highest level of practicable functioning in an environment that enhances each resident's quality of life in the scope of a long term care center. PROCEDURE: Staff and resident are required to follow the procedure listed below. ...8. The Licensed Nurse or designee documents and notifies the resident's physician and responsible party of: Change in condition, including progress and/or decline in physical or mental function, Resident refusal of care or services and Unusual occurrence." 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. C, HTN, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A care plan, dated 01/27/13, documented the resident required anticoagulant therapy related to [MEDICAL CONDITION] history, as a problem. A goal was for the resident's PT/INR to remain WNL. One intervention listed was for the staff to observe the resident for signs of bleeding such as blood in urine, increased pulse, decreased blood pressure, decreased energy level and abdominal pain. The care plan also documented the resident may have incontinence of bowel related to medications ([MEDICATION NAME]) use, as a problem. A goal was for the resident to have decreased elimination of diarrhea. Interventions listed were for the staff to notify the physician as needed and to record the resident's bowel movement for size and consistency and to report any abnormalities to the licensed nurse. A quarterly assessment, dated 12/20/13, documented the resident was moderately impaired with cognition, required extensive assistance of one person for bathing, limited assistance of one person for dressing and required supervision for transfer, bed mobility, ambulation, eating and hygiene and was always continent of bowel and bladder. The resident received an anticoagulant medication for seven days of the seven day look back period. A computerized physician's orders [REDACTED]. orders had an original start date of 11/05/13. "...PT INR to be drawn every 2 weeks-Evening Shift Every 14 days..." A computerized physician's orders [REDACTED]." A MAR, dated February 2014, documented the [MEDICATION NAME] had been held from 02/06/14 through 02/10/14. A Change Of Condition Communication form, dated 02/09/14 at 1400 (2:00 p.m.), documented, "...Black tarry stool started on 02/07/14..." A nurses note on the back of the form documented, "Received report from resident concerning several black tarry stools. Asked resident about onset of blk stools reports initially started 1-2 days before this date. Res states "I didn't want to worry anyone." ABD flat soft nontender c hyperactive BS x 4 quads." The Change Of Condition Communication form documented, in the area for physician notification, the physician had been notified on 02/09/14 at 1400 (2:00 p.m.). The nurses' notes with the same above date contained no other documentation of the black tarry stools or physician notification. A 24 hour report/change of condition report, dated 02/09/14, documented, "(Resident name deleted)...blk stool..." The nurses' notes, dated 02/09/14, contained no documentation the resident's vital signs had been obtained. A Change Of Condition Communication form, dated 02/10/14, documented on the front of the form, "...Hgb 5.1 Hct 17.6 black tarry stools, started on 02/09/[MEDICATION NAME] held since 02/06..." A nurse's note on the back of the form documented, "Received call from PCP reguarding (sic) residents black tarry stools yesterday. Rec'd order for STAT CBC, PT/INR. Spoke c resi about this order. Obtained from RAC (right antecubital) x 1 stick. Resi tol well, pressure applied. Specimen sent to PCP office. 1040 (10:40 a.m.) Rec'd call from PCP, received order to send resi to ER for Hgb 5.1 & Hct 17.6..." The Change Of Condition Communication form contained no documentation the resident's vital signs had been obtained. The nurses' notes, dated 02/10/14, contained no documentation the resident's vital signs had been obtained. On 02/10/14 at 11:35 a.m., the resident was admitted to (Hospital name deleted) where she was diagnosed with [REDACTED]. At 4:22 p.m. the resident was transferred from (Hospital name deleted) to (Hospital name deleted) for further treatment. An admission note from (hospital name deleted), dated 02/10/14, documented, "CHIEF COMPLAINT: History of GI bleed, tarry stools...The stool guaiac-positive...ASSESSMENT AND PLAN: 1. [MEDICAL CONDITION]. At this time, we will transfuse 2 units of packed RBCs. We will check a CBC in the morning..." On 02/18/14 at 9:25 a.m., LPN # 2 was asked if she had notified the physician on 02/09/14 about the resident's complaint of black tarry stools. The LPN stated, "By fax to the physician's office, that's what he prefers." The LPN then stated, "The resident told me her stool had been that way for a couple of days." The LPN was asked if she thought she should have called the physician instead of faxing him. The LPN nodded her head. At 9:50 a.m., CNA #6 was questioned in regard to the resident having black tarry stools. The CNA reported she had assisted the resident with toileting before she went to the hospital the first time and she had black stools. The CNA reported she had told the charge nurse but could not remember the name of the charge nurse. At 10:30 a.m., CNA #4 was questioned in regard to the resident having black tarry stools. The CNA reported the resident's stools were dark. The CNA reported she had told the charge nurse. On 03/21/14 at 8:45 a.m., the DON was questioned in regard to the lack of assessment and vital signs not being completed for the resident. The DON was asked if the assessment should have included vital signs. The DON stated, "Yes they should have been done on both days." The DON reported, the nurse responsible for the incident had a coaching report completed on 02/14/14, due to the physician not being notified in a timely manner and the lack of assessment. There was no in-service completed at the time of the incident to ensure the staff had been made aware of the facility policy for contacting the physician in a timely manner and for assessing, monitoring and intervening changes of a resident's condition. 2. Resident #8 had been admitted to the facility on [DATE]. The resident had current medical [DIAGNOSES REDACTED]. A care plan revised on 01/02/13, documented the following: "Focus ...has a potential alteration in Nutrition Status R/T short term memory...has a weight fluctuation R/T [MEDICAL CONDITION] history and diuretic use Goals ...will have Safe and comfortable ingestion of fluids and solids over the next review. 06/11/14 ...will be free of pressure sites over the next review. 06/11/14 Interventions Diet as ordered Labs as ordered..." An annual assessment, dated 06/12/13, documented the resident required extensive assistance with transfers, ambulation, dressing and bathing, required moderate assistance with hygiene, required set up help with eating, had no ROM deficits in extremities and was occasionally incontinent of bowel and bladder. A quarterly assessment, dated 02/26/14, documented the resident required extensive assistance with transfers, dressing and bathing, required total assistance with hygiene, required limited assistance with eating, had ROM deficits in upper and lower extremities and was always incontinent of bowel and bladder. A nurse's note documented, "3/6/14 pt wt on 3/3/14-182.6, pt wt today on 3/6/14 was 190.0 PCP (personal care physician) notified via Fax request possible BMP lab drawn awaiting response." The medical record was reviewed. No BMP had been completed. There was no follow-up to the nursing note dated 03/06/14. On 03/20/14 at 4:15 p.m., the DON was notified of the nursing note on 03/06/14, with no follow-up. She reported the nurse should have followed up on the request. 3. Resident #6 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/20/14, documented the resident was severely impaired with cognition with disorganized thinking and exhibited moderately severe depression with behaviors. The resident was totally dependent on staff assistance for bed mobility, transfers, ambulation in a wheelchair, personal hygiene and bathing. The resident was always incontinent of bowel and bladder. A care plan, dated on 02/02/14, documented the resident had diabetes type II, as a problem. A goal for the resident was to have no S/S of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. An intervention was for the staff to obtain blood sugars as ordered. A physician's orders [REDACTED]. Prior to 03/05/14, the physician's orders [REDACTED]. The March 2014 computerized physician's orders [REDACTED]. If unable to feed or the FSBS remained below 60 after feeding or giving [MEDICATION NAME], notify the physician. The physician orders [REDACTED]. There were no high level parameters set or obtained from the physician to direct the resident's care. On 03/19/14 at 2:20 p.m., the DON was asked if she expected the resident to have a upper parameter set for the FSBS which indicated when to notify the physician for care directives. The DON stated, "Yes, should have upper parameters." 4. Resident #9 was admitted on [DATE] with numerous [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/27/13, documented the resident was cognitively intact and demonstrated moderate depression. The resident required extensive assistance of two persons to transfer and dress. The resident required extensive assistance of one person to perform personal hygiene and to bathe. The resident did not ambulate in the room or corridor. The resident required limited assistance of one person to move on and off the unit. A computerized physician's orders [REDACTED]. daily for HTN. The order documented, "...hold if SBP is less than 90." There were no B/P parameters in which staff was to notify the physician, in the resident's medical record. On 03/18/14 at 8:00 a.m., the DON was interviewed regarding blood pressure readings in which the staff was to notify the physician. The DON reported the facility should have B/P parameters and she would contact the physician. 5. Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. A computerized physician's orders [REDACTED]." There were no B/P parameters in which the licensed nurses were to notify the physician, documented in the resident's medical record. An annual assessment, dated 03/05/14, documented the resident was cognitively intact and demonstrated mild depression. The resident did not ambulate and was not transferred during the seven day look back period. The resident required extensive assistance of one person to dress, perform personal hygiene and bathe. The resident was always incontinent of bowel and had an indwelling urinary catheter. A care plan, dated 03/12/14, documented the resident had HTN, as a problem. The goal was for the resident to not complain of headaches, dizziness or fatigue. An intervention listed was for the staff to obtain the resident's B/P as ordered or per facility protocol. At 10:30 a.m., the DON was interviewed regarding the resident not having B/P parameters in which to notify the physician. The DON reported she would contact the physician for B/P parameters. 6. Resident #3 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/08/14, documented the resident had severe cognitive impairment, mild depression and no behaviors. The resident was totally dependent on staff assistance for transfers, dressing, eating, personal hygiene and bathing. The March 2014 computerized physician's orders [REDACTED]. "Losartan Potassium 100 MG...give one tab daily...htn... [MEDICATION NAME]...20 MG Tablet...Everyday..HTN/[MEDICAL CONDITION] [MEDICATION NAME]...5 MG tablet..1 PO daily-hold if B/P <90 systolic...UNSPECIFIED ESSENTIAL HYPERTENSION..." The physician's orders [REDACTED]. On 03/19/14 at 10:00 a.m., the DON was asked if the resident should have blood pressure parameters in which to notify the physician. The DON reported the physician informed her he would set parameters on an individual basis for each resident and had not provided parameters for the resident at this time. The DON reported she would address the issue with the physician. 7. Resident #13 was admitted with [DIAGNOSES REDACTED]. A Change Of Condition Communication form, dated 01/25/14 at 7:40 a.m., documented, "Writer standing @ N.S. (nurses' station). was informed by other res that res 'spilled her coffee' Writer turned around obs. Res. in geri chair (with) coffee cup in hand angled toward self (with) lg. wet spot on shirt. Writer went to res. and lifted clothing off skin & assisted to rm...Res. has 6 x 3 cm light pink area to mid (upper left) breast. (No) blistering... 0800 (8:00 a.m.) Area remains light pink (no) blistering.. 0900 (9:00 a.m.) Assessment unchanged... 1000 (10:00 a.m.) Assessment unchanged (No) pain discomfort. Cool compress applied..." A nurse's note, dated 01/26/14 at 11:30 a.m., documented the resident had a light fading pink area to her left breast. There was no other documentation of assessment or monitoring of the burn area. A Non-Pressure Wound And Skin Condition Documentation Form documented the area on 01/25/14. The next entry, dated 02/12/14, documented, "Resolved." There was no weekly skin assessment of the area. There was no assessment of the burn areas size or appearance for 16 days. A comprehensive assessment, dated 02/06/14, documented the resident had severe cognitive impairment, moderate depression and no behaviors. The resident was totally dependent on staff assistance for bed mobility, locomotion, transfers, dressing and personal hygiene. The resident had range of motion impairment of bilateral upper and lower extremities. On 03/20/14 at 3:00 p.m., the ADON was asked if the burn site should have been monitored. The ADON replied, "Yes."

