Every finding on record at Skiatook Nursing Home,Llc

Based on record review and interview, the facility failed to recognize and submit a report of abuse within 2 hours for 2 (#1 and #2) of 3 sampled residents reviewed for abuse. The DON identified 32 residents resided in the facility. Findings: An undated policy titled Policy and Procedure Regarding Responsibility to Report Allegations of Resident abuse, suspected Criminal Acts, Injury of Unknown Source, Neglect, Misappropriations of Property, and Exploitation, read in part, It is the policy of this facility to act on all allegations of abuse, neglect, misappropriation of resident property, exploitation, injuries of unknow source and suspected criminal acts which include reporting the allegations within the prescribed time frame to the appropriate authorities.An initial incident report made to the OSDH, dated 07/28/25, showed CNA #2 witnessed incidents of abuse on 07/27/25. The report showed CNA #2 reported to the administrator CNA #1 got in Resident #1's personal space and forced them to sit on the toilet. The report showed afterward Resident #1 pushed CNA #1, who then pushed the resident back. The report showed CNA #2 reported to the administrator CNA #1 rolled Resident #2 into the wall while changing the resident's bedding. The report showed Resident #2 hit their knees on the wall, causing some discoloration to their knees. On 11/18/25 at 12:00 p.m., the DON stated abuse incidents must be reported to OSDH within two hours. On 11/18/25 at 12:20 p.m., the administrator stated they expected the staff to report abuse immediately. The administrator stated abuse must be reported to OSDH within 2 hours.

Based on record review and interview, the facility failed to ensure residents were free from abuse for 2 (#1 and #2) of 3 sampled residents reviewed or abuse. The DON identified 32 residents resided in the facility. Findings: An undated facility policy titled Policy and Procedure Regarding Prohibition of Resident Abuse Including Corporal Punishment, Neglect and exploitation, read in part, Definitions: Abuse is the willing infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. An incident report, dated 07/28/25, showed CNA #2 reported to the administrator CNA #1 got in Resident #1's personal space and forced them to sit on the toilet. The report showed afterward Resident #1 pushed CNA #1, who then pushed the resident back. The report showed CNA #2 reported to the administrator CNA #1 rolled Resident #2 into the wall while changing the resident's bedding. The report showed Resident #2 hit their knees on the wall, causing some discoloration to their knees. 1.An undated admission form showed Resident #1 had diagnoses which included dementia and Alzheimer's disease. A quarterly assessment, dated 11/13/25, showed Resident #1 was severely cognitively impaired with a BIMS of 2.2. An undated admission form showed Resident #2 had diagnoses which included dementia, anxiety, and OCD.A quarterly assessment, dated 11/06/25, showed Resident #2 was moderately cognitively impaired with a BIMS of 9.On 11/18/25 at 11:02 a.m., the administrator stated CNA #2 called them on 07/28/25 and reported on the evening shift of 07/27/25 CNA #1 was rough with Resident #1 by forcing them down onto the toilet. They stated Resident #1 pushed CNA #1 and CNA #1 pushed the Resident #1 back. The administrator stated CNA #2 also reported that while changing Resident #2's bedding CNA #1 rolled Resident #1 into the wall causing bruising to the resident's knees. The administrator stated when they attempted to interview CNA #1 over the phone regarding the incidents, they became belligerent, and stated they were quitting. The administrator stated they did in-services with the staff regarding abuse.

Based on record review and interview, the facility failed to ensure assessments were transmitted within seven days of completion for eight (#5, 11, 15, 16, 17, 18, 21 and #92) of 14 sampled residents whose assessments were reviewed. The administrator identified 38 residents who resided in the facility. Findings: 1. Resident #5 had diagnoses which included chronic obstructive pulmonary disease. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/11/24, had been submitted late. 2. Resident #11 had diagnoses which included cardiorespiratory conditions. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/27/24, had been submitted late. 3. Resident #15 had diagnoses which included depression. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/20/24, had been submitted late. 4. Resident #16 had diagnoses which included stroke. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/16/24, had been submitted late. 5. Resident #17 had diagnoses which included stroke. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/17/24, had been submitted late. 6. Resident #18 had diagnoses which included diabetes mellitus. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/20/24, had been submitted late. 7. Resident #21 had diagnoses which included cardiorespiratory conditions. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/28/24, had been submitted late. 8. Resident #24 had diagnoses which included bipolar disease. The MDS 3.0 NH Final Validation Report, dated 09/30/24 documented the quarterly assessment, dated 08/20/24, had been submitted late. On 10/04/24 at 10:36 a.m., the administrator stated they were aware MDS assessments were not transmitted timely.

Based on interview and record review, the facility failed to ensure comprehensive care plans were accurate for two (#14 and #31) of three sampled residents who were reviewed for revision of care plans. The administrator identified 38 residents who resided in the facility. Findings: 1. Resident #14 had diagnoses which included vascular dementia, chronic obstructive pulmonary disease, dysphagia, and weight loss. The care plan, dated 08/21/24, did not address any issues with food, difficulty eating, or swallowing. A physician order, dated 09/28/24, documented an order for a speech evaluation. A speech evaluation, dated 09/28/24, determined a regular diet, regular texture, and thin consistency for fluids with compensatory strategies was appropriate. The compensatory strategies included chin tuck, effortful swallows, small bits, and reflux precautions. 2. Res #31 had diagnoses which included metabolic encephalopathy and dementia. A physician order, dated 05/10/24, documented an order for hydroxyzine HCl (antihistamine medication) oral tablet 25 mg. Give 1 tablet by mouth every 4 hours as needed for anxiety. A physician order, dated 05/17/24, documented an order for Cymbalta (SNRI medication) 60 mg. Give 1 capsule by mouth one time a day for depression. A physician assessment, dated July 2024, documented a diagnosis of anxiety. The care plan, dated 08/22/24, did not document a diagnoses of depression or anxiety. It did not document behavior monitoring or assessments for side effects of the prescribed medications. On 10/03/24 at 8:36 a.m., the DON stated medications should not be prescribed unless the resident had a diagnosis for that medication and care plans should be updated with new diagnosis and physician order. On 10/03/24 at 10:51 a.m., the DON provided documentation with the diagnosis of anxiety for Resident #31. They stated the diagnoses list in the resident record, including the care plan, had not been updated. On 10/04/24 at 10:36 a.m., the administrator stated they were aware some care plans were not updated. They stated they had a process in place and were trying to bring all records up to date.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#31) of 14 sampled residents whose resident assessments were reviewed. The administrator identified 38 residents who resided in the facility. Findings: Resident #31 had diagnoses which included metabolic encephalopathy, dementia, acute pain, and diabetes mellitus. A physician order, dated 05/17/24, documented an order for Cymbalta (SNRI medication) 60 mg. Give 1 capsule by mouth one time a day for depression. A physician assessment, dated July 2024, documented a diagnosis of anxiety. The MDS, dated [DATE], did not document a diagnosis of depression or anxiety. The care plan, dated 08/22/24, did not document a diagnosis of depression or anxiety. On 10/04/24 at 10:36 a.m., the administrator stated they were aware some resident MDS's and care plans were not updated. They stated they had a process in place and were trying to bring all records up to date.

Based on interview and record review, it was determined the facility failed to provide Notices of Medicare Non-Coverage for skilled services for three (#20, 21, #22) for three residents who were reviewed for beneficiary protection notification. The administrator identified three residents who had been discharged from medicare skilled services in the last six months. Findings: Resident #20 was admitted to Part A skilled services on 05/24/23, discharged from skilled services on 07/01/23 and remained in the facility. Resident #21 was admitted to Part A skilled services on 04/13/23, discharged from skilled services on 06/14/23 and left the facility. Resident #22 was admitted to Part A skilled services on 08/25/23, discharged from skilled services on 10/11/23 and left the facility On 10/30/23 at 2:30 p.m., the administrator was asked to provide the Notice of Medicare Non-Coverage (NOMNC), for the three residents discharged in the last six months. They stated they would ask the business office manager for them. On 10/30/23 at 2:45 p.m., the business office manager stated that according to the chart they received at a training conference, the residents did not require a Notice of Medicare Non-Coverage. Review of the chart revealed incorrect information from 2018. On 10/30/23 at 3:00 p.m., the administrator stated the correct notices were not provided.

On 05/05/22 at 5:17 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to smoking in the building while wearing oxygen. The facility did not have policies and procedures in place to address smoking material storage for residents who were on oxygen and/or who required supervision to smoke, and failed to assess/reassess residents for smoking safety. On 05/05/22 at 1:10 p.m., a resident who was blind was observed in their room wearing oxygen while smoking a cigarette. At 5:30 p.m., the administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 05/06/22 at 10:00 a.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: 5.5.2022 7:30 PM Proposed IJ Plan of Removal Immediate action: Approximately 1:30 PM May 5, 2022, All residents were asked to produce all cigarette lighters until smoking assessments are completed and it is determined that the resident is safe to maintain their cigarette lighter in their possession. Staff education started at 2:22 PM, May 5, 2022 with the last employee being educated at 6:35 PM May 5, 2022, regarding the storage of cigarette lighters until individual residents were assessed and deemed safe to maintain their lighters. Staff were educated by the Administrator and Director of Nursing. In their absence, the Certified Assistant Administrator or Charge Nurse. All staff will monitor and ensure all smoking residents do not have cigarette lighters on their person or in their room. All cigarette lighters will be maintained in a secure area and staff will access lighters upon request of the resident and retrieve lighters when residents return inside from smoking. Any staff member who observes a resident with a lighter will ask the resident for the lighter and give a reminder that they can obtain the lighter at any time they wish to go outside to smoke. Staff will supervise residents who are deemed unsafe to smoke independently. Residents will have a smoking assessment completed upon admission, on a quarterly basis, or if their condition changes. Staff will report any unsafe behavior or changes to the charge nurse immediately. Staff will observe to ensure that no one is smoking or introducing an open flame near oxygen. We will complete evaluations for each resident and return lighters to those residents who are capable of safely smoking in designated areas without assistance. Residents requiring assistance will have lighters maintained in a secure area. A policy revision was made, please see attached document. All Direct Care staff, Administrative staff, Social, and Activity staff, will be educated no later than 11:59 PM Thursday May 5, 2022. In the event a staff member is not available due to being out of town, on medical leave, etc., they shall be educated prior to being allowed to work their next shift. An alert message has been included in the Electronic Medical Record (EMR) to identify individual residents who are smokers and at what level they have been assessed for smoking. The medical record alert will identify smoking status and the level in which they are deemed to be supervised or unsupervised. Residents who do not require supervision will be provided a lock box to maintain their smoking materials. Residents who require extensive supervision will be identified and their cigarettes and lighting device will be maintained in a secure area and made available upon request. Residents who are utilizing oxygen will be allowed to keep their cigarettes without a lighting device if they meet the criteria for unsupervised smoking they will not be allowed to maintain their lighting device due to oxygen use. On 05/06/22 from 10:59 a.m. to 12:32 p.m., interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Residents were interviewed and stated they did not have their lighters in their room. Residents were observed obtaining their lighters from the nurses prior to going to smoke and were observed returning their lighters to the nurses after smoking. No lighters were found in the resident rooms. At 12:35 p.m., the administrator was notified the IJ was lifted effective 05/05/22 at 11:59 p.m. and the deficiency remained at a level of harm with a limited number of residents affected. Based on record review, observation, and interview, the facility failed to ensure: a. Residents who utilized oxygen were supervised to ensure they smoked without wearing oxygen, in a designated smoking area, and were assessed for smoking safety for one (#22) and; b. Residents who utilized oxygen and/or required smoking supervision were not allowed to keep their smoking materials in their room for four (#6, 13, 22, and #35) of five sampled residents who were reviewed for smoking safety. The administrator identified nine residents who smoked and three residents who smoked and utilized oxygen. Findings: The facility's smoking policy, dated 04/11/17, read in parts, .No resident .shall smoke on the property of this facility unless the following regulations are followed .Not inside of any building .Each resident who chooses to smoke will be assessed on their ability to smoke safely . The administrator reviewed the list of residents who smoked and identified the following residents who required supervision while smoking: Resident #6, #13, and #22. The administrator also identified the facility stored resident #6's smoking material and resident #13's lighter. The administrator stated they were unsure of the status of smoking supervision required for two other residents. 1. Resident #22 had diagnoses which included cortical [CONDITION(S)] (loss of vision without any ophthalmological causes). A care plan, dated 12/30/20, read in part, .[name withheld] chooses to smoke tobacco products .vision is severely impaired .requires staff supervision .staff will hold the lighter to light the cigarette . A care plan revision, dated 4/7/21, read in part, .[name withheld] keeps one pack of cigarettes or less and a lighter in her room . Physician orders, dated May 2022, documented the resident was to receive oxygen at 2 LPM via nasal cannula as needed for shortness of breath and to maintain oxygen saturation above 90%. On 05/05/22 at 1:10 p.m., cigarette smoke was smelled in the hallway of the long hall. Housekeeper #1 was in the hall and stated they also smelled the cigarette smoke. Housekeeper #1 yelled down the hall for the DON and stated She is smoking. Resident #22 was in their room with the oxygen concentrator on with a lit cigarette. The DON was observed leaving the resident's room with a folded plastic lid containing the cigarette. At 1:12 p.m., resident #22 was observed sitting in their wheelchair in their room with oxygen on via nasal cannula. Resident #22 stated It's my fault, I thought I was outside. Resident #22 stated the cigarettes and lighter were in the pocket on the wheelchair. At 1:16 p.m., the administrator stated resident #22 kept cigarettes and lighter in their room. The administrator stated resident #22 would usually ask if they wanted to go out to smoke. The administrator stated resident #22 required supervision to smoke due to [CONDITION(S)]. At 1:35 p.m., the administrator identified two other residents who smoked and utilized oxygen. The two residents who utilized oxygen were both observed to have cigarettes and lighter in their room. At 1:45 p.m., CNA #2 stated resident #22 usually smoked outside with supervision. At 2:05 p.m., resident #22's family member was asked about the resident smoking in the room. Resident #22's family member stated the resident was not usually like this. Resident #22 stated, I thought I was on the patio smoking. At 3:04 p.m., the DON stated they were unsure which residents, who required supervision while smoking, and/or had smoking materials stored in their room. The DON stated the facility determined residents were safe to keep smoking materials in their room by assessing their cognition. The DON stated residents who needed supervision to smoke should not keep their smoking materials in their room. A review of resident #22's electronic clinical record did not reveal a smoking assessment had been completed prior to 05/05/22 at 1:16 p.m. 2. Resident #6 had diagnoses which included [CONDITION(S)] and [CONDITION(S)] (Muscle weakness or [CONDITION(S)] of one side of the body.) following a cerebral infarction (stroke) affecting the left non-dominant side. A smoking safety screen, dated 04/07/22, read in parts, .Does resident need facility to store .cigarette .Yes .Safe to smoke with supervision .resident is in geri chair and cannot extinguish smoking materials without assistance . On 05/05/22 at 1:28 p.m., resident had two packs of cigarettes located in the top drawer of the dresser in the resident's room. At 3:04 p.m., the DON stated resident #6's smoking assessment, dated 04/7/22, documented the facility stored the resident's cigarettes and the resident required supervision to smoke. 3. Resident #13 had diagnoses which included dementia and altered mental status. A care plan, dated 03/08/22, read in part, .staff will encourage .to smoke with supervision .keeps .cigarettes and lighter in the top dresser drawer . A smoking safety screen, dated 02/15/22, read in parts, .Does resident have cognitive loss .Yes . On 05/05/22 at 3:02 p.m., the DON stated resident #13 was safe to smoke and store their cigarettes according to the smoking assessment dated [DATE]. The DON stated resident #13 now needed supervision to smoke due to falls and medication changes. The DON stated they did not think resident #13 kept their cigarettes and lighter in the room. The DON stated the smoking assessment had not been updated with the change. 4. Resident #35 had diagnoses which included extrapyramidal and movement disorder. A smoking safety screen, dated 03/16/22, read in parts, .Does the resident have any dexterity problem(s) .Yes .Does resident need facility to store lighter and cigarettes .Yes . Physician orders, dated May 2022, documented the resident was to receive oxygen at 3 LPM via nasal cannula as needed for shortness of breath and to maintain oxygen saturation above 90%. On 05/4/22 at approximately 3:20 p.m., during an interview with resident #35 cigarettes and a lighter were observed on the resident's bedside table.

Based on record review, observation, and interview, the facility failed to ensure residents were provided privacy during the provision of care for two (#22 and #34) of two sampled residents who were reviewed for privacy. The administrator identified 37 residents resided in the facility. Findings: 1. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated May 2022, documented the resident was to receive wound care to the left and right lower extremities every day shift and bilateral compression dressings on Monday, Wednesday, and Friday, day shift. On 05/11/22 at 10:52 a.m., LPN #1 was observed initiating wound care to resident #22 without providing privacy by closing the resident's door. At 5:58 p.m., LPN #1 stated she had not shut the door to resident #22's room prior to initiating wound care because the care wasn't anything private, it was her legs. On 05/12/22 at 9:18 a.m., the DON stated the resident's door should have been closed during wound care or if the room was semi-private, the privacy curtain should have been pulled. 2. Resident #34 had a indwelling urinary catheter. On 05/11/22 at 4:27 p.m. LPN #1 was observed to provide catheter care to resident #34. LPN #1 did not close the resident's door or privacy curtain during care. LPN #1 stated she did not close the door because nobody ever came down that hall. On 05/12/22 at 9:20 a.m., the DON stated the resident's door should be closed during catheter care.

Based on record review, observation, and interview, the facility failed to have an effective system to denote a resident's resuscitation status for three (#7, 22, and #31) of three residents who were reviewed for advance directives. The administrator identified 37 residents who resided in the facility. Findings: 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the electronic clinical record revealed the resident did not have an advance directive. The electronic clinical record did not have a current physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic clinical record revealed the resident had an Advance Directive for Health Care and a signed Do Not Resuscitate (DNR) Consent Form. The electronic clinical record did not have a current physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic clinical record revealed no current physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/09/22 at 12:42 p.m., CNA #3 was asked how they would identify a resident's code status in an emergency. CNA #3 stated That's a really good question. CNA #3 was asked if the facility had a system in place to identify the residents' code status. CNA #3 stated no. CNA #3 stated, I do not know anybody's code status. On 05/09/22 at 12:44 p.m., LPN #4 stated the DON and the MDS coordinator were responsible for the advance directive. The LPN stated the physician orders the code status and the CNAs and nurses check the electronic clinical record for the code status. LPN #4 stated resident #22 had a signed DNR but there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 stated they did not see a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 was asked how the staff would know resident #7, #22 or resident #31's code status. The LPN stated they would have to ask. On 05/09/22 at 12:45 p.m. CNA #2 stated they would look in the computer for the resident's code status. CNA #2 was asked what the code status was for Resident #7, 22, and #31. CNA #2 looked in the computer and stated their code status was not listed on the care plan or the face sheet. On 05/09/22 at 1:00 p.m., CNA #4 was asked how they knew a resident's code status. CNA #4 stated there was an alert in the computer by the resident's name. CNA #4 stated they thought resident #7 was a DNR, resident #22 was a full code, and they were not sure the code status of resident #31. CNA #4 looked in the computer and stated the code status for resident #7, #22 and #31 was not in the computer. At 1:02 p.m. the DON stated the DON was ultimately responsible for the Advance Directive. The DON stated a resident's code status should be located in the electronic clinical record but they were not all there. The DON was asked how staff would know a resident's code status. The DON stated they would not know.

Based on record review and interview, the facility failed to ensure services were provided to increase or prevent further decrease in range of motion for two (#7 and #26) of three residents reviewed for range of motion. The administrator identified 15 residents with limited range of motion. Findings: A review of the March and April 2022 restorative therapy schedule revealed no restorative therapy was documented 03/04/22 through 03/16/22 or 04/18/22 through 04/30/22. 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment (a resident assessment tool used to identify resident care needs), dated 02/17/22, documented the resident required extensive assistance with bed mobility and transfers and received restorative nursing therapy passive range of motion two of the past seven days. An ADL care plan, dated 02/17/22, read in parts, .has an ADL self-care performance deficit r/t Severe Intellectual Disability .left hip fracture .participates in the restorative care program . A care plan, dated 02/18/22, read in parts, high risk for falls r/t Severe Intellectual Disability, [CONDITION(S)] .left Hip Fracture .is non-ambulatory and utilizes a geri-chair .participates in the Restorative Care Program . On 05/11/22 at 1:09 p.m., CNA #7 stated they did not perform range of motion exercise on residents, the physical therapy staff performed ROM exercises. At 1:54 p.m., the MDS coordinator stated resident #7 should be getting restorative therapy from the physical therapy department. At 5:07 p.m., the COTA was asked how often resident #7 was receiving range of motion services. The COTA stated it varied and depended on what the schedule allowed. The COTA stated ideally the resident would receive restorative therapy three days a week. The COTA stated resident #7 had not received any restorative therapy for the month of May. The COTA was asked about the plan of care for resident #7. The COTA stated resident #7 was on therapy for a fractured hip and then was placed on restorative therapy. The COTA stated she had a flow sheet and kept notes on what ROM therapy resident #7 received. The COTA was asked if the nursing department provided any restorative therapy. The COTA stated, Not to my knowledge. 2. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 04/05/22, documented the resident required extensive assistance with bed mobility, was totally dependent on staff for transfers, had limitation in upper extremity range of motion on one side, and limitation in lower extremity range of motion on both sides. A care plan, dated 04/14/22, documented the resident had limited physical mobility and participated in the Restorative Care Program. A review of resident #26's electronic clinical record did not reveal restorative therapy documentation. On 05/11/22 at 3:27 p.m., the PTA stated the COTA had been performing restorative therapy because the facility did not have a trained CNA to perform restorative therapy. On 05/11/22 at 5:06 p.m., the COTA stated they scheduled residents for restorative therapy after they have been discharged from skilled therapy or after receiving a referral from nursing. The COTA stated the resident's care plan would reflect participation in the restorative program. The COTA stated so far in May, they had not provided restorative therapy at the facility. The COTA stated resident #26 had never received restorative therapy. At 5:28 p.m., the MDS coordinator stated resident's care plans would be updated to include restorative therapy after an interdisciplinary team discussion. The MDS coordinator stated the COTA would receive a list of residents for restorative therapy. The MDS coordinator was asked why resident #26 had not received restorative therapy as indicated in the resident's care plan. The MDS coordinator stated possibly miscommunication, they thought the resident was receiving restorative therapy.

