Every finding on record at South Pointe Rehabilitation and Care Center

Based on observation, record review, and interview, the facility failed to ensure the facility was a clean and sanitary homelike environment during 4 of 4 observations made for a clean and sanitary homelike environment. The administrator identified 212 residents resided in the facility. Findings: On 07/10/26 at 2:02 p.m., the following observations were made on the memory care unit:a. spilled liquid covering an area of 3 feet by 3 feet was dried, sticky with trash and dirt in front of the nurse's station,b. the main hallway up the entire length of the hall was dirty with dirt, dust, and shoes would stick to the floor,c. spilled liquid and food debris was on the dining room floor, andd. room [ROOM NUMBER] had dust, dirt, dirty Kleenex, and was sticky when walked on. On 07/10/26 at 3:02 p.m., the medication room on the memory care unit was observed to have dead and live roaches behind the refrigerator and all equipment. On 07/14/26 at 11:24 a.m., the following observations were made while on tour of the facility with Corporate Maintenance #1:a. room [ROOM NUMBER] hall tile was separated and bare concrete exposed,b.the tile in the hall outside of room [ROOM NUMBER] had finish scraped off, wascracked and raised,c. the tile in the hall outside room [ROOM NUMBER] iwas missing a 2-inch strip of tile with bare floor and dirt in 2-inch crack,d. the toilet in room [ROOM NUMBER] was not bolted to the floor and was loose,e. the tile floor in room [ROOM NUMBER] had dirt and grass, the non-slip strip was peeling from the floor, missing tiles were covered with non-slip strips in the bathroom on the vacant side of the room,f. the wall outside of room [ROOM NUMBER] was damaged with black marks and a 2-inch gouge in the sheet rock, and was missing paint,g. the toilet tank lid in room [ROOM NUMBER] was cracked,h. the ceiling vent in room [ROOM NUMBER] was clogged with lint and dust,i. the personal fan in room [ROOM NUMBER] was covered with dust,j. the threshold gap outside room [ROOM NUMBER] was missing tile and full of dirt,k. the vent over bed in room [ROOM NUMBER] was completely covered with dust debris,l. the oxygen tank holder outside the smoking area on hall 200 was full of trash, cigarette butts, and dirt,m. a banana peel and food wrapper was on the floor in the television room on hall 200,n. the ceiling over the bed in room [ROOM NUMBER] had sheetrock damage and the popcorn sheetrock was peeling off,o. floor tiles in room [ROOM NUMBER] were missing at the door,p. floor tiles were missing in room [ROOM NUMBER] and damaged tile near the bed, andq. room [ROOM NUMBER] had sticky and dirty floors, the sheetrock was scraped and was missing paint by the door. On 07/13/26 at 7:52 a.m., the following observations were made with the DON present on the memory care unit;a. the halls were sticky when walking with dirt and were unclean,b. spider eggs and a web were on the handrail with dead roaches on the floor under the web in the dining room,c. live roaches and dead roaches were in the medication room on the floor and behind equipment,d. live roaches and a large live spider was in the shower room, ande. mice feces were on the floor in the whirlpool and shower room. A policy titled Quality of Life - Home Like Environment, dated 02/01/22, read and part, Residents are provided with a safe, clean, comfortable and home like environment and encourage to use their personal belongings to the extent possible. On 07/10/26 at 10:32 a.m., resident representative #2 stated the floors at the facility were always dirty and sticky when they visited their family. They stated the facility was infested with roaches and was concerned for the welfare of the residents that resided in the facility. On 07/10/26 at 2:03 p.m., CNA #4 stated roaches had been present in the facility for one and half years. They stated residents spilled things on the floor and floor technicians did not clean the floors. On 07/10/26 at 2:04 p.m., CNA #11 stated the floors were usually sticky, they did not clean up spills, and it was not clean and sanitary. CNA #11 stated the facility had roaches and mice. CNA #11 stated the residents tried to kill the roaches and the mice. They stated the facility was not a homelike environment. On 07/10/26 at 2:30 p.m., CNA #5 stated the floor and the facility were nasty. They stated the memory care hall was just dirty and there was a spill with dirt embedded in it outside the nursing station. CNA #5 stated the facility had roaches that had been crawling into residents' beds. They stated after dinner, residents had roaches crawling on them in the whole building. CNA #5 stated the facility had mice throughout the building. On 07/10/26 at 2:27 p.m., CNA #12 stated roaches had been a bad problem. CNA #12 stated they saw residents trying to kill the roaches and residents made comments about the roaches. They stated roaches had been observed every day at the facility. On 07/10/26 at 2:44 p.m., LPN #5 stated the facility had roaches and they crawled on the residents at night. They stated the pest treatments had not been effective. LPN #5 stated the floors were sticky and the cleaning products were not effective. LPN #5 stated this could not have been their home, because they would not live like this. They stated housekeeping did not do a good job and did not always get the floors clean. On 07/10/26 at 2:52 p.m., housekeeper #1 stated the floors were sticky on the memory care unit because the supplies they use were not meant for the floors. They stated the floors were always sticky and did not look clean. Housekeeper #1 stated the facility had a mice and roach infestation. On 07/13/26 at 7:52 a.m., the DON stated the pest management program was not effective. The DON stated the floor technician waxed over debris and the floors were sticky, dirty, and looked like crud. The DON stated they observed spider eggs and a web on the memory care hall in the dining room in the corner, live roaches in the medication room, live roaches in the shower room, and mice feces in the whirlpool and shower room. The DON stated the pests made them feel squeamish. On 07/13/26 at 8:16 a.m., the AIT toured the memory care unit and stated the pest control program was not effective, and the facility was not a clean and sanitary homelike environment. On 07/14/26 at 11:24 a.m., Corporate Maintenance #1 stated missing hall tiles could hurt a resident's foot and needed to be repaired. They stated the facility was not a clean and sanitary homelike environment. Corporate Maintenance #1 stated they did not have any open work orders for the repairs.

Based on observation, record review, and interview, the facility failed to maintain safe hot water temperatures accessible to residents for 10 (#24, 27, 29, 33, 72, 90, 96, 130, 124, and #130) of 10 sampled residents hand sinks water temperature measured. The administrator identified 46 residents resided on hall 100 (locked unit) and 56 residents resided on hall 200. Findings:On 07/15/26 at 9:58 a.m., the water temperature in the sink of Resident #202 and Resident #27's room located on hall 100 (locked unit), showed to be 131 degrees F.On 07/15/26 at 10:17 a.m., the water temperature in the sink of Resident #96 and Resident #90's room located on hall 100 (locked unit), showed to be 130 degrees F.On 07/15/26 at 10:22 a.m., the water temperature in the sink of Resident #202 and Resident #27, located on hall 100 (locked unit), showed to be 130 degrees F.On 07/15/26 at 10:24 a.m., the water temperature in the sink of Resident #24 and Resident #29's room located on hall 100 (locked unit), showed to be 127 degrees F.On 07/15/26 at 10:52 a.m., the water temperature on the 100 hall (locked unit) shower room showed to be 129.7 degrees F.On 07/15/26 at 11:17 a.m., the water temperature in the sink of Resident #130 and Resident #33's room located on hall 200 showed to be 130 degrees F, and the shower room located on hall 200 showed to be 121 degrees F.On 07/15/26 at 11:19 a.m., the water temperature in the sink of Resident #72 and Resident #124's room located on hall 200 showed to be 133 degrees F.On 07/15/26 at 12:56 p.m. the water temperature in the sink of Resident #202 and Resident #27's room located on hall 100 (locked unit), showed to be 127 degrees F with maintenance supervisor's digital thermometer and 120 degrees F with their manual thermometer. On 07/15/26 at 10:55 a.m., CNA #5 stated the water temperatures in the shower room came out hot enough to burn a resident.On 07/15/26 at 10:58 a.m., CMA #2 stated the water came out hot enough to burn residents in the shower room on hall 100 (locked unit).On 07/15/26 at 11:00 a.m., Resident #25 stated the hot water got really hot. On 07/15/26 at 11:17 a.m., Resident #33 stated you had to run cold water because it was hot.On 07/15/26 at 11:30 a.m., the maintenance supervisor stated they had never seen a policy for water temperatures. The maintenance supervisor stated their boss told them to set temperatures at 115 degrees F. The maintenance supervisor stated anyone could hurt themselves, be burned, or scalded with water over 120 degrees F and the average water temperature on hall 100 (locked unit) was 125 to135 degrees F. The maintenance supervisor stated water temperature checks were completed on Wednesdays, and they had only received reports of water not being hot enough. On 07/15/26 at 12:29 p.m., the maintenance supervisor stated they had not been trained in four years on the maximum water temperatures for long term care.On 07/15/26 at 12:49 p.m., the DON stated they did not know the regulations for water temperatures for resident baths. The DON stated there were bedbound, diabetic neuropathy, and wandering residents on hall 100 (locked unit) and hall 200.

Based on observation, record review, and interview, the facility failed to maintain and effective pest management program. The administrator identified 212 residents resided in the facility. Findings:On 07/10/26 at 2:02 p.m., the following observations were made on the memory care unit:a. living and dead roaches were observed in the soiled linen closet on the floor, andb. live roaches and a piece of bread were on the shower room on the floor. On 07/10/26 at 3:02 p.m., dead and live roaches were observed in the medication room on the memory care unit behind the refrigerator and all equipment. On 07/13/26 at 7:52 a.m., the following observations were made with the DON present on the memory care unit;a. spider eggs and a web were on the handrail with dead roaches on the floor under the web in the dining room,b. live roaches and dead roached were in the medication room on the floor and behind equipment,c. live roaches and a large live spider was in the shower room, andd. mice feces were on the floor in the whirlpool and shower room. A policy titled Pest Control, dated 08/02/21, read in part, The facility maintains an effective pest control program to remain free of pest and rodents. Pest-control strategies are developed, emphasizing kitchens, cafeteria, laundry, central supply areas, loading docks, resident rooms, activities, and other regions prone to pest infestations. Environmental services/designee will maintain records of pest control protocol and contract with pest control services.Ongoing measures are taken to prevent, contain, and eradicate, common household pass such as roaches, ants, mosquitoes, flies, mice, and rats. On 07/10/26 at 10:32 a.m., resident representative #2 stated the facility was infested with roaches and was concerned for the welfare of the residents that resided in the facility. On 07/10/26 at 2:03 p.m., CNA #4 stated roaches had been present in the facility for one and half years. They stated residents spilled things on the floor and floor technicians did not clean the floors. On 07/10/26 at 2:04 p.m., CNA #11 stated the facility had roaches and mice. CNA #11 stated the residents tried to kill the roaches, and the mice. On 07/10/26 at 2:30 p.m., CNA #5 stated the facility had roaches that had been crawling into the residents' beds. They stated after dinner, residents had roaches crawling on them in the whole building. CNA #5 stated the facility had mice throughout the building. On 07/10/26 at 2:27 p.m., CNA #12 stated roaches had been a bad problem. CNA #12 stated they saw residents trying to kill the roaches and residents made comments about the roaches. They stated roaches had been observed every day at the facility. On 07/10/26 at 2:44 p.m., LPN #5 stated the facility had roaches and they crawled on the residents at night. They stated the pest treatments had not been effective. LPN #5 stated the floors were sticky and the cleaning products were not effective. LPN #5 stated this could not have been their home, because they would not live like this. They stated housekeeping did not do a good job and did not always get the floors clean. On 07/10/26 at 2:52 p.m., Housekeeper #1 stated the facility had a mice and roach infestation. On 07/13/26 7:52 a.m., the DON stated the pest management program was not effective. The DON stated they observed on the memory care hall in the dining room in the corner, spider eggs and a web, live roaches in the medication room, live roaches in the shower room, and mice feces in the whirlpool and shower room. The DON stated the pests made them feel squeamish. On 07/13/26 at 8:16 a.m., the AIT toured the memory care unit and stated the pest control program was not effective, and the facility was not a clean and sanitary homelike environment.

Based on observation, record review, and interview, the facility failed to: a. ensure medications were secure for 1 (Hall 400) of 1 medication/treatment carts observed. b. ensure stored medications were monitored at proper temperatures and other appropriate controls to preserve their integrity on 4 (hall 100, 200, 400, and 600) of 4 medication storage rooms observed. The DON identified 209 residents receive nutrition from the kitchen. Findings:Findings: On 07/10/26 at 12:56 p.m., a treatment cart on hall 400 was observed to be unlocked. Supplies observed included insulin needles, lancets, breathing treatment medications, ointments, lotions, and nutrition supplements. A policy Medication Storage in the Facility, dated 01/2026, read in part, Medication rooms, carts, and medication supplies are locked or attended to by person with authorized access. On 07/10/26 at 1:01 p.m., LPN #6 stated the policy was to have their treatment cart and their computer locked when they walked away from it. 07/16/26 at 10:45 a.m., the medication storage room on Hall 400 was observed and did not contain a thermometer to monitor the temperature. 07/16/26 10:45 a.m., the medication storage room on Hall 600 was observed and did not contain a thermometer to monitor the temperature. 07/16/26 11:19 a.m., the medication storage room on Hall 100 was observed. There was a small thermometer on the wall that was not in workable order to monitor the temperature. 07/16/26 11:58 a.m., the medication storage room on Hall 100 was observed and did not contain a thermometer to monitor the temperature. A policy titled Medication Storage in the Facility, dated 01/ 2024, read in part, Medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees F (16 C) and 85 degrees F (30 C). On 07/16/26 at 11:21 a.m., LPN #2 stated there should be a thermometer in the medication storage rooms and the room temperature should be monitored. On 07/16/26 at 11:54 a.m., DON stated the medication storage rooms should have a thermometer to monitor the temperatures and were in the process of getting them now.

Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse by failing to protect a resident (#213) from staff's use of physical intervention during meal service. The administrator identified 212 residents resided in the facility. Findings:On 07/09/26 at 12:44 p.m., after finishing their lunch, Resident #213 was observed to stand up and walk with their walker. Resident #213 was observed to approach another resident who was eating at a nearby table. Resident #213 was observed to reach toward the other resident's meal, picked up the food (taco meat) from the plate with their hand, and began raising the food towards their mouth. CNA #10 yelled, [Resident #213], no! CNA #10 then grasped Resident #213's hand containing the food, pulled the resident's hand downward, and removed the food from the resident's hand. CNA #10 redirected the resident from the dining hall, removed the other resident's plate, and left the unit to replace the food. A care plan for Resident #213, dated 07/01/26, showed the resident's prescribed diet consisted of mechanical soft foods and excluded dairy products. These restrictions did not include taco meat.An annual assessment for Resident #213's, dated 12/03/25, showed the resident had memory deficits and could not easily make self-understood.A facility policy titled Abuse, Neglect and Exploitation, reviewed 01/20/26, showed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment. The policy defined willfulness as acting deliberately with or without the intention of harm. The policy defined abuse to include, but not limited to, hitting, shoving, punching, biting, kicking, pinching, spanking, slapping of hands, flicking or hitting residents with objects, and yelling at residents.On 07/09/26 at 1:15 p.m., CNA #4 stated it was never appropriate to pull food or other items from a resident's hand.On 07/09/26 at 1:16 p.m., CNA #10 stated they were a bit intense because lunch served that day had the potential to upset Resident #213's stomach and they did not want the resident to develop diarrhea. CNA #10 stated they intervened and redirected residents when they attempted to eat food from another resident's plate. CNA #10 demonstrated a swiping and slapping motion with their hands when describing their intervention with Resident #213.On 07/16/26 at 1:44 p.m., the DON stated staff should immediately report suspected or witnessed abuse to the abuse coordinator, the DON, or the AIT.

Based on observation, record review, and interview, the facility failed to ensure MDS assessments were accurate for 3 (#2, 4 and, #50) of 48 sampled residents reviewed for accurate MDS assessments. The administrator identified 212 residents resided in the facility. Findings: 1.On 07/14/26 at 10:50 a.m., Resident #2 was observed to have a wound vac attached to their left medial thigh via tubing and dressings. A policy titled MDS 3.0, dated 04/25/19, read in part, 2. The MDS Coordinator and/or IDT will use the following when completing the assessment as directed by the RAI User's Manual: Direct Observation Communication with Resident, Family, and Staff Documentation in the Medical Record. 4. The facility will address the needs and strengths of each resident through completion of the MDS 3.0 and the Care Area Assessment (CAA) to develop a comprehensive person-centered care plan.8. Everyone completing a portion of the assessment must sign and certify the accuracy of the portion of the assessment has been completed. A physician's diagnosis list for Resident #2, dated, 06/12/26, showed diagnoses which included diabetes mellitus, stage 4 pressure ulcer, and muscle wasting. A physician's order for Resident #2, dated 06/12/26 showed medications which included: a. Arginaid packet nutritional supplement twice daily for wound healing, b. protein gelatein twice daily for wound healing, and c. ascorbic acid 250mg once daily for wound healing. A physician's order for Resident #2, dated 06/12/26, showed wound care to left medial thigh with wound vac with continuous pressure, change dressing on Tuesdays and Fridays. A 5-day skilled assessment for Resident #2, dated 06/15/26, showed the resident was admitted [DATE] with diagnosis which included stage 4 pressure ulcer which required the use of a wound vac. The assessment showed the resident had a stage 4 pressure ulcer on admission. An admission assessment for Resident #2, dated 06/22/26 did not show the resident had a pressure ulcer. On 07/14/26 at 11:14 a.m., the MDS coordinator stated the skin section should have been marked yes. 2. On 7/13/26 at 11:53 a.m., Resident #4 was observed on the memory care unit with poor cognition and was unable to answer questions regarding their care. A hospital discharge record for Resident #4, dated 01/30/26, showed the resident had diagnosis which of bipolar disorder. A care plan for Resident #4, dated 01/30/26, did not show a focus, goal, and or interventions to address the resident's bipolar diagnosis. A quarterly assessment for Resident #4, dated 02/26/26, showed the resident was readmitted to the facility on [DATE]. The following MDS assessments did not show Resident #4 had a diagnosis of bipolar disorder: a. a 5-day assessment, dated 02/10/26, b. a quarterly assessment, dated 02/26/26, c. a significant change assessment dated [DATE], and d. a quarterly assessment dated [DATE]. On 07/13/26 at 11:53 a.m., LPN #1 stated Resident #4 was administered divalproex sodium oral capsule 500 mg extended release (depakote a mood stabilizer) 500 mg by mouth at night for bipolar disorder. On 07/14/26 at 8:50 a.m., the DON stated MDS #1 missed the bipolar diagnosis on the hospital discharge paperwork for Resident #4 on 01/30/26. The DON stated the MDS assessments completed for Resident #4 after the resident discharged from the hospital with a bipolar diagnosis on 01/30/26 were not accurate because they assessments did not show the bipolar diagnosis. 07/14/26 at 10:25 a.m., MDS #1 stated they missed Resident #4's bipolar diagnosis from the resident's hospital discharge paperwork, dated 01/30/26. MDS #1 stated the MDS assessments completed after 01/30/26 for Resident #4 were not accurate because the assessments did not show the residents bipolar diagnosis.

Based on observation, record review, and interview, the facility failed to:ensure a hair restraint was used while in the food holding area.ensure 1 (Hall 200) of 2 resident refrigerators in the medication storage room had drinks labeled, dated, and not expired.The administrator identified 212 residents resided in the facility.Findings: 1.On 07/07/26 at 12:49 p.m., CNA #4 was observed to enter a food serving room on hall 300 without a hairnet. On 07/07/26 at 12:50 p.m., CNA #4 stated the policy was hairnets should be worn in food areas. On 07/07/26 at 12:52 p.m., LPN #5 stated, we all have to wear hairnets in that room. 2. On 07/16/26 at 12:06 p.m., the resident refrigerator in medication storage room located on hall 200 which had nutritional ready to drink liquids was observed to have the following: a. a sticky dark brown substance at the bottom of the refrigerator, b. three half-empty water bottles, c. a container of honey ham with an expiration date of 05/22/26 and no resident label, d.a jar of Kool-Aid with blue liquid and fruit in it and no resident label, and e. a freezer in the resident refrigerator had approximately three inches of frost. A policy titled Medication Storage in the Facility, dated 01/2024, read in part, Refrigerated medications are .separate from fruit juices, applesauce, and other foods used in administering medications. Other foods are not stored in this refrigerator. On 07/16/26 at 12:08 p.m., LPN #3 stated the honey ham should have been labeled and because it was expired, should have been removed. On 07/16/26 at 12:08 p.m., LPN #3 and CMA #1 stated they believed the food items belonged to staff and the staff should place their food in the residents' refrigerator. On 07/16/26 at 12:12 p.m., LPN #3 and CMA #1 stated the refrigerator needed to be cleaned and defrosted, and it was assigned to staff for cleaning. LPN #3 and CMA #1 stated they were not sure when it was last cleaned.

Based on observation, record review, and interview, the facility failed to ensure that the narcotic controlled substance card count was correctly reconciled for 1 (Hall 200) of 8 medication carts observed.The administrator identified 212 residents resided in the facility. Findings: On 07/16/26 at 12:15 p.m., during the medication cart review on hall 200, CMA #1 was observed counting the narcotic controlled substance cards. CMA #1's final count was 17 cards. The narcotic control substance form showed at 7:00 a.m., there were 15 total narcotic cards. On 07/16/26 at 12:15 p.m., CMA #1 stated there had been no added cards since her original count at 7:00 a.m. and did not know why the count was incorrect. CMA #1 acknowledged their signature on the form and stated they did physically count that morning, but the number 15 had already been written in when she arrived for their shift. On 07/16/26 at 3:55 p.m., the DON stated staff should not pre document the narcotic controlled substance count prior to the shift count. On 07/16/26 at 4:00 p.m., the DON reviewed the narcotic controlled substance card count form and acknowledged with CMA #1 the actual count was 17.

Based on observation, record review, and interview, the facility failed to notify the resident and/or resident representative of the risk and benefits of a psychotropic medication for 1 (#4) of 5 sampled residents reviewed for notifications. The DON identified 156 residents were prescribed psychotropic medications. Findings:On 07/13/26 at 11:53 a.m. Resident #4 was observed on the memory care unit with poor cognition and was unable to answer questions regarding their care. A policy titled Psychotropic Management Guidelines, dated 07/26/23, read in part, Upon admission the licensed nurse will implement the following: .b. Psychoactive Medication Consent from Resident/Responsible Party. A hospital discharge record for Resident #4. dated 01/30/26, showed the resident had diagnoses which included bipolar disorder and dementia. A quarterly assessment for Resident #4, dated 02/26/26, showed the resident had a BIMS score of 09 which indicated their cognition was moderately impaired. A medication administration record for Resident #4, dated 06/12/26, showed the resident was being administered divalproex sodium (mood stabilizer) oral capsule 500 mg extended release for mixed bipolar affective disorder. On 07/13/26 at 11:23 a.m., resident representative #1 stated they did not sign consents or receive notification Resident #4 was receiving divalproex sodium 500 mg extended release for bipolar disorder. On 07/13/26 at 11:53 a.m., LPN #1 stated Resident #4 was administered divalproex sodium oral capsule 500 mg extended release (Depakote) 500 mg by mouth at night for bipolar disorder. On 07/13/26 at 12:09 p.m., the DON stated any medications that was mood altering, should have had a consent signed by the resident and/or family representative. They stated Resident #4 and/or the family representative had not been notified and did not sign consent for the divalproex sodium oral capsule 500 mg extended release (Depakote, a mood stabilizer) medication to be administered.

Based on observation, interview and record review, the facility failed to promote care for residents in a manner that maintained or enhanced the residents' dignity by using non-dignified terminology when communicating to and about residents. Specifically, staff referred to residents who required assistance eating as feeders, residents who exhibited vocal behaviors as screamers, and incontinence products as diapers. The administrator identified 212 residents resided in the facility.Findings:On 07/07/26 between 11:57 a.m. and 12:56 p.m., an uneaten meal tray for Resident #228 was observed on the tray collection rack for disposal. LPN #1 was observed to ask CNA #4 why the meal remained unserved. CNA #4 stated the facility did not have enough staff to feed all the feeders. The statement was made in the presence of multiple residents and family members.A policy titled Quality of Life Dignity, dated 02/01/24, read in part, the resident should be cared for in a manner that promoted and enhance quality of life, dignity, respect, and individuality. addressing the resident by his or her name of choice.On 07/09/26 at 1:05 p.m., CNA #4 stated staff seated residents who required assistance with eating at the feeders table. CNA #4 stated when staffing was insufficient, some residents waited until staff finished feeding another feeder before receiving assistance with their meal.On 07/17/26 at 11:35 a.m, CNA #5 stated staff placed anxious residents, including the screamers and the feeders, together on one side of the dining room away from the other residents. CNA #5 stated calling residents feeders or screamers in the presence of residents or family members did not maintain resident dignity.On 07/17/26 at 12:32 p.m, the DON stated residents should be addressed with dignity by using their name of choice. The DON stated residents who required assistance with eating should have not been called feeders, and residents who exhibited vocal behaviors should have not been called screamers. On 07/13/26 at 5:18 a.m., during an incontinent care observation, CNA #6 stated to Resident #30 they were going to change their diaper prior to providing incontinent care. On 07/13/26 at 5:42 a.m., CNA #6 stated it was not dignified to refer to incontinence briefs used for residents as diapers when speaking to a resident. On 07/17/26 at 12:32 p.m., the DON stated staff should refer to the incontinence product as a brief rather than a diaper when providing incontinent care. The DON stated calling the product a diaper was not dignified.A policy titled Quality of Life Dignity, dated 02/01/24, read in part the resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality The policy defined treating with dignity as maintaining and enhancing [residents'] self-esteem.

