Every finding on record at Shawnee Colonial Estates Nursing Home

On 04/08/25 at 3:50 p.m., the Oklahoma State Department of Health was notified and verified the existence of an Immediate Jeopardy situation related to the facility's failure to provide supervision to prevent elopement from the facility. Resident #22 was identified as being at risk for elopement. Resident #22 made it out to the parking lot through the front door within sight of the nurse's station unattended. A visitor notified staff Resident #22 was in the parking lot. On 04/08/25 at 3:55 p.m., the administrator, director of nursing, assistant director of nursing, business office manager, and corporate nurse were notified of the immediate jeopardy and provided the immediate jeopardy template. On 04/09/25 at 11:54 a.m., an amended plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, A) Immediate interventions initiated for Resident #22 following elopement on 02/03/25: *15 minute checks *Physician notification with medication changes *Pain evaluation *Alternative placement referral. *Interventions successful. Resident #22 has not had further attempts to elope from facility and did not require alternative placement. Once resident #22 was determined to be at risk, [they] was placed on the facility Code White program. Exit seeking behaviors were monitored every shift and continue. Signage placed on facility doors to instruct family members to call for assistance instead of pulling the doors open and to ensure facility residents are not following them outside when they leave. Facility staff received re-education on 11/13/24, 02/01/25, 02/06/25 and a Code [NAME] Drill was performed on 02/10/25. Immediate interventions for Resident #95 on 02/17/25. *1:1 until discharge to memory care facility. B) All facility residents who are at risk for elopement will be considered at risk for this alleged deficient practice. C) A Code [NAME] Drill was held on 04/08/25 with facility staff at 1815. Steps of the mock elopement drill completed per facility protocol and response time was immediate with the resident being found within 3 minutes. Re-education with all staff was provided to include definitions and identifying exit seeking behaviors. CNAs interviewed were well versed with the facility Code [NAME] Program. Door alarms are working properly. D) Residents considered at risk for elopement were reviewed on 04/08/25 with interdisciplinary team to ensure interventions in place continue to be successful. E) Plan of Correction completed on 04/08/25 at 1830. Additional questions from surveyors: 1. What do staff do when visitors are pulling on the door to enter/exit? The door alarm sounding is the initial safety measure. Staff then reset the code and educate visitors to use code provided and to ensure residents do not follow them outside when leaving. A call multiplier was sent to all family contacts. Signage was updated with a Stop sign with instructions on how to enter/exit without pulling on door. This information will be added to the admission packet and orientation packet to ensure continual compliance. 2. With other residents at risk for elopement, what do employees do with exit seeking behaviors and how do staff know what interventions to use and effectiveness. Non-pharmacological resident specific interventions have been identified for both residents and can be found on the TARs, MARs and in POC. Outcome of non pharmacological interventions are documented in the nurses notes. Resident #1 non-pharmacological interventions for target behavior (exit seeking) include 1. Talk about president [name withheld] 2. Offer cup of coffee and active listening 3. Offer favorite snack i.e [that is] oatmeal cream pie 4. Deep breaths 5. Call [family]. Resident #2 non-pharmacological interventions for target behavior (exit seeking) include: 1. Offer favorite snack (any type of cookie) 2. Talk about painting fences 3. Call [family] 4. Coffee time 3. How do employees know what interventions are used and if effective? Target behaviors and Non-pharmacological interventions are monitored every shift. Once a target behavior is identified, non-pharmacological resident specific interventions are available for each resident on the TAR, MAR and in POC. The outcome of utilizing non-pharmacological interventions can be found in the nurses notes and will be reviewed at resident care plan meetings and/or quality assurance meetings to determine if additional plans of action need to be implemented. On 04/09/25 after interviews with facility staff, review of resident elopement wander risk assessments, and in-services, the immediacy was lifted, effective 04/09/25 at 11:00 a.m. The deficient practice remained at a pattern level with potential for more than minimal harm. Based on observation, record review and interview, the facility failed to: a. provide supervision and interventions to prevent elopement for 2 (#22 and #95) of 3 sampled residents reviewed for elopement; b. provide supervision for a resident who wandered and was at risk for elopement for 1 (#20) of 3 sampled residents reviewed for elopement; and c. utilize a mechanical lift as ordered for transfers which resulted in a fall for 1 (#21) of 4 sampled residents reviewed for accident hazards. LPN #1 identified 40 residents resided in the faciilty. The administrator identified two residents at risk for elopement resided in the facility. Findings: On 04/08/25 at 10:27 a.m., the chain link fenced in area on the North side of the building was observed to have the handle closed but without a locking device in place. The gate could be opened. Four of the exit doors had red writing on them that provided instructions to hold the door for 15 seconds to get it to open. A policy titled Emergency Procedure- Missing Resident, revised August 2018, read in part, Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. 1. Resident #22 was admitted to the facility on [DATE] with diagnosis which included dementia. A Nurse Note, dated 01/09/25, showed Resident #22 pulled the fire alarm and stated, the alarm said pull, so I pulled it. The note showed Resident #22 also stated the door sign indicates if you hold it down for 15 seconds it will open. The note showed the physician and family were notified of the incident with family stating Resident #22 had never tried to exit seek before. On 01/10/25, the care plan was updated to include wandering and elopement with interventions of Resident #22 to be added to the elopement list for staff to be more aware of their exit seeking, distracting resident, and providing structured activities. A Nurse Note, dated 02/03/25, showed Resident #22 exited North hall entrance, a family member alerted the ADON and they responded immediately by assisting resident back into the facility without further incident. The note showed Resident #22 was noted to be in the parking lot, alarm to North doors noted to be sounding. The note showed Resident #22 was alert to self and noted to have increased confusion of time and place. The note showed Resident #22 stated they were going to other place, but unable to verbalize what place, the resident was assisted back to their room, and attempted to reorient without success. The note showed family called and discussed concerns with exit seeking and elopement, and alternative placement options. The note showed the resident was currently on code white list with 15 minute checks initiated. An incident report form, dated 02/03/25, showed Resident #22 was noted to exit North hall entrance. The report showed family members alerted the ADON and DON, they responded immediately assisting the resident back into the facility without further incident. The report showed Resident #22 was noted to be in the parking lot, alarm to North doors noted to be sounding. The report showed Resident #22 was alert to self and had increased confusion of time and place. The report showed Resident #22 stated they were going to other place, but was unable to verbalize what place, the resident was assisted back to their room and attempted to reorient without success. The report showed the DON had visited with family members regarding this behavior, physician had ordered new medications and Resident #22 was to see a counselor. The report showed the DON talked with Resident #22 about any pain they may have been experiencing and Resident #22 denied pain. The report showed Resident #22 remained on 15 minute checks and the DON spoke with the family regarding the interventions the facility had implemented and they let them know if they did not work, Resident #22 might need to find a different placement. The care plan did not have any additional interventions listed after the 01/09/25 incident. On 04/08/25 at 10:19 a.m., the DON stated, We put a stop sign on the door that said please call this number for assistance. staff knows that [Resident #22] is code white, we make a mental note that [Resident #22] is close to the door. Family member of another resident had the alarms going off and when the resident got out they notified staff who was able to easily redirect them back into the building. The alternative placement did not work out due to financial concerns. 