Every finding on record at Sienna Extended Care & Rehab

Based on observation, record review, and interview, the facility failed to post the most recent state survey results of the facility in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 68 residents resided in the facility. Findings: On 04/17/25 at 9:17 a.m., a framed form that showed Copies of all [NAME] surveys and results are available to view on the table at the north end of our main entrance was observed on the wall directly outside of the dining room. On 04/17/25 at 9:21 a.m., the surveyor walked to the front entrance and did not observe the survey results on any table at the north end of the main entrance. A Survey Results policy, revised 04/2007, read in part, A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports .along with the state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. An undated facility form titled, Resident's/Patient's Rights, read in part, You have the right to examine that [sic] last facility state survey .Anyone who denies any of these rights is punishable by fine and/or imprisonment .If you are denied your rights, you may also be allowed punitive damages. On 04/17/25 at 11:38 a.m., the resident council stated they had never seen the State survey results. They stated they could request to see them, however, staff then wanted to know why they were wanting to see them and what was going on. The resident council stated the facility did not discuss them. On 04/17/25 at 12:54 p.m., the activity director stated they had been responsible for resident council for almost a year. On 04/17/25 at 12:58 p.m., the activity director stated they believed survey results were available somewhere in the building. The activity director walked over to the sign that showed survey results were available on a table at the north end of the main entrance. On 04/17/25 at 1:00 p.m., the activity director walked over to the main entrance and stated, I don't see any table with anything on it. They stated the survey results were supposed to be in the front lobby area. On 04/17/25 at 1:01 p.m., the activity director asked the administrator where the survey results were. The administrator stated they were usually on the table, and pointed to a table in the front lobby area. The administrator stated they did not know where they were. On 04/17/25 at 1:02 p.m., the administrator handed the surveyor a red three ring binder they obtained from an office. As the surveyor began to open the binder, the administrator stated, There's nothing in it. The binder did not contain survey results, rather several empty clear page protector sleeves.

Based on record review and interview, the facility failed to ensure the total amount of resident funds in the facility trust account did not exceed the amount covered under the facility surety bond. The DON identified 11 residents in the facility trust account resided in the facility. Findings: An undated facility form titled, Personal Funds Authorization, read in part, The facility maintains one trust fund account for both private and Medicare resident/patients .The facility has purchased a surety bond, or otherwise provided assurance satisfactory to the Secretary of the Department of Health and Human Services, to assure the security of all personal deposited with the facility. The facility trust account showed the following balances: a. statement date 06/30/24 beginning balance $39,450.07 ending balance $40,587.06; b. statement date 08/31/24 beginning balance $32,086.12; c. statement date 02/28/25 ending balance $28,346.24; and d. statement date 03/31/25 beginning balance $28,346.24. The facility surety bond, current bond term 08/20/22 through 08/20/25, showed the bond amount was $25,000. On 04/18/25 at 9:24 a.m., the administrator stated the purpose of the surety bond was to protect the money that was in the trust. On 04/18/25 at 9:25 a.m., the administrator stated the facility surety bond amount was $25,000 and the term was August of 2022 to August of 2025. The administrator reviewed the above balances that exceeded the $25,000 amount covered under the surety bond and stated the FDIC limit of $100,000 per account with the bank protected the resident funds which exceeded the surety bond limit. The administrator stated, The surety bond is redundant protection. On 04/18/25 at 9:28 a.m., the administrator stated the facility had more residents than normal and they probably should have looked into it as the account amounts had gone up.

Based on record review and interview, the facility failed to ensure residents had the right to voice grievances to the facility without fear of discrimination or reprisal and failed to promptly resolve grievances the residents had in the resident council group. The administrator identified 68 residents resided in the facility. Findings: An undated facility form, Resident's/Patient's Rights, read in part, You have the right to voice problems that you are concerned about regarding your treatment .Anyone who denies any of these rights is punishable by fine and/or imprisonment .If you are denied your rights, you may also be allowed punitive damages .There can be no retaliation of any type by the facility staff because of a complaint presented to the staff. The resident council minutes, dated 01/27/25, showed old business: still out of dietary items and everything they ordered or requested was usually out. The resident council minutes showed to see the 01/29/25 meeting for how the issue was resolved. The minutes showed new business: dietary rush when asking for orders and are always out of things, and the residents wanted squash and greens more seasoned. The resident council minutes, dated 01/29/25, showed old business: follow up meeting from 01/27/25 dietary present to explain the state and federal regulation on diet portions and explain budget and cost and how things had to be ordered. The resident council minutes, dated 02/25/25, showed old business: still all the same issues and would like another meeting with the dietary manager. The How are these issues being resolved section was blank. The resident council minutes showed new business: the dining room got worse, food was late, food was still being out of stock of items, meals were not on time, breakfast and lunch was not good, and they were not getting what they ordered. It showed second meeting was requested and held by the dietary manager. The resident council minutes, dated 03/25/25, showed old business: dietary staff still need improvement. The resident council minutes showed the dietary manager had spoken to their team and the issue was resolved. The resident council minutes showed new business dietary: food was lukewarm, the service was not prompt and seemed slower, and the orders were not right after waiting a long time for it. On 04/17/25 at 11:07 a.m., the resident council stated they had complained about receiving greens everyday with their meal. They stated the facility then cut back on a lot of foods after this concern was voiced. They stated they could not have one piece of bacon and a piece of sausage. They stated the facility came up with some strange processes for dining. They stated after they complained about food, their breakfast items were cut from four pieces of bacon to two pieces of bacon. The resident council stated, It was to make us understand if we complained, this was going to happen. The resident council stated if they ordered a hamburger, they had to wait 30 to 45 minutes. They stated the facility served the hall trays first, and if they did not run out of the special for the day, the dining room would be allowed to have the special. They stated they ran out of the scheduled meal often. On 04/17/25 at 11:19 a.m., the resident council stated, It's a big problem anytime we complain. They stated, It's a big mistake. They stated, We get hell if we complain, it's a simple fact. They stated, Retribution, it happens big time. They stated dietary staff would not even let them complete their whole order before moving to the next resident. They stated, We are old, what can I say, we are a little slow. On 04/17/25 at 12:54 p.m., the activity director stated the resident council's complaints generally were related to dining. They stated depending on the complaint, they would take it to the administrator and the department head to try to get a resolution. They stated the dining complaints were reviewed by the administrator. The activity director stated the administrator called in the dietary manager and went over the concerns and held a separate meeting with the residents who had complaints about the dietary department and dining. The activity director stated they would get back with them and say the issue had been resolved, but the same complaints would happen at the next resident council meeting. On 04/17/25 at 12:58 p.m., the activity director stated they did not know the process if a resident felt retaliated against, because they had never had that issue. They stated they would more than likely take the concern to the administrator.

Based on record review and interview, the facility failed to ensure resident assessments were coded for 2 (#1 and #48) of 19 sampled residents reviewed for accuracy of resident assessments. The administrator identified 68 residents resided in the facility. Findings: 1. A hospice services contract, dated 11/08/24, showed Resident #1 had started hospice services on that date. A significant change MDS assessment, dated 11/19/24, was completed due to Resident #1 beginning hospice services. The assessment showed Resident #1 had a diagnosis of heart disease and a BIMS score of 12, indicating they were moderately cognitively impaired. A care plan, dated 01/20/25, showed Resident #1 had a terminal diagnosis and was receiving hospice services. A quarterly MDS assessment, dated 02/19/25, showed that Resident #1 was not on hospice services. On 04/17/25 at 11:05 a.m., the MDS coordinator stated the quarterly assessment was coded incorrectly and should have shown that Resident #1 was receiving hospice services. On 04/17/25 at 11:08 a.m., the DON stated the MDS assessments are supposed to be accurate. 2. A care plan, dated 02/26/24, showed Resident #48 required dialysis every Monday, Wednesday, and Friday due to renal failure. A physician's order, dated 07/22/24, showed Resident #48 was to go to dialysis every Monday, Wednesday, and Friday. An annual MDS assessment, dated 03/06/25, showed Resident #48 had not required dialysis while in the facility over the last 14 days. On 04/17/25 at 2:29 p.m., the MDS coordinator stated Resident #48's annual assessment was inaccurate and should have indicated they were on dialysis while in the facility.

Based on observation, record review, and interview, the facility failed to: a. follow EBP during the provision of care for 1 (#14) of 3 sampled residents reviewed for activities of daily living; and b. transport dirty linen appropriately and sanitize their hands between meal set up for different residents on hall 200. The administrator identified 68 residents resided in the facility. The DON identified 18 residents were on EBP. Findings: 1. On 04/15/25 at 12:42 p.m., CNA #4 entered Resident #14's room to answer their call light. The resident's representative informed CNA #4 the resident was wet. On 04/15/25 at 12:43 p.m., CNA #4 donned gloves. There was an EBP sign on the resident's closet. Gowns were observed on top of the resident's closet. There was an EBP sign, gloves, and hand sanitizer by the resident's room entrance. Resident #14 ambulated to the bathroom with CNA #4's supervision. There was a yellow ring on the center of the resident's sheet. On 04/15/25 at 12:50 p.m., CNA #4 assisted the resident with toileting and changed their clothing. CNA #4 did not have a gown on. On 04/15/25 at 12:51 p.m., CNA #4 left the room with a bag of soiled clothing. On 04/15/25 at 12:53 p.m., CNA #4 came back with a tan brief and a pair of blue socks. They donned gloves and went into the bathroom to assist the resident into the new brief and socks. On 04/15/25 at 1:01 p.m., CNA #4 stripped Resident #14's bedding and took them out of the room in a yellow barrel. The yellow barrel was placed outside of the residents door. CNA #4 did not have a gown on. An undated policy titled Enhanced Barrier Precautions (EBP), read in part, EBP is defined as the targeted use of gowns and gloves during high-contact resident care activities .These include, but not limited to: Dressing/undressing, Transferring, Changing Linens, Providing hygiene, Assisting with toileting or assisting with toilet. A care plan, dated 04/01/25, showed Resident #14 had diagnoses which included dysphagia, oral phase and unspecified protein-calorie malnutrition. The care plan showed the resident had a peg tube placed. On 04/15/25 at 1:34 p.m., CNA #4 stated they had to wash their hands, put on a gown, and gloves for care of residents on enhanced barrier precautions. They stated they were to wear a mask if needed. On 04/15/25 at 1:35 p.m., CNA #4 stated Resident #14 was on enhanced barrier precautions due to their peg tube. They stated they did not follow the facility's enhanced barrier precaution process. On 04/16/25 at 1:17 p.m., the DON stated anyone with a peg tube, indwelling catheter, or chronic wounds was put on enhanced barrier precautions. On 04/16/25 at 1:18 p.m., the DON stated the required personal protective equipment for care of residents on enhanced barrier precautions was a gown and gloves. 2. On 04/16/25 at 8:06 a.m., CNA #1 was observed taking dirty clothing that was not bagged to dirty linen room and wearing gloves through the hallway. On 04/16/25 at 8:10 a.m., CNA #1 stated they did not know what the policy was for washing or sanitizing hands after taking care of a resident. They stated they would get back to me on that policy. They stated they are allowed to wear gloves in the hallway to transport linen. On 04/16/25 at 1:32 p.m., CNA #1 was observed passing out lunch trays to residents on hall 200. They did not wash their hands or wear gloves between setting up trays for residents. They were observed moving a bedside table, opening a milk carton, and taking the plastic off of the food. On 04/16/25 at 2:37 p.m., CNA #1 stated they had been too busy to find out the policy for handwashing or sanitizing hands between residents when providing care or passing trays. On 04/21/25 at 10:09 a.m., the administrator stated the policy was to transport dirty linen in a bag, never wear gloves in the hall, and wash or sanitize hands between residents when providing care. 49701

Based on record review and interview, the facility failed to ensure residents were free from misappropriation for 1 (#177) of 3 sampled residents reviewed for abuse. The administrator identified 68 residents resided in the facility. Findings: The facility abuse, neglect, exploitation and misappropriation prevention program, revised 04/2021, read in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. A new employee form showed CNA #2 had a hire date of 12/06/24. A quarterly resident assessment, dated 02/24/25, showed Resident #177 had severe cognitive impairment (BIMS 07). An email correspondence to the administrator, dated 03/17/25, showed the family of Resident #177 discovered six unauthorized charges to the resident's debit card during their stay at the facility. The email correspondence showed there were four withdrawals made and deposited to a cash app account on 01/01/25 for a total of $2900. The email correspondence showed the bank reported the name on the cash app account was CNA #2. The email correspondence showed the card was also used at a food establishment and a gas station on 12/27/24. The email correspondence showed there was a police report filed. The email correspondence showed the family was not aware of Resident #177 leaving the facility or having unknown visitors during the time. A combined intital and final facility reported incident, dated 03/17/25, showed it was reported to the DON on 03/17/25 that Resident #177, who had been discharged , discovered unauthorized charges to the resident's missing bank debit card. The incident report showed Resident #177's family reported four withdrawals were made and deposited in a cash app account belonging to CNA #2. The report showed the facility removed CNA #2 from the schedule. The incident report showed a total of $2900 was sent to CNA #2's cash app along with two charges to a food establishment and a gas station. It showed a police report was filed. It showed CNA #2 had previously been removed from the schedule due to not showing up for work. It showed management staff had been educated to report to the administrator or DON if CNA #2 was seen entering the facility. The report was signed as completed by the DON. A termination form, dated 03/17/25, showed CNA #2 had been terminated on 03/17/25. An order summary report, dated 04/18/25, showed Resident #177 had diagnoses which included encephalopathy, chronic kidney disease, and dysphagia oral phase. On 04/18/25 at 11:06 a.m., CNA #1 stated the facility monitored for sexual abuse, physical abuse, and verbal abuse. They stated they monitored for all of the types of abuse in the facility. They stated if abuse was observed or reported to them, they would report it to the nurse. On 04/18/25 at 11:12 a.m., LPN #1 stated staff monitored for all types of abuse including verbal, mental, and physical abuse. They stated abuse was taking something from a resident they felt they should have. They stated there was financial abuse and exploitation as well. On 04/18/25 at 11:13 a.m., LPN #1 stated if abuse was observed or reported to them they would go straight to the DON and then the administrator. They stated if the abuse involved staff, they would immediately be removed from the resident's care and the building pending the investigation. They stated they would walk the staff member up to the exit to ensure they left the building. They stated they would also remove residents from dangerous situations. On 04/18/25 at 11:14 a.m., LPN #1 stated the DON, administrator, family, police, and if needed state were notified of the allegation of abuse. On 04/18/25 at 1:45 p.m., the DON was asked to provide all documentation related to the abuse investigation for Resident #177. They stated the only thing they thought they had were some statements. On 04/18/25 at 1:54 p.m., the DON stated the facility reported incident was initiated based on the email received on 03/17/25. They stated the resident discharged from the facility on 03/12/25. They stated CNA #2 had not worked at the facility since 02/22/25. The DON stated it was initiated because the resident's family member was already investigating two people, one of which was the facility employee, misappropriating Resident #177's funds. On 04/21/25 at 12:29 p.m., the DON stated the facility was notified by email after Resident #177 had discharged , the family was investigating charges that were known to be from CNA #2. They stated the employee was still on the prn rotation but had not worked at the facility since February. They stated CNA #2 was completely removed from the roster and was reported to the appropriate licensing board. They stated it had already been reported to the police. On 04/21/25 at 12:33 p.m., the DON stated the facility did not interview any other residents because most of the residents did not have the same kind of bank cards and stuff Resident #177 had. They stated no staff were interviewed related to this misappropriation allegation. They stated the only inservice the facility had related to misappropriation was the one from 01/22/25. On 04/21/25 at 12:34 p.m., the DON stated the administrator or the business office would be able to say what measures the facility put in place to keep a resident's money/property from being misappropriated since the allegation involving Resident #177. On 04/21/25 at 12:37 p.m., the administrator stated they reinforced the policy they had in place following the abuse allegation. They stated Resident #177 was no longer a resident when they were notified. The administrator stated they went ahead and completed a state reportable, but they weren't required to do one since they were no longer a resident. The administrator stated during the police investigation, they had identified charges that were paid to CNA #2 and they were removed from the schedule. They stated they had called the police and told them if they had anything else they needed from the facility to let them know. The administrator stated it was an ongoing investigation with APS and they let APS know they could contact them directly if they needed anything. The administrator stated no other resident's CNA #2 cared for were interviewed because Resident #177 was already discharged . They stated the resident was no longer at the facility and CNA #2 was no longer an employee.

Based on record review and interview, the facility failed to ensure: a. an abuse allegation was reported to APS for 2 (#8 and #21); and b. an initial abuse allegation was reported to the state agency within two hours for 1 (#21) of 3 sampled residents reviewed for abuse. The administrator identified 68 residents resided in the facility. Findings: An Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised 09/2022, read in part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .The stated licensing/certification agency responsible for surveying/licensing the facility .Adult protective services .Immediately .within two hours of an allegation involving abuse. 1. A quarterly resident assessment, dated 02/13/25, showed Resident #21's cognition was intact (BIMS 15). A final facility reported incident, dated 02/27/25, showed an allegation of misappropriation involving Resident #21. The incident report showed Resident #21 reported they were missing $75 to the BOM that was in their purse in their room and was no longer there. It showed the BOM had witnessed Resident #21 having the money on 02/25/25. The incident report showed the resident denied using the money or giving the money to anyone. The incident report showed the police, administrator, family, and physician were notified. The report was signed as completed by the DON. There was no initial facility reported incident located for this allegation of abuse. There was no documentation APS had been notified of this allegation of abuse. On 04/15/25 at 11:14 a.m., Resident #21 stated they had money taken out of their billfold twice at the facility and they had reported it. Resident #21 stated the police were called both times. They stated they had gotten money out at the bank and placed it in their billfold. On 04/15/25 at 11:16 a.m., Resident #21 stated $200 was taken the first time and $100 was taken the second time. On 04/15/25 at 11:17 a.m., Resident #21 stated the first time it happened was before Christmas and the last time was early March. They stated they reported it to the BOM and they reported it to the police. An order summary report, dated 04/18/25, showed Resident #21 had diagnoses which included diabetes mellitus and angina pectoris. On 04/18/25 at 11:06 a.m., CNA #1 stated if abuse was observed or reported to them, they would report it to the nurse. On 04/18/25 at 11:13 a.m., LPN #1 stated if abuse was observed or reported to them they would go straight to the DON and then the administrator. They stated if the abuse involved staff, they would immediately be removed from the resident's care and the building pending the investigation. They stated they would walk the staff member up to the exit to ensure they left the building. They stated they would also remove residents from dangerous situations. On 04/18/25 at 11:14 a.m., LPN #1 stated the DON, administrator, family, police, and if needed state were notified of the allegation of abuse. On 04/18/25 at 11:29 a.m., the DON stated they could not find an initial state reportable for the 02/27/25 allegation of misappropriation involving Resident #21. They stated the timeline for completing the initial reportable incident was two hours. On 04/18/25 at 12:07 p.m., the BOM stated they did take Resident #21 to the bank. They stated they went once a month when the resident's vender payment was due. They stated the resident took out their payment and additional money for personal use. On 04/18/25 at 12:11 p.m., the BOM stated they had taken Resident #21 to the bank and they took out $75. They stated the resident reported the money was missing to them. They stated the DON and administrator were notified and they were the ones who notified the police and completed everything. The BOM stated the resident never reported to them if the money was ever found. On 04/18/25 at 12:13 p.m., the administrator stated the money had not been found to their knowledge. On 04/18/25 at 12:20 p.m., the DON stated if abuse was observed or reported to staff, they would notify the DON or the administrator. They stated they would follow their policy, investigate it, and report it. On 04/18/25 at 12:21 p.m., the DON stated they had not notified APS on abuse allegations. They reviewed the above facility reported incident where APS was an option under notifications made and stated, I guess it would be for an abuse allegation. The DON stated honestly they had not ever notified APS of abuse allegations. On 04/18/25 at 12:25 p.m., the DON stated the BOM had witnessed Resident #21 having money one day, and one day later it came up missing. The DON stated the money was never found. 49701 2. A Combined Initial and Final Incident Report Form, dated 03/24/25, showed an allegation of misappropriation of resident property. The report showed the facility was notified by Resident #8's family member Resident #8's phone had been missing since the previous week. Staff stated the phone was last seen on the bedside table the prior Friday. The family member told the DON they had reported the phone stolen to the police. A police officer told the DON the phone was last pinged in close proximity to the facility dumpster on the prior Friday 03/21/25. The phone was unable to be pinged on 03/24/25 due to being dead or turned off. It was believed the phone accidentally fell into the waste basket next to the bed. Family, physician, Resident #8 and the police were notified. There was no initial facility reported incident located for this allegation of abuse. There was no documentation APS had been notified of this allegation of abuse. On 04/16/25 at 11:49 a.m., the Combined Initial and Final Incident Report Form, dated 03/24/25 was faxed to the Oklahoma State Department of Health. The fax stated it was received successfully. On 04/21/25 at 1:05 p.m., the administrator stated the family reported the phone missing and the police pinged it. Seems to have been in the dumpster of the facility. The admission contract states the facility is not responsible for stolen or missing items. On 04/21/25 at 1:07 p.m., the DON stated they were unaware that the regulation required Adult Protective Services to be notified with any type of abuse/misappropriation situation, so it was not reported to them.

