Every finding on record at Seminole Pioneer Nursing Home

Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for 2 (#1 and #3) of 3 sampled residents reviewed for abuse. The administrator identified 44 residents resided in the facility. Findings: An undated facility policy titled 'Allegations of Abuse, Neglect, Exploitation or Mistreatment,' read in part, Definitions: 'Abuse' is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 1. An undated admission record showed Res #1 had diagnoses which included schizoaffective disorder, mild cognitive impairment, and major depressive disorder. A quarterly assessment, dated 03/10/25, showed the resident was cognitively intact and had a BIMS of 15. The assessment showed the resident did not have verbal or physical behaviors directed toward others. An OSDH incident report, dated 05/12/25, showed Res #1 stated Res #2 had grabbed their breasts. The report showed no staff witnessed the incident. The report showed Res #2 had been in staff line of site over the past few days due to manic behaviors. On 05/15/25 at 12:45 p.m., Res #1 was sitting in the lobby area for the lunch meal. The resident stated they did not want to eat in the dining room because Res #2 was in the dining room and they were loud and disruptive. The resident stated they would leave the area or go to their room if Res #2 entered the area. On 05/15/25 at 2:30 p.m., the DON stated Res #2 was monitored per the incident report line of site. The stated they could not provide documentation regarding the line of site monitoring. The DON stated per the investigation the facility could not substantiate the incident regarding Res #2 grabbing Res #1's breasts. On 05/19/25 at 2:03 p.m., the care plan coordinator stated the care plan for Res #2 should have been updated with new behavior interventions after each incident and was not. 2. An undated admission record showed Res #3 had diagnoses which included vascular dementia with behavioral disturbances, schizoaffective disorder bipolar type, mood affective disorder, and moderate intellectual disabilities. A quarterly assessment, dated 04/22/25, showed Res #3 was moderately impaired for daily decision making. The assessment showed the resident did not have verbal or physical behaviors directed toward others. An OSDH incident report, dated 05/10/25, showed a facility CMA witnessed Res #2 hit Res #3 in the face unprovoked. The report showed the other resident was redirected. The report showed the police were notified and spoke with Res #3 and staff. An incident note, dated 05/10/25 at 7:25 a.m., showed Res #3 was sitting in the lobby when another resident hit them in the face. 3. An undated admission record showed Res #2 had diagnoses which included dementia with behavioral disturbances, mood disorder, psychosis, schizophrenia, and major depressive disorder. A discharge return anticipated assessment, dated 04/17/25, showed the resident was modified independent for daily decision making. The assessment showed the resident had verbal behaviors directed toward others. An OSDH incident report, dated 05/10/25, showed Res #2 hit Res #3 in the face. The report showed the police arrived and spoke with Res #2 and staff. The report showed the police had been called to the facility before regarding other incidents regarding Res #2. A incident note, dated 05/10/25 at 7:25 a.m., showed Res #2 was pacing around in the lobby area. The note showed the resident hit another resident in the face who was sitting in the lobby area. A behavior note, dated 05/10/25 at 7:40 a.m., showed the police were present in the facility regarding the incident. The note showed after the police left the facility, Res #2 was pacing the hallways, rammed the front door with their shoulder, kicking a trash can, yelling, and cussing. The note showed the resident was disruptive to residents and staff. The note showed the resident was redirected, but was only effective for short periods of time. The note showed the police were notified again at 7:40 p.m. due to the resident yelling, cussing, and kicking the wall. A behavior note, dated 05/11/25 at 4:02 p.m., showed Res #2 was in the lobby yelling, cussing, hitting the wall, and kicking the front door. The note showed attempts to calm the resident was unsuccessful. The note showed the facility notified the APRN and the resident's antipsychotic medication was adjusted. A behavior note, dated 05/11/25 at 9:08 p.m., showed Res #2 was more calm with occasional outbursts. A behavior note, dated 05/12/25 at 10:19 a.m., showed Res #2 had been instigating arguments and verbal altercations with peers. The note showed the resident had to be separated from peers and redirected to a different area. A behavior note, dated 05/12/25 at 2:38 p.m., showed the resident continued with erratic behavior an unable to redirect. The note showed disruption to peers environment, was asked not to get in faces of others or in their personal space. The note showed continued rambling, delusions, and hallucinations.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2 hour required time frame for 1 (#3) of 3 sampled residents reviewed for abuse The administrator identified 44 residents resided in the facility. Findings: An undated facility policy titled Allegations of Abuse, Neglect, Exploitation or Mistreatment, read in part, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, .All alleged violations, whether oral or in writing, must be immediately reported to the Administrator of this facility and to other officials in accordance with State law through established procedures. An undated admission record showed Res #3 had diagnoses which included vascular dementia with behavioral disturbances, schizoaffective disorder bipolar type, mood affective disorder, and moderate intellectual disabilities. A quarterly assessment, dated 04/22/25, showed Res #3 was moderately impaired for daily decision making. The assessment showed the resident did not have verbal or physical behaviors directed toward others. An OSDH incident report, dated 05/10/25, showed a facility CMA witnessed Res #2 hit Res #3 in the face unprovoked. The report showed the other resident was redirected. The report showed the local police were notified at 7:25 a.m. and were present in the facility at 7:40 a.m. A fax transmittal page showed the state agency was notified of the incident occurring on 05/10/25 at 4:05 p.m. The facility failed to report to the State Agency within the two hour time frame for the incident on 05/10/25 after the police waere notified at 7:25 a.m. On 05/19/25 at 10:55 a.m., the DON stated the incident on 05/10/25 happened over the weekend. The DON stated the OSDH incident report was submitted by the weekend charge nurse. The DON stated it was not reported within the two hour required time frame. The DON stated the administrator was unable to be contacted.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 (#3) of 3 sampled residents reviewed for abuse. The administrator identified 44 residents resided in the facility. Findings: An undated facility policy titled Abuse Prevention Program, read in part, This facility has developed comprehensive policies and procedures to prevent abuse, neglect, exploitation, or mistreatment of residents. The abuse prevention program provides policies and procedures that govern, as a minimum: .f. Development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse, and resident to staff abuse, etc. g. Timely and thorough investigations of all reports and allegations of abuse. An undated admission record showed Res #3 had diagnoses which included vascular dementia with behavioral disturbances, schizoaffective disorder bipolar type, mood affective disorder, and moderate intellectual disabilities. A quarterly assessment, dated 04/22/25, showed the resident was moderately impaired for daily decision making. The assessment showed the resident did not have verbal or physical behaviors directed toward others. An OSDH incident report, dated 05/10/25, showed a facility CMA witnessed Res #2 hit Res #3 in the face unprovoked. The report showed the other resident was redirected. The report showed the local police were notified and were present in the facility at 7:40 a.m. A review of the investigation documentation regarding the incident on 05/10/25 for Res #3 was completed. There were no staff or resident statements regarding the incident. On 05/15/25 at 2:30 p.m., the DON stated the incident on 05/10/25 did not have staff or resident statements documenting what occurred. The DON stated it was not a thorough investigation.

Based on observation and interview, the facility failed to ensure foods in the kitchen were dated and labeled. The administrator reported 50 residents resided in the facility. Findings: On 11/03/24 at 8:45 a.m, a tour of kitchen was conducted. A commercial refrigerator was observed to contain a pitcher of brown liquid, a pitcher of yellow liquid, 11 cups of different colored liquids, and a pitcher of fruit. There were no dates or labels on the food products. On 11/03/24 at 9:21 a.m., [NAME] #1 reported everything in the refrigerator should have been dated and labeled.

Based on observation, record review, and interview, the facility failed to maintain an infection control program for enhanced barrier precautions for one (#33) of one sampled resident reviewed for wound care. MDS Coordinator #1 identified three residents with pressure ulcers. Findings: An Enhanced Barrier Precautions policy, undated, read in parts, Enhanced Barrier Precautions refer to an infection designated to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions .An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers .and/or indwelling medical devices (e.g., urinary catheters) .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact resident care activities include: wound care: any skin opening requiring a dressing .Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Res #33 had diagnoses which included stage III left heel pressure ulcer, dementia, and cerebral infarction. An admission assessment, dated 02/20/24, documented the resident was cognitively intact, required setup to partial assistance with mobility, and had one stage III pressure ulcer present upon admission. A physician's order, dated 09/11/24, documented to cleanse left heel with normal saline, apply five tobramycin eye drops to wound bed, apply Medihoney, then apply calcium alginate to wound bed, apply Exudry pad and secure with kerlix and tape one time a day for open wound. On 11/03/24 at 12:08 p.m., Res #33 was observed lying in bed. A gauze dressing was observed wrapped around Res #33's left heel. Res #33 stated they had a wound on the back of their heel and the staff provided wound care daily. On 11/05/24 at 10:52 a.m., LPN #1 was observed performing wound care on Res #33. LPN #1 was observed to have worn gloves during the treatment. LPN #1 was not observed to have worn a personal protective gown during the wound care treatment. No personal protective equipment was observed outside or near Res #33's room. On 11/05/24 at 12:15 p.m., the DON stated they had never heard of enhanced barrier precautions. They stated the IP was responsible for infection control and the facility had not implemented enhanced barrier precautions. On 11/05/24 at 12:30 p.m., CNA #1 stated they had not been educated on the use of enhanced barrier precautions during high-risk activities for residents with pressure wounds. On 11/05/24 at 12:56 p.m., LPN #1 stated they should have donned a gown prior to providing wound care on Res #33. They stated the facility had not implemented the use of enhanced barrier precautions. On 11/05/24 at 1:07 p.m., the IP stated the facility had not implemented the use of enhanced barrier precautions.

Based on observation, record review, and interview, the facility failed to develop a care plan for smoking for one (#32) of one sampled resident reviewed for smoking and failed to develop a care plan for a wound for one (#48) of two sampled residents reviewed for pressure ulcers. The administrator identified eight residents who smoked. MDS Coordinator #1 identified three residents with wounds. Findings: 1. Res #32 had diagnoses which included history of stroke and hypertension. On 11/04/24 at 9:06 a.m., Res #32 was observed on the front porch of the facility smoking a cigarette during the facility designated smoking time. A record review did not document a smoking care plan was developed for Res #32. On 11/04/24 at 3:20 p.m., MDS Coordinator #1 stated Res #32's care plan should have included smoking. 2. Res #48 admitted to the facility on [DATE] with diagnoses which included schizophrenia. A physician's order, dated 10/16/24, documented to cleanse wound to left upper buttocks with wound cleanser, pat dry, apply calcium alginate, and cover with dressing. A record review did not document a wound care plan. On 11/04/24 at 2:22 p.m., MDS Coordinator #1 stated there should have been a wound care plan, but there was not.

Based on observation, record review, and interview, the facility failed to obtain a physician's order for a catheter for one (#14) of one sampled resident reviewed for catheters. The administrator identified 50 residents resided in the facility. Findings: Res #14 was admitted with diagnoses which included chronic kidney disease, Parkinson's without dyskinesia, COPD, and personal history of UTIs. On 11/03/24 at 1:49 p.m. Resident #14 was observed resting in their bed with their eyes open. The resident's catheter was observed draining to gravity at bedside. The resident's record was reviewed and did not contain a physician's order for the catheter. On 11/05/24 at 10:25 a.m., LPN#1 reported the resident had a catheter since May 2022 due to a wound that had to be surgically repaired. On 11/05/24 at 10:52 a.m., MDS Coordinator #1 was informed there was no order for a catheter. They reported there should have been an order for the catheter.

Based on record review, and interview, the facility failed to ensure residents were free of significant medication errors for one (#49) of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents resided in the facility. Findings: Res #49 had diagnoses which included mood disorders. A physician's order, dated 10/21/24, documented to administer Zyprexa (an antipsychotic) 5 mg at bedtime for mood disorder. An October 2024 MAR documented blanks for the PM doses of Zyprexa on 10/22/24 and 10/30/24. A behavior monitoring tracker for October 2024 documented Res #49 had behaviors on 10/22/24 and 10/30/24. On 11/05/24 at 9:22 a.m., CMA #1 stated the blanks on the MAR meant the medication was not given. On 11/05/24 at 9:24 a.m., the DON stated there was no way to prove the medications were administered if the administration record was blank. They were made aware of the resident's behaviors on the days the medication was not given. They shrugged and had no additional comment regarding the behaviors.

Based on record review and interview, the facility failed to ensure a significant change assessment had been completed after a resident admitted to hospice for one (#30) of 17 sampled residents reviewed for assessments. The administrator identified 50 residents in the facility. Findings: Resident #30 admitted to the facility with diagnoses which included dementia. A physician's order, dated 06/06/24, documented the resident was admitted to hospice. The resident's record was reviewed and contained no documentation a significant change assessment had been completed. On 11/04/24 at 1:31 p.m., MDS Coordinator #1 reported a significant change assessment should have been completed when the resident admitted to hospice.

Based on record review and interview, the facility failed to accurately complete a level I PASARR for a new admit resident for one (#48) of one sampled resident reviewed for a PASARR. The administrator identified 50 residents in the facility. Findings: Res #48 admitted to the facility on [DATE] with diagnoses which included schizophrenia. A level I PASARR assessment, dated 10/10/24, documented Res #48 did not have a diagnosis of a serious mental illness. On 11/04/24 at 11:20 a.m., the administrator stated they were unaware of the diagnosis at admit and did not accurately complete the form.

Based on record review and interview, the facility failed to complete a baseline care plan for one (#48) of two sampled residents reviewed for pressure ulcers. The administrator identified 50 residents in the facility. MDS Coordinator #1 identified three residents with pressure ulcers. Findings: Res #48 admitted to the facility on [DATE] with diagnoses which included depression and schizophrenia. A record review did not document a baseline care plan was completed. On 11/04/24 at 1:54 p.m., MDS Coordinator #1 stated there was no baseline care plan completed for Res #48.

Based on record review and interview, the facility failed to assess a pressure ulcer upon admission for one (#48) of two sampled residents reviewed for pressure ulcers. MDS Coordinator #1 identified three residents with pressure ulcers. Findings: Res #48 admitted to the facility on [DATE] with diagnoses which included schizophrenia. A record review did not document a wound assessment upon admission. A progress note, dated 10/16/24, documented the nurse was informed the resident had a pressure ulcer that was not assessed on admission. It was documented the physician was notified and treatments were ordered. On 11/04/24 at 12:40 p.m., the ADON stated Res #48 admitted to facility a wound to the buttock. They stated they were out of town when the resident admitted and the charge nurse should have completed the assessment, but did not.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was dated for one (#52) of one resident sampled for oxygen. The administrator identified 50 residents resided in the facility. Findings: Res #52 admitted to the facility with diagnoses which included COPD. On 11/04/24 at 1:58 p.m., Resident #52's oxygen tubing was observed with no date. On 11/05/24 at 12:05 p.m., the DON reported the tubing was supposed to be changed weekly and dated.