2. Resident #95 was admitted to the facility on [DATE] with diagnoses that included general anxiety disorder. An admission Minimum Data Set assessment, with an assessment reference date of 01/24/25, showed Resident #95 had a brief interview for mental status score of 13 indicating Resident #95 was cognitively intact. The assessment showed no wandering behavior and required moderate assistance with walking. Resident #95's Wandering Risk Review, dated 02/01/25, showed they were newly at risk for elopement. An incident report form, dated 02/17/25, showed the ADON heard the center [NAME] door alarm and went to check and saw Resident #95 walking on the sidewalk outside. The report showed Resident #95 left their wheelchair at the door and pressed the bar on the door for 15 seconds and the door opened, and they walked outside. The report showed Resident #95 was looking for their family member. The report showed one on one was implemented immediately, and family stated they thought the code on the door would keep Resident #95 inside. The note showed family advised they wanted the facility to send the medical records to the memory care unit in Shawnee. A Nurse Note, dated 02/17/25, showed the ADON heard the door alarming and upon approach saw Resident #95's wheelchair in front of the door. The note showed Resident #95 was noted to be looking over the fence asking where their house was. The note showed they were easily redirected back inside the building and placed on one on one and the physician and family were notified of the incident. There was no documented care plan regarding elopement. On 04/08/25 at 10:14 a.m., MDS coordinator #1 stated they should have put elopement in the care plan for Resident #95 once it was identified on the elopement risk assessment, but they did not. On 04/08/25 at 10:27 a.m., the DON stated Resident #95 was ambulatory at that time and walked to the middle doorway and pushed the door open and the ADON responded immediately. On 04/08/25 at 1:14 p.m., CNA #3 was able to verbalize their responsibility, if they were to see a resident trying to get out the door, would be to try to stop them, try to redirect them, let them know where they are, keep eyes on them, and tell the nurse about the behavior. CNA #3 stated they were told that when they first started on 03/26/25. CNA #3 stated they have not seen anyone try to get out. On 04/08/25 at 1:19 p.m., CMA #1 stated the last training concerning code white was about a month ago. CMA #1 stated they had mock drills. CMA #3 identified exit seeking behaviors as hanging out by the doors or things they talked about. CMA #3 stated the one they watch the most was Resident #22 because they are always looking for their truck. CMA #1 stated their responsibility was to alert the nurse and try to stop the residents by convincing them to come back in. 3. On 04/07/25 at 10:12 a.m., Resident #20 was observed standing up independently from a recliner in the front living room, used a standard walker, and walked over to the front exit door of the facility. The resident looked out the glass door, but did not touch the door. Resident #20 then turned to the side with their walker. On 04/07/25 at 10:13 a.m., Resident #20 began ambulating away from the front door and towards the hall that ran alongside the dining room. The resident continued down the hall towards the administrator's office. RN #1 stopped the resident and asked them to walk with them towards the nurse's station. The resident followed RN #1. On 04/07/25 at 10:17 a.m., Resident #20 walked towards the front living room again. On 04/07/25 at 10:19 a.m., Resident #20 walked a little closer to the front door, turned around, and began walking towards RN #1. The resident stood next to RN #1. On 04/07/25 at 10:21 a.m, RN #1 and Resident #20 walked down the hall until they arrived at the resident's room. RN #1 explained to Resident #20 they had arrived to their room. CNA #6 entered the room and asked the resident to go to the bathroom. Resident #20 was heard to be saying get out of here to the CNA. CNA #6 opened the door, called for help and two staff members entered the room. The surveyor did not enter the room as Resident #20 was verbally upset. On 04/07/25 at 10:49 a.m., Resident #20 was observed walking with their walker to the common area and ambulated with another resident to the front exit door. Resident #20 did not touch the door. The two residents continued to stand by the door while the other resident remarked about how windy it was outside. On 04/07/25 at 10:54 a.m., both residents remained standing by the front exit door. RN #2 approached Resident #20 and asked if they could shave the resident. RN #2 placed their hand on Resident #20's back and pointed them in the direction of their room. RN #1 stated to Resident #20 lets go down to your room and get you shaved. RN #1 joined RN #2 in Resident #20's room to shave them. Resident #20 had diagnosis which included cognitive communication deficit. A behavior note, dated 01/07/25, showed Resident #20 had been actively exit seeking for the last 1.5 hours walking nonstop from one end of the North hall to the other. The note showed the resident had been able to set the alarm off on the northwest door twice by pressing it repeatedly. The note showed staff was able to get Resident #20 before the door opened. The note showed the facility notified family and a family member was going to come sit with the resident. An admission elopement/wandering risk assessment, dated 01/07/25, showed Resident #20 was at risk for elopement/wandering as evidenced by exit seeking trying to go to work while approaching exit doors. The assessment showed interventions which included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, the personalization of room with familiar objects and photographs and provide structured activities: toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes. A nurse's note, dated 01/09/25, showed Resident #20 was noted to aimlessly wander throughout the facility. The note showed the resident's family was at their side and voiced concerns about the resident's constant pacing and wandering throughout the facility. An admission resident assessment, dated 01/12/25, showed Resident #20 had severe cognitive impairment (BIMS 00) and did not exhibit wandering behaviors. An alert note, dated 01/20/25, showed Resident #20 was pacing and refused their morning medication. The note showed once the resident's family member arrived, the resident took their medications and the pacing stopped. A nurse's note, dated 01/30/25, showed Resident #20 had increased behaviors when their family member left that afternoon. The note showed the resident was walking towards exit asking to go check on them. The note showed the resident was noted to calm down after staff provided one on one care. A behavior note, dated 02/06/25, showed Resident #20 was combative while staff were attempting to change them. It showed the resident came out of their room, went up and down the hallways, and stated [they] were walking to that door. The note showed the resident walked to the end door, stood there with staff and then turned around and headed back to their room. A behavior note, dated 03/29/25, showed Resident #20 had been anxiously wandering the facility that morning. It showed the resident was down the northeast hall and a CMA tried to give the resident medications which they refused. The note showed Resident #20 pushed the door at the end of the hall open and started to go out. It showed the CMA yelled for help and a CNA went to help. The note showed they got the resident turned around and back up the hallway. The note showed the facility called family to come be with the resident. An alert note, dated 04/09/25 at 7:11 p.m., showed the facility called Resident #20's family and notified them the resident was at the front door when a delivery person pushed the code and came in the door. The note showed Resident #20 tried to get out the front door. The note showed the resident did not get out the door as staff was present at the front door and walked the resident back to the nurses' desk. The note showed staff offered the resident a cookie. The note showed staff were concerned for Resident #20's safety and believed the resident was capable of getting out of the door. An alert note, dated 04/09/25 at 7:40 p.m., showed Resident #20 would be one on one while at the facility. On 04/03/25 at 10:37 a.m., family member #1 stated Resident #20 experienced sad and aggressive behaviors at times. They stated the resident was able to get up on their own using their walker. They stated Resident #20 had tried to exit the facility before and wanted to get out. Family Member #1 stated the resident still wanted to work and [NAME]. They stated Resident #20 had been known to push on the door, and staff would come to distract the resident to help them forget why they were trying to get out. Family Member #1 stated Resident #20 had stepped out of the building but not very far off the property. They stated the streets were very busy around the property. On 04/07/25 at 10:43 a.m., CNA #6 stated every one to two hours staff would check on Resident #20. They stated the resident required redirection due to confusion. They stated staff helped the resident shower. They stated the resident had family who came to the facility often. They stated the resident required cueing at times. CNA #6 stated the resident was normally sweet, loving, and laid back. They stated sometimes the resident would get a little upset. They stated the resident did exhibit wandering behaviors and staff would redirect the resident with the television, a snack, or an activity. On 04/07/25 at 10:45 a.m., CNA #6 stated they had not noticed Resident #20 exhibiting exit seeking behaviors. They stated they were not aware of the resident ever eloping from the facility. On 04/08/25 at 12:13 p.m., CNA #2 stated Resident #20 was combative at times and they would get another staff member to assist the resident when this occurred. They stated the resident was able to ambulate independently with their walker. On 04/08/25 at 12:15 p.m., CNA #2 stated there was a time Resident #20 walked out the door at the end of the hall. They stated a CMA saw it occur and ran to catch the resident. CNA #2 stated they did not know if the door was locked or not, but they ran to help as well. They stated the resident was wanting to hit them as they helped them back inside. They stated CNA #1 also helped them get the resident inside. CNA #2 stated Resident #20 wandered the building everyday up and down the hall. They stated they tried to keep the middle doors shut so the resident wouldn't go down there. They stated the doors had a code and would alarm if they were touched/pushed. CNA #2 stated after pushing for 15 seconds, the door would unlock. On 04/08/25 at 12:19 p.m., CNA #2 stated staff would try to entertain Resident #20 with food and the television when they exhibited these behaviors. They stated staff kept an eye on the resident. On 04/08/25 at 12:21 p.m., CNA #2 stated elopement was exiting the building or getting away. On 04/08/25 at 12:22 p.m., CNA #2 stated they did not know if Resident #20 had ever left the facility without staff witnessing. They stated when residents were at risk for elopement staff would keep an eye on them and maybe do every 15 minute checks. On 04/08/25 at 12:46 p.m., CNA #1 stated Resident #20 was able to ambulate with a walker and was very confused. They stated staff checked on the resident every two hours for toileting needs. On 04/08/25 at 12:47 p.m., CNA #1 stated no (opposite sex) could go and assist Resident #20 or they would get mad. They stated the resident could get