On 03/18/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician in a timely manner when a resident who was on [MEDICATION NAME] had black tarry stools. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 1:55 p.m., the ADM, DON, corporate ADM and corporate RN were notified of the IJ situation. At 3:35 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal documented the following: "Physician notification/Assessment and Monitoring 1. 100% in-service of licensed nurses on the requirement for physician notification requirements, care and care services policy, notification of physician (CALL when abnormal findings are noted). Fax is only appropriate in non-emergent circumstances when no abnormal findings are noted. In-service will include the requirements for assessment and monitoring and reporting changes to the MD. In-service will be completed at 4 p.m. on 03/18/14. Any nurse that does not attend this in-service will not be allowed on the floor until the in-service is complete. 2. 100% in-service of CNA's will be completed regarding reporting changes in condition to licensed nurse as soon as noted. This in-service will be completed on 03/18/14 at 4 p.m. any aide that does not complete the in-service at this time will not be allowed to work until the in-service is complete. 3. An audit by staff and resident interview will be complete at least three times weekly to ensure compliance with nurse notification of changes from the CNA. 4. The resident had previously been admitted to the hospital for treatment. 5. Complete a 100% audit of current residents documentation (January through current date) to ensure that any changes of condition have been communicated to the doctor. This audit will be completed by 1 pm on 03/19/14. 6. Audit of the 24 hour report will be completed and documentation reviewed three times weekly to ensure continued compliance. 7. Any identified non-compliance will result in one on one in-servicing and progressive disciplinary action. 8. Results of the audits will be presented to the facility QA committee monthly for a period of no less than 90 days for further evaluation, review and changes." On 03/19/14 at 9:00 a.m., a copy of the facility's in-service on the subject of physician notification, change of condition, assessment and monitoring of the patient and CNAs' notifying the nurse of changes in condition was received by the survey team. A copy of the in-service topics included: "03/18/14 4:00-4:45 LPN's/RN Physician Notification of Changes 1. The doctor must be notified with ANY change in the resident condition of abnormal findings. The notification must be completed at the time the change is noted. Example: Fall, Wound, Abnormal Labs etc. How do we notify the Physician? 1. Fax- this method may only be used when the situation is non-emergent and there are no abnormal findings. (Minor skin tear, lab results received are normal etc.) If you are unsure if you should fax or call, notify your DON for guidance. 2. Call-the doctor must be called when abnormal findings are noted or when the situation is emergent. (New complaint of pain level, abnormal labs, falls with injury etc) ANY CHANGE IN CONDITION MUST BE COMMUNICATED TO THE DOCTOR 1. When completing an assessment vital signs should be completed. The change of condition form is used for documentation and should be complete (sic) filled out. When changes are noted follow up documentation and assessment should be completed to monitor the progress of the condition of the resident. CNA YOU ARE THE FIRST LINE OF DEFENSE! You see the resident more than any other staff. You will be the first to notice small changes and big changes. It is your responsibility to report any and all changes to the nurse! Examples: Walking to the dining room and want a wheelchair, dressing self and now are unable, discolored or stinky urine, not drinking, not eating, skin issue, etc. any change that is not the norm for the resident must be report to the nurse for further evaluation. No matter how small you think the change is, always report." The names on the in-service form were compared to the staffing roster. Staff members from various shifts of the nursing department were interviewed in regard to the in-service. The staff members reported they received information including reporting, assessment, monitoring and intervening for change in condition. The staff answered questions appropriately in regard to the in-service. The IJ was removed on 03/19/14 at 1:00 p.m. The deficiency remained at the level of actual harm that was not immediate jeopardy, at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to notify the physician: a) When a resident experienced black tarry stools for one (#2) of one sampled resident who experienced black tarry stools. b) Of a stage one pressure sore for one (#2) of one sampled resident who had a stage one pressure sore. c) Of a stage two pressure ulcer for three (#7, 8 and #17) of four sampled residents who had a stage two pressure ulcer. d) Of an abnormal blood pressure for one (#2) of one sampled resident who had an abnormal blood pressure. This had the potential to affect all 75 residents who resided in the facility. Findings: A facility policy, dated 02/05/13, documented, "Care and Services-POLICY: It is the center's policy to provide residents with the necessary care and services to maintain his/her highest level of practicable functioning in an environment that enhances each resident's quality of life in the scope of a long term care center. PROCEDURE: Staff and resident are required to follow the procedure listed below. ...8. The Licensed Nurse or designee documents and notifies the resident's physician and responsible party of: Change in condition, including progress and/or decline in physical or mental function, Resident refusal of care or services and Unusual occurrence." 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. C, HTN, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A care plan, dated 01/27/13, documented the resident required anticoagulant therapy related to [MEDICAL CONDITION] history, as a problem. A goal was for the resident's PT/INR to remain WNL. One intervention listed was for the staff to observe the resident for signs of bleeding such as blood in urine, increased pulse, decreased blood pressure, decreased energy level and abdominal pain. The care plan also documented the resident may have incontinence of bowel related to medications ([MEDICATION NAME]) use, as a problem. A goal was for the resident to have decreased elimination of diarrhea. Interventions listed were for the staff to notify the physician as needed and to record the resident's bowel movement size and consistency and to report any abnormalities to the licensed nurse. A quarterly assessment, dated 12/20/13, documented the resident was moderately impaired with cognition, required extensive assistance of one person for bathing, limited assistance of one person for dressing and required supervision for transfer, bed mobility, ambulation, eating and hygiene and was always continent of bowel and bladder. The resident received an anticoagulant medication for seven days of the seven day look back period. A computerized physician's order, dated 02/01/14, documented, "[MEDICATION NAME] ([MEDICATION NAME] Sodium) 2 MG tablet by mouth (Oral) -Evening Shift Everyday: give one tablet daily btwn 6p-[MEDICATION NAME] ([MEDICATION NAME] Sodium) 2.5 MG tablet by mouth (Oral) -Evening Shift Everyday: give one tablet daily btwn 6p-9p..." The [MEDICATION NAME] orders had an original start date of 11/05/13. "...PT INR to be drawn every 2 weeks-Evening Shift Every 14 days..." A computerized physician's order, dated 02/06/14, documented, "Hold [MEDICATION NAME] until 4 Recheck pt/inr on that date." A MAR, dated February 2014, documented the [MEDICATION NAME] had been held from 02/06/14 through 02/10/14. A Change Of Condition Communication form, dated 02/09/14 at 1400 (2:00 p.m.), documented, "...Black tarry stool started on 02/07/14..." A nurses note on the back of the form documented, "Received report from resident concerning several black tarry stools. Asked resident about onset of blk stools reports initially started 1-2 days before this date. Res states "I didn't want to worry anyone." ABD flat soft nontender c hyperactive BS x 4 quads." The Change Of Condition Communication form documented, in the area for physician notification, the physician had been notified on 02/09/14 at 1400 (2:00 p.m.). The nurses' notes on the same above date contained no documentation of the black tarry stools or physician notification. A 24 hour report/change of condition report, dated 02/09/14, documented, "(Resident name deleted)...blk stool..." A Change Of Condition Communication form, dated 02/10/14, documented on the front of the form, "...Hgb 5.1 Hct 17.6 black tarry stools, started on 02/09/[MEDICATION NAME] held since 02/06..." A nurse's note on the back of the form documented, "Received call from PCP reguarding (sic) residents black tarry stools yesterday. Rec'd order for STAT CBC, PT/INR. Spoke c resi about this order. Obtained from RAC (right antecubital) x 1 stick. Resi tol well, pressure applied. Specimen sent to PCP office. 1040 (10:40 a.m.) Rec'd call from PCP, received order to send resi to ER for Hgb 5.1 & Hct 17.6..." On 02/10/14 at 11:35 a.m., the resident was admitted to (Hospital name deleted) where she was diagnosed with [REDACTED]." At 4:22 p.m. the resident was transferred from (Hospital name deleted) to (Hospital name deleted) for further treatment. On 02/18/14 at 9:25 a.m., LPN # 2 was asked if she had notified the physician on 02/09/14 about the resident's complaint of black tarry stools. The LPN stated, "By fax to the physicians office, that's what he prefers." The LPN then stated, "The resident told me her stool had been that way for a couple of days." The LPN was asked if she thought she should have called the physician instead of faxing him. The LPN nodded her head. At 9:45 a.m., the ADON was questioned in regard to physician notification. The ADON reported, the physician had a cellphone and a home phone where he could be contacted. If he didn't answer when called, he would call the facility back fairly quickly. The nurse could text the physician, in the event of a change in condition, and he would call back. At 9:50 a.m., CNA #6 was questioned in regard to the resident having black tarry stools. The CNA reported she had assisted the resident before she went to the hospital the first time and she had black stools. The CNA reported she had told the charge nurse but could not remember the name of the charge nurse. At 10:30 a.m., CNA #4 was questioned in regard to the resident having black tarry stools. The CNA reported the resident's stools were dark. The CNA reported she had told the charge nurse. At 11:20 a.m., the DON was questioned in regard to the resident having black tarry stools and the physician not being notified by phone in a timely manner. The DON reported the physician should have been called right away and not faxed. The DON reported, the nurse responsible for the incident had a coaching report completed on 02/14/14, due to the physician not being notified in a timely manner. There was no in-service completed at the time of the incident to ensure the staff had been made aware of the facility policy for contacting the physician in a timely manner for changes in a resident's condition. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. C, HTN, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A care plan, dated 06/12/12, documented the resident had a potential for alterations in skin integrity, as a problem. A goal was for the resident to be free of dry skin and skin irritation or redness. Interventions listed were for the staff to document on a flow sheet if skin was intact, reddened or had open areas, report to charge nurse any bruising, bleeding, redness, irritation or open areas and perform weekly skin assessment per protocol. A quarterly assessment, dated 12/20/13, documented the resident was moderately impaired with cognition, required extensive assistance of one person for bathing, limited assistance of one person for dressing and required supervision for transfer, bed mobility, ambulation, eating and hygiene and was always continent of bowel and bladder. A re-admission nursing assessment, dated 03/08/14, documented, "...13. Integumentary/feet 1. Skin/Wound condition present: yes Stage I to coccyx area and rash to sacral area..." A nurse's note, dated 03/08/14 at 11:00 a.m., documented, "readmitted to facility...Sacrum c lg amt. redness present area blanches sluggishly. Dietary notified of readmit, call light in reach." The physician had not been notified of the resident's return to the facility or the new Stage I sore to the coccyx area. On 03/20/14 at 9:15 a.m., the DON and the corporate RN were shown the nurse's note and the re-admission note and asked if the physician had been notified. The DON stated, "It's not in the notes so it doesn't look like it." The DON was then asked if the physician should have been notified. The DON stated, "Yes." 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. C, HTN, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A care plan, dated 06/12/12, documented the resident had a potential for alteration in cardio status r/t [DIAGNOSES REDACTED]. A goal was for the resident to be free of headaches, dizziness or fatigue. One intervention listed was for the staff to notify the licensed nurse of any bleeding or bruising and of symptoms of headache, dizziness and/or fatigue. A quarterly assessment, dated 12/20/13, documented the resident was moderately impaired with cognition, required extensive assistance of one person for bathing, limited assistance of one person for dressing and required supervision for transfer, bed mobility, ambulation, eating and hygiene and was always continent of bowel and bladder. The February 2014 computerized physician's orders documented the resident received [MEDICATION NAME] 60 mg daily and [MEDICATION NAME] 50 mg daily for [MEDICAL CONDITION]. These medications were diuretics and also used to manage hypertension in some residents. A nurse's note, dated 02/23/14 at 10:30 a.m., documented a blood pressure reading of 105/58. There was no documentation the physician had been notified. A nurse's note, dated 02/25/14 (no time documented) documented a blood pressure reading of 110/56. There was no documentation the physician had been notified. A nurse's note, dated 02/27/14 at 3:00 a.m., documented a blood pressure reading of 100/49. There was no documentation the physician had been notified. A nurse's note, dated 03/02/14 at 1:15 p.m., documented a blood pressure reading of 100/44. There was no documentation the physician had been notified. A nurse's note, dated 03/03/14 at 4:00 p.m., documented a blood pressure reading of 110/54. There was no documentation the physician had been notified. A nurse's note, dated 03/04/14 at 4:00 a.m., documented a blood pressure reading of 105/50. There was no documentation the physician had been notified. A nurse's note, dated 03/05/14 at 3:00 a.m., documented a blood pressure reading of 101/42. There was no documentation the physician had been notified. A nurse's note, dated 03/08/14 at 5:00 p.m., documented a blood pressure reading of 110/58. There was no documentation the physician had been notified. A nurse's note, dated 03/11/14 at 3:00 a.m., documented a blood pressure reading of 111/51. There was no documentation the physician had been notified. A nurse's note, dated 03/12/14 at 2:00 a.m., documented a blood pressure reading of 96/47. There was no documentation the physician had been notified. A nurse's note, dated 03/12/14 at 6:00 p.m., documented a blood pressure reading of 100/50. There was no documentation the physician had been notified. A nurse's note, dated 03/14/14 at 1:50 a.m., documented a blood pressure reading of 116/50. There was no documentation the physician had been notified. A nurse's note, dated 03/14/14 at 10:30 a.m., documented a blood pressure reading of 100/56. There was no documentation the physician had been notified. A nurse's note, dated 03/15/14 at 12:05 a.m., documented a blood pressure reading of 94/56. There was no documentation the physician had been notified. A nurse's note, dated 03/16/14 at 10:00 a.m., documented a blood pressure reading of 110/56. There was no documentation the physician had been notified. A nurse's note, dated 03/17/14 at 3:00 a.m., documented a blood pressure reading of 107/45. There was no documentation the physician had been notified. A nurse's note, dated 03/18/14 at 3:00 a.m., documented a blood pressure reading of 101/40. There was no documentation the physician had been notified. On 03/18/14 at 5:15 p.m., the DON was shown the above nurses' notes with the abnormal blood pressure readings and asked when she expected the physician to be notified. The DON reported she expected the physician to be notified if the diastolic reading was below 60. The DON was then asked if she thought the physician should have been notified. The DON stated, "Yes, I do." 4. Resident #8 had been admitted to the facility on [DATE]. The resident had current medical [DIAGNOSES REDACTED]. An annual assessment, dated 06/12/13, documented the resident required extensive assistance with transfers, ambulation, dressing and bathing, required moderate assistance with hygiene, required set up help with eating, had no ROM deficits in extremities and was occasionally incontinent of bowel and bladder. A quarterly assessment, dated 02/26/14, documented the resident required extensive assistance with transfers, dressing and bathing, required total assistance with hygiene, required limited assistance with eating, had ROM deficits in upper and lower extremities and was always incontinent of bowel and bladder. A care plan revised on 01/02/13, documented the following: "Focus ...has a potential for skin Alteration r/t (decreased) mobility and occasional incontinence of bladder. Goals ...will be free of skin irritation and skin redness over the next review. 06/11/14 ...will be free of pressure sites over the next review. 06/11/14 Interventions Notify L.N. (licensed nurse) of any skin irritations or redness Report new open areas to LN." A review of the resident's medical record was completed. There was no documentation of a pressure ulcer. A Braden Scale- For Predicting Pressure Sore Risk, dated 02/10/14, documented the resident was High Risk for pressure ulcers. On 03/19/14 at 4:30 p.m., the facility was asked for a list of residents with pressure sores. At that time, ADON #2 presented a list of residents with pressure sores. Resident #8's name was on the list. A Pressure Ulcer Documentation Form documented, "03/12/14 size in CM 2x2 Depth less than 0.1." The area had not been staged. At that time, LPN #1, who had signed the form was asked about the pressure sore. She reported a CNA had identified the area and she had filled out the form. She was asked if the physician had been notified, a treatment order had been obtained or if she had documented the area in the nurses' notes or anywhere else. She reported she had not done any of the above. She was asked what she had been doing for the area. She reported she had been using a barrier cream on the area. She also reported she should have made an incident report, called the doctor, got a treatment and documented the area in the nurses' notes. A nurse's note, dated 03/19/14 documented, "PCP notified that resident had small open area to coccyx measuring approx 2 cm x 2 cm on 03/12/14, He was also notified that this area is now healed. Did receive PRN order for Zguard for redness-Family aware." On 03/20/14 at 10:15 a.m., the resident's buttocks and coccyx area were viewed. No open areas were noted. On 03/20/14 at 10:30 a.m., the DON was asked about the pressure sore identified on 03/12/14. She reported the nurse should have notified the physician and the family. 5. Resident #7 was admitted on [DATE] with numerous [DIAGNOSES REDACTED]. A care plan, dated 02/22/14, documented the resident was at risk for alteration in skin integrity, as a problem. The goal was for the resident's skin to remain intact and free of redness. An intervention listed was for the staff to report any changes in the resident's skin to the physician immediately. An annual assessment, dated 03/05/14, documented the resident was cognitively intact and demonstrated mild depression. The resident did not ambulate and was not transferred during the seven day look back period. The resident required extensive assistance of one person to dress, perform personal hygiene and bathe. The resident was always incontinent of bowel and had an indwelling urinary catheter. On 03/20/14 at 9:50 a.m., LPN #2 was observed to perform indwelling urinary catheter care and wound care. The LPN completed the first procedure and assisted the resident to her side. An open area was observed to the resident's coccyx. The LPN stated, "That's new." The LPN covered the resident and left the room to obtain a measuring tape. The surveyor told the resident she had a new open area to her coccyx. The resident stated, "No, they found that yesterday when they were cleaning me up." CNA #5 was assisting the resident's roommate. The curtain was drawn. The CNA stated, "Yes, that was me, I found the area yesterday evening and reported it to (LPN's name deleted, LPN #1)." The resident was asked if LPN #1 had observed her wound the day before. The resident stated, "I don't think so." LPN #2 returned to the residents room and measured the wound at 1.9 cm X 0.3 cm and reported the wound was a stage two and she would contact the physician for treatment orders. The resident's medical record was reviewed. There was no documentation to reflect the physician had been notified of the wound. The facility wound sheets were reviewed there was no documentation of the wound which had been reported to LPN #1 on the previous day. At 11:00 a.m., the corporate nurse and DON were interviewed regarding the resident's wound. The corporate nurse reported the wound should have been documented and the physician should have been notified and a treatment obtained, when the wound was found. Both the facility and the surveyor attempted to contact LPN #1 by phone for an interview and were unsuccessful after several attempts. 6. Resident #17 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/29/14, documented the resident was severely impaired with cognition and exhibited moderately severe depression. The resident required one person extensive assistance for bed mobility, transfer, ambulation, dressing, personal hygiene and bathing. The assessment indicated the resident was at risk for pressure ulcers. The Pressure Ulcer Documentation form, dated 03/12/14, documented an open area to the coccyx with a treatment of [REDACTED]. The resident's medical record contained no physician order for [REDACTED]. The resident's medical record contained no documentation the physician was notified of the coccygeal ulcer. On 03/20/14 at 2:00 p.m., LPN #2 was observed to provide pressure ulcer treatment to the resident's left buttock. At that time, the LPN was asked about the coccygeal ulcer which was documented on the Pressure Ulcer Documentation form. The LPN reported she had no knowledge of the specific ulcer. No coccygeal ulcer was observed. At the time of the treatment observation, an open (stage two) ulcer to the resident's right buttock was observed. LPN #2 reported she was unaware of the open ulcer to the right buttock. The LPN reported no one had reported the area had opened. The LPN reported two days prior the area was reddened. There was no physician or family notification documented about the reddened area, which the LPN had reported was present two days prior. No treatment order had been obtained when the reddened area was first identified. At 2:40 p.m., an interview with LPN #2 (treatment nurse) was conducted. The LPN reported the physician and family should have been notified. At 4:20 p.m., the DON was interviewed and asked if the physician should have been notified of the resident's skin condition and a treatment order obtained. The DON reported the physician should have been notified. The DON reported any lesion or red areas should be monitored and treatment obtained from the physician. The DON reported skin assessments would be completed on all residents.