Based on observation and interview, the facility failed to ensure census information was posted with the daily staffing roster. The administrator identified 50 residents resided in the facility. Findings: On 11/05/24 at 9:14 a.m., the staffing roster was observed posted next to the nurses station. The census was not included in the posted information. On 11/05/14 at 9:16 a.m., the administrator stated they were unaware the census had to be posted.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for three (#3, 5, and #7) of three residents, and provided assistance with dressing for two (#5 and #7) of three sampled residents reviewed for assistance with ADLs. The administrator identified 41 residents who resided in the facility. Findings: A Shower List, dated 03/01/24, read in part, . Residents are to be cleaned and free from odors at all times. Showers are based on need as well as the schedule. If a resident needs or desires a shower, it is to be done . 1. Res #3 was admitted with diagnoses which included dementia, anxiety, and tremor. A facility shower list documented Res #3 was to receive staff assisted showers on Tuesday, Thursday, and Saturday weekly. A care plan, dated 07/15/23, documented the resident needed assistance with ADLs and required staff intervention to remain clean, neat, and free of body odors. The care plan documented an intervention to provide/assist with bath or shower two to three times weekly or more often as desired by the resident. The December 2023 bathing record documented Res #3 was not bathed 12/05/23 through 12/12/23. No refusals were documented during these dates. The January 2024 bathing record documented Res #3 was not bathed 01/06/24 through 01/10/24. No refusals were documented during these dates. A quarterly assessment, dated 01/09/24, documented the resident was moderately impaired in cognition for daily decision making and dependent on bathing. On 03/04/24 at 12:30 p.m., Res #3 was observed sitting in a wheelchair in the dining room. Food particles were observed on the resident's clothes. 2. Res #5 was admitted with diagnoses which included schizoaffective disorder, anxiety, and acute hepatic failure. A facility shower list documented Res #5 was to receive staff assisted showers on Monday, Wednesday, and Friday weekly. A care plan, dated 05/03/23, documented the resident needed assistance with ADLs and required staff intervention to remain clean, neat, and free of body odors. The care plan documented an intervention to provide/assist with bath or shower two to three times weekly or more often as desired by the resident. The December 2023 bathing record had no documentation Res #5 had received a bath/shower. The record documented seven refusals for the month. The January 2024 bathing record had no documentation Res #5 had received a bath/shower. The record documented five refusals for the month. A quarterly assessment, dated 01/12/24, documented the resident was moderately impaired in cognition, required partial to moderate assistance with bathing, and required supervision to clean-up assistance with dressing. The February 2024 bathing record had no documentation Res #5 had received a bath/shower. The record documented one refusal for the month. On 03/04/24 at 10:20 a.m., Res #5 was observed sitting on their bed. The resident was dressed in a blue blouse and black sweatpants. The resident stated sometimes they received a bath and sometimes they didn't. Res #3 stated the staff are busy and don't always have time to assist them with care. On 03/05/24 at 8:20 a.m., Res #5 was observed ambulating in the hall with a walker. The resident was dressed in the same blue blouse and black sweatpants as the previous day. One 03/06/24 at 9:00 a.m., Res #5 was observed sitting on their bed. The resident was dressed in the same blue blouse and black sweatpants from two days previously. 3. Res #7 was admitted with diagnoses which included pain, depression, and psychosis. A facility shower list documented Res #7 was to receive staff assisted showers on Monday, Wednesday, and Friday weekly. A care plan, dated 03/30/23, documented the resident needed assistance with ADLs and required staff intervention to remain clean, neat, and free of body odors. The care plan documented an intervention to provide/assist with bath or shower two to three times weekly or more often as desired by the resident. A significant change assessment, dated 01/12/24, documented the resident was moderately impaired in cognition and required partial to moderate assistance with bathing and dressing. The January 2024 bathing record documented Res #7 was bathed eight out of thirteen opportunities. No refusals were documented. The February 2024 bathing record documented Res #7 was bathed four out of fourteen opportunities. Two refusals were documented. On 03/04/24 at 11:53 a.m., Res #7 was observed sitting on their bed dressed in a blue and green plaid shirt and blue jeans. Res #7 had unkempt hair with white flakes observed on their scalp and forehead. The resident stated the staff do not always assist them with showers or getting dressed. On 03/05/24 at 8:00 a.m., Res #7 was observed sitting on their bed. The resident was dressed in the same blue and green plaid shirt and blue jeans as the previous day. Res #7's hair was unkempt and white flakes remained on their scalp and forehead. One 03/06/24 at 8:45 a.m., Res #7 was observed ambulating in the hall. The resident was dressed in the same blue and green plaid shirt and blue jeans from two days previously. Res #7's hair was unkempt and white flakes remained on their scalp and forehead. On 03/06/24 at 9:15 a.m., CNA #1 stated it was difficult to get Res #5 and Res #7 to change clothes or shower often. They stated the residents are bathed according to the shower list schedule. CNA #1 stated all baths/showers should have been documented as completed or refused on the ADL bathing record. On 03/06/24 at 11:00 a.m., the DON stated baths/showers should have been completed or documented as refused on the scheduled days. They stated the residents should have been dressed in clean clothes daily or on their scheduled bath days at a minimum.

Based on observation and interview, the facility failed to ensure staff followed infection control guidelines to prevent the potential spread of communicable disease in the shower rooms. The administrator identified 41 residents who resided in the facility. Findings: An Environmental Services Cleaning guideline, dated 2020, read in part, .It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, and tasks being performed in the area .The purpose is to provide standard operation procedures for a clean, safe, and sanitary environment for the residents .Surfaces such as sinks, tubs, shower floors and all other surfaces will be cleaned daily using an EPA approved hospital grade disinfectant - detergent solution .These surfaces will also be cleaned as needed when spills or soiling occur . On 03/04/24 at 11:15 a.m., a tour of three shower rooms was conducted. The following observations were made: a. the shower room located on Hall 1 (room [ROOM NUMBER]) had an accumulation of black patches of residue along the bottom of the tiled wall of the shower stall area, b. the shower room located at the end of Hall 1 had black patches in the white grout lines around the tiled floor and drain of the shower stall area. The shower room had a musty odor, and c. the shower room located on Hall 3 had an accumulation of black patches of residue on the plaster ceiling above the shower stall area. A metal pipe adjacent to the ceiling had an accumulation of black patches of residue. The shower room had a musty odor. On 03/04/23 at 11:25 a.m., CNA #1 stated all shower rooms were supposed to be disinfected after a resident shower. CNA #1 stated a spray bottle of disinfectant should have been available in all three shower rooms to ensure proper disinfection occurred between each shower. They stated the black patches of residue in the shower areas looked like mold and the areas should have been cleaned better. On 03/04/24 at 2:18 p.m., the maintenance supervisor and maintenance #1 were made aware of the shower observations. The maintenance supervisor stated they were not aware of the black patchy residue on the ceiling or metal pipe in the shower room on Hall 3 until this morning. Maintenance #1 stated the black patches looked like mold and could make the residents sick if not treated. The maintenance supervisor stated the area had just been treated with mold/mildew removing spray a few hours ago. On 03/05/24 at 8:45 a.m., the IP was asked how the facility ensured infection control guidelines were followed in the shower rooms. The IP stated the CNAs were expected to spray each shower area with a facility approved disinfectant after each shower. The IP stated a bottle of spray disinfectant should have been in each shower room for use. They stated housekeeping was supposed to have been deep cleaning each shower room daily. On 03/05/24 at 9:00 a.m., the housekeeping supervisor stated the black patchy residue should not have been in any of the shower areas. They stated an approved hospital grade disinfectant should have been available in each room for use after each residents' shower.

Based on observation and interview, the facility failed to ensure the physical environment was maintained in good repair. The administrator identified 41 residents who resided in the facility. Findings: On 03/04/24 at 1:30 p.m., the following observations were made: a. a white five-gallon plastic bucket seated directly beneath the fire alarm control panel box in the front lobby. The bucket had approximately one inch of brown-tinged water with dark sediment in the bottom. A clear plastic light cover had been partially opened directly above the bucket. The plaster ceiling above the light cover had brown watermark stains and patches of black residue directly beside the lighting and wiring, and b. the dining room ceiling had three large areas without plaster exposing the sheetrock above. The areas had brown watermark stains. On 03/04/24 at 2:00 p.m., the maintenance supervisor stated the facility had several roof leaks over the last couple of months. They stated a roofing crew had patched the leaks in the dining area a few weeks ago but the area above the fire alarm control panel box had leaked recently. The maintenance supervisor stated they were waiting for a crew to be available to patch this area until the entire roof could be replaced. On 03/06/24 at 2:05 p.m., the administrator stated the roof over the dining area had leaked during the last ice storm and a roofing crew had repaired the leaks. They stated the residents were not able to use the dining area for meals during this time. The administrator stated a small area in the roof above the fire control panel box had leaked recently and they were currently awaiting the roofing company to assess and repair the damage. They stated the facility has plans to replace the entire roof soon.

Based on record review and interview, the facility failed to ensure an nurse had a valid nursing license. The Resident Census and Conditions of Residents form, dated 10/24/23, documented 44 residents resided in the facility. Findings: An Oklahoma Board of Nursing Verification Report, dated 10/24/23, documented LPN #1's license had lapsed as of 06/30/23. An hours report for July 2023, documented LPN #1 worked 21 shifts without a license from 07/01/23 through 07/31/23. A hours report for August 2023, documented LPN #1 worked 23 shifts without a license from 08/01/23 through 08/31/23. A hours report for September 2023, documented LPN #1 worked 18 shifts without a license from 09/01/23 through 09/30/23. An Employee Details Report for October 2023, documented LPN #1 worked as a LPN without a license on 10/02/23, 10/03/23, and 10/04/23. A typed statement from the administrator documented LPN #1 was discovered to not have a valid license on 10/04/23 and was removed from the floor and providing patient care. The statement documented LPN #1 had not been performing nursing duties since 10/04/23 and will not be allowed to do so until their license is in good standing. On 10/24/23 at 3:29 p.m., LPN #1 stated they were unaware their license had lapsed. They stated the last day they worked as a nurse in the facility was 10/04/23.