verbally aggressive at times. On 04/08/25 at 12:48 p.m., CNA #1 stated when behaviors were experienced, staff would try to calm the resident down and sit the resident in the recliner. On 04/08/25 at 12:49 p.m., CNA #1 stated they did not have any idea what the word elopement meant. They stated Resident #20 was walking out the door on the northeast hall. They stated the resident was wandering with their walker, threw the walker, and tried to walk out the door. They stated staff observed this happen. On 04/08/25 at 12:51 p.m., CNA #1 stated they would go next to them, try to calm them down, and take them back to their room. They stated Resident #20 was trying to get home because it was the day their family member was sick and they wanted to go home to see them. On 04/08/25 at 12:52 p.m., CNA #1 stated stated has not received any training for behaviors or residents trying to leave the building without staff present. On 04/08/25 at 12:53 p.m., LPN #1 stated Resident #20 could ambulate with their walker independently. On 04/08/25 at 12:54 p.m., LPN #1 stated Resident #20 exhibited behaviors which included exit seeking, yelling, and hitting. They stated staff tried to talk to the resident, would step back and let them cool off, and if that did not work, they would call family to come sit with the resident. On 04/08/25 at 12:55 p.m., LPN #1 stated elopement was when a resident got out the door and left the building. They stated even if they just got out the door, it was elopement. On 04/08/25 at 12:56 p.m., LPN #1 stated Resident #20 had tried to elope. They stated the resident opened the door and staff was present. They stated they did not know what the facility was doing to prevent it from happening again. On 04/08/25 at 12:57 p.m., LPN #1 stated staff just tried to keep a better eye on residents at risk for elopement. They stated if they were close to the door, LPN #1 would hand out at the nurse's station as they charted to keep an eye on them. On 04/08/25 at 12:58 p.m., LPN #1 stated they placed residents who tried to elope on every 15 minute checks until they had not tried to elope for so many days. LPN #1 stated every 15 minute checks were discontinued on Resident #20 on 02/04/25 and they were not sure when the order was written. The order LPN #1 described related to every 15 minute checks was not observed in Resident #20's clinical record and was not reflected on the resident's January or February 2025 MAR/TAR. On 04/08/25 at 1:17 p.m., the DON stated Resident #20 was pretty independent with occasional incontinent episodes. They stated sometimes the resident forgot to use their walker. They stated the resident had good days and bad days. On 04/08/25 at 1:19 p.m., the DON stated just the other day, Resident #20 was more confused but most of the time they were easily redirected. They stated they recently discovered the resident preferred female caregivers. They stated staff were educated on using redirection and utilizing non pharmacological interventions for residents with poor recall this morning. On 04/08/25 at 1:20 p.m., the DON stated Resident #20 wandered, but it was not goal driven because the resident did not voice the desire to leave. On 04/08/25 at 1:21 p.m., the ADON stated sometimes Resident #20 would say they were going to work or wanted their family member. The ADON and DON were read the behavior notes dated 01/07/25, 02/06/25, and 03/29/25 and were asked if the notes documented exit seeking behaviors. The DON stated they were not saying the resident was not exit seeking, they were saying can the resident put those two together. The DON stated Resident #20 was on the facility code white and did wander. On 04/08/25 at 1:25 p.m., the DON stated staff would redirect the resident when they exhibited these behaviors by offering coffee. The DON stated the resident's family was heavily involved. On 04/08/25 at 1:26 p.m., the DON stated the interventions should be in the nurses' notes. The ADON stated documentation was also in documentation system the CNAs used and on the TAR. They were asked if it documented what staff did in response to the behavior on the TAR. The ADON stated if there were any behaviors observed, staff would chart in a nurses' note. On 04/08/25 at 1:26 p.m., the DON stated elopement was when residents were exit seeking and got out of the building. They stated residents with elopement risk had the potential to get out of the building. On 04/08/25 at 1:27 p.m., the DON stated Resident #20 had the potential to elope which was the reason they were on the code white. The DON stated when residents were at risk for elopement, staff would try to involve them in activities, offer coffee, and offer snacks. They stated they would be updating interventions staff can do so they can document it. 4. On 04/08/25 from 9:22 a.m. through 9:33 a.m., CNA #2 and CNA #4 were observed transferring Resident #21 from their wheelchair to the bedside commode, then from the bedside commode to the resident's bed utilizing a mechanical lift. On 04/08/25 from 9:53 a.m. through 10:10 a.m., Resident #21 was observed receiving turning assistance in bed, perineal care, and transfer assistance from the bed to the shower chair with a mechanical lift with the assistance of CNA #2, CNA #4, and CNA #5. Resident #21 had diagnoses which included coagulation defect and chronic kidney disease stage 5. A quarterly resident assessment, dated 02/13/25, showed Resident #21's cognition was intact (BIMS 15) and they were dependent on staff for the task of toileting hygiene, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. A physician order, dated 02/13/25, read in part NWB RLE (utilize Hoyer [mechanical] lift for transfers). A physician order, dated 02/14/25, read in part, use Hoyer [mechanical] lift for all transfers every shift for NWB status to RLE. An incident report, dated 03/27/25, showed a CNA had summoned the nurse to Resident #21's room. The report showed the resident had to be lowered to the floor while dressing the resident after a shower. The report showed upon entering the room, the resident was noted to be sitting on the floor in front of the shower chair. The report showed CNA staff reported they were standing Resident #21 up to dress them and the resident's legs buckled, causing them to lower the resident to the floor. The report showed no injury was noted and the intervention was to dress the resident in bed rather than standing the resident from a chair to dress. On 04/03/25 at 11:12 a.m., Resident #21 stated they fell last week when transferring to the shower chair. They stated they did not have skid socks on and slide to the ground. They stated two staff were with them when they fell . Resident #21 stated they were supposed to use a full body lift, but the lift was either occupied or the battery was dead. They stated staff were transferring them from the shower chair to the wheelchair when the resident slid. Resident #21 stated two staff members physically lifted them with their arms. They stated the staff members were new. Resident #21 stated when they first started sliding, they instructed staff to let them down easy. They stated they were non weight bearing due to a wound on their right foot. They stated they had to have bone in their heel removed. On 04/08/25 at 10:14 a.m., CNA #2 stated Resident #21 required a mechanical lift for transfers. On 04/08/25 at 10:17 a.m., CNA #2 stated staff had transferred the resident before without a lift. CNA #2 stated the resident had a wound on their right foot and was non weight bearing. They stated the DON, ADON, or therapy determined when a lift was needed for transfers. On 04/08/25 at 10:18 a.m., CNA #2 stated Resident #21 had experienced a fall not very long ago. They stated it was in the resident's room and a CNA and an agency CNA assisted the resident to the floor. CNA #2 stated they did not know the details of the fall. On 04/08/25 at 10:20 a.m., CNA #2 stated if a lift was not available, they would speak to the DON, ADON, and therapy to see what they needed to do if the resident was wanting to get up. They stated if the lift was not charged, they would wait for it to be charged. They stated the facility did not have a system in place to charge the batteries and it had been a problem before. On 04/08/25 at 10:25 a.m., CNA #4 stated Resident #21 was a maximum assistance by two staff members right now. They stated the resident had a wound on their heel and was non weight bearing. They stated a mechanical lift had to be used for all transfers. On 04/08/25 at 10:27 a.m., CNA #4 stated to their knowledge staff were not transferring Resident #21 without using the lift. They sated if staff transferred the resident without a lift, they would be putting weight on that heel. On 04/08/25 at 10:27 a.m., CNA #4 stated the DON, ADON, and therapy usually would look at a resident to determine when a lift was needed for transfers. On 04/08/25 at 10:28 a.m., CNA #4 stated Resident #21 had experienced a fall not long ago. They stated staff were transferring the resident from the shower chair to the bed using a gait belt. They stated it was an assisted fall, the resident's feet gave out, and staff lowered them to the floor. They stated staff were inserviced that they had to use what was in their plan of care. They stated Resident #21 did not have any injuries from the fall. They stated staff would charge the lift batteries after every two to three transfers. On 04/08/25 at 10:32 a.m., CNA #4 stated if the lift was unavailable or not functioning properly, they would let the resident know it would be a few minutes and they would be back as soon as possible. They stated the facility had two lifts. On 04/10/25 at 10:07 a.m., LPN #2 stated Resident #21 was 100 percent reliant on staff for transfers. They stated the resident required a mechanical lift because they were non weight bearing on their right leg. They stated there was a wound to their right heel. On 04/10/25 at 10:09 a.m., LPN #2 stated Resident #21 sometimes thinks they can do more than they can. They stated the resident was at risk for falls because their leg would buckle and they didn't have enough strength. They stated the resident was especially a fall risk now because they were not non weight bearing to the right leg. On 04/10/25 at 10:11 a.m., LPN #2 stated Resident #21 had an order to continue non weight bearing to right foot that was dated 03/06/25. They stated there was also an order [TRUNCATED]