On 03/18/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene when a resident who was on [MEDICATION NAME] had black tarry stools. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 1:55 p.m., the ADM, DON, corporate ADM and corporate RN were notified of the IJ situation. At 3:35 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal documented the following: "Physician notification/Assessment and Monitoring 1. 100% in-service of licensed nurses on the requirement for physician notification requirements, care and care services policy, notification of physician (CALL when abnormal findings are noted). Fax is only appropriate in non-emergent circumstances when no abnormal findings are noted. In-service will include the requirements for assessment and monitoring and reporting changes to the MD. In-service will be completed at 4 p.m. on 03/18/14. Any nurse that does not attend this in-service will not be allowed on the floor until the in-service is complete. 2. 100% in-service of CNA's will be completed regarding reporting changes in condition to licensed nurse as soon as noted. This in-service will be completed on 03/18/14 at 4 p.m. any aide that does not complete the in-service at this time will not be allowed to work until the in-service is complete. 3. An audit by staff and resident interview will be complete at least three times weekly to ensure compliance with nurse notification of changes from the CNA. 4. The resident had previously been admitted to the hospital for treatment. 5. Complete a 100% audit of current residents documentation (January through current date) to ensure that any changes of condition have been communicated to the doctor. This audit will be completed by 1 pm on 03/19/14. 6. Audit of the 24 hour report will be completed and documentation reviewed three times weekly to ensure continued compliance. 7. Any identified non-compliance will result in one on one in-servicing and progressive disciplinary action. 8. Results of the audits will be presented to the facility QA committee monthly for a period of no less than 90 days for further evaluation, review and changes." On 03/19/14 at 9:00 a.m., a copy of the facility's in-service on the subject of physician notification, change of condition, assessment and monitoring of the patient and CNAs' notifying nurse of changes in condition. A copy of the in-service topics included: "03/18/14 4:00-4:45 LPN's/RN Physician Notification of Changes 1. The doctor must be notified with ANY change in the resident condition of abnormal findings. The notification must be completed at the time the change is noted. Example: Fall, Wound, Abnormal Labs etc. How do we notify the Physician? 1. Fax- this method may only be used when the situation is non-emergent and there are no abnormal findings. (Minor skin tear, lab results received are normal etc.) If you are unsure if you should fax or call, notify your DON for guidance. 2. Call-the doctor must be called when abnormal findings are noted or when the situation is emergent. (New complaint of pain level, abnormal labs, falls with injury etc) ANY CHANGE IN CONDITION MUST BE COMMUNICATED TO THE DOCTOR 1. When completing an assessment vital signs should be completed. The change of condition form is used for documentation and should be complete (sic) filled out. When changes are noted follow up documentation and assessment should be completed to monitor the progress of the condition of the resident. CNA YOU ARE THE FIRST LINE OF DEFENSE! You see the resident more than any other staff. You will be the first to notice small changes and big changes. It is your responsibility to report any and all changes to the nurse! Examples: Walking to the dining room and want a wheelchair, dressing self and now are unable, discolored or stinky urine, not drinking, not eating, skin issue, etc. any change that is not the norm for the resident must be report to the nurse for further evaluation. No matter how small you think the change is, always report." The names on the in-service form were compared to the staffing roster. Staff members from various shifts of the nursing department were interviewed in regard to the in-service. The staff members reported they received information including reporting, assessment, monitoring and intervening for change in condition. The staff answered questions appropriately in regard to the in-service. The IJ was removed on 03/19/14 at 1:00 p.m. The deficiency remained at the level of actual harm that was not immediate jeopardy, at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to: a) Assess and monitor a resident with black tarry stools for one (#2) of one sampled resident who experienced black tarry stools. This had the potential to affect two residents, identified by the DON, who had black tarry stools in the past three months. b) Have FSBS elevated parameters in which to notify the physician for one (#6) of three sampled residents who had FSBS ordered. This had the potential to affect 26 residents, identified by the DON, who had FSBS ordered. c) Follow up on a laboratory analysis with the physician for one (#8) of 10 sampled residents who required laboratory analysis. This had the potential to affect all 75 residents who resided in the facility. d) Have blood pressure parameters in which to notify the physician for three (#3, 7 and #9) of three sampled residents who required blood pressure readings. This had the potential to affect 19 residents, identified by the DON, who required blood pressure readings. e) Assess and monitor a burn for one (#13) of one sampled resident who experienced a burn. This had the potential to affect two residents, identified by the DON, who had a burn in the past three months. Findings: A facility policy, dated 02/05/13, documented, "Care and Services- POLICY: It is the center's policy to provide residents with the necessary care and services to maintain his/her highest level of practicable functioning in an environment that enhances each resident's quality of life in the scope of a long term care center. PROCEDURE: Staff and resident are required to follow the procedure listed below. ...8. The Licensed Nurse or designee documents and notifies the resident's physician and responsible party of: Change in condition, including progress and/or decline in physical or mental function, Resident refusal of care or services and Unusual occurrence." 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. C, HTN, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A care plan, dated 01/27/13, documented the resident required anticoagulant therapy related to [MEDICAL CONDITION] history, as a problem. A goal was for the resident's PT/INR to remain WNL. One intervention listed was for the staff to observe the resident for signs of bleeding such as blood in urine, increased pulse, decreased blood pressure, decreased energy level and abdominal pain. The care plan also documented the resident may have incontinence of bowel related to medications ([MEDICATION NAME]) use, as a problem. A goal was for the resident to have decreased elimination of diarrhea. Interventions listed were for the staff to notify the physician as needed and to record the resident's bowel movement for size and consistency and to report any abnormalities to the licensed nurse. A quarterly assessment, dated 12/20/13, documented the resident was moderately impaired with cognition, required extensive assistance of one person for bathing, limited assistance of one person for dressing and required supervision for transfer, bed mobility, ambulation, eating and hygiene and was always continent of bowel and bladder. The resident received an anticoagulant medication for seven days of the seven day look back period. A computerized physician's orders [REDACTED]. orders had an original start date of 11/05/13. "...PT INR to be drawn every 2 weeks-Evening Shift Every 14 days..." A computerized physician's orders [REDACTED]." A MAR, dated February 2014, documented the [MEDICATION NAME] had been held from 02/06/14 through 02/10/14. A Change Of Condition Communication form, dated 02/09/14 at 1400 (2:00 p.m.), documented, "...Black tarry stool started on 02/07/14..." A nurses note on the back of the form documented, "Received report from resident concerning several black tarry stools. Asked resident about onset of blk stools reports initially started 1-2 days before this date. Res states "I didn't want to worry anyone." ABD flat soft nontender c hyperactive BS x 4 quads." The Change Of Condition Communication form documented, in the area for physician notification, the physician had been notified on 02/09/14 at 1400 (2:00 p.m.). The nurses' notes with the same above date contained no other documentation of the black tarry stools or physician notification. A 24 hour report/change of condition report, dated 02/09/14, documented, "(Resident name deleted)...blk stool..." The nurses' notes, dated 02/09/14, contained no documentation the resident's vital signs had been obtained. A Change Of Condition Communication form, dated 02/10/14, documented on the front of the form, "...Hgb 5.1 Hct 17.6 black tarry stools, started on 02/09/[MEDICATION NAME] held since 02/06..." A nurse's note on the back of the form documented, "Received call from PCP reguarding (sic) residents black tarry stools yesterday. Rec'd order for STAT CBC, PT/INR. Spoke c resi about this order. Obtained from RAC (right antecubital) x 1 stick. Resi tol well, pressure applied. Specimen sent to PCP office. 1040 (10:40 a.m.) Rec'd call from PCP, received order to send resi to ER for Hgb 5.1 & Hct 17.6..." The Change Of Condition Communication form contained no documentation the resident's vital signs had been obtained. The nurses' notes, dated 02/10/14, contained no documentation the resident's vital signs had been obtained. On 02/10/14 at 11:35 a.m., the resident was admitted to (Hospital name deleted) where she was diagnosed with [REDACTED]. At 4:22 p.m. the resident was transferred from (Hospital name deleted) to (Hospital name deleted) for further treatment. An admission note from (hospital name deleted), dated 02/10/14, documented, "CHIEF COMPLAINT: History of GI bleed, tarry stools...The stool guaiac-positive...ASSESSMENT AND PLAN: 1. [MEDICAL CONDITION]. At this time, we will transfuse 2 units of packed RBCs. We will check a CBC in the morning..." On 02/18/14 at 9:25 a.m., LPN # 2 was asked if she had notified the physician on 02/09/14 about the resident's complaint of black tarry stools. The LPN stated, "By fax to the physician's office, that's what he prefers." The LPN then stated, "The resident told me her stool had been that way for a couple of days." The LPN was asked if she thought she should have called the physician instead of faxing him. The LPN nodded her head. At 9:50 a.m., CNA #6 was questioned in regard to the resident having black tarry stools. The CNA reported she had assisted the resident with toileting before she went to the hospital the first time and she had black stools. The CNA reported she had told the charge nurse but could not remember the name of the charge nurse. At 10:30 a.m., CNA #4 was questioned in regard to the resident having black tarry stools. The CNA reported the resident's stools were dark. The CNA reported she had told the charge nurse. On 03/21/14 at 8:45 a.m., the DON was questioned in regard to the lack of assessment and vital signs not being completed for the resident. The DON was asked if the assessment should have included vital signs. The DON stated, "Yes they should have been done on both days." The DON reported, the nurse responsible for the incident had a coaching report completed on 02/14/14, due to the physician not being notified in a timely manner and the lack of assessment. There was no in-service completed at the time of the incident to ensure the staff had been made aware of the facility policy for contacting the physician in a timely manner and for assessing, monitoring and intervening changes of a resident's condition. 2. Resident #8 had been admitted to the facility on [DATE]. The resident had current medical [DIAGNOSES REDACTED]. A care plan revised on 01/02/13, documented the following: "Focus ...has a potential alteration in Nutrition Status R/T short term memory...has a weight fluctuation R/T [MEDICAL CONDITION] history and diuretic use Goals ...will have Safe and comfortable ingestion of fluids and solids over the next review. 06/11/14 ...will be free of pressure sites over the next review. 06/11/14 Interventions Diet as ordered Labs as ordered..." An annual assessment, dated 06/12/13, documented the resident required extensive assistance with transfers, ambulation, dressing and bathing, required moderate assistance with hygiene, required set up help with eating, had no ROM deficits in extremities and was occasionally incontinent of bowel and bladder. A quarterly assessment, dated 02/26/14, documented the resident required extensive assistance with transfers, dressing and bathing, required total assistance with hygiene, required limited assistance with eating, had ROM deficits in upper and lower extremities and was always incontinent of bowel and bladder. A nurse's note documented, "3/6/14 pt wt on 3/3/14-182.6, pt wt today on 3/6/14 was 190.0 PCP (personal care physician) notified via Fax request possible BMP lab drawn awaiting response." The medical record was reviewed. No BMP had been completed. There was no follow-up to the nursing note dated 03/06/14. On 03/20/14 at 4:15 p.m., the DON was notified of the nursing note on 03/06/14, with no follow-up. She reported the nurse should have followed up on the request. 3. Resident #6 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/20/14, documented the resident was severely impaired with cognition with disorganized thinking and exhibited moderately severe depression with behaviors. The resident was totally dependent on staff assistance for bed mobility, transfers, ambulation in a wheelchair, personal hygiene and bathing. The resident was always incontinent of bowel and bladder. A care plan, dated on 02/02/14, documented the resident had diabetes type II, as a problem. A goal for the resident was to have no S/S of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. An intervention was for the staff to obtain blood sugars as ordered. A physician's orders [REDACTED]. Prior to 03/05/14, the physician's orders [REDACTED]. The March 2014 computerized physician's orders [REDACTED]. If unable to feed or the FSBS remained below 60 after feeding or giving [MEDICATION NAME], notify the physician. The physician orders [REDACTED]. There were no high level parameters set or obtained from the physician to direct the resident's care. On 03/19/14 at 2:20 p.m., the DON was asked if she expected the resident to have a upper parameter set for the FSBS which indicated when to notify the physician for care directives. The DON stated, "Yes, should have upper parameters." 4. Resident #9 was admitted on [DATE] with numerous [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/27/13, documented the resident was cognitively intact and demonstrated moderate depression. The resident required extensive assistance of two persons to transfer and dress. The resident required extensive assistance of one person to perform personal hygiene and to bathe. The resident did not ambulate in the room or corridor. The resident required limited assistance of one person to move on and off the unit. A computerized physician's orders [REDACTED]. daily for HTN. The order documented, "...hold if SBP is less than 90." There were no B/P parameters in which staff was to notify the physician, in the resident's medical record. On 03/18/14 at 8:00 a.m., the DON was interviewed regarding blood pressure readings in which the staff was to notify the physician. The DON reported the facility should have B/P parameters and she would contact the physician. 5. Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. A computerized physician's orders [REDACTED]." There were no B/P parameters in which the licensed nurses were to notify the physician, documented in the resident's medical record. An annual assessment, dated 03/05/14, documented the resident was cognitively intact and demonstrated mild depression. The resident did not ambulate and was not transferred during the seven day look back period. The resident required extensive assistance of one person to dress, perform personal hygiene and bathe. The resident was always incontinent of bowel and had an indwelling urinary catheter. A care plan, dated 03/12/14, documented the resident had HTN, as a problem. The goal was for the resident to not complain of headaches, dizziness or fatigue. An intervention listed was for the staff to obtain the resident's B/P as ordered or per facility protocol. At 10:30 a.m., the DON was interviewed regarding the resident not having B/P parameters in which to notify the physician. The DON reported she would contact the physician for B/P parameters. 6. Resident #3 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/08/14, documented the resident had severe cognitive impairment, mild depression and no behaviors. The resident was totally dependent on staff assistance for transfers, dressing, eating, personal hygiene and bathing. The March 2014 computerized physician's orders [REDACTED]. "Losartan Potassium 100 MG...give one tab daily...htn... [MEDICATION NAME]...20 MG Tablet...Everyday..HTN/[MEDICAL CONDITION] [MEDICATION NAME]...5 MG tablet..1 PO daily-hold if B/P <90 systolic...UNSPECIFIED ESSENTIAL HYPERTENSION..." The physician's orders [REDACTED]. On 03/19/14 at 10:00 a.m., the DON was asked if the resident should have blood pressure parameters in which to notify the physician. The DON reported the physician informed her he would set parameters on an individual basis for each resident and had not provided parameters for the resident at this time. The DON reported she would address the issue with the physician. 7. Resident #13 was admitted with [DIAGNOSES REDACTED]. A Change Of Condition Communication form, dated 01/25/14 at 7:40 a.m., documented, "Writer standing @ N.S. (nurses' station). was informed by other res that res 'spilled her coffee' Writer turned around obs. Res. in geri chair (with) coffee cup in hand angled toward self (with) lg. wet spot on shirt. Writer went to res. and lifted clothing off skin & assisted to rm...Res. has 6 x 3 cm light pink area to mid (upper left) breast. (No) blistering... 0800 (8:00 a.m.) Area remains light pink (no) blistering.. 0900 (9:00 a.m.) Assessment unchanged... 1000 (10:00 a.m.) Assessment unchanged (No) pain discomfort. Cool compress applied..." A nurse's note, dated 01/26/14 at 11:30 a.m., documented the resident had a light fading pink area to her left breast. There was no other documentation of assessment or monitoring of the burn area. A Non-Pressure Wound And Skin Condition Documentation Form documented the area on 01/25/14. The next entry, dated 02/12/14, documented, "Resolved." There was no weekly skin assessment of the area. There was no assessment of the burn areas size or appearance for 16 days. A comprehensive assessment, dated 02/06/14, documented the resident had severe cognitive impairment, moderate depression and no behaviors. The resident was totally dependent on staff assistance for bed mobility, locomotion, transfers, dressing and personal hygiene. The resident had range of motion impairment of bilateral upper and lower extremities. On 03/20/14 at 3:00 p.m., the ADON was asked if the burn site should have been monitored. The ADON replied, "Yes."