Based on observation, record review, and interview, the facility failed to ensure residents were free from restraints for 1 (#50) of 1 sampled resident reviewed for restraints. The administrator identified 212 residents resided in the facility and one resident had a restraint.Findings: On 07/08/26 at 10:47 a.m., Resident #50 was observed to have a canvas belt positioned at their lap.On 07/08/26 at 11:11 a.m., the DON was observed to ask Resident #50 to demonstrate releasing the seat belt. The resident was unable to release the safety belt. On 07/08/26 at 11:56 a.m., Resident #50 was observed to be asked by the DON to demonstrate their ability to remove their safety belt. Resident #50 attempted but was unable to successfully remove the belt. A physician's order Resident #50, dated 05/06/26, showed a self-releasing seat belt while up in wheelchair for safety every day and evening shift.A physician's order for Resident #50, dated 07/08/26, showed to check the seatbelt while in the wheelchair for proper use every two hours.A physician's order Resident #50, dated 07/08/26, showed the resident may utilize the seatbelt while up in wheelchair per Resident #50's request. To promote independence and wellbeing.On 07/08/26 at 10:48 a.m., Resident #50 was asked what was around their waist. Resident #50 stated, it's a safety belt. They were asked what the belt was used for. They stated, to keep me from falling out of my seat. Resident #50 was asked if they were able to release the seat belt and if so, would they demonstrate how they do it. The resident stated, Yes. Resident #50 was observed to put their right thumb into a loop at the end of the belt and attempted to release the seat belt. After attempting to remove the seat belt, the resident stated, I can't.On 07/08/26 at 11:02 a.m., CNA #13 stated the seat belt on the resident's waist was to keep them from falling, it was doctor ordered. CNA #13 was asked if they removed the belt and if so, how often. The CNA stated, it is released to perform care. On 07/08/26 at 11:10 a.m., LPN #8 stated the canvas belt around Resident #50's waist was a safety belt and it was used to prevent the resident from falling out of the chair. LPN #8 stated the staff did not release the seat belt because Resident #50 could release the belt. LPN #8 was informed of the observation which Resident #50 was unable to self-release the belt. LPN #8 stated, Well [they] usually can. LPN #8 was asked if the resident was unable to release the belt how often was the belt released. The LPN stated, [They] can do it, the staff does not release [their] belt, [They] can release it when [they] want to if [they] cannot release it, [they] tell the staff and they release it. On 07/08/26 at 11:20 a.m., The DON stated the safety belt was not a restraint and Resident #50 could release the seat belt themself. The DON stated the facility would complete restraint assessment paperwork if the seat belt was a restraint. The DON was asked if Resident #50 was able to release their seat belt. The DON stated Resident #50 was able to release the seat belt.

Based on record review and interview, the facility failed to notify the resident representative of discharge to another facility for 1(#223) of 1 sampled residents reviewed for discharge.The administrator identified 212 residents resided in the facility.Findings: A nurses note for Resident #223, dated 04/16/25, read in part, Resident was discharged to [name withheld] facility The nurses note did not document the representative was notified for Resident #223.On 07/17/26 at 1:08 p.m., Social Services #1 stated they could not find documentation the family was notified of the discharge to another facility.On 07/17/26 at 1:36 p.m., the DON stated the facility did not have documentation the family was notified of the discharge.

Based on observation, record review, and interview, the facility failed to revise a resident's care plan to include bipolar disorder for 1 (#4) of 48 sampled residents reviewed for revisions of care plans. The DON identified 156 residents had mood altering diagnoses. Findings: On 07/13/26 at 11:53 a.m., Resident #4 was observed on the memory care unit with poor cognition and was unable to answer questions regarding their care. A policy titled Comprehensive Person- Centered Care Plan, dated 01/23/19, read in part, 3. The interdisciplinary Team, along with the Resident and/or Resident Representative, will identify resident problems, needs, strengths, life history, preferences, and goals.4. For each problem, need, or strength, a resident-centered measurable goal is developed. A policy titled MDS 3.), dated 04/25/19, read in part, 4. The facility will address the needs and strengths of each resident through completion of the MDS 3.0 and the Care Area Assessment (CAA) to develop a comprehensive person-centered care plan. A hospital discharge record for Resident #4, dated 01/30/26, showed Resident #4 had a diagnosis of bipolar disorder. A care plan for Resident #4, dated 01/30/26, did not show a focus, goal, or intervention to address the resident's bipolar diagnosis. A quarterly assessment for Resident #4, dated 02/26/26, showed the resident had a BIMS score of 09 which indicated their cognition was moderately impaired and was not diagnosed with bipolar disorder. A medication administration record for Resident #4, dated 06/12/26, showed the resident was being administered divalproex sodium oral capsule 500 mg extended release (Depakote a mood stabilizer) for mixed bipolar affective disorder. On 07/13/26 at 11:53 a.m., LPN #1 stated Resident #4 was administered divalproex sodium oral capsule 500 mg extended release (Depakote a mood stabilizer) 500 mg by mouth at night for bipolar disorder. On 07/14/26 at 8:50 a.m., the DON stated MDS #1 missed the bipolar diagnosis on the hospital discharge paperwork for Resident #4 on 01/30/26. The DON stated the care plan was not comprehensive because had not been revised to include Resident #4's bipolar diagnosis when the resident returned from the hospital on [DATE]. On 07/14/26 at 10:25 a.m., MDS #1 stated the care plan dated 01/30/26 was not revised and did not address the resident's bipolar diagnosis.

Based on record review and interview, the facility failed to ensure pneumococcal vaccines were offered to residents for 3 (#105, 123, and #133) of five sampled residents reviewed for vaccines. The DON identified 177 residents resided in the facility. Findings: The pneumococcal vaccine policy, last reviewed 04/28/22, read in part, The opportunity to receive the Pneumococcal Vaccine will be extended to all Residents. The Facility will provide pertinent information regarding the Risks/Benefits of receiving the Vaccine .Residents will be offered the Pneumococcal Vaccine upon Admission. 1. An admission record, dated 04/24/25, showed Resident #105 admitted to the facility on [DATE]. There was no documentation Resident #105 had been offered a pneumococcal vaccine. 2. An admission record, dated 04/24/25, showed Resident #123 admitted to the facility on [DATE]. There was no documentation Residents #123 had been offered a pneumococcal vaccine. 3. An admission record, dated 04/24/25, showed Resident #133 admitted to the facility on [DATE]. There was no documentation Residents #133 had been offered a pneumococcal vaccine. On 04/24/25 at 11:11 a.m., the IP stated they sent out letters to families of resident's who could not answer for themselves if they wanted to receive a vaccine. They stated for residents who could, they would ask them if they wanted to receive a vaccine. On 04/24/25 at 11:13 a.m., the IP stated immunizations were documented in the resident's clinical record. They stated it documented whether the resident or family agreed or declined the vaccine. On 04/24/25 at 11:14 a.m., the IP stated Resident #105 received a pneumonia vaccine on 11/02/98 and would be due for another pneumonia vaccine. On 04/24/25 at 11:33 a.m., the IP stated Resident #123 received the influenza vaccine at the hospital but not the pneumonia vaccine. On 04/24/25 at 11:37 a.m., the IP stated Resident #133 had not received a pneumonia vaccine.

Based on observation and interview, the facility failed to serve the noon day meal in a manner that minimized the risk of infection/cross contamination for 174 or 174 residents who ate meals prepared from the kitchen. The adminstrator identified 174 residents who ate meals from the facility kitchen. On 04/22/25 at 12:15 p.m., cook #1 was observed to plate food from the steam table to be served to residents. With gloved hands, the cook touched the counter, shelving, and utensils other kitchen staff had touched as well. [NAME] #1 was observed to use their gloved hands to hold plated food in position by placing their gloved fingers on the plate and pushing the food together to one side of the plate. The cook then used their gloved hands to place a roll on the residents' plates. On 04/22/25 at 12:25 p.m., the dietary manager stated the kitchen staff were to use serving utensils and tongs to plate food and not their gloved hands.

Based on observation and interview, the facility failed to provide in between meal snacks for 1 (Hall 3) of 1 halls reported during resident council meeting. The administrator reported 174 residents were provided meals from the kitchen. Findings: A policy titled Meals and Snacks, dated 11/27/23, read in part, Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. Nutritional Services shall be delivered to the nursing units by nutritional services personal. Nursing shall be responsible for distributing snacks to the residents. On 04/28/25 at 2:37 p.m., it was observed on hallway 3, no snacks were offered or distributed to residents. On 04/28/25 at 2:38 p.m., Resident #24 was visiting on hallway 3 and stated they did not get a 2:00 p.m. snack. On 04/28/25 at 2:46 p.m., Resident #79 stated they did not get a snack. On 04/28/25 at 3:16 p.m., the DON stated the snacks were not getting offered or distributed to the residents.

Based on record review and interview, the facility failed to ensure resident assessments were coded to reflect the status for 3 (#105, 126, and #175) of 35 sampled residents reviewed for resident assessments. The DON identified 177 residents resided in the facility. Findings: 1. Resident #105's care plan, dated 4/24/25, showed the resident had diagnoses which included dementia, heart failure and chronic obstructive pulmonary disorder. A progress note, dated 04/12/25, showed a nurse confirmed there was a new open wound on Resident #105's left buttock that was not there the week before. A quarterly MDS assessment, dated 04/15/25, showed Resident #105 had no wounds. On 04/28/25 at 1:25 p.m., MDS #2 stated they would expect the MDS to catch the wound and put it somewhere, once staff determined what kind of wound it was. On 04/28/25 at 2:55 p.m., the DON stated it was expected the MDS assessments be accurate. 2. Resident #175's care plan, dated 4/24/25, showed the resident had diagnoses which included severe intellectual disabilities and metabolic acidemia noted at birth. A progress note, dated 3/17/25 at 10:27 a.m., showed the nurse found no [NAME] tube (a low profile gastrostomy tube used for delivering nutrition). The note showed the physician sent Resident #175 to ER for replacement. A progress note, dated 3/17/25 at 4:27 p.m., showed Resident #175 returned from the ER with no peg tube in place and no new orders. A quarterly assessment, dated 04/09/25, showed peg tube as present even though it was not. On 04/23/25 at 9:07 a.m., LPN #2 stated Resident #175 was not on a feeding tube because they pulled it out on 3/17/25. LPN #2 stated Resident #175 ate well and their family stated they were the happiest they have ever been. On 04/24/25 at 12:27 p.m., MDS #1 stated Resident #175 does not have a peg tube. The quarterly assessment was coded inaccurately. 3. Resident #126's care plan, dated 04/16/2025, showed the resident had diagnoses which included unspecified dementia and abnormalities of gait and mobility. A fall incident report, dated 03/05/25, showed the resident was found face down on the floor. The report showed the resident was assessed and assisted back in bed. A fall incident report, dated 03/21/25, showed the resident was observed laying on the fall mat on their left side. The report showed the resident was assisted into their wheelchair. Resident #126's quarterly resident assessment, dated 03/26/25, showed the resident had no falls since admission/entry or reentry or the prior assessment. On 04/24/25 at 2:14 p.m., MDS #2 stated the 03/26/25 quarterly resident assessment showed the resident had no falls. On 04/24/25 at 2:15 p.m., MDS #2 stated the assessment should have captured the fall on 03/05/25 and 03/21/25. 48344

Based on record review and interview, the facility failed to ensure residents were educated and offered the opportunity to create an advance directive for 5 (#46, 55, 77, 94, and #175) of 35 sampled residents reviewed for advance directives. The DON identified 177 residents who resided in the facility. Findings: 1. Resident #46 was admitted to the facility on [DATE]. A review of Resident #46's electronic health records showed no advance directive information had been provided. 2. Resident #55 was admitted to the facility on [DATE]. A review of Resident #55's electronic health records showed no advance directive information had been provided. 3. Resident #77 was admitted to the facility on [DATE]. A review of Resident #77's electronic heath record showed no advanced directive information had been provided. 4. Resident #94 was admitted to the facility on [DATE]. A review of Resident #99's electronic heath record showed no advanced directive information had been provided. 5. Resident #175 was admitted to the facility on [DATE]. A review of Resident #175's electronic heath record showed no advanced directive information had been provided. On 04/23/25 at 9:19 a.m., the DON stated the advance directive acknowledgement form was not completed on many residents because prior to March, they were just asking them about advance directives and putting the DNR in the chart if they had one.

Based on record review and interview, the facility failed to ensure residents had access to their personal funds during non banking hours for 2 (#27 and #39) of 3 sampled residents reviewed for personal funds. The BOM identified 103 residents in the facility trust account. Findings: An undated resident trust fund policy and procedure, read in part, The resident or their legal guardian are the only ones who can designate what the monies are spent on and have the right to request their Resident Trust Fund Ledger at anytime .Residents shall be able to make withdrawals from their account at any time. 1. Resident #27's fund management service agreement, dated 03/09/23, read in part, I may make deposits to and withdrawals from my resident fund account at the facility. A quarterly resident assessment, dated 03/12/25, showed Resident #27's cognition was intact (BIMS 15). On 04/22/25 at 11:47 a.m., Resident #27 reported they had not been able to get their own money from their personal funds to give to their family member. They stated they had filed a grievance. 2. Resident #39's fund management service agreement, dated 02/21/21, read in part, I may make deposits to and withdrawals from my resident fund account at the facility. A quarterly resident assessment, dated 03/26/25, showed Resident #39's cognition was severely impaired (BIMS 04). On 04/22/25 at 12:59 p.m., family member #1 voiced concerns with whether or not Resident #39 was receiving their money. On 04/24/25 at 1:55 p.m., the BOM stated there was a box kept at the front receptionist desk that held personal funds for the residents to access when needed. They stated each day residents could request funds. They stated the receptionist would fill out the appropriate form and give the resident's up to $50 at a time. They stated if it was over the $50 amount, they would print out a receipt and have the resident sign it so it could get scanned in. The BOM stated the receptionist was only there during working hours. The BOM stated after that, the box was placed in a safe. On 04/24/25 at 1:11 p.m., the BOM stated the facilty had a receptionist on the weekend from 8:00 a.m. to 5:00 p.m. They stated the facility did not have a process in place for residents to access their funds during non banking hours. On 04/24/25 at 1:42 p.m., the BOM stated residents had access to their funds seven days a week during the hours of 8:00 a.m. to 5:00 p.m.

Based on record review and interview, the facility failed to act upon grievances presented during residents council meetings or provide rationale as to why concerns could not be provided from the facility. The DON identified 177 residents resided in the facility. Findings: A facility's policy titled Grievance/Missing Property, revised 04/26/23, read in part, Purpose: To provide an opportunity for Residents, Resident Representatives, and/or Families to present concerns or Grievances to the proper authorities at the Facility and to receive responses to the issue(s) raised. On 04/28/25 at 11:37 a.m., resident council minutes were reviewed and no rationale was provided for the past 6 months from the facility staff. On 04/28/25 at 1:11 p.m., the administrator stated no issues or concerns in resident's council meetings had not been addressed in the past 6 month (November 2024, December 2024, January 2025, Feburary 2025, March 2025 and, April 2025.) On 04/28/25 at 1:12 p.m., the administrator stated resident council had requested lawn furniture since November 2024. Resident council had also expressed concerns with food temperatures and missing items in laundry rooms. On 04/28/25 at 1:13 p.m. the administrator stated they were not doing resident council grievances as they should.

On 02/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure safety and supervision for Resident #4 who smoked. On 02/24/25 at 5:40 p.m., Resident #7 was observed in the outside courtyard smoking area without staff present. Resident #7 was observed to remove a cigarette, lit it with a match, and began to smoke. Resident #7 stated they had only been at the facility for a week. Resident #7 stated they smoked whenever they wanted to and kept their own cigarettes and matches. A Smoking Policy, dated 11/06/24, read in part, The facility shall maintain safety for residents who request to Smoke, as well as for those who do not. Residents requesting to smoke during their stay may be permitted with staff assistance of handling, igniting, and extinguishing (as needed) of smoker materials and may only smoke in designated areas .For Safety concerns, Residents will be Supervised during Smoking. Resident #4's Smoking Safety Evaluation, dated 01/13/25, read in part, Supervision will be required for all Residents during designated smoking times. This evaluation showed admission as the description of the assessment. A significant change resident assessment, dated 01/15/25, showed Resident #4's cognition was intact with a BIMS score of 14 and they required substantial/maximum assistance for personal hygiene, shower/bathe self, lower body dressing, and toilet hygiene. A State incident report form, dated 02/14/25, showed at approximately 5:05 p.m., the charge nurse was making rounds and smelled cigarette smoke in the hallway (Hall 200) and began opening doors to investigate. The report showed the charge nurse opened Resident #4's door and observed a Kerlix wound dressing to the resident's leg on fire. The report showed the nurse observed a lit cigarette and lighter on the vanity and the room was filled with smoke. The report showed third degree burns were noted to the resident's right posterior lower extremity. The report showed the skin was charred and fascia exposed. The report showed the resident was sent to the emergency room for an evaluation and treatment. An incident note, dated 02/14/25 at 5:10 p.m., showed LPN #1 entered Resident #4's room and observed flames of fire burning on the bandage wrapped around the entire right foot. The note showed the flame was observed to affect the resident's pants as well. The note showed LPN #1 used a bed pad and extinguished the fire. The note showed upon examination the resident had suffered burns to the right lower leg on the posterior aspect. The note showed LPN #1 was asked to send a picture of the affected area to the DON. The note showed it was then rated as a third degree burn and LPN #1 was instructed to send Resident #4 to the emergency room . A wound progress note, dated 02/21/25, showed Resident #4 had a full thickness burn of the right calf which measured length 9 cm, width 22 cm, depth 0.2 cm. There was no Smoking Safety Evaluation located in Resident #7's clinical record. On 02/25/25 at 2:24 p.m., the DON stated smoking evaluations were to be completed on admission. They stated all residents who smoked were to be supervised for safety. On 02/25/25 at 2:48 p.m., the DON stated Resident #7 admitted to the facility on [DATE] and there was not a smoking assessment in the computer. They stated they were not sure if the resident smoked. On 02/25/25 at 3:03 p.m., the social services supervisor stated they did not complete a smoking assessment for Resident #7. They stated they were not aware the resident was a smoker. On 02/25/25 at 3:29 p.m., the social service assistant stated they had a mess up. They stated Resident #7 did not smoke until they admitted to the facility. They stated they completed an assessment today and went over the policy for smoking. On 02/25/25 at 5:27 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/25/25 at 5:30 p.m., the DON was notified of the IJ situation. On 02/26/25 at 10:41 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, South Pointe IJ Abatement Plan for Removal 2.25.25 The preparation of the following plan of correction for this deficiency does not constitute and should not be interpreted as admission nor an agreement by the facility of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction prepared for these deficiencies was executed solely because provisions of State and Federal law require it. 1) Immediate Fix 2) Potential Residents Affected 3) System Changes 4) Monitoring/QAPI 5) DOC 1. a. Resident #4 had a smoking safety evaluation completed on 2/14/25 by the DON. Resident #4 was educated on the smoking policy/procedures/smoking times on 2/14/25. Ad hoc QAPI was completed on 2/14/25 by the DON. b. Resident #7 had a smoking safety evaluation completed on 2/25/25 by Social Services. Resident #7 was educated on smoking policy/procedures/smoking times by Social Services on 2/25/25. c. Resident rooms will be searched on 2/25/25 by Social Services and Unit Managers to ensure no residents have lighters, matches, cigarettes, or vape. Any items found will be added to the smoking cart. d. All residents will have a smoking assessment completed on 2/25/25 by the DON, Unit Managers, and Social Services. Residents that smoke will receive education on smoking policy and smoking times on 2/25/25. 2. Residents who smoke have the potential to be affected. 3. Staff will be educated on 2/25/25 by the DON/LNHA on smoking policy/procedures including rounding between smoking times. No residents will be permitted to smoke without supervision. No staff will work until education is conducted. All new employees will be educated on smoking policies and procedures prior to working. 4. Rounding between smoking times will be completed randomly x 90 days to ensure compliance. Monitored findings will be brought to the monthly QAPI for review. 5. DOC: 2/25/25 at 9:42 PM. The IJ was lifted, effective 02/25/25 at 9:42 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure: a. safety and supervision for a resident who smoked for 2 (#4 and #7); and b. smoking assessments were completed on admission and quarterly for 2 (#1 and #7) of 3 sampled residents reviewed for smoking. ADON #1 identified 182 residents resided in the facility. The DON identified 39 residents who smoked resided in the facility. Findings: 1. On 02/24/25 at 5:45 p.m., Resident #4 was observed being assisted to a lying position in bed by CMA #1. Resident #4 was observed to have a dressing in place to their right lower leg. CMA #1 was unable to identify the reason for the resident's dressing. Resident #4's room was observed to have the odor of burned flesh present. Resident #4 was unable to answer questions by the surveyor appropriately. A Smoking Policy, dated 11/06/24, read in part, The facility shall maintain safety for residents who request to Smoke, as well as for those who do not. Residents requesting to smoke during their stay may be permitted with staff assistance of handling, igniting, and extinguishing (as needed) of smoker materials and may only smoke in designated areas .For Safety concerns, Residents will be Supervised during Smoking. Resident #4 had diagnoses which included unspecified lack of coordination, muscle weakness, and muscle wasting and atrophy of the left shoulder. Resident #4's Smoking Safety Evaluation, dated 01/13/25, read in part, Supervision will be required for all Residents during designated smoking times. This evaluation showed admission as the description of the assessment. A significant change resident assessment, dated 01/15/25, showed Resident #4's cognition was intact with a BIMS score of 14 and they required substantial/maximum assistance for personal hygiene, shower/bathe self, lower body dressing, and toilet hygiene. A State incident report form, dated 02/14/25, showed at approximately 5:05 p.m., the charge nurse was making rounds and smelled cigarette smoke in the hallway (Hall 200) and began opening doors to investigate. The report showed the charge nurse opened Resident #4's door and observed a Kerlix wound dressing to the resident's leg on fire. The report showed the nurse observed a lit cigarette and lighter on the vanity and the room was filled with smoke. The report showed third degree burns were noted to the resident's right posterior lower extremity. The report showed the skin was charred and fascia exposed. The report showed the resident was sent to the ER for an evaluation and treatment. An incident note, dated 02/14/25 at 5:10 p.m., showed LPN #1 entered Resident #4's room and observed flames of fire burning on the bandage wrapped around the entire right foot. The note showed the flame was observed to affect the resident's pants as well. The note showed LPN #1 used a bed pad and extinguished the fire. The note showed upon examination the resident had suffered burns to the right lower leg on the posterior aspect. The note showed LPN #1 was asked to send a picture of the affected area to the DON. The note showed it was then rated as a third degree burn and LPN #1 was instructed to send Resident #4 to the emergency room . Resident #4's care plan, revised 02/17/25, showed the resident was at risk for adverse reactions due to smoking cigarettes. The care plan showed Resident #4 was a supervised smoker secondary to smoking in their room. The care plan showed Resident #4's smoking materials and lighters would be locked up with staff and the resident would attend the supervised smoking times to smoke. A wound progress note, dated 02/21/25, showed Resident #4 had a full thickness burn of the right calf which measured length 9 cm, width 22 cm, depth 0.2 cm. On 02/25/25 at 8:38 a.m., Resident #13 stated the facility should have been enforcing smoking rules before Resident #4 burnt their foot. Resident #13 stated they sat right on their bed and saw what happened. On 02/25/25 at 8:55 a.m. Resident #13 stated Resident #4 was in their room smoking. Resident #13 removed a notebook from their room and stated it was 02/14/25 and the ambulance came and took Resident #4 who had burnt their foot. On 02/25/25 at 9:10 a.m., Resident #4 stated they had been at the facility about a year. When asked to explain the dressing to their right lower leg, the resident replied, It's kind of a long story. Resident #4 stated, It's fear I'm gonna lose my leg. Resident #4 stated, All of a sudden it starts aching. Resident #4 stated, I smoke outdoors I don't smoke inside. Resident #4 started closing their eyes. On 02/25/25 at 9:14 a.m., CMA #2 entered Resident #4's room and assisted the resident to a lying position. Resident #4 closed their eyes and did not continue the interview. On 02/25/25 at 1:00 p.m., CNA #4 stated the facility really did not have a smoking policy before Resident #4 burnt their leg. CNA #4 stated, It was supervised smoking, but they weren't following protocol. CNA #4 stated residents were going out by themselves and had their own cigarettes. CNA #4 stated now staff were supervising all residents when they smoked and the cigarettes and lighters were kept in the Hall 200 medication room in a lock box. On 02/25/25 at 1:10 p.m., CNA #5 stated the facility just started enforcing the smoking policy after Resident #4 caught themselves on fire. They stated now staff supervised residents on scheduled smoke breaks every two hours. CNA #5 stated before the policy was enforced, residents kept their own cigarettes and lighters and went out on their own. On 02/25/25 at 1:28 p.m., LPN #3 stated residents were not allowed to have cigarettes or lighters on their person or in their room. They stated residents were taken out by staff every two hours for supervised smoke breaks. They stated no residents could safely smoke by themselves. LPN #3 stated this process took place after Resident #4 burnt their leg. LPN #3 stated Resident #4 was smoking in their room due to the cold weather and dropped their cigarette on their bandage. On 02/25/25 at 2:10 p.m., LPN #1 stated the facility had scheduled times to smoke and residents were not allowed to have lighters or cigarettes in their rooms. LPN #1 stated staff had a locked box with smoking supplies. They stated no residents smoked without supervision. LPN #1 stated the day of the incident, they were walking by Resident #4's room and smelt burning. LPN #1 stated they started opening resident rooms, and the second door they opened was Resident #4's room. LPN #1 stated they saw a flame on the resident's leg. LPN #1 stated they immediately called for help, and used a bed pad to get the flame out. LPN #1 stated Resident #4 had a package of cigarettes and a cigarette and lighter on the bed. LPN #1 stated they saw ashes on the bed and smoke spots. LPN #1 stated the flame affected the right foot dressing and they had to peel it off. LPN #1 reported they called the administrator and physician and sent the resident to the hospital. On 02/25/25 at 2:24 p.m., the DON stated the facility had supervised and unsupervised smokers before the incident with Resident #4. The DON stated after the 02/14/25 incident, staff collected all smoking materials and explained to residents and staff the new supervised smoking schedule. The DON stated right now everyone was supervised and staff had to light cigarettes for them. The DON stated smoking evaluations were to be completed on admission. They stated all residents who smoked were to be supervised for safety. The DON stated they received a call immediately when the incident with Resident #4 happened. They stated staff reported seeing flames on Resident #4's leg and used bed pads to extinguish the fire. They stated Resident #4 admitted to smoking in their room and they were sent to the emergency room for an evaluation. On 02/25/25 at 2:40 p.m., the DON stated a smoking schedule was put in place the night it happened. They stated the same policy was in effect when the incident occurred and residents should have been supervised during smoking. The DON stated now all cigarettes were on a count sheet and staff had to sign them out. They stated smoking supplies were locked in the Hall 200 medication room. 2. On 02/24/25 at 5:02 p.m., a facility smoke break was observed. CNA #1 stated resident cigarettes had their names on them and they along with the lighters were kept locked up in the medication room. CNA #2 was observed filling out a binder during the smoke break. CNA #2 stated they documented the resident name, date, cigarette time, and how many cigarettes were given in the log book. CNA #3 was observed lighting cigarettes for residents during the smoke break. There were eleven smokers observed during this supervised smoke break. On 02/24/25 at 5:40 p.m., Resident #7 was observed in the outside courtyard smoking area without staff present. Resident #7 was observed to remove a cigarette, lit it with a match, and began to smoke. Resident #7 stated they had only been at the facility for a week. Resident #7 stated they smoked whenever they wanted to and kept their own cigarettes and matches. Resident #7 had diagnoses which included nontraumatic subarachnoid hemorrhage and acute respiratory failure with hypoxia. Resident #7's admission record showed the resident admitted to the facility on [DATE]. There was no Smoking Safety Evaluation located in Resident #7's clinical record. On 02/24/25 at 5:15 p.m., Resident #7 stated the facility staff took all lighters and cigarettes from residents after Resident #4 caught themselves on fire. They stated smoke breaks were now supervised by staff. On 02/25/25 at 2:24 p.m., the DON stated smoking evaluations were to be completed on admission. They stated all residents who smoked were to be supervised for safety. On 02/25/25 at 2:48 p.m., the DON stated Resident #7 admitted to the facility on [DATE] and there was not a smoking assessment in the computer. They stated they were not sure if the resident smoked. On 02/25/25 at 3:03 p.m., the social services supervisor stated they did not complete a smoking assessment for Resident #7. They stated they were not aware the resident was a smoker. On 02/25/25 at 3:29 p.m., the social service assistant stated they had a mess up. They stated Resident #7 did not smoke until they admitted to the facility. They stated they completed an assessment today and went over the policy for smoking. 3. Resident #1 had diagnoses which included paraplegia and anxiety disorder. Resident #1 had a Smoking Safety Evaluation completed on 07/23/24. An annual resident assessment, dated 01/08/25, showed yes for current tobacco use. There was no Smoking Safety Assessment completed in conjunction with this annual resident assessment. On 02/26/25 at 9:10 a.m., the DON reviewed Resident #1's smoking evaluations. They stated they were completed on 02/13/24, 07/23/24, and 02/25/24. The DON stated Resident #1's MDS assessments were completed on 02/13/24, 05/08/24, 07/31/24, 10/23/24, and 01/08/25. The DON stated they could not explain the reason a smoking evaluation/assessment was not completed for Resident #1 between 07/23/24 and 02/25/25. The DON stated, There should have been one with every quarterly and annual.