Based on record review, observation, and interview, the facility failed to ensure: a. Infection control was maintained during wound care for one (#28) of one sampled resident who was observed for wound care; b. PPE was worn when providing care to a resident who was on contact isolation for one (#34) of one resident who was on transmission based precautions; c. Infection control was maintained during a finger stick blood sugar test for one (#10) of three residents who were observed during a finger stick blood sugar test; and d. Infection control was maintained during personal care for one (#31) of one sampled resident who was observed for personal care. The DON identified 37 residents who resided in the facility, one resident who was on transmission based precautions, and 18 residents who received finger stick blood sugar tests. Findings: 1. On 05/04/22 at 3:02 p.m., resident #28 was observed at the nurses' station with blood on their arm. LPN #1 cleansed the skin tear at the treatment cart in the hall, after cleansing the skin tear, the LPN did not perform hand hygiene. LPN #1 donned a new pair of gloves and retrieved the steri strips from inside the cart. LPN #1 placed the steri strips on the resident's arm, removed their gloves, and returned the wound cleanser to the cart. LPN #1 did not perform hand hygiene after providing the wound care. LPN #1 left the cart and went to the smoking area. On 05/04/22 at 3:48 p.m., LPN # 1 stated they were not sure why hand hygiene had not been performed during wound care to the skin tear on resident #28's arm. 2. Resident #34 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a cart outside the room with PPE supplies. Resident #34 had a sign on the door indicating gown and gloves were required prior to entering the room. On 05/10/22 at 9:14 a.m., CNA #1 removed the gown and gloves while in resident #34's room. CNA #1 picked up dishes in the resident's room with bare hands, left the room, and went to the dining area counter. CNA #1 then returned to resident #34's room without donning gloves or gown prior to entering the room. CNA #1 then touched resident #34's blanket. At 9:27 a.m., CNA #1 stated resident #34 was on isolation for an infection of the foot. CNA #1 stated she had not worn gloves when she touched the dishes or blanket but had used hand sanitizer. On 05/10/22 at 9:31 a.m., the DON stated resident #34 had [CONDITION(S)] in the wound on left ankle. The DON stated staff should wear yellow gown and gloves when entering the room. The DON stated the staff should have worn gloves when they touched the dirty dishes and the blanket in resident #34's room. On 05/11/22 at 4:02 p.m., LPN #1 was observed performing wound care to resident #34's wound. LPN #1 donned PPE and brought supplies into the room, LPN #1 removed the dressing to resident #34's wound. LPN #1 stated they had forgotten the normal saline. LPN #1 removed their gloves and used hand sanitizer. LPN #1 then left resident #34's room with the isolation gown on and went to the nurse's treatment cart. On 05/12/22 at 9:19 a.m., the DON stated the nurse should have removed the isolation gown before they left the room to get more supplies for wound care. 3. Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Physician orders, dated May 2022, documented the resident was to receive a finger stick blood sugar test before meals and at bedtime. On 05/10/22 at 7:46 a.m., LPN #5 was observed to sanitize hands, donn gloves, enter the resident's room, and prep the resident's skin for a finger stick blood sugar test. The LPN received an error after placing the test strip in the glucometer, returned to the treatment cart, and obtained another test strip from the canister. The LPN was not observed to change gloves or sanitize hands before obtaining the second test strip from the canister. On 05/10/22 at 10:15 a.m., LPN #5 stated the finger stick blood sugar test strips were shared among residents. The LPN stated they had tried to tip the canister to obtain the second test strip for resident #10 but stated that did not ensure infection control. 4. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/04/22 at approximately 2:00 p.m., two CNAs were observed providing personal care to resident #31. Following the provision of personal care, without performing hand hygiene, CNA #2 was observed to straighten the resident's bed linens, remove one glove, and hand the resident their call light and water pitcher. On 05/11/22 at 2:03 p.m., CNA #2 stated they ensured infection control when providing personal care by performing hand hygiene and using clean gloves. The CNA stated they failed to perform hand hygiene during personal care for resident #31 because they were nervous.

Based on record review and interview, the facility failed to ensure residents/representatives signed acknowledgement of the advance notice of discharge from Medicare Part A skilled services for one (#34) of three sampled residents who were reviewed for beneficiary protection notification. The DON identified three residents who had been discharged from Medicare Part A skilled services, with benefit days remaining, in the last six months. Findings: An undated facility instruction sheet titled, Form Instructions Advance Beneficiary Notice of Noncoverage (ABN), read in part, .Signature Box .Once the beneficiary reviews and understands the information contained in the ABN, the Signature Box is to be completed by the beneficiary (or representative) .The beneficiary (or representative) must sign the notice to indicate that he or she has received the notice and understands its contents . Resident #34's Medicare 5-day MDS assessment (a resident assessment tool used to identify resident care needs), dated 03/02/22, documented the resident was moderately impaired in cognition and participated in completion of the assessment. Form CMS- , Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), was signed by the DON and MDS coordinator and dated 03/02/22. Neither the resident nor a representative signed the notice. Form CMS -NOMNC, Notice of Medicare Non-Coverage, was signed by the DON and MDS coordinator and dated 03/02/22. Neither the resident nor a representative signed the notice. The clinical record revealed resident #34 was discharged from Medicare part A skilled services on 03/03/22, but remained in the facility. A review of the resident's contact information in the clinical record revealed three family members were listed as contacts. On 05/11/22 at 12:10 p.m., the MDS coordinator stated the family had initiated ending the resident's skilled services. The MDS coordinator stated the family could not be reached to sign the Notice of Medicare Non-Coverage or the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage. The MDS coordinator stated although discontinuation of skilled services had been discussed with the family, it had not been documented.

Based on interview and record review, it was determined the facility failed to: ~Ensure [MEDICAL CONDITION] medications ordered on an as needed basis were not ordered for more than 14 days for two (#20 and #1) of three sampled residents who the facility identifed as receiving an as needed [MEDICAL CONDITION] medication; and ~Discontinue the use of a [MEDICAL CONDITION] medication as ordered by the physician for one (#21) of five sampled residents whose records were reviewed for unnecessary medications. The Census and Condition identified 25 residents who received [MEDICAL CONDITION] medications. Findings: A policy titled, Policy For The Management of Resident Medication, dated (MONTH) (YEAR), documented, .It shall be the policy of this facility to maintain each resident's medication regimen free of unnecessary drugs .The facility, through a collaborative effort with the resident's physician, the consulting pharmacist and the interdisciplinary team, will make every effort to insure (sic) residents receive the dose and duration of medication necessary to treat the condition for which it was prescribed .For residents who require the use of these medications, gradual dose reductions will be attempted unless contraindicated . 1. Resident #20 had [DIAGNOSES REDACTED]. Monthly physician orders, dated (MONTH) (YEAR), documented, .[MEDICATION NAME] .0.5 MG TAB-GIVE 1 TAB PO Q 6 HRS PRN X 60 DAYS .DX: ANXIETY . The [MEDICATION NAME] had an ordered date of 09/12/16. Monthly medication regimen reviews, dated 11/15/18, 12/11/18, 01/03/19, and 02/12/19, documented the pharmacist recommended to discontinue the resident's use of [MEDICATION NAME] 0.5 mg on an as needed basis due to PRN use of a [MEDICAL CONDITION] medication being limited to 14 days. The physician had signed the recommendations but had not provided a rationale as to why he declined the resident's use of PRN [MEDICATION NAME]. A pharmacist recommendation, dated 03/13/19, recommended to discontinue the use of [MEDICATION NAME] on an as needed basis due to PRN use of a [MEDICAL CONDITION] medication being limited to 14 days. The physician declined the recommendation and documented the resident continued to have anxiety. A pharmacist recommendation, dated 04/10/19, recommended to discontinue the use of [MEDICATION NAME] on an as needed basis due to PRN use of a [MEDICAL CONDITION] medication being limited to 14 days. The physician documented to discontinue the medication. A quarterly assessment, dated 11/15/19, documented the resident was moderately impaired in cognition for daily decision making. A care plan, dated 11/22/19, documented the resident had anxiety and had taken [MEDICAL CONDITION] medications. On 01/08/20 at 10:37 a.m., the DON was asked what the facility policy was regarding the duration of PRN [MEDICAL CONDITION] medications. He stated they were to be limited to 14 days. He was asked why resident #20 had PRN [MEDICATION NAME] ordered from (MONTH) (YEAR) through (MONTH) 2019 with no clinical rationale documented by the physician. He stated the resident had always been on PRN [MEDICATION NAME] but did not know why the physician had not provided a clinical rationale. 2. Resident #1 had [DIAGNOSES REDACTED]. A physician order, dated 02/12/16 documented the resident was ordered [MEDICATION NAME] 0.5 mg by mouth every six hours PRN for anxiety. Monthly Pharmacist's recommendation for (MONTH) through (MONTH) 2019, documented PRN orders for [MEDICAL CONDITION] drugs were limited to 14 days and recommended discontinued use of the PRN [MEDICATION NAME]. The physician had not documented a rationale on any of the recommendations made on the monthly medication regimen reviews as to why he continued use of the [MEDICATION NAME]. Record review of the MARs, dated (MONTH) 2019 through (MONTH) 2019, revealed the resident had never been administered the PRN [MEDICATION NAME]. A pharmacist's recommendation, dated 05/02/19, documented PRN orders for [MEDICAL CONDITION] drugs were limited to 14 days and recommended discontinued use of the PRN [MEDICATION NAME]. The physician responded with an order to discontinue the [MEDICATION NAME]. On 01/08/20 at 10:37 a.m., the DON was asked why the physician had not addressed the pharmacist recommendation to discontinue the PRN [MEDICATION NAME]. He stated he could not give an answer as to why the physician had not responded to the recommendations with a rationale. He was asked who was responsible to ensure the physician responded to the pharmacist recommendations. He stated he was responsible. 3. Resident #21 had [DIAGNOSES REDACTED]. A Pharmacy consult, dated 02/12/19 documented, .Recommend re-evaluate current [DIAGNOSES REDACTED]. The physician responded with an order to discontinue [MEDICATION NAME]. A review of the MAR, dated (MONTH) through (MONTH) 2019, revealed the resident had been administered [MEDICATION NAME] 25MG daily. On 01/08/20 at 10:38 a.m., the DON was asked what the procedure was for recommendations made by the pharmacist on monthly medication reviews. He stated he was responsible for reviewing the pharmacist recommendations. He was asked what he looked for on the monthly pharmacy reviews. He stated any change in medication orders, any notes made by the physician, and the physician's rationale if not making changes as recommended by the pharmacist. He was asked why resident #21's [MEDICATION NAME] had not been discontinued as ordered by the physician on the monthly pharmacy review dated 02/12/19. He stated he was responsible for noting any physician orders [REDACTED]. He was asked what the procedure was after he noted physician orders [REDACTED]. He was asked who was responsible for ensuring the physician orders [REDACTED]. He stated he was responsible. He was asked who monitored the pharmacy reviews to ensure physician orders [REDACTED].

Based on interview and record review, it was determined the facility failed to ensure the physician had been notified of a significant weight loss for one (#1) of one sampled residents whose records were reviewed for weight loss. The facility identified six residents with a significant weight loss. Findings: An undated policy titled, Nutrition Policy, documented, .The resident will be assessed for weight gain or loss. The significant gain or loss will be reported to the resident's physician for possible diet adjustment . Resident #1 had [DIAGNOSES REDACTED]. An annual assessment, dated 06/28/19, documented the resident had a weight loss of 5% or more in the last month or loss of 10% in the last six months, was not on a physician prescribed weight loss regimen, and received a therapeutic mechanically altered diet. The resident's weights were documented as follows: ~ 09/19/19 = 152.2 pounds; and ~ 10/24/19 = 131.8 pounds. This revealed a significant weight loss of 13.4% in one month. On 01/07/20 at 5:12 p.m., the DON was asked how the facility identified weight loss. He stated the facility had a trend and tracking program that identified weight loss. He stated if the residents had a five percent loss or increase they would be weighed again for a comparison weight. He was asked how the physician had been notified of the resident's weight loss. He stated the dietitian reviewed the residents' weights once a month and made recommendations to the physician regarding weight loss. He was asked to provide the dietitian's documentation where she had notified the physician. On 01/08/20 at 9:59 a.m., the MDS coordinator was asked when weight loss was identified who was responsible to notify the physician. She stated the DON or any of the nurses. She was asked when the physician had been notified regarding the resident's weight loss. She stated when the dietitian identified any concerns regarding resident weights, recommendations were then faxed to the attending physician. She was asked how often the dietitian visited the facility. She stated once a month. She was asked if the dietitian was responsible for identifying weight loss. She stated the DON, nurses, and administrator discussed weights and identified any significant weight loss. On 01/08/20 at 10:53 a.m., the DON was asked who notified the physician regarding the resident's weight loss. He stated he did not know because the dietitian reviewed resident weights every month and faxed her recommendations directly to the physician. He was asked why a follow up weight had not been obtained for the resident after the (MONTH) weight loss. He stated the old scale had been re-calibrated and then the facility purchased a new scale. He stated when the weights were obtained using the new scale all resident weights had increased. Documentation regarding physician notification had not been provided by end of survey.

Based on observation, interview, and record review, it was determined the facility failed to ensure medications were administered per physician orders [REDACTED].#28) of 14 sampled residents whose medication administration was reviewed. The facility identified all 38 residents who resided in the facility received medications. Findings: Resident #28 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/06/19, documented the resident was cognitively intact and independent with most ADLs. A physician order, dated 12/12/19, documented .[MEDICATION NAME] Tablet 1 GM ([MEDICATION NAME]) Give 1 tablet by mouth before meals and at bedtime for gastrointestinal discomfort dissolve tablet in small glass of water . The MAR, dated (MONTH) 2020, documented, .[MEDICATION NAME] Tablet 1 GM ([MEDICATION NAME]) Give 1 tablet by mouth before meals and at bedtime for gastrointestinal discomfort dissolve tablet in small glass of water . On 01/08/20 at 9:40 a.m., CMA #1 was asked what the physician order [REDACTED].#28's [MEDICATION NAME] medication. She stated to give 1 tablet by mouth before meals and at bedtime for gastrointestinal discomfort dissolve tablet in small glass of water. She was asked why the [MEDICATION NAME] had not been dissolved in water when it was administered to the resident on 01/07/20. She stated the resident did not always like the medication dissolved in water, she wanted to take the pill whole. She was asked if the resident had been asked if she would take the [MEDICATION NAME] dissolved in water before administering the medication on 01/07/20. She stated no. At 9:45 a.m., LPN #1 was asked if the physician had been notified of the resident's request to not dissolve the [MEDICATION NAME] medication in water per physician order. She stated she was sure it had been mentioned during a physician visit. She was asked if the physician notification had been documented. She stated probably not. At 10:40 a.m., the DON was asked what the procedure was when a medication had not been administered per physician order. He stated the CMA or nurse would document why the medication had not been given per the physician order [REDACTED]. He was asked if the physician had been notified of resident #28's [MEDICATION NAME] medication not being dissolved in water as ordered. He stated if the physician had been notified, it would have been documented.

Based on interview and record review, it was determined the facility failed to ensure infection control data was analyzed for trends. This had the potential to affect all 32 residents who resided in the facility. Findings: A policy titled, Infection Prevention and Control Program, dated 04/26/17, documented, .trend the infections to identify patterns of infections . Review of the infection control log revealed the facility tracked infections on a monthly flow sheet. There was no documentation which indicated the infection control information had been analyzed for trends. On 11/05/18 at 3:22 p.m., the DON (Director of Nursing) was asked how he monitored infections in the facility. He stated he monitored physician orders [REDACTED]. He was asked why he did not analyze the infection data to determine if trends in infections had occurred from (MONTH) (YEAR) through (MONTH) (YEAR). He stated he was behind on them. By the end of the survey no further documentation had been provided to the survey team.

Based on interview and record review, it was determined the facility failed to initially report and submit a final report to the proper agencies regarding allegations of abuse in a timely manner for three (#16, #19, and #232) of three incident reports reviewed for allegations of abuse. This had the potential to affect all 32 residents who resided in the facility. Findings: A policy titled, Abuse, Neglect and Misappropriation of Client/Resident Property, Client/Resident To Client/Resident Occurrences and Injuries of Unknown Origin Reported or Alleged by Clients, Residents, Employees, Staff and Visitors, dated 10/10/18, documented, .Report/Respond .A report shall be made to the Health Department that the facility received and (Sic) allegation of abuse .within 24 hours of when the incident is reported or known about .If the event that caused reasonable suspicion result in serious bodily injury to a resident, the administrator, or his designee, shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .A report shall be made to the Health Department .within 24 hours of when the incident is reported or known about .upon completion of the investigation, a written report will be submitted within five (5) working days . On 11/08/18 at 11:27 a.m., the DON (Director of Nursing) was asked what the required time was for reporting to the proper agencies an allegation of abuse. He stated, I believe less than 2 hrs. He was asked why an allegation of abuse from resident #16 was not reported until three and a half hours after the allegation. He stated, I'm not sure, I can't give you an answer. He was asked why an allegation of abuse from resident #19 was not reported until ten hours and 20 minutes after the allegation. He reviewed the incident report and stated, It's another night shift incident. He was asked when an incident was reported to the State Health Department how long the facility had to submit a final report. He stated, Five business days. He was asked why a final report regarding an allegation of abuse for resident #232 had not been submitted for 8 working days. He stated, I don't have no idea.

Based on interview and record review, it was determined the facility failed to review and update their abuse policy and procedure in regards to reporting and submission of final reporting to the State Health Department for three (#16, #19, and #232) of three incident reports reviewed for allegations of abuse. This had the potential to affect all 32 residents who resided in the facility. Findings: A policy titled, Abuse, Neglect and Misappropriation of Client/Resident Property, Client/Resident To Client/Resident Occurrences and Injuries of Unknown Origin Reported or Alleged by Clients, Residents, Employees, Staff and Visitors, dated 10/10/18, documented, .Report/Respond .A report shall be made to the Health Department that the facility received and (Sic) allegation of abuse .within 24 hours of when the incident is reported or known about .If the event that caused reasonable suspicion result in serious bodily injury to a resident, the administrator, or his designee, shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .A report shall be made to the Health Department .within 24 hours of when the incident is reported or known about .upon completion of the investigation, a written report will be submitted within five (5) working days . On 11/08/18 at 11:27 a.m., the DON (Director of Nursing) was asked who was responsible for updating the facility policy and procedures. He stated he, the administrator, and the corporate nurse updated the policies and procedures. He was asked how often the policy and procedures were reviewed and updated. He stated, I don't know off the top of my head but I can find out. He was asked what the required time was for reporting to the proper agencies an allegation of abuse. He stated, I believe less than 2 hrs. He was asked why the facility's Abuse Policy and Procedure had not been updated to reflect that an allegation of abuse should be reported within 2 hours regardless of bodily injury. He stated, I wasn't aware. He was asked why an allegation of abuse from resident #16 was not reported until three and a half hours after the allegation. He stated, I'm not sure, I can't give you an answer. He was asked why an allegation of abuse from resident #19 was not reported until ten hours and 20 minutes after the allegation. He reviewed the incident report and stated, It's another night shift incident. He was asked when an incident was reported to the State Health Department how long the facility had to submit a final report. He stated, Five business days. He was asked why a final report regarding an allegation of abuse for resident #232 had not been submitted for 8 working days. He stated, I don't have no idea.

Based on observation and interview, it was determined the facility failed to: ~ Ensure bedside commodes were clean and sanitary for two (#20 and #4) of six residents whose bedside commodes were observed. The facility identified six residents who utilized a bedside commode; and ~ Ensure unoccupied resident rooms utilized for storage were kept secure for one (#38) of two storage rooms observed. The facility identified two unoccupied resident rooms were utilized for storage. Findings: 1. On 11/05/18 at 11:29 a.m., a strong urine odor was detected in resident #20's room. The bedside commode was observed to be one quarter to half full of urine and feces. A brownish, dried substance was observed on the frame of the bedside commode. At 4:00 p.m., the bedside commode was observed to be cleansed of the urine and feces. The brownish, dried substance remained on the frame. On 11/06/18 at 8:50 a.m., the bedside commode was observed to contain the same brownish, dried substance on the frame. On 11/08/18 at 1:45 p.m., resident #4's bedside commode was observed to have a brown substance on two areas of the seat. On 11/08/18 at 2:30 p.m., the administrator was asked who was responsible to clean and sanitize bedside commodes. She stated the CNAs (certified nurse aides). She was asked how the bedside commodes were monitored to ensure they were clean and sanitary. She stated the commodes should be observed every time a CNA entered the residents' room and cleaned after each use. 2. On 11/05/18 at 9:33 a.m., resident room [ROOM NUMBER] was unoccupied but observed to contain the following items: ~ One motorized wheel chair; ~ One geri chair; ~ Six standard wheelchairs; ~ Two beds; ~ One unassembled bed; ~ One two drawer plastic storage container; ~ Two plastic storage bins; ~ Four walkers; ~ Two bedside tables; ~ Three mattresses; ~ One beauty shop sink; ~ One large television; ~ One wooden dining room type chair; ~ One extra large plastic bin of Halloween decorations; and ~ One wheeled dolley. On 11/08/18 at 1:47 p.m., room [ROOM NUMBER] was observed to have added to previously identified stored items the following: ~ One small television; ~ Two overbed tables; and ~ One box with miscellaneous hoses and metal pieces. On 11/08/18 at 2:34 p.m., the administrator was asked why resident room [ROOM NUMBER] which was used for storage was unsecured. She stated she was unaware the room was not secured. She stated storage rooms were to be locked.