Based on observation, record review, and interview, the facility failed to complete skin assessments as ordered for 3 (#1, 12, and #24) of 5 sampled residents reviewed for non-pressure skin conditions. The administrator identified 68 residents resided in the facility. Findings: 1. Resident #1's order summary report, dated 04/2025, had diagnoses which included peripheral autonomic neuropathy, protein-calorie malnutrition, and need for assistance with personal care. Resident #1's quarterly resident assessment, dated 02/19/25, showed the resident had moderate cognitive impairment with a BIMS of 12. A physician's order, dated 11/04/24, showed weekly skin assessments on Tuesdays from 7 a.m. to 3 p.m. Skin only evaluation (in assessments) was to be filled out. Document all findings. Obtain treatment order if needed one time a day every Wednesday. The last skin assessment for Resident #1 was dated 08/07/24. On 04/21/25 at 9:18 a.m., LPN #1 stated the last skin only evaluation they see in Resident #1's medical records was dated 08/07/24. 2. On 04/16/25 at 8:28 a.m., Resident #12 had moderate white, dry flakes on their face and frontal region of their head. On 04/17/25 at 11:17 a.m., LPN #2 made observation of Resident #12's face and head. Resident #12's quarterly resident assessment, dated 02/27/25, showed the resident had moderate cognitive impairment with a BIMS of 15. Resident #12's order summary report, dated 04/2025, showed the resident had a diagnosis of chronic obstructive pulmonary disease. A physician's order, dated 11/19/24, showed weekly skin assessments on Wednesdays from 7 a.m. to 3 p.m. Skin only evaluation (in assessments) was to be filled out. Document all findings. Obtain treatment order if needed one time a day every Wednesday. The last skin assessment for Resident #12 was dated 02/26/25. On 04/16/25 at 8:28 a.m., Resident #12 stated they always had the dryness on their face. They stated they did not know if they had a treatment order. On 04/17/25 at 11:20 a.m., LPN #2 stated the Resident had white flakiness on their face. On 04/17/25 at 11:21 a.m., LPN #2 stated they were not sure how long the Resident had the dry flakiness on their skin. They stated skin assessments were completed once a week or every two weeks. They stated they were not aware of any treatment order for it, but would inform the provider. On 04/17/25 at 11:28 a.m., LPN #2 stated the dry flakiness on the resident's skin could require a treatment order, but the provider had to give them the order. On 04/17/25 at 1:29 p.m., the DON stated weekly assessments were to be completed as ordered. They stated the assessment included head to toe, any new skin issues or treatment documentation. On 04/17/25 at 1:30 p.m., the DON stated skin assessments were documented as skin checks. They stated the last skin assessment completed for Resident #12 was on 02/26/25. The DON stated the wound nurse was responsible for weekly skin assessments but the task was reverted to nurses. They stated it seemed the nurses were not completing them. 48344 3. On 04/15/25 at 1:14 p.m., Resident #24's right lower leg was observed to have an open area with active bleeding present was approximately the size of a quarter. A physician order, dated 12/17/24, showed weekly skin assessments on Tuesdays was to be filled out. It showed staff were to document all findings and obtain a treatment order if needed. A skin check note, dated 02/18/25, showed Resident #24 had a skin issue that needed addressed on the front right lateral lower leg. The note showed the venous skin issue was acquired in house. A physician order, dated 04/02/25, showed cleanse skin tear to right lower extremity with wound cleanser, pat dry, apply xeroform, cover with dry dressing every evening shift for wound care. A wound physician history and physical note, dated 04/21/25, showed Resident #24 had diagnoses which included an unspecified open wound to the right lower leg. A wound care progress note, dated 04/21/25, showed Resident #24 had an unspecified open wound to the right lower leg initial encounter. The note showed the wound was first noted on 04/04/25 and it was first noted by the wound care provider on 04/21/25. The note showed the wound measured 1cm by 1cm by 0.1cm with serous drainage. There were no weekly skin assessments located in Resident #24's clinical record between the skin check note dated 02/18/25 and the wound care progress note dated 04/21/25. On 04/21/25 at 2:18 p.m., the DON stated they had identified a system error related to wound care. They stated the person responsible for weekly skin assessments stopped working as a wound care nurse in February 2025. They stated the facility had just hired a new wound care nurse. The DON stated they had identified the weekly skin assessments were not being generated to be completed by the nurses on the floor. On 04/21/25 at 2:19 p.m., the DON stated the previous wound care nurse was completing the weekly skin assessments, but they were currently on leave. The DON stated they had spoken to LPN #1 on 04/21/25, and identified the skin assessments were not even populating. The DON stated they had a system error they needed to correct. The DON stated there were shower sheets completed that monitored residents' skin. They stated the shower sheets were completed by the CNAs. On 04/21/25 at 2:22 p.m. the DON reviewed Resident #24's shower sheets for April 2024 and stated they did not document the resident's current skin tear wound. On 04/21/25 at 2:34 p.m., LPN #1 stated apparently the facility had been doing the skin assessments wrong. They stated it was the wound care nurse's responsibility to their knowledge. LPN #1 stated the wound care nurse had left and the weekly skin assessments were not populating. On 04/21/25 at 2:36 p.m., LPN #1 stated the wound care nurse had went on leave around February/March 2025. They stated Resident #24 had a wound to their right lower leg from picking at it. They stated it had resolved at one time, but came back. On 04/21/25 at 2:38 p.m., LPN #1 stated they believed the wound had come back on 04/03/25. They stated the resident's wound care was completed every evening. On 04/21/25 at 2:39 p.m., LPN #1 stated the wound was getting better, but it would be reoccurring as long as the resident picked at their skin. On 04/21/25 at 2:53 p.m., the DON stated they could not find anything else on the resident's skin since the 02/18/25 note. On 04/21/25 at 3:14 p.m., the DON stated they called the previous wound care nurse who stated the 02/18/25 assessment was wrong. They stated the resident did not have a wound during that time. 49701

Based on observation, record review, and interview, the facility failed to administer a resident's oxygen as ordered for 1 (#12) of 3 sampled residents reviewed for respiratory care. The DON identified seven residents received continuous oxygen in the facility. Findings: On 04/16/25 at 8:24 a.m., Resident #12's oxygen concentrator was observed to be at a flow rate of 2 liters per minute via a nasal cannula. On 04/17/25 at 11:16 a.m., LPN #2 made observation of the oxygen flow rate on resident #12's concentrator. A policy titled Oxygen Administration, dated 2001, read in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .Review the physician's orders or facility protocol for oxygen administration. Resident #12's order summary report, dated 04/2025, showed the resident had a diagnosis of chronic obstructive pulmonary disease. A physician's order, dated 02/05/24, showed oxygen via nasal cannula at 5 liters continuously. May titrate to keep saturation above 90%. On 04/17/25 at 11:20 a.m., LPN #2 stated the resident's concentrator was set to deliver oxygen at 2 liters per minute. On 04/17/25 at 11:25 a.m., LPN #2 stated they had checked Resident #12's oxygen saturation this morning, but did not check how many liters the oxygen was set to on the concentrator. They stated the resident's oxygen saturation was 93%. On 04/17/25 at 11:26 a.m., LPN #2 stated the resident's oxygen order was for 5 liters and to titrate up if they had trouble breathing. On 04/17/25 at 1:27 p.m., the DON stated the nurses were to follow the physician's order for the use of oxygen.

Based on observation, record review, and interview, the facility failed to ensure residents' medications were only accessible to qualified staff. The administrator identified 68 residents resided in the facility. The administrator identified the facility had three medication rooms. Findings: On 04/16/25 at 10:55 a.m., life safety was on tour with the maintenance supervisor. The maintenance supervisor used their key to open the medication storage room by the DONs office. No other staff were present at the time. The maintenance supervisor walked over to the medication room on hall 500 and opened the door using their key. No other staff were present at the time. On 04/16/25 at 12:17 p.m., LPN #1 opened the medication storage room by the DONs office. There were numerous containers of residents' medications observed in the room. On 04/16/25 at 12:35 p.m., ACMA #1 opened the medication storage room on hall 500. There were numerous containers of residents' medications observed in the room. On 04/16/25 at 2:45 p.m., the maintenance supervisor had the medication room door by the DONs office open for life safety. There were no nurses observed. The maintenance supervisor asked another staff member to send a nurse up since they had the medication storage door open. On 04/16/25 at 3:40 p.m., the maintenance supervisor opened the medication storage room on hall 500 with their own key which contained medications for residents residing on hall 500. The maintenance supervisor called a nurse over to spot him during this observation. The maintenance supervisor stated the medication room had an attic access in it. A medication storage in the facilty policy, revised 01/2018, read in part, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 04/16/25 at 12:23 p.m., LPN #1 stated nurses, medication aides, the DON and the maintenance supervisor had access to the medication storage room. LPN #1 stated the maintenance supervisor had keys to everything in the building. On 04/16/25 at 12:43 p.m., ACMA #1 stated the nurses, medication aides, and maintenance had access to the medication storage room. On 04/16/25 at 1:52 p.m., the DON stated the maintenance supervisor had access to the front hall medication storage room (by the DON's office) because there was a fire panel control in the room. The DON stated the maintenance supervisor was supposed to get one of us. They stated there were medications in the medication storage rooms, but no controlled medications.

Based on record review and interview, the facility failed to ensure the dietary manager completed certification as a certified dietary manager within three years of beginning employment per state requirement. The administrator identified 68 residents resided in the facility and 66 residents ate from the cafeteria. Findings: The DM was hired on 11/22/2011. There was no documentation the DM had completed certification as a certified dietary manager. On 04/16/25 at 1:23 p.m., the dietary manager stated they had worked in the role of dietary manager since 2011 and had not been certified. They stated they started the classes, but never completed them. They also denied having the other qualifiers accepted by the regulations to be considered certified. On 04/21/25 at 10:04 a.m., the administrator stated the DM was supposed to get certified within 3 years. The administrator stated, I was told they did the class.

Based on record review and interview, it was determined the facility failed to ensure dementia management education was provided to 1 (LPN #2) of 1 staff member who cared for residents with dementia. The administrator identified 18 residents had diagnosis of dementia in the facility. Findings: 1. Resident #3 had diagnoses which included vascular dementia. An annual resident assessment, dated 02/07/25, showed the resident's cognition was severely impaired (BIMS 00). Resident #3's care plan, dated 03/08/24, showed the resident had behavioral issues related to yelling out, throwing food, and was combative at times. 2. Resident #15's care plan, dated 03/24/25, showed the resident had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. It showed the resident had impaired cognitive function or impaired thought processes related to dementia. Resident #15's quarterly resident assessment, dated 03/28/25, showed the resident's cognition was severely impaired with a BIMS of 03. It showed the resident had inattention and disorganized thinking behaviors. There was no documentation of staff in-service or training on dementia management between 04/2024 through 04/2025. On 04/18/25 at 12:41 p.m., LPN #2 stated they had been at the facility for a year. They stated they had not received dementia management training in 2024 and 2025. On 04/18/25 at 1:58 p.m., the DON stated they have not had an in-service for care of residents with dementia from 04/2024 to 04/2025. On 04/21/25 at 12:50 p.m., the administrator stated the facility does not have a mandatory requirement that all staff participate in dementia management training. 35389

Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for one (#1) of one sampled residents reviewed for intravenous medications as order by the physician. Social Services identified 73 residents resided in the facility. Findings: Resident #1 had diagnoses which included sepsis, unspecified organism and cellulitis of left upper arm. A physician's order, dated 09/19/23 documented ceftriaxone sodium injection solution, reconstituted 2 GM (Ceftriaxone sodium) use 2 gram intravenously one time a day for eight days with a start date of 09/20/23. A physician's order, dated 09/20/23 documented flush NS 10 ml per lumen every shift. The September MAR documented blanks on 09/25 and 09/26/23 for the ceftriaxone sodium and the flush documented four blanks out of 21 opportunities. On 02/08/24 at 11:38 a.m., the DON stated I can not verify by the MAR that she received the anitbiotic or flushes or not. On 02/08/24 at 12:03 p.m., LPN #1 stated if there are blanks on the MAR it is assumed it wasn't given, andif there is no documentation, you didn't do it. On 02/08/24 at 12:13 p.m., LPN #2 stated blanks meant the medication was not given. If it's not documented, you didn't do it.

Based on record review and interview, the facility failed to ensure resident assessments were accurately coded for three (#27, 45, and # 52) of 18 sampled residents reviewed for resident assessments. The Administrator identified 70 residents resided in the facility. Findings: 1. Resident #52 had diagnoses which included chronic kidney disease stage four and vascular dementia. An Admission Resident Assessment, dated 09/22/23, documented the resident received a diuretic seven days of the seven day look-back period. There was no documentation Resident #52 had received a diuretic medication. On 12/19/23 at 2:56 p.m., MDS Coordinator #1 stated they reviewed resident charts, talked to staff and residents, and reviewed orders and documents to ensure resident assessments were accurately coded. The stated Resident #52's Admission Resident Assessment documented they received a diuretic and an antidepressant. MDS Coordinator #1 reviewed the resident's record and stated the resident had not received a diuretic medication. 2. Resident #27 had diagnoses which included dementia and palliative care. Resident #27's significant change assessment, dated 10/23/23, documented the resident was taking an antipsychotic medication during the seven day look-back period. It documented the resident had not received an antipsychotic medication since admission/entry or reentry. On 12/20/23 at 10:40 a.m., MDS Coordinator #1 stated an antipsychotic was taken by Resident #27 during the look-back period and it should have documented the resident had received an antipsychotic medication. 48344 3. Resident #45 had diagnoses which included congestive heart failure and hypertension. A physician's order, dated 09/05/23, documented admit to hospice care effective 08/30/23 due to diagnosis of stroke. Resident #45's quarterly resident assessment, dated 12/04/23, documented blank for hospice care. On 12/20/23 at 2:05 p.m., the MDS Coordinator #2 stated Resident #45 was on hospice care. On 12/20/23 at 2:06 p.m., the MDS Coordinator #2 stated Resident #45's quarterly resident assessment, dated 12/04/23 did not document the Resident was on hospice care. 49701

Based on observation, record review, and interview, the facility failed to ensure: a. medications for administration were not left at the resident's bedside for one (#55) of 24 residents observed during initial pool; and b. medications were administered as ordered for two (#27 and #54) of five sampled residents reviewed for unnecessary medications. The administrator identified 70 residents resided in the facility and no residents with orders to self administer medications. Findings: An Administering Medications policy, revised 04/19, read in part, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders .Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision making capability to do so safely . 1. Resident #55 had diagnoses which included schizophrenia, dementia, insomnia, and chronic pain syndrome. On 12/18/23 at 9:16 a.m., Resident #55 stated it took the facility six hours to bring them their pain pill. Resident #55 picked up a medicine cup located on their bedside table and removed a white pill from it and showed the pill to the surveyor. Resident #55 stated they were waiting to eat breakfast before they took their medications. The medication cup was observed to have one light green colored capsule and one light green colored tablet, one red pill, one red and white circular pill, two white circular pills one larger than the other, and the pill the resident identified as the pain pill. Resident #55 stated they were going to go ahead and take their pain pill, removed a white pill from the cup, and took the medication by mouth. On 12/18/23 at 9:29 a.m., CMA #2 stated they were to sit with residents until they took their medications. CMA #2 was asked to explain the cup of medications the surveyor observed at the bedside of Resident #55. They stated the resident was going to the bathroom and complaining about the night shift. They stated there wasn't a reason the medications were left at the bedside. They stated the resident usually took them, but must have decided to go to the bathroom. CMA #2 stated they were the staff member who took Resident #55 the above medications. 48344 2. Resident #27 had diagnoses which included hypertension. A Physician Order, dated 05/16/23, documented give one 50 mg tablet of Metoprolol Tartrate by mouth two times a day related to hypertension and hold if systolic blood pressure was less than 100. Resident #27's November 2023 MAR documented on 11/19/23 the resident's blood pressure was 96/65. It documented the resident was administered their Metoprolol Tartrate. On 12/20/23 at 12:06 p.m., the DON stated the medication was given when it should not have been according to the physician ordered parameters. 3. Resident #54 had diagnoses which included end stage renal disease and hypotension. A physician's order, dated 06/29/23, documented midodrine HCl tablet 10 mg give one tablet by mouth one time a day every Monday, Wednesday, and Friday related to hypotension, hold for systolic blood pressure greater than 110, or diastolic blood pressure greater than 70. The October 2023 MAR documented midodrine was administered on the following dates; a. 10/02/23 blood pressure was 127/76, b. 10/04/23 blood pressure was 127/91, c. 10/06/23 blood pressure was 148/93, d. 10/09/23 blood pressure was 135/69, e. 10/11/23 blood pressure was 165/72, f. 10/13/23 blood pressure was 128/65, g. 10/18/23 blood pressure was 140/66, h. 10/27/23 blood pressure was 128/61, and i. 10/30/23 blood pressure was 124/76. The November 2023 MAR documented midodrine was administered on the following dates; a. 11/01/23 blood pressure was 127/76, b. 11/08/23 blood pressure was 128/60, c. 11/10/23 blood pressure was 138/72, d. 11/15/23 blood pressure was 125/70, e. 11/20/23 blood pressure was 149/87, f. 11/22/23 blood pressure was 125/70, g. 11/24/23 blood pressure was 132/84, and h. 11/27/23 blood pressure was 115/80. The December 2023 MAR documented midodrine was administered on the following dates; a. 12/01/23 blood pressure was 125/80, b. 12/04/23 blood pressure was 135/70, c. 12/06/23 blood pressure was 125/67, d. 12/08/23 blood pressure was 156/84, e. 12/11/23 blood pressure was 140/80, f. 12/13/23 blood pressure was 130/60, g. 12/15/23 blood pressure was 117/67, h. 12/18/23 blood pressure was 145/90, and i. 12/20/23 blood pressure was 145/70. On 12/21/23 at 9:23 a.m., the ADON reviewed Resident #54's 10/23 MAR. They stated midodrine should have been held for the nine days the systolic blood pressure was greater than 110. On 12/21/23 at 9:25 a.m., the ADON reviewed Resident #54's 11/23 MAR. They stated midodrine should have been held for the eight days the systolic blood pressure was greater than 110. On 12/21/23 at 9:27 a.m., the ADON reviewed Resident #54's 12/23 MAR. They stated midodrine should have been held for the nine days the systolic blood pressure was greater than 110. 49701

Based on observation, record review, and interview, the facility failed to ensure food items were dated and labeled appropriately for one of one kitchen observation. The Dietary Manager identified 69 residents who received meals from the kitchen. Findings: A Food Receiving and Storage policy, revised 11/22, read in part, .all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) .other opened containers are dated and sealed or covered during storage . On 12/18/23 at 8:35 a.m., cherry fountain syrup was observed in the dry storage room with no open date with one third of it used. On 12/18/23 at 8:44 a.m., tartar sauce was observed in the refrigerator with no open date and two thirds used. Chocolate cupcakes were observed in the refrigerator with no label or date. On 12/18/23 at 8:46 a.m., garlic spread was observed in the refrigerator with no open date and half used. On 12/18/23 at 9:13 a.m., the Dietary Manager stated they could not identify when the tartar sauce or garlic sauce was opened. They stated there would be no way to identify when the cupcakes were made. On 12/18/23 at 9:15 a.m., the Dietary Manager stated they did not know when the cherry fountain syrup was opened.

Based on observation, record review, and interview, the facility failed to ensure staff donned personal protective equipment in transmission based precautions room for one (#77) of eight residents observed receiving their meal trays. The Daily Census, dated 12/17/23, identified two residents on isolation precautions for COVID-19. Findings: A Personal Protective Equipment policy, revised 10/18, read in part, .personnel who perform tasks that may involve exposure to blood/body fluids .employees who fail to use personal protective equipment when indicated may be disciplined . A Respiratory Surveillance Line List documented Resident #77 had tested positive for COVID-19 on 12/12/23. On 12/18/23 at 12:34 p.m., CNA #1 was observed passing a tray to Resident #77 on hall 400. The CNA did not use any personal protective equipment to enter the room and set up the tray for Resident #77. There was a PPE sign and equipment observed right outside of the resident's room. On 12/18/23 at 12:36 p.m., CNA #1 stated they forgot the resident had a sign on the door and paid no attention honestly.

Based on record review and interview, the facility failed to ensure trust account statements were provided quarterly to three ( #2, 5 and #7) of three sampled residents reviewed for trust accounts. The Administrator identified 15 residents in the resident trust account. Findings: An Accounting and Records of Resident Funds policy, revised 04/21, read in parts .Our facility maintains accounting records of resident funds deposit with the facility .Individual accounting records are made available to the resident through quarterly statements and upon request . The form identified Resident #3, #5 and #7 had trust accounts. 1. Res. #2 had diagnosis which included atrial fibrillation, fluid overload, depression, morbid obesity, and cognitive communication deficit. On 10/11/23 at 10:04 a.m., Resident #7 was asked if they received quarterly statements for the trust account. They stated they were unsure, they would like to see them. 2. Res. #5 had diagnosis which included acute respiratory failure, seizures, diabetes mellitus, anxiety, dementia. 3. Res. #7 had diagnosis which included transient cerebral ischemic attack, history of falling, diabetes mellitus, depression. ON 10/12/23 at 8:17 am., Resident #7 was asked if they were aware how much money was in their trust account. They stated, NO. Resident #7 was asked how they are notified how much money was in their trust account. They stated, Never heard. They were asked if they received trust account statements. They state, No. On 10/12/23 at 9:41 a.m., the BOM was asked if the residents were given quarterly statements. They stated, No.

Based on record review and interview the facility failed to: a. assess bowel sounds post-abdominal surgery for one (#3), b. obtain fingerstick blood sugars as ordered for two (#3 and #4), and c. monitor vital signs every shift as ordered for one (#3) of three sampled residents reviewed for physician orders. The DON identified 21 residents were insulin dependent and 81 residents resided in the facility. Findings: A Diabetes-Clinical Protocol policy, revised 11/20, read in part .As indicated, the Physician will order appropriate lab tests .monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale insulin . An Insulin Administration policy, revised 09/14, read in part .The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin . 1. Resident #3 had diagnoses which included ischemic colon, type two diabetes mellitus, and high blood pressure. Skilled nurses' notes, dated 05/20/23 and 05/21/23, did not contain documentation that bowel sounds had been assessed. A Five Day Assessment, dated 05/22/23, documented Resident #3 required extensive assistance of one for bed mobility, transfers, dressing, and personal hygiene. A Health Status Note, dated 05/22/23 at 8:23 p.m., documented the Resident #3 arrived to the facility at 4:45 p.m., and a FSBS was obtained. There was no documentation Resident #3's bowel sounds had been assessed. A DAR, dated 09/19/23 through 09/22/23 did not document any FSBS's had been obtained as ordered and did not document vital signs were obtained for three of eight shifts. On 10/11/23 at 3:05 p.m., the DON was asked if the skilled notes documented bowel sounds had been assessed on the resident. They stated, No. The DON stated they should have been assessed and documented. On 10/12/23 at 9:23 a.m., the DON was asked how Resident #3's FSBSs had been monitored. They stated they were unsure since the diabetic administration record did not document fingersticks results. On 10/13/23 at 1:39 p.m., the DON was asked if Resident #3's blood pressure had been obtained every shift as ordered by the physician. They stated, No. 2. Resident #4 had diagnoses which included diabetes mellitus with ketoacidosis with coma, type two diabetes mellitus, and depression. An Admission Assessment, dated 05/25/23, documented Resident #4 had mild cognitive impairment, and required assistance of one staff for bed mobility, transfers, dressing, toilet use, and hygiene. A Physician Order, dated 09/18/23, documented to administer Insulin Glargine-yfgn solution 100 units/ml, ten units at 9:00 p.m. Resident #4's DAR, dated 09/01/23 through 09/30/23, did not contain documentation the night time insulin had been administered six of thirteen times. A Physician Order, dated 09/18/23, documented to administer Insulin Aspart Injection Solution 100 units/ml as follows: If 151-200 give two units, 201-250 give four units, 251-300 give six units, 301-350 give eight units, 351 to 400 give 10 units, and if greater than 401 give twelve units recheck in two hours, if still above 400 call the doctor. Resident #4's DAR, dated 09/01/23 through 09/31/23, did not document a fingerstick blood sugar had been obtained nine of 49 opportunities. On 10/13/23 at 10:01 a.m., the DON was asked if Resident #4 had received their sliding scale and night time routing insulin. They stated, No, not according to the DAR. The DON was asked why there were blanks on the DAR where insulin should have been administered. They stated it may have been failure to document and if it is not documented they can't verify it had been done.