On 02/27/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #12 from mental and physical abuse. On 02/25/25 at 3:02 p.m., Resident #12 was interviewed and stated on 01/23/25 at 6:00 p.m. a person came to door 2 (hall 200) pounding on the door. Resident #12 stated CMA #1 let this person in and they immediately staring cussing and making a move to hit CMA #1. Resident #12 stated they took off down towards them and asked the unknown person what they were doing. Resident #12 stated the person took two swings at them and on the second swing hit them on the face. Resident #12 stated it hurt like the [NAME]. Resident #12 stated ever since then, I don't feel safe. Resident #12 stated, It could happen again. Resident #12 stated they did not know who the person was, but they were delivering medications for a company and the administrator and DON would know who they were. Resident #12 stated the cops were called and charges were pressed. Resident #12 stated they needed security at the doors. The Abuse Prevention Policy, dated 10/21/22, read in part, The facility is committed to protecting the facility from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents .Abuse: Willful infliction of injury .with resulting physical harm, pain, mental anguish or emotional distress. An Incident Note, dated 01/23/25, showed around 6:30 p.m., LPN #2 witnessed a confrontation between Resident #12 and the med-delivery person. The note showed LPN #2 saw the person flip their hands towards Resident #12's face. The note showed LPN #2 and other staff asked the person to leave the facility. The note showed the police, resident's family, and DON were notified. An unlabeled document, dated 01/24/25, showed Resident #12 stated they were not afraid, but did not feel safe. Resident #12 stated they felt like security needed to be put in place at night time. This note was signed by the social service supervisor. There was not a State incident report form completed for this incident of abuse. There were no interventions in place to address Resident #12 not feeling safe after this incident. On 02/27/25 at 6:22 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/27/25 at 6:26 p.m., the DON was notified of the IJ situation. On 02/28/25 at 11:04 a.m., an acceptable plan of removal was approved by the Oklahoma Stated Department of Health. The plan of removal, read in part, South Pointe IJ Abatement Plan for Removal 02/28/25 at 3:45 p.m. The preparation of the following plan of correction for this deficiency does not constitute and should not be interpreted as admission nor an agreement by the facility of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction prepared for these deficiencies was executed solely because provisions of State and Federal law require it. 1) Immediate Fix 2) Potential Residents Affected 3) System Changes 4) Monitoring/QAPI 5) DOC 1. a. Trauma informed questionnaire completed for Resident #12 on 2/27/25 by Social Services. Resident #12 stated that [they] had no previous trauma. [Their] intervention to feel safe is journaling which [they] has been provided with a notebook for journaling. Resident #12 has agreed to meeting with social services 5Xs a week and speaking to a psychology service on 2/27/25. b. Social Services educated on psychosocial health regarding abuse incidents by the DON on 2/27/25. Any residents who do not feel safe will have follow up completed by social services regarding obtaining a referral to psychology services and report findings to DON/LNHA. c. All door codes changed by the Maintenance Director on 2/27/25. Signage was placed on 2/28/25 by the Maintenance Director stating 'After 5pm, please go to Unit 400 door and ring doorbell for assistance.' d. Facility staff were educated on the new process on 2/28/25 by Department Heads. Staff will be educated prior to working their next shift. e. Resident safe surveys completed by department heads on 2/27/25. f. Social Services to follow up with resident#12 5Xs a week for one month to ensure no signs of fearfulness. Date of Compliance: 2/28/25 at 10:10am. The IJ was lifted, effective 02/28/25 at 3:45 p.m., when all components of the plan of removal had been verified as complete. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to protect a resident from mental and physical abuse for 1 (#12) of 3 residents sampled for abuse. ADON #1 identified 182 residents resided in the facility. Findings: The Abuse Prevention Policy, dated 10/21/22, read in part, The facility is committed to protecting the facility from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents . Abuse: Willful infliction of injury .with resulting physical harm, pain, mental anguish or emotional distress. Resident #12 had diagnoses which included anxiety disorder and chronic embolism and thrombosis of other specified veins. Resident #12's annual assessment dated [DATE], showed their cognition was intact with a BIMS score of 15. An Incident Note, dated 01/23/25, showed at around 6:30 p.m., during shift, LPN #2 witnessed a confrontation between the Resident #12 and a med-delivery person while observing from the nursing station. The note showed the resident had seen and heard the med-delivery person verbally abuse a staff member by yelling and calling the staff member the B word several times. The note showed the resident then tried to tell the med-delivery person not to speak to the staff member in that manner. The note showed LPN #2 then saw the med-delivery person dip their hand towards the resident's face. The note showed LPN #2 then called 911. The note showed the DON and resident's family member were notified of the incident. The note showed the officer came shortly after and took their statement. On 02/25/25 at 3:02 p.m., Resident #12 stated on 01/23/25 at 6:00 p.m. a person came to door 2 (hall 200) pounding on the door. Resident #12 stated CMA #1 let the person in and they immediately staring cussing and making a move to hit CMA #1. Resident #12 stated they took off down towards them and asked the unknown person what they were doing. Resident #12 stated the person took two swings at them and on the second swing hit them on the face. Resident #12 stated it hurt like the [NAME]. Resident #12 stated ever since then, I don't feel safe. Resident #12 stated, It could happen again. Resident #12 stated they did not know who the person was, but they were delivering medications for a company and the administrator and DON would know who they were. Resident #12 stated the cops were called and charges were pressed. Resident #12 stated they needed security at the doors. On 02/27/25 at 8:52 a.m., CMA #1 stated the med-delivery person was banging on the door. CMA #1 stated they walked by the door and opened it and the med-delivery person stated, Yeah, [expletive], you saw me the first time. CMA #1 stated they told the med-delivery person they had to make a stop first. CMA #1 stated the med-delivery person stated, You heard what the [expletive] I said, and the med-delivery person bucked at them. CMA #1 stated when the med-delivery person bucked at them, Resident #12 came up to them and told the med-delivery person to leave them alone. CMA #1 stated the med-delivery person then swung and hit Resident #12 in the eye. CMA #1 stated they thought the med-delivery person swung two more times. CMA #1 stated Resident #12 and the med-delivery person continued to argue and they told LPN #2 to call the police. On 02/27/25 at 11:49 a.m., the DON stated they had not been notified at the time of the incident. The DON stated they were unaware of Resident #12 not feeling safe. On 02/27/25 at 11:52 a.m., the DON stated they did not know what else they could have done to make Resident #12 feel safe. On 02/27/24 at 11:54 a.m., the DON stated everyone should come through one door, but that was not the way anymore.

Based on observation, record review and interview, the facility failed to ensure residents were free of neglect for one (#3) of four sampled residents reviewed for neglect. Resident #3 took a water pitcher from the medication cart and proceed down the hall. Resident #2 blocked Resident #3 from leaving down the hall and ended up grabbing Resident #3 on the shoulders and base of the neck forcefully pushing them to the ground. Resident #3 sustained a fractured hip requiring surgery. CNA #1 was present and did not intervene to protect Resident #3 from Resident #2. The DON identifed 13 residents who resided on hall 600 memory care unit. Findings: The Abuse Prevention policy, last revised 10/21/22, read in part, .Neglect: failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presents either imminent danger to the health, safety, or welfare of a consumer or substantial probability that death or serious injury would result. This would include, but is not limited to, failure to provide adequate supervision during an event in which one consumer causes serious injury to another consumer . 1. Resident #2 had diagnosis of dementia. Resident #2's care plan, dated 07/10/24 , documented they had impaired cognition with dementia and had impaired process. The care plan documented the resident had difficulty making decisions, impaired decision making and long term memory loss. Resident #2's quarterly MDS, dated [DATE], documented the resident had severe cognitive impairment. 2. Resident #3 had diagnoses which included dementia, depression, psychosis, and schizophrenia. Resident #3's care plan, dated 02/19/24 , documented they had dementia and severe cognitive impairment. Resident #3's quarterly MDS, dated [DATE], documented the resident had severe contrive impairment. An incident progress note, dated 10/12/24 at 6:03 p.m., documented Resident #3 took a water pitcher and poured it on Resident #2. It documented Resident #2 pushed Resident #3 to the floor. It documented Resident #3 had a skin tear and started to yell when attempting to get off the floor. It documented Resident #3 was sent to the hospital for treatment. An initial OSDH incident report, dated 10/12/24, documented Resident #3 had a water pitcher from the medication cart and tossed water on Resident #2. It documented Resident #2 pushed Resident #3 causing them to fall and sustain a skin tear to their left elbow and pain in their left hip and was sent to the hospital for evaluation. It documented the facility was reporting an allegation of abuse or mistreatment. The emergency department to hospital admission record, dated 10/12/24, documented Resident #3 presented with a fall and was assaulted by another resident. The record also documented Resident #3 had a right hip intertrochanteric fracture and had surgery on 10/13/24. On 10/25/24 at 10:23 a.m., the video footage of the incident between Resident #2 and Resident #3 was viewed with the DON. The video clip was dated 10/12/24 at 4:29 p.m. and was 42 seconds long. Resident #3 was observed at the medication cart taking a pitcher of water when CNA #1 approached them in attempts to get the water pitcher. Resident #3 kept turning away from CNA #1 as they attempted to get the pitcher. Resident #2 was observed coming up the hall towards Resident #3. Resident #3 walked down the hall towards Resident #2. Resident #2 stepped in front of Resident #3 and after several attempts to get by Resident #3 threw water from the pitcher on Resident #2. CNA #1 was observed in the video standing about five feet away and did not intervene to separate Resident #2 and Resident #3. CNA #1 was observed taking a few steps towards the resident and then backed away and did not intervene to protect each resident and separate them. Resident #2 grabbed Resident #3 on the shoulders and neck area pushing Resident #3 forcefully to the ground. LPN #1 was observed entering the video after Resident #3 was pushed to the floor and moved Resident #2 away from Resident #3 who was on the floor. On 10/25/24 at 10:45 a.m., Resident #3's POA stated they had been notified Resident #3 was pushed down and had bloody elbows. They stated Resident #3 went to the hospital and had a fracture that required surgical repair. The POA stated they did not feel the residents were being watched like they should have been and they would have expected staff to intervene when any incident occurred like this. On 10/25/24 at 11:26 a.m., the DON stated CNA #1 went towards Resident #2 and Resident #3, but backed away and looked like they were scared. The DON stated CNA #1 should have intervened and attempted to separate the two residents. On 10/25/24 at 11:55 a.m., CNA #1 stated Resident #3 fell to the ground because Resident #2 pushed them to the floor. CNA #1 stated they were right there, but could not intervene and was not going to try and stop the residents because they were hit in the past by residents. CNA #1 stated they were afraid to intervene. CNA #1 stated they had only worked on the hall two other times and had been trained how to handle residents with dementia. On 10/25/24 at 12:07 p.m., LPN #1 stated they were working at the time of the incident with Resident #2 and Resident #3. They stated CNA #1 was close to the residents and did not intervene and stop them. LPN #1 stated they counseled the CNA, who responded they were not going to get beat up and was scared. LPN #1 stated the CNA normally worked on another hall and that was the first shift they had worked together. On 10/25/24 at 12:15 p.m., the DON was asked for a policy on dementia care. The DON stated they did not have one. They stated all they had was the abuse policy that had been provided. The DON stated LPN #1 never told them the aide was afraid to intervene. On 10/25/24 at 12:30 p.m., the administrator stated they had copies of CNA #1's statement from the incident. They stated the nurses charted in the record and that was the nurses' statement. They stated Resident #2 stepped in front of Resident #3 and the aide was behind the residents. The administrator stated CNA #1 looked scared, but they did not ask why they looked scared. The administrator then stated the expectations would be for the aide to intervene and attempt to separate the two residents. On 10/25/24 at 1:07 p.m., the DON was asked what the definition of neglect was. They stated, The willful intent to not take care of anybody. The DON was asked what the abuse policy indicated neglect was. They reviewed the policy and stated, Yes it was neglectful act on behalf of the aide. The DON added there was an altercation causing Resident #3 to fracture their hip and require surgery. On 10/25/24 at 1:21 p.m., the administrator stated neglect was not taking care of someone. When asked what the policy indicated neglect was, the administrator stated they disagreed and would see about that. 45583 Ed Roth

Based on observation, record review, and interview, the facility failed ensure interventions were in place, new intervention were implement after a fall, and staff were aware of fall interventions for two (#156 and #11) of four sampled residents reviewed for accident hazards. Resident #156 had 16 falls over six months. The last fall resulted in Resident #156 sustaining a facial laceration, head contusion, and loosing a tooth. The DON identified 181 residents resided in the facility. Findings: A Fall Management policy, dated 02/28/23, read in part .Prevention/Treatment .Investigate the Circumstances and Surroundings where the Fall Occurred .Implement Intervention to reduce further occurrences .Interdisciplinary Team .Review Post-Fall Residents within 24-72 Hours during Clinical Meeting .Evaluate Circumstances/Probable Cause for Fall .Revise/Modify Care Plan .Implement Interventions according to Treatment approach to minimize further Falls & reduce injury . 1. Resident #156 had diagnoses which included dementia, muscle weakness, difficulty with walking, and unsteadiness on feet. Ten Fall Scale assessments, dated from June 2023 to November 2023, documented the resident was at high risk for falls. A Quarterly Assessment, dated 10/11/23, documented Resident #156 sometimes understood others and sometimes made themselves understood. It documented Resident #156 had severe impaired cognition. It documented Resident #156 required substantial/maximal assistance with ADLs and mobility. It documented Resident #156 had two or more non injury falls, and two or more injury falls since prior assessment. A Fall Incident Report, dated 07/03/23, documented the resident had a fall. It documented the intervention was to put a concave mattress in place. A Fall Incident Report, dated 10/06/23, documented the resident had a fall. It documented the intervention was to drop the back seat of the wheelchair. A Fall Investigation, dated 12/25/23, documented the resident was laying on the floor. It documented a laceration was observed to the center of the resident's forehead and a tooth was found on the floor. It documented the resident was transferred to the hospital. A Progress Note, dated 12/25/23, documented the resident was sent to a local hospital and the resident received eight sutures, then returned to the facility. An After Visit Summary, dated 12/25/23, documented the resident was diagnosed with a facial laceration and a head contusion. On 01/08/24 at 8:47 a.m., Resident #156 was observed up in their wheelchair in the dining room. A closed laceration was observed in the middle of the resident's forehead. Purple and yellow bruising was observed around the laceration, and the bruising extended to the rest of the resident's forehead and down to their cheeks. The back of the resident's wheelchair seat was not observed to have been lowered. On 01/08/24 at 10:49 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave. On 01/09/24 at 9:24 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave. On 01/10/24 at 10:14 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave. On 01/10/24 at 1:06 p.m., the DON stated she was not aware the resident had a fall the last week of December. On 01/10/24 at 2:23 p.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave. The wheelchair was observed in the room and the back of the seat was not observed to be lowered. On 01/10/24 at 2:25 p.m., LPN #1 stated Resident #156 was a very high fall risk. They stated they try to keep the resident in sight and if they observe the resident wanting to get out of the wheelchair, they will assist the resident to lay down. LPN #1 stated they recalled Resident #156 had a fall on Christmas and had to get sutures to their forehead. LPN #1 was not sure what the intervention had been put in place regarding the fall. On 01/10/24 at 2:27 p.m., LPN #1 observed the resident's room. They were able to identify some interventions in place. They did not identify the mattress should be concave nor the back of the wheelchair seat should be lowered. On 01/11/24 at 10:36 a.m., the DON stated staff completed an incident report, unit managers completed room audits to ensure interventions were in place, interventions were put on the kardex for staff to see, and nurses communicated shift to shift. The DON stated some of Resident #156's current fall interventions in place were a concave mattress, and the back of the wheelchair lowered. The DON stated IDT completed risk meetings to review falls, interventions, and make changes if needed. The DON stated the last risk meeting regarding Resident #156 was 10/13/23. The DON stated the intervention for the fall that occurred on 12/25/23 was frequent checks. She stated she would probably change that because the resident had already been on hourly checks. On 01/11/24 at 10:49 a.m., the DON observed Resident #156's room. She stated the mattress was not a concave mattress. On 01/11/24 at 10:51 a.m., the DON observed Resident #156 in their wheelchair. She stated it didn't look like the back of the seat was lowered. 46216 2. Resident #11 had diagnoses which included other abnormalities of gait and mobility and unspecified osteoarthritis. Resident #11's care plan, dated 11/20/23, documented resident had a fall with minor injury on 11/20/23 while transferring out of the wheelchair. The intervention documented was to place anti roll back bars to the wheelchair. A Quarterly Assessment, dated 12/20/23, documented Resident #11 required substantial/maximal assistance with sit to stand. On 01/12/24 at 1:50 p.m., LPN #6 stated Resident #11 was to have anti lock on their chair, however there had been a change in Resident #11's chair and Resident #11 was in a borrowed chair at this time. On 1/12/24 at 1:52 p.m. LPN #6 stated the anti lock was not on Resident #11's chair.