Based on observation, record review and interview, the facility failed to ensure the temperature log was maintained for the medication refrigerator in the medication room. LPN #1 identified 40 residents resided in the facility. Findings: On 04/03/25 at 11:16 a.m., a tour of the medication room was conducted with CMA #1. CMA #1 was unable to locate a temperature log. The refrigerator was found to be 42 degrees Fahrenheit. A Medication Storage in the Facility policy, dated 2021, read in part, Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept on a refrigerator with a thermometer to allow daily temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. On 04/08/25 at 2:19 p.m., the administrator stated, We are supposed to keep a temperature log on the refrigerator in the med [medication] room. It is the responsibility of the day shift CMA to monitor the temperature daily. The administrator stated CMA #1 has worked there long enough to know about the temperature log.

Based on observation and interview, the facility failed to post nurse staffing in a prominent place accessible to residents and visitors for one of one staffing boards observed. LPN #1 identified 40 residents resided in the facility. Findings: On 04/09/25 at 3:13 p.m., a large white board located behind the nurse's station showed one RN, one LPN, and three CNAs were working. The board did not show what shift or how many hours. The date written on the board was 04/06/25. There was no census. On 04/10/25 at 10:18 a.m., the large white board showed RN (name withheld). There was no date, no other staff listed, and no census. On 04/10/25 at 10:40 a.m., LPN #2 stated the white board did not include all the relevant information. They stated the information was down the hall across from the offices. On 04/10/25 at 10:41 a.m., the administrator identified two sheets of paper that contained most of the required information. Neither of the two papers showed the number of hours each staff member was working. The sheets were located on a cork board on a hall that only contained offices. On 04/10/25 at 10:42 a.m., the administrator stated visitors would have to come down that hall to see the posted information. They stated visitors come down there all the time to talk to the administration staff.

Based on observation, record review and interview, the facility failed to ensure resident care plans were accurate and updated for 2 (#21 and #95) of 16 sampled residents reviewed for resident assessments. LPN #1 identified 40 residents resided in the facility. Findings: 1. On 04/08/25 from 9:22 a.m. through 9:33 a.m., CNA #2 and CNA #4 were observed transferring Resident #21 from their wheelchair to the bedside commode, then from the bedside commode to the resident's bed utilizing a mechanical lift. On 04/08/25 from 9:53 a.m. through 10:10 a.m., Resident #21 was observed receiving turning assistance in bed, perineal care, and transfer assistance from the bed to the shower chair with a mechanical lift with the assistance of CNA #2, CNA #4, and CNA #5. Resident #21 had diagnoses which included coagulation defect and chronic kidney disease stage 5. Resident #21's care plan, date initiated 11/01/24, read in part, ADL [activities of daily living] self-care needs Date Initiated: 11/01/2024 .DRESSING: The resident requires extensive assistance by (2) staff to dress. Date Initiated: 11/01/2024 .PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance by (1) staff with personal hygiene and oral care. Date Initiated: 11/01/2024. An admission resident assessment, dated 11/06/24, showed Resident #21 required set-up or clean up assistance for the task of personal hygiene, oral hygiene, toilet hygiene, and lower body dressing. The care plan did not reflect Resident #21's admission resident assessment data. A physician order, dated 02/13/25, read in part NWB RLE (utilize Hoyer [mechanical] lift for transfers). A physician order, dated 02/14/25, read in part, use hoyer [mechanical] lift for all transfers every shift for NWB status to RLE. Resident #21's care plan was not updated to reflect the use of a mechanical lift for transfers. On 04/09/25 at 12:53 p.m., MDS coordinator #1 stated Resident #21's care plan showed the resident required extensive assistance with one person for oral hygiene/personal hygiene which was dated 11/01/24. They stated the care plan showed the resident required extensive assistance times two for dressing which was dated 11/01/24. MDS Coordinator #1 stated they did not complete the resident's care plan. MDS Coordinator #1 reviewed Resident #21's admission assessment and stated it showed they required set-up or clean up assistance for oral hygiene, dressing, and personal hygiene. On 04/09/25 at 12:56 p.m., MDS coordinator #1 stated, They don't match the care plan. They reviewed the resident's order dated 02/13/25 which showed NWB RLE utilize mechanical lift for transfers, and the order dated 02/14/25 which showed use Hoyer (mechanical) lift for all transfers every shift for NWB status to RLE. They stated yes, they saw both orders. On 04/09/25 at 12:58 p.m., MDS coordinator #1 stated the use of the mechanical lift for transfers was not in Resident #21's care plan. 2. Resident #95 was admitted on [DATE] with diagnoses that included anxiety disorder and cognitive communication deficit. A progress note, dated 01/24/25, showed the social worker had spoken to Resident #95 because they wanted help to get out and go home. A progress note, dated 02/17/25, showed Resident #95 made it outside the building and was looking over the fence for their home. The note showed they were in a fenced in area with the closest exit gate approximately 150 away. A progress note, dated 02/17/25, showed Resident #95 was discharged with a family member with a plan for memory care on that same day. An elopement risk assessment, dated 02/25/25, showed Resident #95 was added to the code white list (a document that notifies the staff who is an elopement risk) due to packing a bag and stating they were going home. The care plan did not show elopement precautions. On 04/08/25 at 10:14 a.m., MDS coordinator #1 stated they should have added elopement risk to the care plan once it was identified Resident #95 was exit seeking. On 04/08/25 at 2:17 p.m., the administrator stated the care plan should be updated immediately for elopement risks. 49701

Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 (#19) of 17 sampled residents reviewed for completion of baseline care plans. LPN #1 identified 40 residents resided in the facility. Findings: Resident #19 was admitted on [DATE] with diagnoses which included severe protein-calorie malnutrition, repeated falls, and depression. There was no documentation a baseline care plan was completed within 48 hours of admission. On 04/08/25 at 2:17 p.m., the administrator stated they follow the RAI manual regarding care plans. On 04/09/25 at 10:45 a.m., MDS coordinator #1 stated Resident #19 did not have a 48 hour baseline care plan because they were behind on them.

Based on record review and interview, the facility failed to ensure resident assessments were accurately coded for 1 (#20) of 16 sampled residents reviewed for resident assessments. LPN #1 identified 40 residents resided in the faciilty. Findings: Resident #20 had diagnosis which included cognitive communication deficit. A behavior note, dated 01/07/25, showed Resident #20 had been actively exit-seeking for the last 1.5 hours walking nonstop from one end of the North hall to the other. The note showed the resident had been able to set the alarm off on the Northwest door twice by pressing it repeatedly. The note showed staff was able to get Resident #20 before the door opened. A nurse's note, dated 01/09/25, showed Resident #20 was noted to aimlessly wander throughout the facility. The note showed the resident's family was at their side and voiced concerns about the resident's constant pacing and wandering throughout the facility. An admission resident assessment, dated 01/12/25, showed Resident #20 had severe cognitive impairment (BIMS 00) and did not exhibit wandering behaviors. On 04/08/25 at 2:12 p.m., MDS coordinator #1 stated they used the whole chart and the RAI manual to complete resident assessments. They stated to ensure accuracy, they would go through the chart and complete an actual assessment of the resident. They stated the person who completed Resident #20's assessment was no longer working at the facility. On 04/08/25 at 2:13 p.m., MDS coordinator #1 stated they would go through nurses' notes and the resident's chart to determine if a resident had exhibited wandering behaviors during the look back period. On 04/08/25 at 2:14 p.m., MDS coordinator #1 reviewed Resident #20's admission assessment dated [DATE] and stated there was nothing coded for wandering. They stated the assessment reference date was 01/12/25 so they would look back seven days from that date. On 04/08/25 at 2:15 p.m., MDS coordinator #1 reviewed the resident's record and stated the resident had exhibited wandering during this time and it should have been coded. 49701

Based on record review and interview, the facility failed to ensure a significant change resident assessment was completed for 1 (#21) of 16 sampled residents reviewed for resident assessments. LPN #1 identified 40 residents resided in the facility. Findings: Resident #21 had diagnoses which included coagulation defect and chronic kidney disease stage 5. An admission resident assessment, dated 11/06/24, showed Resident #21's mood score was 09 (mild depression), and the resident required set-up or clean up assistance for the task of toilet hygiene, lower body dressing, and putting on/taking off footwear. The assessment showed the resident was independent for the task of roll left and right, sit to lying, and lying to sitting on the side of the bed. A quarterly resident assessment, dated 02/13/25, showed Resident #21's mood score was 00 (no depression), and the resident was dependent on staff for the task of toileting hygiene, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, and lying to sitting on the side of the bed. There was no significant change resident assessment completed for the change in Resident #21's mood, toileting hygiene, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, and lying to sitting on the side of the bed. On 04/09/25 at 10:53 a.m., MDS coordinator #1 stated they would complete a significant change resident assessment if there was two or more things that had declined or improved or if a resident was going on/coming off hospice or changing hospice providers. On 04/09/25 at 10:54 a.m., MDS coordinator #1 stated Resident #21 was skilled and they completed a quarterly and 5-day assessment on 02/13/25. They stated when the resident came off of skilled, was when they would evaluate whether the resident had met the significant change criteria. They stated there was a chance the resident could rehabilitate out of the change while in therapy. 49701