Based on record review and interview, the facility failed to ensure medications were available for administration for two (#3 and #4) of three sampled residents reviewed for pharmacy services. The DON stated there were 81 residents who resided in the facility. Findings: A Medication Ordering and Receiving from Pharmacy policy, revised 2018, read in part, .Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt . A Admission Criteria policy, revised March 2019, read in part .Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: medication orders, routine care orders . 1. Resident #3 had diagnoses which included ischemic colon, right colectomy, type two diabetes mellitus, and high blood pressure. They admitted to the facility on [DATE]. A hospital Discharge Summary, dated 05/19/23, documented Resident #3 had been ordered the following medications: a. Acetaminophen 500 mg tablet take two tablets every six hours as needed, b. Amlodipine five milligram tablet, take one tablet by mouth once daily, c. Arformoterol 15 mcg/2 ml nebulizer solution, inhale 2 mls by mouth two times a day, d. artificial tears, instill one drop into both eyes three times a day, e. Aspirin 81 mg, take one tablet by mouth one time a day, f. Dipole 0.05% cream, apply to affected area two times a day, g. bumetanide one mg tablet, take one tablet by mouth two times a day, h. calcium carbonate 500 mg chew tablet, take two tablets by mouth every two hours as needed, i. heparin 5000 unit/ml, inject one ml subcutaneously two times a day, j. hydralazine 10 mg tablet, take one tablet by mouth every eight hours, k. hydralazine 20 mg/ml injection, administer 0.5 ml by IV route every six hours as needed, l. Hydrocodone-acetaminophen 7.5-325 mg tablet, take one tablet by mouth every eight hours as needed, m. Hydrophor ointment, apply to affected area two times daily, n, Lactobacillus granules, take one packet by mouth three times a day, o. melatonin five mg, take one tablet by mouth at bedtime, p. Morphine four mg/ml injection, administer 0.5 ml by IV route every four hours as needed, q, Ondansetron four mg tablet, take one tablet by mouth every six hours as needed for nausea/vomiting, r. piperacilline-tazobactam 3.375 g in 0.9% NaCL IV 0.9% 50 ml, 3.375 g by IV route every eight hours, s. tramadol fifty mg tablet, take half a tablet by mouth every six hours as needed, and t. Novolog insulin, inject the following: 0-6 units subcutaneously three times daily with meals, less than 70 follow hypoglycemic guidelines, 70-180 administer two units, 221-260 administer three units, 261-300 administer four units, 301-350 administer five units, and Greater than 350 administer six units and notify the physician. A pharmacy packing slip, dated 05/22/23 at 1:59 a.m., documented Resident #3's medications were delivered to the facility. The following medications were delivered: a. Lactinex granules, b. saline mist, c. ondansetran 4 mg, d. amlodipine five mg tablets, e. arformoterol nebulizer treatment, f. polyvinyl eye drops, g. beta diproponate cream, h. heparin injection solution, i. hydralazine tablets, and j. aquaphor ointment. k. insulin flexpen Novolog, Resident #3's medication administration record, dated May 2023, documented Resident #3 missed the following routine medications: a. Aspirin 81 mg three of three doses, b. melatonin five mg two of two doses, c. Norvasc tablet five mg two of two doses, d. Bumex tablet one mg four of four doses, and e. Lactobacillus packet, six of six doses. Resident #3's treatment administration record, dated May 2023, documented Resident #3 missed the following routine medications: a. Brovana inhalation nebulizer treatment, four of four treatments, b. Diprolene cream 0.05 % four of four treatments, c. heparin injection solution 5000 units/ml four of four doses, d. Hydrophor ointment, four of four treatments, e. artificial tears, six of six doses, and f. saline nasal spray, 22 doses of 22 doses. g. piperacilline-tazobactam 3.375 g in 0.9% NaCL IV 0.9% 50 ml, 3.375 g by IV route every eight hours, for seven of seven doses. On 10/11/23 at 3:56 p.m., the DON was asked why Resident #3 had not received their medications as ordered. They stated they were unsure if the medications had been entered on 05/19/23 or 05/21/23. The DON stated the MAR did not document the resident had received their medications as ordered. A Health Status Note, dated 05/22/23 at 8:23 documented the Resident #3 arrived to the facility at 4:45 p.m., and a FSBS was obtained. 2. Resident #4 had diagnoses which included diabetes mellitus with ketoacidosis with coma, type two diabetes mellitus, and depression. An Admission Assessment, dated 05/25/23, documented Resident #4 had mild cognitive impairment, and required assistance of one staff for bed mobility, transfers, dressing, toilet use and hygiene. A Physician Order, dated 09/18/23, documented to administer Insulin Glargine-yfgn solution 100 units/ml, ten units at 9:00 p.m. An Administration Note, 09/18/2023 at 8:25 p.m., read in part, .new admit waiting on pharmacy to deliver meds . A DAR dated 09/01/23 through 09/31/23, did not contain documentation Resident #4 had been administered their 9:00 p.m. routine insulin as ordered on 09/18/23. A MAR,dated 09/18/23, did not contain documentation Resident #4 had been administered the following medications at 9:00 p.m. a. atorvastatin tablet 20 mg one tablet, b. Gabapentin 100 mg one tablet, c. Hydrocortisone 10 mg one tablet, d. Nortriptyline HCL 25 mg one tablet, e. Potassium 10 meq one tablet, and f. Sucralfate 1 gm one tablet. A pharmacy Packing Slip, dated 09/19/23 at 12:22 a.m., documented Resident #4's medications had been received. An Admission Summary note, dated 09/20/2023 6:28 a.m., documented the resident admitted on [DATE] at 6:00 p.m. It documented the physician had been notified and verified orders. The summary documented orders, tar, and mar had been faxed to the pharmacy and receipt confirmed by pharmacist. On 10/11/23 at 4:02 p.m., the DON was asked when Resident #4 arrived to the facility. They stated there should be a nurse note. They were asked why hadn't Resident #4's medications been administered to them on 09/18/23 at 9:00 p.m. They stated the medications did not arrive until 09/19/23 at midnight.

On 01/06/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure policy was followed regarding allegations of misappropriation of pain medication signed out and not documented as given. On 01/03/23, LPN #1 signed out four narcotic pills for Resident #36, these were not documented as administered on the MAR. Upon interview, Resident #36 stated they did not receive any pain medications on 01/03/23. On 01/04/23, LPN #1 was observed signing out two doses of a narcotic pain medication when the count sheet for Resident #36 count was determined to be inaccurate during shift change. Resident #36 was not in the building at this time. LPN #1 returned to work on 01/04/23 despite the policy stating the employee would be suspended pending an investigation. LPN #1 signed out narcotics for Resident #54 fourteen times from 10/13/22 through 01/03/23 that were not documented as administered to the resident on the MAR. The potential for residents to go with untreated pain is present. The potential for drug diversion is present due to 16 controlled medications awaiting destruction were observed in the DON's office. There was no documentation the medication counts were verified when the medications were received by the DON from staff. There is no way of verifying what was currently awaiting destruction was what had been received. On 01/06/23 at 2:54 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 01/06/23 at 3:18 p.m., the DON and the ADON were notified of the IJ situation related to the facility's failure to ensure the facility policy was followed regarding allegations of misappropriation of controlled medication when narcotic pain medications had been signed out and not documented as given. The Administrator was not present at the time of the initial notification. On 01/06/23 at 7:20 p.m. a plan of removal was submitted to the Oklahoma State Department of Health. On 01/09/23 at 10:38 a.m., an acceptable plan of removal was accepted by the Oklahoma State Department of Health. The Plan of removal documented: Plan of Removal related to the noncompliance that has caused or is likely to cause serious injury, serious harm, serious impairment, or death. Inservice will be conducted on the regulation stating 2 signatures are required for all controlled medications that are DC'd from a patient's MAR or if a patient is discharged from facility. Nurse turning controlled medications over to DON and DON will count together remaining controlled medications and will both sign controlled medication count log. DON will then lock controlled medications in locked drawer and will remain in locked cabinet inside a closet with a keyed lock until destroyed with consulting pharmacist. That will put all controlled medications awaiting destruction behind 2 locked doors all the time and 3 locked doors when office is not occupied by DON and ADON. Complete RN pain assessment on all admitted residents/patients. Inservice all employees on: 1. Signs and symptoms of pain 2. What to do if a patient/resident states they did not receive their pain medications. Inservice dated 01/06/23, no time, documented 62 staff members were in-serviced. It documented one staff member was on leave. Staff Inservice: Educated staff on the following: - Full Pain Assessment and follow-up - P.I.G. method - Properly documenting in EMAR at time of giving medication. - Misappropriation of resident/patient property (including all medications) and discipline action regarding a substantiated claim - General in-service regarding pain - Controlled medications for destruction must be counted with DON and signed by both parties. Resident/Patient Educated residents/patients on the following: - Full RN pain assessment completed on each resident/patient in facility - Interviewed each resident/patient (able to answer verbally) if they received medication when they asked for their medication - Asked if medication is effective when taken - Educated resident/patient how to report not getting PRN medication if they ask for it or not getting education in a timely manner - Pain interviews were completed and submitted for the 69 residents who remained in the facility. On 01/10/23 interviews were conducted with the nurses and medication aides across all shifts. The staff stated they had received in-service training related to misappropriation of medications and pain. The staff were able to identify what to do in the event a resident reported not receiving their pain medication. The facility completed audits on controlled medications awaiting destruction and ensured double signatures were in place verifying the count. Every resident in the facility was evaluated for pain. LPN #1 was suspended per Oklahoma State Reportable dated 01/09/23 at 2:47 p.m. On 01/10/23 at 8:27 a.m., the Administrator was notified the immediacy was lifted effective 01/06/23 at 7:30 p.m. The deficient practice remained at a potential for harm. Based on record review, observation, and interview, the facility failed to ensure the abuse policy was followed regarding the following: A. Allegations of misappropriation of controlled pain medications were signed out and not documented as administered for three (#36, 38 and #54) of five sampled residents reviewed for pain, and B. Controlled medication count records were verified by two licensed nurses when removed from circulation and placed into the drawer for controlled medications awaiting destruction for 10 (#11, 36, 43, 48, 66, 70, 127, 128,129, and #130) of 11 sampled residents reviewed for controlled medications awaiting destruction. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility. Findings: An Abuse Investigation and Reporting policy, revised 07/17, read in part, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property .shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management. Findings of abuse allegations will also be reported . If an incident or suspected incident of resident abuse .the Administrator will assign the investigation to an appropriate individual . The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation . The Administrator will ensure that any further potential abuse . is prevented . All alleged violations involving abuse .misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies . The State licensing/certification agency responsible for surveying/licensing the facility .The local/State Ombudsman .The Resident's Representative .Adult Protective Services .Law enforcement officials .The resident's Attending Physician .The facility Medical Director . An alleged violation of abuse .(including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than .Two (2) hours if the alleged violation involves abuse .or Twenty-four (24) hours if the alleged violation does not involve abuse . A Medication Storage in the Facility policy, effective date 04/18, read in part, .Medications included in the [agency name deleted] classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations . A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule [two], [three], [four] and [five] medications . At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented . Any discrepancy in controlled substance counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies . If a major discrepancy or pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately . The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered . Controlled substance inventory is regularly reconciled to the Medication Administration Record . 1. Resident #36 had diagnoses which included End-Stage Renal Disease and depression. Resident #36's Care Plan, date initiated 12/11/22, documented the resident was at risk for pain with interventions which included administering analgesia as per orders. Resident #36's Five Day Resident Assessment, dated 12/15/22, documented Resident #36's cognition was intact. It documented there was no evidence of an acute change in mental status from the resident's baseline. The areas of inattention, disorganized thinking, and altered level of consciousness were all documented as behavior not present. It documented none of the above for potential indicators of psychosis. It documented Resident #36 received PRN pain medication or was offered and declined. It documented the resident did have pain present, occasionally and rated the pain at an eight on a zero-ten scale. Resident #36's Physician Order, dated 12/29/22, documented the resident was to receive oxycodone-acetaminophen oral tablet 10-325 mg one tablet by mouth every four hours as needed for pain. It documented to give with oxycodone/acetaminophen 5/325mg to equal 15mg. Resident #36's Controlled Drug Receipt/Record/Disposition form, date received 12/23/22, documented oxycodone/acetaminophen tab 10/325mg take one tablet by mouth every four hours as needed. It documented one pill was signed out on the following dates/times: 12/29/22 at 11:30 a.m., 12/30/22 at midnight, 12/30/22 at 4:00 a.m., 01/03/23 at 6:30 a.m., 01/03/23 at 6:06 p.m. and one on 01/04/23 at 6:30 a.m. Resident #36's Physician Order, dated 12/29/22, documented the resident was to receive oxycodone-acetaminophen oral tablet 5/325 mg give five mg by mouth every four hours as needed for pain. It documented to give with oxycodone/acetaminophen 10/325 to equal 15mg. Resident #36's Controlled Drug Receipt/Record/Disposition form, date received 12/27/22, documented oxycodone/acetaminophen 5/325mg take one tablet by mouth (take with 10mg to equal 15mg) every four hours as needed. It documented one pill was signed out on the following dates/times: 12/29/22 at 11:30 a.m., 12/30/22 at midnight, 12/30/22 at 4:00 a.m., 01/03/23 at 6:30 a.m., 01/03/23 at 6:06 p.m. and one on 01/04/23 at 6:30 a.m. Resident #36's December 2022 MAR/TAR did not document the above medications had been administered to the resident. Resident #36's January 2023 MAR/TAR did not document the above medications had been administered to the resident. LPN #1's Employee Daily Punch Report, dated 01/03/23, documented a clock in time of 3:34 p.m. and a clock out time of 8:39 a.m. LPN #1's Employee Daily Punch Report, dated 01/04/23, documented a clock in time of 3:45 p.m. and a clock out time of 8:50 a.m. LPN #1 was not suspended per policy. An Employee Disciplinary Form for LPN #1, dated 01/04/23, read in part, .Employer Statement: Employee failed to document PRN med given in [electronic record system], and properly signed out on Narc at the time it was given . Actions for employee to correct: Employee will be in serviced on punch, initial, given method as well documentation. Employee will be put on PIP . Resident #36's State Reportable, transmission date 01/05/23 at 10:26 a.m., documented the incident report form was a Combined Initial and Final. It documented an investigation for misappropriation of resident property was conducted involving Resident #36 and LPN #1. It documented the incident date was 01/04/23. It documented description of incident: Percocet 10/325mg x1 and Percocet 5/325mg x1 documented on narcotic count log at 6:30 a.m. on 01/04/2023. Resident #36 was out of the facility at dialysis at the documented time. There was no documentation in the Please Include relevant resident history section. In Part C' of the report, it documented the facility interviewed Resident #36 at the time of returning to the facility. Resident stated that he received both percocet pills at 4:30 a.m. prior to leaving facility for dialysis. It documented the staff spoke with LPN #1 who admitted writing down the wrong administration time. It documented LPN #1 was educated and inserviced on using proper P.I.G. method for giving medications. It documented LPN #1 was given a final write up. It documented three residents who received PRN narcotics were interviewed and all stated they received their narcotics when they asked for them during this LPN's shift. It documented no misappropriation of resident's medication had been substantiated. It documented all allegations have been found to be unsubstantiated during the investigation. It documented all narcotics were accounted for. The facility failed to implement their Abuse Investigation and Reporting policy by failing to report an alleged violation of abuse within two hours per their policy. The report had not been filed within 24 hours of the DON being made aware of the alleged misappropriation of a controlled substance involving Resident #36 and LPN #1. The State reportable also failed to address the DON's conversation where Resident #36 reported to the DON they did not receive any pain medication on 01/03/23 and LPN #1 signed out two oxycodone 10/325mg and two oxycodone 5/325mg and did not document the medications as administered to Resident #36 on 01/03/23. LPN #1's Employee Daily Punch Report, dated 01/05/23, documented a clock in time of 3:12 p.m. and a clock out time of 8:21 a.m. LPN #1 was not suspended per policy. Resident #36's State Reportable, transmission date 01/06/23 at 7:53 p.m., documented the same front page State Reportable as above, except the Combined Initial and Final was marked through and Initial was selected. The words Initial Incident Report only .wrong box checked. This was signed by the DON. The facility failed to implement their Abuse Investigation and Reporting policy by failing to immediately suspending the employee who had been accused of resident misappropriation pending the outcome of the investigation and ensuring that any further potential abuse, neglect, exploitation or mistreatment was prevented. LPN #1 worked a double shift on 01/04/23 and 01/05/23 prior to the abuse investigation being complete. Resident #36's State Reportable, transmission date 01/09/23 at 2:47 p.m., documented Follow up Info with relevant resident history: Resident receives medication when asked. Resident stated they received medication prior to leaving for dialysis. No additional information related to the resident's medical history, cognitive status or diagnoses was included. It documented follow up information: Upon further Investigation of auditing narcotic sheets to EMAR, found discrepancies between the two. It documented the LPN was suspended for ongoing investigation, notified LPN Licensing Board. The Complaint Form attached to the State Reportable for Resident #36, dated 01/09/23 at 9:03 a.m., read in part, .[Nursing Board Name Deleted] .Nurse's Name: [LPN #1] .Please specify the length of time the nurse worked in your location .More than five years . Description of Incident: Nurse signed out narcotic at [7:00 a.m.] for a late documentation for a dose given at [6:30 a.m.] on 01/04/23 for [Resident #36] and admitted to another person that [they] gave [error] did in fact give dose at that time. {Resident #36] was not in facility at [6:30 a.m.], as [they] leave for dialysis at [4:30 a.m.] on MWF. Dose of narcotic was also not documented in EMAR. After investigation, there is a pattern with other residents narcotics being signed out but not documented in the EMAR . Did incident include Misconduct or Criminal Behavior .Yes: Theft (including drug diversion) .Did incident result in Patient Harm .Harm- An error occurred which caused a minor negative change in the patient's condition . The report was filled out by the DON. None of the above State Resportables documented Resident #36's family or legal representative was notified per facility policy. None of the above State Reportables documented the Ombudsman, Adult Protective Services, or Law inforcement officials were contacted per the facility Abuse Investigation and Reporting policy. On 01/04/23 at 6:28 a.m., LPN #1 was observed responding to a call light in room [ROOM NUMBER]. LPN #1 remained in the surveyor's line of sight from 6:28 a.m. through 7:20 a.m. On 01/04/23 at 7:20 a.m., LPN #1 was observed conducting a count of the controlled medications located on their medication cart with LPN #3. When they came to Resident #36's oxycodone/acetaminophen 10/325mg, LPN#1, who was reviewing the count book called out, 19, LPN #3 who was looking at the carded controlled medications on the cart, called out, 18. LPN #1 was observed signing out one pill on the count sheet and documented the time as 6:30 a.m. and changed to count to 18. Both nurses continued on with the count. The next card for Resident #36 was oxycodone/acetaminophen 5/325mg, LPN #1, who was reviewing the count book called out, 50. LPN #3 who was looking at the carded controlled medication called out, 49. Again, LPN #1 was observed signing out one pill and documented the time at 6:30 a.m. and changed the count to 49. LPN #1 was asked to explain signing out these meds for the time of 6:30 a.m. They stated, That's when I gave it. LPN #1 was asked to explain the reason they signed out both medications when the count was noted to be wrong. They stated, I forgot to sign it out. They stated, That's all I can tell you. LPN #1 was asked the policy for administering controlled medications. They stated, Punch, sign, give. They stated, That's how we're supposed to do it. Both LPN #1 and LPN#3 failed to follow the Medication Storage in the Facility policy because they failed to immediately report any discrepancy in controlled substance counts to the DON. LPN#1 was not observed administering any medications during the documented time. On 01/04/23 at 9:04 a.m., the DON was asked if Resident #36 had left the facility. She stated the resident had left for dialysis. She stated Resident #36 had left around 4:15 a.m. She was asked what the facility policy was for ensuring resident medications were not misappropriated. She stated staff counted before and after every shift. She was asked if LPN #1 had left for the day. She stated, Yes, I think so. The DON stated, if the count was wrong, no one would leave the shift. She stated staff should report it to the DON and nobody would leave until the count was resolved. She stated they would conduct an investigation. The DON stated, if they could not determine where the medication count was wrong, the staff would be sent home, law enforcement would be notified, and a full investigation would be completed. The DON stated whatever staff member was involved when it went missing, would immediately be placed on suspension, pending the investigation. She stated if she was not at the facility, staff were to notify the ADON and the Administrator had to be notified. She stated staff could not leave until someone was there to investigate. The DON was asked what the policy was for administering controlled substances to residents. She stated staff were to assess the resident first, check orders, administer the correct pain medication for the pain level, verify the count, sign it out on the count log, and document it was administered in the electronic medical record. She stated, It all should be done in real time. She was asked if staff counted off controlled substances at shift change. She stated, Yes. The DON was asked to review Resident #36's January 2023 MAR/TAR and identify the last time the resident received oxycodone 10-325mg. She stated, Monday the second at 4:45 in the morning. She was asked when Resident #36 last received their oxycodone 5/325mg. She stated, Sunday the first at [1:58 p.m.]. The DON was asked to review the count sheet for Resident #36's oxycodone 5/325mg. She was asked if one tablet was signed out at 6:30 a.m. on 01/03/23. She stated, Yes. She was asked if one tablet was signed out at 6:06 p.m. on 01/03/23. She stated, Yes ma'am. She was asked if one tablet was signed out at 6:30 a.m. on 01/04/23. She stated, Yes ma'am. The DON was asked who signed these medications out. She stated, Looks like LPN #1. She was asked to review the count sheet for oxycodone 10/325mg. She was asked if it documented one tablet was signed out at 6:30 a.m. and one tablet at 6:06 p.m. on 01/03/23, and one tablet signed out at 6:30 a.m. on 01/04/23. She stated, Yes. She was asked who signed the medications out. She stated, Looks like LPN #1. The DON then verified none of the doses were documented as administered in the resident's MAR/TAR. The DON was made aware of the above observations involving the narcotic count during shift change with LPN #1 and LPN #3. She was made aware LPN #1 was in direct view of the surveyor during the time she signed out the medications. The DON was asked if Resident #36's medication was misappropriated as it was signed out and not documented as given during the time LPN #1 was observed by the surveyor to not be administering medication and the resident being gone to dialysis during that time. The DON stated Resident #36 Wasn't even in the building. She stated she would conduct an investigation/State Reportable. On 01/04/23 at 9:32 a.m., the DON provided a note which documented a transport company name and the time of 4:30 a.m The DON stated Resident #36 had been picked up by the driver whose name was on the note, the company who picked them up, and the time was 4:30 today [01/04/23]. On 01/04/23 at 10:34 a.m., the DON sated she had started an investigation for the medication. She stated Resident #36 had returned from dialysis. On 01/04/23 at 10:40 a.m. the DON reported Resident #36 definitely received two pills today but the time was inaccurate. She stated for the 6:30 a.m. and 6:06 p.m. doses on 01/03/23, the resident did not get those pills. She stated the resident reported they only take those pain medications if they get out of bed or go to dialysis. The DON stated they were continuing their investigation. On 01/04/23 at 11:07 a.m., Resident #36 was asked if they received any pain medication for the day. They stated they did receive both the 10mg and 5mg of oxycodone before leaving for dialysis. They were asked if they received any pain medications yesterday, 01/03/23. They stated they did not take any pain pills yesterday. They stated they only took them when they went to dialysis or when they got up. On 01/04/23 at 6:45 p.m., the DON was asked if there was an update on the investigation. The DON stated they talked to Resident #36 and was informed by the resident the morning dose was received. She stated Resident #36 stated they had not received pain medication yesterday, 01/03/23. The DON stated LPN#1 had been interviewed and showed her a detailed note book paper they kept. She stated the note book paper had different notations of residents she had given medications to. The DON stated they notified the Administrator and was informed by the Administrator it was missed documentation. The DON stated, He said to not suspend [LPN #1] against my better judgement. She stated, After my full investigation [LPN#1] was in-serviced on the importance of documentation and late entry in our [eMAR]. The DON was asked what she meant by against her better judgement. The DON did not reply. The DON was asked for a copy of the investigation. The DON stated, I can get one together. 01/04/23 at 7:00 p.m., the Administrator stated, I don't know what you talking about missing meds. He stated, It's a documentation error. It is in there now. The Administrator was informed of the allegation of misappropriation that was reported to the DON. The Administrator stated the Resident #36 was forgetful and confused and was in the nursing home because of deficits. The Administrator asked, Do you know the resident's BIMS [cognition]. The Administrator was informed Resident #36's cognition was intact per the medical records. The Administrator was asked if an investigation should be conducted for an allegation of misappropriation. The Administrator stated, LPN #1 probably worked 16 hours and was tired. On 01/04/23 at 7:15 p.m., the DON provided copies of two hand written notes titled Investigation, dated 01/04/23, documented Resident #36 had reported receiving pain medication before dialysis on 01/04/23. It documented the time was inaccurate. It documented LPN #1 was out of the building for eight hours, the abuse investigation was complete. The DON and ADON signed the form. An untitled and undated in-service sheet with LPN #1's name printed with signature was received. A 22-page document, titled Institutional Drug Diversion presented by a consultant Consultant Pharmacist dated January 4 2023 was received. On 01/09/23 at 8:00 a.m., the DON was asked if Resident #36's narcotic count sheet documented one oxycodone 5/325 was signed out on 12/28/22 at 11:30 a.m. She stated, Yes. She was asked if the December MAR/TAR documented the medication was administered to the resident. She stated, I don't see that one. She was asked if the narcotic count sheet documented one oxycodone 5/325 was signed out on 12/30/22 at midnight and one at 4:00 a.m. She stated, Yes. The DON was asked if the same nurse signed out all three. She stated it looked like [LPN#2] signed out all three. She was asked if the resident's MAR/TAR documented the medications were administered to the resident. She stated, I don't see those as well. The DON was asked if Resident #36's narcotic count sheet for oxycodone 10/325mg documented one pill was signed out by the same nurse on 12/29/22 at 11:30 a.m., 12/30/22 at midnight, and 12/30/22 at 4:00 a.m. She stated, Yes. She was asked if the December 2022 MAR/TAR documented these medications were administered to the resident. She stated, I don't see them. On 01/09/23 at 8:48 a.m. the administrator provided copies of the state reportable dates 01/05/23 at 10:26 a.m. he explained the DON mismarked the incident report combined initial and final. He stated the facility resubmitted the incident as an Initial on 01/06/23 at 7:53 p.m. This was after the IJ was announced. He stated the investigation was ongoing because he had five days. 2. Resident #38 had diagnoses which included type two Diabetes Mellitus, lymphoma, major depressive disorder and pressure ulcer left heel. Resident #38's Physician Order, dated 05/26/22, documented Percocet 10/325 (oxycodone/acetaminophen) one tablet by mouth every four hours as needed for pain. Resident #38's Annual Resident Assessment, dated 12/18/22, documented the resident's cognition was intact, the resident received scheduled pain medication, was offered or received PRN pain medication and the resident had no pain present during the past five days. Resident #38's Controlled Drug Receipt/Record/Disposition form, date received 12/16/22, documented oxycodone/acetaminophen 10/325 mg take one tablet by mouth every four hours as needed. It documented one pill was signed out on the following dates/times: 12/20/22 at 6:00 p.m., 12/21/22 at 5:30 p.m., 12/22/22 at 9:00 p.m., 12/23/22 at 1:30 a.m., 12/24/22 at 7:00 a.m., 12/27/22 at 5:53 p.m., 12/28/22 at 7:30 p.m., 12/29/22 at 6:30 a.m., 12/29/22 at 7:40 p.m., 12/30/22 at 3:00 a.m., 12/30/22 at 8:33 a.m., 12/30/22 at 7:00 p.m., 01/02/23 at 6:00 p.m., and 01/03/23 at 5:00 p.m. Resident #38's December 2022 and January 2023 MAR/TAR did not document the above oxycodone/acetaminophen 10/325 were administered to the resident. On 01/09/23 at 12:57 p.m. the DON was interviewed, the Administrator was present during the interview. The DON was asked if Resident #38's narcotic count sheet documented one oxycodone 10/325mg was signed out on 01/02/23 at 6:00 p.m. She stated, Yes. She was asked if there was documentation this medication was administered to the resident on the MAR/TAR. She stated, There's not one documented on 01/02. The DON was asked if the narcotic count sheet documented one oxycodone 10/325mg was signed out on 01/03/23 at 5:00 p.m. She acknowledged it did. She was asked if there was documentation the medication was administered to the resident on the MAR/TAR. She stated, No ma'am. She was asked who signed out the medication. She stated it looked like LPN #1. The DON was asked to review Resident #38's count sheet and identify if one oxycodone 10/325mg was signed out at 3:00 a.m., 8:33 a.m. and 7:00 p.m. on 12/30/22 at 8:33 a.m., 6:30 a.m. and 7:40 p.m. on 12/29/22, 7:30 p.m. on 12/28/22, 5:53 p.m. on 12/27/22, 7:00 a.m. on 12/24/22, 1:30 a.m. on 12/23/22, 9:00 p.m. on 12/22/22, 5:30 p.m. on 12/21/22 and 6:00 p.m. on 12/20/22. She stated yes to all. She was asked if any of these medications were documented as administered on the resident's MAR/TAR. She stated, No. She was asked if the same nurse signed out all of these medications except the dose on 12/30/22 at 8:33 a.m. She stated, Yes. She was asked if she could identify who signed the medications out. She stated, LPN #1. 3. Resident #54 had diagnoses which included pain. Resident #54's Care Plan, revised 03/21/22 documented the resident had a risk for pain. Resident #54's Controlled Drug Receipt form, date received 10/07/22, documented on 10/13 the APAP/Codeine tab 300-30mg (Tylenol with Codeine #3) was signed out two different times. It documented 10/17/22, 10/18/22, 11/03/22, 11/17/22, 12/12/22, 12/15/22, 12/23/22, 12/26/22, 12/27/22, 12/29/22, 12/30/22, and 01/03/23 it was signed out one time each day. Resident #54's October 2022 MAR did not document the Resident had received the Tylenol with Codeine on 10/13/22, 10/17/22, and 10/18/22. Resident #54's November 2022 MAR did not document the Resident had received the Tylenol with Codeine on 11/03/22 and 11/17/22. Resident #54's December 2022 MAR did not document the Resident had received the Tylenol with Codeine on 12/12/22, 12/15/22, 12/23/22, 12/26/22 12/27/22, 12/29/22, and 12/30/22. Resident #54's January 2023 MAR did not document the Resident had received the Tylenol with Codeine on 01/03/23. On 01/06/23 at 11:55 a.m., the DON was asked to identify when Resident #54's Tylenol with Codeine had been signed out on the control drug sheet. She stated it had been signed out on 10/13/22, 10/17/22, 10/18/22, 11/03/22, 11/17/22, 12/12/22, 12/15/22, 12/23/22, 12/26/22, 12/27/22, 12/29/22, 12/30/22, and 01/03/23. They were asked to review Resident #54's MARs for October, November, December, and January. They stated no, it does not appear that they received Tylenol with Codeine on those dates. The DON was asked to identify the signature on the controlled drug receipt for the Tylenol with Codeine, they stated it was LPN # 1. 4. On 01/05/23 at 3:10 p.m., The DON was observed removing controlled medications awaiting destruction from the top drawer of a file cabinet located in the closet in the DON's office. She was asked to explain the process for when a controlled medication was discontinued or the resident discharged . She stated there would be a discontinue order.