Based on observation, record review, and interviews, it was determined the facility failed to: ~ assess and document gastrostomy tube feeding residual amounts prior to providing additional tube feedings; ~ record and monitor daily intake and output amounts for a resident receiving bolus tube feedings; and ~ assess, monitor and intervene for nausea and vomiting for a resident receiving bolus tube feedings for one (#80) of three sampled residents who were reviewed for the use of a gastrostomy tube. The facility identified ten residents who had a gastrostomy tube. Resident #80 experienced nausea and vomiting for a period of two months prior to being hospitalized on [DATE]. There was no documentation of assessing the residual amounts of the resident's gastric contents prior to the administration of bolus tube feedings. On the morning of 04/21/21, the resident was found to have rapid respirations with low oxygen saturation levels (57%), and was vomiting. The resident was sent to the emergency room and presented with shortness of breath and altered mental status. He was placed on [CONDITION(S)] for ventilatory support. On arrival, his PEG tube was placed to wall suction and 1100ml of gastric contents were suctioned. The emergency room notes documented this improved his work of breathing. The resident was admitted with septic shock, [CONDITION(S)] and aspiration pneumonia. Findings: A facility policy and procedure, titled Tube Feeding: Bolus Feeding, dated 02/2016, documented: .Purpose: To provide nutritional support to residents through enteral feedings via the bolus method . .Procedure .Verify tube placement check for residual gastric contents by aspirating the syringe . A facility policy and procedure, titled, Measuring and Documenting Fluid Intake, dated 02/2016, documented: .Purpose: To accurately determine the amount of liquid a resident consumes in a 24-hour period . .General Guidelines .An order should be obtained .if it is medically indicated for the resident to be on intake and output measurement . .Record the fluid intake as soon as possible after the resident has consumed the fluids .At the end of the shift, total the amounts of all liquids the resident has consumed . .Record the amount noted on the intake side of the intake and output record .Record the time the intake was measured . .The following information should be recorded in the resident's medical record .Per the facility guidelines: a. The date and time the resident's fluid intake was measured and recorded. b. The name and title of the individual who measured and recorded the resident's fluid intake and recorded the data. c. The amount of liquid consumed. d. The type of liquid consumed (i.e., tea, milk, coffee, soup, etc.) . A facility policy, titled, Measuring and Documenting Fluid Output, dated 02/2016, documented: .Purpose: To accurately determine the amount of urine that a resident excretes in a 24-hour period. .Procedure .Record the amount noted .Record the time the output was measured . .The following information should be recorded in the resident's medical record . a. The date and time the resident's urine output was measured and recorded. b. The name and title of the individual who measured and recorded the resident's .output. c. The amount .of output . Resident #80 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note, dated 01/12/21, documented, .Problem List .Suspected Aspiration Pneumonia .Dysphagia .Congestive Heart Failure .Medications .[MEDICATION(S)] as needed . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .enteral feed order three times a day related to Gastronomy Status, 1 can Glucerna 1.5 . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Gastrointestinal consult for evaluation and treatment . The TAR, dated 02/2021 did not include documentation the gastric residual had been assessed before the bolus PEG tube feedings were administered three times a day and the bolus water was administered four times a day. A nurse practitioner's progress note, dated 03/08/21, documented, .Bolus feedings at 0100 and 0500 .Vomiting reported in the mornings .New order to discontinue 0100 and 0500 feedings . This document was faxed to the facility on [DATE] and signed by the nurse practitioner on 05/03/21. An Order Summary Report, dated 03/09/21, documented the resident was to receive one can of Glucerna 1.5 three times a day. These orders were signed by the resident's physician on 03/14/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] [MEDICATION(S)] Tablet Disintegrating 4 milligram Give 1 tablet by mouth every 6 hours as needed for Nausea/vomiting If continues vomiting after 1 hour may give another dose . A social services note, dated 03/16/21, documented, .Referral faxed to Digestive Disease specialist . (This was 27 days after the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A social services note, dated 03/19/21, documented, .Social services department made F/U call to check on the status of GI referral. Dr .is reviewing referral and scheduler will contact SSD to schedule. Nursing notified . The care plan, revised on 03/23/21, documented, .The resident requires feeding tube feeding related to (r/t) dysphagia will be free of aspiration . Goals .The resident will be free of aspiration through the review date .The resident will remain free of side effects or complications related to tube feeding through review date . Interventions .Check for tube place and gastric contents/residual per facility protocol and record. Hold feed if residual greater than cc aspirate .The resident is dependent with tube feeding and water flushes. Monitor/document/report to MD as needed .Nausea/vomiting . The care plan did not document the amount of residual required to hold the bolus feeding. A dietary note, dated 03/23/21, documented, .Resident set up for GI consult related to vomiting episodes . The MAR, dated 03/2021, documented the resident had received the as needed nausea medication ([MEDICATION(S)]) 11 out of 18 days. The TAR, dated 03/2021 did not include documentation the gastric residual had been assessed before the bolus PEG tube feedings were administered three times a day and the bolus water was administered four times a day. There was no documentation in the nurse's notes that the resident was assessed for residual before the bolus feedings and water was administered. A nurse's note by LPN #11, dated 04/11/21 at 1:51 p.m., documented, .Focused Assessment r/t Vomiting .started .vomiting, This nurse took vitals 126/78 58 18 bowel sounds present, abdomen soft and non-tender. This nurse called Dr .on Call .was instructed to monitor resident and to notice [sic] Physician if it happens again . A social services note, dated 04/15/21, documented, .GI office did not contact SSD for a virtual visit. SSD called to follow-up and re-schedule. Voicemail left at this time . A social services note, dated 04/16/21, documented, .SSD left .GI scheduler .a VM to re-schedule virtual visit . There was no documentation the resident had their appointment with the GI doctor. The MAR, dated 04/2021, documented the resident had received the as needed nausea medication ([MEDICATION(S)]) 15 out of the first 20 days. There was no documentation the staff had reported the frequent use of the as needed nausea medication to the physician in March and April. The TAR, dated 04/2021 did not include documentation the gastric residual had been assessed before the bolus PEG tube feedings were administered three times a day and the bolus water was administered four times a day. There continued to be no documentation located in the nurse's notes the facility had assessed the resident for residual prior to the bolus feeding and water administration. On 04/20/21 at 9:47 a.m., the resident was observed lying supine in bed. There was a reddish brown dried substance observed on the floor on the right side of the head of the bed and on the fall mat on the floor next to the bed. At 10:12 a.m., the resident was observed lying supine in bed. There was a reddish brown dried substance observed on the floor on the right side of the head of the bed and on the fall mat on the floor next to the bed. At 2:05 p.m., the resident was observed lying supine in bed. There was a reddish brown dried substance observed on the floor on the right side of the head of the bed and on the fall mat on the floor next to the bed. A nurse's note, documented by LPN #2, dated 04/21/21 at 8:25 a.m., documented, .Bp=82/50, p=82, r=40, t=98.4, O2=57% with O2 @ 5l/m per NC. Orange colored emesis and labored respirations noted .on call .Dr .notified. New order received to send to ER for evaluation and treatment . On 04/21/21 at 8:50 a.m., the resident was not observed in his room. CMA #1 was asked where the resident was. The CMA stated the resident was sent to the hospital due to having shortness of breath and throwing up through the night. She stated the substance on the floor against the wall looked like dried emesis. She then stated the resident throws up all the time. The CMA stated she had cleaned up the dried reddish brown emesis on the right side of the bed yesterday, but she had not seen the vomit on the floor on the opposite side of the bed. Emergency Department notes from the hospital, dated 04/21/21 at 9:53 a.m., documented the resident presented with shortness of breath and altered mental status. The notes documented, .EMS (Emergency Medical Services) reports they were told by staff that the patient vomited this morning and there is concerned that he aspirated. On arrival EMS found him tachypneic and hypoxic with an ox (oxygen) saturation of 75% on room air . The resident's temperature was 102.9 (F), his pulse was 112, and his respirations were 48. The notes documented, .Pulmonary: Comments: Patient is tachypneic with diffuse crackles bilaterally and increased work of breathing .Abdominal Mildly distended . On arrival here his room air oxygen saturation is 80%. He is placed on [CONDITION(S)] for ventilatory support .On arrival here his PEG tube was placed to wall suction and 1100ml of gastric contents were suctioned. This also improved his work of breathing . The resident was admitted with septic shock, [CONDITION(S)] and aspiration pneumonia. On 04/21/2 at 10:00 a.m., LPN #2 was asked what their process was for administration of bolus tube feedings. LPN #2 stated they washed their hands, put on gloves, flushed the tube with just a little water to make sure it was not clogged, checked for residual and then poured the feeding into the tube and after the feeding they flushed with the amount of water ordered. The LPN was asked where resident #80 was. He stated the resident went to the hospital this morning because his oxygen saturation was not good and they thought it might be due to aspiration pneumonia. He was asked if the resident had a problem with nausea and vomiting. LPN #2 stated yes, the resident had a problem with vomiting and it looked like he had received as needed [MEDICATION(S)] that was ordered for nausea and vomiting almost every day. He then stated the resident had episodes of nausea and vomiting For a couple of months. At 10:19 a.m., LPN #2 was asked if they had an order to check residual from the gastrostomy tube and documentation of residual amounts for the resident. LPN #2 stated residual amounts were not documented on him. They stated there was not an order or a column to document tube feeding residual amounts for the resident. LPN #2 stated PEG tube residual amounts should be measured and assessed before administering a tube feeding bolus or a water bolus and should be documented. They stated there was not a place in the TAR to document residuals for the resident. He stated he could not tell how much residual the resident had on 04/20/21 before the TID tube feeding boluses or QID water boluses had been administered because there was no documentation. On 04/26/21 at 10:30 a.m., LPN #5 was asked if they documented intake and output for the resident. LPN #5 looked in the 2021 MAR and TAR and stated, There was no documentation of daily intake and output, there should be, but there is not. She then stated there was no area for documentation and there was no documentation showing residual amounts were measured before and after tube feeding or water boluses located on the April 2021 MAR or TAR. She added there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . At 11:30 a.m., LPN #6 was asked if she had worked the night of 04/21/21. She stated she was not sure what day 04/21/21 was, but she usually worked the night shift 10p-6a and had not called in or missed a night of work the previous week. She was asked if she would explain a tube feeding or water bolus administration process. She stated she checked residual before and after the tube feeding, listened to the abdomen for placement, checked vitals on the resident and performed peg tube care as needed. She stated if the residual had more than 60 cc's she held the feeding if the order stated to or if there were no orders she would ask the charge nurse how much residual was needed to hold the tube feeding or water bolus. She added the bolus feeding would be held by her if the residual was 60 cc's or greater. The LPN stated she documented the residual, intake and output on the TAR, there would be an order from the physician for residual amounts to hold the feeding or water boluses. She stated she would write it down on the TAR if there was a space for it to be documented. She stated an empty square on the MAR and TAR indicated the bolus feeding and water was not provided. She then confirmed the only place this was documented was on the MAR and TAR. LPN #6 was asked if she recalled working the night the resident was sent to the hospital on 04/21/21. She stated she was working on hall 200 overnight and taking care of resident #80 the morning the resident was sent to the hospital. She confirmed she did not administer the 1:00 a.m. and 5:00 a.m. bolus feeding due to the resident's nausea, vomiting and residual. She stated she did not know how much residual there was because it had not been documented, but there was a lot. She also stated the resident had vomited a few times during her shift. The LPN confirmed she did administer the water boluses that were initialed on the TAR for the resident on the night of 04/21/21. She then stated, I did administer the water boluses ordered. On 04/27/21 at 3:18 p.m., LPN #1 was asked at what point they notified the physician when a resident was frequently taking an as needed medication for nausea. She stated if it was 24 or 48 hours of constant need for the prn nausea medication they would notify the physician. She then stated the physician would always be notified when an as needed medication was taken daily because it was not an effective intervention. The LPN confirmed the typical orders for bolus tube feeding would include how much water to flush with, how often the tube feeding and water boluses were to be administered and how to assess and residuals. She was asked to describe the process of assessing tube feeding residuals and asked at what point they would hold the tube feeding or water boluses. The LPN stated they would hold the bolus tube feeding anytime they got 30-60 ccs or more of residual back from the PEG tube. She added they would stop the tube feeding and water bolus immediately, notify the doctor immediately, and they would not administer any of the tube feeding formula or water. She then confirmed it was the same process on each shift and the physician should be notified immediately each time. She stated residuals before tube feeding and water boluses were documented on the intake and output sheets on the TAR, and it was possible some nursing staff would document in the nurses notes, but it should always be documented. At 4:21 p.m., LPN #1 confirmed a resident should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/21 at 4:27 p.m., the DON was asked who sets up appointments and arranges the transportation for resident doctor appointments or referrals. She stated social services took care of all of that. She was asked when the GI specialist referral was ordered for the resident. She stated on 03/13/21. She was asked when the resident had seen the GI specialist. She stated the resident never saw the GI specialist because it looked like social services was trying to follow up to schedule the appointment but didn't. At 4:49 p.m., the SSD was asked if the resident had ever saw the GI specialist for the referral appointment ordered on 03/13/21. She stated, No. At 5:00 p.m., the DON was asked what residents required assessments and documented intake and output. The DON stated they should assess intake and output for residents with a PEG tube and residents that have a diet order for nothing by mouth. She was asked if a resident with a bolus feeding and peg tube should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked if staff had documented intake and output for resident #80. She stated, No. The DON was asked how staff would know if the resident received too much fluid, not enough fluid, if intake, output, and residual wasn't being monitored. She stated if the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At 5:13 p.m., the DON was asked what the standard order for a resident with a tube feeding or water bolus was. The DON stated they checked placement, flushed, assessed the amount of residual, complete the bolus, and document intake and output. The DON was asked if the nursing staff should assess and document the residual amount from the resident's PEG tube before every bolus. The DON stated, They are supposed to, but it is not documented on this resident. The DON was asked how nursing staff would know to give a tube feeding or water bolus if they were not assessing and documenting residual. The DON stated, They wouldn't. She was asked if the resident's ordered tube feeding boluses were administered on the morning of 04/21/21 at 1:00 a.m. and 5:00 a.m. The DON stated there was no documentation on the MAR/TAR, so they knew the intervention wasn't done. The DON was asked if the residual amounts of fluid from the resident's PEG tube was assessed and documented. She stated, There are no circle of initials in a square or documentation on the back of the TAR or MAR, therefore it wasn't done. The DON was asked if the 200 milliliters of water bolus ordered four times a day was provided in the morning of 04/21/21 before the resident was sent to the hospital. The DON stated, Yes, it is documented it was given. She stated she would have checked residual and called the doctor if the amount of residual assessed was high. She then confirmed that was not completed for the resident prior to receiving the water bolus. At 5:33 p.m., the DON was asked if residual amounts and daily intake and output should have been measured and documented for the resident from 02/17/21 through 04/21/21. The DON stated, Yes. She was asked if it was documented. The DON stated, No. The DON was asked if the failure to assess and document residual amounts before every PEG tube bolus and not assessing/documenting daily intake and output amounts on a resident with a PEG tube could result in adverse outcomes to the resident. She stated, Yes. On 05/04/21 at 3:46 p.m., NP #1 was asked how she communicated orders to the nursing staff. She stated she either wrote an order or gave a verbal order to the nurse at the facility to enter into the computer. She was asked who she provided the orders dated 03/08/21 for resident #80 and if she had written them. She stated she was familiar with resident #80. She stated if there were orders mentioned in her progress notes, she had either written or given the orders to the nurse verbally. She stated she did not document orders in her progress notes unless she had written them or given the nurse a verbal order to enter the orders into the computer. At 4:05 p.m., the DON was asked how they ensured the physician and nurse practitioner visits and orders were completed and in the clinical record as required. She stated she thought medical records tracked that. She stated she did not know. The DON was asked if there were any orders from the nurse practitioner's visit dated 03/08/21 for resident #80. The DON stated, I think the upload was yesterday and all of NP #1 notes from that visit, were mixed up at the physician's office and not signed by her electronically. The DON was asked what date the nurse practitioner visit for resident #80, dated 03/08/21,was entered into the resident's clinical record. The DON stated on 05/03/21 at 8:19 p.m. The DON was asked what orders were documented on the nurse practitioner visit dated 03/08/21. The DON stated the orders were to discontinue the 1:00 a.m. and 5:00 a.m. tube feeding boluses. She was asked if she could explain the rationale for the order on the NP #1 visit. She stated the order to discontinue the 1:00 a.m. and 5:00 a.m. tube feeding boluses was related to the resident having vomiting reported in the mornings. The DON was asked if nursing staff continued to administer the tube feeding bolus to resident #80 at 1:00 a.m. and 5:00 a.m. from 03/08/21 through 04/21/21. The DON stated, Yes. The DON was asked why the resident was sent to the hospital on 04/21/21. The DON stated the nurse's note the morning the resident was sent to the hospital stated his oxygen saturation tanked and he had orange colored emesis, nausea and vomiting.

Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision, implement appropriate interventions, and provide assistance devices to prevent accidents and/or falls with injury for three (#1, #4 and #2) of three residents reviewed for accidents. Resident #1 experienced a fall which resulted in [MEDICAL CONDITION] and hospitalization . Resident #4 experienced a fall which resulted in nasal fracture and hospitalization . In a separate incident the resident was found outside the facility, had a fall with injuries, and was treated in the emergency room . Findings: A facility policy, Accident & Incident Documentation & Investigation, documented accidents and incidents would be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents. A facility policy on Fall Prevention was requested but not provided. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident note, dated [DATE] at 3:07 a.m., documented the resident was found sitting on the floor and leaning against the bed. The note documented the resident was unable to state what had happened but was found to be incontinent of bowel and bladder. The note documented no obvious injury and the resident would be placed on more frequent checks as an intervention. An incident note, dated [DATE] at 12:15 p.m., documented the resident was found sitting on the floor and leaning against the bed. The note documented the resident stated, I was trying to clean myself up and the resident was found to be incontinent of bowel and bladder. The note documented no obvious injury and did not document interventions to prevent future falls. An incident note, dated [DATE] at 5:08 a.m., documented the resident was found lying on the floor by the bedside. The note documented the resident was incontinent of bowel and found to have a finger-tip abrasion to the right knee. The note documented the resident could not state how he fell and a fall mat was placed as a current intervention. A care plan, updated [DATE], documented the resident was at risk for falls and had experienced falls on ,[DATE], ,[DATE], and [DATE]. Interventions documented on the care plan included to toilet the resident frequently, remind the resident to use the call light, and to place a fall mat by the bedside. An admission assessment, dated [DATE], documented the resident had short-term and long-term memory problems. The assessment documented the resident required extensive assistance with most activities of daily living and ambulated per wheelchair. A progress note, dated [DATE] at 2:03 p.m., documented a provider visit with the resident sitting in a chair without complaints of pain or discomfort. A social services note, dated [DATE] at 11:00 a.m., documented a care plan meeting was held on [DATE]. The note documented PT had reported the resident walked 15 to 20 feet, required minimal assistance for transfers, and maximum assistance with toileting transfers. Goals included continuing to walk long distances with a walker. A late entry progress note, dated [DATE] at 11:05 a.m., documented the resident was transferred from a chair in his room back to bed and started to scream and complained of pain. The resident couldn't say exactly where the pain was and was medicated with Tylenol. The note documented the resident was found to be resting with eyes closed at end of shift. An additional note, with the same date and time, documented it was not unusual for the resident to be resistant to care and would usually calm down. The note documented the fact that the resident screamed or yelled while receiving care was not unusual for him. A progress note, dated [DATE] at 11:53 a.m., documented the resident was complaining of pain and screamed each time he was moved. The physician was notified and orders received for right femur, hip, and knee x-ray. An order was also received for a stronger pain medication, [MEDICATION NAME] ,[DATE] mg every 6 hours PRN. An additional progress note, dated [DATE] at 12:08 p.m., documented the resident was screaming out in pain each and every time he was touched. The note documented there was obvious swelling observed to the right knee and a bruise on the right hip. A nurse note, dated [DATE] at 2:24 p.m., documented x-ray results showed an impacted fracture with slight medial angulation of distal fragment and right femur fracture. The resident was transferred to a local hospital for treatment. An operative report, dated [DATE], documented a procedure of intramedullary nailing of the right femur with a postoperative [DIAGNOSES REDACTED]. An MRI of the brain, dated [DATE], documented multifocal areas of acute and subacute infarct within the left PCA territory. A hospital discharge summary, dated [DATE], documented a discharge [DIAGNOSES REDACTED]. The summary documented the resident was found to have acute left PCA stroke. The discharge summary documented the resident was placed on palliative care and expired on [DATE] in the hospital. On [DATE] at 2:20 p.m., LPN #1 reported the resident would yell out at times when he wanted something but the LPN wasn't sure if he would use the call light. The LPN reported the resident enjoyed sitting up in the chair, watching westerns, and would participate in PT. The LPN was not aware of any falls or incidents after the fall on [DATE]. On [DATE] at 2:42 p.m., LPN #2 reported PT had worked with the resident, even during the time the resident was quarantined following his initial admission. The LPN reported every morning staff would assist the resident to a sturdy chair where the resident preferred to be. The LPN reported staff would give the resident the call light but they did not depend on the resident to use it. The LPN reported he thought the fall mat had been placed after the resident's 2nd fall when they realized he was not going to use his call light. The LPN stated the resident was very different on [DATE] from the previous day, screaming with unbearable pain, and the doctor was called for stronger pain medication and x-rays were ordered. On [DATE] at 3:30 p.m., the DON stated to remind the resident to use the call light was not an appropriate intervention for this resident and a fall mat was placed because they were afraid the resident was going to hurt himself. The DON reported there were additional interventions they could have implemented to prevent falls. The DON reported she was wanting to start root cause analysis training for staff and IDT meetings had just been implemented a few days previous. On [DATE] at 3:50 p.m., the ADM reported she was made aware of the [DATE] fall the following day. The ADM stated on [DATE], PT had given her a note that the resident was complaining of pain and they were going to allow the resident to rest that day. The ADM reported after the resident experienced excruciating pain and x-rays were obtained on [DATE], the unit manager and staffing coordinator called all staff who had worked with the resident from ,[DATE] - ,[DATE], including nightshift, to determine if anyone had witnessed an accident/incident involving the resident. The ADM stated she then watched videos to see if any kind of incident could be identified. The ADM reported staff who worked the evening shift and night shift of [DATE] were interviewed and reported no accidents and/or incidents had occurred. The ADM reported her investigation did not reveal any accident after the fall on [DATE] which would explain the resident's sudden pain on [DATE]. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report, dated [DATE], documented the resident was observed in prone position on the floor of her room, with blood coming from lacerations to the nose and above the right eye. The IR documented the resident was noted without non-skid socks. The IR documented the resident was sent to the ER for treatment. A facility admission note, dated [DATE], noted bruising over the resident's entire face with a small open area to the right elbow. The note documented the bed was placed at the lowest position and a fall mat placed next to the bed. An incident report, dated [DATE] at 6:17 a.m., documented the resident was observed sitting on her buttocks on the floor in her room with feet toward her TV. The resident reported she was going to the bathroom and no injury was noted. Interventions to prevent future falls included non-slip socks to be placed on feet, more frequent rounding, and call light placed within reach with instructions given. A nurse's note, dated [DATE] at 6:23 a.m., documented the resident did not have a walker in her room and the nurse returned her walker to her room. A nurse's note, dated [DATE], documented the resident was evaluated by the facility nurse practitioner due to being readmitted to the facility from the hospital on [DATE] after a fall that resulted in a fractured nose, as well as being found on the floor in her room on [DATE]. The note documented to make sure the resident had a walker in her room and encouraged the resident to ask for assistance when needed. A care plan, dated [DATE], documented a risk for falls related to the resident's cognition and being unaware of safety needs, deconditioning, gait/balance problems, history of falls, and recent illness with increased weakness. Interventions included to anticipate and meet the resident's needs, encourage the resident to call for assistance, assist resident to toilet between meals and before bed as resident allowed, encouraged resident to wear appropriate footwear, ensure resident's personal items were within reach, and to maintain the bed in lowest position. An incident report, dated [DATE], documented at approximately 11:04 p.m., the resident was found by a staff member outside the door of the nurses station on hall 600. The resident was found to be bleeding from her head and left arm and sitting on her walker. The report documented the resident was unable to explain how she got outside. An assessment noted an open area on the left eyebrow with bleeding and skin tear on the left arm with bleeding. The resident complained of pain to the left arm and eyebrow and was sent to the ER for evaluation. An intervention was to change the door codes on unit exit doors for safety. An ER report, dated [DATE], documented laceration repair to left eyebrow and negative CT of the head. An annual assessment, dated [DATE], documented the resident was severely impaired with cognition. The assessment documented the resident required moderate to extensive assistance with ADL's and a walker or wheelchair to ambulate. On [DATE] at 10:45 a.m., the DON reported no documented investigation had been conducted for the incident on [DATE]. The DON had looked into the incident and it was reported the door the resident used to exit the facility had been propped open by staff and left open. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated [DATE], documented the resident was cognitively intact. The assessment documented the resident required supervision and setup help with transfers. An incident report, dated [DATE], documented a fall with hematoma to the upper left forehead. The report documented the resident was found on the floor lying on her left side near her vanity with her wheelchair in front of her. The report documented the resident stated she fell out of her wheelchair and hit her head. A care plan, dated [DATE], documented the resident had a risk for falls with interventions which included an anti-roll back bar to be placed on her wheelchair. The care plan also documented an intervention of non-skid footwear for this resident with bilateral amputations. On [DATE] at 1:28 p.m., the resident was observed outside of the facility smoking in her wheelchair. The wheelchair was observed without the anti-roll back bar in place. On [DATE] at 3:00 p.m., the DON reported she was not aware of the resident having an anti-roll back bar on her wheelchair but would check it out. The DON stated a fall intervention of non-skid footwear for this resident was inappropriate. On [DATE] at 09:12 a.m., the resident was observed in bed with her wheelchair at the bedside. The wheelchair was observed to have an anti-roll back bar in place. On [DATE] at 12:15 p.m., the DON reported when she inspected the resident's wheelchair on [DATE], it did not have an anti-roll back bar on it so she had a staff member get another wheelchair and put the anti-roll back bar on it. The DON reported she did not know if having the anti-roll back bar on the wheelchair would have prevented the fall on [DATE] but it should have been in place.