On 09/20/17, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent falls and to implement interventions to aid in the prevention of falls. Resident #11 had a fall on 09/12/17 that resulted in a fractured left patella. The resident had experienced 11 falls in the past five months with six of the falls resulting in injury. No new interventions had been implemented to prevent future falls. On 09/20/17 at 7:30 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 7:45 p.m., the administrator was informed of the IJ regarding falls. A plan of removal was requested and the facility was informed of being in extended survey. At 8:35 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Skiatook Nursing Home. LLC 7:47 PM 09/20/17 Plan of Removal for alleged IJ Lack of Supervision related to falls A staff member will be assigned to sit with (resident name deleted) around the clock without leaving her side. Staff will be provided a walkie talkie to ask for assistance if they need to leave the area for a restroom break or for any other reason. One on One direct supervision with this resident will continue until such time that she is no longer considered a fall risk. DIRECT CARE STAFF will be in-serviced regarding direct constant supervision for (resident name deleted). In-service training will be provided by (name deleted) BSN, Director of Nursing. A log will be provided with staff to sign off when they arrive in the room and sign out when they leave the room. Any changes in staff members will be immediately documented when they relieve another staff member. The staff member assigned to her will not be allowed to leave until they have been relieved by another staff member ensuring (resident name deleted) is not left alone at any time. All staff members will receive in-service training prior to the start of their shift. All staff will receive in-service training by 11:59 PM on 09/20/17. If a staff member is not reachable by phone. They will not be allowed to come on duty until they have received the in-service training. If the staff member is unable to come to the facility for in-service training, they will receive training over the phone, but will be required to sign the in-service sheet when they report for their next shift. Staff were interviewed on 09/21/17 in regard to their knowledge of the fall in-service to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 09/21/17 at 11:00 a.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#11) of two sampled residents who had experienced falls. Resident #11 experienced a fall on 09/12/17 with no fall interventions initiated to prevent future falls. The resident sustained [REDACTED]. The resident had experienced 11 falls in the past five months with six of the falls resulting in injury. No new interventions had been implemented to prevent future falls. The facility identified 18 residents who were at high risk for falls. Findings: An undated accident policy, documented, .Each resident will receive adequate supervision and assistive devices to prevent accidents .Definition: Accident - the unexpected, unintended event that can cause a resident bodily injury . Resident #11 was admitted with [DIAGNOSES REDACTED]. An undated care plan, documented, Problem .actual fall . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . Approaches .assess for injury, notify physician and responsible party with any fall .make sure resident area is well lit and free of obstacles or clutter .make sure frequently used items are within easy reach of the resident .discourage reaching, bending, stretching for items .make sure resident bed is in the lowest possible position .encourage use of ambulation aid .wheelchair .transfer with staff assist of .1 .encourage use of appropriate foot wear . An incident report, dated 04/24/17 at 1:30 a.m., documented, .resident found on floor in room, W/C next to her .stated she hit her head, but could not tell us how she fell . Neuro checks started, 2 skin tears to R upper and forearm, c bruising. ROM WNL for all extremities .corrective action taken .call light clipped to Res. gown to alert staff if she gets up. When staff see Res. up to BR @ noc - assist her back to bed . A Fall Scene Investigation Report, dated 04/24/17 at 1:30 a.m., documented, .factors observed at time of fall .wheelchair .unlocked .found on floor .what type of assistance was resident receiving at time of fall .alone and unattended .contributing factors to help identify root cause of fall .resident's mental status prior to fall .confused .how does this compare to the resident's usual mental status .normal .resident's psychological status prior to fall .confused .how does this compare to the resident's usual psychological status .normal .footwear at time of fall .slippers .did vision or hearing contribute to fall .possibly, room was dark .gait assist devices at time of fall .none .alarm being used at the time of the fall . An undated care plan, documented, Problem .actual fall .04/24/17 .skin tear R upper arm . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . No new intervention related to the fall on 04/24/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 04/24/17. An incident report, dated 05/07/17 at 8:00 p.m., documented, .resident called out for help .found seated on floor of bathroom in front of toilet .reports bumped head on wall when she fell down and bumped R elbow .small red spot and bruise noted to R elbow .small red spot noted to back of head .reports she lost balance getting to toilet .encouraged res to ask for assist to bathroom, and transfers . A Fall Scene Investigation Report, dated 05/07/17 at 8:00 p.m., documented, .res stated resident (sic) lost their (sic) balance .found on floor .what was resident doing during or just prior to fall .ambulating .alone and unattended .mental status prior to fall .awake, drowsy @ x's .how does this compare to the resident's usual mental status .same, normal .resident's psychological status prior to fall .pleasant .how does this compare to the resident's usual psychological status .same .alarm being used at the time of the fall .no .what appears to be the root cause of the fall .res stated she lost balance .initial interventions to prevent future falls .encourage res to ask for assist w/ transfers . An undated care plan, documented, Problem .actual fall .05/07/17 .bruise R elbow . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . No new intervention related to the fall on 05/07/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 05/07/17. A quarterly assessment, dated 05/23/17, documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with skills for daily decision making. The assessment documented the resident required limited assistance with one person for transfers, dressing, and toileting. The assessment also documented the resident had [DIAGNOSES REDACTED]. An incident report, dated 06/08/17 at 11:00 p.m., documented, .Resident was in bathroom emptying colostomy .hollered help, nurse found resident sitting on bottom next to door .brought to nurse's station to observe for awhile .increased assistance and instructed resident to call for assist prior to transfers . Documentation of a Fall Scene Investigation Report was not found related to the fall on 06/08/17. An undated care plan, documented, Problem .actual fall .06/08/17 .no injury . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . No new intervention related to the fall on 06/08/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 06/08/17. An incident report, dated 06/29/17, documented, .Resident did not lock brakes on wheelchair before trying to stand. Found resident lying on R side. Hit head on oxygen concentrator .resident frequently reminded to call for assistance when transferring .continues to attempt independent transfers . A Fall Scene Investigation Report, dated 06/29/17 at 11:15 p.m., documented, .wheelchair unlocked .found on floor .resident room .attempting to self-transfer .alone and unattended .resident stated she was trying to stand up and forgot to lock her chair .resident's mental status prior to fall .intermittent confusion .how does this compare to the resident's usual mental status .within normal limits .resident's psychological status prior to fall .intermittent confusion .how does this compare to the resident's usual psychological status .within normal limits .footwear at time of fall .gripper socks .gait assist devices at time of fall .none .alarm being used at the time of the fall .no .what appears to be the initial root cause of the fall .resident did not lock her brakes on wheelchair before trying to stand .initial interventions to prevent future falls .encourage resident to ask for assistance before standing . An undated care plan, documented, Problem .actual fall .06/29/17 .no injury . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . No new intervention related to the fall on 06/29/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 06/29/17. An incident report, dated 07/02/17, documented, .Staff passing res restroom, heard Res knock on bathroom door from inside, staff open bathroom door and found res seated on floor of bathroom. Res stated 'I was getting back to my w/c and my legs felt weak, so I fell .' Res denies pain, injury or hitting head .encouraged Res to use the call lights in room, or restroom for assist . Documentation of a Fall Scene Investigation Report was not found related to the fall on 07/02/17. An undated care plan, documented, Problem .actual fall .07/02/17 .no injury . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . No new intervention related to the fall on 07/02/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 07/02/17. An incident report, dated 07/25/17 at 11:30 p.m., documented, .Resident yelled out from room 'is anybody there?' Nurse found resident laying in floor. Resident stated, 'I lost my balance getting into bed.' Denies hitting head .resident has call light in reach. Bed alarm on . A Fall Scene Investigation Report, dated 07/25/17 at 11:30 p.m., documented, .factors observed at time of fall .resident lost their balance .found on the floor .resident room .attempting to self-transfer .alone and unattended .resident's mental status prior to fall .confused at times .resident's psychological status prior to fall .confused at times .footwear at time of fall .shoes .socks .gait assist devices at time of fall .no .alarm being used at time of the fall .no .what appears to be the root cause of the fall .resident lost her balance getting into bed .initial interventions to prevent future falls .encourage resident to use call light before transfer .bed alarm . An undated care plan, documented, Problem .actual fall .07/25/17 .bruising to bottom and left hip . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . No new intervention related to the fall on 07/25/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 07/25/17. An incident report, dated 08/06/17 at 11:00 p.m., documented, .resident tried to transfer self from w/c to bed, after going to restroom, stated that she lost strength upon standing and fell and landed on coccyx .c/o left hip pain .xray ordered .bed alarm added to alert staff. Resident forgetful does not always call for assistance . Documentation of a Fall Scene Investigation Report was not found related to the fall on 08/06/17. An undated care plan, documented, Problem .actual fall .08/06/17 .c/o pain to L hip previous fall bruising . Goal .resident will have no further falls over next review period .resident will have no significant injury related to falls over next review period . Approaches .08/06/17 xray of left hip rt (sic) c/o pain results (-) bruising healing . No new intervention related to the fall on 08/06/17 was documented. Documentation of a fall risk evaluation was not found related to the fall on 08/06/17. An incident report, dated 08/16/17 at 6:00 p.m., documented, .resident notified staff that she fell in bathroom, stated she got herself up off floor and back in w/c. Residents chair alarm was in place and clipped to clothes. Alarm never went off .alarm in place, resident having increased confusion. Monitor for safety. Resident had multiple falls in last 45 days. Unable to get self up .resident had exit alarm attached to person . Documentation of a Fall Scene Investigation Report was not found related to the fall on 08/16/17. Documentation of a fall risk evaluation was not found related to the fall on 08/16/17. The care plan was not updated to include the fall that occurred on 08/16/17. A significant change assessment, dated 08/23/17, documented the resident had a BIMS score of seven. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with one person for transfers, dressing, and toileting. The assessment also documented the resident had [DIAGNOSES REDACTED]. An incident report, dated 09/12/17 at 1:10 a.m., documented, .Resident stated to nurse 'I was in the bathroom earlier and when I stood up my hand slipped on rail and I ended up hitting my cheek on it.' R cheek swollen and reddened. Ice pack applied .no corrective action taken . A nurse's note, dated 09/12/17 at 7:30 a.m., documented, .Resident c/o L knee pain. Nurse observed swelling to L knee. Xray ordered. Dr office (sic) notified, Cont. neuro checks. Enc resident to use call light for assistance . A nurse's note, dated 09/12/17 at 11:00 a.m., documented, .X ray results show fractured left patella. Dr and family notified . A nurse's note, dated 09/12/17 at 8:00 p.m., documented, .Dr here to see resident. N.O. for ice to left knee TID x 5 days X 10min. Cont neuro checks. Resident on routine pain meds Rate 5/10 . Documentation of a Fall Scene Investigation Report was not found related to the fall on 09/12/17. An OSDH incident report form, dated 09/12/17, documented, .Approximately 1:10 AM .resident .was found on the floor in the restroom .(resident name deleted) had removed her personal alarm and attempted to transfer independently to the toilet. She informed the nurse that she had stood up and her hand slipped on the handrail and she hit her cheek on the rail. The nurse completed a focused assessment and noted her right cheek was swollen and had a reddened area. Neurological checks were within normal limits. She did not have any further complaints. Approximately 7:04 AM, she began complaining of pain in her left knee .was unable to move it without experiencing pain .physician was contacted and an order for [REDACTED]. On 09/14/17, a nurse's note, no time, documented, .Dr (name deleted) office contacted by PCP office for check on patella. Can't see resident until 09/27/17 . On 09/19/17 at 6:58 p.m., CNA #3 was asked if she was familiar with the resident. She stated, Yes. She was asked if the resident got out of bed. She stated, Not now since she hurt her knee, that is when she stopped getting up as much. On 09/20/17 at 11:00 a.m., the resident was observed in her room lying in bed. A large bruised area was noted to the resident's right cheek. She was asked what had caused the bruising. She stated she had fallen and hit her face. She was asked what she had been doing when she fell . She stated she had been trying to get to the bathroom. She was asked if she had called for assistance before getting up. She stated she did not need help to get up. The resident was asked if she ever had to use the bathroom during the night. She stated, I might have to use the bathroom at night every eight or nine days. The resident was observed at various times throughout the survey in her room lying in bed. At 5:47 p.m., the MDS coordinator was asked when the resident's last assessment had been completed. She stated, She had a significant change assessment on 08/23/17. She was asked why she had conducted a significant change assessment. She stated the resident had a weight loss of 6.5% in one month and her mood assessment indicated she had less interest in things. Three months before she had no behaviors which progressed to one behavior of yelling at staff for not taking her out to smoke during a storm. She went from no shortness of breath to having shortness of breath and required oxygen which indicated she had a decline in her health. Her falls had increased from two falls to six which indicated a general decline. On 09/20/17 at 6:40 p.m., LPN #1 was asked if the resident requested assistance when getting up, transferring, or toileting. She stated, Before the last fall she would sometimes ask for assistance, but since her last fall she has been asking for assistance more frequently. She was asked if the resident got up during the day. She stated, She normally gets up and moves around but since the last fall she has stayed in bed more. She's been taking meals at her bedside since the last fall. She normally eats in the dining room. She was asked if the resident participated in activities. She stated, She doesn't participate actively, but she would participate passively. She hasn't been passively participating in activities since the last fall. On 09/20/17 at 6:45 p.m., CMA #1 was asked if the resident got out of bed as much as her previous routine. She stated, She got up for breakfast then back to bed. Before she fell the last time she was up and down all the time. She was asked how much assistance the resident required since the last fall. She stated the resident was one person assist. Occasionally when she stands she will become a little shaky. She often times takes the alarm off and gets up on her own. She does not like to hear the alarm. At 6:46 p.m., CNA #1 was asked if the resident got up as much as she did before her last fall. She stated, She fell and can't move as much. She was asked if she required more assistance since the last fall. She stated, I have no idea. At 6:48 p.m., CNA #2 was asked if the resident got up as much as she did before her last fall. She stated, No. She was asked if she required more assistance since the last fall. She stated, Yes, she does require more assistance. On 09/26/17 at 3:19 p.m., CNA #4 was asked what interventions had been implemented regarding the resident's falls. She stated, An alarm for her bed and chair, a fall mat, and encouraging her to use her call light if she needs to get up or go to the bathroom. She was asked if the resident used the call light. She stated, Yes, sometimes. At 3:44 p.m., CNA #3 was asked what interventions had been implemented regarding the resident's falls. She stated, Fall mat, bed alarm, chair alarm, repeatedly telling her to use the call light and making sure she has her call light. I would walk by to see if she was trying to get up or needing assistance. She was asked if the facility had a fall program. She stated, I don't know what that is. She was asked how it was communicated to the CNAs what interventions were implemented for a resident who had experienced falls. She stated, The nurse does report and lets us know what interventions are being put in place. Also I get report from the other CNAs. She was asked if the resident required assistance with getting up and going to the bathroom. She stated, She should be getting assistance, but she won't usually ask for help. She was asked if the resident used the call light. She stated, Very rarely. At 4:45 p.m., LPN #1 was asked what interventions had been implemented regarding the resident's falls. She stated fall mat, bed and chair alarm, frequent toileting, having staff take her outside to smoke, and encourage use of call light. She was asked if the resident used her call light. She stated, She would use the call light sometimes, kind of hit and miss. There was documentation to show frequent toileting had been attempted. She was asked if the facility had a program that identified residents who were at risk for falls. She stated, We don't put anything outside of their rooms that would identify them as fall risks. She was asked how interventions were identified for residents at risk for falls. She stated, We have a meeting and come up with interventions that we think will work best. She was asked if a resident had experienced multiple falls how the root cause of the falls were determined. She stated, We talk to the resident, talk to the aides, and come up with a plan. On 09/26/17 at 6:18 p.m., the administrator and DON were asked why the goals and approaches documented on the care plan were not reviewed after each fall. The DON stated, I have been doing the updates since June and was basically following the previous examples that were in the care plan. They were asked if repeatedly encouraging the resident to use the call light was an appropriate intervention when the resident had consistently refused to use the call light. The administrator stated, No. The DON was asked how often fall risk evaluations were completed. He stated, Every quarter. They were asked if a fall risk evaluation should have been completed after a resident had experienced a fall. The administrator stated, Yes. They were asked why the fall risk evaluations had not been completed for the resident quarterly and after each fall. The DON stated, I wasn't aware that they were supposed to be done. They were asked if the facility had a fall program. The administrator stated, No. She was asked how they identified specific interventions to be implemented with residents who were high risk for falls. She stated, We conduct in-services after a resident has had a fall. She was asked if documentation of fall interventions were part of the in-services. She stated, Yes. No documentation of inservices after the falls was found or provided. The DON was asked how often he re-evaluated the interventions for falls to see if they were effective. He stated, I haven't been. He was asked if they were keeping the resident safe. He stated, No. He was asked how the physician had been involved in determining interventions to prevent further falls for the resident. He stated, He hasn't been.

On 08/11/16, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide supervision of a resident with dementia and sexually aggressive behaviors, which resulted in sexual assault of a female resident. The IJ situation was verified with the Oklahoma State Department of Health. At 8:00 p.m., the administrator was notified of the IJ situation related to failure to provide supervision to prevent resident to resident sexual abuse. On 08/11/16 at 8:50 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: Plan of Removal alleged IJ 08/11/16 .Lack of Supervision to keep female residents safe from a male resident. The facility will provide inservice training to all nursing staff, including licensed nursing staff and CNAs regarding the requirement to keep the male resident away from female residents. Resident will be supervised by continuous direct observation by staff when he is out of bed. Additional inservice regarding the plan of removal for all direct care staff will be completed by 11:59 PM August 11, 2016. No staff will be allowed on the unit without prior inservice training and plan to monitor and document .A monitoring log will be implemented noting his whereabouts and initialed by staff beginning with every 15 minutes and may be adjusted following QA Committee reviews and recommendations. We will continue the monitoring log as long as male resident resides in this facility or until such time comes that he is incapacitated .If staff observe him to be approaching a female resident or reaching for a female resident they will intervene immediately by removing him from the area .The Director of Nursing and Administrator will be responsible for ensuring the monitoring and documentation logs are complete. The DON and Administrator will review the logs and conduct random observations to ensure staff are monitoring and documenting appropriately . An inservice record, dated 08/11/16, documented, .One on one with (resident #7), with charting q 15 minutes. Do not leave unattended or around female residents . The inservice record documented the time staff either attended the inservice or was contacted by phone and provided the information needed to return to work and assume resident care. On 08/15/16 at 9:40 a.m., interviews with staff members began regarding inservice attendance before returning to work. All but one staff member, who was an agency nurse, stated they had received an inservice regarding supervision of resident #7. Documentation revealed the last staff member, the agency nurse, received the inservice on 08/15/16 at 1:55 p.m. On 08/15/16 at 1:55 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at an isolated level with a potential for more than minimal harm. Based on observation, interview, and record review,it was determined the facility failed to provide supervision of a resident with dementia and sexually aggressive behaviors, which resulted in sexual assault of a female resident for one (#7) of 9 sampled residents whose records were reviewed for dementia and behaviors. The census and condition report identified 17 residents diagnosed with [REDACTED]. Findings: An undated policy, titled Abuse by a Client/Resident to other Client/Residents, documented, .Abuse as used in this policy shall refer to all forms of abuse including but not limited to physical, verbal, sexual, and psychological . In the case of abuse from one client/resident to another client/resident, any employee observing the abuse shall immediately intervene in an effort to protect .The clients/residents will be geographically separated and supervised until both are calm and not a risk of harm to themselves or others .An incident report will be completed by the person witnessing the incident .The report shall be presented to the administrator immediately for investigation .all parties involved will be evaluated for injury .The DON shall review the incident .If necessary, there will be separation of the clients/residents into different areas of the building if any conflict continues . Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 06/17/16 at (5:00 p.m.), documented, .Resident observed by CNA (name withheld) to be inappropriately touching female resident in the dining room at dinner time. Resident removed from area et was councilled (sic) on inappropriate action. Police had to be notified r/t it being unwanted advanced (sic) towards female in his attempts to touch her private area et breast . Subsequent nursing notes were reviewed and found no other documentation regarding resident's behavior, monitoring or separation from female resident. A police report, dated 06/18/16 at 12:24 p.m., documented, .Upon arrival, I spoke to (name withheld) DON, and nursing aid (sic) (CNA name withheld). (CNA name withheld) explained on June 17, 2016 at about (4:00 p.m.) she saw a resident, (resident #7), with his hand up a female resident's gown, (resident #8). (CNA name withheld) said she told (resident #7) not to do that and to keep his hands to himself. (CNA name withheld) said she then saw (resident #7) put his had down the top of (resident #8's) gown near her breast. (CNA name withheld) said she told him again to keep his hands to himself and she moved him away from the female resident. (Resident #8) currently has Alzheimer's Disease and is unable to verbalize consent or not. (CNA name withheld) said he has reached several times to try and touch her; but he has never succeeded .(DON name withheld) RN stated that the incident was reported to her the day it occurred. She said she then contacted her supervisor in return stated for her to notify the local police department. (DON name withheld) also stated that the nurses are keeping (resident #7) away from the other female residents . An incident report form, dated 06/18/16, documented, .Date of Incident 6/17/16 time of incident 4:00 pm . Date of initial Report 06/18/16 time of initial report 1:00 PM .Approximately 4:00 PM a CNA walked into the dining room and observed [AGE] year old male resident (resident #7) was observed with his hands up [AGE] year old female resident (resident #8's) gown near her groin area. The CNA immediately told him to take his hands off her. He moved his hand and put his hand down the top of her gown touching her breast. She then moved him away from her and told him he could not be doing that and he needed to keep his hands to himself. The residents were separated and staff were instructed to ensure (resident #7) is not situated near female residents without direct supervision. (Resident #8) did not show any signs of distress or fear. Due to her [DIAGNOSES REDACTED]. The resident's physicians (sic) were notified as well as (resident #8's) daughter. The police department was contacted and a report made. The facility requested the police officer speak to (resident #7) and explain to him in addition to the facility staff having explained to him that he is not allowed to touch other residents without their consent. (Resident #7) will be situated away from female residents unless staff are in direct observation of him to prevent this from occurring in the future. (Resident #7) is alert to person only. He seems to understand what is said to him, however we are not sure about his retention of instructions. This shall be considered our initial report . An update to the care plan, dated 06/18/16, documented, Problem: Thought process, impaired .Approach .dated 06/18/16 .Inappropriate behavior and touching of female resident or staff, will be redirected et not left alone with female residents . A document titled, Attachment 2, dated 06/27/16 at 11:00 a.m., documented, .Description of 5-working Day/Continuing or Final report .During our ongoing investigation and observations, (resident #7) was not allowed to be in the same area as female residents unless staff were present. He denies having touched anyone else. (Resident #7) was taken to the (name withheld) Police Department per the officers request for questioning .(resident #7) will continue to be observed closely when he is in the common areas with female residents to ensure he does not repeat this behavior . A quarterly assessment, dated 07/16/16, documented the resident was severely impaired in cognition for daily decision making, and was independent in locomotion on and off the unit once in his wheelchair. On 08/11/16 at 8:25 a.m., resident #7 was observed in his wheelchair sitting in the hallway near the entry of the facility with a female resident sitting on a bench within arms reach of the resident. Staff were not observed in the area. On 08/11/16 at 8:40 a.m., resident #7 had self propelled his wheelchair to the lobby/activity area and situated himself between two female residents who were within reach. Staff were not observed in the area. On 08/11/16 at 8:50 a.m., resident #7 was observed to be in the same location with his chin on his chest and eyes closed. The two female residents remained on either side of him within his reach with their eyes closed. Staff were not observed in the area. On 08/11/16 at 9:55 a.m., CNA #5 was asked if she had been instructed to observe resident #7 and prevent him from contact with female residents. She stated, No. She was asked if she was aware of an incident where resident #7 had fondled a female resident. She stated, No. On 08/11/16 at 9:58 a.m., CNA # 6 was asked if she had been instructed to observe resident #7 and prevent him contact with female residents. She stated, No. She was asked if she was aware of an incident where resident #7 had fondled a female resident. She stated, No. On 08/11/16 at 10:00 a.m., CNA #7 was asked if she had been instructed to observe resident #7. She stated, Yes, in the past. She was asked why resident #7 had been under observation. She stated he had episodes where he wanted to get friendly and flirt. He will go a month or two without incident of flirtatious behavior then will revert back. She was asked if she was aware of a recent incident where the resident had fondled a female resident. She stated, Yes. She was asked if that was when she was instructed to observe resident #7. She stated, Yes. She was asked if he was still being observed. She stated, Yes. CNA #7 was asked what she had been instructed to observe. She stated she was instructed to ensure the resident did not come into contact with female residents. On 08/11/16 at 3:45 p.m., CNA #1 was asked what she had observed on 06/17/16. She stated she had walked into the dining room and saw resident #7 with his hand up (resident #8's) dress. She was asked if the resident had this type of behavior prior to this incident. She stated, Not to that extent, he will put his hand out and try to touch you. She was asked if the gesture was only towards staff. She stated, Any female. She was asked who she reported the incident to. She stated she reported the incident to the two charge nurses and they notified the DON. She was asked what interventions were implemented regarding resident #7 after the incident. She stated he was fully supervised at all times during the day shift, but did not require supervision when he was in bed. She was asked where they documented their observation and supervision. She stated they did not document but reported to the DON. She stated there would be documentation in the ADLs of the medical record. She was asked what staff was monitoring for resident #7. She stated to ensure he was not making inappropriate advances toward female residents. She was asked what documentation was provided in the ADLs. She stated inappropriate behaviors were documented. She was asked if the resident exhibited any further inappropriate behaviors. She stated not to that extent but he would reach out toward staff. She was asked if new staff was made aware of his behavior. She stated new staff were informed. She was asked how they ensured the safety of female residents who were not ambulatory. She stated by keeping him at the nursing station. She was asked if someone was at the nursing station at all times. She stated someone was there at all times unless there was an emergency. She was asked when staff was inserviced regarding the monitoring of resident #7. She stated about a week after it happened. She was asked if the resident self propelled his wheelchair. She stated he did self propel after assistance with transfer to his wheelchair. She was asked if he could locate his room and the dining room. She stated, Yes. On 08/11/16 at 4:10 p.m., CNA #2 was asked if she was aware of the incident with resident #7. She stated, Yes. She was asked how she was informed of the incident. She stated she was called into the DON's office on her first day back at work and informed the resident was to be supervised. She was asked what was involved with supervision of the resident. She stated the resident would be observed at all times by a nurse or CNA unless he was in bed. She was asked why the resident was being observed at all times. She stated to ensure he did not have contact with female residents. She stated the CNAs were instructed to provide supervision of the resident. She was asked if the CNAs were providing resident care who would assume supervision. She stated the nurse at the desk. She was asked if the nurse's desk was ever unattended. She stated she did not know because she worked the back hall. She was asked if she ever witnessed or observed any inappropriate behaviors from resident #7. She stated she had not personally witnessed or observed but staff members had informed her of his behaviors in the past. On 08/11/16 at 4:30 p.m., CNA #3 was asked if she was aware of the incident with resident #7. She stated she had found out a day or two afterward when she came back to work. She was asked who had informed her. She stated the administrator had informed her and gave her instruction to ensure the resident did not have contact with female residents. She was asked what instructions she had been given. She stated she was instructed to place the resident next to the nurses' station and inform the nurse if she became unable to provide supervision. She was asked if the resident could self propel in his wheelchair. She stated, Yes. She was asked if she ever observed him going into other resident rooms. She stated no but he will stop and talk with residents from the doorway. She stated it was difficult to keep him under constant watch. She was asked where supervision of the resident was documented. She stated, Personally, I don't. She was asked what she had observed regarding the resident's behaviors. She stated when he came out of the dining room, he attempts to move toward the women. She stated she reported the behaviors to the charge nurse. She was asked if the resident was ever unsupervised. She stated, There are times, I won't lie, we get busy, distracted, or put him in front of the nurse. There are occasions. She was asked if she was aware of the resident having any previous behaviors. She stated, No, but he always gave us little winks, nothing inappropriate. It's just (resident #7). She was asked if resident #7 had become more aggressive. She stated she had not noted this but other staff members had verbalized he had. She was asked what type of aggressive behaviors the resident exhibited. She stated, It is always about the ladies. May go a week or several weeks without looking at them. On 08/11/16 at 4:55 p.m., CNA #4 was asked if she was aware of an incident with resident #7. She stated, Yes. She was asked how she was informed of the incident. She stated the DON had informed her. She was asked if she had been instructed to provide additional care for the resident . She stated she was instructed to supervise him at all times. She stated the nurse at the desk, activity staff, or whoever was available, was also to supervise the resident. She was asked where she documented supervision of the resident. She stated she did not document supervision but if the resident exhibited any behaviors it would be documented in the behavior book. She was asked if she had ever observed inappropriate behaviors from the resident. She stated, He is a little flirty. On 08/11/16 at 5:30 p.m., LPN #2 was asked if she had observed inappropriate behaviors from resident #7. She stated, He goes right to bed after meals, and he tries to get me all the time. My butt or anything he can grab. She was asked if staff had received an inservice regarding the resident's behavior. She stated, In the past we have. She was asked if she had received new instructions regarding the resident's care after this incident. She stated the DON had all staff come to the facility the day after the incident. On 08/11/16 at 6:00 p.m., the DON was asked when she had been notified of the incident. She stated she was not notified of the incident the night it happened, but the next day when she arrived at the facility. She was asked who had informed her. She stated she could not recall. She was asked where the incident was documented. She stated she thought they should have put it in the priority book. She was asked what measures the facility had taken to ensure the safety of the female residents. She stated the facility made sure he was not alone in the vicinity of female residents. The DON was informed, by surveyors, of the observations of the resident being in close proximity of female residents without staff members present. She stated it was her responsibility as DON to ensure the safety of the female residents. She stated she tried to do the best she could but this had been an isolated incident. She was asked if the resident had exhibited other behaviors. She stated it had been a month and a half since the incident and he had not attempted that behavior again. She stated monitoring of the resident was not as strict as it had been. She was informed of statements regarding the resident's inappropriate behaviors toward staff and other female residents. She was asked why there was no documentation regarding the resident's behaviors. She stated, I don't know. She was asked if the care plan had been updated after the incident had occurred. She stated, Yes. She was asked if an evaluation had been completed regarding the effectiveness of the interventions that were implemented after the incident. She stated, No. She was asked if the CNP with the psychiatric group had been informed of the resident's behavior during the visit dated 06/28/16. She stated she could not say. She stated the CNP came out on weekends and the weekend RN had the most contact with them. She was asked if the attending physician had addressed the resident's behavior. She stated, No. On 08/11/16 at 6:50 p.m., the administrator was asked when she had been notified of the incident that occurred involving resident #7. She stated she thought she had been notified the same day. She stated she instructed staff to evaluate the female resident involved to ensure she was not traumatized. She was asked what interventions had been implemented to ensure the safety of the female residents. She stated she had instructed staff to monitor resident #7, keep him out of close proximity to female residents at all times, and redirect him if he approached them. She was asked where the monitoring was documented. She stated she did not think the monitoring was documented. The administrator was informed of staff statements in regards to the continuance of the resident's inappropriate behaviors since the incident. She stated it had not been reported. She was asked if the investigation contained more than one interview with a CNA. She stated, There was more than this. I didn't use just (CNA name withheld) statement. No further documentation was provided.