Based on record review, observation and interview, the facility failed to ensure: a. Thorough skin assessment was conducted on readmission, b. Weekly skin monitoring and/or weekly wound assessments were conducted, c. The physician was notified timely of the new or worsening wound; and d. Adequate wound care/treatment was initiated timely for one (#11) of three sampled residents reviewed for pressure ulcers. This resulted in actual harm to Resident #11 who developed a pressure injury which worsened to an avoidable pressure injury with slough visible. The DON identified 71 residents who were at risk for skin breakdown. Findings: The facility's Wound Care policy, revised October 2010, read in parts, The purpose .is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order .Review the resident's care plan to assess for any special needs of the resident .The following information should be recorded in the resident's medical record .The type of wound care given .any changes in the resident's condition All assessment data .Report other information in accordance with facility policy and professional standards of practice. Resident #11 had diagnoses which include atrial fibrillation, chronic pain, seizures, obstructive sleep apnea, osteoporosis, hypertension, prostatic hyperplasia, muscle spasms, myocardial infarction, unsteadiness on feet, history of falling and physical debility. Resident #11's Care Plan, revised 11/28/22, documented the resident had impaired skin integrity with redness to abdomen folds, buttocks, groin and legs recurrent. Interventions to include document any abnormalities found, obtain appropriate treatment. Monitor skin weekly by charge nurse. Weekly skin assessments every Wednesday 7-3 shift. The care plan documented the resident has potential for pressure ulcer development. Interventions to include follow facility policies/protocols for the prevention/treatment of skin breakdown, frequent repositioning and consult with wound nurse on admit and as needed. Monitor/document and report any changes in skin status. Use draw sheet or lifting device to move resident. A Physician's Order, dated 12/5/22, documented to apply wound dressing external cream to buttocks topically every shift for discoloration. A Physician's Order, dated 12/21/22, documented to apply wound dressing external gel to left buttock topically every shift for skin scrape. Resident #11's discharge return anticipated assessment, dated 12/23/22, documented the resident's cognition was severely impaired, and they required extensive to total assistance of one to two staff members for all ADL care. The assessment documented resident was incontinent of bowel and bladder and had no skin concerns. Resident #11 readmitted to facility the on 01/01/23 after an eight day stay in hospital. A Progress Note, dated 01/01/23, read in part, Late Entry Resident return to facility alert and oriented x4, delivered by transporter in w/c. DX. UTI continue orders with orders noted. Scrotum swelling with open area to right buttocks and left thigh. There was no documentation the physician was notified of open area to right buttock and left thigh. There was no documentation of a treatment in place for open area to right buttock and to left thigh. There was no documentation admission assessments were completed upon Resident's #11 readmission to facility. There was no documentation a thorough skin evaluation was completed upon readmission. On 01/03/23 at 12:03 p.m., Resident #11 was observed during incontinent care provided by CNA #6 and CNA #7. A dime sized open area was observed to Resident #11's right upper buttock near the coccyx. A one-inch skin tear was observed with partial flap loss, and a red wound bed located to the left lower buttock closer to left thigh (gluteal fold). CNA #7 stated while wiping resident's buttocks, I need to tell wound nurse about tear on bottom. A Physician's Order, dated 01/03/23, documented to leave tabs open on brief every shift for scrotal edema. A Physician's Order, dated 01/03/23, documented to give Lasix 40 MG by mouth two times a day for edema. A Braden Scale for Predicting Pressure Ulcer Risk, dated 01/06/23, documented a score of 22 (No Risk). The document stated the resident had no impairment in sensory perception, rarely moist (skin is usually dry), walks frequently, had no limitation with mobility, nutrition adequate and no apparent problem with friction and shear. A Skin Only Evaluation, dated 01/06/23, documented, the resident had no current skin issues. On 01/10/23 at 10:16 a.m., LPN #5 was asked what was the protocol when there was a resident admitted or readmitted to the facility. LPN #5 stated the resident would be assessed, vitals taken, a complete skin assessment and review medications with physician. LPN #5 was asked what skin concerns did Resident #11 have. LPN #5 stated Resident #11 had no skin concerns that was reported and none had been seen in the chart. LPN #5 stated they had not seen the resident since the shift started. On 01/10/23 at 10:21 a.m., the DON was interviewed, the Administrator was present during the interview. The DON was asked what was the facility's protocol when a resident admitted or readmitted . The administrator stated, We go through the admission process whether it is an admit or readmit. He stated the staff were expected to follow the admission check list. The administrator asked the DON to retrieve a copy of the check list. The administrator stated the nurses had the check list. The administrator stated, The challenge is the lack of staff and use of agency. The administrator stated the DON and MDS coordinator would monitor what was done or incomplete for the admission/readmission. On 01/10/23 at 10:35 a.m., the administrator was asked to show the documentation where Resident's #11 readmission assessment was completed. The administrator stated, I will need to go look and will let you know. On 01/10/23 at 10:41 a.m., the Administrator provided a copy of a Skin Only Evaluation, dated 01/06/23 which documented No skin issues noted. The administrator stated, Readmission was not completed. On 01/10/23 at 11:35 a.m., the wound care nurse was asked what skin changes were currently being treated for Resident #11. The wound care nurse stated the resident returned from the hospital with scrotal edema and was currently being addressed with medication and scrotal cradle. The wound care nurse stated, It has improved by reduction in size. The wound care nurse was asked how often were skin assessments completed. The wound care nurse stated skin assessment were completed on admission/re-admission, weekly and as needed. The wound care nurse was asked if Resident #11 had any other skin concerns or changes. The wound care nurse reviewed the resident's EMAR and stated the resident had been getting Triad wound external cream since December for discoloration to buttocks. They stated, I do not know what the wound external gel is for, that left buttock skin tear was not on my radar. On 01/10/23 at 11:46 a.m., the wound care nurse was asked to accompany this surveyor to assess Resident's #11 skin. On 01/10/23 at 11:49 a.m., the wound care nurse and this surveyor entered Resident #11's room. The resident was informed by wound care nurse that they needed to conduct a full body skin assessment and Resident #11 agreed. They assessed the resident for pain, performed hand hygiene, donned gloves and proceeded to assist the resident with turning. The resident was turned to the left side, the wound care nurse removed white thick cream that was present on the resident's buttocks and coccyx. They measured the area and stated, small open area to right buttocks 0.2 cm by 6 cm by 0.1 cm. They observed an area to the right lower abdomen. The wound care nurse stated, I don't know what this is 2.1 cm. The wound care nurse observed a 4x4 adhesive border dressing on the left thigh (gluteal fold). The dressing was observed with discoloration visible from outside the dressing. They were observed removing dressing and stated I was not notified; I am sad and mad. They assessed the resident for pain and the resident denied. They described the area as 2.2 cm by 3 cm by 0.1 cm wound bed 50/50 slough and granulation with small amount of purple (half of a pencil eraser). They stated, The peri wound is normal pallor. They stated, I will notify my wound doctor. They stated, The wound doctor stages. On 01/10/23 at 12:12 p.m., the wound care nurse was informed the wound to the left thigh (gluteal fold) had worsened significantly since the observation made on 01/03/23. The wound nurse acknowledge that the wound had worsened, there was no treatment in place, the physician had not been notified, and no skin assessment had been completed on 01/01/23 when the resident readmitted .

Based on observation, interview and record review, it was determined the facility failed to ~ perform thorough skin assessments and obtain wound care orders for one (#2) and ~ intervene in the treatment of [REDACTED].#6) of five sampled residents who were reviewed for quality of care. Resident #2 had a trauma wound upon admission on 11/18/20. The staff failed to thoroughly assess the wound until 12/02/20 (a period of 14 days), when the wound was assessed to have 40% necrotic tissue and required debridement. The resident was seen by the surgeon on 12/03/20 and was diagnosed with [REDACTED]. He was treated in the emergency roiagnom on [DATE] for severe pain in the wound. He received orders for a stronger pain medication and to extend the antibiotic for three days. The facility identified 51 residents who resided in the facility. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Weekly skin assessments .Document all findings Obtain treatment orders if needed . The resident's care plan, dated 11/19/20, documented, .Focus .potential/actual impairment to skin integrity .Goal .maintain or develop clean and intact skin .Interventions .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . A skin evaluation, dated 11/19/20 at 8:30 a.m., documented, .Skin issue #1 .Surgical wound .Add another skin issue .No .General note .pain 3/10 in right leg, no [MEDICAL CONDITION] noted, pedal pulses palpable, surgical dressing to right lower leg, drsg is CDI .no new orders . A physician's progress note, dated 11/19/20, documented, .He .does have concerns about his right lower extremity that appears to have dependent [MEDICAL CONDITION] with saturated surgical dressing .Skin: Surgical DRSG that is saturated to RLE with bruising to digits .Instructed nursing to obtain f/u appointment with Orthopedic .and to obtain surgical dressing changes . A skin/wound note, dated 11/19/20 at 3:52 p.m., documented, .Drainage noted coming from surgical dressing, call placed to surgeon, spoke with surgeons nurse, Surgeon is out of the office today, nurse will get in contact with surgeon and then get in contact with this facility with new orders, this nurse passed along in report to nurse on floor . The clinical record did not include assessment of the skin covered with the surgical dressing on the right lower leg from admission on 11/18/20 until 12/02/20 at 6:11 p.m. A wound evaluation and management summary, dated 12/02/20, documented, .has a wound of the right anterior ankle for at least 13 days duration .Wound Size .7.3 x 4.1 x Not Measurable cm .Exudate .Light Serous .Thick adherent black necrotic tissue (eschar) .40% .Traumatic area over dorsal foot/anterior ankle necrosis debrided . This was the first assessment/documentation of the trauma wound on the right ankle. A skin evaluation, dated 12/02/20 at 6:11 p.m., documented, .Skin issue #1 .Other skin issue .Right anterior ankle .Length .7.3 .Width .4.1 .Wound bed .Necrotic .exudate .Serous .General note .rounds completed with (physician name deleted) .WOUND OF THE RIGHT, ANTERIOR ANKLE- 7.3x4.1, Exudate: Light serous, Thick adherent black necrotic tissue (eschar): 40 %, Skin: 60 %, no [MEDICAL CONDITION] .new orders received for xeroform and dry dressing 3x per week . A health status note, dated 12/03/20 at 6:55 p.m., documented, .Returned from Ortho apt .N/o rec start [MEDICATION NAME] 600mg BID x7 days . A physician's progress note, dated 12/07/20, documented, .complains of pain to the surgical site. In no acute distress .continue pain management for now . A health status note, dated 12/08/20 at 9:42 a.m., documented, .Resident complains of severe pain in wound .order to increase pain meds .administered but resident reports no relief .cont. to request to be sent out .order to send to ER . A physician's progress note, dated 12/11/20, documented, .had ER visit on 12/08/20 due to inadequate pain control and c/o dressing not being changed to right lower extremity .He showed picture of wound uncovered that appears to be healing well .Continue oral [MEDICATION NAME] 600mg PO BID until 12/13/20 . A wound evaluation and management summary, dated 12/16/20, documented, .wound of the right anterior ankle .Wound Size .7.3 x 4.1 x Not Measurable cm .Exudate .Light Serous .Thick adherent black necrotic tissue (eschar) .40% .Remove Necrotic Tissue and Establish the Margins of Viable Tissue . On 12/16/20 at 1:34 p.m., LPN #1 was asked if she was the wound care nurse. She stated yes, but she had been out of the facility from 11/23/20 through 12/07/20 and 12/09/20 through 12/13/20. She was asked who performed the job duties of the wound care nurse in her absence. She stated she did not know. She was asked if she had received report regarding wound care duties when she returned to work. She stated she had not received report. She stated she had to perform her own skin assessments upon her return and she was behind on skin assessments. LPN #1 was asked when they assessed a resident's skin upon admission. She stated the nursing staff did a comprehensive skin assessment within 24 hours of admission. She stated they referred the resident to the wound care physician as needed and the wound care physician would assess the wounds the following Wednesday when he made his weekly rounds. At 2:15 p.m., resident #2 was asked about the care he had received at the facility for the trauma wound on his right ankle. He stated he had repeatedly asked the staff to check his trauma wound on the right foot starting the day he was admitted . He stated, They wouldn't listen to me. He stated the staff told him they could not remove the surgical dressing because they did not have orders. He stated he had told the staff he had another wound on his ankle next to the surgical wound covered by the dressing. The resident stated the staff had not performed wound care on the trauma wound before the first assessment of the wound by the wound physician on 12/02/20. He provided a picture of the wound and stated, This is what is looked like when they took the dressing off that day (12/02/20), it was covered with black stuff and was infected. He stated he went to his orthopedic appointment on 12/03/20 and they put him on an antibiotic for an infection. At 5:40 p.m., the wound care physician was observed to provide wound care for the trauma wound. The wound care physician stated he had observed the wound one time prior to today. He stated he normally got involved with wounds after the initial nursing assessment if the staff felt like he needed to be included in the care. The physician measured the wound at 4.1 x 2.4 cm. The wound bed was observed to be red/pink with some yellow tissue and an area 0.5 cm of eschar. The wound physician surgically debrided the wound. The resident stated the swelling and pain had improved since the onset of the infection. On 12/17/20 at 12:43 p.m., the resident was asked if he had the trauma wound before he was admitted to the facility. He stated yes, the wound was a result of being ran over by a car on 11/07/20. He showed pictures of the wound taken when he had arrived at the ER the date of the accident and while he had a fixation device in place on the right ankle after the surgical repair of the fracture. The resident was asked when the staff had became aware of the trauma wound. The resident stated the wound physician was the first to assess the wound on 12/02/20. At 2:30 p.m., LPN #1 (wound care nurse) was asked what the procedure was for assessing the skin upon admission. She stated as the wound care nurse she assessed the skin within 24 hours of admission if it was a weekday and the following Monday if not. On the weekend the floor nurse assessed the skin within 24 hours and the wound nurse completed an assessment the following Monday. LPN #1 was asked when she first assessed the skin of resident #2. She stated she assessed the surgical dressing on 11/19/20, but she did not remove the dressing because she did not have orders to remove it. She stated surgical dressings usually remained in place until the resident had a follow-up with the surgeon. LPN #1 was asked what orders they had for skin assessments. She stated weekly skin assessments were ordered. She stated they had assessed the surgical dressing on 11/19/20. She stated the next skin assessment was completed on 12/02/20. She was asked if they had followed the physician order [REDACTED]. LPN #1 stated the resident's wounds were covered with a surgical dressing and they did not have orders to remove the dressing. She was asked who was responsible to contact the physician upon admission for wound care orders. She stated the floor nurse. She stated she had called the surgeon on 11/19/20 and his nurse called back on 11/20/20 and wanted to know about the drainage. She stated she had passed this information to the floor nurse and she (the wound nurse) was out of the facility starting 11/23/20. LPN #1 was asked how the floor nurse had followed up on obtaining wound care orders. She stated on 11/20/20 the resident complained of the wound draining and the nurse went in and talked to him and did not see a lot of drainage, the dressing was in place and a small spot of drainage on the bed, they had called the surgeon. LPN #1 stated the first observation of the trauma wound was on 12/02/20. She was asked how the wound progressed from admission to present. She stated on 12/02/20 the wound was 7.3 4.1 cm with thick adherent black necrotic tissue 40% and debridement was performed. LPN #1 was asked what complications had developed with the trauma wound. She stated the resident was placed on an antibiotic for a wound infection when he went to the doctor appointment on 12/03/20 and he had went to theER on [DATE] due to severe pain in the wound with orders to extend the antibiotic three days and a new order for pain medication. 2. Resident #6 had [DIAGNOSES REDACTED]. An alert note, dated 11/26/20 at 10:57 p.m., documented, .blood sugar 28. notified physician and received new orders recheck in 30 minutes. The clinical record did not include interventions taken to bring the resident's blood sugar up or a blood sugar reading 30 minutes later. The next blood sugar reading was documented on 11/27/20 at 6:00 a.m. (seven hours after the order was received to recheck the blood sugar in 30 minutes). A health status note, dated 11/30/20 at 3:55 a.m., documented, Res FSBS 24 and unresponsive. On call MD notified. Gave order to send res out to ER for further evaluation. EMSA called. The clinical record did not include interventions taken to bring the resident's blood sugar up. A hospital note, dated 11/30/20 at 7:48 a.m., documented, .diabetes mellitus type 2 poorly controlled .seen in the nursing home to have been confused and therefore was transferred to the emergency room .worked up and found to be hypoglycemic .was given an amp of D50 however patient continued to remain incoherent . On 12/17/20 at 1:14 p.m., LPN #3 was asked what they did if a resident's blood sugar dropped too low. She stated they notified the physician and gave them a tablet or something sweet to raise the blood sugar. She was asked what the resident's blood sugar was on 11/26/20 at 8:00 p.m. She stated it was documented 28. She was asked if the blood sugar was rechecked in 30 minutes per the physician's orders [REDACTED]. She stated the next blood sugar was documented the next morning. LPN #3 was asked what was documented for the resident's blood sugar on 11/30/20 at 3:55 a.m. She stated it was 24 and the resident was unresponsive. She was asked if the nurse had administered anything to bring the blood sugar up when the resident was unresponsive with a blood sugar of 24. She stated, It doesn't look like it.