Based on observation, policy review, and interview, it was determined the facility failed to ensure its resources were administered effectively and efficiently in terms of the presence of an in-house [MEDICAL TREATMENT] unit and COVID-19 preparation. This failure placed the 154 residents in the facility at risk of serious harm, injury, or death. The facility also failed to develop a facility closure plan, which constituted the widespread potential for harm to residents should the facility close. On 11/10/20 at 5:30 PM the Administrator was informed that an immediate jeopardy existed at F835 for failure to develop and/or implement policies consistent with Centers for Disease Control (CDC) guidelines for COVID-19 preparation and infection control for the provision of [MEDICAL TREATMENT]; and Centers for Medicare and Medicaid Services (CMS) regulatory requirements as they pertain to emergency staffing and [MEDICAL TREATMENT]. The immediate jeopardy was determined to exist beginning on 11/01/20, when Resident (R) 1 was readmitted from the hospital and the facility began providing [MEDICAL TREATMENT] services in room [ROOM NUMBER], which was not in the facility's [MEDICAL TREATMENT] center, through 11/12/20 when a plan for removal of the immediate jeopardy was accepted. The plan for removal for the immediate jeopardy was validated on 11/12/20 through observation, interview, and record reviews. The Administrator was informed of the removal of the immediate jeopardy on 11/12/20 at 4:30 PM. Findings include: 1. On 11/09/20 at 10:30 AM, an interview with the facility's Infection Prevention (IP) Nurse revealed the facility had an in-house [MEDICAL TREATMENT] unit, with services provided via contract with a local [MEDICAL TREATMENT] provider for eight [MEDICAL TREATMENT] residents. At 11:30 AM, a request was made to the Administrator and Regional Director of Operations (RDO) for facility policies pertaining to coordination and communication between the facility and [MEDICAL TREATMENT] unit as they pertained to environmental services, emergency response, and provision of clinically appropriate space within the facility to provide [MEDICAL TREATMENT]. At 3:50 PM, the RDO emailed the surveyor a copy of all the policies and procedures from the [MEDICAL TREATMENT] provider, which did not address the information requested as to how the [MEDICAL TREATMENT] center and facility coordinated on a day-to-day basis. On 11/10/20 at 12:22 PM an interview with the facility Administrator and Director of Nursing (DON) revealed the facility had no specific policies as it pertained to the [MEDICAL TREATMENT] unit or provision of space. The DON stated, I guess we'll just have to develop a policy that says we defer to [MEDICAL TREATMENT] policies. 2. On 11/09/20 at 9:45 AM, the Administrator and RDO were asked to provide the facility's policies and procedures for COVID-19 preparedness, recognition, and response. At 12:00 PM, the Administrator provided several brief documents pertaining to COVID: An undated, single sheet entitled, Process for Persons Under Investigation (PUI) and Positive +COVID. Review of the sheet revealed if a resident was considered a PUI, an N-95 respirator mask should be used for both residents and staff, as well as other PPE (Personal Protective Equipment), although no specific PPE was identified. The sheet further documented that any resident tested positive for COVID-19 was to be sent to the hospital as the facility could not care for them. 3. During the survey, deficient practices were identified as immediate jeopardies at F689 for failure to provide access to an emergency call system or ensure staff were informed about code status for a resident receiving home [MEDICAL TREATMENT] services in room [ROOM NUMBER]; F698 for failure to coordinate and communicate care environment and needs for a residents receiving [MEDICAL TREATMENT] services in the facility; and F880 for failure to provide a clean and sanitary environment for a resident receiving [MEDICAL TREATMENT] services. These failures were found to create the risk for serious harm, injury, or death, and were cited at immediate jeopardy. An interview with the Administrator and RDO on 11/09/20 at 5:45 PM revealed the facility had turned over almost all of its key positions in the past 1-6 weeks, including the IP Nurse (6 weeks ago), the Administrator and DON (4 weeks ago), the Medical Director (2 weeks ago) and the Director of Housekeeping (1 week ago). Additionally, the Administrator and RDO reported the nurse in the [MEDICAL TREATMENT] unit had only been assigned to the facility for approximately three weeks, and her orientation had been cut short because her predecessor became ill with COVID-19. An interview with the Medical Director on 11/10/20 at 10:15 AM revealed he had not been with the facility long enough to have reviewed all the policies and systems yet but understood that to be part of his role and planned on doing so as soon as possible. The Medical Director stated his expectation was the facility would develop and operationalize policies and procedures consistent with current standards of practice and regulatory requirements, particularly with COVID-19 and an onsite [MEDICAL TREATMENT] unit. The Medical Director stated he and his practice were aware the facility had issues prior to taking over and expected they would have to work with the facility to correct some of their practices. An interview with the Administrator on 11/10/20 at 12:22 PM confirmed she was unaware of any additional policies the facility had regarding COVID, [MEDICAL TREATMENT], or emergency staffing. The Administrator stated both she and the DON were interim, with the DON leaving in December and herself leaving very soon. The Administrator stated in the short time she had been in the facility she was aware there were problems but had not had a chance to fully uncover them yet. The Administrator stated she had presumed the regional and corporate managers within the organization had developed and implemented all these policies, and that the facility had undergone previous infection control surveys with only minor deficiencies cited, so she had not recognized the urgency of the situation. An interview with the Administrator on 11/10/20 at 4:53 PM revealed the facility had no evidence either the current or past Medical Directors' had approved or signed off on the facility's COVID policy. 4. On 11/11/20, when information was requested to complete the extended survey as required by immediate jeopardy findings at F689 (Accident Hazards and Supervision) and F698 ([MEDICAL TREATMENT]), the facility provided an undated, unsigned, untitled document which stated the facility did not have a Facility Closure Plan.

Based on observation, interview, policy review, and record review, it was determined the facility failed to ensure the provision of [MEDICAL TREATMENT] services in a manner consistent with professional standards of practice as it pertains to infection control of the environment for one Resident (R) 1 diagnosed with [REDACTED]. R1 was one of eight residents receiving [MEDICAL TREATMENT] services in the facility. The failure to provide [MEDICAL TREATMENT] in a clean and sanitary environment placed the resident at risk for serious infection or death. On 11/10/20 at 3:12 PM, the facility Administrator was informed that an immediate jeopardy at F880 was identified for failure to provide [MEDICAL TREATMENT] services to R1 in a clean and sanitary environment. The immediate jeopardy was determined to exist beginning on 11/01/20, when Resident (R)1 was readmitted from the hospital and the facility began providing [MEDICAL TREATMENT] services in room [ROOM NUMBER], which was not in the facility's [MEDICAL TREATMENT] center, through 11/12/20 when a plan for the removal of the immediate jeopardy was accepted. The plan for removal for the immediate jeopardy at F880 was validated on 11/12/20 through observations, interviews, and record reviews. The Administrator was notified the immediate jeopardy was removed on 11/12/20 at 4:30 PM. Findings include: Review of the 06/18/19 [MEDICAL TREATMENT] Services Agreement between the facility and the [MEDICAL TREATMENT] center providing home [MEDICAL TREATMENT] services revealed, . Facility has agreed to make available a secure designated area for dialyzing . and all utilities necessary to operate [MEDICAL TREATMENT] services, including water and electricity. Facility is responsible for providing a safe environment for the [MEDICAL TREATMENT] treatments . facility staff must be prepared to appropriately address and respond to complications and provide emergency interventions as needed . Facility shall provide housekeeping services including but not limited to medical waste handling and cleaning and waxing floors in a manner consistent with good medical practice . Review of R1's Census tab and [DIAGNOSES REDACTED]. Further review of the Census tab revealed R1 was discharged on [DATE], re-admitted on [DATE], discharged again on 10/29/20, and re-admitted on [DATE]. On 11/09/20 at 10:20 AM, an interview with the facility's Infection Preventionist (IP Nurse) revealed the facility had an in-house [MEDICAL TREATMENT] unit which provided [MEDICAL TREATMENT] treatments to eight of their [MEDICAL TREATMENT]-dependent residents, including R1, who was diagnosed with [REDACTED]. Observation of the facility layout, accompanied by the IP nurse, revealed room [ROOM NUMBER] on a hallway where no residents resided, between the facility's designated [MEDICAL TREATMENT] unit and the COVID-19 unit. The entrance to the 400 hall was approximately 100 feet from the [MEDICAL TREATMENT] unit and around a corner. The entrance to the 400 hall, where room [ROOM NUMBER] was located, consisted of a plywood wall with a plexiglass window, and two solid white doors, which were closed. The floor in these hallways was carpeted. The carpet between the [MEDICAL TREATMENT] unit and the entrance doors to the 400hall showed multiple stained areas, frayed edges, and worn areas. In the 400 unit itself there was an orange traffic cone on the floor where several large chunks of carpeting were missing. The entrance to room [ROOM NUMBER] was approximately 30 feet inside the plywood wall. The frayed edges surrounding the missing areas of carpeting was covered in an oily, dusty gray substance. Further observation of the 400 hall revealed rooms in various stages of disarray, with partially painted walls and construction materials and tools in many rooms. Though the rooms were unoccupied, four call lights were on. The IP Nurse stated the hallway was technically under construction but the facility had decided to use room [ROOM NUMBER] to provide [MEDICAL TREATMENT] services to R1 due to his COVID status. Continued observation/interview with the IP Nurse revealed the door to the room was closed. There was a stop sign on the door and a Personal Protective Equipment (PPE) caddy in the hallway outside the room. The top of the PPE caddy contained a laminated sheet with instructions for the order in which to don and doff PPE. There was no signage that this was an isolation room, or any specific precautions that should be taken. The IP Nurse stated it was her understanding that room [ROOM NUMBER] contained a dedicated [MEDICAL TREATMENT] machine for R1, but that his dedicated [MEDICAL TREATMENT] chair was stored in his room on the COVID unit and used for transport to this location for his [MEDICAL TREATMENT] treatments. When the IP Nurse opened the door to room [ROOM NUMBER], there was a [MEDICAL TREATMENT] chair inside but no [MEDICAL TREATMENT] machine. There was a cardboard container just inside the doorway with a red plastic biohazard bag inside. The container was half-filled with used PPE. There was a small plastic trashcan next to the cardboard container with empty soda cans and other empty food containers. There were small white bits of plastic and paper debris on the floor. The IP Nurse said the room should have had a [MEDICAL TREATMENT] machine but not the chair, and the room was not clean. An interview with the [MEDICAL TREATMENT] unit Registered Nurse (RN)4 on 11/09/20 at 11:21 AM revealed she had only worked at the facility's unit for approximately three weeks. RN4 stated she was supposed to be trained by the previous [MEDICAL TREATMENT] nurse, but that person had become ill with COVID so was unable to train her. RN4 stated as far as she knew, there was no policy for the provision of [MEDICAL TREATMENT] services to a COVID positive resident in the facility, so she tried to follow CDC guidelines. RN4 stated the facility had provided room [ROOM NUMBER] for R1's [MEDICAL TREATMENT] treatments so he could be dialyzed alone, with no other residents using the same [MEDICAL TREATMENT] machine or chair. RN4 stated R1's dedicated [MEDICAL TREATMENT] machine was kept in room [ROOM NUMBER], and his chair was kept in his room on the COVID unit for transport to and from [MEDICAL TREATMENT] treatments. RN4 stated the facility provided a dedicated blood pressure cuff for R1, but [MEDICAL TREATMENT] staff were required to use the same stethoscopes and thermometers for R1 as for the other [MEDICAL TREATMENT] residents and were cleaned by wiping them with a 1:100 bleach solution. An observation of room [ROOM NUMBER] and continued interview with RN4 on 11/09/20 at 11:40 AM revealed R1 had last dialyzed on 11/06/20 and was scheduled for [MEDICAL TREATMENT] at 1:00 PM today, 11/09/20. Prior to opening the door to room [ROOM NUMBER], RN4 stated the room should be clean and ready to go, and should have his [MEDICAL TREATMENT] machine and not much else inside. When RN4 opened the door, the [MEDICAL TREATMENT] chair, cardboard container with used PPE and trash container as in the previous observation with the IP Nurse, as well as the debris on the floor. RN4 stated the room did not appear clean, but it was the facility's responsibility to clean it. RN4 stated she would have to find out what happened to R1's [MEDICAL TREATMENT] machine. The surveyor then accompanied RN4 to the dedicated [MEDICAL TREATMENT] unit and asked Patient Care Technician (PCT) 5 where R1's [MEDICAL TREATMENT] machine was. PCT5 pointed to an idle machine in the unit and stated, It's right there. There's no water supply in (room [ROOM NUMBER]) so I have to bring the machine back here and hook it up to this water supply to fill it between treatments. RN4 stated she was not aware of that, but since she had only worked at the facility for a short time with little to no orientation she was not surprised. An observation of room [ROOM NUMBER] on 11/09/20 at 12:35 PM revealed the trash, used PPE, and debris on the floor were still present. There was no hand sanitizer in the room, but a sink with a soap dispenser. The counter next to the sink contained open packages of 2X2 and 4X4 gauze pads, and an open roll of cloth tape. An observation of room [ROOM NUMBER] on 11/09/20 at 1:15 PM, accompanied by the Administrator, revealed the same items in place. The Administrator stated, It's obvious this room has not been cleaned at all, and that she would ask a housekeeper to come and clean the room before R1's [MEDICAL TREATMENT] treatment began. The Administrator was not aware there was a problem with the water supply in the room that would prevent the [MEDICAL TREATMENT] machine from being stored in that location. An observation on 11/09/20 at 1:30 PM revealed PCT5 moving the [MEDICAL TREATMENT] machine from the [MEDICAL TREATMENT] unit to room [ROOM NUMBER]. As PCT5 was pushing the machine through the 400 hall he had to maneuver the machine around the traffic cone and holes in the carpet. Once in room [ROOM NUMBER], PCT5 moved the [MEDICAL TREATMENT] chair to allow access to the left side, which revealed more scraps of debris on the floor under the chair. PCT5 he had wiped the chair down after R1's last [MEDICAL TREATMENT] treatment three days prior, but otherwise the room did not appear clean. PCT5 stated he was not sure who was supposed to clean the room. At that time, [MEDICAL TREATMENT] Transport (DT) person 6 arrived at the room with R1, and PCT5 took the resident into the room to initiate treatment. Treatment was initiated without the room being cleaned. An interview with the IP nurse on 11/09/20 at 4:30 PM revealed she agreed the carpets in the hallways were soiled and stained and presented an infection control concern. The IP nurse stated it was unacceptable for a [MEDICAL TREATMENT] machine to be transported to and from the [MEDICAL TREATMENT] unit for treatment of [REDACTED]. An interview with RN4 on 11/09/20 at 11:30 AM revealed she was fairly certain the same [MEDICAL TREATMENT] machine was used each time for R1, because the other machines in the unit were all connected to the water supply, but since the machines were not numbered and she had worked in the facility for such a short time, she could not be certain of that. An interview with the Medical Director on 11/10/20 at 10:15 AM revealed he was unaware the facility was using a room in a non-resident care area to provide [MEDICAL TREATMENT] treatment for [REDACTED]. The Medical Director stated it was not acceptable to begin an invasive procedure, such as [MEDICAL TREATMENT], in a room that had not been thoroughly cleaned. The Medical Director stated he had only been at the facility approximately two weeks and had not had a chance to review policies as it pertained to infection control, COVID-19, or [MEDICAL TREATMENT]. The Medical Director stated the facility had gone through many leadership changes recently, including the addition of his practice, which he considered to be positive changes. The Medical Director stated he was aware the facility had some challenges with cleanliness and infection control and would work to help the facility to correct them. On 11/09/20 at 12:00 PM and 4:00 PM requests were made of the Administrator to provide policies for cleaning the [MEDICAL TREATMENT] unit, utilizing an under construction room for the provision of [MEDICAL TREATMENT] for a COVID positive resident, or water supply for that location. The Administrator did not supply those policies.

Based on observation, interview, policy review, and record review, it was determined the facility failed to ensure the provision of [MEDICAL TREATMENT] services in a manner consistent with professional standards of practice as it pertains to infection control and emergency response for one Resident (R) 1 diagnosed with [REDACTED]. These failed practices placed the resident at risk for infection and could likely cause severe injury or death to the resident had he experienced complications during [MEDICAL TREATMENT]. On 11/10/20 at 3:12 PM the Administrator was informed that an immediate jeopardy existed at F698 for failure to develop/implement policies and procedures for coordination and communication with an in-house [MEDICAL TREATMENT] center; failure to provide a clean and sanitary location for the provision of [MEDICAL TREATMENT], failure to ensure staff were aware of a resident's code status, and failure to ensure an emergency call system was operational in room [ROOM NUMBER], where [MEDICAL TREATMENT] services were being provided. The immediate jeopardy was determined to exist beginning 11/01/20, when Resident (R) 1 was readmitted from the hospital and the facility began providing [MEDICAL TREATMENT] services in room [ROOM NUMBER], which was not in the facility's [MEDICAL TREATMENT] center, through 11/12/20 when a plan for removal of the immediate jeopardy was accepted. The plan for removal for the immediate jeopardy was validated on 11/12/20 through observation, interview, and record reviews. The Administrator was informed of the removal of the immediate jeopardy on 11/12/20 at 4:30 PM. Findings include: Review of the 06/18/19 [MEDICAL TREATMENT] Services Agreement between the facility and the [MEDICAL TREATMENT] center providing home [MEDICAL TREATMENT] services revealed, . Facility has agreed to make available a secure designated area for dialyzing . and all utilities necessary to operate [MEDICAL TREATMENT] services, including water and electricity. Facility is responsible for providing a safe environment for the [MEDICAL TREATMENT] treatments . facility staff must be prepared to appropriately address and respond to complications and provide emergency interventions as needed . Facility shall provide housekeeping services including but not limited to medical waste handling and cleaning and waxing floors in a manner consistent with good medical practice . 1. Infection Control On 11/09/20 at 10:20 AM an interview with the facility's Infection Preventionist (IP Nurse) revealed the facility had an in-house [MEDICAL TREATMENT] unit which provided [MEDICAL TREATMENT] treatments to eight of their [MEDICAL TREATMENT]-dependent residents, including R1, who was diagnosed with [REDACTED]. Observation of the facility layout, accompanied by the IP nurse, revealed room [ROOM NUMBER] on a hallway where no residents resided, between the facility's designated [MEDICAL TREATMENT] unit and the COVID-19 unit. The entrance to the 400 hall was approximately 100 feet from the [MEDICAL TREATMENT] unit and around a corner. The entrance to the 400 hall, where room [ROOM NUMBER] was located, consisted of a plywood wall with a plexiglass window, and two solid white doors, which were closed. The floor in these hallways was carpeted. The carpet between the [MEDICAL TREATMENT] unit and the entrance doors to the 400 hall showed multiple stained areas, frayed edges, and worn areas. In the 400 unit itself there was an orange traffic cone on the floor where several large chunks of carpeting were missing. The frayed edges surrounding the missing areas of carpeting was covered in an oily, dusty gray substance. Further observation of the 400 hall revealed rooms in various stages of disarray, with partially painted walls and construction materials and tools in the rooms except for room [ROOM NUMBER]. Though the rooms were unoccupied, four call lights were on. The IP Nurse stated the hallway was technically under construction but the facility had decided to use room [ROOM NUMBER] to provide [MEDICAL TREATMENT] services to R1 due to his COVID status. Continued observation/interview with the IP Nurse revealed the door to room [ROOM NUMBER] was closed. There was a stop sign on the door and a Personal Protective Equipment (PPE) caddy in the hallway outside the room. The top of the PPE caddy contained a laminated sheet with instructions for the order in which to don and doff PPE. There was no signage that this was an isolation room, or any specific precautions that should be taken. The IP Nurse stated it was her understanding that room [ROOM NUMBER] contained a dedicated [MEDICAL TREATMENT] machine for R1, but that his dedicated [MEDICAL TREATMENT] chair was stored in his room and used for transport to this location for his [MEDICAL TREATMENT] treatments. When the IP Nurse opened the door to room [ROOM NUMBER], there was a [MEDICAL TREATMENT] chair inside but no [MEDICAL TREATMENT] machine. There was a cardboard container just inside the doorway with a red plastic biohazard bag inside. The container was half-filled with used PPE. There was a small plastic trashcan next to the cardboard container with empty soda cans and other empty food containers. There were small white bits of plastic and paper debris on the floor. The IP Nurse said the room should have had a [MEDICAL TREATMENT] machine but not the chair, and the room was not clean. An interview with the [MEDICAL TREATMENT] unit Registered Nurse (RN) 4 on 11/09/20 at 11:21 AM revealed she had only worked at the facility's [MEDICAL TREATMENT] unit for approximately three weeks. RN4 stated she was supposed to be trained by the previous [MEDICAL TREATMENT] nurse, but that person had become ill with COVID so was unable to train her. RN4 stated as far as she knew, there was no policy for the provision of [MEDICAL TREATMENT] services to a COVID positive resident in the facility, so she tried to follow CDC guidelines. RN4 stated the facility had provided room [ROOM NUMBER] for R1's [MEDICAL TREATMENT] treatments so he could be dialyzed alone, with no other residents using the same [MEDICAL TREATMENT] machine or chair. RN4 stated R1's dedicated [MEDICAL TREATMENT] machine was kept in room [ROOM NUMBER], and his chair was kept in his room for transport to and from [MEDICAL TREATMENT] treatments. RN4 stated the facility provided a dedicated blood pressure cuff for R1, but [MEDICAL TREATMENT] staff were required to use the same stethoscopes and thermometers for R1 as for the other [MEDICAL TREATMENT] residents and were cleaned by wiping them with a 1:100 bleach solution. An observation of room [ROOM NUMBER] and continued interview with RN4 on 11/09/20 at 11:40 AM revealed R1 had last dialyzed on 11/06/20 and was scheduled for [MEDICAL TREATMENT] at 1:00 PM today, 11/09/20. Prior to opening the door to room [ROOM NUMBER], RN4 stated the room should be clean and ready to go, and should have his [MEDICAL TREATMENT] machine and not much else inside. When RN4 opened the door, the [MEDICAL TREATMENT] chair, cardboard container with used PPE and trash container as in the previous observation with the IP Nurse, as well as the debris on the floor. RN4 stated the room did not appear clean, but it was the facility's responsibility to clean it. RN4 stated she would have to find out what happened to R1's [MEDICAL TREATMENT] machine. The surveyor then accompanied RN4 to the dedicated [MEDICAL TREATMENT] unit and asked Patient Care Technician (PCT) 5 where R1's [MEDICAL TREATMENT] machine was. PCT5 pointed to an idle machine in the unit and stated, It's right there. There's no water supply in (room [ROOM NUMBER]) so I have to bring the machine back here and hook it up to this water supply to fill it between treatments. RN4 stated she was not aware of that, but since she had only worked at the facility for a short time with little to no orientation she was not surprised. An observation of room [ROOM NUMBER] on 11/09/20 at 12:35 PM revealed the trash, used PPE, and debris on the floor were still present. There was no hand sanitizer in the room, but a sink with a soap dispenser. The counter next to the sink contained open packages of 2X2 and 4X4 gauze pads, and an open roll of cloth tape. An observation of room [ROOM NUMBER] on 11/09/20 at 1:15 PM, accompanied by the Administrator, revealed the same items in place. The Administrator stated, It's obvious this room has not been cleaned at all, and that she would ask a housekeeper to come and clean the room before R1's [MEDICAL TREATMENT] treatment began. The Administrator was not aware there was a problem with the water supply in the room that would prevent the [MEDICAL TREATMENT] machine from being stored in that location. An observation on 11/09/20 revealed PCT5 moving the [MEDICAL TREATMENT] machine from the [MEDICAL TREATMENT] unit to room [ROOM NUMBER]. As PCT5 was pushing the machine through the 400 hall he had to maneuver the machine around the traffic cone and holes in the carpet. Once in room [ROOM NUMBER], PCT5 moved the [MEDICAL TREATMENT] chair so as to allow access to the left side, which revealed more scraps of debris on the floor under the chair. PCT5 he had wiped the chair down after R1's last [MEDICAL TREATMENT] treatment three days prior, but otherwise the room did not appear clean. PCT5 stated he was not sure who was supposed to clean the room. At that time, [MEDICAL TREATMENT] Transport (DT) person 6 arrived at the room with R1, and PCT5 took the resident into the room to initiate treatment. Treatment was initiated without the room being cleaned. An interview with the IP nurse on 11/09/20 revealed she agreed the carpets in the hallways were soiled and stained and presented an infection control concern. The IP nurse stated it was unacceptable for a [MEDICAL TREATMENT] machine to be transported to and from the [MEDICAL TREATMENT] unit for treatment of [REDACTED]. The facility was asked, but did not provide, a policy on cleaning the [MEDICAL TREATMENT] unit, utilizing an under construction room for the provision of [MEDICAL TREATMENT] for a COVID positive resident, or water supply for that location. 2. Emergency Response: Review of R1's Face Sheet, located under the Profile tab, and physician's orders [REDACTED]. An observation on 11/09/20 with the Administrator present revealed R1 was receiving his [MEDICAL TREATMENT] treatment in room [ROOM NUMBER], with PCT5 present. When asked, PCT5 stated he was not sure if R1 was a full code or had opted for a Do Not Resuscitate (DNR) order. PCT5 stated he supervised the resident during his entire treatment but was not sure how he would alert the nurse if there was a medical emergency such as [MEDICAL CONDITION], blood pressure changes, or excessive bleeding. PCT5 stated there was no phone in the room and the call light was not working, So maybe I could just yell for help. PCT5 was not sure his calls for help would be heard, since he and R1 were on an unoccupied hallway behind closed doors. PCT5 stated he could leave the resident while he went to find help, but that meant the resident would be unattended in a medical emergency. PCT5 stated if he had his cell phone, he could call for help, so long as he had the appropriate phone numbers programmed in. Continued observation with the Administrator revealed upon leaving room [ROOM NUMBER] and walking approximately 30 feet to the doors leading from the 400 hall, R1's [MEDICAL TREATMENT] machine was audible throughout. Once outside the 400 hall after the doors were closed, the machine was no longer audible. The Administrator stated she felt PCT5's plan to call out for help in an emergency would be effective. A tour of the 400 hall with the Administrator and Regional Director of Operations (RDO) on 11/09/20 at 5:15 PM revealed PCT5 was with R1 in room [ROOM NUMBER] monitoring him after his [MEDICAL TREATMENT] treatment. Four call lights were on. The RDO stated the 400 hall had once been a transitional hall for residents suspected of COVID but was no longer required for that purpose. She further stated the call lights were activated because maintenance had removed the cords for use in other rooms in the facility. The Administrator added that at the present time, the activated call lights did not appear on any monitors at the nurse's stations throughout the facility, and there was no expectation staff would respond to them. The RDO stated the 400 hall was not considered a working hall because they were planning to paint, replace some flooring, and complete some other reconstruction and repairs in the area. She added that, in its present condition, there would have to be some repairs completed before they would consider housing residents there. The Administrator stated the call light system was offline in the area but could be restored quickly if the resident rooms needed to be used again. When asked, the Administrator stated if PCT5 activated the call light in room [ROOM NUMBER] due to an emergency while R1 was dialyzing, no one would likely know, and there was no expectation anyone would respond.