Based on record review and staff interview, it was determined the facility failed to notify the physician when the blood pressure readings were low for one (#6) of seven sampled residents who had blood pressures taken. This had the potential to affect 51 residents, identified by the DON, who required blood pressure readings and blood pressure medications. Findings: Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The history and physical examination [REDACTED]. The January 2014 physician orders [REDACTED]. [MEDICATION NAME] 50 mg one tablet po daily [MEDICATION NAME] HCL 0.1 mg one tablet po BID [MEDICATION NAME] 40 mg one tablet po BID [MEDICATION NAME] 10 mg one tablet po daily The resident's initial care plan, dated 01/24/14, addressed pain, falls and skin integrity. The resident's admission assessment had not been completed at the time of the survey. The resident's nurses' notes upon and since admission, dated 01/21/14 through 01/30/14, were reviewed and documented the resident was alert and oriented. The resident ambulated with a rolling walker without assistance and could transfer herself. The nurses' notes documented the resident at times had an unsteady gait. A nurses' note, dated 01/25/14 at 11:00 a.m., documented the resident's blood pressure as 82/52. There was no entry in the nurses' notes the physician was notified of the lowered B/P measurement. A nurses' note, dated 01/28/14 at 10:00 p.m., documented the resident's blood pressure as 88/48. There was no entry in the nurses' notes the physician was notified of the lowered B/P measurement. On 01/30/14 at 3:15 p.m., the DON was asked if she would have expected the staff to notify the physician of the lowered blood pressure readings. The DON stated, "Yes, I would have."

Based on observation, record reviews and staff interviews, it was determined the facility failed to: a) Ensure a decline in condition was assessed and monitored, which resulted in hospitalization , resulting in harm, for one (#5) of two sampled residents who had been hospitalized . This had the potential to affect all 77 residents, who could experience a change in condition. b) Identify and assess bruises and abrasions for one (#2) of two sampled residents, who experienced bruising and abrasions. This had the potential to affect all 77 residents, who could experience bruising and abrasions. c) Ensure a timely assessment with intervention was obtained for one (#2) of one sampled resident, who experienced a frequent cough with chest discomfort. This had the potential to affect all 77 residents, who could experience a change in condition. d) Ensure pain medication was provided in a timely manner for one (#15) of six sampled residents, who experienced pain. This had the potential to affect 53 residents, who received pain management. e) Ensure a FSBS was obtained for one (#4) of two sampled residents, who had FSBSs ordered by the physician. This had the potential to affect 40 residents, identified by the ADON, who had FSBSs ordered. f) Ensure weekly weights were monitored for one (#4) of one sampled resident, who required weekly weights. This had the potential to affect six residents, identified by the ADON, who required weekly weights to be monitored. Findings: 1. The facility's Change in Condition of a Resident policy documented the following: "Policy Statement It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident. Procedure Action Steps 1. The Licensed Nurse determines if there has been a change in condition of a resident. 2. The Licensed Nurse notifies, via telephone, the attending physician and the resident's responsible party of the specific nature of the change of condition. The primary mode of urgent communication is by telephone. Other media such as fax, beeper, email, etc, may be utilized as a secondary method only after initial contact and agreement with the physician..." Resident #5 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial assessment, dated 11/09/11, identified the resident with cognitive deficits, required total assistance with all ADLs, with the exception of extensive assistance with eating, was frequently incontinent of urine, was continent of bowels, did not currently have a pressure ulcer, but was at high risk for pressure ulcers. The first Weekly skin evaluation had not been completed until 11/26/11. An "I" (intact) was documented. A Norton Plus Pressure ulcer Scale dated 12/05/11, documented a score of 10 (10 or less = High Risk). A Change of Condition Documentation Nursing Progress Note, dated 12/05/11, documented, "This nurse called to Res Room During Pericare found wound to coccyx. Total area of redness 4.8 cm x 7.5 cm, open areas R of midline 0.9 x 1.3 cm Stage 2 L of midline 1 cm x 0.9 cm Stage 2. 1 closed area distal to 2nd open area to L of midline is closed. 1 cm x 0.7 cm blister. Family in room at time found. Dr Notified via Fax." A physician's orders [REDACTED]." A nurse's note, dated 12/09/11, documented, "late entry for 12/9/11, 6 pm. New order obtained for [MEDICATION NAME] to coccyx area p (post) cleaning every 3 days. Family aware." The [MEDICATION NAME] had not been started until 12/08/11. A Pressure Ulcer Documentation Form, dated 12/05/11, for the area distal to the coccyx L side, had a hand written note, dated 12/14/11, documenting, "Consolidated c other 3." A Pressure Ulcer/Vascular Ulcer Log, dated 12/14/11, documented, "Wound Observation 12-14/11 Treatment change N (No) Care Plan updated Y (Yes) Stage Current Week 2 Comments, 5 x 6.8 x 0.1 cm Yellow 80%, Bright Red Blood 20%." There was no documentation the physician had been notified of the decline in the pressure ulcer until faxed on 12/19/11. The fax included, under comments, "Was 4 separate wounds, is now one wound." There was no response to the fax from the physician. A Skin Review (no date), for the resident documented, "PU (pressure ulcer) site Coccyx x 4, PU stage II...Area measured every week Last date measured 12/14/11...Type of Mattress used facility..." A nurse's note, dated 12/18/11, at 4:31 p.m., documented, "Wound care changed [MEDICATION NAME] cut to fit wound bed, cover c optfoam. 4 x 4, cover c [MEDICATION NAME] composit 6 x 6 daily on day shift. Dr Notified. Family in room during dressing changed & informed of new tx." The treatment had been discontinued on 12/21/11 and "[MEDICATION NAME] Wound Dressing 1 ea Pad Topical -Day Shift Everyday: Step 1of 3" had been ordered. A Pressure Ulcer/Vascular Ulcer Log, dated 12/23/11, documented, "Wound Observation 12/23/11 Treatment change N (No) Care Plan updated NA (not applicable) Stage Previous Week 2 Stage Current Week 3 Comments, 3 x 9 x 1.5 x 0.1 cm yellow center c 0.8 cm Gray Brown Center Edges Bright Pink." The physician had been notified of the condition of the wound by fax on 12/23/11. A physician's orders [REDACTED]. Ensure that all edges are adheared well-Day Shift Everyday [MEDICATION NAME] NON-Adhesive foam dressing pad 4 x 4 step 2 of 3- cut and use 1/4 of pad. Cover [MEDICATION NAME] with pad-Day Shift Everyday." A nurse's note, dated 12/23/11 at 8:55 p.m., documented, "Dressing to coccyx changed family & Dr Notified." A nurse's note, dated 12/26/11 at 5:30 p.m., documented, "Resident complained earlier "not feeling good temp 99, clammy & spit up x1 this shift. Report given to oncoming nursing. Now resting in bed N/C voiced @ this time." 5:30 p.m., "Res. in bed and has eyes closed. Responds to vigorous verbal stimuli. Res. up in W/C x1 but put back to bed c assistance due to being very stiff and acting as if she had pain to bottom. Back to bed and coccyx checked. Drsg intact c no drainage or odor noted." 7:30 p.m., "T 100.4/T. Tylenol 325 mg tab 2 given P.O. PRN." 8:50 p.m., "T 99.9/T. Resting quietly in bed c eyes closed." A nurse's note, dated 12/27/11 at 1:00 a.m., "Cont monitor temp. Remains afebrile continue monitor." The nurse's notes continued: "12/29/11 at 4:35 p.m., "N.O. for swallow study. Therapy is working on obtaining an appointment for the coming week. Family & Dr Notified. Cont. NO. [MEDICATION NAME] 5 mg PO q 6 hours PRN. ^ pain Family & Dr Notified. Cont Diet change per speech therapy & family Req. Dr notified & dietary notified. Cont NO. Wound Consult for coccyx Pressure ulcers & ST to eval for Dif swallowing. Dr & Family Notified LE for 12/29/11 (No time) Dr (Name deleted) notified regarding family's concern c Res and their desire to send to ER for Eval. Dr (Name deleted) does not want to send her out but stated "The family can take her if they want to "Im not sending her." Family notified. 12/30/11 12:35 p.m., Dr (Name deleted) paged & then phoned back at 8:50 A. Dr notified of Res change in condition from yesterday to include ^ lethargy decreased response ^ incoherence ^ difficulty c swallowing meds. ^ thick clear phlegm. Dr (Name deleted) stated, "Send to wound care appt and if she needs it send to ER for evaluation after." Order put in to send to ER p Wound clinic if needed. Family notified Res transported to wound clinic appt. ER phoned, Res is to be admitted for [MEDICAL CONDITION]. This nurse asked about wound care. ER nurse stated, "The wound clinic will take care of that while she is here." Family is still c Res @ Hospital." The hospital records were retrieved. An "Emergency Physician Record, dated 12/30/11 at 9:55 a.m., documented, "decubitus Coccyx 5-6 cm-draining..." A hospital progress note, dated 12/30/11 at 5:09 p.m., documented, "Subjective: The patient presented to the ER with decreased mental status, pain, and inability to perform any activities. She also has a stage 4 wound ulcer on her coccygeal area that was being treated. Physical Therapy was consulted for wound care. Objective: Physical Therapy evaluation was performed with the following results. The wound was located in the coccygeal area measuring 3.5 x 1.0 x 1.2 cm. There was a tunnel at 8 o'clock measuring 1.4 cm deep, a tunnel as 12 o'clock measuring 0.08 cm deep, and a tunnel at 6 o'clock measuring 1.0 cm deep. Eschar and necrotic tissue were covering the wound. The wound was selectively derided with a scalpel and forceps from the subcutaneous level down to the lowest tissue that could be done before bleeding occurred into the fascial layers. There was a strong odor, a sweet, musky odor to the wound. There was [DIAGNOSES REDACTED] surrounding the wound that measured approximately 3 to 4 inches away from the wound bed. The edges of the wound were macerated. There was no drainage today... Assessment: The patient has an unstageable wound at this time secondary to necrotic tissue but it appears to be a stage 3 to stage 4 ulcer. There is significant necrosis and a significant odor to the wound that will need to be assessed for any further wound care. Due to her wound, healing will be compromised secondary to increased white blood cell count, decreased nutrition and decreased ability for the patient to mobile in bed..." A physician's progress note, dated 12/31/11, documented, "Hospitalist ...Wound Has 3 cm Sacral Decub Stage IV frank pus draining... Imp 1. Infection/Sepsis-likely 2 (secondary) to decub 2. Dehydration..." A hospital physician's progress note, dated 01/01/12, documented,...Imp (impression) 1. Decub [MEDICAL CONDITION] syndrome 2. Dysphagia-??thrush 3. [MEDICAL CONDITION]/Dehydration..." A Discharge Summary, dated 01/03/12, documented the following: "admitted [DATE] discharge date d 01/03/12 Discharge Diagnoses: [REDACTED]. 2. Urinary tract infection 3. Acute [MEDICAL CONDITION]. 4. Acute altered mental status 5. Stage 3 to 4 sacral decubitum. 6. Protein-caloric [MEDICAL CONDITION] Hospital Course: This [AGE] year-old white female presents from (Facility name deleted) and was on her way to wound-care clinic for her sacral decubitum when it was felt that she had decreased level of consciousness, and she was diverted to the emergency department for evaluation. The patient was accompanied by her daughter. The daughter states that for the last 3-4 days her level of consciousness has slowly deteriorated. Responsive to only pain at times. The patient also had some difficulty swallowing. According to the daughter she had had some difficult times feeding, decreased appetite, and patient's daughter was unsure if she is getting enough fluids. Decubitum had begun draining the past 3-4 days. Local wound care had been done at the nursing home. However, the drainage had increased and therefore, appointment was made for the wound-care clinic to evaluate and treat... ...Upon presentation, the patient's blood pressure 130/64. Pulse was elevated to 125, temperature 99.3... The patient is very cachectic-appearing. Heart was [MEDICAL CONDITION]. The patient did have a stage III to IV decubitum in the sacral area, about as big as a half-dollar, but had had some tunneling present. Patient's white count was elevated at 49,600 with a left shift. BUN was 64 with a creatinine of 2.73. Patient was clinically dry as well. Urine showed trace of occult blood, and few bacteria, and a moderate amount of sediment. Blood cultures x 2 were drawn in the emergency room , and the patient was placed on the medical floor." After discharge from the hospital, the resident had been admitted to a skilled hospital for long term care. The resident had been discharged from the facility on 01/30/12, then re-admitted on [DATE], with a stage IV pressure sore on the coccyx. On 03/15/12 at 11:30 a.m., the DON was interviewed regarding the resident's pressure ulcer. He was notified the resident had been identified as being at high risk for pressure sores on the initial assessment. He was notified the first weekly assessment had not been completed until 11/26/11. He reported he was not the DON at that time. He was then asked to review the medical record before the resident had been sent to the emergency roiagnom on [DATE]. He was asked if the pressure sore had been assessed after 12/23/11. He reviewed the record and reported there was no documentation of the wound before being discharged to the hospital. He was asked if the resident's condition had been assessed before the family had requested she be sent to the ER. He reported there was no documentation of the resident's condition. On 03/15/12 at 2:30 p.m., RN #3, who had documented the resident's condition, before hospitalization on [DATE], was interviewed. She was asked if after the family had requested the resident be sent to the hospital, had she assessed the residents condition. She reported she had been in the resident's room earlier but could not remember details. She was asked if she had taken vital signs or had done a head to toe assessment for the resident when the family member had mentioned the change in the resident's condition. At that time, she reviewed her nurses's notes. She then reported she could not remember specifics about the resident's condition and had not charted anything specific about the resident's condition. 2. Resident #4 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." The December 2011, treatment sheet documented the resident was weighed two of the four weeks ordered. The January 2012, treatment sheet documented the resident was weighed one of the five weeks ordered. The February 2012, treatment sheet documented the resident was weighed two of the four weeks ordered. The March 2012, treatment sheet documented the resident was weighed one of the two weeks ordered. A physician's orders [REDACTED]." On 03/15/12, a review of the treatment sheet documented the 3:00 a.m., FSBS was only done one of two days ordered. On 03/15/12 at 4:30 p.m., the DON was asked about the lack of weekly weights and the missing FSBS which were ordered. He reported they should have been done. 3. Resident #15 had physician's orders [REDACTED]. On 03/14/12 at 3:37 p.m., resident #15 activated the call button. At 3:40 p.m., a CNA #2 asked the resident what she needed. The resident told the CNA she was hurting and needed a pain pill. At that time, CNA #2 informed LPN #1 and CMA #1. At 4:00 p.m., CMA #1 brought pain medication into the resident. At that time, the resident was asked by the surveyor to rate her pain from zero to ten. The resident rated her pain as a ten. On 03/15/12 at 4:00 p.m., CMA #1 was asked why it took twenty minutes for the resident to receive her prn pain medication. She reported, at that time she was busy and was working at the other end of the hall. At 4:30 p.m., the DON was asked about the twenty minute response to the resident's request for pain medication. He reported the resident's pain should have been addressed quicker. 4. Resident #2 had [DIAGNOSES REDACTED]. A care plan, dated 02/06/12, documented a focus area was alteration in skin integrity r/t mobility, use of [MEDICATION NAME] and a bruising potential. Care plan interventions listed were to notify the charge nurse of any bleeding/bruising, weekly skin assessment per protocol and not to bump extremities when care was given. A quarterly assessment, dated 02/07/12, documented the resident was severely impaired in cognition for daily decision making skills, was totally dependent on staff for bed mobility, transfers, dressing, hygiene and toilet use, required setup help with meals and was always incontinent of bowel and bladder. On 03/14/12 at 8:30 p.m., CNA #1 was observed to have assisted the resident to the toilet, ambulated the resident to bed and dressed the resident in her nightgown. At that time, a three inch by one inch bruise was observed on the resident's right lower back/upper buttock area. There was also two abrasions and one bruise on the resident's lower left leg. One of the lower leg abrasions had a 1 cm scab. The other lower leg abrasion was approximately 2 cm in length and 2 cm in width. A 1 cm closed reddened bruised area, with a raised center, was observed on the resident's lower left leg. At that time, the CNA was asked how long had the bruises and abrasions been present. She reported she had just returned to work after two days off. She stated, "They were not there when I left." On 03/15/12 at 11:30 a.m., RN #2 was asked if anyone had reported a bruise to the resident's back or abrasions to the resident's lower left leg. The RN stated, "No." The RN was asked if she would assess the resident's skin with the surveyor. She reported when the resident returned to bed after lunch, the assessment could be conducted. The RN further reported the weekly skin assessment for the resident was due today. At 3:25 p.m., RN #2 assessed the resident's abrasions and bruises. The RN was asked if any staff member had reported the areas to her today. She stated, "No." The RN stated she had conducted the resident's weekly skin assessment last week and the areas were not observed to be present. She further reported the staff had a treatment for [REDACTED]. At 4:30 p.m., CNA #1 was asked if she had reported the abrasions and bruises to anyone. She stated, "No." At 4:45 p.m., the DON was asked if he expected the staff to report when they observed bruises and abrasions on the residents. The DON stated, "Definitely." 5. On 03/14/12 at 4:45 p.m., resident #2 was observed to be toileted by two assistants. The resident had coughed at intervals during the care observed. At 6:10 p.m., the resident was in the dining room and had a frequent non-productive cough. A family member was asked how long the resident had been coughing. The family member reported the resident had the cough for the last three days. The family member reported the staff had not called the physician about the cough. At 8:10 p.m., a family member reported the resident complained about chest and back pain. The family member reported the resident described the pain as "wrapped around" her side. The family reported they had told the CMA on duty about the resident's pain before 8:00 p.m. At the same time, the CMA (unidentified) was asked if she had notified the charge nurse of the chest and back pain. The CMA reported she had told LPN #1 about the resident's pain, but the LPN was with another resident. The CMA further reported the staff would place the resident in bed soon. At 8:25 p.m., the resident's family members reported the resident had not been assessed as yet by LPN #1. At 8:30 p.m., CNA #1 was observed to assist the resident to the toilet and dress the resident in a nightgown. The CNA was asked how long had the resident had a cough. The CNA stated, "A couple of weeks." The resident was asked if her chest hurt when she coughed. The resident stated, "Yes." The resident was asked where her back was hurting. The resident reported the middle of her lower back. At 8:45 p.m., LPN #1 was observed to roll a treatment cart down the hallway past the resident's room. The LPN did not stop to check on the resident. On 03/15/12 at 3:25 p.m., RN #2 was asked if she knew what had been done about the resident's cough. She reported the physician was faxed last night about the cough and it was communicated during shift report. She reported [MEDICATION NAME] DM cough syrup was to be started when obtained today. RN #1 further stated the cough relief medication was first transmitted to the wrong pharmacy. The order had to be transmitted to the correct pharmacy, which caused a delay in the receipt of the medicine. At 6:45 p.m., CNA #1 was asked if she had reported the resident's cough the night of 03/14/12. She stated, "Yes." She further reported she had reported the cough, "when it first started, two to three weeks ago to every charge nurse." At 6:50 p.m., LPN #1 was asked if she assessed the resident on 03/14/12, regarding the cough and chest pain. She reported she assessed the resident between 9:00 p.m. and 9:30 p.m. The LPN was then asked if she contacted the physician regarding the resident's chest pain and/or cough. She showed the surveyor a fax to the physician, dated 03/14/12 at 10:30 p.m., which communicated the resident's cough.