Based on observation, interview and record review, it was determined the facility failed to ~ conduct thorough skin assessments and ~ provide assistance with activities of daily living for a dependent resident to aide in the prevention of the development of pressure ulcers for one (#5) of three sampled residents who were reviewed for wound care. Resident #5 was admitted to the facility on [DATE] without pressure ulcers. On 12/09/20 she had developed a stage III pressure ulcer on her left hip and an unstageable deep tissue injury on her left ischium. On 12/16/20 she had developed an unstageable deep tissue injury on her right upper, medial buttock and the unstageable deep tissue injury on her left ischium had deteriorated. The facility identified 51 residents who resided in the facility. Findings: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 11/23/20, documented, .Focus .has an ADL self-care performance deficit r/t COVID-19 .Goal .will improve current level of function in ADL performance .will be able to return to prior level of functioning .Interventions .BATHING/SHOWERING .Provide a sponge bath when a full bath or shower cannot be tolerated . Focus .has a potential for pressure ulcer development .Goal .will have intact skin, free of redness, blisters or discoloration .Interventions .Follow facility policies/protocols for the prevention/treatment of [REDACTED]. No skin assessment was conducted 11/20/20 through 11/22/20 (a period of three days). A nurse's note, dated 11/23/20, documented, Admit to facility SNF level of care .Dx include Covid+, HTN, GERD, DM, [MEDICAL CONDITION], Ascites, [MEDICAL CONDITION] of liver, and recent fx rt femur. A&Ox3 but forgetful at times. Incont of B&B and had episode of loose stool. Incont care to be provided by staff .No wounds noted to skin but redness to peri area and large bruises covering rt hip and thigh and also extending up into peri area. Denies pain at this time but yells out with incontinent care. Nonambulatory . A five day PPS assessment, dated 11/27/20, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene. She was totally dependent on two people for bathing. She was always incontinent of bowel and bladder. She was at risk for developing pressure ulcers. She did not have pressure ulcers. The ADL documentation, dated 11/21/20 through 11/30/20, documented the following: ~ Bathing: T-TH-SAT EVENINGS .a bath was not documented until 11/26/20 ~ Bed Mobility: eight of 30 missed opportunities ~ Personal Hygiene: eight of 30 missed opportunities ~ Toilet Use: eight of 30 missed opportunities ~ Offer fluids: eight of 30 missed opportunities ~ Eating: 10 of 30 missed opportunities ~ Amount Eaten: 10 of 30 missed opportunities A skin assessment was not conducted from 11/24/20 through 12/03/20 (a period of 10 days). A skin assessment, dated 12/04/20 at 9:50 p.m., documented, .Skin warm & dry, skin color WNL .turgor normal .Does resident have current skin issues .No .assessment completed no new skin breakdown noted . The ADL documentation, dated 12/01/20 through 12/09/20, documented the following: ~ Bed Mobility: five of 27 missed opportunities ~ Personal Hygiene: five of 27 missed opportunities ~ Toilet Use: five of 27 missed opportunities ~ Offer fluids: five of 18 missed opportunities ~ Eating: 10 of 27 missed opportunities ~ Amount Eaten: 10 of 27 missed opportunities A wound physician's note, dated 12/09/20, documented, .stage 3 pressure wound of the left hip for at least 15 days duration .(Site 1) .Wound Size .3.2 x 3.9 x 0.2 cm .Exudate .Light Serous .DRESSING TREATMENT PLAN .Zinc ointment apply once daily and as needed for soiling for 30 days .Recommendations .Limit sitting to 60 minutes; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able . (Site 2) .UNSTAGEABLE DTI OF THE LEFT ISCHIUM .Wound Size .2.2 x 1.7 x Not Measurable cm .Periwound radius .Surrounding DTI (Purple/Maroon) .Exudate .Moderate Serous .DRESSING TREATMENT PLAN .Zinc ointment apply once daily and as needed for soiling for 30 days . FACTORS COMPLICATING WOUND HEALING .[MEDICAL CONDITION] .Non-adherence to plan of care .risks and benefits explained to the patient .Reviewed nutrition, offloading, repositioning, safety, dressing selection, offloading surface options. Patient appears amendable to offload and states she has not today .patient's care was discussed with another health care provider Nursing Staff Member during this visit . A wound physician's note, dated 12/16/20, documented, .(Site 1) STAGE 3 PRESSURE WOUND OF THE LEFT HIP .Wound Size .2.3 x 3.3 x 0.2 cm .Exudate .Light Serous .DRESSING TREATMENT PLAN .Zinc ointment apply once daily and as needed for soiling for 23 days .Recommendations .Limit sitting to 60 minutes; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Roho mattress . (Site 2) .UNSTAGEABLE DTI OF THE LEFT ISCHIUM .Wound Size .2.2 x 3.1 x Not Measurable cm .Periwound radius .Surrounding DTI (Purple/Maroon) .Exudate .Moderate Serous .Wound progress .Deteriorated .DRESSING TREATMENT PLAN .Zinc ointment apply once daily and as needed for soiling for 23 days . (Site 3) .UNSTAGEABLE DTI OF THE RIGHT, UPPER, MEDIAL BUTTOCK .Etiology .Pressure .Wound Size .0.8 x 1.2 x Not Measurable cm .Exudate .Light Serous .DRESSING TREATMENT PLAN .House barrier cream apply Q-shift (3xday) and as needed for soiling for 30 days .Recommendations .Turn side to side and front to back in bed every 1-2 hours if able . On 12/16/20 at 1:34 p.m., LPN #1 was asked if she was the wound care nurse. She stated yes, but she had been out of the facility from 11/23/20 through 12/07/20 and 12/09/20 through 12/13/20. She was asked who performed the job duties of the wound care nurse in her absence. She stated she did not know. She was asked if she had received report regarding wound care duties when she returned to work. She stated she had not received report. She stated she had to perform her own skin assessments upon her return and she was behind on skin assessments. LPN #1 was asked when they assessed a resident's skin upon admission. She stated the nursing staff did a comprehensive skin assessment within 24 hours of admission. She stated they referred the resident to the wound care physician as needed and the wound care physician would assess the wounds the following Wednesday when he made his weekly rounds. At 5:10 p.m., the resident was observed laying in her bed. The wound care physician and wound care nurse were observed to assess the resident's wounds. The resident's brief was soiled with watery stool and urine. The wound care nurse and the CNA performed incontinent care. The brief and the incontinent pad were saturated. The physician asked the resident how long she had been wet and soiled. The resident stated it had not been very long. The wound care physician assessed the pressure ulcers on the left hip and ischium. He stated the wound on the left ischium had gotten larger and the resident had a new deep tissue injury on her right buttock. He stated the resident had bruising in the areas which indicated she had too much pressure for too long in one spot. The wound physician recommended a new mattress for the bed and good nutrition. On 12/17/20 at 1:13 p.m., CNA #4 was asked how much assistance the resident required with incontinent care. She stated she required total assistance of two people. She was asked how often they provided incontinent care and where it was documented. She stated at least every two hours and they documented the care in the computer. CNA #4 was asked if the resident required assistance with repositioning. She stated the resident could pull herself up some, but she needed assistance. She was asked how often they assisted her to reposition. She stated they were supposed to assist her every two hours, but sometimes they got behind. CNA #4 was asked how much assistance the resident required with bathing. She stated the resident required total assistance with bathing and they were supposed to bathe her three days a week. She was asked how soon after admission a resident was supposed to receive a bath. She stated they had to wait on PT to evaluate the resident before they could move a resident from the bed, but they could give a bed bath anytime. At 1:35 p.m., in the presence of the administrator, LPN #1 (wound nurse) was asked how much assistance the resident required with ADL's. She stated one to two people, depending on if she was being transferred. She was asked how the nursing staff monitored to ensure the dependent residents received care with ADL's. She stated they looked in the computer to see if any tasks were red. LPN #1 was asked what the resident's skin condition was on admit. She stated the resident was admitted on [DATE] and there was no skin assessment documented until 11/23/20, at which time it was documented no wounds noted, redness peri area, bruising covering right hip and thigh extending to the peri area. She stated it was documented in a skin assessment on 12/04/20 the resident's skin was clean, dry and intact and no new skin breakdown was noted. LPN #1 stated the first skin assessment she had completed was on 12/09/20 when she had made rounds with the wound physician and the resident had a new stage three pressure ulcer on the left hip and a deep tissue injury to the left ischium. She stated she was out of the facility before 12/09/20 and she could not get any report from the staff on how the pressure wounds started. She was asked if the resident was high risk for skin breakdown. She stated yes, the resident was incontinent of bowel and bladder and unable to move a lot on her own. LPN #1 was asked how many pressure wounds the resident had. She stated three. She was asked how they had progressed. She stated they were worse. She was asked to describe the wounds as of 12/16/20 when she made rounds with the wound physician. She stated the stage three on the left hip was 2.3 by 3.3 by 0.2 centimeters and improved, the unstageable deep tissue injury on the left ischium was 2.2 by 3.1 purple and deteriorated and the new unstageable deep tissue injury on the right upper medial buttock was 0.8 by 1.2. She stated all three areas had developed since the resident was admitted on [DATE]. LPN #1 was asked if the facility had followed their protocol to conduct a weekly skin assessment. She stated it was not documented. She was asked when the first skin assessment was documented. She stated 11/23/20. She was asked who was responsible to conduct skin assessments in her absence. She stated the floor nurse. LPN #1 was asked when the resident received her first bath. She stated it was documented on 11/26/20. She was asked if the days she had not received a bath after admission on 11/20/20 were missed opportunities for the staff to assess her skin. She stated yes. LPN #1 was asked if incontinent care had been completed every shift since admission. She stated it was not documented. She was asked if assistance with repositioning had been completed every shift since admission. She stated it was not documented. LPN #1 was asked if offering fluids, assistance with meals and meal percentages had been completed every shift. She stated they were not documented. She was asked how the staff would know how well the resident had eaten if they were not monitoring her meal intake. She stated they would not know. She was asked if the plan of care had been followed for this resident. She stated, No, if it's not documented.

Based on interview and record review, it was determined the facility failed to assess, monitor and intervene in a timely manner related to pain rated an 8 for one (#1) of three sampled residents who were reviewed for pain management. Resident #1 rated his pain an 8 on a scale of 01-10 upon admission. The staff did not administer pain medication for 26 hours and 24 minutes. The resident called his caregiver during that night to report he was in tremendous pain and the staff had not administered pain medication and he could not sleep due to the pain. The facility identified 49 residents who received pain medication. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Screening, dated 05/06/19 at 7:01 p.m., documented, .BLE, gen pain .Rating .8 .pt is having pain, no pain meds ordered in discharge. Will address and order pain med . The Pain Tool, dated 05/06/19 at 7:02 p.m., documented, .BLE pain, dull, constant .CURRENT PAIN LEVEL .6 .What makes the pain better? medication, position change .What makes the pain worse? some positions, dependent position, activity .EFFECTS OF PAIN ON ADLS .Sleep and rest Yes .Social activities Yes .Appetite Yes .Physical activity and mobility Yes .Describe all methods of alleviating pain and their effectiveness: medication, ordered position change . Review of the clinical record from 05/06/19 at 7:02 p.m. through 05/07/19 at 9:25 p.m. revealed the resident had not received any pain medication. There was no documentation related to the assessment of his pain since the initial assessment upon admission on 05/06/19 at 7:01 p.m. (a time period of 26 hours and 24 minutes). A physician's orders [REDACTED].[MEDICATION NAME] .5-325 MG .1 .every 4 hours as needed for Pain . A pharmacy packing slip, dated 05/07/19, documented the facility had received the [MEDICATION NAME] on this date. The Controlled Drug Receipt record, dated 05/07/19 at 9:26 p.m., documented the resident had received [MEDICATION NAME] 5/325 mg. On 05/28/19 at 3:18 p.m., the DON was asked how often they assessed a resident's pain. She stated every time they administered pain medication. She was asked when they administered pain medication when a resident had pain. She stated on the day a resident was admitted they had to wait on their pharmacy to deliver the medication. She stated, Our pharmacy turn around is four hours. She was asked if they had pharmacy services to ensure they had access to medications in a timely manner. She stated, No, they (the pharmacy) are in Tulsa. The DON was asked if the resident had exhibited pain upon admission on 05/06/19 at 7:01 p.m. She stated he had general pain BLE rated 8. She stated it was documented no pain meds ordered upon D/C, will address and order pain med. She was asked when the resident had received his first dose of pain medication. She stated the pain medication had been ordered on [DATE] at 5:30 p.m. and the first dose had been administered on 05/07/19 at 9:26 p.m. The DON was asked how often the staff had assessed the resident's pain during the time period of 05/06/19 at 7:02 p.m. through 05/07/19 at 9:25 p.m. She stated, Nothing consistent. On 05/29/19 at 11:59 a.m., a resident's representative was asked how the resident's pain was on the day of admission. He stated the resident was in tremendous pain the first night. He stated, He called me saying he was hurting real bad and they weren't giving him anything. The resident representative stated, He said he couldn't sleep at all because of the pain.

Based on interview and record review, it was determined the facility failed to: ~ assess, monitor and intervene related to abdominal distention for one (#3) of three sampled residents who were reviewed for the use of a urinary catheter; ~ assess, monitor and intervene in a timely manner when one (#3) of one sampled resident was experiencing a change in condition; ~ provide bladder irrigations as ordered by the physician for one (#1) of three sampled residents who were reviewed for the use of a urinary catheter; and ~ follow-up with the resident's physician on abnormal urine culture results with the growth [MEDICAL CONDITION] for one (#1) of three sampled residents who were reviewed for the use of a urinary catheter. Resident #3 had complained related to her bladder feeling full. The residents abdomen was assessed to be distended. The staff had not intervened until seven days later. The resident experienced a change in conditon on 12/22/18 - 12/24/18. The resident was lethargic with unclear speech on 12/24/18 at 1:55 a.m., and was not assessed again for 3 hours and 56 minutes when she was found to have shallow breathing, was lethargic, not opening her eyes fully with a temperature of 103.2 degrees Fahrenheit. The resident was unresponsive to verbal and painful stimuli. She was transferred and admitted to the hospital with [REDACTED]. The facility identified one resident who had a urinary catheter. Findings: 1. Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].every 2 weeks on Thu .Start Date 12/13/19 . A physician's orders [REDACTED].every Tuesday . Review of the clinical record from 12/09/18 through 12/15/18, revealed no documentation of the resident's weight. A nurse's note, dated 12/15/18 at 12:59 a.m., documented, .Pt with distention in abdomen during first assessment this shift. Pt stated that her bladder was full, although this felt as though it was too high to be her bladder. This nurse returned to bedside to eval at this time, and distention is still present .Will report to On-Call for further direction. A communication with physician note, dated 12/15/18 at 1:06 a.m., documented, .Situation: Pt with distention in abdomen during first assessment this shift. Pt stated that her bladder was full, although this felt as though it was too high to be her bladder. This nurse returned to bedside to eval at this time, and distention is still present .Recommendations: Unable to reach on-call physician at this time. Review of the clinical record revealed no documentation the physician had been notified related to the assessment of abdominal distention on 12/15/18. Review of the clinical record from 12/16/18 through 12/18/18 (Sunday through Tuesday), revealed no documentation of the resident's weight. A CMA note, dated 12/21/18 at 10:50 a.m., documented, .low b/p 87/44, nurse aware . Review of the clinical record revealed no other documentation related to the resident's blood pressure being low on 12/21/18. It was not documented the physician had been notified of the low blood pressure. A Lab Note, dated 12/22/18 at 10:00 p.m., documented, .Contacted lab for copies of recent lab work drawn 12/20/18 . Review of the clinical record from 12/15/18 at 1:07 a.m. through 12/22/18 at 10:34 p.m. (a seven day time span), revealed no other documentation related to the resident's complaint of her bladder being full or the assessment of abdominal distention that had occurred on 12/15/18. It was not documented the physician had been notified. A communication with physician note, dated 12/22/18 at 10:34 p.m., documented, .change of condition pt lethargic .situation of abdomen distention .Recommendations: straight cath now, report amount . A communication with physician note, dated 12/22/18 at 11:03 p.m., documented, .Pt has had multiple watery stools during the past two hours .12/7 Lab work: BUN 8, Creat 0.48, Hgb 9.7, K 3.6. 12/20 Lab work: BUN 68, Creat 1.38, Hgb 8.4, K 5.2 .Assessment (RN)/Appearance (LPN): Pt lethargic but able to respond appropriately to questions .Abd distended in LLQ, LUQ, possibly bladder. Pt reported pain and tenderness 12/21 night shift but reports no tenderness with palpation 12/22. Unable to determine if pt has urinated with BMs. Recommendations: .Requested one time straight cath to assess bladder condition. An Order Note, dated 12/22/19 at 11:29 p.m., documented, .Orders to place foley cath d/t urine retention for one week and reassess need in one week. A communication with physician note, dated 12/23/18 at 4:35 a.m., documented, .reporting update .pt without any output since we took 2300cc out of bladder via straight cath, then placed foley .Pt remains very lethargic. B/P 96/44 .T 99.0 .Recommendations: PIV 1L NS @ 65/hr. A Health Status Note, dated 12/23/18 at 12:00 p.m., documented, .IV normal saline infusing .T 99.6 BP-140/64 .F/C in place .dark yellow urine in drain bag and lighter yellow urine in tubing .new order Tylenol 625mg Q6hours as needed for elevated temp . Review of the clinical record revealed no documentation the resident had received the Tylenol as ordered for an elevated temperature. A Health Status Note, dated 12/23/18 at 9:33 p.m., documented, Pt resting on her bed family on her bedside,eyes closed but alert and responding,no distress noted .notified family that the patient had been repeating that she wants to (sic) home . An Order Note, dated 12/24/18 at 1:55 a.m., documented, CBC and CMP lab results texed (sic) to Doctor.pt lethargic and dowsy (sic),speech not clear .order received for 20meq one tablet daily for 3days. The next note was A Health Status Note, dated 12/24/18 at 5:51 a.m., documented, .routine check .found the pt breathing shallow,lethargic,and not opening her eyes fully .called the shift supervisor .T 103.2,doctor and family notified .Pt is sent to ER via EMSA. A Health Status Note, dated 12/24/18 at 7:13 p.m., documented, .pt. was non responsive to verbal and painful stimuli. VS were as followed: 127, 123/57, 88% (@4L via NC), 16, and BS 395 .temp up to 103.5(temporal) .EMSA called .left facility @0645. An Emergency Department note, dated 12/24/18 at 8:27 a.m., documented, .Preliminary diagnosis .Urinary tract infection .Sepsis, unspecified organism, Altered mental status .Fever .Bed requested for Intensive Care Unit .Condition is Critical .EMS states that the patient was last seen normal at 2300 last night, drowsy around 0300, and unresponsive this morning .Exam: 12/24 08:05 .is lethargic .febrile . A History and Physical and Discharge summary, dated 12/24/18, documented, .she was found to be in septic shock 2/2 CAUTI likely and possible RLL HCAP. She was given [MEDICATION NAME] in ED and moved to ICU where she was not responding to fluids to required escalation to [MEDICATION NAME] and added [MEDICATION NAME] .family requested she be put on comfort care as apparently her health and mental status had been declining for few months .Death pronounced .at 1533 . On 04/30/19 at 2:10 p.m., the DON was asked what the staff would do if a resident complained of their bladder being full and the nurse assessed abdominal distention. She stated they would notify the physician, try to obtain orders, and assist the resident to void if possible. She was asked when they would take action. She stated upon the resident's complaint and the observation. The DON was asked what orders they had related to obtaining the resident's weight. She stated they had an order dated 12/11/18 to weigh weekly x four weeks every Tuesday. She was asked when the staff had obtained the resident's weight. She stated they had documented a weight on 12/19/18. The DON was asked what the resident had complained about on 12/15/18. She stated, Her bladder was full. She was asked what the staff had done related to the resident's complaint. She stated the nurse did an evaluation and she noted distention present. She stated, I don't see anything else done. The DON was asked if I & O had been tracked for this resident. She stated she did not see any orders for I & O. She was asked if the resident had been weighed when she complained about her bladder being full. She stated they did not have documentation for a weight on 12/15/18. The DON was asked if the physician had been notified related to the abdominal distention on 12/15/18. She stated, Not according to the note. The DON was asked what the status of the resident was after the complaint of her bladder being full on 12/15/18. She stated she rolled out of her bed that same day. She stated there was no other documentation until 12/20/18. The DON was asked what the resident's blood pressure was on 12/21/18. She stated, 87/44. She was asked what the staff had done related to the low blood pressure. She stated, She (the CMA) made the nurse aware and that's about it. The DON was asked when the lab results, which had been drawn on 12/20/18, had been received by the staff. She stated on 12/22/18. She was asked what the lab results showed. She stated the Hgb was low and the BUN, creatinine and potassium were abnormal. The DON was asked what the resident's condition was on 12/22/18 at 10:34 p.m. She stated she was lethargic, abdomen was distended and they had an order to straight cath now and report amount. The DON was asked what the result of the straight cath procedure was. She stated, 2300 cc output. The DON was asked why the resident had not been catheterized until seven days after she had complained of her bladder being full and the nurse had assessed abdominal distention. She stated she would not speculate. She was asked what possible complications could result from [MEDICAL CONDITION] not being treated. She stated, Fluid overload, labs out of wack, confusion and lethargic. She was asked what possible complications could arise from the urine sitting in the bladder. She stated, Infection, [MEDICAL CONDITION]. The DON was asked how much urine had been removed during the straight catheterization procedure. She stated 2300 cc. She was asked what the appearance of the urine was. She stated, It is not indicated. She was asked what the standard of care was for the amount of urine to remove from the bladder at one time. She stated, No more than 300 cc. The DON was asked if I & O and weights had been monitored for the resident since 12/15/18. She stated, No. The DON was asked what the resident's condition was on 12/23/18 at 4:35 a.m. She stated, Without output since the straight cath, remains very lethargic, 96/44, 99.0. The DON was asked what the resident's temperature and condition was on 12/24/18 at 12:00 p.m. She stated the temperature was 99.6 and the urine was dark yellow, there was a new order for Tylenol for an elevated temp. She was asked if the resident had ever received the Tylenol for an elevated temperature. She stated, I'm not finding that she received Tylenol. The DON was asked what the resident's condition was on 12/24/18 at 1:55 a.m. She stated she was lethargic and drowsy and her speech was not clear. She was asked if her condition was declining. She stated, Yes. The DON was asked when the staff had observed the resident after 1:55 a.m. She stated, At 5:51 a.m. She was asked what the resident's condition was at that time. She stated she had shallow breathing, lethargic and not opening her eyes. The DON was asked if the staff had intervened in a timely manner, on 12/15/18, when the resident had complained of a full bladder and the nurse had assessed abdominal distention. She stated, No. 2. Resident #1 was admitted with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].IRRIGATE BLADDER WITH HYDROGEN PEROXIDE 60ML.DILUTE WITH NORMAL SALINE @ QHS every night shift . The care plan, revised 10/31/18, documented, .Focus .The resident has an Indwelling Suprapubic catheter r/t [MEDICAL CONDITION] bladder. Irrigate with 60ml Hydrogen Peroxide and dilute with NS at HS .Goal .The resident will be/remain free from catheter-related trauma through review date .Interventions .SP catheter care as ordered . There was no documentation on the resident's TARs, dated 06/2018 through 04/2019, that irrigation of the suprapubic catheter with hydrogen peroxide and diluted with normal saline at bedtime had been completed. A physician's orders [REDACTED]. A nurse's note, dated 02/09/19 at 12:16 a.m., documented, .Res with order for UA with C&S. Order placed in and called in to (lab name deleted) . A lab report, dated 02/12/19, documented the resident's urine culture was positive [MEDICAL CONDITION]. A nurse's note, dated 02/12/19 at 8:05 p.m., documented, .UA with C&S lab results. Dr. (physician's name deleted) here in facility this evening and saw lab results. Dr. (physician's name deleted) gave the order to repeat UA with C&S and fax current lab results to urologist and nephrologist. UA faxed over respectively. New UA order put in place and called in to (lab name deleted) . A nurse's note, dated 02/12/19 at 10:25 p.m., documented, .Urine specimen collected .Awaiting for lab to come and pick up specimen . A lab report, dated 02/14/19, documented the specimen was collected on 02/12/19 at 10:00 p.m. The report documented, .Test: URINALYSIS MICROSCOPIC (Final Result) .RBC UA >100 (Abnormal) .WBC UA >100 (Abnormal) . A lab report, dated 02/14/19, documented the specimen was collected on 02/12/19 at 10:00 p.m. The report documented , .Test: URINALYSIS DIPSTICK AUT (final result) .Clarity UA Turbid (Abnormal) .Blood UA 2+ (Abnormal) .Protein UA 2+ (Abnormal) .Leukocyte UA 2+ (Abnormal) . A nurse's note, dated 02/15/19 at 11:34 p.m., documented .Res' preliminary UA results back. Dr. (physician's name deleted) here in facility this evening and notified about lab results. No N/O at this time. C&S pending . A lab report, dated 02/16/19, documented the specimen was collected on 02/13/19 at 10:00 p.m. The report documented, .CULTURE, URINE .50,000 - 100,000 CFU/[MEDICAL CONDITION]- [MEDICAL CONDITION] resistant Staph aureus . A handwritten note on the form documented, .Send to urologist .faxed over urologist & Neurologist 2/17 (or 18. The number had been written over)/19 . There was no nurse's note corresponding to the lab report. A review of the record revealed no documentation of a response from the resident's physician, any new physician's orders [REDACTED]. On 04/30/19 at 4:37 p.m., LPN #1 was asked who was responsible for providing catheter care. She stated, The nurses. She was asked if there were any residents on Hall 200 with a catheter. She stated, Yes, (resident #1, name deleted). LPN #1 was asked to review the orders for the resident and state what was included in his catheter care. She reviewed the resident's TAR and stated, Check if in place; can replace if needed; has [MEDICAL CONDITION] bladder; monitor I and O; cleanse with soap and water. LPN #1 was asked if there was an order to irrigate the catheter with hydrogen peroxide diluted with normal saline. She stated, No. She was asked to review the physician's orders [REDACTED]. Dilute with saline at bedtime every night shift. LPN #1 was asked if the order was not included in the PCC TAR. She stated, The order was not put in correctly. It is not showing up on the TAR. LPN #1 was asked if based on what she was reviewing, had the resident received the ordered treatments. She stated, No. At 4:57 p.m., the DON was asked who was responsible for catheter care. She stated, The charge nurse. She was asked if there was a resident on Hall 200 who had a catheter. She stated, Yes, Mr. (resident #1's name deleted.) The DON was asked to review the physician's orders [REDACTED]. The DON was asked how it was ensured that physician orders [REDACTED]. The DON was asked if the order to irrigate the catheter with hydrogen peroxide and normal saline was on the TAR. She stated, It is not. She was asked how she would know it was not being done. She stated, We would not be able to confirm that. The DON was asked if the resident had been receiving his irrigation as ordered by his physician. She stated, I can not confirm that. On 05/01/19 at 12:25 p.m., the DON was asked if a UA had been ordered for resident #1 on 02/09/19. She stated, Yes. She was asked when the results had been received. She stated, 2/10/19. The DON was asked what the results indicated. She stated,[MEDICAL CONDITION]. She was asked if the physician had been notified. She stated, (Yes) According to the note. She was asked what the physician had done. She stated, Ordered a repeat UA with a culture and sensitivity. She was asked if there had been any orders for treatment. She stated, No. The DON was asked if the repeat UA had been completed. She stated, Yes, on 2/12. She was asked when the results had been received. She stated, On 2/14/19. The DON was asked what the UA results had indicated. She stated, Abnormalities. She was asked to specify what they were. She stated, Turbidity, blood, positive protein and leukocytes. The DON was asked if the physician had been notified of the results. She stated, (Yes) According to the note, with no new orders. The DON was asked if there was any additional documentation regarding the UA. She stated, We have a culture and sensitivity dated 2/16/19 with [MEDICAL CONDITION]. She was asked if the physician had been notified. She stated there was no nurse's note but the results form documented the results had been faxed to the urologist. The DON was asked if the urologist had followed up with any new orders. She stated, There is no note indicating and no new orders. She was asked if there had been any additional follow-up by the facility. She stated, No. The DON was asked who monitored lab work to ensure that appropriate follow-up was done. She stated, The charge nurse and nursing management. She was asked if this report should have had follow-up. She stated, Yes. The DON was asked if the standard of care had been followed for this resident. She stated, No, it was not.