Based on observation, interview, and record review, it was determined the facility failed to ensure a COVID positive Resident (R) 1 receiving [MEDICAL TREATMENT] services in the facility had access to emergency assistance from staff should he experience complications, such as [MEDICAL CONDITION], blood pressure changes, or excessive bleeding, during his [MEDICAL TREATMENT] treatment, which was likely to result in serious injury, serious harm, serious impairment, or death. On 11/10/20 at 3:12 PM the Administrator was informed that an immediate jeopardy existed at F689 for failure to ensure staff were aware of a resident's code status, and failure to ensure an emergency call system was operational in room [ROOM NUMBER], where [MEDICAL TREATMENT] services were being provided. The immediate jeopardy was determined to exist beginning on 11/01/20, when Resident (R)1 was readmitted from the hospital and the facility began providing [MEDICAL TREATMENT] services in room [ROOM NUMBER], which was not in the facility's [MEDICAL TREATMENT] center, through 11/12/20 when a plan for removal of the immediate jeopardy was accepted. The plan for removal for the immediate jeopardy was validated on 11/12/20 through observation, interview, and record reviews. The Administrator was informed of the removal of the Immediate Jeopardy on 11/12/20 at 4:30 PM. Findings include: Review of the 06/18/19 [MEDICAL TREATMENT] Services Agreement between the facility and the [MEDICAL TREATMENT] center providing home [MEDICAL TREATMENT] services revealed, . Facility has agreed to make available a secure designated area for dialyzing . and all utilities necessary to operate [MEDICAL TREATMENT] services, including water and electricity. Facility is responsible for providing a safe environment for the [MEDICAL TREATMENT] treatments . facility staff must be prepared to appropriately address and respond to complications and provide emergency interventions as needed . Facility shall provide housekeeping services including but not limited to medical waste handling and cleaning and waxing floors in a manner consistent with good medical practice . Review of R1's Face Sheet, located under the Admission Record section of his Electronic Health Record (EHR) and physician's orders [REDACTED]. An observation on 11/09/20 with the Administrator present revealed R1 was receiving his [MEDICAL TREATMENT] treatment in room [ROOM NUMBER], with PCT5 present. Further observation revealed room [ROOM NUMBER] was not located in the facility's [MEDICAL TREATMENT] center and was on a hallway closed off from the rest of the facility by a plywood wall with closed double doors. When asked, PCT5 stated he was not sure if R1 was a full code or had opted for a Do Not Resuscitate (DNR) order. PCT5 stated he supervised the resident during his entire treatment but was not sure how he would alert the nurse if there was a medical emergency such as [MEDICAL CONDITION], blood pressure changes, or excessive bleeding. PCT5 stated there was no phone in the room and the call light was not working, so maybe I could just yell for help. PCT5 was not sure his calls for help would be heard, since he and R1 were on an unoccupied hallway behind closed doors. PCT5 stated he could leave the resident while he went to find help, but that meant the resident would be unattended in a medical emergency. PCT5 stated if he had his cell phone, he could call for help, so long as he had the appropriate phone numbers programmed in. Continued observation with the Administrator revealed upon leaving room [ROOM NUMBER] and walking approximately 30 feet to the doors leading from the 400 hall, R1's [MEDICAL TREATMENT] machine was audible throughout. Once outside the 400 hall after the doors were closed, the machine was no longer audible. The Administrator stated she felt PCT5's plan to call out for help in an emergency would be effective. A tour of the 400 hall with the Administrator and Regional Director of Operations (RDO) on 11/09/20 at 5:15 PM revealed PCT5 was with R1 in room [ROOM NUMBER] monitoring R1 after his [MEDICAL TREATMENT] treatment. Four call lights were on. The RDO stated the 400 hall had once been a transitional hall for residents suspected of COVID but was no longer required for that purpose. She further stated the call lights were activated because maintenance had removed the cords for use in other rooms in the facility. The Administrator added that at the present time, the activated call lights did not appear on any monitors at the nurse's stations throughout the facility, and there was no expectation staff would respond to them. The RDO stated the 400 hall was not considered a working hall because they were planning to paint, replace some flooring, and complete some other reconstruction and repairs in the area. She added that, in its present condition, there would have to be some repairs completed before they would consider housing residents there. The Administrator stated the call light system was offline in the area but could be restored quickly if the resident rooms needed to be used again. When asked, the Administrator stated if PCT5 activated the call light in room [ROOM NUMBER] due to an emergency while R1 was dialyzing, no one would likely know, and there was no expectation anyone would respond. The facility was asked for, but did not provide, policies pertaining to the provision of [MEDICAL TREATMENT] services to a COVID positive resident, or utilization of an offline room in an area with no functioning call system for the provision of [MEDICAL TREATMENT] services. On 11/10/20 at 10:15 AM, an interview with the Medical Director revealed it was unacceptable that staff caring for R1 during his [MEDICAL TREATMENT] treatment did not know his code status, and that the facility was providing [MEDICAL TREATMENT] services in an area with no functioning call system. The Medical Director stated, This is something that affects not only this person but could affect the next person requiring [MEDICAL TREATMENT] who is positive for COVID. We need to work to fix this immediately.

Based on record reviews and interviews, it was determined the facility failed to ensure a resident who required the use of a sit to stand lift with the assistance of two staff members for transfers, received the necessary assistance for one (#8) of five sampled residents who were reviewed for necessary transfer assistance. The resident acquired an acute right distal femur fracture. The DON (director of nursing) identified 22 residents required the use of a sit to stand lift with two person assistance for resident transfers. Findings: Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 04/27/17, documented, .Focus .ADL (activities of daily living) Function: Self Care Deficit .requires assistance .to safely complete ADLs .at risk for further decline .R/T (related to) generalized weakness, impaired balance .Interventions .Transfers .require 2 person .use a sit to stand .with transfers .always use 2 persons with the lift . A care plan, dated 04/27/17, documented, .Focus .at risk for falls r/t gait/balance problems .Goal .will not sustain serious injury .Interventions .Use sit to stand for transfers . A care plan, dated 04/27/17, documented, .Focus .use a sit to stand .with transfers .at risk for injury or incident related to use of device .Interventions .ensure proper placement of BLE (bilateral lower extremity) when using the lift .prior to using the sit to stand ensure that I am able to properly bear weight and stand upright with bilateral feet properly planted on a flat surface . A quarterly assessment, dated 07/15/17, documented the resident was moderately cognitively impaired for daily decision making skills. The resident required extensive assistance with two persons for transfers. She was not ambulatory and used a wheelchair for mobility. A form titled, CNA Care Flowsheet, undated, documented the resident required X 2 (two) person assistance with transfers and the resident was ambulatory. A physical therapy progress note, dated 10/11/17, documented, .Transfer/ADL Self Performance: Sit to Stand .Current level of function .transition from sit to stand requiring maximal assistance X (times) 2 (two) people (ADL performance: Extensive Assistance) .Note .Changing and maintaining body position functional limitation, current status has been documented based on requiring max assist with bed mobility and transfers . A physical therapy progress note, dated 10/12/17 at 11:19 a.m., documented, .patient in her room .agreeable to participate with therapy but c/o (complained of) pain on right knee. Patient states it started hurting while she was on sit to stand lift in the shower room .nursing notified of patients complaints. Recommended that physician be notified and x-ray .to rule out acute injury . A nursing progress note, dated 10/12/17 at 12:53 p.m., documented, .No acute distress noted .no facial grimace or moaning notes at this time .(Signed by LPN #1 (licensed practical nurse)) . LPN #1 was interviewed during the survey. She reported the nursing note was a late entry. She stated the information contained in the note was from her morning assessment on 10/12/17 between 8:00 a.m. and 9:00 a.m. A MAR (medication administration record), dated 10/12/17 at 1:00 p.m., documented the resident received acetaminophen 500 mg (milligrams) two tablets by mouth for pain. A nursing progress note, dated 10/12/17 at 1:45 p.m., documented, .therapist reported .resident unable to do therapy .c/o (complained of) pain to the right knee. On assessment .area appeared swollen and painful to touch. When asked what happened resident .did not say a word .DR (name withheld) .called n/o (new order) received for STAT (urgent) x-ray to the right knee. X-ray service provider called. Claim # (number) Received (identified claim number) . A physicians order, dated 10/12/17 at 6:44 p.m., documented, STAT (urgent) x-ray to right knee for pain and swelling . A nursing progress note, dated 10/12/17 at 8:58 p.m., documented, .following up about the swollen right kneel (sic) .resident told this nurse .she fell in the shower room in the morning .Resident stated, 'I fell to the floor in the shower room and hit my leg and the two females giving me a shower got me up immediately.' .Acetaminophen tablet 500 mg 2 (two) tablets PO (by mouth) given r/t pain. Dr (name withheld) notified about the fall. STAT order for x-ray r/t the swollen right knee has already been ordered . An x-ray report, dated 10/12/17 at 10:23 p.m., documented, .Conclusion: Intact right knee arthroplasty unchanged from 4/7/2016. Acute fracture of right distal femur with modest displacement new since 4/7/2016 .Radiologist time 9:19 p.m . A nursing progress note, dated 10/12/17 at 10:59 p.m., documented, .received x-ray results with conclusion acute fracture of right distal femur. Dr (name withheld) notified and received an order to send to ER (emergency room ). (identified ambulance service) called .resident left the facility .via stretcher at 10:55 p.m . A hospital H&P (history and physical) report, dated 10/12/17 at 11:27 p.m., documented, .patient x-ray confirms .distal femur fracture .patient will be admitted to hospitalist Dr. (name withheld) and Dr. (name withheld) consulting for orthopedics . A hospital Orthopedic consult report, dated 10/13/17 at 9:14 a.m., documented, .peri-prosthetic right distal femoral fracture .ORIF (open reduction with internal fixation) intervention pending . On 10/16/17 at 3:15 p.m., CNA (certified nursing assistant) #1 was asked if she recalled the event which occurred on 10/12/17 with the resident. She stated the resident did not fall. We (CNA #1 and CNA #2) had her in the sit to stand lift transferring her from the shower to her wheelchair. The sit to stand lift battery went dead and we used the emergency button to lower her down to into the wheelchair. She then stated when she was sitting in the shower chair and the sit to stand was lifting her into a standing position the resident started to let go of the lift grab bar. She stated we told the resident not to let go and we would get her into the wheelchair. She complained of pain when going from a sitting to a standing position with the sit to stand. She further stated the resident complained of pain to her right knee during her shower. She stated CNA #2 stated the resident's right knee was swollen and she stated she would let the nurse know. She was asked how the resident got into the shower chair. She stated another CNA (CNA #3) assisted the resident into the shower chair with CNA #2. CNA #1 was then asked when did the shower room incident with the resident occur. She stated, It was around 10 o'clock, before lunch on last Thursday. (10/12/17 at 10:00 a.m.) At 3:34 p.m., CNA #2 was asked who was present in the shower room when the resident arrived to the shower room. She stated three staff members were present in the shower room before she started the resident's shower. She was asked how the resident was transferred to the shower room. She stated CNA #3 went to the resident's room, got the resident from her room and brought her to the shower room in a wheelchair. CNA #2 was asked when the resident complained of pain. She stated when she began to wash the resident she started complaining of some pain to her right leg. She further stated when the resident's shower was completed they got her dressed and they put her in the sit to stand lift. She then stated the resident complained of her leg hurting worse when she was lifted up to a standing position with the sit to stand. She stated when the resident was seated in the shower chair and the sit to stand was lifting her into a standing position the resident started to let go of the lift grab bar and her legs started sliding out from under her. She stated the battery started dying on the sit to stand lift as the resident was rising to a standing position so CNA #2 pushed the emergency release button and the resident was lowered quickly down into the wheelchair. The CNA stated the resident's knee had pressure on it from sliding out from under her and going down so fast, but the resident was complaining of right knee pain prior to being in the sit to stand lift. CNA #2 was asked how should the resident be transferred. CNA #2 stated, The resident used the sit to stand lift since she stopped standing up on her own about six months ago. She further stated she always had another person helping her when the resident was transferred via the sit to stand lift. At 4:30 p.m., CNA #3 was asked if she transferred the resident from her room to the shower room on 10/12/17. She said, Yeah, I took her to the shower room between 930 (9:30 a.m.) and 10'ish (10:00 a.m.). She stated the resident stood up and pivoted herself from the bed to the wheelchair. She then stated she thought another aide was in the room with her. She stated the other staff member provided no assistance, she stood by and watched. She said, I put the wheelchair beside the bed. The resident stood up by herself. She pivoted. I kinda helped a little bit, but she pivoted to the wheelchair. I kinda got her arms and hands and she pivoted by herself. She further said, The resident did not complain of pain when she was wheeled into the shower room in the wheelchair. Once there I pushed her wheelchair up to the pole, she grabbed hold of the pole and pulled herself up, pivoted and sat on the shower chair. (Named CNA #2) and another CNA (unknown name) were in the shower room at the time. The resident said she did not need assistance to stand up and get on the shower chair. She was then asked if she received any report on how the resident should be transferred. She said, She can pivot a little bit and I asked her. She can tell me what's going on. At 4:59 p.m., LPN (licensed practical nurse) #1 was asked were you informed of any injuries or falls experienced by the resident. She stated yes she was notified of the resident complaining of knee pain between 12:00 p.m. and 1:00 p.m. She then stated therapy notified her the resident was in too much pain and could not participate. She then stated she did an assessment of the resident's knee. She stated her knee was swollen and sore to palpitation. She was asked about the nursing progress note dated 10/12/17 at 1:45 p.m. She stated she completed the note after she assessed the resident and also called and notified the physician and the family. She further stated the x-ray was done on the next shift. She stated they (x-ray services) had not come by the time her shift was over at 3:00 p.m. She was asked if any one reported the resident's complaints of pain in the morning after her shower. She said, No. She was asked if the CNAs reported any issues with the lift or the transfer during the shower. She said, No I don't think so. She was asked again if the CNA's reported the resident was having pain during or after her shower. She said, No, the first thing I knew about it was when the therapist told me the resident complained of pain. At 5:25 p.m., LPN #2 was asked if he recalled what occurred with the resident on 10/12/17. He stated the outgoing nurse said the therapist couldn't do therapy and they got an x-ray ordered. He then stated he went to the resident's room with the CNAs (CNA #4 and CNA #5) and the resident stated she had fallen in the shower room earlier in the morning. The resident was asked if she had reported the fall to a nurse. She stated she didn't want to get the aides in trouble so she did not. He further stated he asked LPN #1 if the resident had told her she fell and she said no. LPN #1 stated she was made aware of the resident's complaints of pain by the therapist only. LPN #1 then reported to LPN #2 she notified the doctor and the family and received an order for [REDACTED]. LPN #2 then stated he did not receive results from the x-ray until his shift (3:00 p.m. to 11:00 p.m.). He stated he notified the physician of the results when he received them. He further stated the physician ordered for the resident to be sent to the emergency room for treatment. LPN #2 was asked how the resident was transferred. He stated it was always two persons with a sit to stand lift and two persons in the shower room. He was not sure if the resident could stand up on her own and pivot. At 5:36 p.m., CNA #4 was asked if she was aware of any incident with the resident on the morning of 10/12/17. She stated she was not sure if the resident had told anyone about the fall or incident in the shower room that morning. She further stated she and CNA #5 asked LPN #2 and he said he didn't know anything about it. She stated she asked him if he knew when the X-ray results would be in for the resident and he stated he had no idea about the resident's injury. She then stated her and CNA #5 notified LPN #2 the resident's knee was swollen. At 5:47 p.m., CNA #5 was asked if she was aware of any incident with the resident on the morning of 10/12/17. She stated the evening of 10/12/17 she went to see the resident and the resident was complaining of pain. She stated the resident had her right leg elevated up on her bedside rail. She stated that was not normal behavior for the resident. She stated then the resident notified her she had fallen before lunch in the shower room on the morning of 10/12/17. She stated she observed the resident's knee and it was swollen. She stated she asked the resident if she had an X-ray done. She stated the resident stated she was waiting on an x-ray to be completed. She stated she then asked LPN #2 and he stated he didn't know anything about an injury or a pending x-ray for the resident. She then stated x-ray arrived at the facility between 6:00 and 7:00 p.m. to complete the physician's orders [REDACTED]. At 6:30 p.m., CMA (certified medication assistant) #1 was asked if she had been informed of the resident incident in the shower or about the resident's pain. She stated she was not informed by any aide the resident complained of pain during or after her shower or that the resident had a fall. She further stated the first time she was aware of the resident having pain was when the therapist told the nurse on duty the resident had complained of knee pain and requested Tylenol. She further stated she then administered Tylenol to the resident on 10/12/17 at 1:00 p.m. On 10/17/17 at 8:20 a.m., PT (Physical Therapist) #1 was asked when he noticed the resident was having knee pain. He stated he went to get the resident up for therapy the morning of 10/12/17. He stated the resident had just finished her shower and her hair was still wet. He then stated during the transfer from the resident's bed to a wheelchair she complained of pain. He stated he asked the resident to lift her leg and she was unable to move her leg. He stated the resident reported the pain started during a sit to stand lift transfer in the shower room. He stated he informed the nurse of the resident's complaints of pain on the way to the therapy department and he recommended for the resident to have an X-ray of the right leg. He was then asked how often the resident complained of pain during routine therapy visits. He stated she complained of arthritis pain to her right knee on occasion, but not very often. He was then asked if the resident was able to transfer and pivot. He stated the resident was able to stand up with assistance but not pivot. He further stated she stands up with two person assistance and used a sit to stand lift with two persons for transfers. At 8:32 a.m., the COTA (certified occupational therapy assistant) was asked if she knew the resident. She said, Yes I'm familiar with the resident. I worked with her once a week for a month. She was asked how did the resident transfer. She stated she was maximum assist or they use a lift. At 9:23 a.m., OT #1 (occupation therapist) was asked what was the resident's transfer status. He stated during the OT evaluation the resident required maximum assistance with transfers. He stated she can do 25% of the work but she had a problem with pivoting. He was asked when the evaluation occurred. He stated he did the evaluation on 09/29/17 or 09/30/17. He was then asked if the resident could stand and pivot if someone just held her hands/arms. He stated, Probably not. At 10:20 a.m., PT #1 was shown the PT progress note dated 10/11/17 which documented the resident required two person assistance with a sit to stand lift. He was asked if he told the staff. He stated, I don't think so. She was already a sit to stand lift use with two persons before she went out to the hospital on September 25th. He further stated the resident had a decline, she was able to stand with 1 person and use a walker but could not pivot. After she came back from the hospital she was a maximum assist with 2 persons and sit to stand lift because she had so much weakness. At 10:37 a.m., (X-ray service provider name deleted) was contacted by telephone. A representative (name withheld) was asked when did they receive the X-ray order for the resident from the facility. He stated the order was received from the facility on 10/12/17 at 6:37 p.m. He then stated the X-ray was completed on 10/12/17 by the radiology staff at 9:19 p.m. At 11:02 a.m., CNA #3 was asked if the resident was a one to two person assist for transfers. She stated the resident was a one person assistance for transfer from the bed to the wheelchair. She was asked how she knew that information. She stated she used to do restorative therapy services on the resident but it had been two to three years. She further stated the resident could stand but they used a sit to stand lift on her. She was asked why she did a one person assisted transfer on the resident on the morning of 10/12/17. She stated the night shift staff members just said the resident didn't want to get up. She stated she did not get any other information about how the resident transferred. She further stated on 10/09/17 she helped the resident stand and she pivoted herself. She stated all she did was hold her arms and hands gently and on the morning of 10/12/17 the resident was transferred in the same manner. She was then asked why did she not utilize a sit to stand lift to transfer the resident. She stated the resident had told her she could stand and pivot so she let her transfer herself. She was asked when the resident was transferred to the shower room did she assist the other CNA in transferring the resident to the shower chair. She stated CNA #2 asked for help to transfer the resident from the wheelchair. She then stated she told her (CNA #2) the resident just transferred herself in the room, so they could let the resident pull up on the rail and transfer herself. She then stated the resident stood herself up by pulling up on the rail and they pulled her pants and brief down. She stated then the resident pivoted herself to the shower chair and was seated. At 11:10 a.m., physician (name withheld) was contacted by telephone. He was asked when the facility contacted him about the resident. He stated he was called earlier in the day right after the fall. He then stated he was notified by staff that they thought the resident had fractured her right leg. He then stated when they called they were concerned and wanted to send her out to the emergency room immediately. He stated he notified the facility staff to obtain an X-ray and wait until the results were available first. He was asked what time he was notified of the X-ray results. He stated he was notified of the X-ray results at 10:17 p.m. on 10/12/17. He stated he then gave orders to send the resident to the emergency room at that time. At 11:41 a.m., LPN #1 was asked if the resident was having pain. She stated no she wasn't having a lot of pain. She was not grimacing or stating she had pain. She stated the resident's leg was sore with palpitation. She further stated the resident did not report she had a fall. She stated she assessed the resident when therapy reported the resident was in too much pain to complete therapy. She stated she then assessed the resident's leg and her right knee was swollen and sore with palpitation. The resident was provided extra strength Tylenol and continued to complain of pain 30 minutes to an hour after the pain medication was administered. The resident's level of pain was not assessed before or after the administration of the pain medication. At 12:35 p.m., the DON was asked how did the nursing staff know what the residents' functional assistance needs and limitations were. She stated it was determined by the therapy evaluation and it was on the CNAs care flowsheet. She stated the aides use the flowsheet to determine what the residents' needs were. The DON left to retrieve the CNA flow sheet and returned with one for the resident. The form documented the resident required X 2 (two) person assistance with transfers and the resident was ambulatory. The DON was asked when the CNA care flowsheet had been put into place or last updated. She stated the flowsheets were updated as needed and she was unsure when it was last updated. She was asked to review the CNA Care flowsheet. She was then asked if the information regarding the residents transfer needs was accurate. She stated the CNA flowsheet documented the resident needed x 2 (two) persons for transfers. She was asked if the sit to stand lift should have been on the flowsheet. She stated yes. At 12:47 p.m. the DON was asked if the resident required a sit to stand lift with two person assist. She stated yes she did. She further stated two staff members were required to utilize a sit to stand lift. She further stated the resident had always required a two person assist with transfers. She was asked if CNA #3 should have had another person assist her or use a sit to stand lift with another person when she transferred the resident by herself the morning of 10/12/17. She stated yes. She was asked if the resident could have been injured if she wasn't transferred with the appropriate amount of assistance. She said, Of course there is always a risk for injury.

Based on observation, record review, and interviews, it was determined the facility failed to ensure a resident, who sustained a second degree burn, was assessed and treatment was provided as soon as possible after the burn was identified for one (#1) of three sampled residents reviewed for accident hazards. The director of nursing identified no additional residents who had sustained a burn in October or November 2015. Findings: Resident #1 had diagnoses, which included dementia, [MEDICAL CONDITION], and depression. A quarterly assessment, dated 10/23/15, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with dressing and eating. An initial incident report to the Oklahoma State Department of Health, dated 11/02/15, documented, .Incident type injury of unknown source .description of incident .Staff were called to (Resident) room by his hospice nurse. (Resident) has a very large burn approximately 23 cm (centimeters) by 13 cm to left side of chest and a smaller burn to his left leg approximately 5 cm by 1 cm. Physician and family notified and an order obtained for silverdine. Investigation into how (Resident) obtained has be (sic) started . A care plan, dated 11/02/15, documented, area of skin concern to (L) (left) chest and (L) thigh. Goal area will resolve (without) complication. Interventions wound care consultant to eval (evaluate) & (and) treat as indicated. Cleanse area apply silverdine cream daily. A hospice aide visit form, dated 11/03/15, documented, .Pt (patient) tolerated care well, reported to the facility nurse (Name deleted). Pt had a big burn on his left upper chest . A weekly wound tracking form, dated 11/04/15, documented, .Type of wound burn .site L chest .in house acquired yes .date acquired 11/01/15 .measurements in cm 10 X 7 .description .light serous, 100% gran (granulation) .treatment Silver [MEDICATION NAME] QD (every day) . A Wound Care Specialist Initial Evaluation, dated 11/04/15, documented, .chief complaint: patient has a wound on their chest. HPI (history of present illness) statement: At request of Dr. (Name deleted), this [AGE] year old male was seen and evaluated today. He presents with a burn wound of the chest of at least 3 days duration .skin chest wound .Burn wound of the left chest focused wound exam .etiology (Quality) burn duration > (greater than) 3 days objective healing wound size (L X W X D) (length, width and depth) 10 X 7 .exudate light serous granulation tissue: 100 % .Assessment and plan burn wound of the left chest .Silver [MEDICATION NAME] once daily .investigations .burn wound of the left chest. large wound . This was the first assessment of the burns. A review of the medication acquisition receipt form for the silver [MEDICATION NAME] documented the facility received the cream on 11/05/15 at 4:08 p.m. A physician's telephone order, dated 11/07/15, documented, apply silver [MEDICATION NAME] cream 1% to burn on upper left chest every shift and as needed every shift for burn . A review of the November 2015, treatment administration record, documented the first treatment of [REDACTED]. The physician's orders [REDACTED]. The November 2015, treatment administration record, also documented, Monitor burn to left chest and under left arm, and left thigh for any changes. Report and record any changes every shift for burn. This was started on 11/10/15. There was no documentation to show [MEDICAL CONDITION] monitored and/or assessed after the wound care specialist assessed them on 11/04/15, until 11/10/15. A weekly wound tracking form, dated 11/11/15, documented, .Type of wound burn .site L chest .in house acquired yes .date acquired 11/01/15 .measurements in cm 10 X 7 .description .light serous, 100% gran .treatment Silver [MEDICATION NAME] QD . A nutrition progress note dated 11/12/15 at 9:45 a.m., documented, Nursing reports burn to left chest, under left arm, and left thigh . A hospice skilled nursing visit report, dated 11/13/15, documented, .Pt denies pain but wines and is guarding right and left upper chest where he has a burn .skin now intact but pink in appearance. Pt not always able to make his needs known .unaware of limitations of safety . A Wound Care Specialist Initial Evaluation, dated 11/18/15, documented, Burn wound of the left chest (Resolved on 11/18/15) . A weekly wound tracking form, dated 11/18/15, documented, .Type of wound burn .site L (left) chest .in house acquired yes .date acquired 11/01/15 .measurements in cm (centimeters) 10 X 7 .description .light serous, 100% gran .treatment resolved 11/18/15 . An interview was conducted, on 11/23/15 at 12:20 p.m., with the resident. He was asked how he was doing. He stated, I got burned. He was asked how he got burned. He just kept saying, I got burned and pointed to his left chest. An interview was conducted, on 11/23/15 at 2:10 p.m., with registered nurse (RN) #1. She was asked when the burn had occurred. She stated, On 11/07/15, when the treatment order started. She was asked how bad the resident was burned. She stated it was a second degree burn. An interview was conducted on 11/23/15, with licensed practical nurse #3. She was asked to locate the assessment of the burn. She stated, There was no assessment done when the burn was first identified. She was asked if there was any documentation in the clinical record regarding the burn. She stated there should have been a change in condition and good nurses' notes. She then added, I'm taken back. It should have been done. An interview was conducted, on 11/23/15 at 3:20 p.m., with the director of nursing. She was asked when the resident received the burn. She stated, We're not sure. She was asked who first identified the resident had a burn. She stated she thought it was the hospice aide. She was asked if the burn had been assessed. She stated it should have been assessed the same day it was identified. She was asked if there was any documentation in the clinical record of the burn. She looked through everything and stated, Documentation is poor. She then added there was nothing documented.