Based on record review, observation and staff interviews, it was determined the facility failed to implement interventions to assess, monitor and prevent a pressure sore from declining, resulting in harm, for one (#5) of two sampled residents with pressure sores. This had the potential to affect three residents with pressure sores, identified on the facility's 'Resident Census and Conditions of Residents' report. The facility's Pressure Ulcer Policy documented, "Objectives Pressure ulcers are a serious concern especially in compromised residents. Using evidence-based treatments, standards of practice, and APIE methodology, this guideline helps the interdisciplinary team to: 1. Prevent pressure ulcers from developing in residents identified as being at risk for developing them. 2. Create care plans for residents who are at risk of developing or have already developed pressure ulcers. 3. Identify newly acquired pressure ulcers. 4. Document the change of condition. 5. Provide standardized treatment and interventions that promote pressure ulcer healing and prevent infection. 6. Evaluate the effectiveness of interventions through the care-planning process and make changes, as necessary, to prevent development of additional pressure ulcers...Notify the physician and responsible party and collaborate on a treatment order. When communicating with the physician, report the resident's pain evaluation results and obtain a physician order [REDACTED]. The facility's Change in Condition of a Resident documented the following: "Policy Statement It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident. Procedure Action Steps 1. The Licensed Nurse determines if there has been a change in condition of a resident. 2. The Licensed Nurse notifies, via telephone, the attending physician and the resident's responsible party of the specific nature of the change of condition. The primary mode of urgent communication is by telephone. Other media such as fax, beeper, email, etc, may be utilized as a secondary method only after initial contact and agreement with the physician..." Resident #5 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]." An initial assessment, dated 11/09/11, identified the resident with cognitive deficits, required total assistance with all ADLs, with the exception of extensive assistance with eating, was frequently incontinent of urine, was continent of bowels, did not currently have a pressure ulcer but was at high risk for pressure ulcers. The assessment had identified the need for a pressure reducing devise for the resident's chair and bed. A care plan, dated 11/12/11, documented the following: "Focus Alteration in Skin integrity r/t <self mobility and incontinence Goals Skin will be free of red, raised or patchy blotches Will be free of itching and scratching Interventions Check for incontinence and provide pericare as needed ac and pc meals, qhs & on rounds during the night Document on Flow Sheet: If skin is intact, mark "Y" If skin is reddened or has open areas, mark "N". Keep resident's fingernails short to avoid damage from scratching. Weekly skin assessment per protocol." The first Weekly skin evaluation had not been completed until 11/26/11. An "I" (skin intact) was documented. A Norton Plus Pressure ulcer Scale dated 12/05/11 documented a score of 10 (10 or less = High Risk). A Change of Condition Documentation Nursing Progress Note, dated 12/05/11, documented, "This nurse called to Res Room During Pericare found wound to coccyx. Total area of redness 4.8 cm x 7.5 cm, open areas R of midline 0.9 x 1.3 cm Stage 2 L of midline 1 cm x 0.9 cm Stage 2. 1 closed area distal to 2nd open area to L of midline is closed. 1 cm x 0.7 cm blister. Family in room at time found. Dr Notified via Fax." A physician's orders [REDACTED]." A nurse's note, dated 12/09/11, documented, "late entry for 12/9/11, 6 pm. New order obtained for [MEDICATION NAME] to coccyx area p (post) cleaning every 3 days. Family aware." The [MEDICATION NAME] had not been started until 12/08/11. A Pressure Ulcer Documentation Form, dated 12/05/11, for the area distal to the coccyx L side, had a hand written note, dated 12/14/11, which documented, "Consolidated c other 3." A Pressure Ulcer/Vascular Ulcer Log, dated 12/14/11, documented, "Wound Observation 12/14/11 Treatment change N (No) Care Plan updated Y (Yes) Stage Current Week 2 Comments, 5 x 6.8 x 0.1 cm Yellow 80%, Bright Red Blood 20%." There was no documentation the physician had been notified of the decline in the pressure ulcer until faxed on 12/19/11. The fax included, under comments, "Was 4 separate wounds, is now one wound." There was no response to the fax by the attending physician. A Skin Review, for the resident documented, "PU (pressure ulcer) site Coccyx x 4, PU stage II...Area measured every week Last date measured 12/14/11...Type of Mattress used facility..." A nurse's note, dated 12/18/11 at 4:31 p.m., documented, "Wound care changed [MEDICATION NAME] cut to fit wound bed, cover c [MEDICATION NAME]. 4 x 4, cover c [MEDICATION NAME] composit 6 x 6 daily on day shift. Dr Notified. Family in room during dressing changed & informed of new tx." The treatment had been discontinued on 12/21/11 and "[MEDICATION NAME] Wound Dressing 1 ea Pad Topical -Day Shift Everyday: Step 1of 3" had been ordered. A Pressure Ulcer/Vascular Ulcer Log, dated 12/23/11, documented, "Wound Observation 12/23/11 Treatment change N (No) Care Plan updated NA (not applicable) Stage Previous Week 2 Stage Current Week 3 Comments, 3 x 9 x 1.5 x 0.1 cm yellow center c 0.8 cm Gray Brown Center Edges Bright Pink." The physician had been notified of the condition of the wound by fax on 12/23/11. A physician's orders [REDACTED]. Ensure that all edges are adheared well-Day Shift Everyday [MEDICATION NAME] NON-Adhesive foam dressing pad 4 x 4 step 2 of 3- cut and use 1/4 of pad. Cover [MEDICATION NAME] with pad-Day Shift Everyday." A nurse's note, dated 12/23/11 at 8:55 p.m., documented, "Dressing to coccyx changed family & Dr Notified." The nurse's notes documented the following: 12/26/11 at 5:30 p.m., "Resident complained earlier "not feeling good temp 99, clammy & spit up x1 this shift. Report given to oncoming nursing. Now resting in bed N/C voiced @ this time." 5:30 p.m., "Res. in bed and has eyes closed. Responds to vigorous verbal stimuli. Res. up in W/C x1 but put back to bed c assistance due to being very stiff and acting as if she had pain to bottom. Back to bed and coccyx checked. Drsg intact c no drainage or odor noted." 7:30 p.m., "T 100.4/T. Tylenol 325 mg tab 2 given P.O. PRN." 8:50 p.m., "T 99.9/T. Resting quietly in bed c eyes closed." 12/27/11 at 1:00 a.m., "Cont monitor temp. Remains afebrile continue monitor." 1:55 p.m., "Dressing changed NO. Hydrogel to coccyx q daily c [MEDICATION NAME] to periwound. Family & Dr Notified. Family is requesting wound care consult. Social worker notified. Dr notified." A physician's orders [REDACTED]." A physician's orders [REDACTED]. Santyl ([MEDICATION NAME]) 250 Unit/GM Ointment Topical (External)- Day Shift Everyday: apply to wound bed of coccyx ulcer. Other Treatment apply moisture barrier to periwound to protect from santyl-Day Shift Everyday. cover coccyx pressure ulcer with [MEDICATION NAME] and secure with bordered gauze daily until healed. Day Shift Everyday." The nurses notes documented the following: 12/28/11 3:30 p.m., "Dressing order changed. See physician orders. Family & Dr Notified."... 12/29/11 435 p.m., "N.O. for swallow study. Therapy is working on obtaining an appointment for the coming week. Family & Dr Notified. Cont. NO. [MEDICATION NAME] 5 mg PO q 6 hours PRN. ^ pain Family & Dr Notified. Cont Diet change per speech therapy & family Req. Dr notified & dietary notified. Cont NO. Wound Consult for coccyx Pressure ulcers & ST to eval for Dif swallowing. Dr & Family Notified LE for 12/29/11, Dr (Name deleted) notified regarding family's concern c Res and their desire to send to ER for Eval. Dr (Name deleted) does not want to send her out but stated "The family can take her if they want to "Im not sending her." Family notified. 12/30/11 12:35 p.m., Dr (Name deleted) paged & then phoned back at 8:50 A. Dr notified of Res change in condition from yesterday to include ^ lethargy decreased response ^ incoherence ^ difficulty c swallowing meds, ^ thick clear phlegm. Dr (Name deleted) stated, "Send to wound care appt and if she needs it send to ER for evaluation after." Order put in to send to ER p Wound clinic if needed. Family notified Res transported to wound clinic appt. ER phoned, Res is to be admitted for [MEDICAL CONDITION]. This nurse asked about wound care. ER nurse stated, "The wound clinic will take care of that while she is here." Family is still c Res @ Hospital." There was no documentation of the condition of the coccyx pressure ulcer after 12/23/11. The pressure ulcer was not assessed, or measured before the resident was sent to the wound clinic and then diverted to the emergency room at the local hospital. The hospital records were retrieved. An "Emergency Physician Record dated 12/30/11 at 9:55 a.m., documented, "decubitus Coccyx 5-6 cm-draining..." A hospital progress note, dated 12/30/11 at 5:09 p.m., documented, "Subjective: The patient presented to the ER with decreased mental status, pain, and inability to perform any activities. She also has a stage 4 wound ulcer on her coccygeal area that was being treated. Physical Therapy was consulted for wound care. Objective: Physical Therapy evaluation was performed with the following results. The wound was located in the coccygeal area measuring 3.5 x 1.0 x 1.2 cm. There was a tunnel at 8 o'clock measuring 1.4 cm deep, a tunnel as 12 o'clock measuring 0.8 cm deep, and a tunnel at 6 o'clock measuring 1.0 cm deep. Eschar and necrotic tissue were covering the wound. The wound was selectively derided with a scalpel and forceps from the subcutaneous level down to the lowest tissue that could be done before bleeding occurred into the fascial layers. There was a strong odor, a sweet, musky odor to the wound. There was [DIAGNOSES REDACTED] surrounding the wound that measured approximately 3 to 4 inches away from the wound bed. The edges of the wound were macerated. There was no drainage today... Assessment: The patient has an unstageable wound at this time secondary to necrotic tissue but it appears to be a stage 3 to stage 4 ulcer. There is significant necrosis and a significant odor to the wound that will need to be assessed for any further wound care. Due to her wound, healing will be compromised secondary to increased white blood cell count, decreased nutrition and decreased ability for the patient to mobile in bed..." A physician's progress note, dated 12/31/11, documented, "Hospitalist ...Wound Has 3 cm Sacral Decub Stage IV frank pus draining... Imp 1. Infection/Sepsis-likely 2 (secondary) to decub 2. Dehydration..." A hospital physician's progress note, dated 01/01/12, documented,...Imp (impression) 1. Decub [MEDICAL CONDITION] syndrome 2. Dysphagia-??thrush 3. [MEDICAL CONDITION]/Dehydration..." A Discharge Summary, dated 01/03/12, documented the following: "admitted [DATE] discharge date [DATE] Discharge Diagnoses: [REDACTED]. 2. Urinary tract infection 3. Acute [MEDICAL CONDITION]. 4. Acute altered mental status 5. Stage 3 to 4 sacral decubitum. 6. Protein-caloric [MEDICAL CONDITION] Hospital Course: This [AGE] year-old white female presents from (Facility name deleted) and was on her way to wound-care clinic for her sacral decubitum when it was felt that she had decreased level of consciousness, and she was diverted to the emergency department for evaluation. The patient was accompanied by her daughter. The daughter states that for the last 3-4 days her level of consciousness has slowly deteriorated. Responsive to only pain at times. The patient also had some difficulty swallowing. According to the daughter she had had some difficult times feeding, decreased appetite, and patient's daughter was unsure if she is getting enough fluids. Decubitum had begun draining the past 3-4 days. Local wound care had been done at the nursing home. However, the drainage had increased and therefore, appointment was made for the wound-care clinic to evaluate and treat... ...Upon presentation, the patient's blood pressure 130/64. Pulse was elevated to 125, temperature 99.3... The patient is very cachectic-appearing. Heart was [MEDICAL CONDITION]. The patient did have a stage III to IV decubitum in the sacral area, about as big as a half-dollar, but had had some tunneling present. Patient's white count was elevated at 49,600 with a left shift. BUN was 64 with a creatinine of 2.73. Patient was clinically dry as well. Urine showed trace of occult blood, and few bacteria, and a moderate amount of sediment. Blood cultures x 2 were drawn in the emergency room , and the patient was placed on the medical floor." After discharge from the hospital, the resident had been admitted to a skilled hospital for long term care. The resident had been discharged from the facility on 01/30/12, then re-admitted on [DATE], with a stage IV pressure sore on the coccyx. A pressure Ulcer/Vascular Ulcer Log, dated 02/08/12, documented the following measurements for the sacral/coccyx pressure ulcer: "Stage Current Week 4 (stage) 4.5 x 2.0 x 0.5 cm c Undermining from 2 o'clock to 6 o'clock to 10 o'clock measuring 1.5 cm..." An initial assessment, dated 02/16/12, identified the resident with cognitive deficits, required total assistance with all ADLs was frequently incontinent of urine and bowels and had a stage IV pressure ulcer. On 03/14/12 at 3:20 p.m., the resident was observed in her room, lying on her back with a pillow flat, under her right side. The resident remained on her back, in a sitting position, during the evening meal, while being fed by staff. Pressure was not relieved from the sacral and coccyx areas. After being fed, the resident was observed lying flat on her back with a pillow flat, under her right side. She remained in the same position until 7:30 p.m. Pressure was not relieved from the sacral and coccyx areas. On 03/14/12 at 7:30 p.m., LPN #1 was observed providing wound care for the pressure sore. LPN #1 measured the wound before the treatment. The wound measured, 4.7 x 3.7 cm, with tunneling at 3.4 cm at 3 o'clock, 0.9 cm at 6 o'clock and 3.0 cm at 9 o'clock. On 03/15/12 at 11:30 a.m., the DON was interviewed regarding the resident's pressure ulcer. He was notified the resident had been identified as being at high risk for pressure sores on the initial assessment. He was notified the first weekly assessment had not been completed until 11/26/11. He reported he was not the DON at that time. He was then asked to review the medical record before the resident had been sent to the emergency roiagnom on [DATE]. He was asked if the pressure sore had been assessed after 12/23/11. He reviewed the record and reported there was no documentation of the wound before being discharged to the hospital. He was asked if the resident's condition had been assessed before the family had requested she be sent to the ER. He reported there was no documentation of the resident's condition. On 03/15/12 at 2:30 p.m., RN #3, who had documented the nurses' notes, before hospitalizion on 12/30/11, was interviewed. She was asked if after the family had requested the resident be sent to the hospital, had she assessed the residents condition. She reported she had been in the resident's room earlier but could not remember details. She was asked if she had taken vital signs or had done a head to toe assessment of the resident when the family member had mentioned the change in the resident's condition. At that time, she reviewed her nurses's notes. She then reported she could not remember specifics about the resident's condition and had not charted anything specific about the resident's condition. On 03/15/12, throughout the day and at the evening meal, the resident remained lying on her back with a pillow flat, either on her right or left sides. Pressure was not relieved from the sacral and coccyx areas. On 03/15/12 at 6:00 p.m., the DON was notified of the resident lying on her back throughout the two day survey. He reported the resident was supposed to be repositioned from side to side off the coccyx and sacral area.