On 06/24/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician in a timely manner for abnormal blood glucose levels and the interventions used in the manangement of diabetes mellitus for residents with a [DIAGNOSES REDACTED]. At 4:40 p.m., the Oklahoma State Department of Health verified the existence of an immediate jeapardy (IJ) situation. At 4:55 p.m., the administrator, DON, and corporate nurse were informed of the IJ. At 8:58 p.m., an acceptable plan of removal was provided by the facility. The plan of removal documented: .Plan of Removal for Alleged IJ for Skiatook Nursing Home 6.24.2015 4:57 pm. 1. Significant Medication Error regarding Insulin. 6.24.2015 at 6:32 pm the Pharmacist and the Medical Director reviewed all current insulins with the current physician's orders [REDACTED]. All were found to be accurate. By 6.25.2015 at 6:00 am each current insulin order on the medication record will be verified with the original order in the resident's medical record. If a discrepancy is noted, the physician will be notified for clarification of the order. By 6.25.2015 at 6:00 pm, each LPN and RN of the facility will be observed by the RN Director of Nursing complete the fingerstick blood sugar, select the insulin, draw the insulin and administer the dose according to the current physician's orders [REDACTED]. No LPN or RN will be allowed to work until they have been observed and found competent to administer insulin. 2. Pharmacy Services Accuracy of Medications. 6.24.2015 at 6:32 pm The Pharmacist and Medical Director have reviewed all current insulins with the physician's orders [REDACTED]. The RN Director of Nursing was instructed to conduct weekly checks on all insulins to insure the medication matches the order by the Medical Director, beginning 7.1.2015. The Pharmacist will check the insulins for accuracy monthly. If the physician provides new insulin orders for any resident, the nurses will verify the telephone order by two nurses. Two nurses will also verify the Treatment record to insure accuracy by noting with their initials. 3. Providing Services for residents receiving insulin. 6.24.2015 at 5:30 pm, each attending physician with residents that currently receive insulin have been contacted and the following parameters have been obtained: When to notify the physician for low and high blood sugars and when to administer [MEDICATION NAME]/[MEDICATION NAME]. For each new admission, the nurse will request parameters as described above. (Physician name withheld): Notify PCP of Blood sugar below 75 or above 450, administer 1 mg [MEDICATION NAME] if resident is unresponsive. (Physician name withheld): Notify PCP if blood sugar below 70 or above 400. Administer 1 mg of [MEDICATION NAME] if unresponsive. These orders are written on telephone orders for each resident and will be placed in each resident's chart. 6.24.2015 at 6:36 pm all facility LPN's and RN's were instructed by the Medical Director to not hold blood sugar medications without notification to the physician. The Pharmacist will provide inservice training to the two day shift LPN's scheduled to work at 6:00 am on 6.25.15 as well as the evening shift LPN present in the facility regarding long acting and short acting insulins with onset and duration and the importance of administering insulins as ordered to obtain a steady blood sugar for each resident. The remaining LPN and RN staff will receive the same inservice training on 6.25.2015 by 5:00pm, unless the individual is not able to come to the facility at which time the Pharmacist will provide training by telephone prior to their next scheduled shift. No LPN or RN will be allowed to work until they have received this training. 4. Notification to Physician of Resident change of condition. 6.24.2015 at 6:36 pm each facility nurse, LPN and RN, see attached list of names, received inservice training by the Medical Director of the addition of parameters to notify the physician of high and low blood sugars and when to administer [MEDICATION NAME]/[MEDICATION NAME]. The nursing staff will be required to document these notifications to the physician in the residents nurse's notes as appropriate. They also received inservice training by the Medical Director regarding symptoms of high and low blood sugars that would reflect a change in resident condition and the requirement to notify the physician and document in the resident's nurse's notes. Medications for blood sugar will not be held without notification to the physician. The facility's policy is to notify the resident's attending physician with any resident change in condition. The LPN's and RN's were instructed to always follow this policy. (Name withheld) RN was not able to be reached by telephone and did not attend the inservice. She is scheduled to work next on (date withheld). She will receive inservice training from the RN Director of Nursing on all of the above prior to her next scheduled shift. 5. The Pharmacist failed to monitor insulin. 6.24.2015 at 6:32 pm The Medical Director and the Pharmacist reviewed all current insulins with the current physician's orders [REDACTED]. The Medical Director instructed the Pharmacist to review all insulins with the current physician's orders [REDACTED]. By 6.25.2015 at 5:00pm, the Pharmacist will complete a review of all resident's blood sugars and insulin usage and will report findings to the resident's attending physician. On 06/25/15 at 3:34 p.m. the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 06/26/15 in regards to their knowledge of the inservice and to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 06/25/15 at 3:34 p.m., when all components of the plan of removal had been completed. The deficient practice remained at pattern with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to notify the physician in a timely manner for abnormal blood glucose levels and the interventions used in the manangement of diabetes mellitus for two (#3, #8) of five sampled residents with diabetes mellitus. The facility also failed to notify the physician that multiple routine doses of insulin were held and failed to notify the physician of administration of the wrong insulin. This had the potential to affect 23 residents with a [DIAGNOSES REDACTED]. Findings: An undated facility policy, titled Procedure for Administration, documented, .The medication administration sheets are checked by the nurse at the beginning of the month, against the doctor's orders and updated during the month as indicated.The nurse or cma will check the package label to make sure that it corresponds with the order on the medication administration sheet.If medication is not administered as ordered, the nurse or cma may circle their initials and then document an explanation on the back of the sheet as to why. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hand written physician admission order, dated 03/16/15, documented, .Insulin detemir ([MEDICATION NAME]) 100u/mL 12u SQ BID Dx: DM.Insulin regular 2u SQ Q6(hours) Dx: DM.Insulin regular sliding scale SQ Q6(hours) 70-100=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. There was no documentation of sliding scale coverage for FSBS readings between 101-140. A hand written physician order, dated 03/20/15, documented, .FSBS checks Q4 (hours) c S/S at meal times. A hand written physician order, dated 03/23/15, documented, .Clarification:.FSBS Q 4(hours) c SSI regular. Regular insulin 2u SQ Q 4 (hours). A hand written physician order, dated 03/27/15, documented, .D/C Regular SSI 70-140 =0u, 141-180 = 1u, 181-220 = 2u, 221-260 = 3u, 261-300 = 4u, 301-340 = 5u, 341-350 =6u. D/C [MEDICATION NAME] 10u SQ Bid. .FSBS Q 4(hours) c Regular SSI 151-200=2u, 201-250=4u, 251-300=6u, 301-350=8u, 351-400=10u, > 400 = 12u & notify [MEDICATION NAME] 20u SQ Bid. An admission assessment, dated 03/30/15, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance with activities of daily living, received 51 percent or more of her total caloric intake through a gastrostomy tube, and received insulin injections for seven days out of the seven days during the look back period. Monthly physician's orders [REDACTED]. DX: DM.FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. A treatment administration record (TAR), dated 04/02/15 at 12:00 a.m., did not document a FSBS was obtained, or the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. 04/05/15 at 12:00 a.m., the TAR documented a FSBS of 110. The clinical record did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 97. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 8:00 a.m., the TAR documented a FSBS of 90. A handwritten notation on the back of the TAR documented, .4/5/15.08:[MEDICATION NAME] R 2 units SQ held FSBS 90. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 p.m., the TAR documented a FSBS of 134. The TAR did not document the resident was administered a scheduled bedtime insulin dose of [MEDICATION NAME] 20 units or two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/5/15.8p.held [MEDICATION NAME] 20u d/t FSBS 134. The clinical record did not document the physician was notified the [MEDICATION NAME] and Novolg insulins were not administered. On 04/06/15 at 08:00 a.m., the TAR documented a FSBS of 126. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/07/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of [MEDICATION NAME] insulin. The clinical record did not document the physician was notified of the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 83. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 08:00 a.m., the TAR documented a FSBS of 137. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME] 20 units as ordered by the physician. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 p.m., the TAR documented a FSBS of 451. The clinical record did not document the physician was notified of a FSBS of 451. On 04/08/15 at 12:00 a.m., the TAR documented a FSBS of 82. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/8/15.04:00.BS @ 65 gave 60cc of coke recheck @ 05:00 (up) to 84. The clinical record did not document the physician was notified of a FSBS of 65, that the insulin was not administered, the administration of coke, or that the FSBS was rechecked and the result. At 08:00 a.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered the scheduled morning dose of [MEDICATION NAME] 20 units per the physician's orders [REDACTED]. At 4:00 p.m.,the TAR documented a FSBS of 403. The clinical record did not document the physician was notified of a FSBS of 403. At 6:30 p.m., a hand written physician's orders [REDACTED].@ AM et HS Dx: DMII. and to start [MEDICATION NAME] 15u subcutaneous inj @ AM et HS Dx: DMII. On 04/09/15 at 12:00 a.m., the TAR documented a FSBS of 55. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 04:00 a.m., the TAR documented a FSBS of 130. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/10/15 at 4:00 p.m., the TAR documented a FSBS of 478. The clinical record did not show the physician was notified of a FSBS of 478. On 04/11/15 at 08:00 a.m., the TAR documented a FSBS of 84. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME] 15 units. A handwritten notation on the back of the TAR documented, .4/11/15.8A.Levmir 15u SQ. The clinical record did not show the physician was notified the insulin was not administered. On 04/12/15 at 08:00 a.m., the TAR documented a FSBS of 100. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/13/15 at 04:00 a.m., the TAR documented a FSBS of 67. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/13.04:00.Insulin held (secondary to) FSBS 67. The clinical record did not document the physician was notified of a FSBS of 67 or that the insulin was not administered. At 08:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/14/15 at 08:00 a.m., the TAR documented a FSBS of 124. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/17/15 at 08:00 a.m., the TAR documented a FSBS of 105. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME] 15 units or the two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 12:00 p.m., the TAR documented a FSBS of 147. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 p.m., the TAR documented a FSBS of 468. The clinical record did not show the physician was notified of a FSBS of 468. On 04/18/15 at 04:00 a.m., the TAR documented a FSBS of 69. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/18.04:00.Insulin held (secondary to) FSBS 69. The clinical record did not document the physician was notified of a FSBS of 69 or that the insulin was not administered. At 08:00 a.m., the TAR documented a FSBS of 82. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or the two units of [MEDICATION NAME] per the physician's orders [REDACTED].4/18/15.[MEDICATION NAME] 15u SQ.held FSBS 82. The clinical record did not document the physician was notified the insulin was not administered. On 04/19/15 at 12:00 a.m., the TAR documented a FSBS of 99. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 191. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 8:00 a.m., the TAR documented a FSBS of 171. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/20/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/20.[MEDICATION NAME] held FSBS 150., and was signed by the DON. The clinical record did not document the physician was notified the insulin was not administered. On 04/21/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/21.[MEDICATION NAME] held FSBS 150. The clinical record did not document the physician was notified the insulin was not administered. At 12:00 p.m., the TAR documented a FSBS of HI. The TAR documented the resident was administered 10 units of [MEDICATION NAME] insulin. A handwritten physician's orders [REDACTED]. The clinical record did not document the physician was notified that 10 units of [MEDICATION NAME]was given instead of 10 units of [MEDICATION NAME] R insulin. At 4:00 p.m., the TAR documented a FSBS of 470. The TAR documented the resident was administered 10 units of [MEDICATION NAME] insulin. The sliding scale insulin for a blood sugar of 470 was 12 units per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 127. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/22/15 at 8:00 p.m., the TAR documented a FSBS of 87. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/23/15 at 12:00 a.m., the TAR documented a FSBS of 71. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/23.12A.Held [MEDICATION NAME] 70 (sic) gave OJ c sugar. The clinical record did not document the physician was notifiedthe insulin was not administered. At 04:00 a.m., the TAR documented a FSBS of 118. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/26/15 at 4:00 a.m., the TAR documented a FSBS of 63. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/26.4A.Insulin (not) admin FSBS 63 - (No) S/S [DIAGNOSES REDACTED]. OJ (down) PEG. The clinical record did not document the physician was notified of a FSBS of 63, the administration of orange juice via the gastrostomy tube or that the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 81. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/26/15.[MEDICATION NAME] 2 units.held FSBS 81.The clinical record did not document the physician was notified the insulin was not administered. On 04/28/15 at 8:00 a.m., the TAR documented a FSBS of 66. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/30/15 at 12:00 p.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/30.[MEDICATION NAME] 2u (not) given - BS 112. The clinical record did not document the physician was notified the insulin was not administered. Monthly physician's orders [REDACTED]. DX: DM.FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. On 05/01/15 at 12:00 p.m., the TAR documented a FSBS of 43. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. The clinical record did not show the physician was notified of a FSBS of 43 or that the insulin was not administered. At 8:00 p.m., the TAR documented a FSBS of 157. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 05/02/15 at 12:00 a.m., the TAR documented a FSBS of 120. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 181. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 05/03/15 at 12:00 a.m., the TAR documented a FSBS of 110. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 p.m., the TAR documented a FSBS of 121. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 05/04/15 at 12:00 a.m., the TAR documented a FSBS of 100. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/4.00:00.Held [MEDICATION NAME] Rt.FSBS low. The clinical record did not show the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 47. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/4.04:00.Held [MEDICATION NAME] low. The clinical record did not document the physician was notified of a FSBS of 47 or that the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 114. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/05/15 at 12:00 a.m., the TAR documented a FSBS of 226. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/5.00:00.Held [MEDICATION NAME] bottomed out previous night. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/5.04:00.Held [MEDICATION NAME] 106. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 85. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/5.20:00.Held 8p [MEDICATION NAME] 87 (sic). The clinical record did not document the physician was notified the insulin was not administered. On 05/06/15 at 12:00 a.m., the TAR documented a FSBS of 81. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/6.12A.Held [MEDICATION NAME] 81. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 167. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/6.4A.Held Nov. The clinical record did not document the physician was notified the insulin was not administered. At 12:00 p.m., the TAR documented a FSBS of 486. The clinical record did not document the physician was notified of a FSBS of 486. At 8:00 p.m., the TAR documented a FSBS of 243. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/07/15 at 12:00 a.m., the TAR documented a FSBS of 261. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/6 (sic).12A.Held [MEDICATION NAME] keeps bottoming out in AM. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 146. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/08/15 at 12:00 p.m., the TAR documented a FSBS of 85. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 108. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/09/15 at 12:00 p.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/10/15 at 8:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/10/15 at 4:00 p.m., the TAR documented a FSBS of 541. The clinical record did not document the physician was notified of a FSBS of 541. On 05/11/15 at 12:00 a.m., the TAR documented a FSBS of 54. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/11.12A.Insulin held.FSBS (low). The clinical record did not document the physician was notified of a FSBS of 54 or that the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 97. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/11.4A.Insulin held.FSBS 97. The clinical record did not document the physician was notified the insulin was not administered. On 05/12/15 at 4:00 a.m., the TAR documented a FSBS of 128. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].