Immediate Jeopardy On 6/13/12 an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure suction equipment and emergency carts were accessible to facility staff. The 375 bed facility had six halls. Each hall had it's own emergency cart containing emergency supplies and equipment. None of the charge nurses had keys to the locked emergency carts. Suction equipment was stored in two oxygen storage rooms on Halls 200 and 300. The suction equipment in the storage room on Hall 300 was not readily accessible due to the large amount of equipment stored and the disorganization of the room. At 10:42 a.m., the Oklahoma State Department of Health was notified and verified the existence of the Immediate Jeopardy. At 10:55 a.m., the facility Executive Director and Director of Nurses were informed of the situation. Plan of removal for Immediate Jeopardy A plan of removal, written by the Executive Director, for the immediate jeopardy was received and approved at 2:40 p.m., on 06/13/12. The plan of removal stated: "1. Immediately remove locking mechanisms on each crash cart (6) for easy access by staff. Lower portion of crash cart will have twist off plastic lock. Medications and syringes will not be stored on crash cart. Syringes are available in the medication room per charge nurse. 2. Licensed Nurses currently working on June 13, 2012 by midnight have received re-education as to crash cart accessibility and removal of locking mechanism of upper crash cart and plastic twist off mechanism for lower portion of crash cart by end of their shift today to remove the potential for immediate jeopardy. Re-education will be given to each Licensed Nurse working at South Park Care and Rehabilitation Center regarding crash cart accessibility and lock removal prior to starting their shift until 100% complete. Effective June 13, 2012, Licensed Nurses will not be allowed to work until re-education of crash cart accessibility/plastic locks is conducted. Some re-education is being conducted per telephone. (See attached education template). In addition crash cart accessibility will become part of each new employee's orientation. 3. A Mock drill of crash cart access on each unit will be conducted when re-education is complete with current staff. Mock drills for remaining staff will be conducted on crash cart accessibility for the evening and night shift to ensure competency. Crash cart access will become part of the Mock drill process going forward. During regular business hours, Central Supply staff will restock crash cart. During off business hours the supervisory on-call nurse will be called to restock the crash cart for supplies. 4. Additional plastic twist off locks will be available in the Maintenance/Central Supply Department and each medication room for replacement as needed. 5. Nursing/central supply staff will check crash cart 4 times weekly for required supplies and will also check for easy access to the crash cart by determining that plastic twist lock is intact. Plastic twist lock will not be broken during check-offs. The plastic twist locks are numbered in sequence and will be used as each one is broken. Once the lock is broken, the number of the sequenced lock is placed on the inventory sheet as it is used. The current checklist of crash cart supplies will be modified to include that the crash carts are easily accessible." The immediate Jeopardy was removed on 06/13/12 at 11:59 p.m., when the facility provided evidence that all components of the plan of removal had been completed, such as the re-education of the nursing staff on accessibility/plastic locks of the crash carts, the removal of the locking mechanisms of the upper crash carts, and storing the medications and syringes in the medication rooms. Crash cart accessibility will become part of each new employee's orientation. A mock drill of crash cart access on each unit will be conducted when re-education is completed. Central supply will restock crash carts during regular business hours. Nursing and central supply will also check crash cart 4 times weekly for required supplies. All nurses employed at the facility were inserviced on accessibility to the crash carts except six and those nurses will be inserviced before they return to work. A list of all nurses was provided. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, record review and staff interview, it was determined the facility failed to ensure the emergency carts on each hall were accessible. This had the likelihood to affect 131 residents identified by the facility with a full code status. Findings: On 06/13/12 the following observations of emergency carts were made with the Director of Nurses and the Registered Pharmacist. ~At 9:15 a.m., the charge nurse on Hall 200 did not have a key to access the emergency cart. The charge nurse looked for and found another set of facility keys, and gave them to the DON. The DON tried several of the keys before finding the key that accessed the emergency cart. Seven to ten minutes lapsed before the emergency cart was accessed. ~At 9:30 a.m., the charge nurse on Hall 100 did not have a key to access the emergency cart. The charge nurse had to find the key and bring it to the DON. Five minutes lapsed before the emergency cart was accessed. ~At 9:40 a.m., the charge nurse on Hall 300 did not have a key to access the emergency cart. The nurse supervisor walked up to the nurses station and the DON asked if she had a key to the emergency cart. The nurse supervisor stated she thought it was on her key ring and handed the DON her keys. Five minutes lapsed before the emergency cart was accessed. ~At 9:45 a.m., the oxygen room on Hall 300 was observed to be cluttered with supplies stored on the counters and supplies stored on a cart that were not accessible. The suction equipment and emergency supplies were not accessible. Oxygen concentrators and oxygen tanks covered the entire floor. There was no room to walk. Suction equipment and supplies were accessible in Hall 200's oxygen room, however, the furthest hall was Hall 500 and it took 7 minutes to walk briskly from Hall 500 to Hall 200, access the oxygen room, get the equipment and supplies needed and return to Hall 500. ~At 9:55 a.m., the charge nurse on Hall 400 did not have a key to access the emergency cart. The DON called for a staff person from central supply to open the emergency cart. Five minutes lapsed before the emergency cart was accessed. ~At 10:05 a.m., the charge nurse on Hall 500 did not have a key to access the emergency cart. The DON called for a staff person from central supply to open the emergency cart. Five minutes lapsed before the emergency cart was accessed. ~At 10:15 a.m., the charge nurse on Hall 600 did not have a key to access the emergency cart. The DON called for a staff person from central supply to open the emergency cart. Five minutes lapsed before the emergency cart was accessed. ~At 10:20 a.m., the Director of Nurses was asked why the charge nurses did not have keys to access the emergency carts. The DON stated they decided to put the same lock on all the crash carts so any of the charge nurses would have access to all the crash carts. She stated she told the maintenance man some time ago to mark all of the keys and they were to be given to each charge nurse to put on their facility key rings. She also stated a key was to be taped to the back of each cart in case the charge nurse misplaced their keys. The DON was asked when the emergency carts were checked for supplies. The DON stated the emergency carts were supposed to be checked by the charge nurse on the 11-7 shift. The DON was asked why the emergency cart daily check list was blank for the months of March, April, May and June 2012 on Hall 300. She stated they were supposed to be filled out by the 11-7 shift charge nurse. At 10:30 a.m., LPN #1 on Hall 200 was asked when the emergency cart was last used. She stated she did not remember, it had been awhile. She stated, "We haven't had a code since we changed it." She was asked what was used before the carts. She stated, "we had plastic bags with the supplies, but we have the black boxes now" (which are the crash carts). At 10:32 a.m., LPN #14 was interviewed and asked which hall she was working on. She stated she worked on Halls 300 and 500. She was asked if she had a key to the crash cart for Halls 300 and 500. She stated no, none of her facility keys go to the crash carts. She was asked if she ever had to use the crash carts. She stated no. At 10:35 a.m., LPN #15 and LPN #16 on Hall 100 were interviewed and asked if they had a key to the crash cart. They both stated that central supply #1 had taken the keys to have them labeled. They were asked if they had to use the crash cart. They both stated no. LPN # 15 stated she had only been employed there two months and has never had to use the cart. LPN #16 stated she has been employed there [AGE] years and had to use emergency supplies in the past. She stated at that time they were kept in a plastic bag. Since they have had the carts, for the past 6 months, she has not had to use it. They were asked if they had an emergency situation right now would they have access to the cart. They stated, "That's a good question. Since we don't have a key, I guess not." At 10:37 a.m., RN #7 on Hall 500 was asked when the emergency cart was last used. She stated "Oh, not for a long time." She was asked if she had a key to the emergency cart. She stated yes we usually do but central supply #1 just came and took it. She was asked if she ever used the box (emergency cart). She stated yes, we have mock codes all the time. She was asked if during the mock codes, did she use or open the emergency cart. She stated, "We had it in the room, but we never opened it." At 10:39 a.m., RN #10, manager for Halls 100 and 600, was asked if she had a key to the crash carts on Halls 100 and 600. She stated she had given her key to central supply #1. She stated the charge nurses have not had to use the crash cart since they got them six months ago. At 10:40 a.m., LPN #11 on Hall 400 was interviewed and asked who has the key to the crash cart. She stated all the nurses here have a key. She was asked if she had a key. She stated, I normally do, but central supply #1 just came and got it. She was asked if she ever opened the cart. She stated yes. She was asked how did she open it. She stated with the key. She was asked if she actually opened the box with her key. She stated no but it worked. She was asked how did she know it worked. She stated, well, they tested it before they gave it to us. She was asked if she could open the cart. She stated no central supply #1 just took it. She was asked if she knew why they took it. She stated she needed to mark it. She was asked if there were a code right now, could you use this cart. There was silence from the nurse. She was then asked who checks the crash cart. She stated the night shift checks it. On 6/14/12 at 9:30 a.m., the DON was asked if she had a facility emergency cart policy. She stated she did not have an emergency cart policy. She stated the only policy she had was the emergency cart check off list.

Based on observations, review of policies and procedures, review of clinical records and staff and resident interviews, it was determined the facility failed to be administered in a manner to enable residents to attain or maintain their highest practicable well-being. The facility's administration did not identify systems failures related to the nurses' accessibility to emergency supplies located on crash carts which resulted in an IJ (immediate jeopardy) situation. The facility's administration did not identify systems failures related to the provision of medically related social services which resulted in actual harm. The facility's administration did not identify systems failures related to the provision of devices and services for vision which resulted in actual harm. The facility's administration did not identify systems failures related to their policies and procedures for abuse/neglect/grievances investigations. These deficient practices had the potential to affect all 224 residents who resided in the facility. The facility failed to: 1. It was determined the facility failed to ensure the emergency carts on each hall were accessible. See F323 for details. 2. It was determined the facility failed to meet the needs of residents by not having a full time Social Service Director on staff for 51 days for two (#3 and #4) of 39 sampled residents whose records were reviewed. This resulted in an actual harm for resident #4 due to the resident's inability to participate in her normal daily activities for 234 days before replacement glasses were received. See F250 for details. 3. It was determined the facility failed to ensure a resident who required glasses for clear vision received replacement glasses for two (#3 and #4) of 10 sampled residents who wore glasses. This resulted in an actual harm for resident #4 due to the resident's inability to participate in her normal daily activities for 234 days before replacement glasses were received. See F313 for details. 4. It was determined the facility failed to respond to grievances reported to the facility for three (#14, 16 and #17) of 39 sampled residents whose records were reviewed. See F166 for details.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who required glasses for clear vision received replacement glasses for two (#3 and #4) of 10 sampled residents who wore glasses. This resulted in an actual harm for resident #4 due to the resident's inability to participate in her normal daily activities for 234 days and the resident also developed eye strain and discomfort before the replacement glasses were received. The DON identified an additional 109 residents residing in the facility who wore glasses. Findings: A facility policy for "Dental/Vision/Hearing Services" documented: "Each resident will have access to...vision...services to meet...needs. The facility will arrange...vision... services...needs for these services are identified through the RAI process and ongoing resident monitoring." 1. Resident #4 was admitted with [DIAGNOSES REDACTED]. A Therapeutic Recreation/Activity assessment dated [DATE], documented the resident's interest was: "Crafts/arts, reading, music, spiritual/religious, educational/intellectual, watching TV and watching movies. The assessment further documented the resident considered it "very important to be around animals/pets...and to go outside to get fresh air when weather is good.... " Other preferences identified included books, newspapers and magazines to read. A comprehensive annual assessment dated [DATE], documented the resident had adequate vision and could see fine detail including regular print. The assessment further documented the resident did not wear any type of corrective lenses. The resident was assessed as being cognitively intact. The activity preferences identified: "it is very important for resident to be around animals/pets,...participates in religious services or practices, and to go outside to get fresh air when weather is good." Other preferences identified included: "Somewhat important to have books, newspapers and magazines to read..." On 02/07/12, the resident was reevaluated by an Optometrist and received a new prescription for lenses. The resident's visual acuity without lenses was documented to be 20/60 (20/20 vision is considered normal) in both eyes during the examination. A quarterly assessment dated [DATE], documented the resident had adequate vision and could see fine detail. A care plan last updated 03/02/12, documented, "Focus: Self initiates activities and enjoys various activities...watching television, reading... crafts/arts...Goals: will continue to participate in activities...Interventions: Provide with the necessary supplies/equipment to engage in self directed activities of choice." On 06/04/12 at 9:20 a.m., an interview was conducted with the alert and oriented resident. The surveyor asked her what she was watching on TV and she replied, "I don't know, I can't see anything." She was then asked what she did to keep busy and she replied, "I really can't do much because I can't see." The surveyor asked her to explain, she replied, "Since I lost my glasses I can't read, watch my shows on TV or watch the birds outside. The smallest birds I can see is a pigeon or a duck, can't see the little ones without my glasses." She was asked when she lost her glasses. She stated, "Last October (2011)." She was asked if she had reported the glasses as lost. She replied she had done what she was 'supposed to' by going to the nurse on her unit first and then to SSA #1. She further stated she had told SSA #1 at least once a week that she needed her glasses. The surveyor asked the resident how the loss of the glasses had affected her. She placed one hand over her eyes and started crying. She stated, "I haven't been able to read, watch my shows or see the birds since I lost my glasses. They had to buy me large print so I could have something to read." She further stated her eyes were strained and hurt since her glasses were lost. On 06/04/12 at 10:12 a.m., an interview was conducted with CNA #7 regarding the process of lost or missing items. She stated, "All information is given to the charge nurse. If she doesn't do anything I will report it to the DON and if she doesn't do anything, I will report it to Administration." On 06/05/12 at 11:22 a.m., an interview was conducted with SSA #1. When asked if she knew about the resident's missing glasses, she stated, "I did but was told by the past administrator the facility would not pay for the replacement glasses." She further stated when the new executive director arrived she thought about mentioning the glasses to him but, "I didn't follow through on that." SSA #1 was asked if a grievance had been written. She stated she didn't know. When she was asked if an incident report was written, she said the nurses would have written one. On 06/05/12 at 1:35 p.m. an interview was conducted with LPN #3. The LPN was asked if she was aware the resident was missing her glasses. She replied, "I only heard about it yesterday." When she was asked what the procedure was for lost items, she replied, "We go look for the item that is lost, we write out an incident report, we call family and if necessary notify the state office and the police." When asked if an incident report was written, she responded, "There's nothing in my computer." When informed of the resident's report of telling nurses on hall 300 about the missing glasses, the nurse replied, "I don't have anything saying she lost her glasses." On 06/05/12, at 2:12 p.m. the DON was asked about an incident report on the missing glasses. She replied, "I can give you a summary of incident reports on this resident, then you let me know which one you want printed." The summary provided to the surveyor did not contain an incident report for the resident's missing glasses. No further incident reports were located regarding the missing glasses. On 06/05/12 at 2:15 p.m., an interview was conducted with LPN #3 regarding the quarterly nursing assessments. When asked why the past two assessments did not address the resident's vision problems, the LPN did not give an answer to the question. She did state she was the person who completed the assessments. On 06/05/12 at 2:20 p.m., LPN #4 was asked if she had assessed the resident for eye pain due to eye strain. She stated she had not. On 06/06/12 at 8:50 a.m., HR department staff #1 was interviewed regarding the social services director position. When asked how long the facility had been without a director, she stated, "The last one left on 04/03/12." She was also asked to provide the start date of the new social service director. She replied, "May 23rd was the start date" for the current social service director. On 06/06/12 at 11:30 a.m., an interview was conducted with SSA #1. She was asked when the previous social service director terminated her employment with the facility. She replied she wasn't sure but thought it was sometime last month. She was asked when the new Social Service director started work. She replied "last week." SSA #1 was asked who was in charge of the department during the absence of a social service director and she replied, another assistant. She was then asked what educational degree qualified the other assistant to be in charge. SSA #1 stated the staff member did not have a degree, but she did have a certificate. On 06/06/12 at 11:45 a.m., the executive director was interviewed regarding the lack of a social service director within the facility. When he was asked if he was aware of the time lapse between social service directors, he stated he was, but he had been "actively pursuing" hiring another person and thought that was sufficient. A recruiting report form reviewed identified an employment advertisement for a Social Services Director was placed on 04/26/12. The previous director resigned on 04/03/12, leaving the facility without a Social Service Director for 51 days. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An interdisciplinary progress note, dated 10/26/11, by the SSD, documented the resident was seen by the Optometrist. It documented, "...Dr. (Name withheld) stated they have tried to get facility to pay for (Resident #3) glasses. According to state law, facilities pay for glasses for residents, if needed and on medicaid only. Dr. (Name withheld) is going to try and request (Resident #3) receive a pair of glasses." On 06/05/12 at 8:30 a.m., an interview was conducted with the resident regarding the need for corrective lenses. The resident had difficulty with verbal communication, but made himself understood with hand motions and signs. The resident was asked if he wore glasses, he responded with a, "Yes." The resident was asked if he wore the glasses all the time and he responded, "No." The resident then took his hand and motioned away from his eye, indicating the need for glasses was for distance only. On 06/05/12 at 11:35 a.m., an interview was conducted with SSA #1. When asked if she knew about the resident's glasses, she stated, "I did, but the resident was not eligible to get his glasses because he didn't have insurance coverage for his glasses." She stated she had not checked into the corrective lenses requested any further, but that "a prescription should be in his chart."

Based on observation, interview and record review, it was determined the facility failed to meet the needs of residents by not having a full time Social Service Director on staff for 51 days for two (#3 and #4) of 39 sampled residents whose records were reviewed. This resulted in an actual harm for resident #4 due to the resident's inability to participate in her normal daily activities for 234 days before replacement glasses were received. This had the potential to affect an additional 222 residents residing in the facility. Findings: 1. Resident #4 was admitted with [DIAGNOSES REDACTED]. A Therapeutic Recreation/Activity assessment dated [DATE], documented the resident's interest were: "Crafts/arts, reading, music, spiritual/religious, educational/intellectual, watching TV and watching movies. The assessment further documented the resident considered it "very important to be around animals/pets...and to go outside to get fresh air when weather is good.... " Other preferences identified included books, newspapers and magazines to read. A comprehensive annual assessment dated [DATE], documented the resident had adequate vision and could see fine detail including regular print. The assessment further documented the resident did not wear any type of corrective lenses and was cognitively intact. On 02/07/12, the resident was reevaluated by an Optometrist and received a new prescription for lenses. The resident's visual acuity without lenses was documented to be 20/60 (20/20 vision is considered normal) in both eyes during the examination. A quarterly assessment dated [DATE], documented the resident had adequate vision and could see fine detail without corrective lenses. A care plan last updated 03/02/12, documented, "Focus Self initiates activities and enjoys various activities...watching television, reading... crafts/arts...Goals will continue to participate in activities...Interventions Provide with the necessary supplies/equipment to engage in self directed activities of choice." On 06/04/12 at 9:20 a.m., an interview was conducted with the alert and oriented resident. The surveyor asked her what she was watching on TV and she replied, "I don't know. I can't see anything." She was then asked what she did to keep busy and she replied, "I really can't do much because I can't see." When the surveyor asked her to explain, she replied, "Since I lost my glasses I can't read, watch my shows on TV or watch the birds outside. The smallest bird I can see is a pigeon or a duck. I can't see the little ones without my glasses." She was asked when had she lost her glasses. She stated, "Last October (2011)." The resident was asked if she had reported the glasses as lost. She replied she had done what she was 'supposed to' by going to the nurse on her unit first and then to SSA #1. She further stated she had told SSA #1 at least once a week that she needed her glasses. The surveyor asked the resident how the loss of the glasses had affected her. She placed one hand over her eyes and started crying. She stated, "I haven't been able to read, watch my shows or see the birds since I lost my glasses. They had to buy me large print so I could have something to read." She further stated her eyes were strained and hurt since her glasses were lost. On 06/04/12 at 10:12 a.m., an interview was conducted with CNA #7 regarding the process of lost or missing items. She stated, "All the information is given to the charge nurse. If she doesn't do anything I will report it to the DON and if she doesn't do anything, I will report it to the administration." On 06/05/12 at 11:35 a.m., an interview was conducted with SSA #1. When asked if she knew about the resident's missing glasses, she stated, "I did, but I was told by the past administrator the facility would not pay for the replacement glasses." The staff member was asked if a grievance form had been completed regarding the lost glasses. She stated she didn't know. When asked if an incident report was completed, she stated the nurses would have written the report, if there was one. On 06/05/12 at 1: 35 p.m., an interview was conducted with LPN #3. The LPN was asked if she was aware the resident was missing her glasses. She replied, "I only heard about it yesterday." When she was asked what the procedure was for lost items, she replied, "We go look for the item that is lost, we write out an incident report, we call family and if necessary notify the state office and the police." When asked if an incident report was written, she responded, "There's nothing in my computer." When informed of the resident's report of telling nurses on hall 300 about the missing glasses, the nurse replied, "I don't have anything saying she lost her glasses." On 06/05/12 at 2:12 p.m., the DON was asked about an incident report on the missing glasses. She replied, "I can give you a summary of the residents' incident reports, then you let me know which one you want printed." The summary provided to the surveyor did not contain an incident report for the resident's missing glasses. No further incident reports were located regarding the missing glasses. On 06/05/12 at 2:20 p.m., LPN #4 was asked if she had assessed the resident for eye pain due to eye strain. She stated she had not. On 06/06/12 at 8:50 a.m., HR department staff #1 was interviewed regarding the social services director position. When asked how long the facility had been without a director, she stated, "The last one left on 04/03/12." She was also asked to provide the start date of the new social service director. She replied, "May 23rd was the start date" for the current social service director. On 06/06/12 at 11:30 a.m., an interview was conducted with SSA #1. She was asked when the previous social service director terminated her employment with the facility. She replied she wasn't sure but thought it was sometime last month. She was asked when the new social service director started work, and replied, "Last week." SSA #1 was asked who was in charge of the department during the absence of a social service director and she replied, "Another assistant." She was then asked what educational degree qualified the other assistant to be in charge. SSA #1 stated the staff member did not have a degree but she did have a certificate. On 06/06/12 at 11:45 a.m., the executive director was interviewed regarding the lack of a social services director within the facility. He was asked if he was aware of the time lapse between social service directors. He stated he was but that he had been "actively pursuing" hiring another person and thought that was sufficient. A recruiting report form reviewed identified an employment advertisement for a social services director was placed on 04/26/12. The previous director resigned on 04/03/12, leaving the facility without a social service director for 51 days. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An interdisciplinary progress note, dated 10/26/11, by the SSD, documented the resident was seen by the Optometrist. It documented, "...Dr. (Name withheld) stated they have tried to get facility to pay for (Resident #3) glasses. According to state law, facilities pay for glasses for residents, if needed and on medicaid only. Dr. (Name withheld) is going to try and request (Resident #3) receive a pair of glasses." On 06/05/12 at 8:30 a.m., an interview was conducted with the resident regarding the need for corrective lenses. The resident had difficulty with verbal communication, but made himself understood with hand motions and signs. The resident was asked if he wore glasses, he responded with a, "Yes." The resident was asked if he wore the glasses all the time and he responded, "No." The resident then took his hand and motioned away from his eye, indicating the need for glasses was for distance only. On 06/05/12 at 11:35 a.m., an interview was conducted with SSA #1. When asked if she knew about the resident's glasses, she stated, "I did, but the resident was not eligible to get his glasses because he didn't have insurance coverage for his glasses." She stated she had not checked into the corrective lenses requested any further, but "a prescription should be in his chart."