Based on observation, record review, and interview, the facility failed to develop and implement interventions and receive adequate supervision to help prevent falls for one (#12) of three sampled residents reviewed for falls. Resident #12 had 12 falls in five months and sustained two closed head injuries. The Resident Census and Conditions of Residents form, dated 08/08/23, documented 45 residents resided in the facility. Findings: Res #12 admitted to the facility on [DATE] with diagnoses which included dementia, atrial fibrillation, and cognitive dysfunction. A fall risk assessment, dated 01/09/23, documented the resident was at high risk for falls. A care plan, dated 01/09/23, documented the following interventions: a. Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence. b. Be sure call light is within reach and encourage to use it for assistance and respond promptly to request for staff assist. c. Anticipate and meet needs. d. Coordinate with appropriate staff to ensure safe environment with: floors even and free from spills or clutter, adequate glare free light, call light available and within reach at all times, bed in low position at night, personal items within reach, and handrails on walls. e. Ambulates with rollator walker. f. Uses a wheelchair at times for mobility. An undated care plan intervention documented, .confused and cognitive function prohibits understanding of interventions staff [up arrow] visual checks in place . A nurse progress note, dated 01/10/23 at 9:00 a.m., documented the resident was assessed, provided first aid, and sent to the ER. An incident report, dated 01/10/23 at 9:00 a.m., documented the resident had a fall from standing in the hallway. The report documented the resident was sent to the emergency room and neuro checks were initiated per facility protocol. There were no intervention documented to prevent reoccurrence. An ER after visit summary, dated 01/10/23, documented the resident sustained a hematoma of the occipital region of scalp. A nurse progress note, dated 01/14/23 at 1:15 p.m., documented the resident had a fall coming out of their room and stated they hit their head. The note documented no injuries. An incident report, dated 01/14/23 at 1:15 p.m., documented the resident had a fall in the hallway without injury. The report documented the intervention was for staff to perform increased visual checks. This intervention was repeated and there was no documentation of the increased visual checks. A progress note, dated 02/04/23 at 11:40 a.m., documented the resident had a fall in their room and sustained a laceration to their head and was complaining of pain. The note documented the resident was provided first aid and sent to the ER. An incident report, dated 02/04/23 at 11:40 a.m., documented the resident had a fall in their room. The incident report documented the resident sustained a laceration to their head and was sent to the ER. The report documented the intervention was, .resi confusion limits accuracy and positive implementation of interventions . A hospital discharge record, dated 02/04/23, documented the resident sustained a 1.5 cm laceration to the forehead. A progress note, dated 02/11/23 at 11:40 a.m., documented the resident had a fall in their room and sustained a bump to the back of their head. An incident report, dated 02/11/23 at 11:40 a.m., documented the resident had a fall in their room. The report documented the resident hit their head on the bottom of the overbed table and the resident was sent to the ER. The report documented an intervention to remove the overbed table from the room. A progress note, dated 02/12/23 at 4:00 a.m., documented staff went to the resident's room when they heard someone yell out. The note documented the resident had a bump on their head and complained of pain to their rib. The note documented the resident was sent to the emergency room for evaluation. There was no intervention to prevent recurrence documented for this fall. A hospital record, dated 02/12/23 at 4:46 a.m. documented the resident was admitted to the hospital. A discharge record, dated 02/14/23, documented the resident was diagnosed with a closed head injury. A progress note, dated 02/20/23 at 3:00 p.m., documented the resident had a fall in their room. The note documented the resident was assessed and had no injuries. There was no intervention to prevent recurrence documented for this fall. A progress note, dated 03/04/23 at 10:50 a.m., documented the resident's neighbor notified staff the resident had fallen. The note documented the resident reported they hit their head. The note documented the resident was assessed and had no injuries. An incident report, dated 03/04/23 at 10:50 a.m., documented the resident had a fall in their bathroom. The report documented the resident had hit their head on the door but had no obvious injuries. The report documented the resident was placed on neuro checks. The intervention that was documented was .Res. has cognitive impairment and unable to comprehend instructions. Has hx of high risk for falls . A progress note, dated 03/20/23 at 5:30 p.m., documented the resident had a fall in their room and was assessed to have no injuries. An incident report, dated 03/20/23 at 5:30 p.m., documented the resident had a fall in their room. The report documented the resident was not injured. The report documented for staff to encourage resident to transfer with staff assistance, the bed was placed in the lowest position, the call light was placed within reach, and staff provided reminders throughout shift. These interventions had been previously documented. A progress note, dated 04/07/23 at 11:00 p.m., documented the resident had a fall and sustained a laceration to the head and was complaining of pain to their hip. The note documented the resident was sent to the ER for evaluation. An incident report, dated 04/07/23 at 11:50 p.m., documented the resident had a fall in the hallway and sustained a laceration to the head. The report documented the resident was sent to the ER for evaluation. The intervention documented the resident was sent to the ER, a CT was performed and was unremarkable, dermabond and steri-strips were applied to the laceration, and the resident returned to the facility. The report documented the resident was cognitively impaired, poor comprehension, was oriented x1, and had a history of high risk for falls. A quarterly assessment, dated 04/12/23, documented the resident was severely cognitively impaired, required limited assistance for transfers, was independent with supervision with walking. The assessment documented the resident had two or more falls with no injury and two or more falls with minor injury. An incident report, dated 04/28/23 at 3:15 p.m., documented the resident had a fall in their room without injury. The resident reported they hit their head but were not injured and not transferred to the hospital. The intervention documented a fall mat was placed. A progress note, dated 05/26/23 at 5:30 a.m., documented the resident had a fall in which the left temple area hit the floor. The note documented the resident complained of a headache and sustained a bruise above the left eye. The note documented the resident was sent to the ER for evaluation. An incident report, dated 05/26/23 at 5:30 a.m., documented the resident had a fall in their room and hit their head. The report documented the resident was sent to the ER. The report documented an intervention of protective mattress was to remain at bedside and staff were to ensure resident was placed in the center of the bed, and encourage to use the call light. A hospital record, dated 05/26/23, documented the resident had a discharge diagnosis of a closed head injury. A progress note, dated 06/24/23 at 4:00 p.m., documented the resident was on the floor in their room. The note documented it appeared the resident slid off the bed and off of the floor mat to the floor. The note documented the resident sustained a 2 cm skin tear to the right forearm. The note documented the wound was treated in the facility. An incident report, dated 06/24/23 at 4:00 p.m., documented the resident had a call in their room. The report documented the resident sustained a laceration to their arm. The report documented an intervention of frequent visual checks to be done by staff, the resident was confused due to cognitive impairment, was unable to comprehend instructions, and had a history of high fall risk. This intervention had already been used. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, and required limited assistance of one staff for ADLs. The assessment documented the resident had two or more falls with minor injury and one fall with no injury. On 08/08/23 at 10:39 a.m., the resident was observed in their room on their bed with eyes closed. A fall mat was observed at bedside. There was an overbed table pushed against the wall by the resident's head of bed. On 08/10/233 at 10:36 a.m., the ADON was asked about the process of how interventions were developed after a resident had a fall. They stated the DON was mostly responsible for the interventions. On 08/10/23 at 12:01 p.m., the DON was asked about the interventions listed on the incident reports for Res #12. They said the staff had a book with interventions to get ideas from but were not using them. They stated the intervention which referred to the resident's cognition was not an intervention to prevent falls or injury. They stated the frequent checks were not documented and there was not a way to verify they were completed.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 45 residents resided in the facility. Findings: On 08/10/23 8:51 a.m., a follow-up tour of the kitchen was conducted. The following observations were made: a. an accumulation of lint and a black substance was on the heat/air return vent, b. a thick accumulation of dirt, debris, and a brown and black residue was surrounding the floors by the base boards in the kitchen and both dining rooms, c. an accumulation of black and brown residue was on the wall beside the kitchen refrigerator, d. an an accumulation of white residue was on the sink in the dining room, e. floor tiles were worn down to the concrete in the kitchen, f. no wastebasket at the handwashing sink, g. an accumulation of dust, debris, and hair was on the counters where the pans were kept, h. an accumulation of dust and debris was underneath the dishwasher, i. the caulking surrounding the counter by the handwashing sink was cracked and peeling, k. an accumulation of a black substance and food particles were on the counter behind the handwashing sink, and l. an empty box was stuck to the bottom shelf of the refrigerator in the storage room. On 08/10/23 at 8:53 a.m., Cook #1 was asked if they had a wastebasket that was kept by the handwashing sink. The cook stated they used the trash can across the room by the dishwasher. The cook was asked should there be a wastebasket by handwashing sink. They stated, Yes. On 08/10/23 at 8:54 a.m., observed a sandwich bag of deli meat in the kitchen refrigerator dated 7/?. The DM was asked what the date written on the bag was. The DM stated it should read 8/9/23. The DM was shown the bag of deli meat with the 7/? written on it. The DM was observed to take the deli meat out of the bag and placed it into another bag and dated it 08/10/23. On 08/10/23 at 10:14 a.m., the DM was asked how staff ensured the kitchen was kept clean and maintained in good repair. The DM stated they cleaned every day and reported maintenance concerns to the maintenance department.

Based on observation, record review, and interview, it was determined the facility failed to notify the physician, family, and hospice services of a resident's change of condition for one (#2) of three residents reviewed for notification of changes. The ADM reported 37 residents lived at the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The monthly physician orders, dated 11/2017, documented an order for [REDACTED]. A physician's orders [REDACTED]. The monthly orders documented the original order date as 11/14/16. The care plan, dated 03/15/17, documented the resident required assistance with ADLs. The care plan documented interventions were for staff to administer medications as ordered; observe, document, and report to the physician prn changes; and for one person assistance with transfers. The care plan, dated 03/15/17, documented the resident had pain/potential for pain related to the aging process and debility. Interventions were documented for the staff to administer pain medications as ordered and provide alternative comfort measures such as heat/cold applications, massage, relaxation, and positioning as needed. The care plan, dated 03/15/17, documented the resident had elected to have hospice services. Interventions documented the resident was to receive comfort measures with pain relieved within one hour of receiving medication and monitoring for signs and symptoms of pain. A quarterly assessment, dated 09/04/17, documented the resident was severely impaired in cognition and required extensive assistance of one person for transfers, dressing, personal hygiene, and toileting. The assessment documented the resident was totally dependent on staff for bathing. The assessment documented the resident had no impairment of upper or lower extremities and was always incontinent of bladder and bowel. A nurse's note, dated 11/17/17 at 10:00 a.m., documented an area to the resident's right lower extremity as healed. The facility nurse's notes form did not contain nurse's notes from 11/17/17 to 11/28/17 at 6:15 a.m. The resident's clinical record contained no documentation the resident experienced a fall or complained of pain. A nurse's note, dated 11/28/17 at 6:15 a.m., documented, It was reported to this nurse during shift (change) that res. (resident) right leg noted (with) swelling/pain (with) sl (slight) touch, rotation of foot (outward) and shortening. 0630 (physician's name deleted) notified (message left) 0700 New order 1 Send to Seminole ER for eval/tx (treatment) 0705 Daughter notified Hospice (and) Admin (Administrator) notified. An OSDH incident report, dated 11/28/17, documented the resident complained of pain in the right leg, was sent to the emergency room for evaluation, and had a right leg fracture. The report documented the investigation was pending. A hospital discharge summary, dated 11/30/17, documented the resident's final [DIAGNOSES REDACTED]. A nurse's note, dated 11/30/17 at 5:30 p.m., documented the resident was readmitted to nursing facility. The resident's November 2017 treatment record documented the resident had no observed signs or symptoms of pain. The resident's November 2017 Medication Administration Record [REDACTED]. Facility in-service training forms, dated 11/30/17, documented the facility conducted inservice training for nurses, CMAs, and CNAs related to incident reporting, charge nurse expectations, documentation guidelines, 24 hour reporting, and physician notification. A final OSDH incident report, dated 12/05/17, documented the resident complained of sudden onset of pain in her leg, had no incident of falls, and the staff had been interviewed and inserviced. The attached documentation contained the interviews with the staff in regard to the resident's falls and any knowledge of staff abuse. On 12/06/17 at 10:45 a.m., LPN #3 reported the previous shift's LPN told her the resident's leg was swollen but had not reported the resident had pain. LPN #3 reported she documented her assessment. On 12/06/17 at 1:30 p.m., CNA #1 was asked if the resident had expressed any sign or symptoms of pain prior to being sent to the hospital. She reported the resident very seldom complained of pain and had not expressed any pain. On 12/06/17 at 2:30 p.m., CNA #2 was asked if the resident had any pain or [MEDICAL CONDITION] on the day prior to being sent to the hospital. The CNA reported she was helping the aides on the resident's hall get the resident up for the evening meal. She reported the resident's right leg was drawn up to her chest, was red, and was hot to touch. The CNA reported the resident cried out in pain when moved. The CNA was asked if she reported to the charge nurse. The CNA stated, Yes. On 12/06/17 at 2:35 p.m., CMA #1 was asked if the resident demonstrated any pain on the evening before being sent to the hospital. The CMA reported no. The CMA reported a CNA had wheeled the resident to the nurse's station in a geri-chair for the charge nurse to assess her. The CMA reported the charge nurse was not available so the aide wheeled the resident to the lobby to wait on the evening meal. The CMA reported the resident was not crying out in pain, but she thought the resident was in pain because of her facial expression. The CMA reported she did not give the resident any pain medication and did not report the resident's pain to the charge nurse. On 12/06/17 at 2:37 p.m., LPN #1 was interviewed by phone. The LPN was asked if the CNAs had reported to her about the resident's swollen and painful leg. The LPN reported yes, and she had observed the resident's leg to be swollen. The LPN reported the resident did not seem to be in pain, had no leg shortening, and the leg was slightly warm to touch. The LPN was asked if she had documented in the clinical record about the resident's leg. The LPN stated, No. The LPN was asked if she told the on-coming shift. The LPN stated, Yes. The LPN reported she had not notified anyone else about the resident's leg being swollen. On 12/06/17 at 3:01 p.m., LPN #2 was interviewed by phone. The LPN was asked when she was first informed of the resident's leg pain. The LPN reported at approximately 5:00 a.m., the CNAs told her the resident had leg pain. The LPN was asked if she assessed the resident's leg. She reported yes, the leg was red and swollen. The LPN was asked if the resident had signs or symptoms of pain. She stated, A little pain. The LPN was asked if she notified the physician. She reported no, she just reported to the next shift. The LPN was asked if she gave the resident medication for pain. The LPN reported the resident had nothing for pain. The resident did not receive the [MEDICATION NAME] as ordered for pain. A review of the 24 hour shift reports found no documentation of an incident involving injury to the resident's leg, nor documentation of the resident's leg [MEDICAL CONDITION], redness, and pain. There was no documentation on the shift report or the clinical record the physician, the family, or hospice had been notified of the resident's change in condition prior to the entry on 11/28/17 at 6:15 a.m. On 12/07/17 at 10:00 a.m., a hospice staff member was interviewed. The staff member reported she had seen the resident on the morning of 11/27/17, and the resident had exhibited no signs of [MEDICAL CONDITION] or pain. The hospice staff member reported on the morning of 11/28/17, she and a facility CNA were in the process of getting the resident up for breakfast. The hospice staff member reported the resident's right leg was red, swollen, and warm to touch. She reported the 6-2 charge nurse entered the room and reported they were sending the resident to the hospital. On 12/07/17 at 11:30 a.m., the ADM was asked if she had completed a thorough investigation to ensure the resident was monitored and assessed when the resident started to experience pain and [MEDICAL CONDITION]. The ADM reported she was focused on finding if the resident has experienced an injury or fall.

