Every finding on record at Southern Pointe Living Center

Based on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours a day for 2 of 3 months of time details for registered nurses reviewed.The administrator identified 42 residents resided in the facility.Findings:A Time Detail Report, dated 07/01/25 through 07/31/25, showed no RN hours for Friday, 07/11/25; Monday, 07/14/25; Monday, 07/28/25; and Tuesday, 07/29/25. A Time Detail Report, dated 08/01/25 through 08/31/25, showed no RN hours for Thursday, 08/07/25; Tuesday, 08/26/25; Friday, 08/29/25; and Sunday, 08/31/25.No other RN documentation was provided at the time of the survey.On 09/18/25 at 12:15 p.m., the business office manager stated the DON's last day of employment was Thursday, 06/20/25.On 09/18/25 at 2:13 p.m., the regional director of operations stated the RN called in Sunday, 08/31/25.

On 04/07/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident's right to be free from neglect. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. There was no documentation upon admission of Resident #3 having any skin issues. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed there were no skin concerns. There were no documented skin assessments between 01/26/25 and 02/10/25. A nursing note, dated 02/10/25 at 6:55 p.m., showed Resident #3 was transferred to hospital for altered mental status and slurred speech. There was no documentation of concerns related to the buttock or coccyx. A hospital wound consult note, dated 02/14/25, showed Resident #3 presented upon admission with an unstageable pressure injury to right medial buttock measuring 2.2 cm x 2.0 cm, an improving unstageable pressure injury to right sided coccyx measuring 0.9 cm x 1.4 cm, an unstageable pressure injury to left sided medial coccyx measuring 0.6 cm x 0.9 cm, and an improving open deep tissue injury to midline coccyx measuring 0.6 cm x 0.4 cm. On 04/07/25 at 2:53 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/07/25 at 3:34 p.m., the administrator was notified of the IJ situation and provided the IJ template On 04/07/25 at 8:57 p.m., an acceptable plan of removal was approved by the Oklahoma Stated Department of Health. The plan of removal, read in part, April 7, 2025 Southern Pointe Living Center Plan of Removal for Neglect Completion Date 4-8-25 4:00 p.m. All staff will be educated on the Abuse and Neglect Policy & Procedures. A sign in sheet will be utilized for employees that are currently working in the facility. Any remaining staff that aren't at the facility will be called and educated over the telephone. Employee name and time of call will be documented. Currently in progress: All residents will be assessed head to toe for skin issues. Skin assessments will be completed for each resident. Wound assessments will be completed for each skin area identified. A SBAR and incident report will be completed for any identified skin areas. Weekly skin assessments will be completed for each resident. Weekly wound assessments will be completed until each skin area is resolved. The physician will be notified for any resident having skin areas and treatment orders will be obtained. The resident/responsible party will be notified of any new orders received from the physician. The dietary manager will be notified of any pressure ulcers identified. Skin care plans will be updated if applicable. The IJ was lifted on 04/08/25 at 5:53 p.m., when all components of the plan of removal had been verified as completed. Staff education related to abuse and neglect, resident skin assessments, and physician notification regarding resident skin issues were reviewed. 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 ensure a resident at risk for pressure ulcers was not neglected by not being assessed and monitored to prevent pressure ulcers for 1 (#3) of 3 residents sampled for pressure ulcers/pressure injury. The administrator identified 41 residents resided in the facility. Findings: A policy titled Abuse-Reportable Events, revised 08/2019, read in part, Neglect .The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Deprivation of Goods and Services .when staff has the knowledge and ability to provide care and services, but choose not to do it or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident .It is the responsibility of every employee to report immediately anything that could adversely affect the health and welfare of any resident. A policy titled Skin Integrity Monitoring System, revised on 04/03/21, read in part, It is the policy of this facility that .A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown .A system will be in place to assure that all residents will be assessed, and preventative measures will be in place to prevent the development of pressure ulcers .A system will be in place to assure any type of skin conditions that do not constitute pressure ulcers will be monitored for any type of complications .CNA's will report any changes in skin integrity to the charge nurse using the daily CNA bath sheet. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Resident #3's admission assessment, dated 07/13/23, showed Resident #3 had no skin issues and no pressure ulcers upon admission, and they were at risk for pressure ulcers. Resident #3's quarterly assessment, dated 01/13/25, showed Resident #3 required substantial/maximal assistance from staff with their ADL's. The assessment showed there were no skin issues. There was no documentation Resident #3 had weekly skin assessments conducted between 01/26/25 through 02/10/25. There was no documentation Resident #3 received treatment for pressure ulcers/pressure injuries. A nursing note, dated 02/10/25 at 6:55 p.m., showed Resident #3 was transferred to hospital for altered mental status and slurred speech. There was no documentation of concerns related to the buttock or coccyx. A hospital wound consult note, dated 02/14/25, showed Resident #3 presented upon admission with an unstageable pressure injury to right medial buttock measuring 2.2 cm x 2.0 cm, an improving unstageable pressure injury to right sided coccyx measuring 0.9 cm x 1.4 cm, an unstageable pressure injury to left sided medial coccyx measuring 0.6 cm x 0.9 cm, and an improving open deep tissue injury to midline coccyx measuring 0.6 cm x 0.4 cm. On 04/03/25 at 10:43 a.m., regional nurse consultant stated there was no documentation of wounds prior to Resident #3 readmitting on 02/20/25 at 4:12 p.m. to the facility. On 04/03/25 at 11:43 a.m., regional nurse consultant stated the expectation of staff was to look at the residents' skin and document any findings on the skin sheet. On 04/03/25 at 11:45 a.m., regional nurse consultant stated none of the CNAs documentation showed Resident #3 had skin issues. On 04/03/25 at 4:50 p.m., regional nurse consultant stated no inservices had been conducted to address the lack of skin assessments.

On 04/07/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. An admission assessment, dated 07/13/24, showed no skin concerns. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed no skin concerns. There were no documented skin assessments between 01/26/25 and 02/10/25. A nursing note, dated 02/10/25 at 6:55 p.m., showed Resident #3 was transferred to hospital for altered mental status and slurred speech. There was no documentation of concerns related to the buttock or coccyx. A hospital wound consult note, dated 02/14/25, showed Resident #3 presented upon admission with an unstageable pressure injury to right medial buttock measuring 2.2 cm x 2.0 cm, an improving unstageable pressure injury to right sided coccyx measuring 0.9 cm x 1.4 cm, an unstageable pressure injury to left sided medial coccyx measuring 0.6 cm x 0.9 cm, and an improving open deep tissue injury to midline coccyx measuring 0.6 cm x 0.4 cm. On 04/07/25 at 2:53 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/07/25 at 3:34 p.m., the administrator was notified of the IJ situation and provided the IJ template. On 04/07/25 at 8:57 p.m., an acceptable plan of removal was approved by the Oklahoma Stated Department of Health. The plan of removal, read in part, April 7, 2025 Southern Pointe Living Center Plan of Removal for Pressure Ulcers Completion Date 4-8-25 4:00 p.m. All staff will be educated on the Skin Policy and Procedures by the Regional Nurse, [name withheld, and/or [name withheld], Regional Director. A sign in sheet will be utilized for staff that are currently in the facility. Any remaining staff will be called to the facility for education; or educated over the telephone. Employee names and time of call will be documented. Currently in progress: All residents will be assessed head to toe for skin issues. Skin assessments will be completed for each resident. Wound assessments will be completed for each skin area identified. A SBAR and incident report will be completed for any identified skin areas. Weekly skin assessments will be completed for each resident. Weekly wound assessments will be completed until each skin area is resolved. The physician will be notified for any resident having skin areas and treatment orders will be obtained. The resident/responsible party will be notified of any new orders received from the physician. The dietary manager will be notified of any pressure ulcers identified. Skin care plans will be updated if applicable. The IJ was lifted on 04/08/25 at 5:53 p.m., when all components of the plan of removal had been verified as completed. Staff education related to skin policy and procedures, resident skin assessments, and physician notification regarding resident skin issues were reviewed. 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 ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers for 1 (#3) of 3 residents sampled for pressure ulcers/pressure injury. The regional nurse consult identified three residents residing in the facility had pressure ulcers. Findings: A policy titled Skin Integrity Monitoring System, revised 04/03/21, read in part, It is the policy of this facility that: .A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown .A system will be in place to assure that all residents will be assessed, and preventative measures will be in place to prevent the development of pressure ulcers .A system will be in place to assure any type of skin conditions that do not constitute pressure ulcers will be monitored for any type of complications .CNA's will report any changes in skin integrity to the charge nurse using the daily CNA bath sheet. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Resident #3's admission assessment, dated 07/13/24, showed Resident #3 had no pressure ulcers upon admission and they were at risk for pressure ulcers. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed no skin issues. There were no documented skin assessments between 01/26/25 and 02/10/25. A nursing note, dated 02/10/25 at 6:55 p.m., showed Resident #3 was transferred to hospital for altered mental status and slurred speech. There was no documentation of concerns related to the buttock or coccyx. A hospital wound consult note, dated 02/14/25, showed Resident #3 presented upon admission with an unstageable pressure injury to right medial buttock measuring 2.2 cm x 2.0 cm, an improving unstageable pressure injury to right sided coccyx measuring 0.9 cm x 1.4 cm , an unstageable pressure injury to left sided medial coccyx measuring 0.6 cm x 0.9 cm, and an improving open deep tissue injury to midline coccyx measuring 0.6 cm x 0.4 cm. On 04/03/25 at 10:43 a.m., the regional nurse consultant stated there was no documentation of wounds prior to Resident #3's readmission on 02/20/25 at 4:12 p.m. to the facility. On 04/03/25 at 10:45 a.m., the regional nurse consultant stated the hospital documented the pressure ulcers as present on admission. On 04/03/25 at 5:20 p.m., Resident #3's family member stated they had not been informed by the facility of the having any skin issues. They stated they were informed on 02/11/25 by the admitting hospital Resident #3 had admitted with pressure ulcers.

Based on observation, record review, and interview the facility failed to develop a comprehensive care plan related to nutrition and elopement for two (#22 and #50) of 12 residents reviewed for care plans. The DON identified 42 residents who resided in the facility. Findings: 1. Res #22 had diagnoses which included muscle wasting and atrophy, hypokalemia, and vitamin deficiency. An admission assessment dated [DATE], documented the resident was intact with cognition and had frequent pain. The assessment documented the resident weight was 241 pounds. The CAA area of the MDS triggered to care plan nutritional status. A quarterly assessment, dated 03/11/24 documented the resident was intact with cognition and documented the resident's weight was 205 pounds and was not on a physician prescribed weight loss program. On 04/01/24 at 12:53 p.m., the resident was observed in the recliner in their room. The noon meal had been served and he was not eating it. The resident stated they eat breakfast then they start having stomach pain. The resident stated they do not want to eat lunch they would just want to sleep. Res #22 stated they were not hungry at all and had lost about 30 pounds. The resident stated they really did not have an issue with the weight loss. On 04/04/24 at 2:21 p.m., the MDS coordinator stated the the resident did not have a nutrition care plan. 45913 2. Res #50 had diagnoses which included dementia and mood disorder. The Elopement policy, undated, read in part, .Upon admission, quarterly and with significant change in status, the nurse will complete an Elopement Screen. Those residents at risk for elopement will have an Elopement Risk Alert completed . An LTC - Admission Assessment/Observation Documentation, dated 11/01/23, documented Res #50 was an elopement risk. A progress note, dated 11/28/23 at 2:35 a.m. documented the resident eloped from the facility through a torn window screen. A progress note, dated 11/28/23 at 1:57 p.m., documented the resident was located at 5:45 a.m. and would be transferred to a geri-psych facilty. A progress note, dated 12/18/23, documented the resident returned to the facility from geri-psych. Res #50's comprehensive care plan did not include an elopement risk care plan at the time the admission assessment documented Res #50 was an elopement risk. On 04/04/24 at 4:15 p.m., RN #2 reported they did not initiate an elopement risk care plan until the resident returned from the geri-psych facility.