On 06/24/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide care and services for residents with diabetes mellitus. The facility failed to ensure residents were consistently provided doses of routine insulin and sliding scale insulin; physicians were notified of fingerstick blood sugars greater than 400 or of low blood sugars; residents were provided with the correct insulin; the correct dosage of insulin; and the facility failed to consistently assess fingerstick blood sugars as required. At 4:40 p.m., the Oklahoma State Department of Health verified the existence of an immediate jeopardy (IJ) situation. At 4:55 p.m., the administrator, DON, and corporate nurse were informed of the IJ situation. At 8:58 p.m., an acceptable plan of removal was provided by the facility. The plan of removal documented: .Plan of Removal for Alleged IJ for Skiatook Nursing Home 6.24.2015 4:57 pm. 1. Significant Medication Error regarding Insulin. 6.24.2015 at 6:32 pm the Pharmacist and the Medical Director reviewed all current insulins with the current physician's orders [REDACTED]. All were found to be accurate. By 6.25.2015 at 6:00 am each current insulin order on the medication record will be verified with the original order in the resident's medical record. If a discrepancy is noted, the physician will be notified for clarification of the order. By 6.25.2015 at 6:00 pm, each LPN and RN of the facility will be observed by the RN Director of Nursing complete the fingerstick blood sugar, select the insulin, draw the insulin and administer the dose according to the current physician's orders [REDACTED]. No LPN or RN will be allowed to work until they have been observed and found competent to administer insulin. 2. Pharmacy Services Accuracy of Medications. 6.24.2015 at 6:32 pm The Pharmacist and Medical Director have reviewed all current insulins with the physician's orders [REDACTED]. The RN Director of Nursing was instructed to conduct weekly checks on all insulins to insure the medication matches the order by the Medical Director, beginning 7.1.2015. The Pharmacist will check the insulins for accuracy monthly. If the physician provides new insulin orders for any resident, the nurses will verify the telephone order by two nurses. Two nurses will also verify the Treatment record to insure accuracy by noting with their initials. 3. Providing Services for residents receiving insulin. 6.24.2015 at 5:30 pm, each attending physician with residents that currently receive insulin have been contacted and the following parameters have been obtained: When to notify the physician for low and high blood sugars and when to administer [MEDICATION NAME]/[MEDICATION NAME]. For each new admission, the nurse will request parameters as described above. (Physician name withheld): Notify PCP of Blood sugar below 75 or above 450, administer 1 mg [MEDICATION NAME] if resident is unresponsive. (Physician name withheld): Notify PCP if blood sugar below 70 or above 400. Administer 1 mg of [MEDICATION NAME] if unresponsive. These orders are written on telephone orders for each resident and will be placed in each resident's chart. 6.24.2015 at 6:36 pm all facility LPN's and RN's were instructed by the Medical Director to not hold blood sugar medications without notification to the physician. The Pharmacist will provide inservice training to the two day shift LPN's scheduled to work at 6:00 am on 6.25.15 as well as the evening shift LPN present in the facility regarding long acting and short acting insulins with onset and duration and the importance of administering insulins as ordered to obtain a steady blood sugar for each resident. The remaining LPN and RN staff will receive the same inservice training on 6.25.2015 by 5:00pm, unless the individual is not able to come to the facility at which time the Pharmacist will provide training by telephone prior to their next scheduled shift. No LPN or RN will be allowed to work until they have received this training. 4. Notification to Physician of Resident change of condition. 6.24.2015 at 6:36 pm each facility nurse, LPN and RN, see attached list of names, received inservice training by the Medical Director of the addition of parameters to notify the physician of high and low blood sugars and when to administer [MEDICATION NAME]/[MEDICATION NAME]. The nursing staff will be required to document these notifications to the physician in the residents nurse's notes as appropriate. They also received inservice training by the Medical Director regarding symptoms of high and low blood sugars that would reflect a change in resident condition and the requirement to notify the physician and document in the resident's nurse's notes. Medications for blood sugar will not be held without notification to the physician. The facility's policy is to notify the resident's attending physician with any resident change in condition. The LPN's and RN's were instructed to always follow this policy. (Name withheld) RN was not able to be reached by telephone and did not attend the inservice. She is scheduled to work next on (date withheld). She will receive inservice training from the RN Director of Nursing on all of the above prior to her next scheduled shift. 5. The Pharmacist failed to monitor insulin. 6.24.2015 at 6:32 pm The Medical Director and the Pharmacist reviewed all current insulins with the current physician's orders [REDACTED]. The Medical Director instructed the Pharmacist to review all insulins with the current physician's orders [REDACTED]. By 6.25.2015 at 5:00pm, the Pharmacist will complete a review of all resident's blood sugars and insulin usage and will report findings to the resident's attending physician. On 06/25/15 at 3:34 p.m. the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 06/26/15 in regards to their knowledge of the inservice and to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 06/25/15 at 3:34 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to provide care and services to promote the resident's highest practicable well-being for two (#3 and #8) of five sampled residents who required management of diabetes mellitus. The facility failed to ensure: ~ residents were consistently provided doses of routine and sliding scale insulin; ~ residents were provided with the correct insulin; ~ residents were provided the correct dosage of insulin; ~ fingerstick blood sugars were assessed as required; and/or ~ physicians were notified of fingerstick blood sugars greater than 400 or of low blood sugars. This had the potential to affect 23 residents with diabetes mellitus who required finger stick blood sugar monitoring and insulin administration. Findings: An undated facility policy, titled Procedure for Administration, documented, .The medication administration sheets are checked by the nurse at the beginning of the month, against the doctor's orders and updated during the month as indicated.The nurse or cma will check the package label to make sure that it corresponds with the order on the medication administration sheet.If medication is not administered as ordered, the nurse or cma may circle their initials and then document an explanation on the back of the sheet as to why. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hand written physician admission order, dated 03/16/15, documented, .Insulin detemir ([MEDICATION NAME]) 100u/mL 12u SQ BID Dx: DM.Insulin regular 2u SQ Q6(hours) Dx: DM.Insulin regular sliding scale SQ Q6(hours) 70-100=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. There was no documentation of sliding scale coverage for FSBS readings between 101-140. A hand written physician order, dated 03/20/15, documented, .FSBS checks Q4 (hours) c S/S at meal times. A hand written physician order, dated 03/23/15, documented, .Clarification:.FSBS Q 4(hours) c SSI regular. Regular insulin 2u SQ Q 4 (hours). A hand written physician order, dated 03/27/15, documented, .D/C Regular SSI 70-140 =0u, 141-180 = 1u, 181-220 = 2u, 221-260 = 3u, 261-300 = 4u, 301-340 = 5u, 341-350 =6u. D/C [MEDICATION NAME] 10u SQ Bid. .FSBS Q 4(hours) c Regular SSI 151-200=2u, 201-250=4u, 251-300=6u, 301-350=8u, 351-400=10u, > 400 = 12u & notify [MEDICATION NAME] 20u SQ Bid. An admission assessment, dated 03/30/15, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance with activities of daily living, received 51 percent or more of her total caloric intake through a gastrostomy tube, and received insulin injections for seven days out of the seven days during the look back period. Monthly physician's orders [REDACTED]. DX: DM.FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. A treatment administration record (TAR), dated 04/02/15 at 12:00 a.m., did not document a FSBS was obtained, or the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. 04/05/15 at 12:00 a.m., the TAR documented a FSBS of 110. The clinical record did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 97. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 8:00 a.m., the TAR documented a FSBS of 90. A handwritten notation on the back of the TAR documented, .4/5/15.08:[MEDICATION NAME] R 2 units SQ held FSBS 90. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 p.m., the TAR documented a FSBS of 134. The TAR did not document the resident was administered a scheduled bedtime insulin dose of [MEDICATION NAME] 20 units or two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/5/15.8p.held [MEDICATION NAME] 20u d/t FSBS 134. The clinical record did not document the physician was notified the [MEDICATION NAME] and Novolg insulins were not administered. On 04/06/15 at 08:00 a.m., the TAR documented a FSBS of 126. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/07/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of [MEDICATION NAME] insulin. The clinical record did not document the physician was notified of the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 83. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 08:00 a.m., the TAR documented a FSBS of 137. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME] 20 units as ordered by the physician. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 p.m., the TAR documented a FSBS of 451. The clinical record did not document the physician was notified of a FSBS of 451. On 04/08/15 at 12:00 a.m., the TAR documented a FSBS of 82. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/8/15.04:00.BS @ 65 gave 60cc of coke recheck @ 05:00 (up) to 84. The clinical record did not document the physician was notified of a FSBS of 65, that the insulin was not administered, the administration of coke, or that the FSBS was rechecked and the result. At 08:00 a.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered the scheduled morning dose of [MEDICATION NAME] 20 units per the physician's orders [REDACTED]. At 4:00 p.m.,the TAR documented a FSBS of 403. The clinical record did not document the physician was notified of a FSBS of 403. At 6:30 p.m., a hand written physician's orders [REDACTED].@ AM et HS Dx: DMII. and to start [MEDICATION NAME] 15u subcutaneous inj @ AM et HS Dx: DMII. On 04/09/15 at 12:00 a.m., the TAR documented a FSBS of 55. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 04:00 a.m., the TAR documented a FSBS of 130. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/10/15 at 4:00 p.m., the TAR documented a FSBS of 478. The clinical record did not show the physician was notified of a FSBS of 478. The TAR documented 10 units of [MEDICATION NAME]was administered. The physician's orders [REDACTED]. On 04/11/15 at 08:00 a.m., the TAR documented a FSBS of 84. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME] 15 units. A handwritten notation on the back of the TAR documented, .4/11/15.8A.Levmir 15u SQ. The clinical record did not show the physician was notified the insulin was not administered. On 04/12/15 at 08:00 a.m., the TAR documented a FSBS of 100. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/13/15 at 04:00 a.m., the TAR documented a FSBS of 67. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/13.04:00.Insulin held (secondary to) FSBS 67. The clinical record did not document the physician was notified of a FSBS of 67 or that the insulin was not administered. At 08:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/14/15 at 08:00 a.m., the TAR documented a FSBS of 124. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/17/15 at 08:00 a.m., the TAR documented a FSBS of 105. The TAR did not document the resident was administered a scheduled morning dose of [MEDICATION NAME] 15 units or the two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 12:00 p.m., the TAR documented a FSBS of 147. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 p.m., the TAR documented a FSBS of 468. The clinical record did not show the physician was notified of a FSBS of 468. On 04/18/15 at 04:00 a.m., the TAR documented a FSBS of 69. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/18.04:00.Insulin held (secondary to) FSBS 69. The clinical record did not document the physician was notified of a FSBS of 69 or that the insulin was not administered. At 08:00 a.m., the TAR documented a FSBS of 82. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or the two units of [MEDICATION NAME] per the physician's orders [REDACTED].4/18/15.[MEDICATION NAME] 15u SQ.held FSBS 82. The clinical record did not document the physician was notified the insulin was not administered. On 04/19/15 at 12:00 a.m., the TAR documented a FSBS of 99. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 191. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 8:00 a.m., the TAR documented a FSBS of 171. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/20/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/20.[MEDICATION NAME] held FSBS 150., and was signed by the DON. The clinical record did not document the physician was notified the insulin was not administered. On 04/21/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/21.[MEDICATION NAME] held FSBS 150. The clinical record did not document the physician was notified the insulin was not administered. At 12:00 p.m., the TAR documented a FSBS of HI. The TAR documented the resident was administered 10 units of [MEDICATION NAME] insulin. A handwritten physician's orders [REDACTED]. The clinical record did not document the physician was notified that 10 units of [MEDICATION NAME]was given instead of 10 units of [MEDICATION NAME] R insulin. At 4:00 p.m., the TAR documented a FSBS of 470. The TAR documented the resident was administered 10 units of [MEDICATION NAME] insulin. The sliding scale insulin for a blood sugar of 470 was 12 units per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 127. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/22/15 at 8:00 p.m., the TAR documented a FSBS of 87. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/23/15 at 12:00 a.m., the TAR documented a FSBS of 71. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/23.12A.Held [MEDICATION NAME] 70 (sic) gave OJ c sugar. The clinical record did not document the physician was notified the insulin was not administered. At 04:00 a.m., the TAR documented a FSBS of 118. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/26/15 at 4:00 a.m., the TAR documented a FSBS of 63. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/26.4A.Insulin (not) admin FSBS 63 - (No) S/S [DIAGNOSES REDACTED]. OJ (down) PEG. The clinical record did not document the physician was notified of a FSBS of 63, the administration of orange juice via the gastrostomy tube or that the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 81. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/26/15.[MEDICATION NAME] 2 units.held FSBS 81.The clinical record did not document the physician was notified the insulin was not administered. On 04/28/15 at 8:00 a.m., the TAR documented a FSBS of 66. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 04/30/15 at 12:00 p.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].4/30.[MEDICATION NAME] 2u (not) given - BS 112. The clinical record did not document the physician was notified the insulin was not administered. Monthly physician's orders [REDACTED]. DX: DM.FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. On 05/01/15 at 12:00 p.m., the TAR documented a FSBS of 43. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. The clinical record did not show the physician was notified of a FSBS of 43 or that the insulin was not administered. At 8:00 p.m., the TAR documented a FSBS of 157. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 05/02/15 at 12:00 a.m., the TAR documented a FSBS of 120. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 181. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 05/03/15 at 12:00 a.m., the TAR documented a FSBS of 110. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. At 4:00 p.m., the TAR documented a FSBS of 121. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED]. On 05/04/15 at 12:00 a.m., the TAR documented a FSBS of 100. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/4.00:00.Held [MEDICATION NAME] Rt.FSBS low. The clinical record did not show the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 47. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/4.04:00.Held [MEDICATION NAME] low. The clinical record did not document the physician was notified of a FSBS of 47 or that the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 114. The TAR did not document the resident was administered [MEDICATION NAME] 15 units or two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/05/15 at 12:00 a.m., the TAR documented a FSBS of 226. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/5.00:00.Held [MEDICATION NAME] bottomed out previous night. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/5.04:00.Held [MEDICATION NAME] 106. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 85. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/5.20:00.Held 8p [MEDICATION NAME] 87 (sic). The clinical record did not document the physician was notified the insulin was not administered. On 05/06/15 at 12:00 a.m., the TAR documented a FSBS of 81. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/6.12A.Held [MEDICATION NAME] 81. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 167. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/6.4A.Held Nov. The clinical record did not document the physician was notified the insulin was not administered. At 12:00 p.m., the TAR documented a FSBS of 486. The clinical record did not document the physician was notified of a FSBS of 486. At 8:00 p.m., the TAR documented a FSBS of 243. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/07/15 at 12:00 a.m., the TAR documented a FSBS of 261. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED].5/6 (sic).12A.Held [MEDICATION NAME] keeps bottoming out in AM. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 146. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/08/15 at 12:00 p.m., the TAR documented a FSBS of 85. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 108. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/09/15 at 12:00 p.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/10/15 at 8:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of [MEDICATION NAME] per the physician's orders [REDACTED]. On 05/10/15 at 4:00 p.m., the TAR documented a FSBS of 541. The clinical record did not document the physician was notified of a FSBS of 541. On 05/11/15 at 12:00 a.m., the TAR documented a FSBS of 54. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].5/11.12A.Insulin held.FSBS (low). The clinical record did not document the physician was notified of a FSBS of 54 or that the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 97. The TAR did not document the resident was administered two units of [MEDICATION NAME]per the physician's orders [REDACTED].