Based on record review and interview, the facility failed to ensure a NOMNC was provided to a resident discharging from skilled services for 1 (#94) of 3 sampled residents reviewed for beneficiary notification. MDS Coordinator #1 identified 15 residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past six months (11/18/24 through 04/03/25). Findings: Resident #94 admitted to the facility on [DATE]. A nurse's note, dated 02/25/25, showed Resident #94 discharged home with home health. The SNF beneficiary notification review showed Resident #94's Medicare Part A skilled services episode start date was 12/07/24 and their last covered day of Part A service was 02/24/25. The notification showed the Medicare Part A service termination/discharge was determined voluntarily and the facility/provider initiated the discharge from Medicare Part A services when when benefit days were not exhausted. The notification showed the resident did not receive a NOMNC because Resident #94 did not stay in the facility. On 04/04/25 at 12:58 p.m., MDS coordinator #1 stated they started speaking about discharge with residents, and if they agreed on a discharge date , the MDS coordinator would fill out the NOMNC form and have the resident sign the form. They stated if the resident was unable to sign the form, they would have the family sign. They stated the form was supposed to be provided 48 hours before discharge from skilled services. On 04/04/25 at 1:01 p.m., MDS coordinator #1 stated both the facility and the resident initiated the discharge. They stated the resident wanted to go home. They stated Resident #94 did have benefit days remaining. They stated they got confused on which form they needed to sign and had them sign the SNFmadvance beneficiary notice of non-coverage instead. 49701

Based on observation, record review, and interview, the facility failed to serve pasteurized eggs and use gloves appropriately. The DON identified 76 residents who received services from the kitchen. Findings: On 11/16/21 at 5:45 a.m., a tour of the kitchen was conducted. There were two (15 dozen) boxes and two flats of unpasteurized eggs on the counter and/or in the reach in cooler #3. A food tally record, undated, documented nine over easy eggs were to be served to the residents at breakfast. Breakfast menus, undated, documented Resident (Res) #57 and Res #77 were to each have received two, over easy fried eggs. At 7:06 a.m., the breakfast meal service was observed. The following observations were made: a. Unpasteurized over easy eggs were plated to be served to the residents, and b. Dietary cook #1 was handling paper menus with her gloved hands and picking up biscuits, toast, bacon, and sausage with the same pair of gloves on. At 7:46 a.m., Res #57 and Res #77 were observed with fried eggs with runny yolks on their breakfast plates. At 7:50 a.m., the DM was asked if the raw shell eggs used for over easy fried eggs were pasteurized. She stated she thought they were. She was asked if the boxes of eggs or the raw shell eggs indicated they were pasteurized. She looked at the boxes and eggs and stated she didn't see anything. She was made aware the unpasteurized eggs were served over easy to the residents. The DM was asked to verify the menu selection process for the residents. She stated the aides took the menus to the residents for their selections. She was asked if staff were to use gloved hands to handle foods in which they handled paper menus. She stated they should have used tongs.

Based on record review and interview, the facility failed to follow a physician's order to reduce a [CONDITION(S)] medication for one (#39) of five sampled residents reviewed for unnecessary medications. The DON identified 37 residents who received antidepressant medications. Findings: Resident (Res) #39's diagnoses included major depressive disorder. A physician order, dated 05/21/21, documented the resident was to have received [MEDICATION(S)] (an antidepressant medication) 30 mg q day. A pharmacist MRR, dated 09/16/21, documented the pharmacist made a recommendation to the physician to attempt to reduce the dosage of the resident's [MEDICATION(S)] from 30 mg to 20 mg q day. The pharmacist MRR, dated 09/16/21, documented the physician agreed to the reduction on 11/15/21. The MRR documented the order was noted by the DON. There was no documentation the order had been changed in the last six days. On 11/21/21 at 11:29 a.m., the DON was shown the MRR. She stated the date the MRR was noted, the order should have been changed. At 11:49 a.m., the DON stated she started the process for changing the order on 11/15/21, but did not finish it.

Based on interview and record review, the facility failed to provide pharmaceutical services for one (#128) of six sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report documented 77 residents resided in the facility. Findings: Resident (Res) #128 was admitted to the facility on [DATE] and had diagnoses which included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], anxiety, and hallucinations. A nurse note, dated 01/15/20 at 12:01 a.m., documented the resident had been up numerous times throughout the night, with and without clothes, asking for money, relatives, and shopping lists, etc. A late entry nurse note, dated 01/17/20, from the former ADON, documented, on 01/15/20 at 4:45 p.m., the resident's family member was upset her mother had been at the facility for almost 24 hours and no medications had been administered. The note documented the nurse reviewed the resident's record and found that was accurate. The note documented the nurse would review the medications the resident had brought in with her and verify with hospice and the physician to see which medications the resident was to resume. The note documented around 9:00 p.m., the nurse was waiting on a fax from hospice regarding the resident's medications. The note documented the family member requested the facility start the medications the following morning since it was late. The note documented the medications were reconciled with the hospice nurse on 01/16/20. The January 2020 MAR documented 19 medications were first administered on 11/16/21. On 11/21/21 at 1:50 p.m., the administrator stated the resident was on hospice and came from home. She stated the facility had communicated to the hospice company several times about needing the physician orders. She stated it took a couple of days to get the orders. She stated the facility usually received the orders before or at the time of admit. On 11/21/21 at 2:27 p.m., the DON stated the facility should have called the medical director or the physician on-call to get orders for the resident's medications.

Based on observation, record review, and interview, the facility failed to: a. firmly attach toilet seat risers to the toilet seats for four (#12, 34, 45, and #49) of seven sampled residents reviewed for accident hazards. b. thoroughly investigate the root cause of falls and implement interventions to prevent further falls for one (#58) of three sampled residents reviewed for falls. The Resident Census and Conditions of Residents identified 77 residents who resided in the facility. Findings: 1. During the resident (Res) council meeting, on 11/18/21 at 9:22 a.m. with ten cognitively intact residents the following statements were made related to toilet seat risers: a. Res #34 stated the handles on her commode was not sturdy. She stated she had requested a new one but had not received one, and b. Res #12 stated room #4 had a toilet seat riser which was not sturdy. On 11/18/21 at 10:11 a.m., the bathroom between rooms one and two was observed. The toilet had both a toilet seat riser and handles attached to the toilet. The handles were observed to be very wobbly and the seat riser was not locked into place. The seat riser was not steady and swiveled from side to side. At 10:21 a.m., the bathroom between rooms three and four was observed. The toilet seat riser was not locked into position and it was not steady and swiveled from side to side. At 10:24 a.m., Res #45 was asked if he had any problems with the bathroom. He stated the first or second time he used the bathroom after moving into that room he went to sit down took hold of the handle and had to sit in the floor. His clinical record documented he had a fall in the bathroom on 10/18/21 without injury. Res #12, 34, 45, and #49 were observed ambulating independently with or without assistive devices during the survey. On 11/21/21 at 1:36 p.m., the administrator and DON were asked if they were aware of any toilet risers being loose. They stated they were not. They were shown the bathrooms between rooms one and two and between rooms three and four. 2. Res #58 had diagnoses that included [CONDITION(S)] and heart failure. An admission assessment, dated 10/14/21, documented the resident was severely impaired with cognition and required limited assistance with activities of daily living. The assessment documented the resident had one fall without injury and one fall with an injury. Review of the resident record revealed the resident had fallen on 10/06/21, 10/14/21, 11/07/21, and 11/08/21. The resident did not have a care plan for falls until 11/17/21. On 11/17/21 at 8:50 a.m., the resident stated he had fallen in the facility and showed the surveyor a scab he had on the left posterior side of his head. He stated he lost his balance and fell . On 11/19/21 at 12:42 p.m., the MDS/care plan coordinator stated the resident's care plan for falls was completed on 11/17/21. She stated interventions for his falls were dated 11/17/21. She looked at 10/06/21 incident report for an intervention for the resident and stated she did not see an intervention on the report. She stated there should have been a root cause analysis done and an intervention with each fall. On 11/19/21 at 12:49 p.m., the DON stated the resident told the facility on admission he was a fall risk and he was moved to a room with a padded floor. She stated the resident should have had a fall care plan on admit.