Based on record review and interview, the facility failed to follow physician orders for three (#1,#22, and #34) of 12 resident reviewed for following physician orders. The DON identified 42 residents who resided in the facility. Findings: 1. Res #22 had diagnoses which included muscle wasting and atrophy, hypokalemia, and vitamin deficiency. A quarterly assessment, dated 03/11/24 documented the resident was intact with cognition. The assessment documented the resident's weight was 205 pounds and was not on a physician prescribed weight loss program. Physician orders, dated 12/09/24, documented to document the amount consumed by the resident for breakfast, lunch, dinner and the amount of fluids consumed with the meals. The meal % documentation was not completed for all meals daily. The documentation was observed for the month of March and to April 4th. On 03/07/23, 03/09/24, 03/14/24, and 03/23/24 there was no meal % documented. On 04/04/24 at 1:30 p.m., The DON stated the meal % were just not being charted as ordered. 45913 2. Res #1 had diagnoses which included diabetes A physician's order, dated 08/22/23, read in part, Novolog U-100 Insulin .per Sliding Scale; If Blood Sugar is less than 70, call MD. If Blood Sugar is 70 to 179, give 0 Units. If Blood Sugar is 180 to 200, give 2 Units. If Blood Sugar is 201 to 230, give 3 Units. If Blood Sugar is 231 to 260, give 4 Units. If Blood Sugar is 261 to 290, give 5 Units. If Blood Sugar is 291 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 7 Units. If Blood Sugar is greater than 350, give 8 Units. If Blood Sugar is greater than 350, call MD. subcutaneous Twice A Day . The Diabetic Flowsheet for March 2024 documented the following: On 03/03/24 at 4:30 p.m., Res #1's blood sugar was 362. There was no documentation the physician was notified of the out of parameter blood sugar. On 03/04/24 at 4:30 p.m., Res #1's blood sugar was 439. There was no documentation the physician was notified of the out of parameter blood sugar. On 03/05/24 at 4:30 p.m., Res #1's blood sugar was 401. There was no documentation the physician was notified of the out of parameter blood sugar. The Diabetic Flowsheet for February 2024 documented the following: On 02/10/24 at 4:30 p.m., Res #1's blood sugar was 358. There was no documentation the physician was notified of the out of parameter blood sugar. On 02/21/24 at 4:30 p.m., Res #1's blood sugar was 369. There was no documentation the physician was notified of the out of parameter blood sugar. 3. Res #34 had diagnoses which included diabetes. A physician's order, dated 03/13/24, read in part, Insulin aspart U-100 insulin pen; 100 unit/mL .per Sliding Scale: If Blood Sugar is less than 70, call MD. If Blood Sugar is 180 to 200, give 4 Units. If Blood Sugar is 201 to 230, give 5 Units. If Blood Sugar is 231 to 260, give 6 Units. If Blood Sugar is 261 to 290, give 9 Units. If Blood Sugar is 291 to 320, give 12 Units. If Blood Sugar is 321 to 350, give 15 Units. If Blood Sugar is greater than 350, give 18 Units. subcutaneous Before Meals and At Bedtime . The Diabetic Flowsheet, for March 2024, documented the following: On 03/25/24 at 11:00 a.m. Res #34's blood sugar was 356. There was no documentation the physician was notified of the out of parameter blood sugar. On 03/30/24 at 11:00 a.m., Res #34's blood sugar was 354. There was no documentation the physician was notified of the out of parameter blood sugar On 03/18/24 at 8:00 p.m., Res #34's blood sugar was 356. There was no the physician was notified of the out of parameter blood sugar. On 04/04/24 at 12:45 p.m., the DON reported the nurses should document either on the back of the Diabetic Flowsheet or in the progress notes when they notify a physician of an out of parameter blood sugar. The DON reported the nurses didn't call the physician but should have.

Based on observation, record review, and interview, the facility failed to ensure menus were followed for one meal service for the puree meals. The DM identified three residents who eat a puree diet. Findings: On 04/03/24 11:18 a.m., the DM started the puree with cherry cobbler. At 11:27 a.m. the cabbage was pureed, at 12:04 pm., the sausage was pureed, and at 12:11 p.m. the potatoes were pureed. Corn bread for the puree meal was not observed. The menu for 04/03/24 was Kielbasa, fried potatoes, cabbage, cornbread, and fruit cobbler. The puree menu documented the residents were to receive a #10 scoop of cornbread. On 04/03/24 at 1:04 p.m., the DM stated the residents who have the pureed meals should have also received cornbread with their meal. The DM stated they were nervous and missed the corn bread.

Based on record review and interview, the facility failed to ensure a resident at risk for elopement was properly assessed and monitored to prevent elopement from the facility for one (#50) of two residents reviewed for elopement risk. Findings: The Elopement policy, undated, read in part, .Upon admission, quarterly and with significant change in status, the nurse will completed an Elopement Screen. Those residents will have an Elopement Risk Alert completed . Res #50 had diagnoses which included dementia and mood disorder. An LTC - Admission Assessment/Observation Documentation, dated 11/01/23, documented Res #50 was an elopement risk. A progress note, dated 11/28/23 at 2:35 a.m., documented the resident eloped from the facility through a torn window screen. A progress note, dated 11/28/23 at 1:57 p.m., documented the resident was located at 5:45 a.m. and would be transferred to a geri-psych facility. A progress note, dated 12/18/23, documented the resident returned to the facility from geri-psych. Res #50's comprehensive care plan did not include an elopement risk care plan at the time the admission assessment documented Res #50 was an elopement risk. On 04/04/24 at 4:15 p.m., RN #2 reported they did not initiate an elopement risk care plan until the resident had returned from geri-psych. RN #2 reported they did complete an elopement risk alert but wasn't sure if it was before or after Res #50's elopement. RN #2 reported a wander guard was placed on the resident but could not recall if placement was done before or after Res #50's elopement. RN #2 was unable to provide any documentation regarding Res #50's wander guard. RN #2 reported an elopement risk assessment has not be completed on Res #50 since their return from geri-psych. RN#2 reported they would be working on completing elopement risk assessments as per their policy.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#4 and #7) of 12 sampled residents whose resident assessments were reviewed. The DON identified 42 residents who reside in the facility. Findings: 1. Res #7 had diagnosis which included COPD, Bipolar disorder, Schizoaffective disorder, and dementia. A significant change assessment, dated 03/06/24, documented the resident was severly impaired with cognition and required partial to moderate assistance with most ADLs. The assessment documented a GDR had not been contraindicated. A MRR request, dated 09/27/23, documented the following medications are due for consideration of a GDR for clonazepam, Vraylar, and Risperdal. On 10/02/23 the physician did not wish to reduce the medication. The physician documented the resident was on hospice. On 04/03/24 at 2:12 p.m., the corporate nurse consultant #1 stated the contraindication should have been dated 09/27/23 on the MDS. 45913 2. Res #4 had diagnoses which included osteoporsis. Progress notes dated 02/06/24 at 1:09 a.m., through 02/07/24 at 10:00 a.m., documented Res #4 fell in their bathroom and sustained a left hand fracture. The discharge resident assessment, dated 02/25/24, documented in error Res #4 had a fall with injury. Fall with major injur should have been documented. On 04/04/24 at 4:07 p.m., the MDS Coordinator reported they did not think a fractured finger/hand would be considered a major injury especially because no treatment was required. The MDS Coordinator reported they thought a major injury would be considered a hip fracture or another major bone. The MDS Coordinator reported not being sure what the RAI manual documented regarding falls with major injury.

Based on record review and interview, the facility failed to notify OHCA of a new diagnoses of serious mental illness for one (#7) of one sampled resident whose PASRR I was reviewed. The DON identified 42 residents who resided in the facility. Findings: Res #7 was admitted to the facility on [DATE] and had diagnoses which included Schizoaffective disorder and major depressive disorder. On 11/07/22 A PASRR I was completed. The PASRR I did not document the resident had a serious mental illness. On 12/30/22, the resident received a new diagnosis of Bipolar disorder, unspecified. OHCA was not contacted regarding the new diagnoses. On 04/04/24 at 8:45 a.m., corporate nurse #1 confirmed OHCA was not called when the resident got a new diagnoses in December of 22.

Based on record review and interview, the facility failed to complete a PASRR I for a newly admitted resident who remained in the facility for one (#7) of one sampled resident whose PASRR I was reviewed. The DON identified 42 residents who resided in the facility. Findings: Res #7 had was admitted to the facility on [DATE] and had the diagnoses of Schizoaffective disorder. A PASRR I was not located as completed on admission. On 02/14/22 the resident received the diagnosis of major depressive disorder, recurrent, moderate. On 11/07/22 A PASRR I was completed. The PASRR I did not document the resident had a serious mental illness. On 12/30/22, the resident received a new diagnosis of Bipolar disorder, unspecified. On 04/04/24 at 8:47 a.m., corporate nurse #1 stated the PASRR I was completed late they were not able to fine a PASRR I on admission.

Based on record review and interview, the facility failed to ensure resident's rights to allow/receive visitors of the resident's choice for one (#33) of one sampled resident reviewed for visitation. The DON identified 42 resident who resided in the facility. Findings: An undated facility policy titled VISITING REGULATIONS, read in part, .Establish a measurable goal for active participation and social interaction with visitors of the resident's choice . Res #33 had diagnoses which included chronic pain syndrome, chronic kidney disease, and adjustment disorder with depressed mood. A five day assessment, dated 03/16/24, documented the resident was intact with cognition and required supervision or touch assistance with most ADLs. On 04/01/24 at 10:22 a.m., the resident councel president stated the can have visitors of choice. They stated Res #33 had talked to them about not being allowed visitor of choice. The resident councel president stated they had talked to the administrator and the ombudsman had been to the facility and now Res #33 can have the visitor of their choice. On 04/02/24 at 9:00 a.m., Res #33 stated when they were in the hospital their friend was the only person who came to see them. Res #33 stated their friend came to see them after they got out of the hospital. Res #33 stated the visitor came on a Sunday to her room and brought a gown and robe. Res #33 stated the friend was asked to leave the facility by the facility staff. Res # 33 stated they had talked to the administrator and they were told the friend was not allowed in the facility anymore. Res #33 stated they told the administrator that was their friend and they wanted to see them. Res #33 stated the ombudsman had been in the facility and visited with them and the administrator. Res #33 stated her friend had been a wonderful friend, someone they could talk to and share their dreams with. On 04/03/24 at 2:34 p.m., CNA #1 stated they were told by the administrator Res #33's friend could not be in the facility without the administrator being there. CNA #1 stated the administrator told them to ask the friend to leave the facility. CNA #1 stated the friend left the facility as asked. CNA #1 stated they were told the friend was not allowed on the premises. 04/03/24 02:43 p.m., CNA #2 stated their boss had asked CNA #1 to ask Res #33's friend politely to leave the facility. CNA #2 stated they were in the residents room when the visitor was asked to leave. CNA #2 stated they were not aware of why the friend was not able to visit. On 04/03/24 at 2:47 p.m., the DON stated they did not know much about the visitation issue. The DON stated they were not aware of why the person was not allowed to visit the resident. She stated she did not have a concern of the person visiting Res #33. On 04/03/24 at 2:54 p.m., the administrator stated the visitor was an previous employee which ended working at the facility on bad terms. The administrator stated they knew the resident could have visitors of their choice but from their point of view they were trying to protect the resident of things the resident may not be aware of. The administrator stated they did not want to upset the resident and knows they can not control who visits but felt they were acting in the best interest of the resident.

Based on observation, record review and interview the facility failed to conduct pain assessments for two (#10 and #24) of two resident reviewed for pain. The DON identified 42 residents who resided in the facility. Findings: The Pain - Clinical Protocol policy, last revised October 2010, read in part, .2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is an onset of new or worsening of existing pain. 3. The staff will staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. 1. Res #10 had diagnoses which included pain. An annual assessment, dated 01/17/24, documented the resident was moderately impaired with cognition and was independent with most ADLs. The assessment documented the resident had occasionaly pain that affected sleep and interfered with activities. The assessment documented the resident received PRN pain medication. The resident did not have any pain assessments in the EHR. The residents care plan, last revised 01/29/24, documented the resident complained of pain prn with muscle spasms. The care plan documented to monitor and record any complaints of pain, location, frequency effect on function, intensity, alleviating factors, aggravating factors. On 04/01/24 at 12:45 p.m., Res #10 was observed in the dining room rubbing their right knee. Res #10 reported they were having pain in their knee. The resident stated, I heard and felt something pop in my knee and ever since it has been hurting. Reported topical pain medication helped with pain. Received as needed oral pain medication and reports it helps but that her knee was not getting better. Resident reported they had told staff and denied receiving an X-Ray or any evaluation of pain. On 04/01/24 at 1:00 p.m., Res #10 was observed to sit down in recliner in the television room. The resident cried out in pain, grabbed right knee and was rubbing it and stated, Something sure is wrong with my knee! Reported she has been hurting for several days like this. 04/01/24 at 1:10 p.m., Res #10 was observed in the lobby getting up from a seated position. Res #10 was grimacing in pain during observation. On 04/04/24 at 11:07 a.m., the DON stated they just started a new system this month and they would perform a pain assessment quarterly to co inside with the MDS. On 04/04/24 at 10:35 a.m., the DON and MDS coordinator could not provide a pain assessment that wasn't the MDS. 45913 2. Res #24 had diagnoses which included chronic pain, peripheral autonomic neuropathy, and peripheral vascular disease Res #24's moderate chronic pain care plan, dated 07/12/21, read in part, .Assess characteristics of pain; location, duration, aggravating/alleviating factors, radiation and intensity . There were no pain assessments in Res #24's clinical record. 04/01/24 at 1:15 p.m. Res #24 reported they had pain not relieved by their current medication regime. Res #24 reported they received their pain medication every six hours and have requested their pain medication be given more frequently, at least every three to four hours. Res #24 reported they have asked the charge nurses and the physician to get their pain medication more often, but the administration times have not changed. Res #24 reports break through pain between 6:00 p.m. and midnight and midnight and 6:00 a.m. Res #24 reported they could not get relief from their pain around the clock. Res #24 reported their pain was related to an old right foot fracture and neuropathy. On 04/04/24 at 2:35 p.m., the DON and MDS Coordinator reported they were unaware Res #24 was having pain not relieved by their current medication regime. They reported the DON just started doing pain assessments in March. The DON and MDS reported the MDS was a form of a pain assessment, but acknowledged it did not include the components required by their policy and care plan.