On 09/28/10, an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to assess surgical wounds at the site of an open reduction external fixation of the ankle, and failed to seek medical attention when the resident developed heavy drainage and white/yellow eschar for one sampled resident who had two surgical wounds. The resident was admitted to the hospital and required a [MEDICAL CONDITION]. On 09/28/10 at 2:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 2:50 p.m., the ADM and the corporate RN were notified of the IJ situation, which constituted substandard quality of care. At 7:15 p.m., the facility presented a plan of removal as follows: "...The following plan outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: Center nursing staff will perform head to toe skin assessments of current residents beginning immediately. Assessments will be documented on Skin Evaluation Non-pressure ulcer documentation form, pressure ulcer documentation form with additional documentation in nursing notes as needed. DNS (Director of Nursing Services)/RDCO and designee will notify MD of any identified skin conditions to obtain physician orders. The care plan and nurse aide care card will be updated as indicated and treatment implemented. DNS/Designee will review and monitor treatment orders and documentation of existing skin conditions daily. Clinical staff will be re-educated regarding skin assessment, documentation, physician notification, monitoring and reporting skin changes. Rounds will be completed by the DNS/designee each shift to validate interventions and documentation is in place. An Ad hoc PI meeting will be held with Medical Director, Region Vice President, Administrator and Director of Nursing Services September 29, 2010 to review wound care, both pressure and surgical. Please accept this letter as our credible allegation of compliance for the Notice of Determination of Immediate Jeopardy issued to September 28, 2010." The IJ was removed on 09/29/10 at 10:00 a.m., when all interviewed staff had knowledge of signs and symptoms of infection and to whom to report a change in wound conditions. The deficient practice remained at a pattern level of actual harm. Based on record review, observation and staff interviews, it was determined the facility failed to: a) Ensure surgical wounds were assessed at least weekly and the physician was notified when the surgical wounds developed heavy drainage and white/yellow eschar for one (#3) of two sampled residents with surgical wounds. The resident was transferred to the hospital and required a [MEDICAL CONDITION] of her leg due to a gangrene infection. This had the potential to affect 3 residents identified by the facility with surgical wounds. b) Ensure residents admitted with open wounds were assessed at least weekly per facility policy, for one (#1) of one sampled residents with open wounds. Findings: The facility's policy and procedure for Skin care & Pressure Ulcer Management documented: "...Daily Monitoring: Nursing assistants play a key role in preventing pressure ulcers. Because they work so closely with residents, nursing assistants are most often in a position to identify the development of a pressure ulcer at an early stage. A quick-acting nursing assistant can make a difference in a resident's condition by documenting and communicating new skin issues to the charge nurse immediately, so that treatment can begin as soon as possible. To do this, nursing assistants use the daily skin documentation pad/book. Weekly Evaluation: A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record (TAR)... Investigation Process... Notify the physician and responsible party and collaborate on a treatment order. When communicating with the physician, report the resident's pain evaluation results and obtain a physician order [REDACTED]. 1. The medical record for resident #3 documented the resident had been admitted to the facility 08/20/10. A physician's orders [REDACTED]. "[MEDICATION NAME] 7.5-324 mg tablet... PRN give one tab po q 4 hrs prn pain... [MEDICATION NAME] 50mg tablet by mouth- prn- give one tab po q 8 hours prn pain..." A physician's orders [REDACTED]. (exercise), there act (activities), gait training, neuro reduction, and w/c management in group/individual setting." A care plan, dated 08/21/10, documented: "Focus: (Name deleted resident #3) was admitted to the skilled nursing unit for pt/ot services, for aftercare of an ORIF (open reduction internal fixation) of right ankle... Interventions: Observe toes right lower extremity for color, warmth, etc. with care. Report abnormalities to charge nurse/physician. f/u appt with orthopedic physician as ordered. Keep right lower extremity elevated as much as possible. Treatment to rt ankle as per orders. Monitor for [MEDICAL CONDITION], circulation, pain, etc." A nursing admission assessment documented the resident had several scattered bruises, a cast on her right leg and a black area on top of her left great toe. A nurse's note, dated 08/26/10 at 2:00 p.m., documented, "noted open area to coccyx 0.9 x 0.3 blisters to (R) upper post leg. Cleansed Dr. (Name deleted) and family notified." A nurse's note, dated 08/26/10 at 7:00 p.m., documented, "Res given shower by CNA & aide accidentally stepped on (L) great toe causing 1.2x1 mm abrasion. Cleansed & band-aid applied Dr (Name deleted) notified- attempted to notify spouse/ no answer- skin w/d to touch..." A non-pressure wound and skin condition documentation form, dated 08/26/10, documented the (L) great toe had an abrasion measuring 1.2 cm x 1 cm. No further wound assessments were charted in relation to the abrasion on the left great toe. A non-pressure wound and skin condition documentation form, dated 08/26/10, documented: "Site: (R) posterior upper leg. Wound type code: (blank). Wound measurements: Length: 2 cm. Width: 2 cm." The above was the only documentation in relation to the open area on the posterior side of the upper right leg. A physician's orders [REDACTED]. "[MEDICATION NAME] 500 units/Gm ointment... everyday... cleanse blisters to right upper posterior thigh with NS, pat dry, apply [MEDICATION NAME] and cover with [MEDICATION NAME], secure with medfix daily until healed..." A physician's orders [REDACTED]." A 14 day assessment, dated 08/30/10, documented the resident had adequate short and long term memory, was independent with decision making skills, required extensive assistance with bed mobility, was totally dependant on staff for transferring between surfaces, was not ambulatory, required extensive assistance with hygiene and bathing, experienced moderate pain less than daily, had one stage II pressure ulcer, had abrasions and surgical wounds and received ulcer and surgical wound care. The September 2010, physician's orders [REDACTED]. A nurse's note, dated 09/01/10 at 12:00 p.m., documented, "Returned c N.O. to follow up c Dr (Name deleted) in one week for suture removal, Keep (R) leg dry, walker boot to (R) leg- NWB (non weight bearing)... Cleanse (R) ankle c NS, apply Xeroform, cover c gauze, wrap c [MEDICATION NAME] & secure daily..." A physician's orders [REDACTED]. "Xeroform [MEDICATION NAME] Dressing...4x4 pad topical... everyday...cleanse incision to right ankle with NS, pat dry, apply Xeroform, cover with gauze, wrap with [MEDICATION NAME] and secure with Medifix daily until healed surgical incision. Keflex...500mg capsule...bid for 7 days sutures..." A physician's progress note, dated 09/01/10, documented: "Ortho note... s/p ORIF open (R) bimalleolar ankle fx. Incision/wound c scant serosanguinous drainage. Orders- - Walker boot (R) leg, non-weight bearing. - Change dressing to right ankle daily- xeroform drg (dressing) 4x4s. - Keep leg dry. - Keflex 500mg po bid for 7 days. - F/U (Follow/Up) c Dr (Name deleted) (one) wk for suture removal- arrive early for x-rays right ankle." A nurse's note, dated 09/01/10 at 4:30 a.m., documented, "...Res has a 3 cm x 1 cm open area to (R) inner thigh. Also open blister 2.5 cm x 1 cm." The September 2010 treatment sheet documented daily dressing changes had been completed to the right ankle. The treatment sheet did not contain assessments of the wound or condition of the wound during the dressing changes. The September 2010 treatment sheet documented the treatment to the right upper posterior thigh had been completed six of the 11 times the treatment had been ordered. A nurse's note, dated 09/06/10 at 6:00 a.m., documented, "...Tx done to (R) lower leg. 0 s/s of infection noted..." A nurse's note, dated 09/06/10 at 9:10 p.m., documented, "...Tx to RLE done. 0 s/s of infection noted..." A social service note, dated 09/07/10, documented, "Res also reported to me at this time that tx was not being done all the time on evening shift to right ankle...Reported c/o to administration and DON..." A nurse's note, dated 09/07/10 at 6:00 p.m., documented, "...Sutures to (R) ankle in place & intact. Slight drng (drainage) noted. Drsg changed per clean technique..." A physician's progress note, dated 09/08/10, documented: "Ortho note: (S) 3 weeks s/p ORIF open (R) bimalleolar ankle fx. Pain well controlled. 0 complaints. (O) Incision healing, still area of questionable skin over open area open wound closure but 0 purulent drainage. Heel c area of pressure breakdown... (P) sutures/staples removed today. Dressing changed daily. Dry 4x4's/ Kerlix. Ok to shower s boot or dressing- ok to get incision wet now- no scrubbing, pat dry p shower. Ok to sleep s boot- must be on whenever out of bed except during showers. Continue non-weight bearing, transfers. Follow-up in 4 weeks, sooner prn problems." A physician's orders [REDACTED]. A nurse's note, dated 09/08/10 at 9:00 p.m., documented: "...drsg c light bloody drainage- sutures had been removed- pt stated at Dr's office today- multiple steri-strips on medial & lateral of (R) ankle, cleansed area c N.S.- pat dry c gauze 4x4 applied & wrapped c 1 roll gauze bandage & secured c medi fix tape..." A physician's progress note, dated 09/10/10, documented: "...make sure leg dressing is changed daily...Patient bed at this time. Got good news from her orthopedic doctor. He states that her leg is doing fairly well..." An update to the care plan, dated 09/10/10, documented, "ensure dressings are changed daily." A nurse's note, dated 09/11/10 at 11:00 a.m., documented: "...During wound care noted unstageable wound and stage 2 to (R) calf. In same area where boot stops. Cleansed and dressed, Dr. (Name deleted) notified, N.O, for Santyl..." A physician's orders [REDACTED]. "[MEDICATION NAME] everyday, cleanse open area to right upper calf with NS, pat dry, apply [MEDICATION NAME], cover with gauze, wrap with [MEDICATION NAME] and secure with Medifix daily until healed. Santyl... everyday, cleanse open area to right mid calf with NS, pat dry, apply Santyl to slough tissue, cover with gauze, wrap with Kerlix and secure with Medifix daily until healed, open area- unstageable." A nurse's note, dated 09/12/10 at 12:30 p.m., documented, "...Dressing to (R) ankle, CDI..." A nurse's note, dated 09/12/10, for the 3-11 p.m. shift, documented, "...Stayed in rm for meal- later up to be showered & drsg on R ankle area changed after shower steri strips in place and intact..." A nurse's note, dated 09/13/10 at 4:30 a.m., documented, "...drsg to (R) lower leg C/D/I..." A nurse's note, dated 09/13/10 at 12:30 p.m., documented, "...(R) leg propped up. Drsg CDI..." An update to the care plan, dated 09/13/10, documented, "(Changed) drsg to RLE. Heavy drainage noted on inside of old drsg. Whitish yellow eschar in all wounds. No s/s infection..." There was no documentation to show the physician had been notified of the heavy drainage or of the eschar in the wounds. A nurse's note, dated 09/13/10 at 8:00 p.m., documented, "...No problems @ this time. changed drsg to (R) leg. No s/s infection..." An update to the care plan, dated 09/14/10, documented, "Drsg (changed) RLE, white & yellow eschar noted in all wounds. Heavy drainage noted from interior ankle wound." There was no documentation to show the physician was notified of the eschar in all wounds or the heavy drainage from the interior ankle wound. An update to the care plan, dated 09/15/10, documented, "Drsg to RLE (changed) as ordered. Wounds cont to have whitish yellow eschar. Inner leg wound conts to have heavy drainage." There was no documentation to show the physician was notified of the whitish yellow eschar in the wounds or of the heavy drainage to the inner leg wound. A nurse's note, dated 09/15/10 at 9:30 p.m., documented, "...Res appears pale & is c/o increased pain in RLE unrelieved by prn pain meds...T 100 (degrees) F...will cont to monitor." There was no documentation to show the physician was notified of the residents increased in pain in the right lower extremity which was unrelieved by her pain medications. A nurse's note, dated 09/16/10 at 10:00 a.m., documented, "Notified by PT that pt's (R) leg is hot/red. Noted (lower) leg red/warm to touch. Assisted to room. Dressing to (R) foot saturated c serosanguineous drainage. Removed dressing noted incision to (R) inner ankle macerated, strong odor, wound noted to go down to bone. Wound to top of (R) foot has slough. Noted 2x1 stg 2 to (R) heel. Removed steri strips culture obtained and sent to lab. Cleansed all wounds & redressed. Dr. (Name deleted) notified N.O. to send to orthopedic Dr. stat. Appt c Dr Name deleted) today at 3:15 p.m. Family notified." physician's orders [REDACTED]. "C&S of right ankle wound today." "Appt with Dr. (Name deleted) 9-16-10 at 3:15 PM D/T right ankle wound decline." A report from the physician's office, dated 09/16/10, documented: "Subjective: The patient comes in today and states that she has had some wound breakdown on her wounds and comes in for evaluation, post-op right ankle. The patient is now one month status [REDACTED]. She was doing well at the last hospital visit two weeks post-op when the staples were removed. Now comes in with open draining wound; Denies any further injury. She states that it has been getting progressively worse since she was seen here in the clinic. She states that otherwise she is doing well other then the pain in the right ankle. Objective: The patient dressings were taken down. She has a full thickness wound all the way down to the level of the periosteal on the medial side where the open injury was at the time of surgery with very slight purulent drainage. The remainder of the suture line appears to be healing okay. The lateral suture line had a mild dehiscence not completely down to the level of the fascia. No significant drainage or [DIAGNOSES REDACTED] on that area. Impression: Wound breakdown and probable infection ORIF of right open bimalleolar ankle fracture. Plan: The patient will be admitted to the hospital, kept NPO tonight. We will take her down to the operating room tomorrow; obtain deep cultures. We will do a wound washout and debridement and placement of a wound vac at that time. The patient will be admitted to the hospital and further treatment dictated by the response to treatment." A history and physical, dated 09/16/10, from (Name deleted) hospital documented: "Chief Complaint: Right ankle wound breakdown, status [REDACTED]. History of present illness: (Name deleted) is an 83- year-old female who was treated for [REDACTED]. Patient was admitted to the hospital, 08/16/10, underwent surgery...Patient underwent surgery and was doing well, placed in a splint. Was in (Name deleted) nursing home, did well on initial dressing change. However, the area of open fracture subsequently broke down while patient was supposed to be having daily dressing changes and in a walker boot. With the wound break down, the boot was discontinued and dressing changes were initiated. However now, patient comes in for follow up just under one month, status [REDACTED]. Also, a dehiscence of the lateral wound which looked good the last time the patient was seen in clinic. Patient now is being admitted for wound care... Physical examination:...Musculoskeletal: In the extremities, patient has venous stasis of bilateral lower extremities. The right lower extremity is [MEDICAL CONDITION]. The incision on the lateral side has a dehiscence in the cental area near where the open injury was. Patient previously had an 8 cm laceration, full thickness, to the ankle bone with an open fracture at the time of surgery. This area now has about a 2.5 x 3 cm area that has broken down with soft tissue exposed all the way down to the level of the periosteum. The lateral incision has also had mild dehiscence and excoriation of the opening, but is only do to the level of the fascia. There is no active bleeding at this time. The toes are warm with good capillary refill and are sensate... Plan: Patient will be admitted to the hospital, made NPO after midnight. We will plan on taking her to the operating room tomorrow for debridement, washout and placement of wound-vac on this medial wound, and debridement of the lateral wound. We will then begin regular wound care of the lateral wound on the floor. Plan on leaving the sponge in over the weekend, and we will change and re-evaluate the wound on Monday..." A nursing admission physical assessment from the hospital, dated 09/16/10, documented: "Pressure Wound: Stage 2 to R heel 3 cm in length- see pics. Surgical wound: R posterior calf wound 2 cm wide- clear drng, foul odor, R posterior ankle- deep wound 11 cm in length, clear drainage with foul odor. R lateral calf- 2 cm wound, interior. R ankle- 6 cm wide, purulent drng with foul odor- see pics. Other: R lateral foot bruise 4 cm, left lower leg, large bruise 5 cm wide, left knee- scattered small bruising, left lower leg- bruise 6 cm wide. see pics, scattered bruising to BUE- see pics." A physician's progress note, dated 09/19/10, documented, "...Dr. (Name deleted) plans to take her back to the operating room tomorrow for BKA..." A Report of Operation, dated 09/20/10, documented: "Preop Diagnosis: [REDACTED]. Gangrene/Infection, right ankle, status [REDACTED]. Postop Diagnosis: [REDACTED]. Name of procedure: Right through knee amputation..." A letter, dated 09/24/10, presented by the DON, documented: "To whom it may concern: On September 16, 2010 charge nurse (Name deleted LPN #2) came to me and said would you come look @ (Name deleted resident #3) Rt ankle because she could not find anyone else. When we got back to her room, what looked like to me was @ a 1 inch whole (sic) almost clear to bone, red & hot all the way up to knee. I told (Name deleted LPN #2) let me go get (Name deleted LPN #3), she really should look @ this. I found (Name deleted LPN #3), took her to the room she stated resident should be shipped out to hospital, I thought I heard (Name deleted LPN #3) say she was going to call Dr.