On 11/17/16 at 4:45 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to thoroughly investigate, report and protect residents from abuse. At 4:50 p.m., the director of nursing (DON) was informed of the IJ situation related to the facility's failure to investigate, report and protect residents from abuse. The DON verbalized understanding. On 11/18/16 at 2:15 p.m., the acting administrator and the DON provided the survey team with an acceptable plan of removal. The plan of removal documented the following: .Action Plan: By 21:00 (9:00 p.m.) on 11/17/16 the facility policies on abuse and reporting abuse will be reviewed to ensure that they contain the following elements to protect residents: 1) Reporting procedures 2) Investigative procedures 3) Family/physician notification 4) Notification to authorities if a crime is suspected 5) Physical examinations 6) Immediate protective measures to ensure resident safety during investigation 7) Ongoing Staff Training 8) Abuse identification Once the internal policies and procedures have been updated and verified to contain the above elements, all facility staff will be inserviced by 5pm by the DON/Administrator on 11/18/16 on the approved policies to ensure a thorough understanding of the facility policies and procedures on abuse. Also, by 5pm on 11/18/16, all residents in the building will be interviewed with the new Resident Safe Survey form to ensure that no other allegations of abuse have occurred . A monitoring visit was conducted on 11/21/16. The immediate jeopardy was removed on 11/18/16 at 5:00 p.m., after all the components of the plan of removal were carried out. The deficient practice remained at a level of actual harm, isolated. Based on observation, record review, and interviews, it was determined the facility failed to ~ report, protect and thoroughly investigate allegations of abuse for one (#5) of three sampled residents who were reviewed for abuse and, ~ thoroughly investigate an allegation of abuse for one (#6) of three sampled residents who were reviewed for abuse. The facility identified 76 residents who resided in the facility. Findings: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 10/29/15, documented the resident was incontinent of her bladder. Interventions included to provide perineal care after each incontinent episode. A quarterly assessment, dated 07/15/16, documented the resident's cognition was severely impaired. The assessment documented she required extensive assistance with transfers, dressing, personal hygiene, bathing, bed mobility and toilet use. An incident report, dated 10/05/16 at 10:00 a.m., documented, .alledge (sic) sexual abuse .writer informed by aid (sic) this morning that resident stated she was raped in the night & (and) she want to go to hospital. Upon assessment (no) signs of physical trauma in genetals (sic). She told writer 'He said he will not hurt me.' A nurse's note, dated 10/05/16 at 12:32 p.m., documented, Resident alert and stable this shift. Writter (sic) was informed by the aid (sic) this am that the outgoing nurese (sic) and the aid told her residetn (sic) stated she was raped last night. Writter (sic) did enterviewd (sic) resident and she stated He was in my room and for a short while but I asked him to leave. Writter (sic) asked if she was physically or sexually touched? She said no. Wriiter (sic) with the company of two aids (sic) did a physical assessment on resident. She had some redness in the perinial (sic) area and extending to the butt chicks (sic) and outer vaginal fold areas which appeared to be either fungi or diapper (sic) rash. The aid (sic) said its nothing unusual for her redness, its always been there. She denies pain at this time and appear to be in comfortable and stable condition . The clinical record and incident report was reviewed. There was no documentation the resident was assessed and protected at the time of the alleged rape and the incident thoroughly investigated. There was also no documentation to indicate the physician, administrator, DON or family was notified at the time the incident occurred. A statement, written by the former administrator, from certified nurse aide #1 (CNA) who was identified by the resident as having raped her, documented, CNA came in turned on light identified himself told (Resident #5) he was going to provide care - provided care as he pulled up blankets resident seemed alarmed that aide was black and at that point asked aide to leave. Did not report to nurse b/c (because) there seemed to be no issues. A handwritten statement by the administrator, dated 10/05/16, obtained from the charge nurse documented, (LPN #1) went in responding to resident showing emotional distress 'That N***** was in here and he raped me' Nurse knew that the Aide had been in the room only a couple of minutes. Provided emotional support and redirected resident. Reported behaviors to oncoming shift. A handwritten note at the bottom of the statement documented the LPN was educated to call the administrator with any further allegations. A statement provided by CNA #2 documented, On the morning of Oct. 5th, 2016, I (CNA #2) came on duty and got report from (LPN #1) and (CNA #1), they notified me that (Resident #5) had stated she was raped. CNA #1 had said she (resident #5) directed it at him. Report ended! When going to get resident (resident #5) up for breakfast. Resident was startled still and had stated as we were on way to dining room she think she needed to go to hospital, but didn't state why she wanted to go. At breakfast table resident asked to go to bathroom, so aide (CNA #3) took her to bathroom and sat her on toilet. After he came to me and asked if I would help get (Resident #5) back up because she stated again she was raped earlier. Nurse was notified! A statement provided by CNA #3 documented, On the morning of [DATE] I (CNA #3) was helping (Resident #5) to the bathroom. She told me that she had been raped. When asked she did not know by who or when. There was no documentation to indicate other staff members who were working on the night of the alleged incident were interviewed. A safe survey questionnaire, dated 10/05/16, was conducted on thirteen residents. The questions did not address sexual, physical or verbal abuse. An initial Oklahoma State Department of Health (OSDH) incident report form, documented the incident occurred on 10/06/16. The form was received at OSDH on 10/07/16 at 6:07 p.m. The report further documented a visual examination was completed, the physician was notified and the incident was currently being investigated. The clinical record was reviewed and there was no documentation to indicate the resident was examined and the physician and family notified at the time of the incident. A confirmation sheet documented CNA #1 was reported to the nurse aide registry on 10/19/16. The report documented the CNA was not suspended and/or terminated. A final OSDH incident report form, dated 10/19/16, documented, .the Aide had gone into residents room and come immediately out stating that she became upset right before he provided care and requested the nurses assistance .she did not allege to him any type of abuse .The nurse reported the agitation to the oncoming nurse and upon interview the resident stated to the nurse that she had been raped, but could not say by whom or when .The resident was interviewed by the on-coming nurse and then examined with no bruising or discoloration to the skin. This administrator notified the family . The report further documented the allegation was unsubstantiated based on the statements and safe surveys. On 11/17/16 at 2:55 p.m., the DON was asked according to facility's incident report, what was the date and time of the alleged rape incident. She stated on 10/05/16 at 10:00 a.m. She was then asked when the state reportable incident documented the date and time of the alleged rape. She stated on 10/06/16. The DON was asked if she was aware of the allegation of rape. She stated she was not involved in this, she was not in the facility. She was asked if CNA #1 was suspended after the allegation of rape by resident #5. She reviewed the file, and stated she did not know according to the documentation. She was asked if the information would be documented in the employees personnel file if he had been suspended. She stated, if she was to do the investigation, it would be in her synopsis. The DON was asked if she would expect LPN #1 to complete a full assessment of the resident and report the allegation of rape to her or other administration immediately. She stated, Yes. She was asked if there was documentation to indicate an assessment was performed by the LPN charge nurse upon notification of the allegation. She stated, No. She was asked if an incident report was completed by LPN #1. She stated, No. She was asked if there was documentation to indicate the physician, administrator, family and/or police were notified at the time of the allegation of rape. She stated, No. She was asked what process should have been followed regarding the allegation. She stated to remove the resident from the situation, do a head to toe assessment and send the resident to the emergency room for a medical evaluation. The DON was then asked if she felt a thorough investigation was completed. She stated, No. The DON was asked if CNA #1 was presently employed with the facility. She stated no, he was terminated on 10/18/16, however, he was not terminated due to this allegation. The facility time cards documented CNA #1 continued to work after the allegation of rape on the 11:00 p.m. - 7:00 a.m. shift on 10/06/16, 10/09/16, 10/12/16, 10/15/16 and on 10/16/16 on the same hall in which the resident resided. 2. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 07/08/16, documented the residents cognition was intact, she required extensive assistance with all activities of daily living except eating and required the use of a wheelchair for mobility. An initial OSDH incident report form documented, .Incident Date 08-08-2016 .Resident daughter came to this Administrator to report that her mother's room mate had reported that she believed that her mother had been abused the night before by the male CNA on duty .The investigation is on-going . A fax confirmation sheet documented the form was sent to the OSDH on 08/09/16. A confirmation sheet documented CNA #6 was reported to the nurse aide registry on 08/08/16. The report documented the CNA was suspended and not terminated. A final OSDH incident report form, documented, .This allegation was UNSUBSTANIATED. Resident was assessed by her physicians PA (physicians assistant) in addition to nursing performing a head to toe assessment. Resident-safe surveys were completed, and multiple staff were interviewed . The clinical record and incident reports were reviewed. There was no documentation to indicate a thorough investigation was conducted. On 11/18/16 at 1:30 p.m., the administrator was asked if there was documentation of staff and resident interviews related to the allegation of abuse against CNA #6. He stated if it is not there, then there probably is not one. The administrator was asked if CNA #6 was still employed with the facility. He provided documentation the CNA was terminated on 09/18/16 for a no call/no show.

On 11/17/16 at 4:45 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to implement their abuse policy to thoroughly investigate, report and protect residents from an allegation of abuse. At 4:50 p.m., the director of nursing (DON) was informed of the IJ situation related to the facility's failure to implement their abuse policy and procedure to investigate, report and protect residents from an allegation of abuse. The DON verbalized understanding. On 11/18/16 at 2:15 p.m., the acting administrator and the DON provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: .Action Plan: By 21:00 (9:00 p.m.) on 11/17/16 the facility policies on abuse and reporting abuse will be reviewed to ensure that the contain the following elements to protect residents: 1) Reporting procedures 2) Investigative procedures 3) Family/physician notification 4) Notification of authorities if a crime is suspected 5) Physical examinations 6) Immediate protective measures to ensure resident safety during investigation 7) Ongoing Staff Training 8) Abuse identification Once the internal policies and procedures have been updated and verified to contain the above elements, all facility staff will be inserviced by 5pm by the DON/Administrator on 11/18/16 on the approved policies to ensure a thorough understanding of the facility policies and procedures on abuse. Also, by 5pm on 11/18/16, all residents in the building will be interviewed with the new Resident Safe Survey form to ensure that no other allegations of abuse have occurred . A monitoring visit was conducted on 11/21/16. The IJ was removed on 11/18/16 at 5:00 p.m., after all the components of the plan of removal were carried out. The deficient practice remained at a level of actual harm, isolated. Based on observation, record review, and interviews, it was determined the facility failed to ~ implement their abuse policy to report, protect and thoroughly investigate an allegations of abuse for one (#5) of three sampled residents who were reviewed for abuse and, ~ thoroughly investigate an allegation of abuse for one (#6) of three sampled residents who were reviewed for abuse. The facility identified 76 residents who resided in the facility. Findings: The abuse policy and procedure, dated 11/01/15, documented, .PROCEDURE FOR MANAGEMENT OF SUSPECTED ABUSE/NEGLECT .In the event there is an allegation or incidents involving employee to resident .abuse, the following shall occur: 1. The individuals involved in the abuse should be immediately separated by the staff. 2. A complete assessment of the resident and other parties should be done by the charge nurse. 3. Once safety is established, the Administrator and Director of Nursing should be notified immediately. 4. The charge nurse should complete an incident report, being very precise about the incident and obtain statements from any witnesses to the incident. 5. The incident report and statements must be completed before the end of the shift. 6. Place the incident report on Q-shift (every shift) focused charting of any incidents or other behaviors. If there is an allegation of abuse against the employee: .The Administrator and Director of Nursing must address the employee situation immediately by placing the employee on unpaid leave of absence pending completion of the facility's investigation . .INVESTIGATING ALLEGATIONS OF SEXUAL ABUSE . All reported incidents of sexual abuse are promptly and thoroughly investigated . 1. Immediately contact the Director of Nursing, Administrator and the resident's physician. 2. Director of Nursing or Administrator will contact the police department. 3. Assess the resident for possible injury. 4. Provide the resident with emotional support. 5. Do NOT shower, bathe, or change resident's clothing . 6. Do not disturb the location where the alleged rape took place; prepare the resident for transfer to the hospital examination; and 7. In consultation with the police, continue the facility's investigation . .Protection: The facility shall protect individuals from abuse during investigation of all allegations of abuse . .Investigations: The facility shall ensure in a timely and thorough manner, objective investigation of all allegations of abuse . .Report/Respond: .The facility shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility shall also report to the State Nurse Aide Registry or licensing authorities .any actions .which would indicate an employee is unfit for service . 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 10/29/15, documented the resident was incontinent of her bladder. Interventions included to provide perineal care after each incontinent episode. A quarterly assessment, dated 07/15/16, documented the resident's cognition was severely impaired. The assessment documented she required extensive assistance with transfers, dressing, personal hygiene, bathing, bed mobility and toilet use. An incident report, dated 10/05/16 at 10:00 a.m., documented, writer was informed by aid (sic) this morning that resident Stated she was raped in the night and she want to go to hospital. Upon assessment (no) signs of physical trauma in genetals (sic). She told writer, 'He said he will not hurt me.' A nurse's note, dated 10/05/16 at 12:32 p.m., documented, Resident alert and stable this shift. Writter (sic) was informed by the aid (sic) this am that the outgoing nurese (sic) and the aid told her residetn (sic) stated she was raped last night. Writter (sic) did enterviewd (sic) resident and she stated He was in my room and for a short while but I asked him to leave. Writter (sic) asked if she was physically or sexually touched? She said no. Wriiter (sic) with the company of two aids (sic) did a physical assessment on resident. She had some redness in the perinial (sic) area and extending to the butt chicks (sic) and outer vaginal fold areas which appeared to be either fungi or diapper (sic) rash. The aid (sic) said its nothing unusual for her redness, its always been there. She denies pain at this time and appear to be in comfortable and stable condition . A statement written by the former administrator, dated 10/05/16, obtained from certified nurse aide #1 (CNA) who was identified by the resident as having raped her, documented, CNA came in turned on light identified himself told (Resident #5) he was going to provide care - provided care as he pulled up blankets resident seemed alarmed that aide was black and at that point asked aide to leave. Did not report to nurse b/c (because) there seemed to be no issues. A handwritten statement by the administrator, dated 10/05/16, obtained from the charge nurse on duty documented, (LPN #1) went in responding to resident showing emotional distress 'That N***** was in here and he raped me' Nurse knew that the Aide had been in the room only a couple of minutes. Provided emotional support and redirected resident. Reported behaviors to oncoming shift. A handwritten note at the bottom of the statement documented the licensed practical nurse was educated to call the administrator with any further allegations. A statement provided by CNA #2 documented, On the morning of Oct. 5th, 2016, I (CNA #2) came on duty and got report from (LPN #1) and (CNA #1), they notified me that (Resident #5) had stated she was raped. CNA #1 had said she (resident #5) directed it at him. Report ended! When going to get resident (resident #5) up for breakfast. Resident was startled still and had stated as we were on way to dining room she think she needed to go to hospital, but didn't state why she wanted to go. At breakfast table resident asked to go to bathroom, so aide (CNA #3) took her to bathroom and sat her on toilet. After he came to me and asked if I would help get (Resident #5) back up because she stated again she was raped earlier. Nurse was notified! A statement provided by CNA #3 documented, On the morning of [DATE] I (CNA #3) was helping (Resident #5) to the bathroom. She told me that she had been raped. When asked she did not know by who or when. The OSDH reportable incident documented the incident occurred on 10/06/16. The report documented the resident stated she was sexually assaulted. A nurse's note, dated 10/06/16 at 5:34 a.m., documented a urinalysis was obtained per the physician's orders [REDACTED]. A nurse's note, dated 10/13/16 at 4:59 a.m., documented the resident was on an antibiotic for a urinary tract infection. On 11/17/16 at 2:55 p.m., the DON was asked according to facility's incident report, what was the date and time of the alleged rape incident. She stated on 10/05/16 at 10:00 a.m. She was then asked when was the state reportable incident documented the date and time of the alleged rape. She stated on 10/06/16. The DON was asked if she was aware of the allegation of rape. She stated she was not involved in this, she was not in the facility. She was asked if CNA #1 was suspended after the allegation of rape by resident #5. She reviewed the file, and stated she did not know according to the documentation. She was asked if the information would be documented in the employee's personnel file if he had been suspended. She stated if she was to do the investigation, it would be in her synopsis. The DON was asked if she would expect LPN #1 to complete a full assessment of the resident and report the allegation of rape to her or other administration immediately. She stated, Yes. She was asked if there was documentation to indicate an assessment was performed by the LPN charge nurse upon notification of the allegation. She stated, No. She was asked if an incident report was completed by LPN #1. She stated, No. The DON was asked if the abuse policy regarding reporting, investigating and protecting the residents had been implemented according to the documentation. She stated, No. She was asked if there was documentation to indicate the physician, administrator, family and/or police were notified of the allegation of rape. She stated, No. She was asked what process should have been followed regarding the allegation. She stated to remove the resident from the situation, do a head to toe assessment and send to the emergency room . The DON was asked if CNA #1 was presently employed with the facility. She stated no, but he was not terminated due to this allegation. The facility time cards documented CNA #1 continued to work after the allegation of rape on the 11:00 p.m. - 7:00 a.m. shift on 10/06/16, 10/09/16, 10/12/16, 10/15/16 and on 10/16/16 on the same hall in which the resident resided. 2. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 07/08/16, documented the residents cognition was intact, she required extensive assistance with all activities of daily living except eating and required the use of a wheelchair for mobility. An initial OSDH incident report form documented, .Incident Date 08-08-2016 .Resident daughter came to this Administrator to report that her mother's room mate had reported that she believed that her mother had been abused the night before by the male CNA on duty .The investigation is on-going . A fax confirmation sheet documented the form was sent to the OSDH on 08/09/16. A confirmation sheet documented CNA #6 was reported to the nurse aide registry on 08/08/16. The report documented the CNA was suspended and not terminated. A final OSDH incident report form, documented, .This allegation was UNSUBSTANIATED. Resident was assessed by her physicians PA (physicians assistant) in addition to nursing performing a head to toe assessment. Resident-safe surveys were completed, and multiple staff were interviewed . The clinical record and incident reports were reviewed. There was no documentation to indicate a thorough investigation was conducted. On 11/18/16 at 1:30 p.m., the administrator was asked if there was documentation of staff and resident interviews related to the allegation of abuse against CNA #6. He stated if it is not there, then there probably is not one. The administrator was asked if CNA #6 was still employed with the facility. He provided documentation the CNA was terminated on 09/18/16 for a no call/no show.