Based on record review and interview the facility failed to complete a MRR in the required time frame for one (#7) of five residents reviewed for unnecessary medications. The DON identified 42 residents who resided in the facility. Findings: An undated facility policy Medication Monitoring Medication Regimen Review and Reporting, read in part .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days . Res #7 had diagnoses which included bipolar disorder, major depressive disorder, and schizoaffective disorder. A MRR, dated 02/21/24, documented lorazepam 1 mg every six hours PRN anxiety or lorazepam 2 mg/ml 0.25 ml (0. 5mg) every two hours PRN anxiety/restlessness. The MRR documented are both of the above orders needed at this time or could one be stopped. The physician documented to discontinue the lorazepam 2 mg/ml every two hours PRN anxiety/restlessness. The MRR was dated 04/02/24. The GDR request was not completed in the 30 time frame in the facilities MRR policy. A significant change assessment, dated 03/06/24, documented the resident was severly impaired with cognition and had inattention and altered level of consciousness that comes and goes. the assessment documented the resident received an antipsychotic, antianxiety, antidepressant , and a hypnotic during the look back period. On 04/03/24 at 10:28 a.m., the DON stated the physician did not respond to the 02/21/24 MRR request with in the 30 day time frame.

Based on record review and interview the facility failed to ensure residents did not receive psychotropic medication, unless for a specific diagnoses condition for one (#7) of five residents reviewed for unnecessary medication. The DON identified 42 residents who resided in the facility. Findings: Res #7 had diagnoses which included bipolar disorder, major depressive disorder, and schizoaffective disorder. A significant change assessment, dated 03/06/24, documented the resident was severly impaired with cognition and had inattention and altered level of consciousness that comes and goes. the assessment documented the resident received an antipsychotic, antianxiety, antidepressant , and a hypnotic during the look back period. A physician order, dated 05/03/23, documented risperidone 0. 5 mg daily for major depressive disorder. A physician order, dated 05/03/23, documented Vraylar 1.5 mg administer daily for major depressive disorder. A physician order, dated 05/19/23, documented clonazepam administer 0.5 mg TID for schizoaffective disorder. A physician order, dated 02/21/24, documented lorazepam administer 1 mg every six hours PRN for bipolar disorder. On 04/03/24 at 10:28 a.m., the DON stated the diagnoses for the antipsychotic medications needed to be changed. On 04/03/24 at 12:53 p.m., the pharmacist stated the diagnoses for the antipsychotic medications needed to be clarified.

Based on record review, and interview, the facility failed to protect the resident's right to privacy of personal and medical record information for one (#1) of one sampled resident whose medical records were reviewed. The Resident Roster, dated 12/29/23, documented a census of 45 residents. Findings: Res #1 had diagnoses which included Alzheimer's dementia, rheumatoid arthritis, and convulsions. An event report, dated 11/26/23, time unknown, documented the resident had a fall with injury which required transfer to the local hospital for evaluation. A 30 day discharge notice, dated 12/08/23, which was given to the resident's POA, read in part, .By this letter, I am informing you that a decision has been made to discharge [Res #1 name withheld] from our facility on January 9th, 2024 .[Res #1 name withheld] is being discharged because the facility cannot meet the resident's needs .We are sorry that it has come to this, but we feel you have left us with no other options . On 12/29/23 at 4:23 p.m., the POA reported on 12/06/23, their family member (name and relation withheld) who had no involvement in Res #1's care, was contacted by a facility representative and told they were going to serve Res #1's POA with a 30 day discharge on 12/08/23. On 01/02/24 at 11:41 a.m., the POA's family member (name and relation withheld) reported they were called on 12/06/23 by the facility's representative and told Res #1 had a fall and the POA was upset they could not obtain an incident report related to the fall. The POA's family member reported they were informed the facility would be giving the POA a 30 day discharge notice for Res #1 on 12/08/23. The POA's family member reported they had nothing to do with the care of Res #1 and was not a contact to call in Res #1's record. On 01/02/24 at 2:40 p.m., the administrator reported the POA's family member was contacted by the facility's representative to tell the family member about the 30 day discharge. The administrator reported they did not feel like discussing a 30 day discharge was a HIPAA violation.

Based on record review and interview, the facility failed to document the required information regarding an involuntary discharge in the medical record for one (#1) of one sample resident who was reviewed for discharge. The Resident Roster, dated 12/29/23, documented a census of 45 residents. Findings: Res #1 had diagnoses which included Alzheimer's disease, rheumatoid arthritis, and convulsions. On 12/08/23, Res #1's, POA, was given a 30 day discharge notice. The notice, read in part, .By this letter, I am informing you that a decision has been made to discharge [Res #1 name withheld] from our facility on January 9th, 2024 .[Res #1 name withheld] is being discharged because the facility cannot meet the resident's needs .We are sorry that it has come to this, but we feel you have left us with no other options . A Second Summary Order Overruling Involuntary Discharge, dated 12/21/23, read in part, .the facility failed to comply .When the facility transfers or discharges a resident under any of the circumstances specified .the resident's clinical record must be documented. The documentation must be made by .the resident's physician when transfer or discharge is necessary .the facility must notify the .resident's representative of the transfer or discharge and the reasons for the move in writing .The procedure for involuntary discharge .was not followed. It is therefore ordered, adjudged and decreed that the facility shall not involuntarily discharge this resident without obtaining a written order of this Court . There was no documentation in the resident's medical record by Res #1's physician or the facility staff regarding an involuntary discharge. On 12/29/23 at 5:05 p.m., the administrator reported they were not aware of the requirements for an involuntary discharge.

Based on observation, record review, and interview, the facility failed to ensure a fall with injury was documented in the medical record and the resident was monitored appropriately post fall for one (#1) of one sampled resident who was reviewed for a fall. The Resident Roster, dated 12/29/23, documented a census of 45 residents. Findings: A Fall - Evaluation and Prevention policy, last revised on 12/2019, read in part, .If there was a loss of conscious [sic] or the fall was unwitnessed, neuro signs should be initiated .Following a fall, the following steps should be undertaken .Complete an incident and accident report . An undated Condition change, of the resident (observing, recording and reporting) policy'', read in part, 1. After all resident falls, injuries or changes in physical or mental function .3. Complete an incident, accident or risk management report .5. Monitor resident's condition frequently . Res #1 had diagnoses which included Alzheimer's disease, rheumatoid arthritis, and convulsions. A Neurological Assessment Flow Sheet was initiated on 11/26/23 at 3:30 a.m. Vital signs only were documented every 15 minutes x 1 hour, every 30 minutes x 1.5 hours, every hour x 3 hours, and every 4 hours x 12 hours. There were no neurological checks documented. A nursing note, dated 11/26/23 at 9:06 a.m. documented Res #1 was transferred to the hospital for evaluation of bruising to the left eye due to a fall. A review of Res #1's nursing notes, did not include documentation of a fall prior to Res #1's transfer to the hospital. An event report, completed late on 11/26/23 at 9:24 p.m. documented Res #1 had an unwitnessed fall which resulted in bruising, redness and a bump to Res #1's right forehead. The event report documented the following order, Fall: with suspected head trauma - neuro checks Q 15 minutes x4, then Q1 hours x2, Then Q2 hours x2, then Q4 hours x2 . A review of Res #1's nursing notes did not include any monitoring of Res #1 after their unwitnessed fall. On 12/29/23 at 3:00 p.m., Res #1 was noted to have bruising around both eyes and at both cheek bones. On 12/29/23 at 12:30 p.m., the DON reported the resident fell on [DATE] at approximately 2:59 a.m. since they were notified of the fall at 2:59 a.m. The DON reported an incident report was not completed when Res #1 fell . The DON reported they had LPN #1 complete an incident report late. The DON reported there was no documentation of monitoring in the nursing notes or neuro checks for Res #1 after the fall on 11/26/23 from 2:59 a.m. until their transfer to the hospital at 9:06 a.m.

On 05/17/23 at 3:05 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure background screenings were completed for 3 of 51 employees. On 05/17/23 at 3:12 p.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation. On 05/17/23 at 3:15 p.m., the Administrator was notified of the IJ situation. On 05/17/23 at 5:44 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Completion Date 5-17-23 9:00 p.m. The Administrator and Business Office Manager will be educated on employee background checks and fingerprinting. The Administrator will be educated over the telephone due to the fact that he is on vacation. Currently in progress: Reviewing all employee personnel records to verify background checks and fingerprinting are completed. Any employee without background checks and fingerprinting will not be allowed to return to work until completed. New hires will have background checks performed before staring work and fingerprinting completed within 60 days of date of hire. The IJ was lifted, effective 05/17/23 at 9:00 p.m., when all components of the plan of removal had been completed. The deficiency remained at a widespread level with a potential for harm. Based on record review and interview, the facility failed to ensure background screenings were completed prior to employment for 11 of 51employees reviewed for background screening. Corporate Nurse #1 reported there were 51 employees. Findings: A Background Screening Investigation policy, revised 03/19, read in parts, .Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment . A Paycom Report Writer Generated Report, undated, documented 51 employees. The Southern Pointe Employee Roster, dated 05/17/23, provided by the ONBC (OK-Screen) & Detention Programs, documented the facility had not requested screening for 3 current employees for the year 2023. On 05/17/23 at 2:00 p.m., the Business Office Manager reported they were unable to locate background checks for 11 current employees. On 05/17/23 at 5:00 p.m., the Regional Director of Operations reported the corporate office did not have background checks for 11 current employees.

Based on observation, record review, and interview, the facility failed to ensure an LPN Charge Nurse was licensed to practice nursing in the state of Oklahoma. The Resident Census and Conditions of Residents, dated 05/17/23, documented a census of 35 residents. Findings: On 05/17/23 at 2:00 p.m., LPN #1 was observed to be working in the facility as a charge nurse. A review of LPN #1's employee file documented a hire date of 01/31/22. The file did not contain documentation to show LPN #1 was licensed to practice nursing in the State of Oklahoma. The facility did not provide an Oklahoma nursing license for LPN #1. On 05/17/23 a review of the Oklahoma State Board of Nursing website failed to show a nursing license for LPN #1. On 05/17/23 at 3:30 p.m., the business office manager #1 stated, She used to have a compact license, but the Oklahoma State Board of Nursing made a mistake and LPN #1 has been fighting with them since she renewed her license to get her Oklahoma license. The business office manager reported LPN #1 did not have an Oklahoma nursing license. On 05/17/23 at 4:05 p.m., Corp Nurse Consultant #1 reported LPN #1 was sent home.

Based on observation, record review, and interview, the facility failed to ensure a resident received their narcotic pain medication as ordered by the physician for one (#1) of three sampled residents reviewed for narcotic pain medication use. Corp Nurse Consultant #1 identified 20 residents who received narcotic pain medication. Findings: On 05/18/23 at 8:55 a.m., Res #1 was up in a geri-chair in the TV lounge. Observed Fentanyl (narcotic pain medication) patch to be on Res #1's right shoulder. The patch was covered with a clear bandage and dated 05/18/23 with CMA #3's initials. On 05/21/23 at 5:10 p.m., Res #1 was in a geri-chair outside of the dining room with LPN #2 and CMA #1 standing beside them. Observed RN #1 applying a pain patch to Res #1's left shoulder. On 05/21/23 at 5:13 p.m., observed Fentanyl patch on Res #1's left shoulder. The patch was dated 05/21/23 with CMA #1's initials. A physician's order, dated 05/11/23, read in parts, .Fentanyl Patch 12mcg/hr .apply patch once a morning every 3 days: AM 06:00 - 11:00 . A Medication Administration Record for May 2023, read in parts, Fentanyl patch 72 hours 12mcg/hr .at morning q 3 days, 6-11. On 05/21/23 at 5:18 p.m., LPN #2 reported they were not aware of what time of day Res #1's Fentanyl patch was ordered to be applied and stated, You will have to ask CMA #1. On 05/21/23 at 5:20 p.m., CMA #1 reported there was no specific time Res #1's Fentanyl's patch was to be applied and stated, You just have to wait until a good time because [Res #1] can get mad. On 05/21/23 at 5:21 p.m., CMA #1 did respond when asked what time Res #1's Fentanyl patch was applied on 05/21/23. On 05/21/23 at 5:22 p.m., LPN #2 reported Res #1's Fentanyl patch was applied between 3:00 and 4:00. No, between 2:00 and 3:00. On 05/22/23 at 8:30 a.m., CMA #3 reported Res #1's Fentanyl patch was ordered to be applied during day shift around 8:00 a.m. every three days. On 05/22/23 at 9:39 a.m., RN #1 reported they applied Res #1's Fentanyl patch on 05/21/23 at 5:00 p.m. RN #1 reported Res #1's Fentanyl patch was ordered to be applied, Every three days, and did not respond when asked what time Res #1's Fentanyl patch was ordered to be applied. On 05/22/23 at 2:25 p.m., Corp Nurse #1 reported the Fentanyl patches should have been applied in the morning.