Based on observation, record review, and interview, it was determined the facility failed to provide care and treatment for one (#2) of three residents reviewed for quality of care. The facility failed to assess, monitor, and provide pain management for resident #2. The ADM reported 37 residents lived at the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The monthly physician orders, dated 11/2017, documented an order for [REDACTED]. A physician's orders [REDACTED]. The monthly orders documented the original order date as 11/14/16. The care plan, dated 03/15/17, documented the resident required assistance with ADLs. The care plan documented interventions were for staff to administer medications as ordered; observe, document, and report to the physician prn changes; and for one person assistance with transfers. The care plan, dated 03/15/17, documented the resident had pain/potential for pain related to the aging process and debility. Interventions were documented for the staff to administer pain medications as ordered and provide alternative comfort measures such as heat/cold applications, massage, relaxation, and positioning as needed. The care plan, dated 03/15/17, documented the resident had elected to have hospice services. Interventions documented the resident was to receive comfort measures with pain relieved within one hour of receiving medication and monitoring for signs and symptoms of pain. A quarterly assessment, dated 09/04/17, documented the resident was severely impaired in cognition and required extensive assistance of one person for transfers, dressing, personal hygiene, and toileting. The assessment documented the resident was totally dependent on staff for bathing. The assessment documented the resident had no impairment of upper or lower extremities and was always incontinent of bladder and bowel. A nurse's note, dated 11/17/17 at 10:00 a.m., documented an area to the resident's right lower extremity as healed. The facility nurse's notes form did not contain nurse's notes from 11/17/17 to 11/28/17 at 6:15 a.m. The resident's clinical record contained no documentation the resident experienced a fall or complained of pain. A nurse's note, dated 11/28/17 at 6:15 a.m., documented, It was reported to this nurse during shift (change) that res. (resident) right leg noted (with) swelling/pain (with) sl (slight) touch, rotation of foot (outward) and shortening. 0630 (physician's name deleted) notified (message left) 0700 New order 1 Send to Seminole ER for eval/tx (treatment) 0705 Daughter notified Hospice (and) Admin (Administrator) notified. An OSDH incident report, dated 11/28/17, documented the resident complained of pain in the right leg, was sent to the emergency room for evaluation, and had a right leg fracture. The report documented the investigation was pending. A hospital discharge summary, dated 11/30/17, documented the resident's final [DIAGNOSES REDACTED]. A nurse's note, dated 11/30/17 at 5:30 p.m., documented the resident was readmitted to nursing facility. The resident's November 2017 treatment record documented the resident had no observed signs or symptoms of pain. The resident's November 2017 Medication Administration Record [REDACTED]. Facility in-service training forms, dated 11/30/17, documented the facility conducted inservice training for nurses, CMAs, and CNAs related to incident reporting, charge nurse expectations, documentation guidelines, 24 hour reporting, and physician notification. A final OSDH incident report, dated 12/05/17, documented the resident complained of sudden onset of pain in her leg, had no incident of falls, and the staff had been interviewed and inserviced. The attached documentation contained the interviews with the staff in regard to the resident's falls and any knowledge of staff abuse. On 12/06/17 at 10:45 a.m., LPN #3 reported the previous shift's LPN told her the resident's leg was swollen but had not reported the resident had pain. LPN #3 reported she documented her assessment. On 12/06/17 at 1:30 p.m., CNA #1 was asked if the resident had expressed any sign or symptoms of pain prior to being sent to the hospital. She reported the resident very seldom complained of pain and had not expressed any pain. On 12/06/17 at 2:30 p.m., CNA #2 was asked if the resident had any pain or [MEDICAL CONDITION] on the day prior to being sent to the hospital. The CNA reported she was helping the aides on the resident's hall get the resident up for the evening meal. She reported the resident's right leg was drawn up to her chest, was red, and was hot to touch. The CNA reported the resident cried out in pain when moved. The CNA was asked if she reported to the charge nurse. The CNA stated, Yes. On 12/06/17 at 2:35 p.m., CMA #1 was asked if the resident demonstrated any pain on the evening before being sent to the hospital. The CMA reported no. The CMA reported a CNA had wheeled the resident to the nurse's station in a geri-chair for the charge nurse to assess her. The CMA reported the charge nurse was not available so the aide wheeled the resident to the lobby to wait on the evening meal. The CMA reported the resident was not crying out in pain, but she thought the resident was in pain because of her facial expression. The CMA reported she did not give the resident any pain medication and did not report the resident's pain to the charge nurse. On 12/06/17 at 2:37 p.m., LPN #1 was interviewed by phone. The LPN was asked if the CNAs had reported to her about the resident's swollen and painful leg. The LPN reported yes, and she had observed the resident's leg to be swollen. The LPN reported the resident did not seem to be in pain, had no leg shortening, and the leg was slightly warm to touch. The LPN was asked if she had documented in the clinical record about the resident's leg. The LPN stated, No. The LPN was asked if she told the on-coming shift. The LPN stated, Yes. The LPN reported she had not notified anyone else about the resident's leg being swollen. On 12/06/17 at 3:01 p.m., LPN #2 was interviewed by phone. The LPN was asked when she was first informed of the resident's leg pain. The LPN reported at approximately 5:00 a.m., the CNAs told her the resident had leg pain. The LPN was asked if she assessed the resident's leg. She reported yes, the leg was red and swollen. The LPN was asked if the resident had signs or symptoms of pain. She stated, A little pain. The LPN was asked if she notified the physician. She reported no, she just reported to the next shift. The LPN was asked if she gave the resident medication for pain. The LPN reported the resident had nothing for pain. The resident did not receive the [MEDICATION NAME] as ordered for pain. A review of the 24 hour shift reports found no documentation of an incident involving injury to the resident's leg, nor documentation of the resident's leg [MEDICAL CONDITION], redness, and pain. There was no documentation on the shift report or the clinical record the physician, the family, or hospice had been notified of the resident's change in condition prior to the entry on 11/28/17 at 6:15 a.m. On 12/07/17 at 10:00 a.m., a hospice staff member was interviewed. The staff member reported she had seen the resident on the morning of 11/27/17, and the resident had exhibited no signs of [MEDICAL CONDITION] or pain. The hospice staff member reported on the morning of 11/28/17, she and a facility CNA were in the process of getting the resident up for breakfast. The hospice staff member reported the resident's right leg was red, swollen, and warm to touch. She reported the 6-2 charge nurse entered the room and reported they were sending the resident to the hospital. On 12/07/17 at 11:30 a.m., the ADM was asked if she had completed a thorough investigation to ensure the resident was monitored and assessed when the resident started to experience pain and [MEDICAL CONDITION]. The ADM reported she was focused on finding if the resident has experienced an injury or fall.

Based on record review, observation and staff interviews, it was determined the facility failed to: a) Ensure interventions were implemented to prevent a fall with injury, resulting in harm, for one (#10) of four sampled residents who had experienced falls. This had the potential to affect all 46 residents who resided in the facility. b) Ensure a transfer was completed with a gait belt and not by lifting the resident from under their arms which could cause an injury and/or accident for one (#1) of five sampled residents who required assistance with transfers. This had the potential to affect 36 residents, identified by the Resident Census and Conditions Of Residents form, who required assistance with transfers. c) Ensure a sit-to-stand lift was utilized in a manner to prevent injuries and/or accidents, for one (#4) of one sampled resident who required a sit-to-stand lift be used for transfers. This had the potential to affect one resident, identified by the DON, who required a sit-to-stand lift be used for transfers. Findings: 1. Resident #10 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 04/05/14, documented the resident was high risk for falls and/or had a history of [REDACTED]. Approaches documented to prevent falls included the following: Gather information on past falls and attempt to determine the cause of falls. Encourage the resident to wear a soft helmet due to multiple falls with head injuries. Be sure the call light is within reach and encourage to use it for assistance and respond promptly to request for staff assistance. Provide activities that minimize the potential for falls. Encourage activities that promote exercise, physical activity for strengthening and improved mobility. There was no documentation any of the above interventions had been implemented. A quarterly assessment, dated 08/03/15, documented the resident was severely impaired in cognition, required extensive assistance with transfers, dressing, eating and hygiene. The resident required total assistance with bathing. The resident did not walk and had deficits in range of motion for the upper extremities on one side and range of motion deficits for the lower extremities on both sides. The assessment documented the resident was not steady and was only able to stabilize with assistance when moving from seated to standing position and during surface to surface transfers. The assessment documented the resident had a history of [REDACTED]. A nurse's note, dated 08/05/15 at 6:30 p.m., documented, Res' out in lobby in geri chair. Leaned forward & fell hitting head on tile floor. Laceration noted c large amt of blood. Sent to ER via EMS Large raised area appearing c area upon transport to hospital. (POA name deleted) notified. Dr. (Name deleted) notified. Report given to (Hospital name deleted) ER. O (no) other injuries noted @ this time. A nurse's note, dated 08/05/15 at 8:35 p.m., documented, Returned to facility via ambulance. Assisted from Gurney to bed. 3 person assist .Drsg to FH (forehead) came off during transfer .replace O sutures or staples noted . An incident report, dated 08/05/15, documented, (Resident's Name deleted) leaned forward in the geri chair and fell , hitting her head on the tile floor. She was sent to (Hospital name deleted) ER for evaluation and treatment with a large amount of blood noted to the forehead. Under the section To Prevent Re-Occurrence, the incident report documented, .Resident instructed re: not leaning forward in chair. Staff instructed to remind resident frequently/prn to not lean over in chair and to let staff pick up/retrieve items from the floor. A nurse's note, dated 08/06/15 for the 10:00 p.m. to 6:00 a.m. shift, documented, Resident resting in bed, large laceration noted to forehead c large amt dried blood to facial area, cleaned per this nurse .bruising noted to surrounding skin & R eye . A nurse's note, dated 08/30/15 at 9:45 a.m., documented, CNA called for nurse, res in floor in front of geri chair in front lobby face down, has 2.5 cm laceration above R eyebrow. alert but confused .Confused and oriented x1-alert. (Dr's name deleted) notified and order received to send to ER for eval and tx . A nurse's note, dated 08/30/15 at 12:45 p.m., documented, Returned from .hosp ER .alert oriented to name only resp unlabored .assisted to bed-R eyebrow laceration was glued in ER and left open to air . A Discharge Instruction Sheet from the ER visit on 8/30/15 documented, [DIAGNOSES REDACTED]. An incident report, dated 08/30/15, documented, CNA called for nurse, resident in floor in front of gerichair in front lobby face down. Has a 2.5 cm laceration above her right eyebrow .Sent to (Hospital name deleted) ER for eval and tx. Under the section To Prevent Re-Occurrence, the incident report documented, Reinstructed resident to call for assistance, and instructed staff to check resident frequently while up in gerichair. There was no documentation the resident was checked frequently while up in the Geri chair. A nurse's note, dated 08/31/15 at 2:30 a.m., documented, .swelling/discoloration cont above Rt eye . A nurse's note, dated 08/31/15 at 9:45 a.m., documented, .Cont c purple discoloration/swelling noted to bilat eyes & F.H. (forehead) . On 09/30/15 at 8:45 a.m., the resident was observed in the front lobby in a Geri chair. The resident had been placed toward the front windows facing the front of the building. The resident was observed bending forward in the Geri chair. The Geri chair was in an upright position and not reclined. No staff were present during the observation. At 9:30 a.m., the DON was notified of the observation of the resident in the front lobby in the Geri chair. The DON reported the resident did not like to recline. The DON was notified of the resident's two falls from the Geri chair while in the front lobby. The DON reported the resident was prone to falls and the facility had tried different methods to prevent falls. At that time, the DON was shown the resident's care plan addressing falls. The DON was asked what measures other than reminding the resident to not bend over had been implemented. The DON reported she had no other documentation of the interventions on the care plan. The DON reported there was no other documentation of other interventions being implemented to prevent the resident from falling forward. At 10:00 a.m., the resident was observed in her room in a recliner with her feet elevated. The call light was observed beside the resident. The resident was asked if she could use her call light. The resident was unable to understand the question and did not attempt to pick up the call light. The resident could only respond appropriately to her name. On 09/30/15 at 1:30 p.m., the corporate nurse and the ADM were notified of the two falls with injuries for the resident. The corporate nurse reported she felt like other interventions had been tried but there was no documentation of any other interventions by the staff. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Resident Status Sheet, a care plan for the CNA staff, documented the resident was to be transferred with the use of a wheelchair and one staff member. On 09/28/15 at 2:50 p.m., CNAs #1 and #2 were observed to transfer the resident using a sit-to-stand lift. The sit-to-stand lift sling was placed under the resident's arms. During the transfer, the resident was observed not to bear weight. A purple discoloration was noted on the resident's left lateral chest wall. The CNAs were asked how and when the purple discoloration occurred. The CNAs reported they were unaware when the incident occurred. At 4:00 p.m., the MDS coordinator was asked if the resident should be transferred with a sit-to-stand lift. The MDS coordinator reported the resident should be transferred using a full body lift. At 4:20 p.m., the DON was asked if she expected the resident to be transferred with a sit-to-stand lift. The DON reported the resident should be transferred using a full body lift. The DON reported the staff would be educated. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 09/01/15, documented the resident was severely impaired with cognition and exhibited mild depression. The assessment documented the resident required extensive assistance with transfers and ambulation. On 09/28/15 at 1:00 p.m., CNA #3 and CNA #4 were observed transferring the resident from the dining room chair to the resident's wheeled walker. Both CNAs placed their arms under the resident's arms and lifted the resident out of the chair and into the seat of the wheeled walker. The resident was observed to be non weight bearing during the transfer. On 09/29/15 at 10:30 a.m., CNA #3 was interviewed regarding how the resident was transferred from one surface to another. The CNA reported the staff was to use a gait belt when transferring the resident. The CNA was asked if the resident was transferred properly during lunch the day before. The CNA stated, No, she was not. At 11:30 a.m., the DON was interviewed regarding how the staff should transfer residents. The DON reported the staff should always use a gait belt or a lift to transfer the residents from one position to another. The DON was informed of the observation of the resident being transferred by CNA #3 and CNA #4 by placing their arms under the resident's arms. The DON reported she would in-service the staff.

On 02/24/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure hot water temperatures were not ranging from 134.7 to 142 degrees Fahrenheit. The Oklahoma State Department of Health was notified and verified the existence of the immediate jeopardy situation. At 11:30 a.m., the ADM was notified of the IJ situation with the hot water temperatures. At 12:30 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Immediate Jeopardy---Hot water temperatures exceed maximum of 115 1. Hot water tank immediately shut off for inspection 2. Hot water tank then restarted by maintenance personnel with a lower temperature 3. Alert residents advised not to use the hot water 4. All other residents off the hall or unable to use the sink 5. Administrator, Business office manager, maintenance and cna (CNA) provided increased supervision to residents on the hallway 6. Shower room inspected by administrator, and shut down. CNA reported no water pressure from hot water line and was only able to give 2 showers on hall 1 and then went to hall 2 to give shower 7. 4 rooms with staff supervision were turned on to drain the remaining water from the water line 8. Maintenance general manager for company called to facility for further inspection of valves and system Currently hot water on the hallway is ranging from 104.8-107.6 Mixing valve required hand adjustment and will be monitored to ensure no repeat occurrence." At 4:00 p.m., the immediate jeopardy was removed when the hot water temperatures were rechecked by the surveyor and were at acceptable temperatures. The deficiency remained at no actual harm with potential for more than minimal harm, at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to: a) Ensure water was provided to residents at a temperature to prevent burns for one (Hall #1) of three facility halls. This had the potential to affect 12 residents, identified by the DON, who resided on Hall #1 and seven residents, identified by the DON, who utilized the residents' bathroom on Hall #1. b) Ensure water was not leaking in the floor of the bathroom designated for resident use only on Hall #1. This had the potential to affect seven residents, identified by the DON, who used the bathroom on Hall #1. Twelve residents were identified by the DON as ambulatory and independent with toileting. Findings: 1. On 02/24/14, on the first day of the survey, the survey team was placed in room #3 on Hall #1 to work during the length of the survey. At 10:35 a.m., the surveyor attempted to wash her hands in the sink, but had to pull them back due to the extreme hot water temperature.. At that time, the water temperature was taken. The water registered 134.7 degrees Fahrenheit. At that time, the following rooms on Hall #1 were checked for water temperatures: Room #1 registered 141.8 degrees Fahrenheit. Room #2 registered 140.7 degrees Fahrenheit. The residents' bathroom registered 140.8 degrees Fahrenheit. Room #7 registered 142.8 degrees Fahrenheit. Water temperatures on Halls #2 and #3 were checked and were within acceptable temperature ranges. At 10:50 a.m., the staff were asked if any of the residents who resided on Hall #1 were confused with wandering behaviors. Residents #1 and #2 were identified as confused with wandering behaviors. Resident #1 resided in room #2 on Hall #1. A significant change assessment, dated 02/20/14, documented the resident was cognitively impaired, had wandering behaviors, was able to walk, and was independent with wheelchair mobility. During the three day survey, the resident was observed ambulating independently in the hallways in a wheelchair. On the last day of the survey, the resident was observed being assisted by the DON to walk with a walker. Resident #2 resided in room #1 on Hall #1. The nurses' notes documented the following: "11/26/13 (6-2p) Res conts to wander aimlessly Multiple attempts to redirect res to remain in w/c is unsuccessful Res conts to amb s (without) assist.. @ 1830 (6:30 p.m.)Resi ^ (up) ad lib gait unsteady, assist x 1, wanders, redirection c 0 success..." A quarterly assessment, dated 01/24/14 documented the resident was cognitively impaired, had wandering behaviors and was able to walk independently. During the three day survey, the resident was observed ambulating independently on all three Halls of the facility. The staff were observed redirecting the resident when appropriate. On 02/24/14 at 11:25 a.m., the ADM was called to resident #2's room and was shown the hot water temperature in the residents room. The water registered at 141.8 degrees Fahrenheit. At that time, the ADM turned the resident's call light on and when answered instructed the CNA to find the two maintenance staff members. When they arrived, she instructed them to turn the water temperatures down. She reported the facility had obtained tankless water heaters. She reported they would replace them with regular hot water tanks. At 11:40 a.m., the maintenance supervisor was asked for the water temperature log for February. He reported (Name deleted) maintenance assistant had done them. At 11:45 a.m. the maintence assistant reported he had completed part of January and the maintenance supervisor had done the rest of January. At that time, the maintenance supervisor was asked for the water temperatures for January and February. He looked through three clipboards and couldn't find them. On 02/26/14 at 11:30 a.m. the maintenance supervisor presented the water temperatures for February. No water temperatures had been recorded for the 22nd and the 23rd of February. 2. On 02/25/14 at 8:50 a.m., an environmental tour of the facility was conducted. A leak was observed in the bathroom designated for residents on Hall #1. Water was observed around the base of toilet. The floor was wet from the toilet to the sink and bathtub. The bathroom was observed by the surveyors until 10:45 a.m., when a resident was observed going into the bathroom. At that time, the maintenance supervisor was shown the bathroom. He reported the toilet was off the base and causing it to leak. He then removed the toilet and put an out of order sign on the door. At 10:50 a.m., housekeeper #1 was asked about the residents' bathroom toilet leaking. He reported he had not cleaned the bathroom and didn't know it was leaking. At 10:55 a.m., the housekeeping supervisor was asked about the leak in the residents' bathroom. She reported she was not aware of the leak. On 02/26/14 at 10:50 the ADM reported she had been told about the toilet and would get a new toilet for the bathroom.