On 06/24/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure significant medication errors did not occur. Resident #8 had blood sugars as high as 587 and as low as 43. The facility failed to provide the correct insulin, failed to provide the correct dosage of insulin, and held the insulin on multiple occasions without notifying the physician. At 4:40 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:55 p.m., the administrator, DON, and corporate nurse were informed of the IJ situation. At 8:58 p.m., an acceptable plan of removal was provided by the facility. The plan of removal documented; .Plan of Removal for Alleged IJ for Skiatook Nursing Home 6.24.2015 4:57 pm. 1. Significant Medication Error regarding Insulin. 6.24.2015 at 6:32 pm the Pharmacist and the Medical Director reviewed all current insulins with the current physician's orders [REDACTED]. All were found to be accurate. By 6.25.2015 at 6:00 am each current insulin order on the medication record will be verified with the original order in the resident's medical record. If a discrepancy is noted, the physician will be notified for clarification of the order. By 6.25.2015 at 6:00 pm, each LPN and RN of the facility will be observed by the RN Director of Nursing complete the fingerstick blood sugar, select the insulin, draw the insulin and administer the dose according to the current physician's orders [REDACTED]. No LPN or RN will be allowed to work until they have been observed and found competent to administer insulin. 2. Pharmacy Services Accuracy of Medications. 6.24.2015 at 6:32 pm The Pharmacist and Medical Director have reviewed all current insulins with the physician's orders [REDACTED]. The RN Director of Nursing was instructed to conduct weekly checks on all insulins to insure the medication matches the order by the Medical Director, beginning 7.1.2015. The Pharmacist will check the insulins for accuracy monthly. If the physician provides new insulin orders for any resident, the nurses will verify the telephone order by two nurses. Two nurses will also verify the Treatment record to insure accuracy by noting with their initials. 3. Providing Services for residents receiving insulin. 6.24.2015 at 5:30 pm, each attending physician with residents that currently receive insulin have been contacted and the following parameters have been obtained: When to notify the physician for low and high blood sugars and when to administer [MEDICATION NAME]/[MEDICATION NAME]. For each new admission, the nurse will request parameters as described above. (Physician name withheld): Notify PCP of Blood sugar below 75 or above 450, administer 1 mg [MEDICATION NAME] if resident is unresponsive. (Physician name withheld): Notify PCP if blood sugar below 70 or above 400. Administer 1 mg of [MEDICATION NAME] if unresponsive. These orders are written on telephone orders for each resident and will be placed in each resident's chart. 6.24.2015 at 6:36 pm all facility LPN's and RN's were instructed by the Medical Director to not hold blood sugar medications without notification to the physician. The Pharmacist will provide inservice training to the two day shift LPN's scheduled to work at 6:00 am on 6.25.15 as well as the evening shift LPN present in the facility regarding long acting and short acting insulins with onset and duration and the importance of administering insulins as ordered to obtain a steady blood sugar for each resident. The remaining LPN and RN staff will receive the same inservice training on 6.25.2015 by 5:00pm, unless the individual is not able to come to the facility at which time the Pharmacist will provide training by telephone prior to their next scheduled shift. No LPN or RN will be allowed to work until they have received this training. 4. Notification to Physician of Resident change of condition. 6.24.2015 at 6:36 pm each facility nurse, LPN and RN, see attached list of names, received inservice training by the Medical Director of the addition of parameters to notify the physician of high and low blood sugars and when to administer [MEDICATION NAME]/[MEDICATION NAME]. The nursing staff will be required to document these notifications to the physician in the residents nurse's notes as appropriate. They also received inservice training by the Medical Director regarding symptoms of high and low blood sugars that would reflect a change in resident condition and the requirement to notify the physician and document in the resident's nurse's notes. Medications for blood sugar will not be held without notification to the physician. The facility's policy is to notify the resident's attending physician with any resident change in condition. The LPN's and RN's were instructed to always follow this policy. (Name withheld) RN was not able to be reached by telephone and did not attend the inservice. She is scheduled to work next on (date withheld). She will receive inservice training from the RN Director of Nursing on all of the above prior to her next scheduled shift. 5. The Pharmacist failed to monitor in insulin. 6.24.2015 at 6:32 pm The Medical Director and the Pharmacist reviewed all current insulins with the current physician's orders [REDACTED]. The Medical Director instructed the Pharmacist to review all insulins with the current physician's orders [REDACTED]. By 6.25.2015 at 5:00pm, the Pharmacist will complete a review of all resident's blood sugars and insulin usage and will report findings to the resident's attending physician. On 06/25/15 at 3:34 p.m. the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 06/26/15 in regards to their knowledge of the inservice and to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 06/25/15 at 3:34 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure significant medication errors did not occur for one (#8) of 5 sampled residents who required insulin administration. The facility identified 23 residents who required insulin administration. Findings: A facility policy, dated July 1992, and titled Policy & Procedure on Medication Errors, documented, .It shall be the policy of this facility to insure that medications error rates are not greater than 5% and residents will be free of any significant medication errors. Medications will be administered only with a written physician's orders [REDACTED]. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hand written admission orders [REDACTED]=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. A hand written physician's orders [REDACTED].FSBS Q 4(hours) c SSI regular. Regular insulin 2u SQ Q 4(hours). A hand written physician's orders [REDACTED].=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. D/C [MEDICATION NAME] 10u SQ Bid. A hand written physician's orders [REDACTED].=2u, 201-250=4u, 251-300=6u, 301-350=8u, 351-400=10u, > 400 = 12u & notify [MEDICATION NAME] 20u SQ Bid. The comprehensive assessment, dated 03/30/15, documented the resident was severely impaired in cognition, required extensive assistance in activities of daily living, received 51 percent or more of her total caloric intake through a gastrostomy tube, and received insulin for seven days out of the seven days during the look back period. The April 2015 monthly physician's orders [REDACTED]. DX: DM. FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 UNITS. [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. On 04/01/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered routine four times and it was held two times. On 04/02/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered routine five times and it was held once at 12:00 a.m. On 04/05/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine two times and it was held four times at 12:00 a.m., 4:00 a.m., 8:00 a.m. and 8:00 p.m. A notation on the back of the TAR for 8:00 a.m., documented, 4/5/15.08:[MEDICATION NAME] R 2 units SQ held FSBS 90. There was no documentation to show the physician had been notified of the FSBS results or that the insulin had been held. At 8:00 p.m., the TAR documented the [MEDICATION NAME]was not administered. A notation on the back of the TAR for 8:00 p.m., documented, .4/5/15.8p.held [MEDICATION NAME] 20u d/t FSBS 134. There was no documentation to show the physician had been notified that the routine [MEDICATION NAME] and the routine regular insulin had been held. On 04/06/15, at 8:00 a.m., the TAR documented the resident's FSBS was 126. The TAR documented the a.m. dose of [MEDICATION NAME]was not administered. On 04/07/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 12:00 a.m. and 4:00 a.m. At 12:00 a.m., the resident's FSBS was 150 and at 4:00 a.m. the resident's FSBS was 83. There was no documentation to show the physician had been notified of the FSBS results or that the insulin was not administered. On 04/07/15 at 08:00 a.m., the TAR documented the resident's FSBS was 137. The TAR documented the resident did not receive the 20 units of [MEDICATION NAME]ordered routine. There was no documentation in the clinical record to show the physician was notified of the resident's FSBS of 137 and that the [MEDICATION NAME] was not administered. On 04/08/15 at 12:00 a.m., the TAR documented the resident's FSBS was 82. The TAR documented the 2 units of [MEDICATION NAME]was not administered. There was no documentation to show the physician was notified of the FSBS or that the insulin was not administered. On 04/08/15 at 08:00 a.m., the TAR documented the resident's FSBS was 106. The TAR documented the resident did not receive the 20 units of [MEDICATION NAME]as ordered by the physician. There was no documentation to show the physician was notified of the resident's FSBS of 106 or that the [MEDICATION NAME]was not administered. On 04/08/15 at 6:30 p.m., a hand written physician's orders [REDACTED].@ AM et HS Dx: DMII. and to start [MEDICATION NAME] 15u subcutaneous inj @ AM et HS Dx: DMII. On 04/09/15 at 4:00 a.m., the TAR documented the resident's FSBS was 130. The TAR documented the 2 units of [MEDICATION NAME]was not administered. There was no documentation to show the physician was notifed of the FSBS or that the insulin was not administered. On 04/10/15, the TAR documented ten units of [MEDICATION NAME]was administered at 4:00 p.m. for a FSBS of 478. The orders specified 12 units of [MEDICATION NAME]were to be administered for a FSBS greater than 400 and the physician was to be notified. On 04/11/15 at 08:00 a.m., the TAR documented the resident's FSBS was 84. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]ordered routine. A notation on the back of the TAR documented, .4/11/15.[MEDICATION NAME] 15u SQ.held FSBS 84. There was no documentation into show the physician was notified of the resident's FSBS of 84 and that the [MEDICATION NAME]was not administered. On 04/11/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once. On 04/12/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times. On 04/14/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once at 8:00 a.m. The TAR documented the resident's FSBS was 124 at 8:00 a.m. On 04/17/15 at 08:00 a.m., the TAR documented the resident's FSBS was 105. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]ordered routine. There was no documentation to show the physician was notified of the resident's FSBS of 105 or that the [MEDICATION NAME]was not administered. On 04/17/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 8:00 a.m and 12:00 p.m. The resident's FSBS was 105 at 8 a.m. and 147 at 12:00 p.m. There was no documentation to show the physician was notified that the insulin was not given. On 04/18/15 at 08:00 a.m., the TAR documented the resident's FSBS was 82. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]ordered routine. A notation on the back of the TAR documented, .4/18/15.[MEDICATION NAME] 15u SQ.held FSBS 82. There was no documentation to show the physician was notified of the resident's FSBS of 82 or that the [MEDICATION NAME]was not administered. On 04/18/15, the TAR documented the resident's FSBS was 82 at 8:00 a.m. the 2 units of Novolag insulin was not administered. There was no documenatation to show the physician was notified that the insulin was not administered. On 04/19/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 8:00 a.m. The TAR documented the resident's FSBS was 99 at 12:00 a.m., 191 at 4:00 a.m. and 171 at 8:00 a.m. There was no documentation to show the physician was notified of the FSBS results or that the insulin was not administered. On 04/20/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once at 12:00 a.m. The TAR documented the resident's FSBS was 150 at 12:00 a.m. A handwritten notation on the back of the TAR documented, .4/20.12A.Novolag held FSBS 150. There was no documentation to show the physician was notified that the insulin was held. The TAR also documented the resident received five units of [MEDICATION NAME]at 4:00 p.m. for a FSBS of 311. (Note the April 2015 order for [MEDICATION NAME] sliding scale documented two different dosages for a FSBS of 311. The sliding scale documented a FSBS of 301-340 = 5 units or 301-350 = 8 units of [MEDICATION NAME] insulin.) On 04/21/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 12:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 150 at 12:00 a.m. and 127 at 8:00 p.m. There was no documentation to show the phsician was notified that the insulin was held. The TAR also documented the resident received five units of [MEDICATION NAME]at 4:00 a.m. per the ordered sliding scale for a FSBS of 321, eight units of [MEDICATION NAME]at 8:00 a.m. for a FSBS of 307, ten units of [MEDICATION NAME]at 12:00 p.m. for a FSBS of Hi, ten units of [MEDICATION NAME]at 4:00 p.m. for a FSBS of 470. On 04/21/15 at 12:00 p.m., the TAR documented the resident's FSBS was Hi. The TAR documented the resident received 10 units of [MEDICATION NAME] insulin. A hand written physician's orders [REDACTED]. There was no documentation of the administration of 10 units of [MEDICATION NAME] R insulin as ordered by the physician. At 4:00 p.m., the TAR documented a FSBS of 470. The TAR documented the resident was administered 10 units of [MEDICATION NAME] insulin. The physician's orders [REDACTED]. The care plan, dated 04/22/15, documented, .Problem:.Diet RT Diabetes.Goal:.Will not have high blood sugars due to [DIAGNOSES REDACTED].FSBS, routine insulin and sliding scale insulin as ordered. On 04/23/15, at 8:00 a.m., the TAR documented the resident's FSBS was 118 and the 2 units of [MEDICATION NAME]was not given. On 04/26/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times. The TAR at 8:00 a.m. documented the resident's FSBS was 81. A notation on the back of the TAR documented, .4/26/15.[MEDICATION NAME] 2 units.held FSBS 81. There was no documentation to show the physician was notified that the insulin was held. On 04/28/15 at 8:00 a.m., the TAR documented the resident's FSBS was 66. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]or the 2 units of [MEDICATION NAME]ordered routine. There was no documentation to show the physician was notified of the resident's FSBS of 66 or that the [MEDICATION NAME]and the [MEDICATION NAME]were not administered. On 04/30/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once at 12:00 p.m. The TAR documented the resident's FSBS was 112 at 12:00 p.m. There was no documentation to show the physician was notified that the insulin was held. The May 2015 monthly physician's orders [REDACTED]. DX: DM. FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 UNITS. [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. On 05/01/15 at 8:00 p.m., the TAR documented the resident's FSBS was 157. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]as ordered routine or the 2 units of [MEDICATION NAME]ordered routine every four hours. There was no documentation to show the physician was notified that the [MEDICATION NAME]and [MEDICATION NAME]was not administered as ordered. On 05/02/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 120 at 12:00 a.m., 112 at 4:00 a.m. and 181 at 8:00 p.m. There was no documentation to show the physician was notified that the insulin was held. On 05/03/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times, it was held two times at 12:00 a.m. and 4:00 p.m., and not documented once. The TAR documented the resident's FSBS was 110 at 12:00 a.m. and 121 at 4:00 p.m. There was no documentation to show the physician was notified the insulin was held. On 05/04/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times and it was held three times. The TAR documented the resident's FSBS was 100 at 12:00 a.m. and 114 at 8:00 a.m. The resident's [MEDICATION NAME] routine insulin was also held at 8 a.m. There was no documentation to show the physician was notified that the routine insulin was held. On 05/05/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine two times and it was held four times at 12:00 a.m., 4:00 a.m., 8:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 226 at 12:00 a.m. A notation on the back of the TAR documented, .5/5.00:00.Held [MEDICATION NAME] bottomed out previous night. The TAR documented the resident's FSBS was 106 at 4:00 a.m., 112 at 8:00 a.m. and 85 at 8:00 p.m. There was no documentation to show the physician was notified that the insulin was held. The TAR also documented the resident did not receive coverage at 12:00 a.m. per the ordered sliding scale for a FSBS of 226. On 05/06/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 81 at 12:00 a.m., 167 at 4:00 a.m. and 243 at 8:00 p.m. On 05/07/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 12:00 a.m. and 8:00 a.m. The TAR documented the resident's FSBS was 261 at 12:00 a.m. A notation on the back of the TAR documented, .5/6 (sic).12A.Held [MEDICATION NAME] keeps bottoming out in AM. The TAR also documented the resident did not receive coverage at 12:00 a.m. per the ordered sliding scale for a FSBS of 261. The TAR documented the resident's FSBS was 146 at 8:00 a.m. On 05/08/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 12:00 p.m. and 8:00 p.m. The TAR documented the resident's FSBS was 85 at 12:00 p.m. and 108 at 8:00 p.m. On 05/09/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once at 12:00 p.m. The TAR documented the resident's FSBS was 106 at 12:00 p.m. On 05/11/15, at 4:00 a.m., the TAR documented the resident's FSBS was 97. The TAR documented the 2 units of [MEDICATION NAME]was not administered. On 05/12/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 4:00 a.m. and 12:00 p.m. The TAR documented the resident's FSBS was 128 at 4:00 a.m. and 301 at 12:00 p.m. On 05/13/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 4:00 p.m. and 8:00 p.m. The TAR documented the resident's FSBS was 75 at 4:00 p.m. and 275 at 8:00 p.m. On 05/15/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times,it was held two times at 12:00 a.m. and 4:00 a.m., and not documented once. The TAR documented the resident's FSBS was 149 at 12:00 a.m. and 137 at 4:00 a.m. On 05/16/15 at 8:00 p.m., the TAR documented the resident's FSBS was 80. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]ordered routine or the 2 units of [MEDICATION NAME] insulin. There was no documentation to show the physician was notified that the [MEDICATION NAME]and the [MEDICATION NAME]were not administered. On 05/17/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine two times, it was held two times at 12:00 a.m. and 4:00 a.m., and the TAR documented the resident was out of the facility for two opportunities of administration. The TAR documented the resident's FSBS was 262 at 12:00 a.m. and 176 at 4:00 a.m. On 05/18/15, at 4:00 a.m., the TAR documented the resident's FSBS was 426. The resident received 12 units of [MEDICATION NAME]per sliding scale for the blood sugar of greater than 400. There was no documentation to show the resident received the 2 units of [MEDICATION NAME]ordered routinely every four hours. On 05/21/15, at 12:00 a.m. and 4:00 a.m., there was no documentation on the TAR to show a FSBS had been performed. A notation on the back of the TAR documented, 5/21 0000 (12:00 a.m.).BS had Bottom out held insulin There was no documentation to show the routine [MEDICATION NAME]had been administered. On 05/22/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once at 12:00 a.m. The TAR documented the residenet's FSBS was 92 at 12:00 a.m. On 05/24/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 12:00 a.m. and 4:00 p.m. The TAR documented the resident's FSBS was 118 at 12:00 a.m. and 91 at 4:00 p.m. On 05/25/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 12:00 p.m. The TAR documented the resident's FSBS was 87 at 12:00 a.m., 94 at 4:00 a.m. and 168 at 12:00 p.m. On 05/26/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine four times and it was held two times at 4:00 a.m. and 12:00 p.m. The TAR documented the resident's FSBS was 84 at 4:00 a.m. and 162 at 12:00 p.m. On 05/27/15, the TAR documented the resident received the two units of [MEDICATION NAME]ordered every four hours routine five times and it was held once at 12:00 a.m. The TAR documented the resident's FSBS was 73 at 12:00 a.m. On 05/28/15 at 12:00 a.m., the TAR documented the resident's FSBS was 83. A note on the back of the TAR documented, 5/28/15 12.Insulin held (secondary to) (low) FSBS. On 05/28/15 at 8:00 a.m., the TAR documented the resident's FSBS was 88. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]ordered routine or the 2 units of [MEDICATION NAME] ordered routine. A notation on the back of the TAR documented, 5/28/15 8AM [MEDICATION NAME] 2u + [MEDICATION NAME] 15u held d/t (low) BS There was no documentation to show the physician was notified of the resident's FSBS of 88 or that the [MEDICATION NAME]and [MEDICATION NAME]were not administered. On 05/29/15 at 12:00 a.m., the TAR documented the resident's FSBS was 82 and the 2 units of [MEDICATION NAME]was not administered. A notation on the back of the TAR documented, 5-29 0000.Held [MEDICATION NAME] d/t FSBS 82. On 05/29/15 at 8:00 a.m., the TAR documented the resident's FSBS was 75. The TAR documented the resident did not receive the 15 units of [MEDICATION NAME]or the 2 units of [MEDICATION NAME]ordered routine. There was no documentation to show the physician was notified of the resident's FSBS of 75 or that the [MEDICATION NAME] and [MEDICATION NAME] insulins were not administered as ordered. An incident report, dated 05/29/15, documented, .At approximately 1:00 PM.resident (name omitted for resident #8) was found on the floor in the rest room.Upon evaluation at the ER, it was noted that she had a fracture of her right hip. She remains in the hospital. The hospital patient discharge instruction sheet, dated 06/01/15 at 1:16 p.m., documented, .insulin [MEDICATION NAME] ([MEDICATION NAME]) (insulin [MEDICATION NAME] 100 units/mL subcutaneous solution), sliding scale dose, Subcutaneous, Before Meals, at Bedtime and at 3am.70-140 = 0 units; 141-180 = 1 units, 181-220 = 2 units; 221-260 = 3 units; 261-300 = 4 units; 301-340 = 5 units; 341-350 = 6 units.insulin detemir ([MEDICATION NAME]) (insulin detemir 100 units/mL subcutaneous solution) 12 units, Subcutaneous, Twice Daily. A hand written physician's orders [REDACTED].1) Readmit to SNH.10) Resume S/S insulin & Detemir 12 u Sub q. On 06/02/15, the TAR documented the resident received 6 units of [MEDICATION NAME]at 6:30 a.m. for a FSBS of 412 and 6 units of [MEDICATION NAME]at 11:30 a.m. for a FSBS of 482. The sliding scale insulin orders did not provide instructions for FSBS's greater than 350. The TAR also documented the resident was administered 3 units of [MEDICATION NAME]at 8:00 p.m. for a FSBS of 275. The orders specified the resident should have received 4 units of [MEDICATION NAME] insulin. On 06/03/15, the TAR documented the resident received 6 units of [MEDICATION NAME]at 4:30 p.m. for a FSBS of 412, and 6 units of [MEDICATION NAME]at 8:00 p.m. for a FSBS of 396. The sliding scale insulin orders did not provide instructions for an amount of insulin to be administered whent he FSBS was greater than 350. On 06/04/15, the TAR documented the resident received 5 units of [MEDICATION NAME]at 6:30 a.m. for a FSBS of 227. The orders specified the resident was to have received 3 units of [MEDICATION NAME] insulin. On 06/05/15, the TAR documented the resident received 6 units of [MEDICATION NAME]at 4:30 p.m. for a FSBS of 396. The sliding scale insulin orders did not provide instructions for an amount of insulin to be administered whent he FSBS was greater than 350. On 06/06/15, the TAR documented the resident received 6 units of [MEDICATION NAME]at 6:30 a.m. for a FSBS of 375, and 6 units of [MEDICATION NAME]at 4:30 p.m. for a FSBS of 357. The sliding scale insulin orders did not provide instructions for an amount of insulin to be administered whent he FSBS was greater than 350. The June 2015 monthly physician's orders [REDACTED].>[MEDICATION NAME] 100U/ML GIVE 15 UNITS SQ AM & HS. DX: DM. FSBS Q 4 HOURS WITH [MEDICATION NAME] R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD. [MEDICATION NAME] R INSULIN 2 UNITS SQ Q 4 HOURS. The DON signed the monthly physician orders [REDACTED]. A review of the June 2015 TAR revealed there was no documentation for the routine administration of [MEDICATION NAME] R every four hours as ordered. The orders on the TAR for [MEDICATION NAME]and for sliding scale insulin were not changed after these orders were reviewed and approved by the physician and DON on 06/08/15. On 06/08/15, the TAR documented the resident received 12 units of [MEDICATION NAME]at 8:00 a.m. and 8:00 p.m. The TAR also documented the resident received 4 units of [MEDICATION NAME]at 6:30 a.m. for a FSBS of 194 and 3 units of [MEDICATION NAME]at 11:30 a.m. for a FSBS of 239. On 06/09/15, the TAR documented the resident received 12 units of [MEDICATION NAME]at 8:00 p.m. The TAR also documented the resident received 6 units of [MEDICATION NAME]at 4:30 p.m. for a FSBS of 356, and 5 units of [MEDICATION NAME]at 8:00 p.m. for a FSBS of 315. On 06/10/15, the TAR documented the resident received 12 units of [MEDICATION NAME]at 8:00 a.m. and 8:00 p.m. The TAR also documented the resident received 2 units of [MEDICATION NAME]at 3:00 a.m. for a FSBS of 214, 2 units of [MEDICATION NAME]at 6:30 a.m. for a FSBS of 213, 6 units of [MEDICATION NAME]at 4:30 p.m. for a FSBS of 383, and 3 units of [MEDICATION NAME]at 8:00 p.m. for a FSBS of 255. On 06/11/15, the TAR documented the resident received 12 units of [MEDICATION NAME]at 8:00 a.m. and 8:00 p.m. The TAR also documented the resident received 3 units of [MEDICATION NAME]at 3:00 a.m. for a FSBS of 250, 4 units of [MEDICATION NAME]at 6:30 a.m. for a FSBS of 289, 6 units of [MEDICATION NAME]at 11:30 a.m. for a FSBS of 469, 6 units of [MEDICATION NAME]at 4:30 p.m. for a FSBS of 436, and 6 units of [MEDICATION NAME]at 8:00 p.m. for a FSBS of 542. The skilled daily nurse's not