Based on observation, interview and record review, it was determined the facility failed to identify and implement new interventions to aid in the prevention of falls for two (#1 and #41) of four residents who were reviewed for falls. This caused actual harm to resident number #1 when a fall resulted in a hip fracture. This caused harm to resident #41 when repeated falls resulted in head injuries. This had the potential to affect 22 residents who were identified by the facility as having falls in the last four months. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/18/14, documented the resident had severely impaired cognition; required assistance with all activities of daily living; no range of motion (ROM) deficits; and had a history of [REDACTED]. An incident report, dated 11/17/14 at 4:45 p.m., documented a fall had been witnessed in the hallway when the resident fell on her buttocks after getting out of her wheelchair (W/C) and trying to take a step. The report documented the resident had continued to be non-compliant with instructions to always call for assistance with activities of daily living (ADLs), transfers, and ambulation. The report also documented a personal alarm had been in place at the time of the fall. No injuries were documented. No new preventive measures were documented. A nurse's note, dated 11/17/14 at 4:45 p.m., documented, "...Pt. (patient) remains on PT/OT (physical/occupational therapy) for balance and strengthening exercises. Pt. is anxious and won't sit still and/or in place but a few minutes, approx. (approximately) 5 minutes at a time. Pt. pleasant but forgetful...Pt got up out of w/c by self and personal alarm went off and nurse aides times 2 was (sic) standing a couple feet away from pt. and charge nurse saw pt stand up and try to take a step, but fell on buttocks..." The care plan, revised on 11/17/14, documented, "...resident had body and chair alarm in place, both sounding, self release musical lap belt was released, staff unable to reach her in time..." No new preventive measures were documented. An incident report, dated 11/20/14 at 8:30 p.m., documented, "...Pt got out of w/c without calling for assist and was ambulating, and fell in front of loveseat in living room...No s/s (signs or symptoms) of injuries noted..." The report documented the fall was witnessed and a self- releasing musical belt and personal alarm were in use at the time of the fall. No new preventive measures were documented. The care plan, revised on 11/20/14, documented, "...Resident got up out of w/c without calling for assistance, low bed, personal alarm in place and fell on buttocks in front of love seat in living room, no injuries...staff to continue safety interventions and along with therapy ambulating..." No new preventive measures were documented. An incident report, dated 11/27/14 at 7:40 a.m., documented the resident had loosened her self-release lap belt, got up from her W/C, and fell . No new preventive measures were implemented. A mobile X-ray report, dated 11/27/14, documented, "...Findings consistent with minimally displaced fracture of the right greater trochanter..." The care plan, revised 11/27/14, documented, "...Res with self removal of lap belt while up in W/C, alarm sounding, nurse unable to reach resident before falling on floor...X-ray result reveal greater trochanter fracture non displaced..." No new preventive measures were identified. An incident report, dated 12/24/14 at 8:19 p.m., documented the staff was alerted to the sound of the self-releasing musical lap belt. The resident was found on the floor in front of her W/C. No injuries were reported. No new preventive measures were implemented. A care plan, revised on 12/24/14, documented, "...Staff alerted to musical lap belt sounding indicating resident had removed upon reaching her, staff noted her lying on floor on her back in front of wheelchair with alarm sounding resident trying to get self back up off of floor...continue therapy, continue use of musical lap belt, continue use of non slid socks and shoes, and toileting every 1-2 hours..." There were no new interventions identified. An incident report, dated 02/02/15 at 2:35 p.m., documented the resident had tried to get up from the W/C and slid to the floor. The report documented the fall was witnessed and there were no injuries. No new preventive measures were implemented. The care plan, revised on 02/02/15, documented, "...Resident attempting to get up from wheelchair removed Velcro self- release belt causing alarm to sound, slid to floor off end of seat with nurse as witness, nurse did have hands on resident to help control slide to floor no injury did not bump head, review with therapy for eval, resident alz (Alzheimer's) progression has been noted to require more extensive amount of assist from staff..." No new interventions were identified. A significant change assessment, dated 02/09/15, documented the resident had severely impaired cognition, disorganized thinking, required extensive assistance with activities of daily living, had two falls with no injury and one fall with injury. On 02/23/15 at 4:24 p.m., the resident was observed in the living room, sitting in her W/C, with a personal alarm and self-releasing lap belt in place. On 02/27/15 at 8:34 a.m., the assistant director of nursing (ADON)/Care Plan Coordinator was asked why there were no new interventions to prevent the resident from falling from the W/C. She said they had "run out-of-things to try." The ADON searched the care plans and nurses' notes and said she could not find any additional interventions. On 02/27/15 at 10:30 a.m., the surveyor came out of the room where an interview with the ADON had taken place. At that time, the resident was observed sitting in her W/C with a lab buddy in place. On 02/27/15 at 10:53 a.m., physical therapy assistant (PTA) #1 was asked if there was anything different they could they have tried to keep the resident from falling out of a W/C. The PTA #1 said they had made suggestions such as different positions. The PTA reported nursing had just begun, in February, to fill out a fall screen form to communicate to PT that a fall had occurred. The PTA said the fall screens help, because sometimes falls happen on nights or evenings and they would not know about the fall. The PTA stated, "We will try to help with interventions if we know they (the residents) have fallen." 2. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 10/29/14, documented the resident had moderately impaired cognition; required extensive assistance with bed mobility, transferring between surfaces, dressing, eating and hygiene; was not ambulatory; was frequently incontinent of bowel and bladder; and had experienced a fall with injuries. The assessment also documented the resident was not steady with moving from a seated to standing position; walking; turning around; moving on and off a toilet; or transferring from surface to surface. The care plan, dated 11/09/14, documented, "...Resident attempted to self transfer lost balance and fell backwards hit head landed on right side no other injuries noted no hematoma..." The care plan, dated 11/22/14, documented the resident could use a self-releasing lap belt while up in the wheelchair. It was documented to release the belt every two hours, including for personal care. An incident report, dated 12/17/14, was sent to OSDH (Oklahoma State Department of Health), due to a head injury. The report documented, "...Resident is an 91/YO (year old) white female whom (sic) is on of our memory lane. Resident continues to be endstage Alzheimer's disease process. Disoriented x 3 which is not a new onset. Resident attempts to stand and walk without assist. Resident has in place a bed, chair alarms, fall mat, pressure reducing mattress, bed to its lowest position and on fall precautions with lap releasing belt to wheelchair...STPR (steps to prevent recurrence) - interventions-immediate measures taken: lap belt and ER (emergency room )." A physician's telephone order, dated 12/22/14, documented, "...DC (discontinue) use of self release musical lap belt, replace with wedge cushion..." On 12/26/14, a "fall risk assessment" identified the resident had a total score of 18. The assessment documented, "...Total score above 10 represents High Risk (for falls)..." An incident report, dated 01/18/15 at 3:00 p.m., documented the resident had been in the dining room and fell when she tried to stand-up from the wheelchair. The report did not document whether the resident was injured. It was documented a wedge cushion was in place, and a personal alarm was attached to the resident's clothing. The incident report contained the following interventions to prevent further falls: bed alarm, wheelchair alarm, landing pad to floor, bed lowered to the lowest position, bed as well as body alarm, and a lap release alarm belt. The resident's care plan, updated 01/18/15, documented, "...No apparent injury, continue personal alarm and wedge cushion, therapy screen, family elected no therapy..." No new interventions were identified or implemented to aid in the prevention of falls from a wheelchair for the resident. An incident report, dated 02/02/15 at 8:20 p.m., documented, "...Resident up in W/C, alarm in place with wedge cushion. Having events of leaning forward. Family and hospice are aware of condition. They continue to choose to D/C (discontinue) use of self release belt...CNA (certified nurse aide) standing next to her turned to address another resident when resident leaning forward from chair falling on her head causing soft tissue edema & small laceration to forehead...call to EMS (Emergency Medical Service) for transport...out of facility..." No new interventions were identified or implemented to aid in the prevention of falls. A hospital computerized tomography scan (CT) result, with an an encounter date of 02/02/15 through 02/05/15, documented, "...Final Diagnoses: [REDACTED]. A care plan revision, dated 02/02/15, documented, "...Wedge cushion, nurse and hospice decided to discontinue lap belt..." A physician's telephone order, dated 02/05/15, documented the resident was to wear a cervical collar when out of bed to provide neck support and limit movement of the neck. An incident report, dated 02/14/15 at 3:45 p.m., documented, "...Nurse in office with hospice nurse. Hospice nurse exited office and alerted nurse that resident was in floor on left side, small laceration to left side of head noted. Location of fall hallway, what was resident doing just prior to fall- up in wheelchair in hallway...laceration...Upon inspection nurse noted small laceration to left side of head. STPR (steps to prevent recurrence)= interventions- immediate measures taken- direct pressure to wound, personal alarm, rest..." No new interventions were identified or implemented to aid in the prevention of falls. The resident's care plan, updated on 02/14/15, documented, "...Alarm sounded, neuro checks... wedge cushion, personal alarm, bed alarm fall mat, low bed, hospice." No new interventions were identified or implemented to aid in the prevention of falls. On 02/23/15 at 11:46 a.m., the resident was observed sitting in a wheelchair in the dining room. The resident was wearing a cervical collar and watching other resident's work puzzles. On 02/26/15 at 8:30 a.m., the resident was observed sitting in her wheelchair in the dining room. The resident was observed eating her breakfast, and a personal alarm was attached to the resident's clothing. On 02/27/15 at 9:17 a.m., the resident was observed sitting up in her wheelchair in the dining room. The resident was observed to have a personal alarm on, a cervical collar was on the resident's neck, and she was sitting on a wedge cushion. On 03/02/15 at 11:22 a.m., a phone call was made to an unidentified family member. The family member was asked about the resident's repeated falls. They stated the family felt the resident had been removing the musical lap belt due to wanting the hear the music it played. On 03/02/15 at 3:45 p.m., licensed practical nurse (LPN) #2 was interviewed regarding the facility's policy related to falls. The LPN stated when a resident fell , she would assess them, then call the physician and the family. She then stated she would complete an incident report. The LPN was asked how she determined which interventions would be implemented to prevent a recurrence of falls. She stated she would look at what was being done for the falls at the time they occurred. The LPN then stated she would try to come up with something else. The LPN was asked what interventions the facility had put into place to aid in the prevention of falls for resident #41. She stated she did one on one observation with the resident a lot but did not have time to chart it most of the time. She stated the resident was determined to walk and would fall. The LPN stated the resident had used a lap belt for awhile, but it was discontinued due to the family believing the resident was disconnecting the belt to hear the music and would then fall. She stated the facility and hospice had decided to try a wedge cushion in the resident's wheelchair. On 03/02/15 at 4:12 p.m., the resident was observed sitting up in her wheelchair in the dining room. On 03/03/15 at 1:52 p.m., the ADON was interviewed regarding the resident's repeated falls. The ADON was asked what interventions had been put into place after the resident had fallen on 01/18/15, 02/02/15 and 02/14/15. The ADON reported the facility was working on a new program to track falls and effective interventions.

Based on observations, interviews, and record reviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility failed to identify and implement a plan of action to correct system failures related to falls. The facility identified 22 residents with falls in the last four months. This had the potential to affect 52 of 52 residents who resided at the facility. Findings: The facility failed to identify and implement new interventions to aid in the prevention of falls for two (#1 and #41) of four sampled residents who were reviewed for falls. This caused actual harm to resident number #1 when a fall resulted in a [MEDICAL CONDITION]. This caused harm to resident #41 when repeated falls resulted in head injuries. See F-323. On 03/03/15 at 2:21 p.m., the Administrator (ADM) was interviewed regarding the facility's quality assessment and assurance committee (QAA). He said they meet at least quarterly with the heads of department staff and the two medical directors. The ADM said the QAA committee had identified a problem with having a high percentage of falls. The ADM was asked what approaches the QAA committee had decided on for a decrease in the percentage of falls. He stated at first they had asked for family input for interventions, but now realized that had not worked. He stated they had identified they needed to change their interventions. The ADM stated they had been tracking falls and antipsychotic medications for the past three months. The ADM stated they had joint meetings with the two medical directors, the director of nursing (DON), therapy, sometimes dietary, and the certified nurse aides for care plan meetings. He said the families had significant input into the interventions that had been put into place for falls. On 03/03/15 at 3:30 p.m., the assistant director of nursing was interviewed regarding the QAA committee. She stated they had talked about falls in the QAA meetings and were working on fall prevention. On 03/04/15 at 7:11 a.m., the assistant activity director, who was observed out on the halls, was asked what she knew of the QAA meetings. She stated when she was out on the halls she noticed things and would discuss the issues she saw with the activity director. She stated the activity director attended the QAA meetings and would let them know what had been brought to her attention. At 7:22 a.m., the restorative aide (RA) was interviewed regarding QAA meetings. She stated she knew the QAA had discussed falls. The ADON and DON had told her about the problems with falls that had been identified in the QAA meetings. The RA had been asked if she had any suggestions for interventions to implement to try to lower the fall percentage rate. At 9:00 a.m., the AD was interviewed regarding the QAA meetings. She said she had attended the QAA meetings. She was asked what had they discussed as a problem in the meetings. She said one of the QAA discussions had been a high number of falls.