On 08/15/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician when a resident (#3) experienced a change in condition with a wound. At 4:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 4:55 p.m. At 5:00 p.m., the corporate ADM and the DON were notified of the IJ situation. At 6:45 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "A Plan of removal for Seminole Pioneer Skin assessments to be completed on every resident in the facility for any skin problems by license nurses and physician will be notified and obtain orders as need for interventions. All nursing staff will be inserviced on what to look for and all nurses will be in-serviced on documentation, staging pressure ulcers and interventions. C.N.A.s will be in-serviced to report immediately to the charge nurse. The C.N.A. will be given examples of skin changes to report. Staff will notify consultant as needed. Assess pressure ulcers for changes in wound, size, odor, drainage and the doctor will be notified of changes. This will be completed by 5 PM 08-16-2012. Doctor will be notified of worsening wound or if wound is not responding to treatment. The doctor will be notified to obtain new treatment orders. Nursing staff will assess, monitor, and intervene with any changes. This will be completed by 5 PM on 08-16-2012." The plan of removal was signed by the DON. On 08/20/12 at 11:15 a.m., the staff were interviewed and were knowledgeable in regard to the reporting of residents' condition changes. All licensed staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. The Immediate Jeopardy was removed as of 08/16/12 at 5:00 p.m., after the staff had been inserviced. The deficient practice remained at actual harm at a pattern. Based on record reviews, observations, and staff interviews, it was determined the facility failed to: a) Ensure the physician was notified when there were changes in the condition of a vascular wound (size/drainage/odor) for one (#3) of one sampled resident. This had the potential to affect seventeen residents, identified by the DON, receiving skin treatments. b) Ensure the physician and POA were notified when one (#2) of one sampled resident hit his head, obtained a skin tear and had skin condition changes. This had the potential to affect 63 residents, identified by the DON, who had experienced incidents in the past three months. Findings: A policy, titled "WOUND ASSESSMENT PROTOCOL" documented ..... "Assessment:... 5. Wound evaluation and documentation will be completed weekly. 6. Wound treatments will be reevaluated at least every 2 weeks for possible changes. Interventions/implementation:... 2. Residents identified at risk for pressure ulcers or with pressure ulcers will be evaluated for proper body positioning and will have routine skin assessments completed. 5. A plan of care will be developed to establish goals and approaches to meet the resident needs. Evaluation: ... 2. Effectiveness of pressure ulcer treatments will be evaluated weekly. Treatment changes made per wound protocol per physician orders..." 1. Resident #3 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/30/12, documented the resident was cognitively intact with behaviors less than daily, was totally dependent of two persons for transfers, required extensive assistance of one person for dressing, hygiene and bathing. The resident required limited assistance of one person for bed mobility and eating. The resident was mobile per wheelchair. The resident had range of motion impairment on both sides of his lower extremities. The assessment documented the resident had two Stage I pressure ulcers, one Stage II pressure ulcer, and had one venous/arterial ulcer. A nurse's note, dated 06/11/12 at 10:00 a.m., documented, "Res noted to have abrasion to outer R ankle some bleeding noted. Redness noted around area. N/O (new order) received...Area approx 3 cm in diameter No depth/ Some tenderness c touch..." A skin assessment non pressure form documented the wound to the outer right ankle was first observed on 06/11/12, with physician notification documented. A physician's orders [REDACTED]. The wound assessments were as follows: Date: 06/11/12 Location: Right outer ankle Size (length/width/depth in cm): 2 cm diameter no depth was documented Appearance: Bed pink scant bleeding Treatment: DWC Pat dry TAO There was no staging of the wound documented in the clinical record. Date: 06/21/12 Location: Right outer ankle Size: 4 cm diameter no depth Appearance: Dark scab on wound bed with small area yellowish odor Treatment: Seen per Dr. (name deleted) w/c (wound clinic) no Tx change. There was no staging of the wound documented in the clinical record. On 08/15/12 at 12:30 p.m., LPN #1, the treatment nurse, was interviewed and was asked what the meaning was of "w/c" in the above skin assessment. The LPN reported the physician saw the wound and wanted the resident to be seen by the wound clinic. She reported w/c meant wound clinic. A physician's progress note, dated 06/21/12, documented, "...Initiate wound care." A skin assessment was documented as follows: Date: 06/25/12 Location: Right outer ankle Size: 5 cm diameter 1/8 depth Appearance: Dark & purulent scabbing present to entire wound Redness around outer edges Treatment: Attempted wc (wound clinic) 06/22/12 No answer Cont Tx Elevate foot. There was no staging of the wound documented in the clinical record. The wound had increased in size and it was the first time to have depth. There was no documentation of the physician being notified of the changes of the wound. A physician's orders [REDACTED]." A note by an advanced practice RN, dated 06/28/12, documented, "DM (diabetes mellitus) ulcer L foot-Wound nurse eval Tx." The wound was located on the outer upper sole of the left foot. There was no documentation the physician was notified of the left foot wound site. The foot care note was noted by LPN #3. The resident was started on an antibiotic at that time for the left foot wound. On 08/15/12 at 2:25 p.m., LPN #1, the treatment nurse, was asked if she knew about the noted order for the resident to be seen by a wound nurse for evaluation and treatment of [REDACTED]. Later, the LPN reported the DON had tried to contact the wound clinic but was unsuccessful in reaching anyone. The LPN reported she did not know if there had been any follow up. The LPN reported the DON was to take care of the wound evaluation. There was no documentation of further attempts to contact the wound care nurse for the left foot wound. LPN #1, the treatment nurse, was asked if she had seen the area on the resident's outer upper sole of his left foot. The LPN reported there had been an area there at one time, which had begun as a blister. The LPN reported the wound was no longer present. The LPN stated the area had healed and was not a problem. She could not remember having seen it, since it healed and dried up. There was no current documentation which concerned skin assessments of the resident's left foot. The social services notes were reviewed. The social services notes did not contain any information about any attempts to contact the wound center or the wound nurse for evaluation of the resident's left foot wound. The skin assessments continued as follows: Date: 07/02/12 Location: Right outer ankle Size: Site 1: 6 cm 1/8 depth Site 2: 2 1/2 cm diameter Appearance: ^ (increase) odor Dark around edges Wound bed dry decreased drainage Treatment: no change in Tx Cont WC (wound clinic) to be scheduled Two sites on the right ankle were identified and no staging of the wounds was documented. There was no documentation of the physician being notified of the second site of the right outer ankle, the increase of the size of the first wound on the right outer ankle, or the increase of odor. On 08/15/12 at 2:25 p.m., LPN #1, the treatment nurse, was asked where the second site was located. The LPN reported it was posterior to the first site on the outer right ankle. Skin Assessment: Date: 07/09/12 Location: Right outer ankle Size: Site 1: 6 cm 1/8 depth Site 2: 2 1/2 cm dia (diameter) 1/4 depth Appearance: No change Treatment: Cont current Tx (TAO) There was no notification of the physician in the residents's clinical record which concerned no change or improvement in the wounds to the right outer ankle with the current treatment. The second site on the right outer ankle now had depth and the physician was not notified. No staging of the two wound sites was documented in the clinical record. Skin Assessment: Date: 07/20/12 Location: Right outer ankle Size: Site 1: 6 1/2 cm 1/8 depth Site 2: 2 1/2 cm dia 1/4 depth Appearance: Small ^ size blackish sloughing No s/s of infection Treatment: To WC [MEDICATION NAME] (Resident had not gone to wound clinic until 07/27/12 and had continued the treatment of [REDACTED].) No staging of the two wound sites was documented in the clinical record. No notification of the physician which concerned the blackish sloughing was in the resident's clinical record. Skin Assessment: Location: Right outer ankle Date: 7/27/12 Size: Site 1: 6 1/2 cm 1/8 depth Site 2: 2 1/2 cm 1/4 depth Appearance: No change Treatment: To WC [MEDICATION NAME] No staging of the two wound sites was documented in the clinical record. A post procedure physician orders, dated 07/27/12, from (name deleted) wound center, documented the following: "Wound location: 1. Right Lateral Ankle Type Stage: Arterial Ulcer... Measurements (cm): 4.9 x 5.6 x obs Wound location: 2. Right Posterior Ankle Type Stage: Arterial Ulcer... Measurements (cm): 1.2 x 1.5 x 0.2 ... Wounds 1, 2 were debrided in clinic today... Cleanse wound with: Normal Saline Apply to Wound Bed: [MEDICATION NAME] AG Apply to Periwound Tissue: [MEDICATION NAME], Skin Prep or skin barrier of choice Cover Wound With: Tape, Kerlix/ Conform Discharge Home Instructions: Wound care is to be performed 2 x week & prn Next Wound Center Visit: 1 week Offloading: Pillow under calves Restrictions: No tub bath Diet/Nutrition: Protein Supplement (Juven, Promod or equiv) 3 x day Diagnostics: Radiology: Arterial Doppler 07/30/12 at Facility (name deleted) Additional Orders: Written Rx given to patient [MEDICATION NAME] mg i (one) po bid x 10 d (days)..." The physician's orders [REDACTED]. The resident did not have his first visit to the wound clinic until 07/27/12, when the [MEDICATION NAME] AG was first ordered at that time. The advanced practice RN saw the resident on 06/28/12, and recommended he be seen by a wound nurse to evaluate and treat the left foot wound. This was not addressed until he was sent to the wound clinic on 07/27/12. There was no documentation to show the physician had been notified of the delay in the resident being sent to the wound clinic. A physician's orders [REDACTED]. The order was transcribed incorrectly from the wound clinic's order to perform wound care two times weekly and as needed: The treatment record, dated July 2012, documented the following: "7/27 Cleanse wound to ankle, cleanse c NSS. pat dry, apply [MEDICATION NAME] AG Cover c ABD pad, wrap c Kling secure c tape q 2 weeks" (this was ordered to be provided 2 times weekly and prn). There was a nurse's initials to indicate the treatment had been performed on 07/27/12. The treatment administration record, dated August 2012, documented the following: "7/27/12 Cleanse wound c NS, apply [MEDICATION NAME] AG, cover c ABD pad wrap c gauze, secure c tape q 2 wks and prn" (this was ordered to done 2 times weekly and prn). The treatment sheet documented the treatment was done on 08/07/12. No other treatment had been documented since the original physician's orders [REDACTED]. The wound had gone eleven days without a treatment. No notification to the physician was in the clinical record of the missed treatments of the wounds. The treatment administration record, dated August 2012, documented the following physician's orders [REDACTED]. "8/10/12 Cleanse wound c NS Apply [MEDICATION NAME] AG Cover c ABD pad wrap c gauze/Kerlix Secure c tape 2 x wk." This wound treatment change was to be performed two times weekly and should have started on 07/27/12 after the first wound clinic visit as ordered. Skin Assessment: Date: 08/03/12 Location: Right outer ankle Size: Site 1: 6 1/2 cm 1/8 depth Site 2: 2 3/4 cm 1/4 depth Appearance: small ^ in size Treatment: To WC [MEDICATION NAME] Date: 08/10/12 Location: Right outer ankle Size: Site 1: 7 cm 1/2 depth Site 2: 2 1/2 cm 1/4 cm Appearance: Increase size Odor noted Treatment: WC [MEDICATION NAME]. No physician notification was in the clinical record of the increase size of the wound or the odor present. A post procedure physician order [REDACTED]. "Wound Location: 1. Right Lateral Ankle Type Stage: Arterial Ulcer... Measurements (cm): 5.8 x 5.8 x 0.5 Wound Location: 2. Right Posterior Ankle Type Stage: Arterial Ulcer... Measurements (cm): 0.8 x 0.7 x 0.1 Wounds 1 , 2 were debrided in clinic today...No changes in wound care... Discharge home instructions: Wound care is to be performed: by facility 2 x week... Restrictions: No whirlpool/shower. No tub bath. Keep wounds dry. Diet/Nutrition: Continue Multi Vitamin daily, Vitamin C 500 mg twice daily, Protein Supplement (Juven, Promod or equiv) 3 x day... Consults/Referrals: Vascular Consult Dr. (name deleted} 8/15/12 at 11 :45 a.m..." On 08/15/12 at 3:00 p.m., the DON was asked if the physician should have been notified of the changes with the resident's wound when one wound site increased in size, had odor or drainage, or there was no change in the wound with the current treatment. The DON stated, "Yes." The DON further reported there was no answer previously when they had attempted to contact the wound nurse for evaluation of the left foot wound. There was no documentation in the clinical record which concerned the attempt to notify the wound nurse. At 5:10 p.m., the corporate ADM was informed about the resident's wound changes, the lack of physician notification and the lack of ordered wound care interventions in the clinical record. The corporate ADM reported the facility had released the wound consultant company they had previously utilized about two weeks to a month ago. The corporate ADM reported they were in the process of obtaining a new contract with another company. The corporate ADM reported the physician would be notified of the resident's wound status and the wound situations would be addressed. 2. Resident #2 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. An admission nursing assessment, dated 06/27/12, documented, "...skin condition... comments: Multiple Bruising, slight redness to scrotum area..." A skin data non pressure form, dated 06/27/12, documented, ".....Type of wound: (not checked), describe type Dark Redness Location: buttocks bilaterally, General Appearance: Dark red skin intact no drainage..." An "Interim Plan of Care," dated 06/27/12, documented, ".... Potential for breakdown and Skin Tears due to Multiple medical conditions creating poor skin integrity... 7/5/12 Resident readmitted with large area of dark redness to bilateral buttocks no open areas. Dr. (name deleted) notified N.O. received. 7/10/12 Dark red/purplish... Goals: No breakdown and Skin Tears will resolve without complications, infection or discomfort as they occur... Approaches: 1. Tx as ordered [MEDICATION NAME]. 2. Monitor for s/s of infection 3. Notify MD if current Tx is not effective... 7/5/12 [MEDICATION NAME] BID..." Resident was sent to (name deleted) hospital on [DATE] with [DIAGNOSES REDACTED]. An "Admission Nursing Assessment," dated 07/05/12, documented, "Skin Condition... comments: 1. Dark redness to Bilat buttocks, no open area. L groin/red.Special Treatment &Procedures:[MEDICATION NAME] to all redness." A skin data non pressure form documented the following: "Date 7/5/12, Time 1055, Size length/width/depth in cm, 6 cm diameter, Appearance Dark redness, Treatment [MEDICATION NAME] to buttocks BID. Physician notified: Date 7/5/12 Time 1100. Family notified: 7/5/12 Time 1100, no answer." There was no documentation to show further attempts had been made to notify the POA. No staging of the wound was documented in the clinical record. A Physician's Telephone Order, dated 07/05/12, documented, "....[MEDICATION NAME]- Apply to upper and lower buttocks bilaterally BID d/t redness." A five-day admission assessment, dated 07/05/12, documented the resident's cognitive skills for daily decision making was modified independence with some difficulty in new situations only. The resident required extensive assistance of two persons with bed mobility, transfers and toileting. The resident required extensive assistance of one person with ambulation in the room, dressing and personal hygiene, and required limited assistance of one person with locomotion off the unit. The assessment did not document any skin conditions or pressure ulcers. The assessment did document the resident was at risk for the development of pressure ulcers. No other skin issues were documented on the assessment. A skin data non pressure form documented the following: Date 7/10/12, Time 10a, Size length/width/depth in cm, approx 7 cm diameter, Appearance Dark purplish redness, increase [MEDICATION NAME] to buttocks q shift." No staging of the wound was documented in the clinical record. A Physician's Telephone Order, dated 07/10/12, documented, "Change [MEDICATION NAME]- Apply to upper and lower buttocks bilaterally q shift to redness (dark)." A physician's telephone order, dated 07/10/12, documented, "Discharge to (name deleted) hospital." A daily skilled nurses note, dated 07/10/12 at 3:00 p.m., documented, "Out of facility @ this time via (name deleted) company van assisted by 2 male workers. 2 person max assist with transfer from w/c into van. During transfer staff from (name deleted) bumped resi head and bumped resi arm causing s/t to R arm. Resi denies pain. V/S before departure B/P 127/79, P-91, R-18, T-97.3, Spo2 95% with 2 L O2 via N.C. Denies any c/o before departure all personal belonging sent with resi. Report called to (name deleted hospital) by DON (name deleted)." On 08/15/12 at 10:15 a.m., an interview was conducted with LPN #1, the treatment nurse, concerning the resident hitting his head and obtaining a skin tear. The LPN was asked if an incident report was completed and if a treatment was started on the resident, after the resident had hit his head and obtained a skin tear. She reported she had not completed an incident report on the resident or provided a treatment on the skin tear. At 10:30 a.m., the DON was asked if there was an incident report for the resident on 07/10/12. The DON looked in the incident report book and reported there was no incident report for the resident on that day. The DON reported the incident report was not completed because it happened during a transfer into a van that was transferring the resident to another facility. The DON was asked if the skin tear the resident had obtained was treated. She stated "No." The DON was asked if an assessment had been performed on the resident's head and if a neurological check had been performed. The DON stated, "No." No documentation was found in the resident's medical record to show the physician or the POA had been notified when the resident bumped his head and obtained a skin tear to his arm. There was no documentation in the clinical record to show the POA was notified of the above. No assessment was completed on the resident after hitting his head and obtaining a skin tear. No treatment order was found in the chart for the skin tear to the resident's arm. At 5:00 p.m., the DON was asked if the the physician and POA had been notified of the incident of the resident hitting his head and receiving a skin tear. She stated "No." The DON was asked if the POA was notified of the resident's change in skin condition. The DON stated, "No."