(Name deleted), then I left." On 09/27/10 at 10:50 a.m., the DON was asked about wound assessments for the resident's right leg with the surgical incision. The DON reported she had not been aware of the problems with the resident's incision until the resident's daughter brought it to her attention. She reported she had obtained the chart at that time and reviewed it. The RN was then asked if there were wound assessments for the incision and the other areas. She reviewed the documentation list above and reported she had not been able to locate any other wound assessments. At 4:20 p.m., the Corporate RN was interviewed. The RN was shown the skin assessments. She was asked what the facility's policy and procedure was for wound assessments. She stated, "They should be assessed with [REDACTED]. But I don't know that we have a policy stating that." On 09/28/10 at 2:00 p.m., PTA #1 was asked to describe the resident's leg when he reported it to the nursing staff. The PTA reported he had the resident in the therapy room. She was complaining of her leg hurting. He removed the blanket from her lap to reposition her leg. When he did he noticed her leg was red and warm to touch to just below her knee. He reported he then looked at the dressing on her ankle and the dressing was saturated with drainage. That was when he reported the findings to her charge nurse. On 09/29/10 at 8:20 a.m., LPN #2 was asked what the resident's leg had looked like the day she was sent to the physician's office. The LPN reported the steri strips were still intact, there was a small amount of blood on the dressing, the leg was red and warm to touch, a yellow odorous drainage was on the dressing. The wound was very deep almost to the bone and that was when she called the physician. 2. The medical record for resident #1 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Wounds assessed by the facility included the following: a. A non-pressure wound and skin condition form documented: "Site: (L) shoulder-distal: date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 0.5 cm. Width 0.4 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 0.8 cm. Width 0.4 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 0.9 cm. Width 0.6 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 0.9 cm. Width 0.7 cm. date: 9/23/10 Wound type code: 15 (other) Wound measurements: Length 0.7 cm. Width 0.5 cm." The wound to the left distal part of the shoulder was not assessed from 08/05/10 till 09/01/10 and from 09/07/10 till 09/23/10. b. A non-pressure wound and skin condition form documented: "Site: (L) shoulder-proximal: date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 0.4 cm. Width 0.4 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 0.3 cm. Width 0.3 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 0.7 cm. Width 0.5 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 0.8 cm. Width 0.6 cm." The wound to the left proximal part of the shoulder was not assessed from 08/05/10 till 09/01/10 and from 09/07/10 till present 09/27/10. c. A non-pressure wound and skin condition form documented: "Site: (L) lower abd. farthest L: date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 1.5 cm. Width 1 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 1.5 cm. Width 1.2 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 1.4 cm. Width 1.3 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length 1.3 cm. Width 1.2 cm. date: 9/22/10 Wound type code: 15 (other) Wound measurements: Length 2.5 cm. Width 3 cm." The wound to the abdomen lower farthest left was not assessed from 08/05/10 till 09/01/10. d. A non-pressure wound and skin condition form documented: "Site: (L) lower abd. farthest R: date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 1 cm. date: 8/25/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 1 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 1.3 cm. Width 1.4 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 1.3 cm. Width 1.3 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length 1.2 cm. Width 1.3 cm." The wound to the abdomen lower farthest right was not assessed from 08/05/10 till 08/25/10. e. A non-pressure wound and skin condition form documented: "Site: (L) inner thigh. date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 0.9 cm. Width 0.5 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 0.4 cm. Width 0.2 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length .5 cm. Width .3 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 0.8 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length 1.2 cm. Width 0.7 cm. date: 9/23/10 Wound type code: 15 (other) Wound measurements: Length 1.1 cm. Width 0.8 cm." The wound to the left inner thigh was not assessed from 08/05/10 till 09/01/10. f. A non-pressure wound and skin condition form documented: "Site: (R) lower knee- inner. date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 2 cm. Width 1.7 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 0.5 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 2.3 cm. Width 1 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 2.4 cm. Width 1.3 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length 2.3 cm. Width 1.3 cm. date: 9/23/10 Wound type code: 15 (other) Wound measurements: Length 2.1 cm. Width 1.2 cm." The wound to the right lower inner knee was not assessed from 08/05/10 till 09/01/10. g. A non-pressure wound and skin condition form documented: "Site: (R) upper shin. date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 2 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 0.4 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length .7 cm. Width 1 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length .9 cm. Width 1.2 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length .9 cm. Width 1 cm. date: 9/23/10 Wound type code: 15 (other) Wound measurements: Length 0.8 cm. Width 0.9 cm." The wound to the right upper shin was not assessed from 08/05/10 till 09/01/10. h. A non-pressure wound and skin condition form documented: "Site: (R) clustered area upper calf. date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 5.5 cm. Width 3.5 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 5 cm. Width 0.3 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 1 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 1.3 cm. Width 1.2 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length 1.2 cm. Width 1.2 cm. date: 9/23/10 Wound type code: 15 (other) Wound measurements: Length 1.2 cm. Width 1 cm." The wound to the right upper calf was not assessed from 08/05/10 till 09/01/10. i. A non-pressure wound and skin condition form documented: "Site: (R) inner calf. date: 7/26/10 Wound type code: 15 (other) Wound measurements: Length 2 cm. Width 2 cm. date: 8/5/10 Wound type code: 15 (other) Wound measurements: Length 0.3 cm. Width 0.2 cm. date: 9/1/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 1 cm. date: 9/7/10 Wound type code: 15 (other) Wound measurements: Length 1.2 cm. Width 1 cm. date: 9/15/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 1 cm. date: 9/23/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 0.8 cm." The wound to the right inner calf was not assessed from 08/05/10 till 09/01/10. j. A non-pressure wound and skin condition form documented: "Site: (L) upper buttock. date: 8/6/10 Wound type code: 15 (other) Wound measurements: Length 5 cm. Width 3 cm. date: 8/11/10 Wound type code: 15 (other) Wound measurements: Length 1.9 cm. Width 1.2 cm. date: 8/18/10 Wound type code: 15 (other) Wound measurements: Length 0.8 cm. Width 0.2 cm. Healed." k. A non-pressure wound and skin condition form documented: "Site: (L) post foot. date: 9/25/10 Wound type code: 15 (other) Wound measurements: Length 1 cm. Width 1 cm." A care plan, dated 08/10/10, documented: "Problem: Altered Skin Integrity AEB: Multiple wound over entire body related to: Insect bites and (Name deleted resident #1) picking at sores... Interventions: Administer treatment as ordered. Change dressing as per order. Notify MD if wounds worsen or s/s of infection increase or persist. Observe insect bites for signs/symptoms of infection (redness, warmth, [MEDICAL CONDITION], pain/tenderness, drainage). Notify MD if symptoms increase or persist." An updated note on a care plan, dated 08/28/10, documented, "Res continues to have multiple areas of open sores from admission seed ticks have been identified. She continues to scratch..." A nurse's note, dated 09/17/10 at 2:00 p.m., documented, "...scratching abd. Educated on risk of scratching, voiced understanding..." A nurse's note, dated 09/18/10 at 12:45 a.m., documented, "...open areas noted to all ext..." A nurse's note, dated 09/18/10 at 7:00 p.m., documented, "...Res scratching open areas on (L) hip et upper (R) thigh causing them to bleed et ooze serosanguinous drng. Open areas c drng cleaned c NSS et covered c gauze. PRN [MEDICATION NAME] effective..." A 60 day assessment dated [DATE], documented the resident had inadequate short term memory, adequate long term memory, was moderately impaired with decision making skills, required limited assistance with bed mobility, required extensive assistance with transferring between surfaces, was not ambulatory and was incontinent of bowel and bladder. A nurse's note, dated 09/19/10 at 5:00 a.m., documented, "Message faxed to Dr (Name deleted) R/T res open wounds to (L) hip et upper (R) thigh c serosanguinous drng..." A nurse's note, dated 09/19/10 at 5:30 p.m., documented, "...res on contact isolation [MEDICAL CONDITION] in wounds..." A nurse's note, dated 09/20/10, documented, "N.O. rec'd 1.) culture wound on (L) hip and (R) thigh. 2.) Apply [MEDICATION NAME] to open wounds BID after cleansing." A nurse's note, dated 09/22/10 at 2:00 p.m., documented, "...cont c large open wounds to hips/thighs. Pt continues to scratch. Educated daily on risks from scratching, voices understanding..." A nurse's note, dated 09/25/10 at 1:00 p.m., documented, "Cont c SNF. Notified by CNA of blister to L foot. Noted serous-filled dime size blister to post (L) foot... Cleansed & left OTA (open to air). Dr (Name deleted) aware... A nurse's note, dated 09/25/10 at 10:00 p.m., documented, "...cont c SNF care has large amount open areas on trunk of body esp (L) side that she scratches all the time ointment applied. Contact precautions for open wounds." A nurse's note, dated 09/26/10 at 11:00 p.m., documented, "...Res has large open areas to bilat arms, (L) side and lower extremities. On contact isolation..." On 09/27/10 at 2:00 p.m., LPN #4 and LPN #5 were observed to provide wound care and assessment for the resident. The resident was observed to have numerous open areas over her entire body. LPN #5 reported they would all be stage II. A large one on the resident's left hip measured 4.5 X 3.5 cm. LPN #5 was observed to clean the open wounds with normal saline and apply Mupirocin and cover with gauze. The LPNs were asked how often the wounds should be asses

On 09/28/10, an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to assess, obtain treatment orders and treat pressure sores for one (#3) sampled resident who had pressure sores. On 09/28/10 at 2:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 2:50 p.m., the ADM and the corporate RN were notified of the IJ situation, which constituted substandard quality of care. At 7:15 p.m., the facility presented a plan of removal as follows: "...The following plan outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: Center nursing staff will perform head to toe skin assessments of current residents beginning immediately and continuing weekly. The 24 hour change in condition report including newly identified skin conditions will be discussed in the morning clinical stand up meeting to validate physician notification and treatments are documented and to assure proper inventions are implemented correctly. Rounds will be completed by the DNS (Director of Nursing Services)/designee each shift to validate interventions and documentation is in place. Skin assessments will be documented on non-pressure ulcer documentation form or pressure ulcer documentation form to include measurements with additional documentation in nursing notes as needed. DNS/RDCO and designee will review skin assessments to ensure treatments are in place and skin areas have appropriate treatments ordered by the physician. DNS will notify MD of any previously unidentified skin issues and ensure any new orders are in place. Wound/Skin treatments will be care planned accordingly. Clinical staff will be re-educated regarding skin assessment, documentation, and physician notification, monitoring and reporting skin changes. An Ad hoc PI meeting will be held with Medical Director, Regional Vice President, Administrator and Director of Nursing Services on September 29, 2010 to review wound care, both pressure and surgical. Please accept this letter as our credible allegation of compliance for the Notice of Determination of Immediate Jeopardy issued on September 28, 2010." The IJ was removed on 09/29/10 at 10:00 a.m., when all interviewed staff had knowledge of signs and symptoms of infection and to whom to report a change in wound conditions. The deficient practice remained at a pattern level of actual harm. Based on record review, observation and staff interviews, it was determined the facility failed to: a) Ensure pressure sores were identified, treatment orders were obtained from the physician and treatments were administered for one (#3) of one sampled residents with pressure sores. This had the potential to affect 10 residents identified by the facility as having pressure sores. Findings: The facility's policy and procedure documented: "Skin care & Pressure Ulcer Management Program Standard This Skin Care & Pressure Ulcer Management Guideline describes the interdisciplinary approach to managing pressure ulcers, the cornerstone of which is the "War on Wounds" program and uses the "APIE" approach to care giving. Assess, Plan, Implement & Evaluate. The program relies on evidence-based treatment protocols and standards of practice and focuses on two aspects of care: Prevention of pressure ulcer development to promoting healing and preventing infection when skin breakdown occurs. Treatment- using a standardized approach to promoting healing and preventing infection when skin breakdown occurs. This program uses a variety of reports and other tools to identify and analyze care outcome trends, to support continuous quality improvement efforts. Objectives: ...Identify newly acquired pressure