Based on record review, observation and staff interview, it was determined the facility failed to ensure interventions were implemented including adequate supervision to prevent resident to resident altercations for two (#2 and #5) of seven sampled residents with behaviors. These two residents had caused harm to three other residents. This had the potential to affect 13 of 13 residents residing on the locked 'Memory Unit' per the DON. Findings: 1. Resident #2 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 09/29/12, documented, "Problem: Aggressive with staff and verbally abusive, he can be redirected easily, with terms 'Allowing him to do things' he does not like to hear 'can't do something.'" A quarterly assessment, dated 12/25/12, documented the resident had inadequate short and long term memory, severely impaired cognition, exhibited behavioral symptoms toward others and wandered about the facility daily. A nurse's note, dated 01/19/13 at 9:00 p.m., documented, "...resident has been upset all day with another male resident for being intimately close with a female resident. He has also been upset with the female resident..." A nurse's note, dated 01/20/13 at 8:30 p.m., documented, "...cont to be annoyed c other male resident at times today R/T both showing affection for the same female resident." A nurse's note, dated 02/04/13 at 1:50 p.m., documented, "(Name deleted resident #2) hit (Name deleted resident #1) due to (Name deleted resident #2) thought (Name deleted resident #1) was being intimate c his mother..." A care plan, dated 02/04/13, documented, "Problem: Resident has physical behavioral symptoms toward others - hitting. On 02/04/13 this resident (#2) hit another resident (#1). APS, police and physician notified with no new orders." An incident/accident report, dated 02/04/13, documented, "(Name deleted resident #1) was struck by (Name deleted resident #2) on the left hand side of face...2.5 x 2.5 abrasion on cheek bone and scratch on nose..." The initial incident/accident report, dated 02/04/13, was sent to OSDH and documented the following: Resident #2 went to the door of female resident #3 and entered her room. He saw female resident #3 on the bed with male resident #1. Resident #2 then approached male resident #1 and hit him on the right side of the face, below the eye and on the right side of his nose. This caused a small abrasion on the nose and a 2.5 cm abrasion under the eye. A nurse immediately entered the room and separated the residents. The 5 day and final report documented, after a week of monitoring both male residents, there had been no other signs of altercations. Resident #2 enjoys outside gardening, outside games (weather permitting), television programing, interactive conversation with staff and peers. Memory care staff in-serviced as to the redirection plan." The inservice dated 02/08/13, to instruct the staff as how to redirect the resident was never given to ALL the staff. A nurse's note dated 03/15/13 at 10:45 a.m., documented, "...(female) Resident (#6) was going through dresser drawer and (Name deleted resident #2) states she (resident #6) went to hallway and got a wet floor sign and hit him, so he hit her (resident #6) in back of head c the sign. Called (Name deleted physician) got referral to (Name deleted) geri-psych..." An incident/accident report, dated 03/15/13 at 10:00 a.m., documented female resident #6 had received dime sized small hematoma to the back of her head from male resident #2. Steps to prevent recurrence were 1:1 with nurse until resident (#2) is removed from the facility. On 03/15/13, resident #2 was transferred to a geri-psych facility. On 03/26/13 at 5:00 p.m., LPN #4 was asked how the staff in the 'Memory Care Unit' prevented resident to resident altercations. The LPN reported they tried to keep the residents busy, but with everything the staff had to do, it was very difficult. She also reported she tried to monitor explosive and/or sexual behaviors and tried to redirect the residents. On 03/27/13 at 2:00 p.m., the ADM was asked what steps had been put in place to prevent resident to resident altercations by resident #2, after the first incident on 02/04/13. The ADM stated, "We sent him out the second time it happened." The ADM further reported the staff had tried to monitor him closely. 2. The medical record for resident #5 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The medical record documented the resident had been transferred to the 'Memory Unit' on 07/16/12. An annual assessment, dated 01/19/13, documented the resident had severely impaired cognition and decision making skills, required limited assistance with transfers and ambulation, had no mood indicators and had behaviors of wandering one to three days during the assessment period. The resident's care plan was dated 01/19/12. An addition to the care plan, dated 01/24/13, documented the resident had socially inappropriate/disruptive behavioral symptoms as evidenced by often becoming verbally abusive to staff when asked simple questions. Interventions included assessing whether the behavior endangers the resident or others, avoiding over-stimulation, conveying an attitude of acceptance, maintaining a calm environment, placing resident on specially designed therapeutic unit and providing comfort measures for basic needs when behavior begins. A nurse's note, dated 03/03/13 at 4:25 p.m., documented the resident had an argument with another resident. They called each other names and the two residents were found on the floor. The note documented, "This resident stated the other resident pushed her down & then fell on top of her. This resident stated she did it on purpose & started slapping at the other resident. Residents were separated. This resident stated if she could get up she would kill her." An incident report dated 03/03/13, documented the altercation. The report documented to monitor and redirect to an activity. A nurse's note, dated 03/05/13, documented resident #5 had slapped another resident because the other resident had knocked her down over the weekend. Resident #5 told the other resident she wasn't through with her. The nurse's note also documented resident #5 was in her W/C roaming up and down the hall going into other residents' rooms. A nurse's note, dated 03/12/13 at 9:35 a.m., documented the resident had taken a shower and started cursing everyone and threatening to kill whoever got in her way. At 10:00 a.m., the nurse's note documented resident #5 had ran into another resident's leg and foot with her W/C. The other resident kicked her and she attempted to run over him again. The note documented the other resident had been injured, "...bruise measures 4 1/2 cm X 5 1/2 cm..." An incident report dated 03/12/13, documented the above incident. The report documented the residents were separated and resident #5 was instructed to 'watch where she was going.' The resident's care plan was reviewed for documentation the care plan had been revised to address the residents behaviors. There was no documentation the behaviors had been addressed and no new interventions were found to prevent the resident's aggressive behaviors. On 03/26/13 at 5:00 p.m., resident #5 was observed in the dining area at a table in her W/C. The resident was speaking to the residents at the table with her. On 03/27/13 at 11:20 a.m., the DON was interviewed regarding the care plan not being revised. The DON reported the care plan should have had new interventions to address the aggressive behaviors to the residents. At 3:30 p.m., the DON was interviewed regarding a behavior management program to address aggressive behaviors on the Memory unit. She was also asked about any specialized training for the staff on the Memory unit. The DON reported they did not have a behavior management program for the residents and they did not have special training for the locked unit (Memory unit) staff. When asked for a policy and procedure for addressing behaviors, she reported they did not have such a policy. The DON reported they had a manual just for the Memory unit, but it had not been put into place. She reported she did not know why they did not have a 'behavior' policy in place or why they had not sent the staff to a special training.