On 08/15/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor and intervene, when resident (#3) experienced a change in condition with a wound. At 4:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 4:55 p.m. At 5:00 p.m., the ADM and the DON were notified of the IJ situation. At 6:45 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Skin assessments to be completed on every resident in the facility for any skin problems by license nurses and physician will be notified and obtain orders as need for interventions. All nursing staff will be inserviced on what to look for and all nurses will be in-serviced on documentation, staging pressure ulcers and interventions. C.N.A.s will be in-services to report immediately to the charge nurse. The C.N.A. will be given examples of skin changes to report. Staff will notify consultant as needed. Assess pressure ulcers for changes in wound, size, odor, drainage and the doctor will be notified of changes. This will be completed by 5 PM 08-16-2012. Doctor will be notified to worsening wound or if wound is not responding to treatment. The doctor will be notified to obtain new treatment orders. Nursing staff will assess, monitor, and intervene with any changes. This will be completed by 5 PM on 08-16-2012." On 08/20/12 at 11:15 a.m., the staff were interviewed and were knowledgeable in regard to the reporting of residents' condition changes and assessment, monitoring and intervening with condition changed. All licensed staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. The Immediate Jeopardy was removed as of 08/16/12 at 5:00 p.m., after the staff had been inserviced. The deficient practice remained at actual harm at a pattern. Based on record reviews, observations, and staff interviews, it was determined the facility failed: a) To assess and intervene for one (#3) of three sampled residents, when a wound had changed in size, drainage, odor and depth. This had the potential to affect all 42 residents that required weekly skin assessments. b) To assess and intervene with treatment for one (#2) of one sampled resident, who received a skin tear and hit his head before leaving the facility. This had the potential to affect 63 residents, identified by the DON, who had experienced an incident in the past three months. Findings: A Skin Care Protocol documented, "Interventions/implementation:... 2. Residents identified at risk for pressure ulcers or with pressure ulcers will be evaluated for proper body positioning and will have routine skin assessments completed... 5. A plan of care will be developed to establish goals and approaches to meet the resident needs... Evaluation:... 2. Effectiveness of pressure ulcer treatments will be evaluated weekly. Treatment changes made per wound protocol per physician orders..." 1. Resident #3 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/30/12, documented the resident was cognitively intact with behaviors less than daily, was totally dependent of two persons for transfers, required extensive assistance of one person for dressing, hygiene and bathing. The resident required limited assistance of one person for bed mobility and eating. The resident was mobile per wheelchair. The resident had range of motion impairment on both sides of his lower extremities. The assessment documented the resident had two Stage I pressure ulcers, one Stage II pressure ulcer, and had one venous/arterial ulcer. A nurse's note, dated 06/11/12 at 10:00 a.m., documented, " Res noted to have abrasion to outer R ankle some bleeding noted. Redness noted around area. N/O (new order) received...Area proxy 3 cm in diameter No depth/ Some tenderness c touch..." A skin assessment non pressure form documented the resident's skin assessments. The wound to the outer right ankle was first observed on 06/11/12 with physician notification documented. A physician's orders [REDACTED]. The wound assessments were as follows: Date: 06/11/12 Location: Right outer ankle Size (length/width/depth in cm): 2 cm diameter no depth Appearance: Bed pink scant bleeding Treatment: DWC Pat dry TAO No staging of the wound had been documented in the resident's clinical record. Date: 06/21/12 Location: Right outer ankle Size: 4 cm diameter no depth Appearance: Dark scab on wound bed with small area yellowish odor Treatment: Seen per Dr. (name deleted) w/c (wound clinic) no Tx change No staging of the wound had been documented in the resident's clinical record. On 08/15/12 at 12:30 p.m., LPN #1, the treatment nurse, was asked what was the meaning of "w/c" in the above skin assessment. The LPN reported the physician saw the wound and wanted the resident to be seen by the wound clinic. The LPN reported w/c meant wound clinic. A physician's progress note, dated 06/21/12, documented, "...Initiate wound care." A skin assessment was documented as follows: Date: 06/25/12 Location: Right outer ankle Size: 5 cm diameter 1/8 depth Appearance: Dark & purulent scabbing present to entire wound Redness around outer edges Treatment: Attempted wc (wound clinic) 06/22/12 No answer Cont Tx Elevate foot No staging of the wound had been documented in the resident's clinical record. The right outer ankle wound had increased in size and it was the first time to have depth. There was no notification of the physician which concerned the wound changes or interventions in the resident's clinical record. A physician's orders [REDACTED]." A note by a foot care service, which was written by an advanced practice RN, dated 06/28/12, identified an ulcer to the outer upper sole of the resident's left foot. There was no notification to the physician in the clinical record of the ulcer site. The note documented , "DM (diabetes mellitus) ulcer L foot-Wound nurse eval Tx." The foot care note was noted by LPN #3. The resident was started on an antibiotic at that time for the left foot ulcer. No notification of the resident's attending physician was in the clinical record which concerned the resident's left foot. On 08/15/12 at 12:30 p.m., LPN #1, the treatment nurse, was asked if she knew about the noted order for the resident to be seen by a wound nurse for evaluation and treatment of his left foot. The LPN reported she had not known about the order. The LPN then reported the DON had tried to contact the wound clinic but was unsuccessful in reaching anyone. The LPN reported she did not know if there was any follow up completed. The LPN reported the DON was to take care of the wound evaluation. At that time, LPN #1, the treatment nurse, was asked is she had seen the area to the resident's outer upper sole of his left foot. The LPN reported there had been an area there at one time which had begun as a blister. The LPN reported it was no longer present. The LPN reported maybe the wound nurse thought it was a fresh wound. The LPN stated the area had healed and was not a problem and she could not remember about seeing it since it healed and dried up. No current documentation was in the resident's clinical record pertaining to the resident's left foot. The social services notes were reviewed. The social services notes did not contain any information about any attempts to contact the wound center or wound nurse for evaluation of the resident's wound. Skin assessments continued as follows: Date: 07/02/12 Location: Right outer ankle Size: Site 1: 6 cm 1/8 depth Site 2: 2 1/2 cm diameter Appearance: ^ (increase) odor Dark around edges Wound bed dry decreased drainage Treatment: no change in Tx Cont WC (wound clinic) to be scheduled No staging of the wounds had been documented in the resident's clinical record. There was no notification of the physician in the resident's clinical record of the new identified second site, the increase of size of the first wound, and the increase of odor. LPN #1 was asked where the second site was located. The LPN reported it was posterior to the first site on the right outer ankle. Skin Assessment: Location: Right outer ankle Date: 07/09/12 Size: Site 1: 6 cm 1/8 depth Site 2: 2 1/2 cm dia (diameter) 1/4 depth Appearance: No change Treatment: Cont current Tx No staging of the wounds had been documented in the resident's clinical record. There was no notification of the physician in the residents's clinical record which concerned the wound had no change or improvement with the current treatment. The second site now had depth and the physician was not notified. Skin Assessment: Location: Right outer ankle Date: 07/20/12 Size: Site 1: 6 1/2 cm 1/8 depth Site 2: 2 1/2 cm dia 1/4 depth Appearance: Small ^ size blackish sloughing No s/s of infection Treatment: To WC [MEDICATION NAME] (The resident had his first visit to the wound clinic on 07/27/12 and the [MEDICATION NAME] treatment was not ordered until 07/27/12.) No staging of the wounds had been documented in the resident's clinical record. No notification of the physician concerning the blackish sloughing was documented in the resident's clinical record. The treatment record, dated July 2012, documented the change from the previous order of TAO which had been applied to the wound continued through 07/26/12. Skin Assessment: Location: Right outer ankle Date: 7/27/12 Size: Site 1: 6 1/2 cm 1/8 depth Site 2: 2 1/2 cm 1/4 depth Appearance: No change Treatment: To WC [MEDICATION NAME] A post procedure physician orders, dated 07/27/12, from (name deleted) wound center, documented the following: "Wound location: 1. Right Lateral Ankle Type Stage: Arterial Ulcer... Measurements (cm): 4.9 x 5.6 x obs Wound location: 2. Right Posterior Ankle Type Stage: Arterial Ulcer... Measurements (cm): 1.2 x 1.5 x 0.2 ... Wounds 1, 2 were debrided in clinic today... Cleanse wound with: Normal Saline Apply to Wound Bed: [MEDICATION NAME] AG Apply to Periwound Tissue: [MEDICATION NAME], Skin Prep or skin barrier of choice Cover Wound With: Tape, Kerlix/ Conform Discharge Home Instructions: Wound care is to be performed 2 x week & prn Next Wound Center Visit: 1 week Offloading: Pillow under calves Restrictions: No tub bath Diet/Nutrition: Protein Supplement (Juven, Promod or equiv) 3 x day Diagnostics: Radiology: Arterial Doppler 07/30/12 at Facility (name deleted) Additional Orders: Written Rx given to patient [MEDICATION NAME] mg i (one) po bid x 10 d (days)..." The physician's orders [REDACTED]. The resident did not have his first visit to the wound clinic until 07/27/12, when the [MEDICATION NAME] AG was first ordered at that time. The advanced practice RN saw the resident on 06/28/12, and recommended he be seen by a wound nurse to evaluate and treat the left foot wound. This was not addressed until he was sent to the wound clinic on 07/27/12. There was no documentation to show the physician had been notified of the delay in the resident being sent to the wound clinic. A physician's orders [REDACTED]. to perform wound care two times weekly and as needed. The treatment record, dated July 2012, documented the following: "7/27 Cleanse wound to ankle, cleanse c NSS. pat dry, apply [MEDICATION NAME] AG Cover c ABD pad, wrap c Kling secure c tape q 2 weeks" (this was ordered from the wound clinic to be provided two times weekly and prn). There were nurse's initials indicated the treatment had been performed on 07/27/12. The treatment administration record, dated August 2012, documented the following: "7/27/12 Cleanse wound c NS, apply [MEDICATION NAME] AG, cover c ABD pad wrap c gauze, secure c tape q 2 wks and prn. (this was ordered from the wound clinic to be provided two times weekly and prn). The treatment sheet documented the treatment was provided on 08/07/12. No other treatment had been documented since the original physician's orders [REDACTED]. The wound had gone eleven days without a treatment. No notification to the physician was in the clinical record of the missed treatments for the wounds. The treatment administration record, dated August 2012. documented the following physician's orders [REDACTED]. "8/10/12 Cleanse wound c NS Apply [MEDICATION NAME] AG Cover c ABD pad wrap c gauze/Kerlix Secure c tape 2 x wk." This wound treatment change was to be performed two times weekly and should have started on 07/27/12 after the first wound clinic visit as ordered. Skin Assessment: Location: Right outer ankle Date: 08/03/12 Size: Site 1: 6 1/2 cm 1/8 depth 2. 2 3/4 cm 1/4 depth Appearance: small ^ in size Treatment: To WC [MEDICATION NAME] Date: 08/10/12 Location: Right outer ankle Size: Site 1: 7 cm 1/2 depth Site 2: 2 1/2 cm 1/4 cm Appearance: Increase size Odor noted Treatment: WC [MEDICATION NAME] No physician notification was in the clinical record of the increase size of the wound or the odor present. A post procedure physician orders [REDACTED]. "Wound Location: 1. Right Lateral Ankle Type Stage: Arterial Ulcer... Measurements (cm): 5.8 x 5.8 x 0.5 Wound Location: 2. Right Posterior Ankle Type Stage: Arterial Ulcer... Measurements (cm): 0.8 x 0.7 x 0.1 Wounds 1 , 2 were debrided in clinic today...No changes in wound care... Discharge home instructions: Wound care is to be performed: by facility 2 x week... Restrictions: No whirlpool/shower. No tub bath. Keep wounds dry. Diet/Nutrition: Continue Multi Vitamin daily, Vitamin C 500 mg twice daily, Protein Supplement (Juven, Promod or equiv) 3 x day... Consults/Referrals: Vascular Consult Dr. (name deleted} 8/15/12 at 11 :45 a.m..." On 08/15/12 at 3:00 p.m., the DON was asked if the physician should have been notified of the changes with the resident's right outer ankle wound when they increased in size, had odor or drainage, or there was no change in the wound with current treatment. The DON stated, "Yes." The DON further reported there was no answer previously when they had attempted to contact the wound nurse for evaluation of the left foot wound. There was no documentation in the resident's medical record of the attempts to notify the wound nurse for the evaluation. At 3:15 p.m., the transport staff member was interviewed. The transport staff member, reported she had gone that day (08/15/12) with the resident to visit the physician for his vascular consult. She reported the resident asked if the physician was going to remove his right foot. She stated the physician reported he was going to try and save his right foot. She stated the resident was going to have a stent surgically placed in his leg next week. At 5:10 p.m., the corporate ADM was informed about the changes in the resident's wounds, no physician notification and the lack of ordered wound care interventions in the clinical record. The corporate ADM reported the facility had released the wound consultant company they had previously utilized about two weeks to a month ago. The corporate ADM reported they were in the process of obtaining a new contract with another company. The corporate ADM reported the physician would be notified of the resident's wound status and the wound situations and interventions would be addressed. 2. Resident #2 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. A five-day admission assessment, dated 07/05/12, documented the resident's cognitive skills for daily decision making was modified independence with some difficulty in new situations only. The resident required extensive assistance of two persons with bed mobility, transfers and toileting, and required extensive assistance of one person with ambulation in room, dressing and personal hygiene, and required limited assistance of one person with locomotion off the unit. The assessment did not document any skin conditions or pressure ulcers. The assessment did document the resident was at risk for the development of pressure ulcers. No other skin issues were documented on the assessment. A Physician's Telephone Order, dated 07/10/12, documented, "Discharge to (name deleted) hospital." A Daily Skilled Nurses Note, dated 07/10/12 at 3:00 p.m., documented, "Out of facility @ this time via (name deleted)company van assisted by 2 male workers. 2 person max assist with transfer from w/c into van. During transfer staff from (name deleted) hospital bumped resi head and bumped resi arm causing s/t to R arm. Resi denies pain. V/S before departure B/P 127/79, P-91, R-18, T-97.3, Spo2 95% with 2 L O2 via N.C. Denies and c/o before departure all personal belonging sent with resi. Report called to (name deleted) hospital by DON (name deleted)." No assessment was completed on the resident after hitting his head and obtaining a skin tear. No treatment order was found in the medical record for the skin tear to the resident's arm. On 08/15/12 at 2:15 p.m., an interview was conducted with LPN #1, the treatment nurse, concerning the resident hitting his head and obtaining a skin tear. The LPN was asked if an incident report was completed and if a treatment was provided for the resident after the resident had hit his head and obtained a skin tear. She reported she had not completed an incident report for the resident or begun a treatment on the skin tear. At 2:00 p.m., the DON was asked if there was an incident report for the resident on 07/10/12. The DON looked in the incident report book and reported there was no incident report for that day. The DON reported the incident report was not completed because it happened during a transfer into a van that was transferring the resident to another facility. The DON was asked if the skin tear the resident had obtained was treated. She stated "No." The DON was asked if an assessment had been performed on the resident's head and if a neurological check had been performed. The DON stated, "No."