Based on interview and record review, the physician failed to respond to pharmacist MRRs timely and according to the facility's policy for three (#10, 62, and #77) of five sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report documented 77 residents resided in the facility. Findings: The facility's undated Drug Regimen Review'' policy read in parts, .The report is provided by the Consultant Pharmacist or facility to the Primary Physician and the Director of Nursing within seven working days of review, or according to facility policy. The physician provides a written response of the report to the facility within one month after the report is sent . 1. Resident (Res) #62 had diagnoses which included [CONDITION(S)] disorder, anxiety, depressive disorder, and [CONDITION(S)] disorder. A physician order, dated 12/13/19, documented [MEDICATION(S)] (an anti-[CONDITION(S)] medication) 250 mg four times a day for anxiety disorder. A physician order, dated 08/04/20, documented [MEDICATION(S)] (an antidepressant medication) 60 mg two times a day for depression. A pharmacist ''Medication Regimen Review, dated 05/25/21, documented a consideration for a GDR for [MEDICATION(S)] and [MEDICATION(S)]. A physician response to the MRR was not documented. A pharmacist ''Medication Regimen Review, dated 08/18/21, documented a consideration for a GDR for [MEDICATION(S)] and [MEDICATION(S)]. A physician response to the MRR was not documented. On 11/18/21 at 4:51 p.m., the DON stated she could not locate a physician response for the MRRs. 2. Res #77 had diagnoses which included [CONDITION(S)] disorder, anxiety, depressive disorder, and [CONDITION(S)] disorder. A physician order, dated 12/15/18, documented to administer [MEDICATION(S)] (an antidepressant medication) 5 mg in the evening for [CONDITION(S)] disorder. A physician order, dated 12/15/18, documented to administer [MEDICATION(S)] ([MEDICATION(S)], an antidepressant medication) 20 mg one time a day related to major depressive disorder. Pharmacist MARs dated 11/16/20 and 08/18/21, documented a consideration for a GDR for [MEDICATION(S)] and [MEDICATION(S)]. A physician response to the MRRs was not documented. On 11/18/21 at 4:50 p.m., the DON stated she could not locate the physician response for the MRRs. 3. Res #10 had diagnoses that included cerebral infarction, major depressive disorder, and [CONDITION(S)] with behavioral disturbances. A physician order, dated 02/22/20, documented [MEDICATION(S)] (an anticonvulsant medication) 25 mg two tablets BID. A physician order, dated 06/19/20, documented [MEDICATION(S)] ([MEDICATION(S)], an antidepressant medication) 30 mg daily. An Expanded DRR Report for 11/16/20 documented the pharmacist asked for a reduction in [MEDICATION(S)] 30 mg qd or [MEDICATION(S)] 50 mg BID. A physician response was not provided by the facility for this request. A ''Medication Regimen Review dated 03/15/21, documented the pharmacist asked for a reduction in either N-acetlylsteine 600 mg BID or [MEDICATION(S)] 5 mg BID. On 05/27/21, (over 10 weeks later) the physician responded to reduce N-acetlysteine to 600 mg daily. A Director of Nursing Report, dated 05/24/21, documented the pharmacist asked for a reduction of [MEDICATION(S)] 30 mg daily or [MEDICATION(S)] 25 mg two tabs BID. A handwritten note on the report, which was not dated, documented to reduce [MEDICATION(S)] to 20 mg daily. The report was not signed or dated by the physician. An order for the reduction was documented 94 days later on 08/26/21. A physician order, dated 08/26/21, documented to administer [MEDICATION(S)] 20 mg one time a day. On 11/18/21 at 11:42 a.m., the DON stated she was responsible for the MRRs. She stated she started in the DON position in February of 2021. She stated she did not know when or if the physician received the consults within a month. She stated the [MEDICATION(S)] for the resident was reduced in August 2021. She stated according to the facility policy the MRR should return to facility from the physician within a month.

Based on observation, interview, and record review, the facility failed to provide oxygen therapy as ordered by the physician for one (#58) of two sampled residents reviewed for respiratory care. The DON identified 25 residents who received oxygen therapy. Findings: Resident #58 was admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 10/11/21, documented oxygen at 2L per NC. The care plan, dated 10/01/21, documented to set the oxygen setting per the physicians orders. On 11/16/21 at 6:15 a.m., the resident was observed in his bed with oxygen in use per NC at 2.5L On 11/17/21 at 8:41 a.m., the resident was observed with oxygen in use per NC at 3L. On 11/19/21 at 11:10 a.m., the resident was observed in bed with oxygen in use per NC at 3L. On 11/19/21 at 12:03 p.m., LPN #2 stated the oxygen setting was showing 3L for the resident. The LPN looked at the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated no one should be changing the setting of oxygen unless the order changed.

Based on record review and staff interview, the facility failed to obtain lab tests as ordered for one (#10) of five sampled residents reviewed for labs. The Resident Census and Conditions of Residents documented there were 77 residents who resided in the facility. Findings: Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 01/28/19, documented to draw CBC, CMP, TSH, Free T4, and FLP every January. A review of the resident's medical record showed there were no lab results for January 2021. On 11/18/21 at 1:17 p.m., the DON stated January labs were missed.

Based on observation and interview the facility failed to provide window screens for resident windows and/or keep the screens in good repair. The Resident Census and Conditions of Residents identified 77 residents who resided in the facility. Findings: On 11/21/21 at 12:05 p.m., a tour of the outside of the building was conducted. Several screens were observed off the windows of the facility, two known resident rooms were without screens. Several other resident screens were in poor condition with broken screen frames and/or holes in the window screens. On 11/21/21 at 1:07 p.m., the administrator stated the maintenance supervisor was not in the facility today but he had kits and was working on making new screens for the facility windows. She stated all the resident rooms should have screens on the windows and be in good repair.

Based on record review and interview, it was determined the facility failed to have the signed ''Oklahoma Do-Not-Resuscitate (DNR) Consent Form'' in the electronic health record for one (#11) of 24 sampled residents whose records were reviewed. The Resident Census and Conditions of Residents identified 77 residents who resided in the facility. Findings: The electronic clinical health record for Res #11 documented the resident had a DNR order. The DNR consent form was not found in the record. The DNR form was not found in the DNR notebook kept at the nurses' station. On 11/17/21 at 10:05 a.m., the DON was asked to provide the DNR consent form. At 11:22 a.m., LPN #1 was asked about the resident's DNR status. She stated the computer listed him as a DNR, however, there was no form scanned in the computer. After looking in the DNR book, she stated there was no copy of his DNR form in the book, either. At 12:05 p.m., the DON provided a copy of the DNR form and stated they had finally located it. She acknowledged the consent form was not in the clinical record or DNR book where it should have been and not readily accessible to staff should it be needed.

Based on interviews, the facility failed to provide mail delivery to residents on Saturday. The Resident Census and Conditions of Residents identified 77 residents who resided in the facility. Findings: On 11/18/21 at 9:22 a.m., a group meeting was held with ten alert and oriented residents. They all stated the mail came to the facility but did not get distributed every day and especially not on Saturdays. They stated the mail is distributed by social services or the nurses. One resident stated they had not received mail in three weeks and received 19 pieces of mail yesterday. On 11/18/21 at 10:03 a.m., the social services director stated the mail usually came to the facility around 4:00 p.m. to 4:30 p.m. She stated the business office manager will get the facilities mail and then someone will let her know the mail had arrived or they will put it in her mail slot. She stated she then will separate the mail by resident and deliver the mail to the residents. She stated she would stay late if she had to. She stated Saturday mail should be delivered by the North Hall nurse. She stated she could not say if the mail was delivered on Saturdays. On 11/18/21 at 10:08 a.m., the administrator stated the mail was delivered by social services during the week and no one was consistent with Saturday mail. She stated the mail did not come until late in the afternoon and the weekend nurse may already have gone home before the mail arrived at the facility.