On 02/04/13 at 6:45 p.m., an immediate jeopardy (IJ) situation was determined to exist due to the findings of rodent droppings in a macaroni storage bin and in the utensil and towel drawers of the facility's kitchen. On 02/04/13 at 7:03 p.m., the Oklahoma State Department of Health (OSDH) was notified of the immediate jeopardy situation related to the rodent droppings in the facility's kitchen. The IJ situation was verified. On 02/04/13 at 7:12 p.m., the Administrator and ADON were informed of the IJ situation. On 02/04/13 at 8:30 p.m., the Adm. provided the survey team with an acceptable plan of removal which documented: "On February 4, 2013, agents from the State Survey Team cited an immediate jeopardy situation and notified the Administrator and ADON. The citing was in the dietary department where rodent droppings were found in the utensil drawers and an open bin of macaroni. In the beginning of January, the facility was aggressively addressing this rodent issue. It was identified by the Dietary Manager who reported to the Administrator. I notified the Maintenance Supervisor who put out some bait traps that he had received in case of a rodent sighting. I then called (Name deleted) Pest Control and they came out and placed more bait stations. The Dietary Manager began cleaning the food storage areas however the rodent droppings were still identified. Plan of removal: 1) All drawers will be pulled out, cleaned with a cleaning solution and clean rags; new contact paper placed in each drawer; All exposed food was immediately discarded; cleaning rags and napkins exposed to the rodent debris will be discarded; All utensils found in all the drawers will be cleaned through the kitchen dishwasher by the Dietary Manager and Designated Personnel on February 4, 2013. 2a) All other areas including the storage rooms and shelves of the kitchen will be thoroughly cleaned and free from rodent droppings and debris by the Dietary Manager and Designated Personnel on February 4, 2013. 2b) All residents will be assessed by the facility RN and LPNs for any signs or symptoms of changes that may be related to cited deficiency on February 4, 2013 and any identified signs or symptoms will be communicated with the physician immediately. 3) Dietary Manager will be in-serviced by the Administrator on February 4, 2013 and the Dietary Manager will in-service all Dietary staff prior to returning to work to immediately report any signs of rodent infestation to the administrator. 4) (Name deleted pest control company) will be instructed to leave out bait traps each month by the administrator on February 05, 2013, Maintenance Director will perform an environmental inspection and seal any areas that may be a point of entry for rodents on February 05, 2013; the Dietary Manager or designated representative will do a daily kitchen inspection to ensure the dietary department remains free from signs of rodent infestation and report to the Administrator immediately. Any food exposed will be discarded and equipment immediately cleaned with the facility's dishwasher. Any findings will be reviewed by the Quality Assurance Department." On 02/05/13, at 2:00 p.m., the IJ was removed, when the last staff member had been in-serviced and the staff verbalized an understanding of the in-service. The deficient practice remained at the level of no actual harm with the potential for more than minimal harm widespread. Based on observation, interview, and record review, it was determined the facility failed to ensure: a) A plastic storage bin containing macaroni was free of rodent droppings. b) A plastic storage bin lid was free of rodent droppings. c) Four drawers containing cooking and serving utensils were free of rodent droppings. d) Two drawers containing towels were free of rodent droppings. e) Cabinets under the kitchen counter were free of rodent droppings. f) The shelf under the steam table was free of greasy grime and dust. g) The bottom shelf of a food preparation table was free of greasy grime and crumbs. h) Shelves on a rolling cart were free of greasy grime and dust. i) The inside of a container holding silverware was free of grime. This had the potential to affect 53 of 53 who received meals from the facility's kitchen per the ADON. Findings: "Sanitation and Infection Control POLICY: Each facility will be maintained free from insects and rodents through a pest-control program. The pest-control program will include the facility and surrounding grounds. SUBJECT: PEST CONTROL PROCEDURES: 1. The kitchen must be kept clean; free from litter and rubbish; and protected from rodents, roaches, flies, and other insects. ...3. Properly store food to eliminate food sources for pests...." On 02/04/13 at 5:25 p.m., the facility's food pantry storage room was observed. A rodent dropping was observed on top of a lid of a white plastic bin which contained bowtie pasta. Three rodent droppings along with four elbow macaroni were observed inside another clear plastic food bin. At 5:30 p.m., the residents in the dining room were observed to be finished with their evening meal and some were leaving the dining room. At 6:05 p.m., the bottom shelf of a food preparation table was observed to have a greasy grimy substance and food crumbs on it. The edges of three clean sheet pans were touching the shelf. At 6:08 p.m., a wheeled cart was observed with greasy grime and dust on it's four shelves. Clean cake pans were setting on the shelves. At 6:10 p.m., a plastic container containing silverware was observed setting near the steam table. The dietary aide was asked to remove the silverware from the container. The inside of the container on the bottom was covered with a brownish colored substance. At 6:12 p.m., the DM was asked how often the shelves and silverware container were cleaned. She said they should be cleaned everyday. At 6:15 p.m., the DM was shown the rodent droppings in the store room. She said the elbow macaroni that was in the clear food bin was stored in the original plastic packaging inside the bin. The DM was asked how often the storage room was cleaned. She said she cleaned the storage room shelves every week and the plastic bins should be washed before refilling. The DM said the pest control company was there on Friday and also the week before. They put out poison bait and found one dead mouse by the back door. At 6:20 p.m., four drawers containing cooking and serving utensils were observed. The drawers contained numerous rodent droppings, wood shavings, and unidentified brown debris. At 6:22 p.m., the doors under the kitchen counter were opened and the shelves were observed. There were rodent droppings on the shelves. There were packages of napkins and one package had been opened. At 6:23 p.m., two drawers containing towels were observed. The drawers contained rodent droppings, wood shavings and unidentified brown debris. At 6:25 p.m., the DM was asked when the last time the back of the drawers were cleaned. She stated, "They haven't lately." At 6:26 p.m., the steam table was moved out from against the wall. The bottom shelf of the table was observed to have a greasy grime and food debris on it's surface. On 02/04/13 at 8:05 p.m., the 'Dietary Cleaning Schedule' posted on the kitchen wall was reviewed. The schedule documented the cooks were to clean the storage room daily. The cleaning schedule was not initialed to show the storage room had been cleaned. The schedule did not document to clean drawers or under cabinets.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure a thorough skin assessment had been completed on admission for one (#3) of two sampled residents with pressure sores. b) Ensure residents did not develop avoidable pressure sores for one (#3) of two sampled residents with pressure sores. c) Accurately and consistently assess skin integrity for one (#3) of two sampled residents with pressure sores. d) Notify the physician when pressure sores were first observed to obtain a treatment for one (#3) of two sampled residents with pressure sores. e) Notify the physician with recommendations from the wound care consultant for one (#3) of two sampled residents with pressure sores. This had the potential to affect two residents identified with pressure sores per the ADON. This was actual harm to the resident. Findings: Resident #3, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 06/09/12, a nurse's note, documented, "Buttocks with pink blanchable to bil aspect". This had been handwritten in on the side column of a nurse's note. The skin assessment flowsheet, dated 06/09/12, did not document the presence of breakdown to the (R) or (L)buttocks. An admission assessment, dated 06/16/12, documented, the resident's cognition was severely impaired, had long and short term memory loss, required extensive assistance with all ADL's, had an indwelling urinary catheter, was always incontinent of bowel, was at risk for developing pressure sores, had two stage I pressure sores, had one Stage II pressure sore present on admission to the facility. On 06/18/12, a nurse's note documented a Stage II noted to (L) buttock. An assessment was not initiated and no measurements were documented. On 06/18/12, the skin assessment flowsheet did not document the presence of breakdown to the (R) or (L)buttocks. A care plan, dated 06/20/12, documented the resident had potential for impaired skin integrity due to decreased mobility and an approach included to use a lift sheet to prevent shearing. On 06/26/12, a nurse's note documented, "Breakdown noted to buttocks. Barrier cream applied. To be evaluated further by tx nurse, (Name deleted)." On 06/27/12, the 'Skin Assessment Flowsheet' documented the following signed by the treatment nurse: "(R) buttock - Stage II pressure ulcer A. 1 x 1 x SF. B. 1 x 1 x SF C. 0.5 x 0.5 x SF Edges inflamed. Granulation tissue. (L) buttock - Stage II 1.5 x 1.5 x SF. Edges inflamed. Granulation tissue." The pressure sore had gone from one pressure sore documented in a nurse's note on 06/18/12, on the (L) buttock to a total of four pressure sores identified on 06/27/12. On 06/27/12, the treatment nurse notified the physician and received a treatment order, "Cleanse stage II to inner buttocks bilat, apply Silver Hydrogel, Cologen, foam pad, and tape". This was the first documentation the physician had been notified and a treatment had been obtained. On 07/04/12, the 'Skin Assessment Flowsheet' documented, "(R) buttock healed. (L) 0.5 x 0.5 x SF Granulation tissue Inflamed edges." On 07/11/12, the dimensions of the pressure sore on the (L) buttock remained the same as on 07/04/12. On 07/11/12, the treatment was changed. On 07/18/12, the skin flow sheet documented, "(L) buttock Stage II 0.5 x 0.7 x SF." On 07/24/12, the treatment was changed. On 07/25/12, the skin flow sheet documented: "(R) buttock Stage II 3.0 cm. x 2.7 cm. x Eschar center. (L) buttock Stage II 3.0 x 2.7 x Eschar center." On 07/27/12, the treatment was changed. On 07/30/12, the treatment was changed. On 08/01/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore the facility had identified on the resident's coccyx. 6 x 3 x ? has Eschar patches. (No site documented) On 08/01/12, the treatment was changed. On 08/09/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 6 x 3 x 1.5 cm. (No site documented) On 08/13/12, the treatment was changed. On 08/16/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 3 x 5.5 x 1cm. with Eschar patches and slough. (No site documented) On 08/27/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 3 x 5 x 0.7 cm. (No site documented) On 08/29/12, the treatment was changed. On 09/03/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 3 x 5 x 0.7cm. Eschar to center wound bed. (No site documented) On 09/10/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 3 x 4 x 1.0 cm. (No site documented) On 09/17/12 - (same size as the week before) (No site documented) On 09/18/12, the treatment was changed. On 09/24/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 4 x 6 x 1 cm Eschar. (No site documented) On 09/26/12, the treatment was changed. On 10/01/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 4 x 5 x 1.0 cm Eschar gone Slough in wound bed. (No site documented) On 10/01/12, the treatment was changed. On 10/08/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 3.7 x 4.5 x 1.0 cm. Granulated (No site documented) On 10/15/12, the 'Skin Assessment Flowsheet' documented the following measurements of the Stage II pressure sore - 3.7 x 4.7 x 1.0 Eschar absent (No site documented) On 10/15/12, the treatment was changed. On 10/20/12, the treatment was changed. A wound nurse consultant began assessments on 10/23/12. The wound nurse consultant documented, the pressure sore, "Coccyx, full thickness, pressure - Unstageable 4.00 x 4.50 x 1.0. Undermining (cm) 1.5 from 12-1:00 O'clock..." On 10/23/12, the treatment was changed. On 10/30/12, the 'Skin Assessment Flowsheet' documented the following measurements - "3.7 x 4.3 x 0.8 cm" (No site documented) On 11/06/12, the 'Skin Assessment Flowsheet' documented the following measurements - "4 x 4.5 x 0.5 cm" (No site documented) On 11/06/12, the treatment was changed. On 11/13/12, the 'Skin Assessment Flowsheet' documented the following measurements - "3.9 x 4.3 x 0.5 cm" (No site documented) (The pressure sore was not assessed the week of 11/20/12.) On 11/20/12, the treatment continued the same. On 11/27/12, the wound care nurse recommended changing the treatment. She documented, "...Coccyx Stage III with undermining 0.6 from 9-3:00. Dimensions of: length- 3.6, width-3.6, depth-0.5cm. Treatment intervention: Clean area with NS wound cleanser, apply Silver Calcium Alginate. Cover with Bordered foam. Treatment to be performed daily." On 12/04/12, the 'Skin Assessment Flowsheet' documented the following measurements - "3.5 x 3.5 x 0.5 cm." (No site documented) On 12/11/12, the skin flowsheet documented no change in the pressure sore. "Undermining continues." A quarterly assessment, dated 12/18/12, documented the resident had severe cognitive impairment, long and short term memory loss, required extensive assistance with all ADL's, was always incontinent of bowel, had an indwelling urinary catheter, at risk for pressure sores and had one Stage III pressure sore. On 12/18/12, the 'Skin Assessment Flowsheet' documented the pressure sore as "3.3 x 3.4 x 0.5cm." (No site documented) On 12/24/12, the Wound Care Nurse Consultant documented the pressure ulcer to coccyx as a stage III with undermining 1.0 from circumferentia. Dimensions increased to 4.2 x 4.0 x 1.0 cm. On 12/27/12, the treatment was changed. The skin flowsheet documented the following: 01/03/13 - "4.0 x 3.8 x 1.0 Granulation" (No site documented) 01/10/13 - "4.0 x 3.8 x 1.0 cm. Granulated yellow slough" (No site documented) The plan of care, last updated 01/11/13, documented presence of a wound to the coccyx. The care plan included the treatment to the pressure sore. On 01/12/13, the treatment was changed. 01/17/13 - "3.5 x 4 x 1 cm. Red beefy" (No site documented) 01/25/13 - "3.5 x 4.0 x 0.9 Red beefy granulated" (No site documented) 02/01/13 - "3.0 x 4.0 x 0.9 Undermining Good granulation Tape irritation on (L) buttock" On 02/06/13 at 11:00 a.m., LPN #4 was observed providing pressure sore treatment for the resident. The LPN cleansed the pressure sore on the coccyx with NS, [MEDICATION NAME] applied, and then Calcium Alginate applied. Measurements were documented as: length - 4.0 and width - 3.5 cm. Depth was not measured at that time. At 3:00 p.m., the ADON was interviewed. She reported she thought the resident had been admitted to the facility with a pressure sore already present, but agreed the nurses' notes and the skin flowsheets did not reflect the presence of a pressure sore on admission. On 02/08/13 at 2:00 p.m., the ADON was interviewed and asked if the facility had additional documentation from the wound care nurse consultant. She reported she would look in the DON's office, because the DON who had resigned on 01/24/13, may have left unprocessed orders in her office. At 2:15 p.m., the ADON returned with paperwork the DON had left on her desk after she had quit. The paperwork contained a recommendation dated 01/21/13, by the wound care nurse consultant regarding a change in treatment for the pressure sore. The paperwork documented the following: "01/21/13 Coccyx - full thickness - Pressure Ulcer Stage III - Excudate Heavy - Undermining 1.0 from cicumferentially - Size 4.20 x 5.00 Depth - 1.0 Prescribed topical medication ordered by the doctor - Santyl/[MEDICATION NAME] Justification Item 1: Larger size needed due to fragile new epithelization as well as undermining Item 2: x2 needed due to depth/undermining. Frequency QD Dressings 1. Bordered Foam White Slick (6x6) QD 2. Calcium Alginate (2x2) QD Wound Bed: 75% moist beefy red granulation tissue. 25%thin yellow slough that does not obscure depth. Periwound: fragile, moist, malodorous. Clinical Rationale/Wound Comments: Daily Santyl will enzymatically debride necrotic tissue. Daily [MEDICATION NAME] ordered by Physician to manage bioburden to wound site. Calcium Alginate will absorb excess wound exudate as well as manage bioburden to wound site. Foam will promote thermal regulation as well as protect from urine and feces due to incontinence. Daily dressing changes required due to frequent incontinent episodes compromising dressing integrity in less than a 24 hour time frame. Treatment Intervention: Clean area with NS/Wound cleanser. Apply nickel thick layer of Santyl. Apply thin layer of [MEDICATION NAME]. Apply Calcium Alginate. Cover with Bordered Foam. Treatment to be performed daily." The ADON was asked at that time if she thought the physician had been notified of the recommendations. The ADON stated, "No." She reported the physician did not know or he would have responded to the new treatment.

Based on record review and staff interviews, it was determined the facility failed to ensure a resident's dignity was maintained. A mentally challenged resident was straight cathed without a physician's orders [REDACTED].#1) of three sampled residents with behavior problems. The unnecessary and invasive treatment caused harm to the resident. This had the potential to affect all 41 residents. Findings: Resident #1 was admitted on [DATE], from a Geri-psych hospital. The [DIAGNOSES REDACTED]. The care plan, dated 12/14/11, documented the resident required adjustment for her chronic medical condition/diagnosis. The goal was for her to accept her [DIAGNOSES REDACTED]. Another problem, included in the care plan, was the side effects from her antipsychotic medication regimen. The goal was for the resident to reach her highest practicable level of function with regards to her physical, mental and psychosocial well being. Interventions included the importance of allowing her individual space & to not violate her personal space without permission. A 30 day assessment, dated 01/18/12, documented the resident had displayed disorganized thinking, had a problem concentrating, had [MEDICAL CONDITION], resisted care at times, required assistance of one with bathing, was able to ambulate without assistance around the facility, was never incontinent of bowel and was occasionally incontinent of bladder. The March 2012, physician's orders [REDACTED]. "[MEDICATION NAME] 1000mg 1 po Q hs for [MEDICAL CONDITION], [MEDICATION NAME] 10mg 1 PO Q 12 hours for cognition, [MEDICATION NAME] 400mg 1 PO Q 12 hours for [MEDICAL CONDITION], [MEDICATION NAME] 900mg for aggression, [MEDICATION NAME] 2mg 1 PO Q 8 hours prn for anxiety, [MEDICATION NAME] 10mg 1 PO TID @ 0800-1400-2000 for aggression." A nurse's (LPN #1) note, dated 03/05/12 (Monday), at 8:00 p.m., labeled as a 'Late entry', documented, "Pt states 'I'm in labor, I'm having a baby', later pt. observed crying when pt. assessed she c/o pressure 'down there' while pointing toward vagina. Upon observation 0 abnormalities seen when abd. palpated WNL, pt. pulled back the blanket & abducted legs, pulled labia apart & began to push. When pt. pushed a penis was observed protruding the vagina. Physician was notified. 0 N/O were obtained. Pt. stated 'When I was born my mom wanted a girl.' 0 other c/o noted @ this X." On 03/12/12, at 11:30 a.m., the DON and the ADON were interviewed concerning the above incident. The DON stated on Thursday, when she had returned to work, she had found out the resident had been straight cathed by the ADON without a physician's orders [REDACTED]. The DON stated on Thursday, LPN #1 had reported to her the resident's complaint of pain and what she had observed when assessing the resident. The ADON was asked why she had straight cathed the resident. She said she was trying to help the resident since the resident had complained of pain the day before. The ADON stated she was trying to see if the resident's urine was "bad." The ADON was asked what she had done with the urine obtained when she had straight cathed the resident. The ADON stated she had flushed the urine down the toilet since it had been yellow in color and had no odor. The ADON was asked if she had called the physician for an order to straight cath the resident. She stated, "No. I take full responsibility." The ADON continued on to say it had been her idea and she had been the one in charge that day. The physician had never been notified of the ADON straight cathing the resident. On 03/12/12, at 12:00 p.m., LPN #2 was interviewed. LPN #2 stated on 03/06/12, she had been informed in a nursing report the resident had both male and female genitalia. LPN #2 stated the ADON came to her on 03/06/12 (day shift), and told her they needed to examine the resident because another nurse said the resident had a penis. The LPN was asked how she prepared the resident for the catheterization procedure. The LPN stated they had just told the resident she needed to get ready to be examined. The LPN said no one told the resident she was going to be straight cathed before she was examined. LPN #2 stated the resident laid down on her bed and they (LPN #2 and the ADON) palpated the resident's abdomen. The LPN stated the resident's stomach was not distended or hard. The LPN stated the ADON then checked the resident's vaginal area. The LPN heard the ADON tell the resident to bear down like she was having a baby. LPN #2 stated at that time, an appendage shaped like a penis came out of the vaginal opening. She said the penis like appendage had a white discharge. The LPN was asked where the ADON had straight cathed the resident. She stated the ADON straight cathed her in the female part of the urethra. The LPN stated at that time, the penis went back into the vagina. The LPN stated they got 30 - 50cc of urine. LPN #2 was asked how the resident responded to the examination and the straight cath. She stated, "The resident had been embarrassed and got teary eyed, so I stayed with her for a while afterwards." LPN #2 was asked why there was no documentation in the nurses' notes about the examination and the straight cath. She stated, "I don't know why there wasn't." The resident was examined and straight cathed one day after she had complained of pain. LPN #1 had already assessed her at that time, had contacted the physician and no new orders were received. There was no documented reason for the resident to have been subjected to an examination and catheterization.