On 08/15/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to identify, assess, monitor and intervene when one resident (#2) experienced changes in condition with pressure ulcers. At 4:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 4:55 p.m. At 5:00 p.m., the ADM and the DON were notified of the IJ situation. At 6:45 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Skin assessments to be completed on every resident in the facility for any skin problems by license nurses and physician will be notified and obtain orders as need for interventions. All nursing staff will be inserviced on what to look for and all nurses will be in-serviced on documentation, staging pressure ulcers and interventions. C.N.A.s will be in-serviced to report immediately to the charge nurse. The C.N.A. will be given examples of skin changes to report. Staff will notify consultant as needed. Assess pressure ulcers for changes in wound, size, odor, drainage and the doctor will be notified of changes. This will be completed by 5 PM 08-16-2012. Doctor will be notified to worsening wound or if wound is not responding to treatment. The doctor will be notified to obtain new treatment orders. Nursing staff will assess, monitor, and intervene with any changes. This will be completed by 5 PM on 08-16-2012." On 08/20/12 at 11:15 a.m., the staff were interviewed and were knowledgeable in regard to the reporting of residents' condition changes. All licensed staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. The Immediate Jeopardy was removed as of 08/16/12 at 5:00 p.m., after the staff had been inserviced. The deficient practice remained at actual harm at a pattern. Based on record review and staff interviews, it was determined the facility failed: a) To ensure accurate wound/skin assessments were completed for one (#2) of two sampled residents who experienced pressure ulcers. This had the potential to affect all 42 residents, identified by the DON, who required skin assessments in the last three months. b) To identify and assess a wound for one (#1) of two sampled residents, who had pressure ulcers. This had the potential to affect all 42 residents, identified by the DON, who required skin assessments in the last three months. Findings: A policy, titled "Wound Assessment Protocol", documented the following: "Interventions/implementation: 2. Residents identified at risk for pressure ulcers or with pressure ulcers will be evaluated for proper body positioning and will have routine skin assessments completed. 5. A plan of care will be developed to establish goals and approaches to meet the resident needs. Evaluation: 2. Effectiveness of pressure ulcer treatments will be evaluated weekly. Treatment changes made per wound protocol per physician orders..." 1. Resident #2 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. An admission nursing assessment, dated 06/27/12, documented, "...skin condition... comments: Multiple Bruising, slight redness to scrotum area..." No other skin issues were documented on the assessment. An "Interim Plan of Care," dated 06/27/12, documented, ".... Potential for breakdown and Skin Tears due to Multiple medical conditions creating poor skin integrity... 7/5/12 Resident readmitted with large area of dark redness to bilateral buttocks no open areas. Dr. (name deleted) notified N.O. received. 7/10/12 Dark red/purplish... Goals: No breakdown and Skin Tears will resolve without complications, infection or discomfort as they occur... Approaches: 1. Tx as ordered [MEDICATION NAME]. 2. Monitor for s/s of infection 3. Notify MD if current Tx is not effective... 7/5/12 [MEDICATION NAME] BID..." A five-day admission assessment, dated 07/05/12, documented the resident's cognitive skills for daily decision making was modified independence with some difficulty in new situations only. The resident required extensive assistance of two persons with bed mobility, transfers and toileting, and required extensive assistance of one person with ambulation in room, dressing and personal hygiene, and required limited assistance of one person with locomotion off the unit. The assessment did not document any skin conditions or pressure ulcers. The assessment did document the resident was at risk for the development of pressure ulcers. No other skin issues were documented on the assessment. A Skin Data Non Pressure form, dated 06/27/12, documented, ".....Type of wound: (not checked), describe type Dark Redness Location: buttocks bilaterally, General Appearance: Dark red skin intact no drainage..." No staging of the wound was documented in the clinical record. The resident was sent to (name deleted) hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE]. An "Admission Nursing Assessment," dated 07/05/12, documented, "Skin Condition... comments: 1. Dark redness to Bilat buttocks, no open area. L groin/red.Special Treatment &Procedures: [MEDICATION NAME] to all redness." A Skin Data Non Pressure form, dated 07/5/12 at 10:55 a.m., documented, "Size length/width/depth in cm, 6 cm diameter, Appearance Dark redness, Treatment [MEDICATION NAME] to buttocks BID....Physician notified: Date 7/5/12 Time 1100. Family notified: 7/5/12 Time 1100, no answer." No staging of the wound was documented in the clinical record. A Physician's Telephone Order, dated 07/05/12, documented, "....[MEDICATION NAME]- Apply to upper and lower buttocks bilaterally BID d/t redness." A Skin Data Non Pressure form, dated 07/10/12 at 10:00 a.m., documented, "Size length/width/depth in cm, approx 7 cm diameter, Appearance Dark redness, increase [MEDICATION NAME] to buttocks q shift." No staging of the wound was documented in the clinical record. A Physician's Telephone Order, dated 07/10/12, documented, "Change [MEDICATION NAME]- Apply to upper and lower buttocks bilaterally q shift to redness (dark)." A Physician's Telephone Order, dated 07/10/12, documented, "Discharge to (name deleted) hospital." A Daily Skilled Nurses Note, dated 07/10/12 at 3:00 p.m., documented, "Out of facility @ this time via (name deleted)." The resident was admitted to (name deleted hospital) on 07/10/12. There was no skin condition status report given verbally or a written report to the hospital from the facility. On 07/10/12 at 3:36, a (name deleted hospital) initial interview documented, "The Appearance on Admission-Hygiene: documented, hygiene inadequate, pt dirty, clothes don't fit him, he has bleeding wounds on his buttocks which are not covered, no under clothing, socks are urine soiled, feet are dirty, dirt on sole of feet, and between toes, pt cath is leaking so it was in cath carrier which was 1/2 full of urine, pt face has dried scaly, fingernails and toenail are over grown describe: poor oral hygiene, pt tongue is dried, teeth dry. pt cough is productive coughs when given water to drink." A hospital nurse's note dated 07/10/12 at 4:00 p.m., documented an entry (one hour after discharge from the facility) as follows, "During assess found very large pressure ulces (sic) to bilat buttocks/coccyx with necrotic area thru out the wounds. He has no feeling there. I cleansed with soap, water, applied [MEDICATION NAME] AG, Mediplex to cover until wound care orders received. Pt was wet from leaking cath, draining wounds which were not covered. Pt has scaly skin all over his face, nails are long and untrimmed. His tongue is very dry, Pt coughs when given water, productive cough, thick mucousy. Pt is very poor historian, unable to give me basically any information. POA is son...Pt. has unstageable pressure ulcers to buttocks, coccyx bilaterally, also has traumatic appearing wound to top of L foot..." The Hospital (name deleted) Unit Comprehensive Skin/Body Marks Assessment Form, documented, "A. 07/10/12, Upper Left Coccyx, Pressure Ulcer Necrotic. B. 07/10/12, Upper Right Coccyx, Pressure Ulcer Necrotic. C. 07/10/12, Mid Left Buttocks, Pressure Ulcer Necrotic. D. 07/10/12, Mid Right Buttocks, Pressure Ulcer Necrotic. E. 07/10/12, Dorsal Right Foot, Trauma Part. thickness. F. 07/10/12, Inferior Left Scrotum, Vesicle Intact." On 08/15/12 at 2:15 p.m., an interview was conducted with LPN #1, the treatment nurse, concerning the resident's skin assessment to his buttocks. The LPN was asked to describe what the resident's buttocks looked like the last time she saw it. She reported the buttocks were red with some purplish areas in the middle of the reddened area. At 3:15 p.m., an interview was conducted with LPN #2 concerning the resident's skin condition. She reported completing the skin assessment for the resident when he returned from (name deleted hospital) on 07/05/12. She reported the resident's bottom was red with purple areas. At 5:00 p.m., an interview was conducted with the DON concerning the resident's buttocks. The DON was informed of the hospital nurses' notes description of the resident's buttocks upon admission. The DON reported the resident's buttocks did not look like that when he left the facility. 2. Resident #1 was admitted on [DATE], with numerous [DIAGNOSES REDACTED]. A treatment order, dated 09/15/11, documented,..."Triple antibiotic ointment cleanse all open areas on feet and toes bilaterally with dermal wound cleanser, apply until resolved- cover prn." The treatment sheet documented the open areas to toes bilaterally healed on July 1, 2012. A Plan of Care, dated 06/09/12, documented.... "Problem/Need resident (name deleted) will attend wound clinic one time a week for optimal healing of decubitus ulcers that were presented on admission to facility. Goals/Objectives: The pressure ulcers will heal without complication with appropriate interventions and resident cooperation... Approaches: Evaluate/record/report to MD prn s/sx of deterioration in pressure ulcer: increase in size/depth, change in color, drainage, odor, pain. Provide weekly documentation on wound report of wound color, drainage, odor, and size (length x width x depth)..." A Weekly Pressure Ulcer Healing Record, dated 06/01/12 and 06/22/12, had no skin assessments or measurements documented for these weeks. The resident was discharged to the hospital on [DATE]. A discharge assessment, dated 07/06/12, documented the resident's cognitive skills for daily decision making were independent. The resident was independent with bed mobility, required extensive assistance of two persons with transfers, toileting and personal hygiene, ambulation in room did not occur, and the resident was independent with eating. The pressure ulcer area of the assessment documented the resident had two stage four pressure ulcers to her left and right ischium. No other break down was documented. The resident was admitted to hospital (name deleted) for wound treatment. The hospital assessment dated [DATE], documented, "Assessment 1. Stage IV bilateral ischium decubitus ulcers. 2. Left great toe wound". A Wound Care (name deleted) Post Procedure Physician order [REDACTED]." No documentation was found in the resident's medical record concerning a left great toe wound prior to admission to the hospital. On 08/15/12 at 2:45 p.m., the resident was asked if she was admitted on [DATE] to the hospital with a great toe wound. She reported she was admitted to the hospital with [REDACTED]. At 3:50 p.m., an interview was conducted with LPN #1 concerning the resident's great toe wound. The LPN was asked if the resident had ever had a wound to her great toe. The LPN reported she was never aware of a wound to the resident's great toe. At 5:00 p.m., the DON was asked if she was aware the resident had a stage three pressure ulcer to her left great toe upon admission to the hospital on [DATE]. She stated, "No."