ulcers. ...Provide standardized treatment and interventions that promote pressure ulcer healing and prevent infection. ...Daily Monitoring: Nursing assistants play a key role in preventing pressure ulcers. Because they work so closely with residents, nursing assistants are most often in a position to identify the development of a pressure ulcer at an early stage. A quick-acting nursing assistant can make a difference in a resident's condition by documenting and communicating new skin issues to the charge nurse immediately, so that treatment care begin as soon as possible... Weekly Evaluation: A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record (TAR)... ... Notify the physician and responsible party and collaborate on a treatment order. When communicating with the physician, report the resident's pain evaluation results and obtain a physician order [REDACTED]. The medical record for resident #3, documented the resident had been admitted to the facility 08/20/10. A physician's orders [REDACTED]. "[MEDICATION NAME] 7.5-324 mg tablet... PRN give one tab po q 4 hrs prn pain... [MEDICATION NAME] 50mg tablet by mouth- prn- give one tab po q 8 hours prn pain..." A care plan, dated 08/21/10, documented: "Focus: (Name deleted resident #3) was admitted to the skilled nursing unit for pt/ot services, for aftercare of an ORIF (open reduction internal fixation) of right ankle... Interventions: Observe toes right lower extremity for color, warmth, etc. with care. Report abnormalities to charge nurse/physician. f/u appt with orthopedic physician as ordered. Keep right lower extremity elevated as much as possible. Treatment to rt ankle as per orders. Monitor for [MEDICAL CONDITION], circulation, pain, etc." A nurse's note, dated 08/26/10 at 2:00 p.m., documented, "noted open area to coccyx 0.9 x 0.3 blisters to (R) upper post leg. Cleansed Dr. (Name deleted) and family notified." A non-pressure wound and skin condition documentation form dated 08/26/10, documented: "Site: (R) posterior upper leg. Wound type code: (blank). Wound measurements: Length: 2 cm. Width: 2 cm." This was the only documentation in relation to the open area on the posterior side of the upper right leg. A physician's orders [REDACTED]. "[MEDICATION NAME] 500 units/Gm... everyday... cleanse blisters to right upper posterior thigh with NS, pat dry, apply [MEDICATION NAME] and cover with [MEDICATION NAME], secure with medfix daily until healed..." A pressure ulcer documentation form, dated 08/26/10, documented: "Site: Coccyx. Wound measurements: Length: 1.5 cm Width: 0.3 cm" A physician's orders [REDACTED]. "[MEDICATION NAME] Skin Protectant topical, everyday, cleanse open area to coccyx with NS, pat dry, apply [MEDICATION NAME] q shift until healed Stage 2..." The pressure sore was not assessed again until 09/06/10. At that time, a nurses note documented it was healed. A 14 day assessment, dated 08/30/10, documented the resident had adequate short and long term memory, was independent with decision making skills, required extensive assistance with bed mobility, was totally dependant on staff for transferring between surfaces, was not ambulatory, required extensive assistance with hygiene and bathing, experienced moderate pain less than daily, had one stage II pressure ulcer, had abrasions and surgical wounds and received ulcer and surgical wound care. The September 2010, physician's orders [REDACTED]. A nurse's note, dated 09/01/10 at 12:00 p.m., documented, "Returned c N.O. to follow up c Dr (Name deleted) in one week for suture removal, Keep (R) leg dry, walker boot to (R) leg- NWB (non weight bearing)... Cleanse (R) ankle c NS, apply Xeroform, cover c gauze, wrap c [MEDICATION NAME] & secure daily..." A nurse's note, dated 09/01/10 at 4:30 a.m., documented, "...Res has a 3 cm x 1 cm open area to (R) inner thigh. Also open blister 2.5 cm x 1 cm." The September 2010 treatment sheet documented the treatment to the right upper posterior thigh had been completed six of the 11 times the treatment had been ordered. A physician's progress note, dated 09/08/10 at 10:44 a.m., documented, "...Heel c area of pressure breakdown..." The facility did not contact the physician to obtain a treatment order for the pressure sore on the resident's heel, nor was an assessment completed on the pressure sore, until the resident was discharged from the facility on 09/16/10. A nurse's note, dated 09/11/10 at 11:00 a.m., documented, "...During wound care noted unstageable wound and stage 2 to (R) calf. In same area where boot stops. Cleansed and dressed, Dr. (Name deleted) notified, N.O, for Santyl..." A pressure ulcer documentation form, dated 09/11/10, documented: "Site: (R) calf. Stage: 2 Wound Measurements: Length: 0.4 cm. Width: 0.4 cm. A pressure ulcer documentation form, dated 09/11/10, documented: "Site: (R) calf. Stage: U. Wound Measurements: Length: 1.5 cm. Width: 1 cm." A physician's orders [REDACTED]. Santyl... everyday, cleanse open area to right mid calf with NS, pat dry, apply Santyl to slough tissue, cover with gauze, wrap with Kerlix and secure with Medifix daily until healed, open area- unstageable." A care plan, dated 09/11/10, documented, "DC walker boot cleanse, unstageable to (R) calf apply santyl & dressing daily. Cleanse stg 2 apply [MEDICATION NAME] & dressing daily. Monitor for s/sx of infect, notify Dr as needed." A nurse's note, dated 09/15/10 at 9:30 p.m., documented, "...res appears pale & is c/o increased pain in RLE unrelieved by prn pain meds...T 100(degrees) F...will cont to monitor." A nurse's note, dated 09/16/10 at 10:00 a.m., documented, "Notified by PT that pt's (R) leg is hot/red. Noted (lower) leg red/warm to touch. Assisted to room. Dressing to (R) foot saturated c serosanguineous drainage. Removed dressing noted incision to (R) inner ankle macerated, strong odor, wound noted to go down to bone. Wound to top of (R) foot has slough. Noted 2x1 stg 2 on (R) heel... (Name deleted) notified N.O. to send to orthopedic Dr. stat. Appt c Dr (Name deleted) today at 3:15 p.m. Family notified." The resident was seen at the physician's office and then admitted to the hospital. A history and physical, dated 09/16/10, from (Name deleted) hospital documented: "Chief Complaint: Right ankle wound breakdown, status [REDACTED]. History of present illness: (Name deleted) is an 83- year-old female who was treated for [REDACTED]. Patient was admitted to the hospital. 08/16/10, underwent surgery...Patient underwent surgery and was doing well, placed in a splint. Was in (Name deleted) nursing home, did well on initial dressing change. However, the area of open fracture subsequently broke down while patient was supposed to be having daily dressing changes and in a walker boot. With the wound break down, the boot was discontinued and dressing changes were initiated. How ever now, patient comes in for follow up just under one month, status [REDACTED]. Also, a dehiscence of the lateral wound which looked good the last time the patient was seen in clinic. Patient now is being admitted for wound care... Physical examination:...Musculoskeletal: In the extremities, patient has venous stasis of bilateral lower extremities. The right lower extremity is [MEDICAL CONDITION]. The incision on the lateral side has a dehiscence in the cental area near where the open injury was. Patient previously had an 8 cm laceration, full thickness, to the ankle bone with an open fracture at the time of surgery. This area now has about a 2.5 x 3 cm area that has broken down with soft tissue exposed all the way down to the level of the periosteum. The lateral incision has also had mild dehiscence and excoriation of the opening, but is only do to the level of the fascia. There is no active bleeding at this time. The toes are warm with good capillary refill and are sensate... Plan: Patient will be admitted to the hospital, made NPO after midnight. We will plan on taking her to the operating room tomorrow for debridement, washout and placement of wound-vac on this medical wound, and debridement of the lateral wound. We will then begin regular wound care of the lateral wound of the floor. Plan on leaving the sponge in over the weekend, and we will change and re-evaluate the wound on Monday..." A nursing physical admission assessment from the hospital dated 09/16/10, documented: "Pressure Wound: Stage 2 to R heel 3 cm in length- see pics. Surgical wound: R posterior calf wound 2 cm wide- clear drng, foul odor, R posterior ankle- deep wound 11 cm in length, clear drainage with foul odor. R lateral calf- 2 cm wound, interior. R ankle- 6 cm wide, purulent drng with foul odor- see pics. Other: R lateral foot bruise 4 cm, left lower leg, large bruise 5 cm wide, left knee- scattered small bruising, left lower leg- bruise 6 cm wide. see pics, scattered bruising to BUE- see pics." A physician's progress note, dated 09/19/10, documented, "...Dr. (Name deleted) plans to take her back to the operating room tomorrow for BKA..." A Report of Operation, dated 09/20/10, documented: "Preop Diagnosis: [REDACTED]. Gangrene/Infection, right ankle, status [REDACTED]. Postop Diagnosis: [REDACTED]. Name of procedure: Right through knee amputation..." A letter, dated 09/24/10, presented by the DON, documented: "To whom it may concern: On September 16, 2010 charge nurse (Name deleted LPN #2) came to me and said would you come look @ (Name deleted resident #3) Rt ankle because she could not find anyone else. When we got back to her room, what looked like to me was @ a 1 inch whole (sic) almost clear to bone, red & hot all the way up to knee. I told (Name deleted LPN #2) let me go get (Name deleted LPN #3), she really should look @ this. I found (Name deleted LPN #3), took her to the room she stated resident should be shipped out to hospital, I thought I heard (Name deleted LPN #3) say she was going to call Dr. (Name deleted), then I left." On 09/27/10 at 10:50 a.m., the DON was asked about pressure sore assessments for the residents right leg and heel. The DON reported she had not been aware of the problems with the resident's skin. However when the resident's daughter had brought it to her attention she had obtained the resident's chart and reviewed it. The DON was then asked if she had been able to obtain skin assessments for the pressure sore. She stated, "This is all I could locate." At 4:20 p.m., the Corporate RN was interviewed. The RN was shown the skin assessments. She was asked what the facility's policy and procedure was for pressure sore assessments. She stated, "They should be assessed with [REDACTED]."

Based on record review and staff interviews, it was determined the facility failed to ensure two (#5 and #15) of eight sampled residents who had experienced falls, received adequate supervision and assistance to prevent falls. This resulted in actual harm for resident #15, who sustained a left hip fracture. This had the potential to affect 29 residents identified by the facility's resident level quality measure/indicator report with falls. Findings: 1. Resident #15 was admitted to the facility on [DATE], with multiple medical [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented the following: "Focus: Risk for falls related to use of psychotropic medications, unsteady gait Goals: No significant injury related to a fall Interventions: Assist (Resident name deleted) with getting in and out of bed with assistance using a roll walker Encourage resident to communicate needs/ask for assistance Encourage resident to transfer and change positions slowly..." A quarterly assessment, dated [DATE], documented the resident was moderately cognitively impaired and had both short and long term memory problems. The resident needed extensive assistance with transfers, was unable to ambulate and had fallen in the past 30 days and in the past ,[DATE] days. An interdisciplinary progress note, dated [DATE] at 1:30 a.m., documented, "CNA reported to charge nurse resident fell with skin tear to right hip. Dr notified, family notified, DON notified, SN obtained orders to have resident sent out to hospital. Resident stated, 'I slid out of bed trying to get up and go to bathroom' Resident confused stated, 'I don't know how it happened, it happened so fast.' Vital signs obtained." A facility incident report, dated [DATE], documented the following: "At approximately 0130 CNA answered call light. Resident was found in bathroom by CNA with blood on her right leg and hip. CNA reported findings to charge nurse. CNA stated 'Resident fell in room unwitnessed and bleeding from right hip and resident stated that she fell .' SN nurse to pt room observed pt in bathroom on toilet. Right hip bleeding and SN asked pt what happened. Pt stated, 'I slid out of bed I was wanting to go to bathroom' Evidence of blood trail show pt got up and went ahead to bathroom...Pt complained of pain upon ambulation...pt to hospital for x-ray to check for fx. 911 called... Relevant History: Has hx of dementia confusion will continue to monitor pt more frequently to assist pt to restroom at pt request and as needed to prevent future falls." No other preventative measures were documented to prevent further falls. An interdisciplinary progress note, dated [DATE] at 6:45 a.m., documented, "Res yelling out 'Help' res on the floor in middle of room on her hands and knees. Asked res what happened. States, 'I got up and fell by the bed'...complained of pain and had abrasion to left buttock..." The resident was sent to the local hospital via emergency medical services and was diagnosed with [REDACTED]. No documentation was found to indicate the facility implemented any further measures to prevent injuries. On [DATE], the resident returned to the facility. The resident's hip fx was not able to be set by surgery, due to medical complications. An interdisciplinary progress note, dated [DATE] at 8:15 p.m., documented, "Resident yelling 'Help.' Entered resident's room. Resident found on floor beside bed lying on her right side..." No documentation was found to indicate the facility implemented any further measures to prevent injuries until [DATE] at 9:00 p.m. An interdisciplinary progress note, dated [DATE] at 9:00 p.m., documented, "Resident being very persistent about wanting to get up. Resident turned and repositioned to make more comfortable. New low bed arrived, resident transferred at that time. Fall mat in place new mat approx 6 inches thick at bedside." The resident expired on [DATE]. On [DATE] at 4:30 p.m., the DON and ADON were interviewed regarding the multiple falls experienced by the resident, with no identifiable interventions. The ADON reported she would investigate the falls further to see if there were any interventions put in place other than to verbally remind the confused resident to use the call light. On [DATE] at 10:00 a.m., the ADON reported the facility had placed a bed alarm on the resident prior to the injury but was uncertain when it was placed. There was no documentation in the medical record of an alarm being placed on the resident or the resident's bed. She reported the low bed and mattress had not been initiated until after the resident's fall with a fracture. 2. Resident #5 was admitted to the facility on [DATE]. The resident had multiple [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident had short term memory problems, required physical assistance with transfers, did not ambulate, had fallen in the past 30 days and in the past ,[DATE] days. A risk management system events form, dated [DATE] at 9:36 a.m., documented, "Summoned to Rm...per HSKPG (housekeeping). Resident found on her knees in front of w/c, next to bed...No visible injuries noted..." No steps to prevent reoccurrence were found in the medical record. A risk management system events form, dated [DATE] at 7:30 p.m., documented, "resident found sitting on her knees in front of W/C. no apparent injuries" The facility staff placed a bed alarm in the resident's bed. A facility risk management system events form, dated [DATE] at 2:00 p.m., documented, "CNA came to this nurse stating res on floor. CNA reports volunteer reported to him res on floor. Upon entering room res found sitting on floor on buttocks beside bed. Res stated to this nurse got out of W/C to go to bed, sit on edge of bed and slid off landing on bottom. Checked res no visible injuries noted. Res able to move all extremities with out difficulty. Res denies hitting hesd (sic). Neuros initiated due to unwitnessed fall." No further steps to prevent reoccurrence were located. On [DATE] at 9:00 a.m., the ADON was asked about the lack of steps to prevent reoccurrence of falls for the resident. She stated, "We are working on making interventions more appropriate."