Based on observation, record review and staff interview, it was determined the facility failed to provide care/services to prevent the development of pressure ulcers for two (#9 and #12) of nine sampled residents whose clinical records were reviewed for the development of pressure ulcers. This deficient practice resulted in the development of a stage III pressure ulcer which was determined to be avoidable for resident #9. The DON and the administrator identified 22 residents at risk for the development of pressure ulcers (the 10 residents who already had pressure ulcers and 10 other residents.) The Census and Conditions report, presented upon entrance, documented 48 residents were receiving preventative skin care. Findings: The Resident Census and Conditions of Residents, provided by the facility upon entrance, documented 10 residents had a stage II or greater pressure ulcer. It documented two of the 10 residents had a stage II or greater pressure ulcer upon admission to the facility. This indicated eight of the 10 residents' pressure ulcers were facility-acquired. The weekly summary of residents' skin conditions, written following the wound physician's rounds on 05/02/16, documented eight residents had a [DIAGNOSES REDACTED]. Of those eight residents, four also had at least one stage II or greater pressure ulcer. A 'Pressure Ulcer Risk Assessment' policy, revised 2005, documented, General Guidelines .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues . Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.) . Assessment .Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers . A 'Pressure Ulcer Treatment' policy, revised 2005, documented, .The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers . Stage I Protocol .Turn Schedule . A 'Prevention of Pressure Ulcers' policy, revised 2005, documented, The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors . General Guidelines .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues . Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.) . Interventions and Preventive Measures: General .Identify risk factors for pressure ulcer development . For a person in bed . Change position at least every two hours or more frequently if needed . Determine if resident needs a special mattress . If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated . For a person in a chair . Change position at least every hour . Use foam, gel or air cushion as indicated to relieve pressure . Interventions and Preventive Measures: Residents with Risk Factors . Risk Factor - Moisture . Place resident on a minimum of a q 2 hour check and change program . Risk Factor - Friction and Shear . Use a draw sheet to assist in moving resident from side to side and up in the bed . Use a draw sheet or other mechanical device for lifting . Risk Factor - Bed-fast . Change position at least every two hours and more frequently as needed . Use a special mattress that contains foam, air, gel, or water, as indicated . Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees (e.g., for residents with tube feeding or respiratory issues) . Risk Factor - Chair-fast .Change position at least q 1 hour . Consider the need for pressure relief/reducing device . Change position at least every hour and use foam, gel or air cushion as indicated to relieve pressure . Risk Factor - Bowel/Bladder Incontinence . Check resident for incontinence at least q 2 hours and clean skin when soiled . The following are additional clinical conditions, treatments and abnormal lab values that indicate that a resident is at risk for pressure ulcer . Impaired/decreased mobility and decreased functional ability . Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus . Impaired diffuse or localized blood flow . Cognitive impairment . Exposure of skin to urinary and fecal incontinence . 1. Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube which supplied his nourishment and hydration needs. The admission physician's orders [REDACTED].Braden Scale (a pressure ulcer risk assessment tool) on admit then weekly X 3 weeks . HO (water) to run with [MEDICATION NAME] (a tube feeding formula) at 50 ml per hour . NPO . [MEDICATION NAME] Skin Protectant Paste .Apply to BUTTOCKS AND SACRUM topically every shift for SACRAL DISCOLORATION . A Nursing Admission Screening/History note, dated 04/19/16 at 1:32 p.m., documented, .Unarousable/Coma/Persistent Vegetative State (Yes) . Paralysis (checked) . Incontinent of bowels (checked) . Incontinent of bladder (checked) . Note all skin issues .Abdomen - PEG tube .Sacrum - Darken . Treatment ordered or required (checked) . Bed Mobility Totally - Dependent (checked) . Transfers - Totally Dependent (checked) . Toilet Use - Totally Dependent (checked) . Personal Hygiene - Totally Dependent (checked) . Bathing - Activity Does Not Occur (checked) . A Braden Scale, dated 04/19/16, documented the resident was a High Risk for developing pressure ulcers. No other Braden Scale assessments were located in the record. A nurse's progress note, dated 04/19/16 at 5:28 p.m., documented, Patient does not respond to verbal stimulas (sic) or physical stimulas (sic). Family states he has been this way for 10 days .New peg tube . A telephone physician's orders [REDACTED].#4, dated 04/19/16, documented a wound care consult was ordered. The care plan, dated 04/20/16, documented, Focus .Risk for impairment in skin integrity. Res is incontinent of bowel and bladder. admitted with discoloration to sacrum/buttocks . Interventions .Educate resident/family/caregivers of causitive factors and measures to prevent skin injury . Encourage good nutrition and hydration in order to promote healthier skin . Follow facility protocols for treatment of [REDACTED]. Identify/document potential causitive factors and eliminate/resolve where possible . Monitor for side effects of the antibiotics and over-the-counter pain medication: gastric distress, rash, or allergic reactions which could exacerbate skin injury . Monitor/document location, size and treatment of [REDACTED]. to MD . Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by physician . Focus .The resident has potential for pressure ulcer development r/t decreased mobility . Interventions .Administer medications as ordered. Monitor/document for side effects and effectiveness . Administer treatments as ordered and monitor for effectiveness bilateral boots to feet for heel protection . Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning . Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the resident/family/caregivers of any new area of skin breakdown . Monitor nutritional status. Serve diet as ordered, monitor intake and record . Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . A skilled charting form, dated 04/24/16 at 9:40 p.m., documented, closed dime sized blister on L glut (gluteal), closed quarter and nickel size blister R glut. No documentation the physician had been notified was located in the record. A skilled charting form, dated 04/25/16 at 5:35 a.m., documented. Breakdown on buttocks. A Skin Observation Tool, dated 04/25/16, documented a shear wound on the right buttock measuring 1.0 x 1.0 cm and a shear wound on the left buttock measuring 3.1 x 1.1 cm. A nursing progress note by the wound nurse, dated Late Entry 04/25/16 at 6:50 p.m., documented, .Skin Assessment completed. Noted the following Areas of concern: 1) Shear Wound of the (R) Buttocks measuring 3.1 x 1.1 cm. no drainage noted. treatment order obtained along with order for Air mattress, vitamin c 500 mg bid, zinc sulfate 220 mg daily x 14 days. pre-[MEDICATION NAME] is WNL at 33 (normal range is 20-40). will refer to (wound physician's name deleted) to follow for wound care needs. 2) Shear Wound of the (L) buttocks measuring 1.0 x 1.0 cm. no drainage noted. treatment order, supplements and air mattress ordered. will refer to (wound physician's name deleted) for wound care needs . The admission MDS, dated [DATE], documented the resident; ~ was in a persistent vegetative state; ~ was totally dependent on one to two person assistance with all ADLs; ~ was always incontinent of bowel and bladder; ~ was at risk of developing pressure ulcers; ~ had no unhealed pressure ulcers at a Stage I or higher; and ~ had moisture associated skin damage. The Skin and Ulcer Treatments section of the assessment documented the resident had a pressure reducing device for the bed and applications of ointments/medications other than to the feet. The areas for pressure reducing device for chair, turning/repositioning program, nutrition and hydration interventions to manage skin problems and pressure ulcer care were not checked as being in use. A psychosocial progress note, dated 04/27/16, documented, Care plan meeting held on this day for (resident's name deleted). Wife (name deleted) in attendance .(Wife's name deleted) happy that the air mattress is in placed and working correctly. Nursing letting (wife's name deleted) know that (resident's name deleted) has 3 areas of shearing to his skin that they are treating. (Wife's name deleted) requesting that nursing get (resident's name deleted) up in the Geri Chair two times a day, once in the morning and once in the afternoon .No further social service needs at this time. Continue with POC . A Wound Care Specialist Initial Evaluation, dated 05/02/16, documented, .Groin/Buttock: Excoriations, Irritated [MEDICAL CONDITION], Wound . Stage 3 Pressure Wound of the Sacrum . Wound size (L x W x D): 8 x 8 x Not Measurable cm Exudate: Light Serous Thick Adherent Devitalized Necrotic Tissue: 35% Yellow Necrotic: 35% Granulation Tissue: 30% Recommendation: Gel cushion to chair, Low air loss mattress .Limit sitting to 60 minutes, Off-load wound, Reposition per facility protocol . Procedure: Surgical Excisional Debridement of Subcutaneous Tissue . Post-Debridement Depth(CM): 0.3 . Other Diagnosis: [REDACTED].Buttocks . A 14-day MDS, dated [DATE], documented in the skin and ulcer treatments section, the resident had a pressure reducing device for the bed, applications of nonsurgical dressings other than to the feet and applications of ointments/medications other than to the feet. The areas for pressure reducing device for chair, turning/repositioning program, nutrition and hydration interventions to manage skin problems and pressure ulcer care were not checked as being in use. On 05/09/16 at 9:15 a.m., a family member of resident #9, who had a background in the medical profession, was asked about the care the resident received. She stated she was afraid to leave him because there was not enough staff to provide the care he needed. She stated they were not checking on the resident every two hours and she would place a urinal between his legs because the staff had let him lay in urine and feces for long periods of time. She stated she had told the nurses she was concerned about his bottom turning purple and the development of pressure ulcers. She stated that right after admission, she had asked the wound nurse if the resident could be placed on an air mattress and the wound nurse had told her he did not need one. She stated when he developed the pressure ulcers, the wound nurse had told her they were only shearing tears to the skin. She stated the resident had a Stage 3 open, yellow wound at the present. She stated she had informed the DON and the administrator about the care and her concerns. She stated they had only put up a sign-in sheet on the wall of the resident's room. She pointed to a Turn/Reposition Form on the resident's wall, dated May 2016. The form had a list of times in two hour increments and the position the resident was to be repositioned to at that time. There were only 53 of 84 entries initialed from 05/02/16 at 8:00 a.m. and 05/09/16 at 8:00 a.m. She stated the CNAs either signed the form when they have not given the care or they don't sign it at all. At 11:30 a.m., following a dressing change to the pressure ulcers on the buttocks, resident #9 was observed to be positioned on his back in the bed with the head of the bed up 30 degrees. At 12:30 p.m., the resident was observed on his back in the bed with the head of the bed up 30 degrees. There had been no change in his position. At 1:30 p.m., resident #9 was observed on his back in the bed with the head of the bed up 30 degrees. There had been no change in his position. At 2:00 p.m., the resident was observed in the geri-chair covered with a sheet. The chair was in a reclined position. At 3:10 p.m., resident #9 was observed in the geri-chair. The chair was in a reclined position. There had been no change in his position. At 4:00 p.m., the resident was observed in the geri-chair covered with a sheet. The chair was in a reclined position. There had been no change in his position. At 4:30 p.m., resident #9 was observed in the geri-chair covered with a sheet. The chair was in a reclined position. LPN #3 had performed a fingerstick blood sugar on the resident but had not changed his position. At 5:30 p.m., the resident remained in the geri chair. His position had not been changed. On 05/10/16 at 8:45 a.m., LPN #3 was observed administering medication via feeding tube to resident #9. The resident was in the geri chair with his head up 30 degrees. The LPN was asked how long the resident was to stay up in the chair. She stated he was to be up for two hours in the morning and two hours in the afternoon. At 9:48 a.m., resident #9 received a breathing treatment. His position was unchanged in the geri chair. At 10:16 a.m., the resident received PEG tube care. His position was unchanged in the geri chair. At 11:15 a.m., resident #9's position was unchanged in the geri chair. At 11:45 a.m., the resident was observed in the geri chair leaning to the left with his neck hyperextended. The pillows that had been used for support and positioning were observed on the floor. The resident's tongue guard had came out and blood was observed in his mouth. At 11:55 a.m., the resident was placed back in the bed via hoyer lift. Incontinent care was performed and he was positioned on his left side. The geri chair was observed to not have had any pressure reducing cushions in place. At 12:00 p.m., the Turn/Reposition form on the resident's wall contained no documentation of the resident having been repositioned from 05/09/16 at 8:00 a.m. through 05/10/16 at 4:00 a.m. At 1:30 p.m., the resident remained in the same position on his left side in the bed. At 3:00 p.m., the resident had been repositioned to his right side. The bed had been lowered to the lowest position and was cutting off the air supply to the mattress so it was not working properly. On 05/11/15 at 10:30 a.m., LPN #3 was asked if she had admitted resident #9. She stated she had. She was asked it the resident had any wounds when he was admitted . She stated she had looked at his skin and it was pink with blood but he did not have any wounds when he was admitted . She was asked if a family member of resident #9 had requested an air mattress when the resident was admitted . She stated she had not been asked but the family member had asked the evening shift nurse about it. She was asked if she had assessed the resident as a high risk for pressure ulcers when she admitted him. She stated he would have been high risk because he couldn't move himself. She was asked what interventions would have been put in place. She stated the resident should have been turned every two hours and couldn't be up in the geri chair longer than two hours She was asked if the resident had a cushion for his geri chair. She stated, No. At 11:10 a.m., the resident's wound was observed. He was positioned on his back in the bed. Two CNAs repositioned the resident to his left side so the wounds could be observed. They used a turn sheet to pull him across the bed and then turn him onto his side. LPN #3 removed a bordered dressing from the buttock area. Two large wounds were observed on the buttocks. They were on both buttocks and met at the gluteal crease. Both had definitive edges where the wounds had been surgically debrided. The area around the wound and across the buttocks was macerated with redness and slight weeping observed. A thin layer of zinc oxide ointment covered most of the areas. The left wound was approximately 4 inches long by 2 inches wide and approximately 1/8th inch deep. The bed was a blackish red in color and had small amount of serous drainage. The right wound was approximately 3 inches long by 1.5 inches wide and 1/8th inch deep. The bed was pinkish to yellowish with serous drainage. The LPN placed a new dressing and the resident was repositioned onto his back. At 11:15 a.m., the wound care nurse was interviewed. She was asked how long she had been the wound nurse. She stated she had started in January 2016. She was asked about her training regarding wounds. She stated she had no formal training but knew what any floor nurse would know. She was asked if she assessed all new residents upon admission for skin issues or preventative interventions. She stated she did not, unless a wound consult was ordered. She stated she hoped to be able to assess all admissions in the future but didn't at the present. She was asked if she had assessed resident #9's skin on admission. She stated she had looked at it with another nurse. She stated there was no discoloration or open areas on admission. She stated she ordered [MEDICATION NAME] ointment as a preventative measure. The wound nurse was asked if she had assessed the resident as being at risk for pressure ulcers. She stated his pre-[MEDICATION NAME] was good and he didn't have any open wounds so she didn't think there was much risk except he was incontinent of bowel and bladder. She was asked if the resident's family had requested an air mattress on admission to prevent pressure ulcers. She stated they had requested it but, He wasn't open yet, so he didn't need it. She again referred to the resident's pre-[MEDICATION NAME] as being good. She stated she ordered an air mattress when he developed the shear wounds. She was asked what made her classify the wounds as 'shear wounds'. She stated, Pressure ulcers don't come up that fast. She was asked if the resident should have received shear wounds if the staff were using proper technique to reposition him. She stated, No. She was asked if the resident should have a cushion in his geri chair. She stated, Yes. At 11:45 a.m., the DON was interviewed. She was asked what training the wound care nurse had regarding wounds. She stated she was supposed to watch some online trainings when she started in January. She stated she didn't know how many she had watched or if she had watched any. She was asked if she had made rounds with the wound care nurse when she conducted the skin assessments. She stated she had not. The DON was asked what it meant when a 'wound care consult' was ordered. She stated it meant the wound care nurse was to assess the resident and decide if the wound care physician should be consulted. She was asked what the wound nurse responsibilities were. She stated she made rounds with the wound physician when he was in the building. She was to perform wound assessments on all the wounds weekly and make sure the floor nurses were staging the wounds correctly. She was to assess residents at risk of pressure ulcers for any interventions or devices to be put into place as prevention measures. She was asked what interventions were put into place when a resident was assessed as being at risk for pressure ulcers. She stated it depended on what the wound care nurse decided they required. She was asked if she knew what interventions had been implemented when resident #9 had been admitted . She stated she thought the turning schedule had been. The DON was asked if she would have assessed the resident as 'at risk' for pressure ulcers. She stated his pre-[MEDICATION NAME] was good but she would have considered him a high risk since he was unable to move himself. She was asked what interventions she would have implemented. She stated he would have been placed him on a turning schedule, put him on an air mattress and started him on the prevention protocol. She was asked if she was aware the resident's family had requested an air mattress when he was admitted but the wound care nurse had denied the request. She stated she knew they had placed him on one when he developed wounds but didn't know they had requested one on admission. She stated they started a turning schedule at that time and placed a schedule on the wall. She was asked if the schedule was being used. She stated she hadn't looked at the schedule. She was asked if the resident should have a pressure reducing device in the geri chair. She stated he should have. She was informed there was no device in the chair and she stated she didn't know he didn't have one. The DON was asked if the resident had developed the pressure ulcer in the facility. She stated he had. She was informed of the observations of the lack of repositioning while in the the bed and extended times up in the geri chair. She stated, That's not good. At 5:00 p.m., LPN # 4 was asked if resident #9 had any open wounds on admission. She stated he did not have any wounds. She was asked if a family member had requested an air mattress on admission. She stated they had and she had put in a 'wound care consult' so they could get the air mattress. She stated she thought the air mattress would help prevent pressure ulcers from developing. 2. Resident #12 had [DIAGNOSES REDACTED]. A pre-[MEDICATION NAME] level, obtained 12/29/15, documented the resident's pre-[MEDICATION NAME] level was 25. The normal range was 20-40. The annual assessment, dated 02/21/16, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfer and toilet use; was always incontinent of bowel and bladder; was at risk for the development of pressure ulcers; had moisture associated skin damage; did not have a pressure relieving device in chair; was not on a turning/repositioning program; and had no nutrition/hydration interventions. A Braden scale for predicting pressure ulcer risk, dated 02/21/16, documented the resident was at moderate risk for the development of a pressure ulcer. The care plan, dated 02/24/16, documented the resident had a problem which pertained to his ADL self-care performance deficit related to his decreased mobility. An intervention for the ADL of bed mobility was, the resident requires extensive assistance by staff to turn and reposition in bed every 2 hours and as necessary. The care plan addressed the resident's risk for impaired skin integrity and documented he had moisture associated [MEDICAL CONDITION] to the right buttock on 04/19/16 and a pressure ulcer to the right buttock on 04/28/16. The goal was for the resident's skin to remain clean, dry and intact during the review period. Interventions for the problem did not include turning/repositioning every two hours and as needed or to toilet/change the resident's incontinent brief every two hours and as needed. A skin/wound note, dated 04/18/16, written by the wound nurse, documented the resident had moisture associated [MEDICAL CONDITION] of the right buttock. A skin/wound note, dated 04/25/16, written by the wound nurse, documented the resident had a stage II pressure wound to the right buttock, area of [MEDICAL CONDITION] opened up measuring 3.4 x 2.5 x 0.1 cm (centimeters). A treatment order was obtained for Duoderm to be applied every 3 days and as needed. The note documented the wound specialist physician would follow-up on 05/02/16. (Later in the survey, the wound nurse informed the surveyor this note, dated 04/25/16, should have been dated 04/28/16.) A verbal physician's orders [REDACTED]. A skin/wound note, dated 05/02/16, documented the resident had a stage II pressure wound of the right buttock, measuring 3.0 x 2.5 x 0.1 cm. The note documented the treatment of [REDACTED]. A skin/wound note, dated 05/09/16, documented the resident had been seen by the wound specialist physician and had moisture associated [MEDICAL CONDITION] of the right buttock. The note documented the progress is improved and the treatment of [REDACTED]. Follow-up would occur in 7 days. There was no documentation in the clinical record which indicated the resident had been on a program to turn/reposition every two hours and as needed. On 05/11/16 at 9:34 a.m., three registered nurse surveyors observed LPN #3 as she performed the treatment to resident #12's buttocks and coccyx. When the Duoderm dressing was removed and the bilateral buttocks were cleaned with normal saline, the three surveyors observed a stage II pressure ulcer of the right buttock which measured approximately 6 x 3 x 0.1 cm. A stage II pressure ulcer which measured approximately 4 x 3 x 0.1 cm was observed on the left buttock. At 9:45 a.m., the resident was asked if the facility staff had ever instructed/encouraged him to lie on his side or stay off of his back. He stated staff had never talked to him about that issue. Beginning on 05/11/16 at 9:00 a.m. to 05/12/16 at 11:30 p.m., the surveyor made intermittent observations of the resident during the day. The resident was never observed positioned on his side or with his weight off loaded from his buttocks. On 05/11/16 at 2:45 p.m., the surveyor reviewed the skin/wound note, dated 04/18/16, with the DON and asked if any interventions had been initiated to prevent the development of pressure ulcers once the resident had been diagnosed with [REDACTED]. She stated [MEDICATION NAME] was ordered to be applied. The DON was asked if a turn/reposition program had been initiated at that time. The DON stated, No. The surveyor reviewed the skin/wound note, dated 04/25/16 (later changed to 04/28/16), and asked the DON if any interventions had been initiated to heal the stage II pressure ulcer and/or prevent the development of other pressure ulcers. She stated the physician had ordered a Duoderm dressing. The surveyor asked if a turn/reposition program had been initiated at that time. The DON stated, No. The surveyor reviewed the care plan intervention which documented the resident required extensive assistance by staff to turn and reposition in bed every two hours and as necessary. The surveyor asked the DON if the resident had been turned/repositioned every two hours. The DON stated, No. The surveyor asked if the care plan had been followed to turn and reposition the resident every two hours. She stated, I hope so. The DON was informed the MDS, dated [DATE], documented the resident was not on a turn/reposition program and asked her to produce documentation of the turn/reposition program. The DON reviewed the clinical record and stated she could not produce documentation the resident had been turned/repositioned. She stated turning/repositioning was not listed on the direct care ADL sheets. The surveyor informed the DON of the observation by the three RN surveyors of the stage II pressure ulcers to the resident's bilateral buttocks earlier that morning. She indicated she was not aware the resident had the pressure ulcers. The DON requested the wound nurse to consult about the pressure ulcers. When the wound nurse arrived in the room, she also indicated she was not aware the resident had pressure ulcers because the wound doctor had documented he had moisture associated [MEDICAL CONDITION] on 05/09/16. The surveyor asked the wound nurse if the resident had been turned and repositioned to prevent the development of a pressure ulcer. She stated she knew he had been repositioned because she had seen him up in his wheelchair. The surveyor asked if pressure remained on the resident's buttocks when he was up in his wheelchair. The wound nurse acknowledged pressure to the buttocks remained when the resident was in his wheelchair. The surveyor asked if she had ever observed the resident with his weight off loaded from his buttocks. She stated she had not. On 05/11/16 at 4:05 p.m., the DON asked the resident if staff had ever put a pillow under his back to turn him to his side. The resident stated they had not. The DON then observed the open areas to the resident's buttocks and stated they were shearing, not pressure ulcers. On 05/12/16 at 10:05 a.m., the surveyor asked LPN #3 if she recalled doing the treatment to resident #12's buttocks the morning of 05/11/16. She stated she remembered. The surveyor asked what type of skin issues she had observed. The LPN stated the resident had stage II pressure ulcers to the right and left buttocks. The surveyor asked if she had reported the observations of the pressure ulcers to anyone. She stated she had reported her observations to the wound nurse following the treatment. At 10:15 a.m., the surveyor info

Based on observation, record review and interviews, it was dertermined the facility's administration failed to identify system failures; ~ to provide care/services to prevent the development of pressure ulcers for two (#9 and #12) of nine sampled residents whose clinical records were reviewed for the development of pressure ulcers. This deficient practice resulted in the development of a stage III pressure ulcer which was determined to be avoidable for resident #9. ~ to provid timely incontinent care and turning, and repositioning to aide in the prevention in skin break down. Resident #9 and #12 developed avoidable pressure ulcers and were observed without being turned, repositioned and/or provided incontinent care for greater than two hours. This resulted in an actual harm to resident #9; and ~ to have an effective quality assurance program to identify and implement corrective actions for avoidable pressure ulcers, incontinent care, turning, and repositioning. This resulted in an actual harm to resident #9 who developed an avoidable pressure ulcer. The facility identified 85 resident resided in the facility. Findings: 1. Avoidable pressure ulcer developement: See tag F314 for details. 2. Quality Assurance Program: See F520 for details.

Based on observation, record review and interviews it was determined the facility failed to have an effective quality assurance program that identified and implemented corrective actions for equability of care issues. The facility failed to identify and implement corrective actions for avoidable pressure ulcers, staffing, incontinent care, turning, and repositioning. This resulted in an actual harm to resident #9 who developed an avoidable pressure ulcer. The facility identified 85 residents resided in the facility. Findings: The Resident Census and Conditions of Residents report, provided by the facility upon entrance, documented 10 residents had a stage II or greater pressure ulcer. It documented 2 of the 10 residents had a stage II or greater pressure ulcer upon admission to the facility. This indicated 8 of the 10 residents' pressure ulcers were facility-acquired. The weekly summary of residents' skin conditions, written following the wound doctor's rounds on 05/02/16, documented 8 residents had a [DIAGNOSES REDACTED]. Of those 8 residents, 4 also had at least one stage II or greater pressure ulcer. 1. The facility failed to ensure residents were provided incontinent care and turned and repositioned. Refer to F-312. 2. The facility failed to provide turning, repositioning and incontinent care to aide in the prevention of skin break down. Refer to F-314. An interview was conducted on 05/12/16 at 11:43 a.m., with the administrator. She was asked if the facility had identified a problem with in-house acquired pressure ulcers, moisture [MEDICAL CONDITION], staffing, and ADL assistance being provided. She stated, back in January, the facility identified a problem with the number of in-house acquired pressure ulcers. She then stated the facility felt they had improved in that area. She stated they had implemented a wound nurse and weekly skin meetings to discuss current wounds and residents that were at risk. She was asked if the facility had identified a problem with staffing and ADLs assistance not being provided. She stated they had identified a problem with staffing and had slowly increased staffing since she had started in January 2016. She then added the facility had not identified a problem with the ADL assistance. She was asked how effective the quality assurance program was for implementing corrective actions in those care areas. She stated, I thought we were making progress.