Based on record review and staff interviews, it was determined the facility failed to ensure a physician's order had been obtained before straight cathing a mentally challenged resident, for one (#1) of three sampled residents with behavior problems. This had the potential to affect all 41 residents. Findings: Resident #1 was admitted on [DATE], from a Geri-psych hospital. The [DIAGNOSES REDACTED]. The care plan, dated 12/14/11, documented the resident required adjustment for her chronic medical condition/diagnosis. The goal was for her to accept her [DIAGNOSES REDACTED]. Another problem, included in the care plan, was the side effects from her antipsychotic medication regimen. The goal was for the resident to reach her highest practicable level of function with regards to her physical, mental and psychosocial well being. Interventions included the importance of allowing her individual space & to not violate her personal space without permission. A 30 day assessment, dated 01/18/12, documented the resident had displayed disorganized thinking, had a problem concentrating, had [MEDICAL CONDITION], resisted care at times, required assistance of one with bathing, was able to ambulate without assistance around the facility, was never incontinent of bowel and was occasionally incontinent of bladder. The March 2012, physician's orders documented the resident received the following medications: [REDACTED] "[MEDICATION NAME] 1000mg 1 po Q hs for [MEDICAL CONDITION], [MEDICATION NAME] 10mg 1 PO Q 12 hours for cognition, [MEDICATION NAME] 400mg 1 PO Q 12 hours for [MEDICAL CONDITION], [MEDICATION NAME] 900mg for aggression, [MEDICATION NAME] 2mg 1 PO Q 8 hours prn for anxiety, [MEDICATION NAME] 10mg 1 PO TID @ 0800-1400-2000 for aggression." A nurse's (LPN #1) note, dated 03/05/12, at 8:00 p.m., labeled as a 'Late entry', documented, "Pt states 'I'm in labor, I'm having a baby', later pt. observed crying when pt. assessed she c/o pressure 'down there' while pointing toward vagina. Upon observation 0 abnormalities seen when abd. palpated WNL, pt. pulled back the blanket & abducted legs, pulled labia apart & began to push. When pt. pushed a penis was observed protruding the vagina. Physician was notified. 0 N/O were obtained. Pt. stated 'When I was born my mom wanted a girl.' 0 other c/o noted @ this X." On 03/12/12, at 11:30 a.m., the DON and the ADON were interviewed concerning the above incident. The DON stated on Thursday, when she had returned to work, she had been informed of the resident being straight cathed by the ADON without a physician's order. She said she had talked to the ADON and told the ADON, she should not have straight cathed the resident without a physician's order. The ADON, at that time, had told the DON about observing the penis shaped appendage coming out of the resident's vaginal area. The DON stated on Thursday, LPN #1 had reported to her the resident's complaint of pain and what LPN #1 had observed when checking the resident. The DON stated LPN #2, who had been with the ADON at the time of the straight cath, had told her (the DON) about the appendage observed. LPN #2 had told the DON the resident was a Hermaphrodite. The DON stated she had informed the corporate ADM of the straight cathing incident that Friday morning. The DON said they had discussed speaking to the resident's family about the findings to see if the family would like a gynecologist to examine the resident. The ADON was asked why she had straight cathed the resident. She said she was trying to help the resident since the resident had complained of pain the day before. The ADON stated she was trying to see if the resident's urine was "bad." The ADON was asked what she had done with the urine obtained when she had straight cathed the resident. The ADON stated she had flushed the urine down the toilet since it had been yellow in color and had no odor. The ADON was asked if she had called the physician for an order to straight cath the resident. She stated, "No. I take full responsibility." The ADON continued on to say it had been her idea and she had been the one in charge that day. The physician had never been notified of the ADON straight cathing the resident. On 03/12/12, at 12:00 p.m., LPN #2 was interviewed. LPN #2 stated on 03/06/12, she had been informed in a nursing report the resident had both male and female genitalia. LPN #2 was asked if the resident had ever complained of pain before then. The LPN stated on 1 or 2 occasions she had heard the resident complain of hurting as if she was in labor and having a baby. She stated the physician had never been contacted as far as she knew. LPN #2 stated she was told the resident had complained of hurting the night before, to the evening charge nurse. LPN #2 had been told in report that when the evening nurse had examined the resident she had observed the resident had both male and female genitalia. LPN #2 stated the ADON came to her on 03/06/12 (day shift), and told her they needed to examine the resident because another nurse said the resident had a penis. The LPN was asked how she prepared the resident for the catheterization procedure. The LPN stated they had just told the resident she needed to get ready to be examined. The LPN said no one told the resident she was going to be straight cathed before she was examined. LPN #2 stated the resident laid down on her bed and they (LPN #2 and the ADON) palpated the resident's abdomen. The LPN stated the resident's stomach was not distended or hard. The LPN stated the ADON then checked the resident's vaginal area. The LPN heard the ADON tell the resident to bear down like she was having a baby. LPN #2 stated at that time, an appendage shaped like a penis came out of the vaginal opening. She said the penis like appendage had a white discharge. The LPN was asked where the ADON had straight cathed the resident. She stated the ADON straight cathed her in the female part of the urethra. The LPN stated at that time, the penis went back into the vagina. The LPN stated they got 30 - 50cc of urine. LPN #2 was asked if they should have received a physician's order to straight cath the resident before proceeding on with the procedure. The LPN stated, "Not necessarily." She said it was a 'nursing judgement' and some physicians would expect a nurse to do it if needed without a physicians' order. The nurse was asked who the physician was for the resident. She stated, "Dr. (Name deleted). The LPN was then asked if Dr. (Name deleted) would have wanted the nurse to call first and get a physician's order before straight cathing the resident. She stated, "I'm not sure if he would allow us to straight cath without an order from him first." As of 03/12/12, almost a week after the above observations, the DON had not notified the family of the cathing without a physician's order or about the penis shaped appendage observed coming out of the resident's vagina. The physician had not been notified of the ADON straight cathing the resident without an order. The resident's physician had not examined the resident to see what had protruded from the resident's vagina nor had a physician's appointment been scheduled for the resident to be examined.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure a resident was thoroughly assessed and treated for pain after a fall, which resulted in a hip and finger fracture, for one (#10) of six sampled residents with falls. This had the potential to affect four residents identified by the DON with falls during November 2011. The DON also identified 34 residents as having a prn pain medication ordered. This deficient practice caused harm to the resident who had sustained a fracture to the hip and finger and had complained of severe pain and was not medicated for the pain. b) Ensure residents were not treated for head lice without obtaining physicians' orders for treatment for two (#4 and #12) of two sampled residents identified as being treated for head lice. Only two residents were identified as having been treated for head lice. c) Ensure a laxative was administered as ordered, after a resident had been identified and hospitalized with a fecal impaction, for one (#14) of one sampled resident identified with a fecal impaction. This had the potential to affect 12 residents identified by the DON with orders for a stool softener and four residents with orders to receive a laxative. d) Ensure indwelling urinary catheter care was completed using warm soapy water as per the facility's policy and procedure for two (#5 and #8) of three sampled residents identified with indwelling urinary catheters. This had the potential to affect five residents with indwelling urinary catheters, per the ADON. Findings: The facility policy and procedure for 'Resident Incident/Accident' documented, "...Vital signs, including neurological checks, must be recorded every shift and resident's condition described for at least 72 hours, or longer as appropriate, following and incident/accident where there is a possibility of head injury. This will include all unwitnessed falls..." The facility's policy and procedure documented: "Catheter Care (Indwelling Catheter)... Equipment: Basin with warm water and soap... Procedure: ... Wash perineum well with soap and warm water, taking care to wash from front to back. Note: do not contaminate area with feces. If resident has had an involuntary bowel movement. Clean this area first. Wash your hands and obtain clean equipment for catheter care..." 1. The closed medical record for resident #10 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's physician's orders [REDACTED]. The resident's MDS assessment was not due. The only assessment completed was the discharge assessment. An incident report (IR), dated 11/01/11 at 2:00 p.m., documented the resident was on the floor on his side. The report documented the resident was trying to go to the bathroom. The IR documented the resident had sustained a skin tear to the left hand and elbow. Steps to prevent recurrence documented to instruct resident to use call light for assistance and a new order for personal alarm. The IR documented the physician had been faxed. A nurse's note, dated 11/01/11 at 2:00 p.m., documented the resident was found on the floor and the resident had reported trying to go to the bathroom. The nurse's note documented the resident had small skin tears to his L hand and left elbow, bruising to his left hand and forearm and the resident did not complain of pain. A copy of the fax, which was returned to the facility from the physician, documented the physician had not responded until 11/02/11 at 11:33 a.m. The fax documented to clean wound and put antibiotic ointment to site. An incident report, dated 11/02/11 at 1:00 a.m., documented the resident had been found on his knees holding onto the side rail. The resident had stated he was going to the bathroom. The resident's level of consciousness was documented as alert and oriented x2 and confusion. Steps to prevent recurrence documented the resident had a personal alarm on the bed and was instructed how to use the call light. A nurse's note was dated 11/02/11 at 1:00 a.m., documented the following: "...CNA went to answer the call light. Found resdt (resident) on floor on his knees holding onto the side rails - Assisted back on the bed - ROM done to bil knees - able to move freely n/c c (no complaints with) pain- has bruises on (L) forearm c 3 S/T's and 1/1 on (L) hand - denies pain - states he was going to the BR to urinate - reminded him he has a F/C - appears confused and sedated from his meds taken earlier...Faxed Dr (Name deleted) of fall...Personal alarm was in use." A nurse's note, dated 11/02/11 at 6:00 a.m., documented the resident slept off and on rest of night with no complaints of pain. A copy of the fax, dated 11/02/11 at 6:00 a.m., sent to the physician's office, documented the physician had been notified at 6:00 a.m. The fax documented, "Resdt trying to get up to go to BR s assist - fell on knees - note no pain or injury at this time." A nurse's note, dated 11/02/11 at 7:00 a.m., documented the following: "In bed C/O severe L hip pain. Unable to straighten out leg or rotate. C/O severe pain to L hand voiced upon assess 2+ [MEDICAL CONDITION] and bruising noted lateral L digits. Unable to clinch fist or stretch fingers. VS WNL. Physician notified. May send to ER..." A physician's telephone order, dated 11/02/11 at 8:00 a.m., documented to send the resident to ER for further evaluation and treatment. A response to the fax, dated 11/02/11 at 6:00 a.m., documented to continue to monitor and advise physician. The fax had been returned to the facility on [DATE] at 9:51 a.m. An ER record from the hospital, approximately 14 miles from the facility, documented the resident had arrived at the ER at 9:32 a.m., with complaint of pain after a fall. The report documented the onset of symptoms had been one day ago and were present in the left hand, left hip and pelvis. A consult report from the hospital, dated 11/02/11 at 9:45 a.m., documented, "The following [DIAGNOSES REDACTED]." The report documented the diagnostic test results as follows: "Left Hand -- Acute non -displaced [MEDICAL CONDITION] metacarpal of the left hand. Left Hip -- Acute femoral neck fracture without displacement." A hospital pain assessment, dated 11/02/11 at 2:00 p.m., documented the resident had experienced pain to the left hip and wrist. The resident identified the pain as a seven on a scale of 1-10. The pain was described as constant. The resident's medical record was reviewed for documentation the resident had been treated for the severe pain, as documented in the nurses' notes on 11/02/11 at 7:00 a.m. There was no documentation in the nurses' notes the resident had received anything for the severe pain. The MAR indicated [REDACTED]. On 01/27/12 at 3:50 p.m., the DON was interviewed regarding the lack of a thorough assessment of the resident for a hand and hip injury or a possible head injury. The DON was shown the documentation in the nurses' notes of the resident having severe pain to his left hip and hand. The DON was then shown the lack of a pain medication being given the resident. The DON reviewed the record and reported the nurse should have medicated the resident for the pain when identified. The DON reported the resident could have sustained the fracture to his hip and hand when he fell the first time. The DON reported the nurse had failed to adequately assess the resident. The DON reported the nurse should have checked everything. The DON reported the nurses' notes did not address the resident's hip. The DON reported the nurse was a new nurse. On 01/27/12 at 6:00 p.m., LPN #6 was interviewed. The nurse was identified as the nurse on duty on 11/02/11 at 1:00 a.m., when the resident had fallen from his bed. The LPN was asked if she had attempted any ROM on the resident's hips. The LPN reported she had not assessed the range of motion of his hips after the fall, but had checked his knees because he was on his knees when she found him. The LPN report the resident's knees were able to straighten and bend without complaint. She reported she did not think the resident had been hurt. The LPN was asked if she had done any neuro checks on the resident. The LPN reported she had not done neuro checks. The LPN reported she thought he had fallen out of the bed on his knees, because he was on his knees holding onto the side rail. The LPN was asked what the policy and procedure was for an unwitnessed fall. She reported, if the resident is in the floor neuro checks should be done. The LPN was asked if she had medicated the resident for pain. She reported she had not. The LPN reported the aides had checked on the resident through the night and had not reported the resident was in any pain. 2. Resident #4 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's care plan dated, 10/19/11, documented the resident had short term memory loss and would maintain her ability to make her own decisions independently. A quarterly assessment, dated 01/06/12, documented the resident was cognitively intact and required limited assistance with hygiene and bathing. On 01/25/12 at 3:45 p.m., the resident was observed in her room. The resident reported she and her room mate had been treated for head lice in August of last year. On 01/25/12 at 4:00 p.m., LPN #2 was asked if she was aware the resident had been treated for head lice. The LPN reported she was aware. On 01/26/12 at 8:45 a.m., CNA #1 was asked if she had been aware of the resident being treated for head lice. The CNA reported she had heard the resident had been treated for lice. The resident's medical record did not contain any documentation the resident had been treated for head lice. There were no nurses' notes documenting the resident had head lice or had been treated for head lice. There was no documentation in the medical record to show the physician had been notified or that an order had been obtained to treat head lice. On 01/26/12 at 5:00 p.m., the DON was interviewed regarding the resident's medical record not documenting the resident's physician had been notified or an order had been obtained for treatment. The DON reported she could not find any documentation regarding the notification or an order. The DON reported she could not find where the medication to treat had been ordered or had been delivered. On 01/28/12 at 4:00 p.m., the DON was asked how the treatment had been obtained. The DON reported the physician and not been notified and there was no order for the treatment. She reported some one had picked up the medicated shampoo at the dollar store and they treated the two residents. 3. The closed medical record for resident #12 (who was the room mate of resident #4) documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly assessment documented the resident was cognitively intact, independent with hygiene and required extensive assist with bathing. A nurse's note, dated 08/03/11 at 10:00 p.m., documented, "TX given c NIX shampoo - for lice - complete linen change done..." There was no other documentation regarding the resident having head lice. There was no documentation the physician had been notified or an order obtained for the treatment of the head lice. On 01/27/12 at 5:40 p.m., LPN #3 was interviewed regarding the lack of notification of the physician and the lack of a physician's orders [REDACTED]. On 01/28/12 at 4:00 p.m., the DON reported there was no notification or order. She reported some one had picked up the medicated shampoo at the dollar store and they treated the two residents. 4. A nurses' note, dated 09/03/11, at 7:00 p.m., for resident #14, documented, "Resident was sitting in W/C in TV area. Slumped over. Was unable to awaken him. Lethargic. Arms flaccid, color increased paler. Skin W/C. Called (Name deleted physician)..." A nurse's note documented at 10:30 p.m., "Resident will be admitted to hospital for severe fecal impaction." A history and physical report from the hospital, dated 09/03/11, documented: "Chief Complaint: Fecal Impaction. History of present illness: This is a [AGE] year-old male who presented to the ER at approximately 2012 (8:12 p.m.) on 09/03/11. After being assessed by the nursing home personnel, the patient was observed to have an altered mental status from his baseline state. According to the nursing home personnel the patient had a blood glucose in the 30s. They fed him throughout the day, and his blood sugar came up to around the 300s. The staff believed he was still acting somewhat odd and became concerned. On arrival to the emergency room , the patient was found to have a severely distended colon after he reported that he had not had a bowel movement in some time... Assessment: Constipation/Fecal impaction..." A radiological report, dated 09/03/11, documented: "ABD PAIN...Finding:...There is prominent stool within the rectosigmoid colon with the largest diameter of the rectal stool ball estimated at 12 cm. There is questionable pneumatosis in the rectal wall along the left lateral and posterior..." The physician's re-admit order, dated 09/07/11, documented, "Diagnosis: [REDACTED]." The September 2011, MAR indicated [REDACTED]. The September 2011, ADL flow sheet documented, the resident did not have a bowel movement on the 15, 16, 17, 18 and 19th. Then had an extra large bowel movement on the 2-10 shift and the 10-6 shift on the 20th. The medication administration sheet documented the resident had been given MOM on the 16th and again on the 20th. The September 2011, ADL flow sheet documented, the resident did not have a bowel movement on the 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th and 30th. The October 2011, ADL flow sheet could not be located in the resident's medical record by the surveyor or the ADON. The October 2011, MAR indicated [REDACTED]. A dietary progress note, dated 10/14/11, documented, "...admitted to hospital 9/3/11 d/t fecal impaction..." A care plan, dated 01/13/12, documented, "Problem: At risk for constipation R/T decreased mobility and routine pain medications... Interventions: [MEDICATION NAME] 100 mg po q day. MOM 30 cc po q day PRN constipation. Encourage resident to report s/s of constipation such as distended abdomen, hard, chalky stools, etc... Monitor BM's q shift. If no BM in 3 days, administer PRN laxative." A quarterly assessment, dated 01/13/12, documented the resident had inadequate short and long term memory, had severely impaired cognition, was independent with bed mobility, required extensive assistance with transferring between surfaces, ambulation, dressing, hygiene and bathing, was frequently incontinent of bowel and had a suprapubic catheter. On 01/25/12, at 4:00 p.m., the resident was observed sitting up in a W/C in the lobby at an activity event. On 01/27/12, at 6:00 p.m., the resident was observed lying in his bed. On 01/28/12, at 9:30 a.m., the DON was interviewed. She was asked for the facility's policy for monitoring bowel movements. The DON reported the charge nurse and CMA monitored the log daily and administered a laxative to residents that have not had a bowel movement in 3 days. At 10:30 a.m., the ADON was asked if the resident had received the [MEDICATION NAME] the physician had ordered when the resident returned from the hospital with a fecal impaction. The ADON obtained the log of received medications and reported the medication had been received from the pharmacy, but had been returned. The medications had been ordered because the staff thought the resident would be receiving skilled services. The ADON was asked if the resident had received the [MEDICATION NAME]. She reviewed the record and reported he had never received the [MEDICATION NAME]. At 11:40 a.m., the ADON reported the [MEDICATION NAME] order had never been carried over from the re-admission physician's orders [REDACTED]. 5. A care plan, dated 12/09/09, for resident #8, documented, "Problem: (Name deleted resident #8) has a foley catheter... Interventions: Foley catheter care q shift..." A quarterly assessment, dated 12/11/11, documented the resident had an indwelling urinary catheter, was frequently incontinent of bowel, was at risk for pressure sores, but did not have any at the time of the assessment. The January 2012, physician's orders [REDACTED]. The orders documented, "Foley catheter care every shift..." An admission assessment, dated 01/09/12, documented, "...F/C patent flowing yellow clear urine..." On 01/29/12, at 2:45 p.m., LPN #4 was observed to provide indwelling urinary catheter care for the resident. The LPN was observed to have two wash cloths. The LPN went to the sink and wet the cloths with warm water. She then took a wet cloth and cleaned the resident's vaginal area, and around the catheter insertion site. The LPN then took a second cloth and cleaned the resident's groin areas. The LPN did not clean down the tubing. The LPN did not use soap and water for the catheter care as the facility's policy and procedure stated. Before beginning the care, the LPN was overheard asking the resident if she had any peri wash. The resident reported she thought it was in a drawer of the night stand. The LPN told the resident she would do the catheter care without the peri wash this time. On 01/29/12, at 3:00 p.m., the DON was interviewed. The DON was asked what the facility's policy was for indwelling urinary catheter care. She reported they were to use peri wash and wet wash cloths or use the pre-wet wipes. 6. A care plan, dated 09/14/11, for resident #5, documented, "Problem: Altered urinary elimination pattern related to foley catheter... Interventions: Observed for clinical S/SX of UTI..." A telephone physician's orders [REDACTED]. Dx: UTI." A laboratory report, dated 11/29/11, documented, a urinalysis had a large amount of leukocytes and the resident had recently completed a round of antibiotics. The culture for the urinalysis documented the results of the culture as, Pseudomonas Aeruginosa. A quarterly assessment, dated 12/14/11, documented the resident had an indwelling urinary catheter and was occasionally incontinent of bowel. The January 2012, physician's orders [REDACTED]. On 01/26/12, at 10:45 a.m., LPN #5 was observed providing indwelling urinary catheter care for the resident. The resident was observed lying in the bed on her back. The LPN was observed to use wash cloths wet with water only. She was observed to have a wash cloth which she used to clean around the catheter insertion site and down the tubing. The LPN was observed to complete this process two different times, with two different cloths. The LPN did not use soap and water for the catheter care as the facility's policy and procedure documented. On 01/28/12, at 3:00 p.m., the DON was interviewed. The DON was asked what the facility's policy was for indwelling urinary catheter care. She reported they were to use peri wash and wet wash cloths or the pre-wet wipes.