Based on record reviews and interviews, it was determined the facility failed to implement prompt efforts to investigate and/or resolve grievances for one (#1) of one resident reviewed for grievance. The facility identified seven grievances in the past three months. Findings: A facility policy titled Filing Grievance/Complaints, revised November 2010, documented, Upon receipt of a grievance and/or complaint .will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint . The Administrator will review the findings with the person investigating .to determine what corrective actions .need to be taken .A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 12/31/20, documented the resident was severely impaired in cognition and required total care with all activities of daily living. A typed note, signed by the administrator, dated 02/13/21, located in a binder titled Grievance, documented, [named family member], reported her mom [resident #1] went 5.5 hours with no one in her room and recommended we check her skin. Reported to the DON (director of nurses). There was no documentation this grievance was investigated or resolved by facility. A hand written note, signed by the DON dated 03/03/21, located in a binder titled Grievance, documented, Resident #1 daughter verbalized with this writer that there was an extended amount of time that resident appeared to have minimal staff contact per her camera, voiced concern that patient was not offered fluids like she wants. Verbalized understanding by this writer. Inservice placed for care directive of patient. There was no documentation this grievance was investigated or resolved promptly. A typed note, signed by the administrator, dated 04/04/21, located in a binder titled Grievance, documented, [named family member], resident #1 daughter, text me at 10:03 am and reported no one had been in her mom's room from 11pm- 4am. Family has camera in her room. I reported to DON .DON working on this issue. There was no documentation the grievance was investigated or resolved. On 04/14/21 at 4:40 p.m., the administrator was asked who investigated and resolved a concern/grievance from a resident or family member. The administrator stated both her and the DON handled complaints/grievances. At 4:41 p.m., the administrator and DON was asked to review the documents dated 02/13/21, 03/03/21, and 04/04/21 and was asked how did the facility addressed these concerns. The administrator and DON stated they would need to check for records. At 4:49 p.m., the DON presented an in-service education, dated 03/30/21, subject covered care directive [named resident's initials] please read sign. An attached typed document, signed by the DON dated 03/30/21, documented [named resident] needs assistance with adl's (activity of daily living) TAP (turn and repositioned) Q (every) 2 hours along with incontinent care. Fluids will be offered every time staff in in room while assisting with peri care and ADLs. [named resident] is to be assisted up to geri (geriatric) chair during the day for at least 2 meals a day. At 5:04 p.m., the administrator was asked again if the concerns/grievances for resident #1 were investigated promptly and resolved in a timely manner. The administrator replied I have no report, No.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services related to [MEDICAL TREATMENT] for one (#66) of one resident reviewed for [MEDICAL TREATMENT]. The facility failed to assess and monitor the resident after he returned from [MEDICAL TREATMENT]. The facility failed to provide a renal diet as ordered by the physician. The facility reported three residents required [MEDICAL TREATMENT] services. Findings: Resident #66 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order documented for the resident to have a 1200 ml fluid restriction and daily weights. The physician orders [REDACTED]. An in service documentation, dated 05/02/19, documented instructions for nurses regarding [MEDICAL TREATMENT] residents. A care plan, dated 06/11/19, documented the resident had [MEDICAL TREATMENT] three times a week. The care plan interventions documented the resident had a 1200 milliliter (ml) fluid restriction, the access site monitored for signs and symptoms of infection every shift and as needed for redness, heat, and or drainage. The care plan documented the resident was to have daily weights and monitor intake and output every shift. The care plan documented the resident had [MEDICAL CONDITION]. The care plan documented the resident was to receive a diabetic diet. A quarterly assessment, dated 07/09/19, documented the resident was moderately impaired with cognition. The assessment documented the resident was totally dependent of two staff for activities of daily living. The assessment documented the resident required [MEDICAL TREATMENT] services. The clinical record documented the resident received 17 [MEDICAL TREATMENT] treatments in (MONTH) and (MONTH) 2019. The clinical record documented six incomplete [MEDICAL TREATMENT] communication records. The resident's diet card documented he was to receive a regular diet, no added salt, and no fried food. On 09/09/19 at 4:17 PM, the resident reported the staff did not assess him before or after [MEDICAL TREATMENT]. On 09/10/19 at 5:15 PM, cook #1 reported residents who were to receive a renal diet were served a regular diet. On 09/10/19 at 5:40 PM, the licensed practical nurse (LPN#1), reviewed the resident's clinical record and stated communication with the [MEDICAL TREATMENT] facility had not been completed, and she had not assessed the resident that day after he returned from [MEDICAL TREATMENT]. On 09/10/19 at 5:45 PM, the resident was observed sitting at the dining room table. The resident reported he had not refused his meals and ate what the facility provided. The resident reported he had not received a renal diet. At 5:55 PM he was served fried fish, hush puppies, and macaroni and cheese. He told the dietary staff he could not have the macaroni and cheese and was served pinto beans. On 09/11/19 at 10:51 AM, the dietary manager reviewed the resident's diet card and physician order. The dietary manage reported the resident had not received the diet as ordered. On 09/12/19 at 9:00 AM, the assistant director of nurses (ADON), reported assessments had not been completed for the resident after returning from [MEDICAL TREATMENT].

Based on observation, record review and interview, it was determined the facility failed to implement interventions to prevent the development of a pressure ulcer for one (#9) of three sampled residents with a pressure ulcer. This resulted in an actual harm for the resident. This had the potential to affect an additional 55 residents who were identified by the facility to be chair/bed fast and/or incontinent of bowel and/or bladder. Findings: The facility policy for "Pressure Ulcer, Care and Prevention Of" documented, "Purpose: To prevent and treat further breakdown of pressure sores. Equipment:...Heel protector...Pillows...Use pressure reducing devices to relieve pressure...Use elbow and heel protectors if needed...Treatment: ...The nurse is responsible for...implementing measures to prevent pressure ulcers." Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. An "Admission Nursing Evaluation" dated 03/30/12, documented in the section for skin condition, " 1) L top of foot 2.0 (cm) x 3.5 70 % yellow slough 2) R top of foot 9.0 x 10.0 10 % yellow slough black 3) RLE 1.0 x 1.0 x 0.1 red 4) 3.0 x 1.0 x 0.1 red RLE 5) RLE 1.0 x 1.2 scabbed 6) Port." An "Acute/Temporary Care Plan" dated 04/02/12, documented: Problem: Promote wound healing. Change treatment to left top foot. Approaches: [MEDICATION NAME] extra one carton twice daily, cleanse with normal saline, pat dry, apply medi honey, apply dry dressing, change every three days and as needed for dislodgement. A comprehensive 5 day Medicare assessment dated [DATE], documented the resident required total staff assistance with transfers and extensive staff assistance with bed mobility and assist of two or more staff with toileting. The assessment further documented the resident was frequently incontinent of bowel and bladder, had no pressure ulcers, but did have other skin breakdown not related to pressure. A "Daily Skilled Nurse's Note" dated 04/09/12 at 10:30 a.m., documented, "Res was noted to have a new open area to R heel measuring 2.2 x 3.0 x 0.1. No exudate noted. Wound bed red. Area cleansed c/ NS. Medi-honey applied covered c/ foam drsg et secured to be changed q M-W-F et PRN. Dr. (Name withheld) notified. TAR ^ dated. Seq. faxed." An "Acute/Temporary Care Plan" dated 04/09/12, documented: Problem: Wound. Approaches: Cleanse open area to right heel. Apply medi honey. Cover with foam dressing and secure. Change every Monday, Wednesday and Friday and as needed for dislodgment. A "Interdisciplinary Team Meeting" form dated 04/10/12, documented the resident had developed a pressure ulcer to the left (should be right) heel due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions were to turn and position, free float the resident's heels and use pillows as positioning devices. The current treatment was for Medi-honey, nutritional interventions included [MEDICATION NAME] extra (04/02/12), vitamin C (03/30/12), zinc (03/30/12) and nutritional supplements. The form also documented the resident had a severe contracture to the left leg. The resident's care plan dated 04/12/12 and last updated 05/14/12, documented: Problem: (Resident #9) is at risk for skin breakdown r/t has multiple wounds to lower legs r/t bil knee contractures. Goal: Skin will not demonstrate further breakdown and will show s/s of healing this quarter. Approaches: Free-float heels while in bed. Difficult to off load pressure r/t contractures and resident comfort. Boot to right leg as ordered. (05/12/12) Wound care to R heel as ordered. A physician's telephone order dated 05/14/12, documented, " 1) PT to eval R heel for debridement. 2) Cleanse R heel c/ NS Pat dry apply Santyl/Gent cover with exudry secure c/ gauze and [MEDICATION NAME] change daily." A quarterly assessment dated [DATE], documented the resident required total staff assistance with transfers and extensive staff assistance with bed mobility and assist of two or more staff with toileting. The assessment further documented the resident was occasionally incontinent of bowel and bladder, had one unstageable pressure ulcer and other skin breakdown not related to pressure. On 07/17/12 at 10:45 a.m., LPNs #1 and #2 were observed providing a wound treatment to the resident's right heel. An open area approximately the size of a half dollar, with a concave indentation in the center, was observed. The center of the pressure sore was observed with yellow slough with new tissue granulation around the center area. The area was cleansed with NS, then Santyl/[MEDICATION NAME] was applied to the center of the pressure sore. The area was covered with an Exudry dressing then wrapped and taped. LPN #1, who performed the treatment, was asked if the resident developed the pressure sore before admission to the facility or after admission. She stated the resident developed the pressure sore "in-house." She was asked if the facility used any type of interventions to prevent the development of the pressure sore. She stated they were using a pressure reduction boot. When asked if the boot was implemented before or after the development of the pressure sore, she stated they did not try the boot until after the pressure sore developed. She stated they tried to keep the pressure off the resident's heels by the use of pillows for positioning. She stated the positioning with pillows was not effective because it caused the resident pain due to the knee contractures and the resident would maneuver herself onto her back because of the discomfort caused by the positioning. On 07/19/12 at 8:45 a.m., an interview was conducted with the DON. She was asked if the resident's pressure ulcer to the right heel developed prior to the facility implementing the pressure reduction boot. She stated, "Yes."