On 06/24/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to have pharmacy procedures in place to ensure the accurate administration of medications for residents with diabetes. Resident #8 had blood sugars as high as 587 and as low as 43. The facility failed to provide the correct insulin, failed to provide the correct dosage of insulin, and held the insulin on multiple occasions without notifying the physician. At 4:40 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:55 p.m., the administrator, DON, and corporate nurse were informed of the IJ situation. At 8:58 p.m., an acceptable plan of removal was provided by the facility. The plan of removal documented; .Plan of Removal for Alleged IJ for Skiatook Nursing Home 6.24.2015 4:57 pm. 1. Significant Medication Error regarding Insulin. 6.24.2015 at 6:32 pm the Pharmacist and the Medical Director reviewed all current insulins with the current physician's orders [REDACTED]. All were found to be accurate. By 6.25.2015 at 6:00 am each current insulin order on the medication record will be verified with the original order in the resident's medical record. If a discrepancy is noted, the physician will be notified for clarification of the order. By 6.25.2015 at 6:00 pm, each LPN and RN of the facility will be observed by the RN Director of Nursing complete the fingerstick blood sugar, select the insulin, draw the insulin and administer the dose according to the current physician's orders [REDACTED]. No LPN or RN will be allowed to work until they have been observed and found competent to administer insulin. 2. Pharmacy Services Accuracy of Medications. 6.24.2015 at 6:32 pm The Pharmacist and Medical Director have reviewed all current insulins with the physician's orders [REDACTED]. The RN Director of Nursing was instructed to conduct weekly checks on all insulins to insure the medication matches the order by the Medical Director, beginning 7.1.2015. The Pharmacist will check the insulins for accuracy monthly. If the physician provides new insulin orders for any resident, the nurses will verify the telephone order by two nurses. Two nurses will also verify the Treatment record to insure accuracy by noting with their initials. 3. Providing Services for residents receiving insulin. 6.24.2015 at 5:30 pm, each attending physician with residents that currently receive insulin have been contacted and the following parameters have been obtained: When to notify the physician for low and high blood sugars and when to administer Glucagon/Glucagen. For each new admission, the nurse will request parameters as described above. (Physician name withheld): Notify PCP of Blood sugar below 75 or above 450, administer 1 mg Glucagon if resident is unresponsive. (Physician name withheld): Notify PCP if blood sugar below 70 or above 400. Administer 1 mg of Glucagon if unresponsive. These orders are written on telephone orders for each resident and will be placed in each resident's chart. 6.24.2015 at 6:36 pm all facility LPN's and RN's were instructed by the Medical Director to not hold blood sugar medications without notification to the physician. The Pharmacist will provide inservice training to the two day shift LPN's scheduled to work at 6:00 am on 6.25.15 as well as the evening shift LPN present in the facility regarding long acting and short acting insulins with onset and duration and the importance of administering insulins as ordered to obtain a steady blood sugar for each resident. The remaining LPN and RN staff will receive the same inservice training on 6.25.2015 by 5:00pm, unless the individual is not able to come to the facility at which time the Pharmacist will provide training by telephone prior to their next scheduled shift. No LPN or RN will be allowed to work until they have received this training. 4. Notification to Physician of Resident change of condition. 6.24.2015 at 6:36 pm each facility nurse, LPN and RN, see attached list of names, received inservice training by the Medical Director of the addition of parameters to notify the physician of high and low blood sugars and when to administer Glucagon/Glucagen. The nursing staff will be required to document these notifications to the physician in the residents nurse's notes as appropriate. They also received inservice training by the Medical Director regarding symptoms of high and low blood sugars that would reflect a change in resident condition and the requirement to notify the physician and document in the resident's nurse's notes. Medications for blood sugar will not be held without notification to the physician. The facility's policy is to notify the resident's attending physician with any resident change in condition. The LPN's and RN's were instructed to always follow this policy. (Name withheld) RN was not able to be reached by telephone and did not attend the inservice. She is scheduled to work next on (date withheld). She will receive inservice training from the RN Director of Nursing on all of the above prior to her next scheduled shift. 5. The Pharmacist failed to monitor in insulin. 6.24.2015 at 6:32 pm The Medical Director and the Pharmacist reviewed all current insulins with the current physician's orders [REDACTED]. The Medical Director instructed the Pharmacist to review all insulins with the current physician's orders [REDACTED]. By 6.25.2015 at 5:00pm, the Pharmacist will complete a review of all resident's blood sugars and insulin usage and will report findings to the resident's attending physician. On 06/25/15 at 3:34 p.m. the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 06/26/15 in regards to their knowledge of the inservice and to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 06/25/15 at 3:34 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to have pharmacy procedures in place to ensure the accurate administration of medications for two (#3, #8) of 5 sampled residents who required insulin. The facility identified 23 residents who required insulin monitoring and intervention. Findings: A facility policy, dated July 1992, and titled Policy & Procedure on Medication Errors, documented, .It shall be the policy of this facility to insure that medications error rates are not greater than 5% and residents will be free of any significant medication errors. Medications will be administered only with a written physician's orders [REDACTED]. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hand written admission orders [REDACTED]=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. A hand written physician's orders [REDACTED].FSBS Q 4(hours) c SSI regular. Regular insulin 2u SQ Q 4(hours). A hand written physician's orders [REDACTED].=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. D/C Levemir 10u SQ Bid. A hand written physician's orders [REDACTED].=2u, 201-250=4u, 251-300=6u, 301-350=8u, 351-400=10u, > 400 = 12u & notify phy.Levemir 20u SQ Bid. The comprehensive assessment, dated 03/30/15, documented the resident was severely impaired in cognition, required extensive assistance in activities of daily living, received 51 percent or more of her total caloric intake through a gastrostomy tube, and received insulin for seven days out of the seven days during the look back period. The April 2015 monthly physician's orders [REDACTED]. DX: DM. FSBS Q 4 HOURS WITH NOVOLOG R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 UNITS. NOVOLOG R INSULIN 2 UNITS SQ Q 4 HOURS. On 04/01/15, the TAR documented the resident received the two units of Novolog insulin ordered routine four times and it was held two times. On 04/02/15, the TAR documented the resident received the two units of Novolog insulin ordered routine five times and it was held once at 12:00 a.m. On 04/05/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine two times and it was held four times at 12:00 a.m., 4:00 a.m., 8:00 a.m. and 8:00 p.m. A notation on the back of the TAR for 8:00 a.m., documented, 4/5/15.08:00.Novolog R 2 units SQ held FSBS 90. There was no documentation to show the physician had been notified of the FSBS results or that the insulin had been held. At 8:00 p.m., the TAR documented the Levemir insulin was not administered. A notation on the back of the TAR for 8:00 p.m., documented, .4/5/15.8p.held Levemir 20u d/t FSBS 134. There was no documentation to show the physician had been notified that the routine Levemir and the routine regular insulin had been held. On 04/06/15, at 8:00 a.m., the TAR documented the resident's FSBS was 126. The TAR documented the a.m. dose of Levemir insulin was not administered. On 04/07/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 12:00 a.m. and 4:00 a.m. At 12:00 a.m., the resident's FSBS was 150 and at 4:00 a.m. the resident's FSBS was 83. There was no documentation to show the physician had been notified of the FSBS results or that the insulin was not administered. On 04/07/15 at 08:00 a.m., the TAR documented the resident's FSBS was 137. The TAR documented the resident did not receive the 20 units of Levemir insulin ordered routine. There was no documentation in the clinical record to show the physician was notified of the resident's FSBS of 137 and that the Levemir was not administered. On 04/08/15 at 12:00 a.m., the TAR documented the resident's FSBS was 82. The TAR documented the 2 units of Novolog insulin was not administered. There was no documentation to show the physician was notified of the FSBS or that the insulin was not administered. On 04/08/15 at 08:00 a.m., the TAR documented the resident's FSBS was 106. The TAR documented the resident did not receive the 20 units of Levemir insulin as ordered by the physician. There was no documentation to show the physician was notified of the resident's FSBS of 106 or that the Levemir insulin was not administered. On 04/08/15 at 6:30 p.m., a hand written physician's orders [REDACTED].@ AM et HS Dx: DMII. and to start .Levemir 15u subcutaneous inj @ AM et HS Dx: DMII. On 04/09/15 at 4:00 a.m., the TAR documented the resident's FSBS was 130. The TAR documented the 2 units of Novolog insulin was not administered. There was no documentation to show the physician was notifed of the FSBS or that the insulin was not administered. On 04/10/15, the TAR documented ten units of Novolog insulin was administered at 4:00 p.m. for a FSBS of 478. The orders specified 12 units of Novolog insulin were to be administered for a FSBS greater than 400 and the physician was to be notified. On 04/11/15 at 08:00 a.m., the TAR documented the resident's FSBS was 84. The TAR documented the resident did not receive the 15 units of Levemir insulin ordered routine. A notation on the back of the TAR documented, .4/11/15.8A.Levemir 15u SQ.held FSBS 84. There was no documentation into show the physician was notified of the resident's FSBS of 84 and that the Levemir insulin was not administered. On 04/11/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once. On 04/12/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times. On 04/14/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once at 8:00 a.m. The TAR documented the resident's FSBS was 124 at 8:00 a.m. On 04/17/15 at 08:00 a.m., the TAR documented the resident's FSBS was 105. The TAR documented the resident did not receive the 15 units of Levemir insulin ordered routine. There was no documentation to show the physician was notified of the resident's FSBS of 105 or that the Levemir insulin was not administered. On 04/17/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 8:00 a.m and 12:00 p.m. The resident's FSBS was 105 at 8 a.m. and 147 at 12:00 p.m. There was no documentation to show the physician was notified that the insulin was not given. On 04/18/15 at 08:00 a.m., the TAR documented the resident's FSBS was 82. The TAR documented the resident did not receive the 15 units of Levemir insulin ordered routine. A notation on the back of the TAR documented, .4/18/15.8A.Levemir 15u SQ.held FSBS 82. There was no documentation to show the physician was notified of the resident's FSBS of 82 or that the Levemir insulin was not administered. On 04/18/15, the TAR documented the resident's FSBS was 82 at 8:00 a.m. the 2 units of Novolag insulin was not administered. There was no documenatation to show the physician was notified that the insulin was not administered. On 04/19/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 8:00 a.m. The TAR documented the resident's FSBS was 99 at 12:00 a.m., 191 at 4:00 a.m. and 171 at 8:00 a.m. There was no documentation to show the physician was notified of the FSBS results or that the insulin was not administered. On 04/20/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once at 12:00 a.m. The TAR documented the resident's FSBS was 150 at 12:00 a.m. A handwritten notation on the back of the TAR documented, .4/20.12A.Novolag held FSBS 150. There was no documentation to show the physician was notified that the insulin was held. The TAR also documented the resident received five units of Novolog insulin at 4:00 p.m. for a FSBS of 311. (Note the April 2015 order for Novolog sliding scale documented two different dosages for a FSBS of 311. The sliding scale documented a FSBS of 301-340 = 5 units or 301-350 = 8 units of Novolog insulin.) On 04/21/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 12:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 150 at 12:00 a.m. and 127 at 8:00 p.m. There was no documentation to show the phsician was notified that the insulin was held. The TAR also documented the resident received five units of Novolog insulin at 4:00 a.m. per the ordered sliding scale for a FSBS of 321, eight units of Novolog insulin at 8:00 a.m. for a FSBS of 307, ten units of Novolog insulin at 12:00 p.m. for a FSBS of Hi, ten units of Novolog insulin at 4:00 p.m. for a FSBS of 470. On 04/21/15 at 12:00 p.m., the TAR documented the resident's FSBS was Hi. The TAR documented the resident received 10 units of Novolog insulin. A hand written physician's orders [REDACTED]. There was no documentation of the administration of 10 units of Humulin R insulin as ordered by the physician. At 4:00 p.m., the TAR documented a FSBS of 470. The TAR documented the resident was administered 10 units of Novolog insulin. The physician's orders [REDACTED]. The care plan, dated 04/22/15, documented, .Problem:.Diet RT Diabetes.Goal:.Will not have high blood sugars due to [DIAGNOSES REDACTED].FSBS, routine insulin and sliding scale insulin as ordered. On 04/23/15, at 8:00 a.m., the TAR documented the resident's FSBS was 118 and the 2 units of Novolog insulin was not given. On 04/26/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times. The TAR at 8:00 a.m. documented the resident's FSBS was 81. A notation on the back of the TAR documented, .4/26/15.8A.Novolog 2 units.held FSBS 81. There was no documentation to show the physician was notified that the insulin was held. On 04/28/15 at 8:00 a.m., the TAR documented the resident's FSBS was 66. The TAR documented the resident did not receive the 15 units of Levemir insulin or the 2 units of Novolog insulin ordered routine. There was no documentation to show the physician was notified of the resident's FSBS of 66 or that the Levemir insulin and the Novolog insulin were not administered. On 04/30/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once at 12:00 p.m. The TAR documented the resident's FSBS was 112 at 12:00 p.m. There was no documentation to show the physician was notified that the insulin was held. The May 2015 monthly physician's orders [REDACTED]. DX: DM. FSBS Q 4 HOURS WITH NOVOLOG R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 UNITS. NOVOLOG R INSULIN 2 UNITS SQ Q 4 HOURS. On 05/01/15 at 8:00 p.m., the TAR documented the resident's FSBS was 157. The TAR documented the resident did not receive the 15 units of Levemir insulin as ordered routine or the 2 units of Novolog insulin ordered routine every four hours. There was no documentation to show the physician was notified that the Levemir insulin and Novolog insulin was not administered as ordered. On 05/02/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 120 at 12:00 a.m., 112 at 4:00 a.m. and 181 at 8:00 p.m. There was no documentation to show the physician was notified that the insulin was held. On 05/03/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times, it was held two times at 12:00 a.m. and 4:00 p.m., and not documented once. The TAR documented the resident's FSBS was 110 at 12:00 a.m. and 121 at 4:00 p.m. There was no documentation to show the physician was notified the insulin was held. On 05/04/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times and it was held three times. The TAR documented the resident's FSBS was 100 at 12:00 a.m. and 114 at 8:00 a.m. The resident's Levemir routine insulin was also held at 8 a.m. There was no documentation to show the physician was notified that the routine insulin was held. On 05/05/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine two times and it was held four times at 12:00 a.m., 4:00 a.m., 8:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 226 at 12:00 a.m. A notation on the back of the TAR documented, .5/5.00:00.Held Novolog.FSBS bottomed out previous night. The TAR documented the resident's FSBS was 106 at 4:00 a.m., 112 at 8:00 a.m. and 85 at 8:00 p.m. There was no documentation to show the physician was notified that the insulin was held. The TAR also documented the resident did not receive coverage at 12:00 a.m. per the ordered sliding scale for a FSBS of 226. On 05/06/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 8:00 p.m. The TAR documented the resident's FSBS was 81 at 12:00 a.m., 167 at 4:00 a.m. and 243 at 8:00 p.m. On 05/07/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 12:00 a.m. and 8:00 a.m. The TAR documented the resident's FSBS was 261 at 12:00 a.m. A notation on the back of the TAR documented, .5/6 (sic).12A.Held Novolog.FSBS keeps bottoming out in AM. The TAR also documented the resident did not receive coverage at 12:00 a.m. per the ordered sliding scale for a FSBS of 261. The TAR documented the resident's FSBS was 146 at 8:00 a.m. On 05/08/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 12:00 p.m. and 8:00 p.m. The TAR documented the resident's FSBS was 85 at 12:00 p.m. and 108 at 8:00 p.m. On 05/09/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once at 12:00 p.m. The TAR documented the resident's FSBS was 106 at 12:00 p.m. On 05/11/15, at 4:00 a.m., the TAR documented the resident's FSBS was 97. The TAR documented the 2 units of Novolog insulin was not administered. On 05/12/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 4:00 a.m. and 12:00 p.m. The TAR documented the resident's FSBS was 128 at 4:00 a.m. and 301 at 12:00 p.m. On 05/13/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 4:00 p.m. and 8:00 p.m. The TAR documented the resident's FSBS was 75 at 4:00 p.m. and 275 at 8:00 p.m. On 05/15/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times,it was held two times at 12:00 a.m. and 4:00 a.m., and not documented once. The TAR documented the resident's FSBS was 149 at 12:00 a.m. and 137 at 4:00 a.m. On 05/16/15 at 8:00 p.m., the TAR documented the resident's FSBS was 80. The TAR documented the resident did not receive the 15 units of Levemir insulin ordered routine or the 2 units of Novolog insulin. There was no documentation to show the physician was notified that the Levemir insulin and the Novolog insulin were not administered. On 05/17/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine two times, it was held two times at 12:00 a.m. and 4:00 a.m., and the TAR documented the resident was out of the facility for two opportunities of administration. The TAR documented the resident's FSBS was 262 at 12:00 a.m. and 176 at 4:00 a.m. On 05/18/15, at 4:00 a.m., the TAR documented the resident's FSBS was 426. The resident received 12 units of Novolog insulin per sliding scale for the blood sugar of greater than 400. There was no documentation to show the resident received the 2 units of Novolog insulin ordered routinely every four hours. On 05/21/15, at 12:00 a.m. and 4:00 a.m., there was no documentation on the TAR to show a FSBS had been performed. A notation on the back of the TAR documented, 5/21 0000 (12:00 a.m.).BS had Bottom out held insulin There was no documentation to show the routine Novolog insulin had been administered. On 05/22/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once at 12:00 a.m. The TAR documented the residenet's FSBS was 92 at 12:00 a.m. On 05/24/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 12:00 a.m. and 4:00 p.m. The TAR documented the resident's FSBS was 118 at 12:00 a.m. and 91 at 4:00 p.m. On 05/25/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine three times and it was held three times at 12:00 a.m., 4:00 a.m. and 12:00 p.m. The TAR documented the resident's FSBS was 87 at 12:00 a.m., 94 at 4:00 a.m. and 168 at 12:00 p.m. On 05/26/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine four times and it was held two times at 4:00 a.m. and 12:00 p.m. The TAR documented the resident's FSBS was 84 at 4:00 a.m. and 162 at 12:00 p.m. On 05/27/15, the TAR documented the resident received the two units of Novolog insulin ordered every four hours routine five times and it was held once at 12:00 a.m. The TAR documented the resident's FSBS was 73 at 12:00 a.m. On 05/28/15 at 12:00 a.m., the TAR documented the resident's FSBS was 83. A note on the back of the TAR documented, 5/28/15 12.Insulin held (secondary to) (low) FSBS. On 05/28/15 at 8:00 a.m., the TAR documented the resident's FSBS was 88. The TAR documented the resident did not receive the 15 units of Levemir insulin ordered routine or the 2 units of Novolog ordered routine. A notation on the back of the TAR documented, 5/28/15 8AM .Novolog 2u + Levemir 15u held d/t (low) BS There was no documentation to show the physician was notified of the resident's FSBS of 88 or that the Levemir insulin and Novolog insulin were not administered. On 05/29/15 at 12:00 a.m., the TAR documented the resident's FSBS was 82 and the 2 units of Novolog insulin was not administered. A notation on the back of the TAR documented, 5-29 0000.Held Novolog d/t FSBS 82. On 05/29/15 at 8:00 a.m., the TAR documented the resident's FSBS was 75. The TAR documented the resident did not receive the 15 units of Levemir insulin or the 2 units of Novolog insulin ordered routine. There was no documentation to show the physician was notified of the resident's FSBS of 75 or that the Levemir and Novolog insulins were not administered as ordered. An incident report, dated 05/29/15, documented, .At approximately 1:00 PM.resident (name omitted for resident #8) was found on the floor in the rest room.Upon evaluation at the ER, it was noted that she had a fracture of her right hip. She remains in the hospital. The hospital patient discharge instruction sheet, dated 06/01/15 at 1:16 p.m., documented, .insulin aspart (Novolog) (insulin aspart 100 units/mL subcutaneous solution), sliding scale dose, Subcutaneous, Before Meals, at Bedtime and at 3am.70-140 = 0 units; 141-180 = 1 units, 181-220 = 2 units; 221-260 = 3 units; 261-300 = 4 units; 301-340 = 5 units; 341-350 = 6 units.insulin detemir (Levemir) (insulin detemir 100 units/mL subcutaneous solution) 12 units, Subcutaneous, Twice Daily. A hand written physician's orders [REDACTED].1) Readmit to SNH.10) Resume S/S insulin & Detemir 12 u Sub q. On 06/02/15, the TAR documented the resident received 6 units of Novolog insulin at 6:30 a.m. for a FSBS of 412 and 6 units of Novolog insulin at 11:30 a.m. for a FSBS of 482. The sliding scale insulin orders did not provide instructions for FSBS's greater than 350. The TAR also documented the resident was administered 3 units of Novolog insulin at 8:00 p.m. for a FSBS of 275. The orders specified the resident should have received 4 units of Novolog insulin. On 06/03/15, the TAR documented the resident received 6 units of Novolog insulin at 4:30 p.m. for a FSBS of 412, and 6 units of Novolog insulin at 8:00 p.m. for a FSBS of 396. The sliding scale insulin orders did not provide instructions for an amount of insulin to be administered whent he FSBS was greater than 350. On 06/04/15, the TAR documented the resident received 5 units of Novolog insulin at 6:30 a.m. for a FSBS of 227. The orders specified the resident was to have received 3 units of Novolog insulin. On 06/05/15, the TAR documented the resident received 6 units of Novolog insulin at 4:30 p.m. for a FSBS of 396. The sliding scale insulin orders did not provide instructions for an amount of insulin to be administered whent he FSBS was greater than 350. On 06/06/15, the TAR documented the resident received 6 units of Novolog insulin at 6:30 a.m. for a FSBS of 375, and 6 units of Novolog insulin at 4:30 p.m. for a FSBS of 357. The sliding scale insulin orders did not provide instructions for an amount of insulin to be administered whent he FSBS was greater than 350. The June 2015 monthly physician's orders [REDACTED].>.LEVEMIR 100U/ML GIVE 15 UNITS SQ AM & HS. DX: DM. FSBS Q 4 HOURS WITH NOVOLOG R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD. NOVOLOG R INSULIN 2 UNITS SQ Q 4 HOURS. The DON signed the monthly physician orders [REDACTED]. A review of the June 2015 TAR revealed there was no documentation for the routine administration of Novolog R every four hours as ordered. The orders on the TAR for Levemir insulin and for sliding scale insulin were not changed after these orders were reviewed and approved by the physician and DON on 06/08/15. On 06/08/15, the TAR documented the resident received 12 units of Levemir insulin at 8:00 a.m. and 8:00 p.m. The TAR also documented the resident received 4 units of Novolog insulin at 6:30 a.m. for a FSBS of 194 and 3 units of Novolog insulin at 11:30 a.m. for a FSBS of 239. On 06/09/15, the TAR documented the resident received 12 units of Levemir insulin at 8:00 p.m. The TAR also documented the resident received 6 units of Novolog insulin at 4:30 p.m. for a FSBS of 356, and 5 units of Novolog insulin at 8:00 p.m. for a FSBS of 315. On 06/10/15, the TAR documented the resident received 12 units of Levemir insulin at 8:00 a.m. and 8:00 p.m. The TAR also documented the resident received 2 units of Novolog insulin at 3:00 a.m. for a FSBS of 214, 2 units of Novolog insulin at 6:30 a.m. for a FSBS of 213, 6 units of Novolog insulin at 4:30 p.m. for a FSBS of 383, and 3 units of Novolog insulin at 8:00 p.m. for a FSBS of 255. On 06/11/15, the TAR documented the resident received 12 units of Levemir insulin at 8:00 a.m. and 8:00 p.m. The TAR also documented the resident received 3 units of Novolog insulin at 3:00 a.m. for a FSBS of 250, 4 units of Novolog insulin at 6:30 a.m. for a FSBS of 289, 6 units of Novolog insulin at 11:30 a.m. for a FSBS of 469, 6 units of Novolog insulin at 4:30 p.m. for a FSBS of 436, and 6 units of Novolog insulin at 8:00 p.m. for a FSBS of 542. The skilled daily nurse's note, dated 06/12/15, documented, .8A(M) Res lying awake in bed.Eats meals in her room - able to feed herself c limited assistance.Usually has good appetite - unl

On 06/24/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure the pharmacist reviewed, identified and reported irregularities related to insulin administration, monitoring and interventions. The facility failed to ensure residents were consistently provided doses of routine insulin and sliding scale insulin; physicians were notified of fingerstick blood sugars greater than 400 or of low blood sugars; residents were provided with the correct insulin; the correct dosage of insulin; and the facility failed to consistently assess fingerstick blood sugars as required. At 4:40 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:55 p.m., the administrator, DON, and corporate nurse were informed of the IJ situation. At 8:58 p.m., an acceptable plan of removal was provided by the facility. The plan of removal documented; .Plan of Removal for Alleged IJ for Skiatook Nursing Home 6.24.2015 4:57 pm. 1. Significant Medication Error regarding Insulin. 6.24.2015 at 6:32 pm the Pharmacist and the Medical Director reviewed all current insulins with the current physician's orders [REDACTED]. All were found to be accurate. By 6.25.2015 at 6:00 am each current insulin order on the medication record will be verified with the original order in the resident's medical record. If a discrepancy is noted, the physician will be notified for clarification of the order. By 6.25.2015 at 6:00 pm, each LPN and RN of the facility will be observed by the RN Director of Nursing complete the fingerstick blood sugar, select the insulin, draw the insulin and administer the dose according to the current physician's orders [REDACTED]. No LPN or RN will be allowed to work until they have been observed and found competent to administer insulin. 2. Pharmacy Services Accuracy of Medications. 6.24.2015 at 6:32 pm The Pharmacist and Medical Director have reviewed all current insulins with the physician's orders [REDACTED]. The RN Director of Nursing was instructed to conduct weekly checks on all insulins to insure the medication matches the order by the Medical Director, beginning 7.1.2015. The Pharmacist will check the insulins for accuracy monthly. If the physician provides new insulin orders for any resident, the nurses will verify the telephone order by two nurses. Two nurses will also verify the Treatment record to insure accuracy by noting with their initials. 3. Providing Services for residents receiving insulin. 6.24.2015 at 5:30 pm, each attending physician with residents that currently receive insulin have been contacted and the following parameters have been obtained: When to notify the physician for low and high blood sugars and when to administer Glucagon/Glucagen. For each new admission, the nurse will request parameters as described above. (Physician name withheld): Notify PCP of Blood sugar below 75 or above 450, administer 1 mg Glucagon if resident is unresponsive. (Physician name withheld): Notify PCP if blood sugar below 70 or above 400. Administer 1 mg of Glucagon if unresponsive. These orders are written on telephone orders for each resident and will be placed in each resident's chart. 6.24.2015 at 6:36 pm all facility LPN's and RN's were instructed by the Medical Director to not hold blood sugar medications without notification to the physician. The Pharmacist will provide inservice training to the two day shift LPN's scheduled to work at 6:00 am on 6.25.15 as well as the evening shift LPN present in the facility regarding long acting and short acting insulins with onset and duration and the importance of administering insulins as ordered to obtain a steady blood sugar for each resident. The remaining LPN and RN staff will receive the same inservice training on 6.25.2015 by 5:00pm, unless the individual is not able to come to the facility at which time the Pharmacist will provide training by telephone prior to their next scheduled shift. No LPN or RN will be allowed to work until they have received this training. 4. Notification to Physician of Resident change of condition. 6.24.2015 at 6:36 pm each facility nurse, LPN and RN, see attached list of names, received inservice training by the Medical Director of the addition of parameters to notify the physician of high and low blood sugars and when to administer Glucagon/Glucagen. The nursing staff will be required to document these notifications to the physician in the residents nurse's notes as appropriate. They also received inservice training by the Medical Director regarding symptoms of high and low blood sugars that would reflect a change in resident condition and the requirement to notify the physician and document in the resident's nurse's notes. Medications for blood sugar will not be held without notification to the physician. The facility's policy is to notify the resident's attending physician with any resident change in condition. The LPN's and RN's were instructed to always follow this policy. (Name withheld) RN was not able to be reached by telephone and did not attend the inservice. She is scheduled to work next on (date withheld). She will receive inservice training from the RN Director of Nursing on all of the above prior to her next scheduled shift. 5. The Pharmacist failed to monitor in insulin. 6.24.2015 at 6:32 pm The Medical Director and the Pharmacist reviewed all current insulins with the current physician's orders [REDACTED]. The Medical Director instructed the Pharmacist to review all insulins with the current physician's orders [REDACTED]. By 6.25.2015 at 5:00pm, the Pharmacist will complete a review of all resident's blood sugars and insulin usage and will report findings to the resident's attending physician. On 06/25/15 at 3:34 p.m. the administrator provided documentation to show the plan of removal had been implemented as described. Staff were interviewed on 06/26/15 in regards to their knowledge of the inservice and to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 06/25/15 at 3:34 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to ensure the pharmacist reviewed, identified and reported irregularities related to insulin administration, monitoring and interventions for one ( #8) of five sampled residents with diabetes mellitus who required monitoring and intervention. The facility identified 23 residents who requiree blood sugar monitoring and insulin administration. Findings: An undated facility policy, titled Policy and Procedure for Drug Regimen Review, documented: .It shall be the policy of this facility that a drug regimen review be completed at least monthly, and more often if indicated, for each resident, by a licensed pharmacist. The pharmacist will conduct a drug regimen review once a month for each facility resident utilizing the current physician orders, the medication administration records, the treatment records and any other clinical information obtained for each resident.In conducting the review, the pharmacist will consider such factors as:.Medication dose, frequency, route, and duration are consistent with the resident's condition, manufacturers recommendations and applicable standards of practice.Indications that the physician and staff have documented progress towards or maintenance of the medication goals.whether the physician and staff have obtained or acted upon lab results, diagnostic studies or other measurements as applicable.Medication errors or circumstances existing that would make an error likely.Whether the physician or staff have noted and acted upon possible medication related causes of recent or persistent changes in the resident's condition such as worsening of an existing condition or the emergence of new signs and symptoms. An undated facility policy, titled Job Description for Consultant Pharmacist, documented: .Will always be alert to detect prescription errors whether in prescribing, compounding or dispensing.Will at all times, be attentive to detail such as accurate labeling.Will review medications, physician's orders [REDACTED]. A facility policy, dated July 1992, and titled Policy and Procedure for Use of Glucometer for Blood Sugar Testing, documented, .It shall be the policy of this facility to monitor blood sugar fingerstck and the use of a glucometer as ordered by a physician. Quality control will be exercised to obtain the most accurate blood sugar findings.Record findings in resident record. Report abnormal findings to the physician immediately. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hand written physician admission order, dated 03/16/15, documented, .Insulin detemir (Levemir) 100u/mL 12u SQ BID Dx: DM.Insulin regular 2u SQ Q6(hours) Dx: DM.Insulin regular sliding scale SQ Q6(hours) 70-100=0u, 141-180=1u, 181-220=2u, 221-260=3u, 261-300=4u, 301-340=5u, 341-350=6u. There was no documentation of sliding scale coverage for FSBS readings between 101-140. A hand written physician order, dated 03/20/15, documented, .FSBS checks Q4 (hours) c S/S at meal times. A hand written physician order, dated 03/23/15, documented, .Clarification:.FSBS Q 4(hours) c SSI regular. Regular insulin 2u SQ Q 4 (hours). A hand written physician order, dated 03/27/15, documented, .D/C Regular SSI 70-140 =0u, 141-180 = 1u, 181-220 = 2u, 221-260 = 3u, 261-300 = 4u, 301-340 = 5u, 341-350 =6u. D/C Levemir 10u SQ Bid. .FSBS Q 4(hours) c Regular SSI 151-200=2u, 201-250=4u, 251-300=6u, 301-350=8u, 351-400=10u, > 400 = 12u & notify phy.Levemir 20u SQ Bid. An admission assessment, dated 03/30/15, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance with activities of daily living, received 51 percent or more of her total caloric intake through a gastrostomy tube, and received insulin injections for seven days out of the seven days during the look back period. Monthly physician's orders [REDACTED]. DX: DM.FSBS Q 4 HOURS WITH NOVOLOG R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 UNITS.NOVOLOG R INSULIN 2 UNITS SQ Q 4 HOURS. A treatment administration record (TAR), dated 04/02/15 at 12:00 a.m., did not document a FSBS was obtained, or the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. 04/05/15 at 12:00 a.m., the TAR documented a FSBS of 110. The clinical record did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 97. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 8:00 a.m., the TAR documented a FSBS of 90. A handwritten notation on the back of the TAR documented, .4/5/15.08:00.Novolog R 2 units SQ held FSBS 90. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 p.m., the TAR documented a FSBS of 134. The TAR did not document the resident was administered a scheduled bedtime insulin dose of Levemir 20 units or two units of Novolog insulin per the physician's orders [REDACTED].4/5/15.8p.held Levemir 20u d/t FSBS 134. The clinical record did not document the physician was notified the Levemir and Novolg insulins were not administered. On 04/06/15 at 08:00 a.m., the TAR documented a FSBS of 126. The TAR did not document the resident was administered a scheduled morning dose of Levemir insulin per the physician's orders [REDACTED]. On 04/07/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of Novolog insulin. The clinical record did not document the physician was notified of the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 83. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 08:00 a.m., the TAR documented a FSBS of 137. The TAR did not document the resident was administered a scheduled morning dose of Levemir 20 units as ordered by the physician. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 p.m., the TAR documented a FSBS of 451. The clinical record did not document the physician was notified of a FSBS of 451. On 04/08/15 at 12:00 a.m., the TAR documented a FSBS of 82. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/8/15.04:00.BS @ 65 gave 60cc of coke recheck @ 05:00 (up) to 84. The clinical record did not document the physician was notified of a FSBS of 65, that the insulin was not administered, the administration of coke, or that the FSBS was rechecked and the result. At 08:00 a.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered the scheduled morning dose of Levemir 20 units per the physician's orders [REDACTED]. At 4:00 p.m.,the TAR documented a FSBS of 403. The clinical record did not document the physician was notified of a FSBS of 403. At 6:30 p.m., a hand written physician's orders [REDACTED].@ AM et HS Dx: DMII. and to start .Levemir 15u subcutaneous inj @ AM et HS Dx: DMII. On 04/09/15 at 12:00 a.m., the TAR documented a FSBS of 55. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 04:00 a.m., the TAR documented a FSBS of 130. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/10/15 at 4:00 p.m., the TAR documented a FSBS of 478. The clinical record did not show the physician was notified of a FSBS of 478. The TAR documented 10 units of Novolog insulin was administered. The physician's orders [REDACTED]. On 04/11/15 at 08:00 a.m., the TAR documented a FSBS of 84. The TAR did not document the resident was administered a scheduled morning dose of Levemir 15 units. A handwritten notation on the back of the TAR documented, .4/11/15.8A.Levmir 15u SQ. The clinical record did not show the physician was notified the insulin was not administered. On 04/12/15 at 08:00 a.m., the TAR documented a FSBS of 100. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/13/15 at 04:00 a.m., the TAR documented a FSBS of 67. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/13.04:00.Insulin held (secondary to) FSBS 67. The clinical record did not document the physician was notified of a FSBS of 67 or that the insulin was not administered. At 08:00 a.m., the TAR documented a FSBS of 65. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/14/15 at 08:00 a.m., the TAR documented a FSBS of 124. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/17/15 at 08:00 a.m., the TAR documented a FSBS of 105. The TAR did not document the resident was administered a scheduled morning dose of Levemir 15 units or the two units of Novolog insulin per the physician's orders [REDACTED]. At 12:00 p.m., the TAR documented a FSBS of 147. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 4:00 p.m., the TAR documented a FSBS of 468. The clinical record did not show the physician was notified of a FSBS of 468. On 04/18/15 at 04:00 a.m., the TAR documented a FSBS of 69. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/18.04:00.Insulin held (secondary to) FSBS 69. The clinical record did not document the physician was notified of a FSBS of 69 or that the insulin was not administered. At 08:00 a.m., the TAR documented a FSBS of 82. The TAR did not document the resident was administered Levemir 15 units or the two units of Novolog per the physician's orders [REDACTED].4/18/15.8A.Levemir 15u SQ.held FSBS 82. The clinical record did not document the physician was notified the insulin was not administered. On 04/19/15 at 12:00 a.m., the TAR documented a FSBS of 99. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 191. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 8:00 a.m., the TAR documented a FSBS of 171. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/20/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/20.12A.Novolog held FSBS 150., and was signed by the DON. The clinical record did not document the physician was notified the insulin was not administered. On 04/21/15 at 12:00 a.m., the TAR documented a FSBS of 150. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/21.12A.Novolog held FSBS 150. The clinical record did not document the physician was notified the insulin was not administered. At 12:00 p.m., the TAR documented a FSBS of HI. The TAR documented the resident was administered 10 units of Novolog insulin. A handwritten physician's orders [REDACTED]. The clinical record did not document the physician was notified that 10 units of Novolog insulin was given instead of 10 units of Humulin R insulin. At 4:00 p.m., the TAR documented a FSBS of 470. The TAR documented the resident was administered 10 units of Novolog insulin. The sliding scale insulin for a blood sugar of 470 was 12 units per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 127. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/22/15 at 8:00 p.m., the TAR documented a FSBS of 87. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/23/15 at 12:00 a.m., the TAR documented a FSBS of 71. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/23.12A.Held Novolog.FSBS 70 (sic) gave OJ c sugar. The clinical record did not document the physician was notified the insulin was not administered. At 04:00 a.m., the TAR documented a FSBS of 118. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 04/26/15 at 4:00 a.m., the TAR documented a FSBS of 63. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/26.4A.Insulin (not) admin FSBS 63 - (No) S/S [DIAGNOSES REDACTED]. OJ (down) PEG. The clinical record did not document the physician was notified of a FSBS of 63, the administration of orange juice via the gastrostomy tube or that the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 81. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/26/15.8A.Novolog 2 units.held FSBS 81.The clinical record did not document the physician was notified the insulin was not administered. On 04/28/15 at 8:00 a.m., the TAR documented a FSBS of 66. The TAR did not document the resident was administered Levemir 15 units or two units of Novolog insulin per the physician's orders [REDACTED]. On 04/30/15 at 12:00 p.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].4/30.12p.Novolog 2u (not) given - BS 112. The clinical record did not document the physician was notified the insulin was not administered. Monthly physician's orders [REDACTED]. DX: DM.FSBS Q 4 HOURS WITH NOVOLOG R SSI.151-200 = 2 UNIT.201-250 = 4 UNITS.251-300 = 6 UNITS.301-350 = 8 UNITS.351-400 = 10 UNITS.>400 = 12 UNITS AND NOTIFY MD.301-340 = 5 UNITS.341-350 = 6 UNITS.NOVOLOG R INSULIN 2 UNITS SQ Q 4 HOURS. On 05/01/15 at 12:00 p.m., the TAR documented a FSBS of 43. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. The clinical record did not show the physician was notified of a FSBS of 43 or that the insulin was not administered. At 8:00 p.m., the TAR documented a FSBS of 157. The TAR did not document the resident was administered Levemir 15 units or two units of Novolog insulin per the physician's orders [REDACTED]. On 05/02/15 at 12:00 a.m., the TAR documented a FSBS of 120. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 4:00 a.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 181. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 05/03/15 at 12:00 a.m., the TAR documented a FSBS of 110. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. At 4:00 p.m., the TAR documented a FSBS of 121. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED]. On 05/04/15 at 12:00 a.m., the TAR documented a FSBS of 100. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].5/4.00:00.Held Novolog Rt.FSBS low. The clinical record did not show the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 47. The TAR did not document the resident was administered two units of Novolog insulin per the physician's orders [REDACTED].5/4.04:00.Held Novolog.FSBS low. The clinical record did not document the physician was notified of a FSBS of 47 or that the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 114. The TAR did not document the resident was administered Levemir 15 units or two units of Novolog per the physician's orders [REDACTED]. On 05/05/15 at 12:00 a.m., the TAR documented a FSBS of 226. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].5/5.00:00.Held Novolog.FSBS bottomed out previous night. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 106. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].5/5.04:00.Held Novolog.FSBS 106. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 112. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED]. At 8:00 p.m., the TAR documented a FSBS of 85. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].5/5.20:00.Held 8p Novolog.FSBS 87 (sic). The clinical record did not document the physician was notified the insulin was not administered. On 05/06/15 at 12:00 a.m., the TAR documented a FSBS of 81. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].5/6.12A.Held Novolog.FSBS 81. The clinical record did not document the physician was notified the insulin was not administered. At 4:00 a.m., the TAR documented a FSBS of 167. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].5/6.4A.Held Nov. The clinical record did not document the physician was notified the insulin was not administered. At 12:00 p.m., the TAR documented a FSBS of 486. The clinical record did not document the physician was notified of a FSBS of 486. At 8:00 p.m., the TAR documented a FSBS of 243. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED]. On 05/07/15 at 12:00 a.m., the TAR documented a FSBS of 261. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].5/6 (sic).12A.Held Novolog.FSBS keeps bottoming out in AM. The clinical record did not document the physician was notified the insulin was not administered. At 8:00 a.m., the TAR documented a FSBS of 146. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED]. On 05/08/15 at 12:00 p.m., the TAR documented a FSBS of 85. The TAR did not document the resident was administered two units of Novolog per the physician's orders [REDACTED].