***SUPPLEMENTAL*** Based on observations, clinical record review, staff interviews and review of facility policy and procedures, it was determined the facility failed to ensure the plan of care was followed for one (#50) of 11 sampled residents whose plan of cares were reviewed. The resident's weight was not monitored and the physician was not notified of weight fluctuations which resulted in actual harm to the resident in which he was sent to the emergency room with an acute exacerbation of [MEDICAL CONDITION]. The Resident Census and Conditions report, dated 11/23/15, documented 93 residents resided in the facility. Findings: A facility policy, titled Care Plans-Comprehensive, documented, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing mental and psychological needs is developed for each resident . Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Each resident's Comprehensive Care Plan has been designed to . Incorporate identified problem areas . Aid in preventing or reducing declines in the resident's functional status and/or functional levels . Resident #50 was admitted with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].DAILY WEIGHT, NOTIFY PHYSICIAN IF GAIN 2-3 LBS OVERNIGHT OR 5 LBS IN ONE WEEK every night shift for [MEDICAL CONDITION] WEIGH RESIDENT IN THE EARLY AM AFTER VOIDING . A care plan, dated 10/29/15, documented, .Focus .The resident has [MEDICAL CONDITION] . Goal .The resident's Body weight will remain within normal limits . Interventions .Monitor/document/report PRN any s/s of [MEDICAL CONDITION] .weight gain unrelated to intake . Weight monitoring daily, notify MD if gains 2-3 lbs in 24 hours or 5 lbs in one week . A facility treatment sheet, dated October 2015, documented, . DAILY WEIGHT, NOTIFY PHYSICIAN IF GAIN 2-3 LBS OVERNIGHT OR 5 LBS IN ONE WEEK . Thu 29 - x Fri 30 - OOF Sat 31 - 209 . There was no documentation of a weight for 10/29/15. A facility treatment sheet, dated November 2015, documented, . DAILY WEIGHT, NOTIFY PHYSICIAN IF GAIN 2-3 LBS OVERNIGHT OR 5 LBS IN ONE WEEK . Sun 1 - blank Mon 2 - blank Tue 3 - blank Wed 4 - blank . There was no documentation of a weight for 01/01/15 thru 01/04/15. A resident admission assessment, dated 11/04/15, documented the resident was moderately impaired in cognitive skills for daily decision making. He required extensive assistance of two people for transfers. He required extensive assistance of one person for ambulating, locomotion, dressing, toileting and personal hygiene. He was totally dependent on one person for bathing. He received [MEDICAL TREATMENT] services. A nurse's note, dated 11/04/15, documented, .11:53 (a.m.) .upon the res return from [MEDICAL TREATMENT], res c/o difficulty urinating, foley cath inserted per order . A facility treatment sheet, dated November 2015, documented, . DAILY WEIGHT, NOTIFY PHYSICIAN IF GAIN 2-3 LBS OVERNIGHT OR 5 LBS IN ONE WEEK . Thu 5 - blank . There was no documentation of a weight for 11/05/15. A form titled Physician Orders, dated 11/05/15, documented, .0030 (12:30 a.m.) .Return to Nursing facility Resume previous orders. Dx 1) [MEDICAL CONDITION] (acute exacerbation [MEDICAL CONDITION]) . A nurses's note, dated 11/05/15, documented, .14:32 (2:32) p.m Order received to d/c catheter. foley d/c'd without difficulty . A nurses's note, dated 11/05/15, documented, .20:02 (8:02 p.m.) .DC'd order for straight cath Q 6-8 hrs as needed .New order from (Physician #2) to straight cath Q 8hrs . A nurse's note, dated 11/05/15, documented, . 22:57 (10:57 p.m.) .Patient complained of tightness in chest and SOB, patient requested transfer to (Hospital Name deleted) .Called for ambulance . A nurse's note, dated 11/06/15, documented, .11:05 (a.m.) .Patient returned from [MEDICAL TREATMENT] at 0930. Complaining of needing to urinate, pain in chest area and difficulty breathing. Abdomen distended .Attempted to straight cath x 2 with no results .(Physician #1) notified and new order was received to send patient to ER . A nurse's note, dated 11/06/15, documented .16:58 (4:58 p.m.) .Discharge instructions from (Hospital name deleted), leave foley catheter in place until we receive further instructions from (Physician #2) . A nurse's note, dated 11/06/15, documented, .01:31 (a.m.) .Res. back from (Hospital Name deleted), no N.O., resume previous orders, [MEDICATION NAME] 80MG was given at hospital as reported by hospital nurse and Paramedic . A facility treatment sheet, dated November 2015, documented, . DAILY WEIGHT, NOTIFY PHYSICIAN IF GAIN 2-3 LBS OVERNIGHT OR 5 LBS IN ONE WEEK . Fri 6 - blank Sat 7 - blank Sun 8 - blank Mon 9 - Ref . A care plan, dated 11/09/15, documented, .Focus .The resident has an Indwelling Catheter r/t [MEDICAL CONDITION] bladder . Interventions .Monitor and document intake and output as per facility policy . There was no documentation of a weight for 11/06/15 thru 11/09/15. A nurse's note, dated 11/09/15, documented, .18:48 (6:48 p.m.) .Patient was complaining of Foley Catheter pain .Called (Physician #1) on call service .said to send patient to the hospital . A hospital form, dated 11/09/15, documented, .Discharge Instructions .Diagnosis: [REDACTED]. A facility treatment sheet, dated November 2015, documented, . DAILY WEIGHT, NOTIFY PHYSICIAN IF GAIN 2-3 LBS OVERNIGHT OR 5 LBS IN ONE WEEK . Tue 10 - 219.8 Wed 11 - ineligible Thu 12 - Ref . There was no documentation of a weight for 11/10/15 thru 11/12/15. On 11/12/15 at 11:04 a.m., LPN #3 was asked who was responsible for obtaining the daily weights. She stated, 11-7 shift at six a.m. She was then asked where it would be documented. She stated, On the TAR. She was asked how it would be communicated that a resident needed to have daily weights. She stated, On the TAR. She was then asked if resident #50 had orders to have daily weights performed. She stated, Not that I am aware of. She was then asked if the resident was on intake and output monitoring. She stated, It should be in front of the treatment book, but I don't see one. She was asked who required intake and output monitoring. She stated, Fluid restrictions, catheters, PEG tubes. There was no documentation of any intake or output monitoring observed related to the indwelling catheter in the resident's clinical record. At 11:08 a.m., LPN #2 stated, He was transferred over to this unit on November 4, from the LTC (long term care) side. She was asked how a resident's care information is communicated from unit to unit. She stated, They give report to each other. At 11:40 a.m., the DON was asked who was responsible for obtaining the daily weights. She stated, Nurses are, or the restorative aide. She was asked how resident information and new orders were communicated to the staff. She stated, Placed on the MAR/TAR, communicated on dashboard in computer. At 11:53 a.m., CNA/Restorative #1 was asked if she did the daily weights for resident #50. She stated, No, only the weekly weights. On 11/12/15 at 4:00 p.m., Physician #1 was asked if the facility had contacted him to report that daily weights were not performed for resident #50. He stated, They haven't been calling me, but they could have called someone else.

Based on observation, interview and record review, it was determined the facility failed to supervise, monitor, and develop specific and appropriate interventions for a resident who transported hot water from the kitchen to her room for one (#1) of three sampled residents who transported hot water/coffee from the kitchen. Resident #1 received a 2nd and 3rd degree burn when the water spilled in her wheel chair. The facility identified three residents received hot water/coffee from the kitchen. Findings: Resident #1 had [DIAGNOSES REDACTED]. The last quarterly assessment, dated 09/24/13, documented resident the was severely cognitively impaired, needed limited assistance of one person for activities of daily living, had minimal difficulty hearing, ambulated via a wheelchair, spoke only Korean and needed an interpreter. A nutritional progress note, dated September 2013, documented, "...daughter wants resident to have hot water at meals Resident has insulated cups for hot water brings to dietary for staff to fill once staff fills it w/ (with) hot water they closed the lid. Resident has habit w/ taking lid off to check to make sure water is hot. D.M. (dietary manager) let resident & family know the risk family & resident is aware." A care plan, dated 09/27/13, documented, "Risk of injury as Resident has impaired vision secondary to Dx (diagnosis) of Glaucoma...Approach...keep surroundings free of small objects or liq (liquid) on the floor..." A nutritional progress note, dated November 2013, documented, "Resident came to dietary as usual to get a cup of hot water staff topped it and handed it to resident, (resident #1) untopped it and tipped it back and left (illegible word) dietary resident got burned from the hot water nursing was notified family as well D.M. stop staff from handing resident hot water they take it to resident table." A care plan, dated 11/17/13, documented, "Resident at risk for falls related to vertigo/osteoporosis hx (history) of falls...Approach 1. Teach resident to call for assistance if feeling dizzy or weak...3. Push fluids if within dietary limitations...5. Monitor resident for rapid changes in position and instruct on rising slowly...Antivert '/. (one) tab (tablet) BID (twice daily)..." The November 2013 and December 2013 physician's orders [REDACTED]. A nurse's note, dated 11/28/13 at 5:00 p.m., documented, "This nurse was called to dining room by CNA (certified nursing assistant) who stated 'Res (resident) spilled hot water while self propelling WC (wheelchair)' Res moaning and grimacing while trying to remove pants. This nurse & CNA escorted Res back to room. This nurse observed deep redness that covered buttocks completely. Res. is assisted on to side where cool rags are applied CMA (certified medication aide) administers Norco 5 mg per prn (as needed) orders. (doctor) notified- n/o (new order) clease (sic) c (with) NS (normal saline), apply silvadene & dry non-adhesive dressings BID (twice daily)...daughter notified & is able to translate for resident via phone..." At 6:30 p.m., the nurse's note documented, "Res remains using call light to express discomfort. Blisters noted on buttocks. 0 (no) open areas. Physician notified. n/o one norco 5 mg now x (times) 1 time. Daughter here to see. This nurse expressed to kitchen to never let resident wheel herself c hot water but to always take it to the table for her..." At 7:50 p.m., the nurse's note documented, "This nurse to examine res buttocks again. Blisters noted-intact. 0 open areas. Skin a deep red. Dressing clean & intact. Res resting well c 0 s/s (signs or symptoms) acute distress." At 10:00 p.m., the nurse's note documented, "CNA summoned this nurse to res room stating drsg (dressing) needed to be (changed). Drsg noted to be saturated c clear sangous (sic) fluid Blister to L (left) buttock still intact c fluid size baseball Res wanting to go to BR (bathroom) Assisted to BR x 2 Blister opened while going to BR. Stage II burn noted deep reddness (sic) Res in distress. Notified (doctor) c n/o received to send to hospital #1 for eval (evaluation) & tx (treatment)...Daughter notified & will meet at hospital #1 ER (emergency room )." The History of Present Illness (HPI) from hospital #1, dated 11/29/13 at 1:00 a.m., documented, "The patient presents with a burn as a result of hot water, making coffee/tea, at home, is located on the buttocks. Onset: The symptoms/episode began/occurred acutely. Burn type and severity: 1st degree: 2nd degree of the buttocks... Exam: 02:12 (2:12 a.m.) Skin: injury, burn(s), 1st degree burn injury covers approximately 5% of the total body surface area, and is located on the buttocks, 2nd degree burn injury covers approximately 2% of the total body surface area, and is located on the buttocks... 03:56 (3:56 a.m.)...Patient is to be sent back to nursing home with instructions for wound care.." A nurse's note, dated 11/19/13 at 5:30 a.m., documented, Returned from hospital @ (at) this time. F/C (foley catheter) to gravity. Drsg to buttocks intact. n.o (new order) to apply silvadene BID." An Accident/Incident Report, dated 11/28/13 at 4:45 p.m., documented, "Describe exactly what you observed or heard: (handwritten) Resident spilled hot water while wheeling chair in dining room." An untimed nurse's note, dated 11/29/13, documented, "Resident A (alert) & O (oriented), confused...wound bed bright red in color. 0 drainage noted. N.O. Valium 2 mg po (by mouth) q (every) 8 hrs (hours) prn for pain x 3 days..." At 10:00 p.m., the nurse's note documented, "...Res medicated x 2 this shift for discomfort...Drsg (dressing) changed x 1 this shift. B (bilateral) bottom 2nd degree burn c dark pink centers at this time..." A nurse's note, dated 11/30/13 at 12:01 a.m., documented, "...Drsg buttocks intact...0 drainage noted to buttock drsg @ this time." At 8:30 a.m., the nurse's note documented, " Tx to buttocks done @ this x. Resident had paper towels & Kleenex stuffed in brief- wound bed bright red. tolerated TX (treatment) c mild discomfort noted. Resident had moderate amount of serous drainage. 0 s/s of infection noted." A nurse's note, dated 12/01/13 at 9:00 a.m., documented, "...Tx to buttocks done per orders- Drsg intact c moderate drainage. Wound bed red serous drainage noted..." At 6:00 p.m., the nurse's note documented, "Resident refused dinner-consumed small amount of health shake. Encouraged fluids po...requires extensive assist c ADLs (activities of daily living)." The Skin Alteration Record, dated 12/01/13, documented the right and left buttocks had slough-moist yellow or gray necrotic tissue with a moderate amount of serous-clear drainage with reddened surrounding skin. Measurements of the right buttock were 10 cm (centimeter) in length, 11 cm in width and 0 cm in depth. Measurements of the left buttock was 14 cm in length, 11 cm in width and 0 cm in depth. A nurse's note, dated 12/02/13 with no time, documented, "...Pt (patient) cont (continue) to grimace occasionaly (sic) & attempt to touch covered wounds." A nurse's note, dated 12/02/13 with no time, documented, "...Wound bed yellow and pink c red surrounding edges. Clear drainage noted...0 s/s distress noted..." At 10:00 p.m., the nurse's note documented, "...Wound is pinkish yellow c reddened edges...unable to communicate c rsd (resident) due to language barriers. Rsd showing s/s of pain c pain meds administered..." A nurse's note, dated 12/02/13 with no time, documented, "Resident OOF (out of facility) to Dr appt (appointment) via medride stretcher, accompanied by daughter. A History and Physical Report from the attending physician at hospital #2, dated 12/04/13 at 1:24 p.m., documented, "...Chief Complaint: This patient is being admitted from clinic today for evaluation and treatment of [REDACTED]. History of Present Illness:...When I evaluated the wounds, they appeared to be more than just superficial, second degree and appeared deeper, and she is being admitted to the hospital for wound care, possible surgical intervention and nutritional support with likely a feeding tube... Impression: 1. Deep second to third degree burns of right and left buttocks approximately 2 percent total body surface area. The patient's burns are going to be treated with silver sulfadiazine. If the wounds fail to heal over a week period of time, she would likely require split thickness skin grafting... Death Summary date of death 12/4/2013 Presumed Cause of Death: Cardiac arrest secondary to severe coronary artery disease. Complicating Factors: 1. Acute kidney injury. 2. [DIAGNOSES REDACTED]with a rapid ventricular response..." On 04/21/14 at 10:15 a.m., the resident's daughter was asked if she knew her mother received hot water out of the kitchen. She stated, "Yes." She stated her mother would go to the kitchen with a thermos and get hot water to take back to her room to make instant coffee. She stated there was decaffeinated coffee and a refrigerator of food in her mother's room. She stated the staff filled the thermos with hot water and gave it to her mother. The daughter stated the evening of Thanksgiving the resident was wanting hot water for coffee. She stated the resident self propelled herself in her wheelchair with her thermos to the kitchen and received hot water in the thermos. The resident put the thermos of hot water behind her back and self propelled herself down the hall to the dining room. The daughter stated she was told by a staff member that resident #1 heard the music playing in the dining room and stopped to listen to it. She was told the resident started clapping her hands and then staff members noticed her trying to take her pants off. The daughter stated she was called a little after 5:00 p.m. by a nurse. She was told resident #1 had burnt herself with hot water and it was pretty bad. On 04/22/14 at 9:50 a.m., LPN (licensed practical nurse) #1 was asked if any residents carried their own hot water, hot coffee or any hot liquids to their rooms. She stated, "Yes, two residents are always doing it." LPN #1 was asked who the two residents were that carried hot liquids to their rooms. She stated, "(resident #4) carries hot coffee in a coffee cup and (resident #5) has a thermos he has filled with hot coffee from the kitchen." At 10:07 a.m., resident #4 was observed in the hallway walking with her cane and an uncovered cup of coffee. The resident asked a staff member to get her wheelchair and take her to the dining room. A staff member was observed pushing resident #4 in her wheelchair. Resident #4 was holding the uncovered cup of coffee in her hands while being pushed down the hallway. At 10:20 a.m., the Assistant Dietary Manager was asked if any residents received hot water or hot coffee from the kitchen on their own. She stated there was one resident who wanted decaffeinated coffee and her daughter had instant decaffeinated coffee for the resident in her room. She stated the resident had a thermos that she brought to the kitchen door and the kitchen staff would fill it with hot water and screw the top back on the thermos. She was asked the name of this resident and she stated resident #1. She was asked to describe the thermos. She stated, "The thermos was more like a mug with a screw on lid with a hole in the top." She stated she heard the resident received a burn from hot water out of her thermos. She was asked if she saw the resident get burned by the hot water. She stated, "No." She remembered she saw the resident get the hot water and leave with the water in her hands. She was asked if there were any other residents who received hot water or hot coffee out of the kitchen. She stated resident #5 has a thermos with a screw on top that he gets coffee with and takes back to his room and resident #4 who receives hot coffee in a coffee cup that is covered with cellophane. At 10:40 a.m., the Dietary Manager was asked how residents who wanted hot water or coffee out of the kitchen received it. She stated they would come to the kitchen door and ring the doorbell and staff would get them what they wanted and hand it to them through the open kitchen door. At 10:42 a.m., two coffee machines and one hot water outlet were observed in the kitchen. She stated the hot water outlet had been disconnected after a resident had been burned by hot water she received out of the kitchen. She was asked who the resident was that was burned by the hot water. She stated resident #1. She was asked how resident #1 received hot water from the kitchen. She stated, "Due to her culture she wanted extremely hot water. She would bring a thermos to the door and say 'hot water.' That was all the English she could speak. Staff would give her the hot water and screw the lid back on. She would unscrew the lid and check to see if the water was hot and them put the lid back on. She would put the hot water thermos by her side and propel down the hall." She stated the resident's daughter had come to her demanding her mom be given hot water for culture reasons. She was asked to describe the thermos the resident would use to get hot water. She stated it was silver with a black cap and was about the size of a water bottle with a screw on lid. She was asked if she saw the hot water accident. She stated, "No, I heard about it." She was asked to take the temperature of the water at the hot water outlet. She stated it had been turned off. She was asked what the temperature was of the hot water coming out of the outlet before it was turned off. She stated, "180 to 190 degrees." At 10:50 a.m., the Dietary Manager and the Administrator brought dietary notes kept by the DM. The Dietary Manager and Administrator was asked if the resident kept food in her room. The ADM stated, "The daughter brought all kinds of foods and decaffeinated coffee to keep in her room." The Dietary Manager was asked for a policy on dispensing hot liquids from the kitchen to residents. She stated if she had a policy for dispensing hot liquids from the kitchen she would make a copy. There was no policy provided by the exit meeting. At 12:49 p.m., dietary aide #2 was asked to take the temperature of the coffee out of the coffee maker tanks. The coffee temperature was 149 degrees Fahrenheit. At 12:52 p.m., the Dietary Manager was asked who the dietary staff member was who gave resident #1 the hot water. She stated, "The Assistant Dietary Manager." The Assistant Dietary Manger was asked if she gave resident #1 the hot water on the night she was burned. She stated, "Yes. She came to the door." The Assistant Dietary Manager was asked what the resident did after she was given the hot water. She stated, "I don't know. I gave it to her at the door , she put it behind her back and left." At 1:05 p.m., the DON (director of nurses) was asked if resident #1 had a care plan for the food in her room and requesting hot water in a thermos at the door of the kitchen. She stated she thought there was one and she would look. At 1:30 p.m., the DON stated there was no care plan prior to the one dated 11/28/13 for resident #1.

Based on clinical record review, review of incident reports, review of policy/procedures and staff interviews, it was determined the facility failed to develop and implement interventions and approaches and; failed to provide supervision to prevent falls for one (#2) of 25 sampled residents identified with falls. The fall on 02/13/13, for resident #2, resulted in a fracture to the resident's left Tibia. Findings: Resident #2 was admitted with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident required extensive assistance with one person assistance for transfers, ambulation, dressing, hygiene and bathing. A quarterly assessment, dated 02/26/13, documented the resident required extensive assistance with one person assistance for transfers, ambulation, dressing, hygiene and bathing. A care plan, dated 05/24/12 and last updated on 02/26/13 documented, "RAP/Problem/Need... I am at risk for falls R/T limited mobility, (arrow down) safety awareness, dx Glaucoma... Impaired Balance, Takes routine Hypnotic, Takes routine Narcotic pain Meds... 2-13-13 To hosp - L Tibia Fx... Goal... Dignity will be maintained Resident will not experience injuries from falls over the next 90 days... CPOC- 8/24/12... CPOC- 12/6/12... CPOC- 3-6-13... CPOC- 5/24/13... Approach... 1) Encourage resident to ask for assistance of staff 2) Ensure call light is in reach, answer promptly 3) Therapy to eval and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance - as tolerated 7) observe For s/s of side effects to med..." "RAP/Problem/Need... I have a history of falls, and must have assist with all transfers and w/c for mobility... 8-20-12 fell ... 7-10-12 fell ... 9-4-12 fell ... 9-12-12 fell ... 2/13 - Fall c Fx to L Tibia... Goal... Dignity will be maintained Resident will not experience injuries from falls over the next 90 days... CPOC- 8/24/12... CPOC- 12/6/12... CPOC 3-6-13... CPCO 5-24-13... Approach... 1) Encourage resident to ask for assistance of staff 2) Ensure call light is in reach, answer promptly 3) Therapy to eval and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance - as tolerated..." No new approaches were added to the care plan from 05/24/12 to 02/26/13 to decrease risk of falls. A nurse's note, dated 01/27/13 at 4:15 a.m., documented, "...Bed in lowest position. Assisted off of floor..." A nurse's note, dated 02/07/13 at 1:00 p.m., documented, "...Resident slipped out chair onto floor on knees..." At 4:50 p.m., "...resident found on all 4's on floor beside bed..." A nurse's note, dated 02/12/13 at 9:15 a.m., documented, "...Alerted to room by CNA, resident was lying on floor L side..." A nurse's note, dated 02/13/13 at 9:22 a.m., documented, "...resident found lying in front of toilet c L leg bent behind her c foot twisted outward...Encouraged resident not to pull @ leg. resident conts to try and pull let (leg) but starts yelling out..." At 9:30 a.m., "...EMSA here. Unable to move resident. First responders called for assistance in moving resident. Residents leg mobilized..." No new interventions or approaches documented in nurse's notes or on incident reports to decrease risk of falls. On 03/25/13 at 1:45 p.m., the DON was asked who was responsible for updating care plans. She stated, the MDS coordinator. She was then asked if care plans should be updated to reflect interventions used to decrease risk for falls. She stated, "Yes."