Immediate Jeopardy On 6/13/12 an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure suction equipment and emergency carts were accessible to facility staff. The 375 bed facility had six halls. Each hall had it's own emergency cart containing emergency supplies and equipment. None of the charge nurses had keys to the locked emergency carts. Suction equipment was stored in two oxygen storage rooms on Halls 200 and 300. The suction equipment in the storage room on Hall 300 was not readily accessible due to the large amount of equipment stored and the disorganization of the room. At 10:42 a.m., the Oklahoma State Department of Health was notified and verified the existence of the Immediate Jeopardy. At 10:55 a.m., the facility Executive Director and Director of Nurses were informed of the situation. Plan of removal for Immediate Jeopardy A plan of removal, written by the Executive Director, for the immediate jeopardy was received and approved at 2:40 p.m., on 06/13/12. The plan of removal stated: "1. Immediately remove locking mechanisms on each crash cart (6) for easy access by staff. Lower portion of crash cart will have twist off plastic lock. Medications and syringes will not be stored on crash cart. Syringes are available in the medication room per charge nurse. 2. Licensed Nurses currently working on June 13, 2012 by midnight have received re-education as to crash cart accessibility and removal of locking mechanism of upper crash cart and plastic twist off mechanism for lower portion of crash cart by end of their shift today to remove the potential for immediate jeopardy. Re-education will be given to each Licensed Nurse working at South Park Care and Rehabilitation Center regarding crash cart accessibility and lock removal prior to starting their shift until 100% complete. Effective June 13, 2012, Licensed Nurses will not be allowed to work until re-education of crash cart accessibility/plastic locks is conducted. Some re-education is being conducted per telephone. (See attached education template). In addition crash cart accessibility will become part of each new employee's orientation. 3. A Mock drill of crash cart access on each unit will be conducted when re-education is complete with current staff. Mock drills for remaining staff will be conducted on crash cart accessibility for the evening and night shift to ensure competency. Crash cart access will become part of the Mock drill process going forward. During regular business hours, Central Supply staff will restock crash cart. During off business hours the supervisory on-call nurse will be called to restock the crash cart for supplies. 4. Additional plastic twist off locks will be available in the Maintenance/Central Supply Department and each medication room for replacement as needed. 5. Nursing/central supply staff will check crash cart 4 times weekly for required supplies and will also check for easy access to the crash cart by determining that plastic twist lock is intact. Plastic twist lock will not be broken during check-offs. The plastic twist locks are numbered in sequence and will be used as each one is broken. Once the lock is broken, the number of the sequenced lock is placed on the inventory sheet as it is used. The current checklist of crash cart supplies will be modified to include that the crash carts are easily accessible." The immediate Jeopardy was removed on 06/13/12 at 11:59 p.m., when the facility provided evidence that all components of the plan of removal had been completed, such as the re-education of the nursing staff on accessibility/plastic locks of the crash carts, the removal of the locking mechanisms of the upper crash carts, and storing the medications and syringes in the medication rooms. Crash cart accessibility will become part of each new employee's orientation. A mock drill of crash cart access on each unit will be conducted when re-education is completed. Central supply will restock crash carts during regular business hours. Nursing and central supply will also check crash cart 4 times weekly for required supplies. All nurses employed at the facility were inserviced on accessibility to the crash carts except six and those nurses will be inserviced before they return to work. A list of all nurses was provided. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, record review and staff interview, it was determined the facility failed to ensure the emergency carts on each hall were accessible. This had the likelihood to affect 131 residents identified by the facility with a full code status. Findings: On 06/13/12 the following observations of emergency carts were made with the Director of Nurses and the Registered Pharmacist. ~At 9:15 a.m., the charge nurse on Hall 200 did not have a key to access the emergency cart. The charge nurse looked for and found another set of facility keys, and gave them to the DON. The DON tried several of the keys before finding the key that accessed the emergency cart. Seven to ten minutes lapsed before the emergency cart was accessed. ~At 9:30 a.m., the charge nurse on Hall 100 did not have a key to access the emergency cart. The charge nurse had to find the key and bring it to the DON. Five minutes lapsed before the emergency cart was accessed. ~At 9:40 a.m., the charge nurse on Hall 300 did not have a key to access the emergency cart. The nurse supervisor walked up to the nurses station and the DON asked if she had a key to the emergency cart. The nurse supervisor stated she thought it was on her key ring and handed the DON her keys. Five minutes lapsed before the emergency cart was accessed. ~At 9:45 a.m., the oxygen room on Hall 300 was observed to be cluttered with supplies stored on the counters and supplies stored on a cart that were not accessible. The suction equipment and emergency supplies were not accessible. Oxygen concentrators and oxygen tanks covered the entire floor. There was no room to walk. Suction equipment and supplies were accessible in Hall 200's oxygen room, however, the furthest hall was Hall 500 and it took 7 minutes to walk briskly from Hall 500 to Hall 200, access the oxygen room, get the equipment and supplies needed and return to Hall 500. ~At 9:55 a.m., the charge nurse on Hall 400 did not have a key to access the emergency cart. The DON called for a staff person from central supply to open the emergency cart. Five minutes lapsed before the emergency cart was accessed. ~At 10:05 a.m., the charge nurse on Hall 500 did not have a key to access the emergency cart. The DON called for a staff person from central supply to open the emergency cart. Five minutes lapsed before the emergency cart was accessed. ~At 10:15 a.m., the charge nurse on Hall 600 did not have a key to access the emergency cart. The DON called for a staff person from central supply to open the emergency cart. Five minutes lapsed before the emergency cart was accessed. ~At 10:20 a.m., the Director of Nurses was asked why the charge nurses did not have keys to access the emergency carts. The DON stated they decided to put the same lock on all the crash carts so any of the charge nurses would have access to all the crash carts. She stated she told the maintenance man some time ago to mark all of the keys and they were to be given to each charge nurse to put on their facility key rings. She also stated a key was to be taped to the back of each cart in case the charge nurse misplaced their keys. The DON was asked when the emergency carts were checked for supplies. The DON stated the emergency carts were supposed to be checked by the charge nurse on the 11-7 shift. The DON was asked why the emergency cart daily check list was blank for the months of March, April, May and June 2012 on Hall 300. She stated they were supposed to be filled out by the 11-7 shift charge nurse. At 10:30 a.m., LPN #1 on Hall 200 was asked when the emergency cart was last used. She stated she did not remember, it had been awhile. She stated, "We haven't had a code since we changed it." She was asked what was used before the carts. She stated, "we had plastic bags with the supplies, but we have the black boxes now" (which are the crash carts). At 10:32 a.m., LPN #14 was interviewed and asked which hall she was working on. She stated she worked on Halls 300 and 500. She was asked if she had a key to the crash cart for Halls 300 and 500. She stated no, none of her facility keys go to the crash carts. She was asked if she ever had to use the crash carts. She stated no. At 10:35 a.m., LPN #15 and LPN #16 on Hall 100 were interviewed and asked if they had a key to the crash cart. They both stated that central supply #1 had taken the keys to have them labeled. They were asked if they had to use the crash cart. They both stated no. LPN # 15 stated she had only been employed there two months and has never had to use the cart. LPN #16 stated she has been employed there [AGE] years and had to use emergency supplies in the past. She stated at that time they were kept in a plastic bag. Since they have had the carts, for the past 6 months, she has not had to use it. They were asked if they had an emergency situation right now would they have access to the cart. They stated, "That's a good question. Since we don't have a key, I guess not." At 10:37 a.m., RN #7 on Hall 500 was asked when the emergency cart was last used. She stated "Oh, not for a long time." She was asked if she had a key to the emergency cart. She stated yes we usually do but central supply #1 just came and took it. She was asked if she ever used the box (emergency cart). She stated yes, we have mock codes all the time. She was asked if during the mock codes, did she use or open the emergency cart. She stated, "We had it in the room, but we never opened it." At 10:39 a.m., RN #10, manager for Halls 100 and 600, was asked if she had a key to the crash carts on Halls 100 and 600. She stated she had given her key to central supply #1. She stated the charge nurses have not had to use the crash cart since they got them six months ago. At 10:40 a.m., LPN #11 on Hall 400 was interviewed and asked who has the key to the crash cart. She stated all the nurses here have a key. She was asked if she had a key. She stated, I normally do, but central supply #1 just came and got it. She was asked if she ever opened the cart. She stated yes. She was asked how did she open it. She stated with the key. She was asked if she actually opened the box with her key. She stated no but it worked. She was asked how did she know it worked. She stated, well, they tested it before they gave it to us. She was asked if she could open the cart. She stated no central supply #1 just took it. She was asked if she knew why they took it. She stated she needed to mark it. She was asked if there were a code right now, could you use this cart. There was silence from the nurse. She was then asked who checks the crash cart. She stated the night shift checks it. On 6/14/12 at 9:30 a.m., the DON was asked if she had a facility emergency cart policy. She stated she did not have an emergency cart policy. She stated the only policy she had was the emergency cart check off list.

On 04/28/11 at 11:52 a.m., an Immediate Jeopardy (IJ) situation was identified in accident hazards/supervision regarding the facility's failure to intervene when resident #8 continued to light cigarettes in her room after 1:1 supervision had been initiated and when the same resident had cigarette burn holes in her clothing. On 04/28/11 at 12:05 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). On 04/28/11 at 1:15 p.m., the facility's executive director and administrator were notified of the IJ pertaining to accident hazards/supervision. The facility was asked for a Plan of Removal for the IJ situation. On 04/28/11 at 5:45 p.m., the executive director and the administrator were notified of an extended survey related to the IJ situation. On 04/28/11 at 6:15 p.m., the Plan of Removal was received and accepted. The facility's Plan of Removal documented: "...The following plan of action outlines immediate interventions employed by the Center to abate any further concerns surrounding the above issue: Specific residents identified The resident was placed on a 2:1 observation on 4/28/11 at 3:30 p.m. A smoking assessment was completed on 04/28/11 by the DON (director of nurses) to evaluate the resident for safe smoking. The resident's room was searched for smoking contraband on 04/28/11 per physician order. The resident is being discharged Against Medical Advice from the center on 4/28/11 at the resident's request. The physician has been notified of the discharge. Identification of resident with potential to be affected: Residents who smoke will be re assessed on 4/28/11 by licensed nurse to identify safe smoking. Systematic Measures * The facility, with a physician's orders [REDACTED]. * Residents who smoke will be re educated on 4/28/11 by the Unit Managers to the centers smoking guidelines and smoking areas. * Staff will be re-educated by Staff Development Coordinator and/or management staff starting on 4/28/11 and complete by 11:30 p.m. on 4/30/11 to notify the DON and/or either the Administrator immediately regarding residents who are non compliant with smoking rules. Staff on leaves of absence or vacation will be re-educated prior to beginning their next scheduled shift. Remaining staff will be re-educated before the beginning of their next shift. * Residents will be monitored for safe smoking each shift by the licensed nurses during rounds. Quality Assurance Measures The Center held an Ad hoc Performance Improvement Committee meeting on 4-28-11 at 3:30 p.m. with the Medical Director to discuss the Plan of Correction. Discussion included steps taken to supervise the resident, identify other residents and reeducation. The Executive Director, Administrator and Director of Nursing will be responsible for oversight." On 05/02/11 at 12:35 p.m., the survey team reviewed documentation of staff inservices, residents' smoking evaluations, residents' acknowledgements of the facility's smoking policy/protocol, and staff monitoring of residents smoking. At her request, resident #8 had been discharged against medical advice on the evening of 04/28/11. Fifty-four staff were interviewed to ensure their attendance to and understanding of the inservice information. Five residents were interviewed to ensure their understanding of the facility's smoking policy/protocol. On 05/02/11 at 4:32 p.m. the facility was informed the IJ had been removed as of 04/30/11 at 11:00 p.m. when the last staff inservice was held. The deficient practice remained at a level of no actual harm with a potential for more than minimal harm at a pattern. Based on record review, observation, and interview, it was determined the facility failed to ensure residents' environment was as free of accident hazards as possible for 1 (#8) of 5 sampled residents who smoked. The facility identified 26 residents in the facility who smoked and 58 residents who resided on hall 3. The facility failed to: a. ensure a resident did not light cigarettes in her room after 1:1 supervision had been initiated. The resident lit a cigarette in her room on 8 occasions beginning on 03/29/11. The facility did not ensure 1:1 supervision was provided at all times and did not follow its policy to conduct a room search to remove smoking contraband when the resident continued to present an accident hazard by lighting cigarettes in her room. The facility failed to ensure the staff communicated all incidents of the resident lighting cigarettes in room to the administration. b. ensure a resident wore protective clothing to prevent burning holes in her clothing/bedding. Findings: Resident #8 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was cognitively intact; had mild depression; required extensive assistance with transfers, dressing, hygiene, and bathing; and had range of motion impairment on both sides of her lower extremities. The assessment documented she had exhibited verbally abusive behavioral symptoms directed toward others on 1-3 days during the 7 days prior to the assessment date. The assessment documented the resident had exhibited other behavioral symptoms not directed toward others on 1-3 days during the 7 days prior to the assessment date. The assessment documented the resident had rejected evaluation of care that was necessary to achieve the resident's goals for health and well-being on 1-3 days during the 7 days prior to the assessment date. The care plan dated 02/07/11 documented the resident had a problem related to "Resident unsafe smoke due to smoking in her bed." The single approach to the problem was "supervised smoker - with staff." The care plan documented she had a problem related to "(exhibits) behaviors: cursing staff, pushing against (wheelchair) of other residents, false accusations against staff and presents with anxiety as well." An intervention was to "explain what unacceptable behaviors are to resident and ensure that she understands this communication." The care plan dated 04/26/11 documented the resident had a problem related to "Smokes cigarettes and is unsafe with smoking habits. Smokes in room while in bed." The goal for the problem was "Will remain safe during smoking with supervision thru next review." Interventions to the problems included, "...Observe clothing for evidence of burns holes if present notify nursing staff immediately. Report any non compliance with smoking safety rules to physician, responsible party and center administrator. Smoking materials to be stored by nursing. Supervise all smoking." The safe burning evaluation dated 04/06/11 documented the following questions/answers: "...Personal belongings free from evidence of burn holes? (No was circled.) History free from smoking-related incidents? (No was circled.)" The staff member who completed the evaluation had not signed the form. A nurse's note dated 03/20/11 at 7:00 p.m. documented, "This nurse was called by aid (with complaint) from a visiting family member of another resident stating they smelled (cigarette) smoke coming out of this (resident's) room. (After) asking (resident) she stated she was not smoking in her room (that) what the aid and visitor were smelling were (cigarette) butts she has in a cigarette pack and she wasn't going to risk having privileges taken away by smoking in her room..." A nurse's note dated 03/29/11 (no time) documented, "Resident was laying in her bed in a supine position under multiple blankets smoking a cigarette. Resident had a can of air freshner on her chest. Resident took a couple of puffs from cigarette then sprayed air freshner. She had a (medication) cup on bedside table half filled (with) water (and) she was using it as an ashtray. This nurse asked resident why she was smoking in her room. She didn't reply. The cigarette was taken from resident. She was reminded of smoking policy. The Executive director (and) DON (director of nurses) notified." A nurse's note dated 03/30/11 at 4:30 p.m. documented, "Resident was smoking in room and social service (and) ADON (assistant director of nurses) notified. Room search done by ADON and social services. 2 1/2 packs of (cigarettes) was removed from room by social service. Resident on possibility of causing a fire and burns, verbalized understanding. Resident stated 'Negative attention better than (no) attention.'" A social services note dated 03/30/11 documented, "On 3/29/11 (Name withheld, resident #8) was caught smoking in her room. The ADON took her cigarettes from her and explained to her that her smoking in her room was against the rules and would not be tolerated. She charted on this. On 3-30-(11) this morning the DON was called because (name withheld, resident #8) was caught for the 2nd time smoking in her room. both times they spoke (with) her about the rules. they took her cigarettes and lighters from her. Social Service was called at 4 pm that she was smoking again in her room. I went (with) ADON to her room. I asked her if she was smoking in her room again, she said she was. I spoke (with) her about the rules and took her lighters and cigarettes again. This is the 3rd time in 2 days (name withheld, resident #8) had been smoking in her room. She seems as though she could care less about the rules and tolerance level of it." A social service note dated 03/31/11 documented, "...Per unit manager I gave her a lighter and 1 cigarette to go outside to smoke. (Name withheld, resident #8) said she would turn in the lighter when she is done smoking." There was no documentation of 1:1 supervision. A nurse's note dated 04/04/11 at 6:00 a.m. documented, "...I (a licensed practical nurse) gave her (resident #8) one (package) of Pall Mall cigarettes per her request this shift." There was no documentation of 1:1 supervision. A nurse's note dated 04/05/11 at 4:18 a.m. documented, "Spoke to resident regarding (incidents) of smoking policy and that since she continued smoking in her room while in bed as evidence of burn holes in her blankets that by smoking assessment she was an unsafe smoker and would need to have staff with her when she smoked she stated, 'that's ok I will call the state on your (a**) because I will not be a supervised smoker' Resident was informed that her lighter and cigarettes would be at the nurses desk and when she was ready to smoke they would assist her." A nurse's note dated 04/08/11 at 10:30 p.m. documented the registered nurse had given the resident an open pack of cigarettes. There was no documentation of 1:1 supervision. A nurse's note dated 04/09/11 at 2:20 p.m. documented, "Continues to have 1:1 care do (sic) to smoking at bedside." A nurse's note dated 04/10/11 at 12:45 p.m. documented, "Smoke smell in hallway noted by this nurse - entered residents room (and) found resident spraying airfreshner. Smoke present in room. Asked resident if she was smoking in room. Resident replied yes. CNA assigned to do 1:1 supervision not present. Cigarettes (received) from resident (and) placed back in (medication) room. CNA assigned to do 1:1 returned stating she had went to lunch. Weekend supervisor (and) on call manager notified." A nurse's note dated 04/10/11 at 1:00 p.m. documented, "Went to residents room, spoke (with) resident (regarding) smoking policy...Informed resident she was not allowed to smoke inside building. 1:1 attendent had gone to lunch and had per statement informed another CNA. (Charge) nurse smelled smoke, removed 1 lighter (and) 1 (cigarette) from her possession. Resident denies any more in her possession. 1:1 care given at bedside. Resident non compliant (with) facility policy on staff request for safety issues of this resident and other residents in facility. (Name withheld, the DON) notified of issues." A nurse's note dated 04/11/11 at 11:30 p.m. documented, "(Resident) came for cigarettes (and) lighter from this nurse. (Received) one pack of cigarettes (and) a lighter. Nurse (initials withheld) witnessed it." There was no documentation of 1:1 supervision. A social services note dated 04/12/11 at 8:15 a.m. documented, "(resident) has also been caught several times smoking in room smells like smoke, is on one on one right now and all (cigarettes) and lighters have been taken..." A nurse's note dated 04/12/11 at 2:05 a.m. documented, "Called the on-call nurse...about resident getting a pack of cigarettes (and) a lighter. She (on-call nurse) asked this nurse to take it back from this resident." A nurse's note dated 04/20/11 at 3:40 p.m. documented, "Reported to this nurse that on am of 4-19-11 she went to provide one on one (with) resident (at) about (8:00 a.m. and) resident was smoking in her room." A nurse's note dated 04/20/11 at 11:00 p.m. documented, "Resident was up in her scooter and was out several times during shift to smoke." There was no documentation of 1:1 supervision. A nurse's note dated 04/22/11 at 11:00 p.m. documented, "Still up in her scooter. Out several times to smoke in this shift." There was no documentation of 1:1 supervision. A nurse's note dated 04/26/11 at 6:45 a.m. documented, "...(Resident) ignored CNA and went out to smoke at (5:35 a.m.)." There was no documentation of 1:1 supervision. A nurse's note dated 04/26/11 at 3:00 a.m. documented, "Resident in (wheelchair) going out to smoke..." There was no documentation of 1:1 supervision. A nurse's note dated 04/26/11 at 4:30 a.m. documented, "(Resident) still awake in her (wheelchair) going out to smoke..." There was no documentation of 1:1 supervision. A nurse's note dated 04/26/11 at 10:00 a.m. documented, "Resident sitting on (bedside commode). one:one took all (cigarettes and) lighter so she thought went (and) stood outside of the room. Nurse doing rounds with on coming staff. When smoke was noted coming from the residents room. ADON notified on coming staff notified. State (investigators) notified I smelled smoke from this resident room. One pack (and) lighter removed from this residents room." On 04/26/11 at 2:50 p.m., 2 surveyors interviewed resident #8 in the designated smoking area of the facility. The resident had possession of a lighter and a small cigar during the interview and attempted to light the cigar repeatedly. Once the cigar was lit, the resident flipped it about as she talked. Ashes fell off the cigar onto her lap, however, the surveyors did not observe any burn holes in her clothing or blanket at that time. When the resident wanted to extinguish the cigar, she pressed it against the arm of her electric wheelchair. A nurse's note dated 04/27/11 at 5:10 a.m. documented, "...1:1 CNA reported to this (charge nurse, resident) lit a cigarette while in bed..." A nurse's note dated 04/27/11 at 3:30 p.m. documented, "Resident in room - smoke odor smelled in hallway - upon entering room smoke noted. Asked resident if she had been smoking and she stated yes that her 1:1 CNA had been gone for 30 (minutes) so she smoked. Resident turned over pack of (cigarettes) to this nurse. ADON notified." A nurse's note dated 04/27/11 at 11:00 p.m. documented, "Resident was out several times today to smoke..." There was no documentation of 1:1 supervision. On 04/28/11 at 10:00 a.m., the surveyor interviewed the ADON regarding resident #8. The ADON reported that staff, including herself, had observed the resident smoking in her bed. The ADON showed the surveyor 3 packs of cigarettes behind the nurses station which were confiscated from the resident by staff. The ADON reported staff were only to give the resident 2 cigarettes at a time. The 1:1 staff was to assist the resident when she went outside to smoke. The surveyor asked the ADON if the resident had ever burned herself or her clothing or bedding. She replied, "Yes." She stated the resident's blanket had numerous holes in it." On 04/28/11 at 10:30 a.m., the surveyor reviewed the resident's smoking evaluation dated 04/06/11 with the DON and ADON. The surveyor noted the evaluation documented the resident's personal belongings were not free of burn holes and asked if, to their knowledge, the resident was still burning holes in her blankets and clothing. The DON stated, "Yes." The ADON stated, "Yes." The surveyor asked the DON if she had been made aware of the smoking incident on 04/27/11 at 5:10 a.m. She stated she did not know the resident had lit a cigarette in her room at that time. On 04/28/11 at 12:40 p.m., the surveyor asked the executive director at what point she knew resident #8 was lighting cigarettes in her room. She stated, "The end of March." The surveyor asked what the facility did at that point to prevent re-occurrence. She stated the facility initiated 1:1 supervision. The surveyor asked what date the 1:1 supervision was initiated. She stated, "The end of March." The surveyor asked if the 1:1 supervision had prevented the resident from lighting cigarettes in her room. She stated, "Not entirely, no." The surveyor asked if the intervention of 1:1 supervision was working, based on the documentation of the resident lighting cigarettes in her room 3 times on 04/27/11. The executive director stated, "Obviously not." The surveyor asked if incident reports had been completed each time the resident had lit a cigarette in her room. The executive director stated, "I don't think so." The surveyor asked if incident reports should have been completed. She stated, "Yes." The surveyor reviewed the resident's care plan interventions pertaining to smoking with the executive director and asked if she had been notified about all the incidents when resident #8 had lit a cigarette in her room. She stated, "No." The surveyor asked if all smoking materials had been stored by nursing. She stated, "No." The surveyor asked if all smoking had been supervised. The executive director stated, "No." The surveyor informed the executive director and administrator the DON and ADON had stated that morning that resident #8 currently burned holes in her clothing and blankets. The surveyor asked if they were aware the resident currently burned holes in her clothing and blankets. They both stated they were not aware. The facility's smoking policy documented: "It is the center's policy to provide a smoke free environment for residents while protecting resident rights...The Interdisciplinary Team ensures a Safe Smoking evaluation...is completed...Residents deemed not safe may be restricted from smoking. Interventions are entered onto the resident's care plan...Violations of smoking rules will be addressed by the center Administrator...Smoking materials will be stored with the Licensed Nurse..." The facility's accidents/incidents policy documented: "It is the center's policy to provide an environment that is free from hazards over which the center has control...Incidents and accident reports are part of the center quality assurance process...An incident or accident is an unexpected occurrence with intention or design, or taking place not in the usual course of things or events - including but not limited to: ...smoking incident...The Licensed Nurse will complete an evaluation of the resident and the environment to identify potential risk factors...In the event an accident or incident occurs the Licensed Nurse: ...Completes an evaluation of the environment and resident(s)...Notifies the physician and responsible party and center administrative staff as needed...completes incident report or applicable automated event management system, immediately following the event...Initiates measure to prevent a re-occurrence...The DON (director of nurses)/designee conducts an investigation of each incident/accident...The DON/designee implements appropriate interventions to protect the resident(s) and prevent re-occurrence...The Administrator/designee files reports with appropriate departments and/or agencies according to state and federal requirements...The DON maintains records related to incidents/accidents and reports regularly to the QM (quality management) Committee." The facility's room search policy documented: "The center reserves the right, when reasonable suspicion is present, to institute resident clothed body or a room search to remove potentially dangerous, unsafe or illegal items...An item is considered dangerous and may result in a room search if: Dangerous objects or potentially dangerous objects are items that may inflict harm or injury to self or others. These items include, but are not limited to...flammable materials such as matches, lighters... cigarettes...will be removed from a resident's easy access...When a staff member identifies or suspects an unsafe situation; A room search may be conducted if there is a strong reason to suspect that a resident has dangerous or unsafe items in his/her possession..." On 05/02/11 at 2:40 p.m., the surveyor reviewed the room search policy with the executive director and asked if the facility had followed the policy when the resident started to light cigarettes in her room. She stated the policy had not been followed.