Based on interview and record review, it was determined the facility failed to provide supervision to prevent falls for two (#1 and #8) of five sampled residents with falls. Resident #8 had four falls. After the last fall the resident was sent to the emergency room and was found to have a hip fracture. Findings: 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 03/30/15, documented the resident was severely impaired in cognition and required extensive two person assist to maximum assist with activities of daily living. The assessment also documented the resident did not ambulate during the seven day look back period. The care plan, dated 04/07/15, documented, .Problem.Trauma, Potential for at (sic) Risk for Fall Due to Mobility Deficit.Goal.Will remain free from falls thru nursing intervention & prevention as evidenced by no falls.Will be free from injury.Approach.Respond to call light promptly. Keep call bell within reach.Keep corridors, rooms well lighted.Keep adjustable bed in low position for safe transfers.Do not leave alone in bathroom, activity, or hairdressing rooms.Encourage to use recommended assistive device in ambulating.Repeat instructions to call for assistance as needed.Counsel wandering, praise appropriate behavior.PT/OT to work with resident for strengthening and mobility as ordered. An incident report, dated 04/12/15 at 9:15 p.m., documented, .Resident found sitting (up) on fall mat c back against bed. Res denies head involvement et C/O pain or discomfort. (No) redness or abraision noted. Res stated she was going to the bathroom.Corrective Action Taken:.Returned fall mat to proper position after assisting res back to bed. Alarm in place. The care plan, dated 04/12/15, documented, .Problem:.Actual Fall.Goal:.Resident will have no further fall over next review period. Resident will have no significant injury related to falls over next review period.Approaches.Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items.Make sure resident bed is in the lowest possible position.Bed alarm. Chair alarm. Fall mat beside bed.Transfer with staff assist (specify number of staff: 1 ). An incident report, dated 04/17/15 at 11:20 a.m., documented, .Called to resident rm by aid found resident sitting on butt by wc. Resident unable to state what happened. Able to move all extremities (sic). (No) observed injuries denies pain, didn't hit head, transfered (sic) back to wc x2 staff. physician & husband notified.Corrective Action Taken:.Encourage resident to use call light for assistance, place chair alarm when resident is (up) in chair. The care plan, dated 04/17/15, documented, .Problem:.Actual Fall.Goal:.Resident will have no further fall over next review period. Resident will have no significant injury related to falls over next review period.Approaches.Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items.Make sure resident bed is in the lowest possible position.Bed alarm. Chair alarm. Fall mat beside bed.Transfer with staff assist (specify number of staff: 1 ).Enc. use of call light. The Physical Therapy Evaluation and Plan of Treatment, dated 05/05/15, documented, .Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: anxiety, decreased ability to return to prior level of supervision, decrease in level of mobility and falls. The Occupational Therapy Evaluation and Plan of Treatment, dated 05/06/15, documented, .Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: Falls. An incident report, dated 05/08/15 at 3:45 p.m., documented, .resident observed sitting in floor in front whirlpool bathroom. No lumps, bumps, or abrasions noted. No C/O pain. Resident able to ambulate w/ assistance to room. Xrays ordered & assessment done.Corrective Action Taken:.Pull alarm. Xray-negative. The care plan, dated 05/08/15, documented, .Problem:.Actual Fall.Goal:.Resident will have no further fall over next review period. Resident will have no significant injury related to falls over next review period.Approaches.Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items.Make sure resident bed is in the lowest possible position.Bed alarm. Pull alarm. Chair alarm. Fall mat beside bed.Encourage use of ambulation aide (specify: cane, walker, crutches, wheelchair (circled), other: ).Transfer with staff assist (specify number of staff: 1 ).Xray L hip & pelvis -neg. Cont therapy to (increase) strength. An incident report, dated 05/29/15, documented, .Visitor notified nurse resident was in res bathroom on floor. Res stated she hit her head et has pain in R leg. Res alarm was in place & res removed alarm & walked herself to bathroom unassisted res being transferred to hospital for evaluation. A State Reportable Incident Report dated 05/29/15, documented, .resident (#8) was found on the floor in the rest room. She had removed her personal alarm from her clothing and got out of bed and ambulated to the rest room next to her room. She had been in her room in bed just prior to the incident.upon standing, she complained of pain.Upon evaluation at the ER, it was noted that she had a fracture of her right hip. The care plan, dated 05/29/15, documented, .Problem:.Actual Fall.Goal:.Resident will have no further fall over next review period. Resident will have no significant injury related to falls over next review period.Approaches.Assess for injury, notify physician and responsible party with any fall. Make sure resident area is well lit and free of obstacles or clutter. Make sure call light is placed within easy reach of the resident. Make sure frequently used items are within easy reach of the resident. Discourage reaching, bending, stretching for items.Make sure resident bed is in the lowest possible position.Bed alarm. Pull alarm. Chair alarm. Fall mat beside bed.Encourage use of ambulation aide (specify: cane, walker, crutches, wheelchair (circled), other: ).Transfer with staff assist (specify number of staff: 1 ).PT to evaluate and treat for strenghening exercises, transferring, ambulation. Place BSC next to bed. Encourage use of appropriate foot wear. (Change) alarm to pressure alarm. To ER to eval & tx. On 06/25/15 at 9:35 a.m., LPN #3 was asked if she worked with resident #8. The LPN stated she was routinely assigned to work with resident #8. The LPN was asked if resident #8 utilized the call light. The LPN stated the resident did not use the call light. She stated she did not think resident #8 could associate using the call light button with receiving help. The LPN was asked if using the call light was an appropriate intervention for the falls resident #8 incurred. The LPN stated, Probably not, no. On 06/25/15 at 2:00 p.m., the DON was asked what were the interventions used in the four documented falls in April and May 2015. She stated they used alarms. The DON was asked if alarms kept residents from falling. She stated, No, but she does not fall right away. The alarm we use now ties into the call light system so it is not just a sound from the alarm to notify you. The DON was asked if encouraging the use of the call light was an appropriate intervention for resident #8. She stated the resident could use the call light. The DON was asked if the resident used the call light system. She stated, No, not really. We started off with an alarm and then changed to a pull alarm and now we have the call light alarm. The DON was asked for the fall investigations for the resident's documented falls. She stated, It's not here. I just reviewed the incident report, spoke with the nurses, and implemented the interventions. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk assessment, dated 12/16/14, documented the resident was not a high risk for falls. An incident report, dated 01/01/15, documented, .Aide observed resident laying on back in front of couch in living room. Resident stated became weak in BLE & fell .Observed bleeding from posterior head upon cleaning area observed 1cm laceration c contusion.Corrective Action Taken.Encourage resident to ask for assistance when feeling weak for transfer. An incident report, dated 01/11/15, documented, .Nurse called to res room by CNA stating res was on the floor. Upon entering the room res was on floor between the bed et wheelchair on her bottom. CNA stated res was transferring et when res landed in the chair it slid out from under her d/t weak brake on the w/c.Corrective Action Taken.Staff to assist res c all transfers. The comprehensive assessment, dated 01/12/15, documented the resident was independent with transfers, ambulation, and dressing. The assessment documented the resident experienced one fall without injury and one fall with minor injury. An incident report, dated 01/18/15, documented, .Resident stood beside bed reaching for wheelchair. Stated she sat down on floor.Corrective Action Taken.Resident reminded to use call light, keep wheelchair within reach at bedside. An incident report, dated 01/29/15, documented, .Res in room c daughter when fall initially occurred.Daughter stated, 'She stood (up) et fell , then I called for help.' Res educated on use of call light et to call for assistance c ADLs.Corrective Action Taken.VS obtained, phys assess performed, neuro (check) initiated immediately. Res et family educated about use of call light et to keep chair by bedside to ask for assistance c ADLs. The nurse's notes, dated 03/23/15, documented, .Res observed sitting on her bottom leaning against the door jam in the bathroom. Small laceration 1.7cm x 0.2cm on the back of her Rt scalp.Res reports that she stood up and was trying to wipe the toilet seat before sitting down.She fell backwards and hit her head. The incident report, dated 03/23/15, documented, .Corrective Action Taken.Res reminded to call for assistance c transfers, toileting, or standing. The state reportable incident report, dated 03/23/15, documented, .resident (#1) was found on the floor in her rest room. When asked what she was doing at the time of her fall, she said she was trying to clean the toilet seat and fell backwards and hit her head.Staff have been instructed to wait for her to finish using the restroom and assist her back to her chair rather than wait for her to alert them she is ready to transfer. (Resident #1) was instructed to ask for assistance with transfers and toileting and has complied with the instructions of waiting for staff assistance. The fall risk assessment, dated 03/24/15, documented the resident was not a high risk for falls. An incident report, dated 04/12/15, documented, .CNA notified nurse of finding resident in floor of her room. Res stated she was trying to get in bed et fell on her back.Corrective Action Taken.Reminded res to use call light for all transfers. Staff not to leave in BR alone so she gets assist c transfer. The quarterly assessment, dated 04/14/15, documented the resident required limited one person assist with transfers and extensive one person assist with dressing. The assessment documented the resident had not ambulated in the seven day look back period. The assessment documented the resident experienced one fall without injury and one fall with minor injury since the last assessment. An incident report, dated 04/23/15, documented, .Called to rm by staff resident sitting on floor in front of wc stated was tranferring self from wc to bed & fell hit head on bedside table 1.5cm hematoma to back of head, 0.5cm laceration to bridge of nose from glasses.Corrective Action Taken.Encourage resident to use call light for assistance c transfers. An incident report, dated 06/06/15, documented, .Transferred self bed to w/chair - alarm in place, leaned forward in w/chair falling to her knees and rolled to R hitting head on floor obtaining laceration (.5cm) above R eye.bruise under R eye from glasses. Abraison (sic) to R knee. Pain L knee.Corrective Action Taken.Remind resident that she needs assist getting out of bed for any reason. Alarm was in place. Staff monitor closely. Remove cushion from w/c. The fall risk assessment, dated 06/07/15, documented the resident was a high risk for falls. On 06/23/15 at 1:20 p.m., resident #1 was asked if she had fallen in the last few months. The resident stated she had fallen recently. The resident was asked why she thought she had fallen. She stated the facility did not want her to walk alone so she had gotten weak. She continued and said she worked on maintaining her strength by using her legs to propel her wheelchair but she couldn't touch the floor easily when the staff put a cushion in her wheelchair. On 06/25/15 at 2:00 p.m., the DON was asked if the fall interventions for resident #1 were appropriate for the falls the resident had experienced. She stated, When she fell out of the wheelchair, it's because she is scooting her butt under the cushion and when she stopped, she fell forward out of the chair. The DON was asked where she documented the fall investigations. She stated it was not with the incident report. The DON was asked if the fall investigations were documented. She stated, No. I reviewed the incident reports, spoke with the nurses and iimplemented the interventions. The DON was asked if other professionals such as physical therapist or pharmacist were involved in the fall investigations. The DON stated the facility had not initiated the use of other professionals in their fall investigations. The DON was asked if the resident used the call light when she needed to get up. The DON stated, No, she does not. The DON was asked if the resident could use a call light. She stated, Yes. The DON was asked why the resident did not use the call light when she needed assistance getting up. The DON stated, Oh yes. She uses her call light. She will press it and then transfer herself to the wheelchair. So I had the aides wait for her when she toileted.

On 05/13/14 at 6:34 p.m., an Immediate Jeopardy (IJ) was determined to exist regarding the facility's failure to ensure hazardous chemicals were out of reach of residents. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 6:34 p.m., the administrator and DON were informed of the IJ regarding hazardous chemicals and a plan of removal was required. They were informed this placed the facility in an extended survey. At 8:18 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: "...All Chemicals were placed behind locked cabinets. Each cabinet is equipped with capability of being locked. All cabinets are secured with locks. Razors removed from the shelf in tub room and over filled sharps containers were removed and disposed of into the biohazard closet. Signs posted on cabinets to remind staff to empty sharps containers when full and not overfill. Charge nurses will monitor restroom areas hourly to ensure chemicals and sharps and properly maintained. Staff have been in-serviced. Two staff members will be in-serviced over the telephone and will be re-educated prior to working on the floor. These staff members live far away and only work weekends. All staff will be in-serviced by 8:45 PM 5/13/14. Staff Inservice: All chemicals are to be maintained behind a locked area. Any chemicals not currently being used shall be maintained in the locked cabinet provided. Ensure cabinet lock is in place and locked. If a lock is not found, all chemicals must be removed prior to staff leaving the area. If giving a bath, when finished, lock chemicals up prior to leaving the area. Sharps containers are to be emptied when the container indicates 'FULL' on the lid. Do not overfill the sharps container. Any razors not capable of fitting into the container and preventing the lid from closing should be placed in a new sharps container. Unused razors are to be stored in a locked cabinet. Do not place razors on any shelf, sink, or any area not secured behind a locked door. Razors are to be maintained by staff. If a resident requests a razor, you must ensure it is properly disposed of. Charge nurses will monitor restrooms and bathing areas to ensure chemicals and razors are not left unsecured and to ensure sharps containers are not over filled." On 05/14/14 at 9:00 a.m., the administrator provided documentation to show the plan of removal had been implemented as described. The administrator provided documentation ensuring all staff had been inserviced on hazardous chemicals and razors. Staff were interviewed on 05/14/14, in regard to their knowledge of the inservice's and to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 05/13/14 at 8:30 p.m. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation and interview, it was determined the facility failed to ensure disposable razors and hazardous chemicals were kept out of reach of residents for four of five bath/restrooms/whirlpool rooms. The facility identified 30 residents who had access to the bath/restrooms/whirlpool rooms. Findings: On 05/13/14 at 5:02 p.m., a restroom/whirlpool room, located at the far west end of the hall, was observed. An unlocked cabinet above the whirlpool contained a bottle of disinfectant-Betco Quat Stat Disinfectant. The label on the disinfectant documented, "Hazardous to humans...Keep out of reach of children...Corrosive...Causes irreversible eye damage and skin burn..." At 5:10 p.m., the front restroom was observed. The top drawer of a table contained, three two-blade disposable razors, an antiperspirant without a lid, and a 6.1oz spray can of Arid extra dry deodorant were observed. At 5:14 p.m., the next restroom/shower room down the hall was observed. The door to the restroom/shower was ajar and would not shut completely. An unlocked cabinet contained a spray bottle of disinfectant (no name on label). The label of the disinfectant documented, "Keep out of reach of children." A sharps container was observed three quarters full and three used two-blade disposable razors were observed resting on the lip of the container. At 5:17 p.m. restroom F was observed. An unlocked cabinet contained a bottle of disinfectant (Quad Stat SC) with a small amount of liquid. Four used two-blade disposable razors were exposed in the sharp container. At 6:43 p.m., an unlocked supply room located on the southside of the hall, approximately 15 feet west of the nurses' station, was observed. The supply room contained unlocked cabinets. Inside one cabinet a one gallon container was observed. The container was half full of a clear liquid. The label on the container, Instant Power Heavy Duty Drain Opener, documented, "...(skull and cross bones)...POISON: harmful or fatal if swallowed. Causes severe burns on contact. Contains sodium hydroxide, potassium hydroxide..." On 05/20/14, the DON was asked how many residents used the restroom/shower/whirlpool rooms and had access to the supply room. She provided a list of residents with 30 names highlighted. The facility had four residents who wandered throughout the building.