Based on record review and staff interview, it was determined the facility failed to notify the physician when a resident experienced 12 low FSBS readings, which resulted in harm and required treatment at a hospital for one (#4) of six sampled residents who had physician orders [REDACTED]. This had the potential to affect seven residents, identified by the DON, who had physician orders [REDACTED]. Findings: A facility policy documented, "When licensed nurse determines resident is hypoglycemic, give instant glucose or [MEDICATION NAME], if ordered. If no orders, give fruit juice (orange or apple) and notify physician." Resident #4 was admitted on [DATE], with a [DIAGNOSES REDACTED]. A care plan, dated 05/17/11, documented the problem of diabetes mellitus type two for the resident. The goal documented the resident would not suffer any adverse symptoms for the next 90 days. An intervention listed was to administer emergency drugs to the resident for low blood sugars and notify the physician. A physician's orders [REDACTED]. Another order documented, [MEDICATION NAME] 35 units SQ at bedtime. An initial assessment, dated 05/30/11, documented the resident was moderately impaired with cognition and demonstrated mild depression. A physician's orders [REDACTED]. A nurse's note, dated 12/20/11, documented the resident's FSBS was 69. A nurse's note, dated 12/23/11, documented the resident's FSBS was 63 and the resident was given a large glass of orange juice. A nurse's note, dated 12/24/11 at 7:30 a.m., documented the resident's FSBS was 69 and the resident was given orange juice. A nurse's note, dated 12/28/11 at 12:10 a.m., documented the resident's FSBS was 64 and the resident was given orange juice. A nurse's note, dated 01/02/12 at 10:45 a.m., documented the resident's FSBS was 51. The note documented the resident was very confused and was yelling. The resident was given orange juice with sugar. A nurse's note, dated 01/06/12 at 1:00 p.m., documented the resident's FSBS was 66. The note documented the resident was given a meal. A nurse's note, dated 01/07/12 at 12:15 p.m., documented the resident's FSBS was 56. The resident was given orange juice. A nurse's note, dated 01/08/12 at 12:20 p.m., documented the resident's FSBS was 64. The note documented the resident was found in the floor . The resident was given juice and the lunch meal. A nurse's note, dated 01/12/12 at 10:20 a.m., documented the resident's FSBS was 64. The resident was lethargic and disoriented with slurred speech. The resident was given a sandwich and chips. A nurse's note, dated 01/12/12 at 12:15 p.m., documented the resident's FSBS was 69. The resident was given orange juice with sugar. A nurse's note, dated 01/23/12 at 10:00 a.m., documented the resident's FSBS was 64. The resident was given orange juice. There was no documentation in the resident's medical record to reflect the physician had been informed of the numerous low FSBS readings. On 01/23/12 at 7:00 p.m., a nurse's note documented the resident's skin was cool and clammy to touch and the resident was not responsive. The nurse called 911 and the resident was transferred to the hospital. There was no documentation the resident's FSBS was obtained prior to transfer to the hospital. An emergency room physician's note, dated 01/23/12 at 7:38 p.m., documented the resident's FSBS, in the ambulance, was 39. The resident was given a dose of 50% glucose upon arrival to the emergency department. The physician documented, "Response improved..." The physician documented, at 8:30 p.m., the resident's FSBS was 89 and the dosage of glucose was repeated. The physician documented, "Response improved..." The resident returned to the facility with a [DIAGNOSES REDACTED]. The physician ordered the resident to have FSBSs performed that night every two hours until 8:00 a.m. the following day. A care plan, dated 01/24/12, documented the resident had a potential for hyper/[DIAGNOSES REDACTED] as a problem. The goal was for the resident to maintain blood sugar levels within an acceptable range per the physician through the review date. An intervention listed was to obtain and monitor diagnostic work as ordered and to report results to the physician. On 02/28/12 at 2:30 p.m., the DON was interviewed regarding the lack of physician notification concerning the numerous low FSBS readings. The DON reported the physician should have been notified of the resident's low FSBSs. The DON reported the facility should have obtained FSBS parameters from the physician.

Based on observation, record review and staff interview, it was determined the facility failed to ensure: a) Resident #4 was assessed and monitored, when the resident experienced 12 low FSBS readings, which resulted in harm and required treatment at a hospital for one (#4) of six sampled residents who had physician orders [REDACTED]. b) Parameters were set to notify the physician of abnormal FSBS values for two (#4 and #10) of three sampled residents, who had physician ordered FSBSs. This had the potential to affect seven residents, identified by the DON, who had physician ordered FSBSs. c) The staff used proper technique for indwelling urinary catheter care and perineal care for one (#2) of two sampled residents who required perineal care and indwelling urinary catheter care. This had the potential to affect three residents with an indwelling or external catheter and 15 residents occasionally or frequently incontinent of bladder, identified by the Resident Census And Conditions Of Residents form, who required indwelling urinary catheter care and perineal care. d) An injury which occurred during a fall, was assessed and monitored for one (#3) of five sampled residents who had experienced a fall. This had the potential to affect 10 residents, identified by the DON, who had experienced falls in past three months. Findings: 1. A facility policy documented, "When licensed nurse determines resident is hypoglycemic, give instant glucose or [MEDICATION NAME], if ordered. If no orders, give fruit juice (orange or apple) and notify physician." Resident #4 was admitted on [DATE], with a [DIAGNOSES REDACTED]. A care plan, dated 05/17/11, documented the problem of diabetes mellitus type two for the resident. The goal documented the resident would not suffer any adverse symptoms for the next 90 days. An intervention listed was to administer emergency drugs to the resident for low blood sugars and notify the physician. A physician's orders [REDACTED]. Another order documented, [MEDICATION NAME] 35 units SQ at bedtime. An initial assessment, dated 05/30/11, documented the resident was moderately impaired with cognition and demonstrated mild depression. A physician's orders [REDACTED]. A nurse's note, dated 12/20/11, documented the resident's FSBS was 69. A nurse's note, dated 12/23/11, documented the resident's FSBS was 63 and the resident was given a large glass of orange juice. A nurse's note, dated 12/24/11 at 7:30 a.m., documented the resident's FSBS was 69 and the resident was given orange juice. A nurse's note, dated 12/28/11 at 12:10 a.m., documented the resident's FSBS was 64 and the resident was given orange juice. A nurse's note, dated 01/02/12 at 10:45 a.m., documented the resident's FSBS was 51. The note documented the resident was very confused and was yelling. The resident was given orange juice with sugar. A nurse's note, dated 01/06/12 at 1:00 p.m., documented the resident's FSBS was 66. The note documented the resident was given a meal. A nurse's note, dated 01/07/12 at 12:15 p.m., documented the resident's FSBS was 56. The resident was given orange juice. A nurse's note, dated 01/08/12 at 12:20 p.m., documented the resident's FSBS was 64. The note documented the resident was found in the floor . The resident was given juice and the lunch meal. A nurse's note, dated 01/12/12 at 10:20 a.m., documented the resident's FSBS was 64. The resident was lethargic and disoriented with slurred speech. The resident was given a sandwich and chips. A nurse's note, dated 01/12/12 at 12:15 p.m., documented the resident's FSBS was 69. The resident was given orange juice with sugar. A nurse's note, dated 01/23/12 at 10:00 a.m., documented the resident's FSBS was 64. The resident was given orange juice. There was no documentation in the resident's medical record to reflect the physician had been informed of the numerous low FSBS readings. There were no FSBS parameters for the resident. On 01/23/12 at 7:00 p.m., a nurse's note documented the resident's skin was cool and clammy to touch and the resident was not responsive. The nurse called 911 and the resident was transferred to the hospital. There was no documentation the resident's FSBS was obtained prior to transfer to the hospital. An emergency room physician's note, dated 01/23/12 at 7:38 p.m., documented the resident's FSBS, in the ambulance, was 39. The resident was given a dose of 50% glucose upon arrival to the emergency department. The physician documented, "Response improved..." The physician documented, at 8:30 p.m., the resident's FSBS was 89 and the dosage of glucose was repeated. The physician documented, "Response improved..." The resident returned to the facility with a [DIAGNOSES REDACTED]. The physician ordered the resident to have FSBSs performed that night every two hours until 8:00 a.m. the following day. A care plan, dated 01/24/12, documented the resident had a potential for hyper/[DIAGNOSES REDACTED] as a problem. The goal was for the resident to maintain blood sugar levels within an acceptable range per the physician through the review date. An intervention listed was to obtain and monitor diagnostic work as ordered and to report results to the physician. On 02/28/12 at 2:30 p.m., the DON was interviewed regarding the lack of physician notification concerning the numerous low FSBS readings. The DON reported the physician should have been notified of the resident's low FSBSs. The DON reported the facility should have obtained FSBS parameters from the physician. 2. Resident #10 had a [DIAGNOSES REDACTED]. An annual assessment, dated 08/04/12, identified the resident with no cognitive deficits, required moderate assistance with dressing and extensive assistance with bathing. A care plan, dated 05/27/11, documented the following: "Problem/Need (Resident's name deleted) Cont to have potential for hyper/[DIAGNOSES REDACTED] or other complications related to DM Will cont c goals & approaches thru next review. Approaches ...Monitor of s/sx of [DIAGNOSES REDACTED]. If overt sx noted, check fingerstick blood sugar and give glucose or [MEDICATION NAME] per protocol..." The resident had the following physician's orders [REDACTED]. "FSBS AC & HS @ 730 A, 1130 AM, 230 PM & 8 PM [MEDICATION NAME]-Inject 24 units @ 8 PM Sliding scale C [MEDICATION NAME] insulin 151-200=Give 5 units SQ chart site 201-250=Give 6 units SQ chart site 251-300=Give 8 units SQ chart site 301-350=Give 10 units SQ chart site." There were no parameters for when to call the physician for high or low FSBS values. On 02/29/12 at 1:40 p.m., the DON was shown the physician's orders [REDACTED]. 3. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/07/11, documented the resident had short and long-term memory deficits with severely impaired cognitive skills for decision making, was totally dependent on two persons for transfers, required extensive assist for bed mobility, dressing, hygiene and bathing. The resident had an indwelling urinary catheter and was occasionally incontinent of bowel. On 02/28/12 at 11:00 a.m., CNA #1 was observed to provide incontinent care for the resident. The resident had an indwelling urinary catheter which was leaking. The top sheet, bed pads and the mattress was wet from urine. There was blood-tinged urine in the urinary bedside drainage bag. The resident was soiled from a bowel movement. The CNA applied gloves and cleansed the resident's left groin, right groin and down the mid perineal area. The CNA used the same washcloth for the three areas without changing sides of the cloth or using separate cloths or wipes. The CNA then cleaned down the mid perineal area again and the used the same cloth to clean the right groin. She then cleaned the posterior right thigh and anus using backward [MEDICAL CONDITION]. She turned the resident and touched the residents hips and buttocks with the same contaminated gloves and removed the soiled bed pad. The CNA then changed her gloves. The CNA then placed a clean bed pad over the wet mattress. When the resident was turned to the other side, the catheter was pulled taut and it was not secured to prevent discomfort from being pulled. The resident yelled out when the catheter was pulled. At that time, the resident's uncovered urinary bedside drainage bag was on the floor. The resident was turned onto her back. The CNA then told the resident she needed to make sure the resident was clean. The CNA took a washcloth and cleaned the mid perineal area again. With the same contaminated washcloth, the CNA washed downward on the urinary catheter tubing three times. The CNA then removed her gloves, removed the wet gown and applied a clean gown and linens for the resident without washing or sanitizing her hands. The soiled linens were placed in a plastic bag which was on the floor. The CNA then picked up the bag from the floor and placed the bag on the resident's bedside table. At 11:15 a.m., the CNA was asked if she would have done anything differently. She reported if she had help she would have washed the bed off as well. At 3:30 p.m., the DON was informed of the perineal care technique with an indwelling urinary catheter observed. She reported the staff would improve the perineal care. 4. Resident #3 was admitted to the facility with the [DIAGNOSES REDACTED]. A nurse's note, dated 02/10/12 at 11:15 p.m., documented "Client attempting to get out of bed without assist, became off balanced and falling. When asked what client hit his head on he stated the table. Client is disoriented and confused on a daily basis. Client received abrasions to (L) elbow and eye brow areas which were cleansed of minute amounts of blood and drsg applied to elbow wound." No documentation was found on the February 2012 treatment sheet for a treatment or for monitoring the abrasions to the L elbow or the L eye brow. A 90 day assessment, dated 02/16/12, documented the resident had short and long term memory deficits, walked in room and corridor independently and required limited assistance with all meals. On 02/28/12 at 4:05 p.m., LPN #2 was asked about the incident which occurred on 02/01/12. The LPN was asked about the abrasion to the resident's L eye brow. The LPN reported the abrasion was a small open area with a minute amount of blood. The LPN was asked if there was an order on the February 2012 treatment sheet for a treatment or for monitoring the elbow or the eye. He stated, "No." On 02/29/12 at 10:30 a.m., the DON was asked if the abrasions to the elbow and the eye brow should have been monitored. The DON stated, "Yes."