Based on observation, record review and interviews, it was determined the facility failed to fully assess a resident for an individualized bladder program for one (#3) of ten sampled residents who were incontinent of bladder and failed to ensure the resident then received assistance to the toilet as needed to prevent the incontinence. This resulted in an actual harm for the resident. The resident census and condition report dated 07/17/12, documented the facility had 44 residents who were occasionally or frequently incontinent of bladder and 33 residents who were on a bladder training program. Findings: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An "Evaluation for Bowel and Bladder Training" dated 08/13/12, documented, " ...Functional status/assist: extensive 2 person /C transfers...present bladder status: (left blank)...voiding pattern: (left blank)...evaluation: able to participate in B/B program-plan: scheduled toileting..." There was no documentation the facility assessed the resident to determine the resident's voiding patterns. An initial assessment dated [DATE], documented the resident's speech was clear, could understand others with clear comprehension, usually was able to make her self understood, had severely impaired cognitive skills for daily decision making, required extensive assistance with transfers and toileting. The assessment also documented the resident was occasionally incontinent of urine and was on a urinary toileting program with the resident having decreased wetness. The CAA results documented incontinence was triggered and would be care planned. A care plan dated 09/02/11, documented, "Problem: Potential for incontinent episodes due to progressive dementia. Toileting program in place. Incontinent at times. Goal: will have no S/SX of UTI; temp WNL and odor free. Approach(S): assist resident by toileting routinely. Assist to toilet prior to meals, activities, therapy and bed. encourage liquids at meals and between meals...relies on staff to perform toileting transfer and hygiene... Problem: High/low bed with mat in place to encourage safe transfers from bed to wheelchair. High risk for falls as (Resident) does not realize physical limitation, impulsive at times. Goals: Resident fall risk factors will be managed to decrease the prevalence of falls with significant injury by next review. Interventions: Explain call bell/light. Assess resident's ability to use. Instruct resident to seek assistance with transfers...keep bed at lowest level at night. Keep frequently used items within reach of resident. Keep in visible area except when privacy is an issue. Keep room free from clutter. Low bed in use with mat present beside to reduce risk of injury as result of falls. personal alarm in place to alert staff of unsupervised transfers in progress...teach resident proper use of assistive devices..." An incident report dated 09/27/11, documented, "...Type of injury: none...describe exactly what you observed or heard: Res tab alarm sounding. Arrived in res room, res sitting (arrow up) on floor legs in front...recommended steps to prevent recurrence: Make frequent visual checks to ensure safety toilet before assisting to bed..." An incident report dated 09/30/11, documented, "...Type of injury: none...describe exactly what you observed or heard: Res tab alarm sounding. Summoned to residents room per staff request upon arrival observed resident sitting in upright in front of recliner /c tab alarm on the recliner. Resident states "I was coming back to the chair and fell " when asked about the tab alarm resident stated I took it off.......recommended steps to prevent recurrence: Keep resident in lobby area while awake. Continue to check resident to make sure tab alarm in place. Encourage resident to wait for assistance...." There was no documentation the resident had been assessed to determine her voiding frequency to establish a scheduled urinary program for her. A note on the "Evaluation for Bowel and Bladder Training" dated 11/13/11, documented, "No chg in B&B eval." A note on the "Evaluation for Bowel and Bladder Training" dated 02/13/12, documented, "cont. incontinent will use toilet when prompted." A note on the "Evaluation for Bowel and Bladder Training" dated 05/13/12, documented, "No chg in B&B." There was no documentation to indicate the facility assessed the resident's voiding patterns to establish an individualized toileting schedule for the resident on each note on the bowel and bladder training dated 11/1311, 02/13/12 and 05/13/12. The resident had two previous falls while attempting to self toilet in 09/11. The resident's care plan had not been updated to address the resident's routine voiding and falls that resulted from attempted self toileting. A quarterly assessment dated [DATE], documented the resident had clear speech, understood others, could be understood by others and was severely impaired with cognitive skills for daily decision making. The assessment also documented the resident required extensive assistance with transfers, walking, and toileting. The resident was assessed to be incontinent of bladder and not on a urinary training program. An incident report dated 07/07/12, documented, "Type of injury (R) leg turned outward. head injury. Resident lying in floor. She took her tab alarm off stated she was trying to get up go to the bathroom. Recommends steps to prevent recurrence. Thicker mat below bed--has good nonslick mat next to bed. We already tested her she took her tab alarm off. therapy notified..." The interventions on the care plan did not address the resident attempting to get up and toilet her self. The care plan did not address a resident specific routine for a toileting program. The facility did not assess the resident for toileting frequency to determine what the resident's routine was. A nurse's note dated 07/07/12, documented, "Heard loud door slam, opened door resident lying in floor up against door had to move resident lifted her back into bed resident c/o severe pain in (R) hip leg turned outward no apparent bruising noted (R) side back of head...resident was crying stating she was in pain...Dr. (Name withheld) ordered to send to ER for eval of (R) hip and head for x ray..." A "Patient Orders for Receiving Facility" dated 07/11/12, documented, "...admitted [DATE] expected D/C date 07/11/12...discharge [DIAGNOSES REDACTED]. An "Admission/Start-Up" dated 07/11/12, documented, "...[DIAGNOSES REDACTED].." A care plan dated 07/13/12, documented, " "Problem: Potential for incontinent episodes due to progressive dementia. Toileting program in place. Incontinent at times... Goal: will have no S/SX of UTI; temp WNL and odor free. Approach(S): assist resident by toileting routinely. Assist to toilet prior to meals, activities, therapy and bed. encourage liquids at meals and between meals...relies on staff to perform toileting transfer and hygiene... Problem: High/low bed with mat in place to encourage safe transfers from bed to wheelchair. High risk for falls as (Resident) does not realize physical limitation, impulsive at times. Goals: Resident fall risk factors will be managed to decrease the prevalence of falls with significant injury by next review. Interventions: Explain call bell/light. Assess resident's ability to use. Instruct resident to seek assistance with transfers. Fall management program with visual indicators in place to alert staff of fall risk. Instruct resident to seek assistance with transfers. Keep bed at lowest level at night. Keep frequently used items within reach of resident. Keep in visible area except when privacy is an issue. Keep room free from clutter. Low bed in use with mat present beside to reduce risk of injury as result of falls. Personal alarm in place to alert staff of unsupervised transfers in progress...Teach resident proper use of assistive devices. Teach resident to identify own physical limitations. Actual fall on 07/07/12 resulting in hip FX. Uses w/c for mobility. Self release seat belt alarm when up in chair to alert staff resident needs assist with transfer." The resident's current care plan continued not to address the resident's routine voiding patterns. There was no documentation the facility assessed the resident's voiding patterns to update the scheduled program and care plan after the fall with the fracture secondary to attempts to self toilet. An initial tour was conducted on 07/16/12, from 9:30 a.m. through 10:45 a.m., with a certified medication aide. The certified medication aide was asked if the resident was continent or incontinent of bladder. She stated, "Occasionally incontinent." She was then asked if the resident was on a toileting program. She stated, "Yes every two hours we check and toilet her." She was asked if the resident had falls. She indicated the resident fell in the previous week and fractured a hip. An observation of the resident's room was made during the initial tour. The resident's room had a bedside commode that was located next to the window. On 07/17/12 at 2:40 p.m., the resident was observed in her room in her wheel chair. She was asked if she could remove the seatbelt. The resident removed her seatbelt and attempted to stand, stating she wanted to go to the bathroom. The bedside commode was approximately fifteen feet away from the resident. An aide entered the room and silenced the alarm on the self releasing seat belt and attempted to place the resident in bed. The resident refused to go to bed informing the aide she needed to go to the bathroom. An interview was conducted on 07/17/12 at 3:15 p.m., with the DON regarding a urinary training program or schedule. She was asked if the facility assessed the resident for her voiding patterns. She stated, "No, we rely on staff to tell us." She was asked if the resident had additional falls prior to 07/07/12, where she had fallen attempting to self toilet. She stated, "Yes." She was asked if the resident's bladder program was reevaluated after the falls with changes as needed. She stated, "No." She was asked if an individualized program was every two hours. She stated, "No, not everyone is on every two hours." The DON was asked how she determined a resident's voiding patterns. She stated, "Staff. I don't exactly adapt the program to what they (residents) are doing (voiding patterns)." An interview was conducted on 07/17/12 at 3:53 p.m., with LPN #3 regarding the resident's fall on 07/07/12. She was asked how the fall occurred. She stated, "(The resident) was trying to go to the bathroom." She was asked if the resident was on a toileting plan or schedule. She stated, "Yes, every two hours." She was asked if every two hours was based on the resident's individualized routine. She stated, "No, all of them are every two hours."