Based on record review, observations and staff interviews, it was determined the facility failed to: a) Ensure the use of bed rails were assessed for safety after a resident experienced injuries by falling out of bed with the bed rails in the upright position, for one (#5) of four sampled residents who utilized bed rails. The Assistant Director of Nursing (ADON) stated the facility had a total of four residents that utilized bed rails. b) Ensure a resident was assessed for safety for the use of a geriatric chair (G/C) after falling out of the G/C and receiving injuries for one (#5) of one sampled resident. The ADON stated the facility had a total of two residents that utilized G/C's. Findings: Resident #5 had a [DIAGNOSES REDACTED]. 2 as an enabler for bed mobility/re-positioning." The physician's monthly orders from 05/07/10, until present documented, "May be up in geri chair for socialization & resident safety." A 14 day Medicare assessment, dated 05/14/10, identified the resident with severe cognitive impairment, short and long term memory loss, altered perception, restlessness, required total assistance with transfers, dressing, hygiene/bathing, used siderails for an enabler, had bowel and bladder incontinence and took an antipsychotic medication, an antidepressant medication and a hypnotic. A quarterly assessment, dated 08/06/10, identified the resident with severe cognitive impairment, short and long term memory loss, resisted care, required total assistance with transfers, dressing, hygiene/bathing, had bowel and bladder incontinence, used siderails for an enabler and took an antipsychotic medication, an antidepressant medication and a hypnotic and had a fall the past 31-180 days. A care plan, dated 08/06/10, documented: "Problem At risk for falls R/T antidepressant use Goals Risk for falls or injury will be minimized Interventions ...Half rails as position enabler May use a geri chair to enable socialization and for resident safety. Problems Cognitive impairment/neurological deficit Goals Disease process will be minimized Interventions ...Requires side rails x 2 as an enabler for bed mobility & re-positioning. May use low bed for resident safety." On 03/03/10 at 3:05 a.m., the resident was found on the floor in her room. The Incident/Accident Report documented the bed rails were present and were up, and the bed height was not adjustable. The description of the incident documented, "CNA found res. in floor. Stated, 'I was trying to get my clean clothes.' Assessed & VS (vital signs) taken. Assist back to bed - MAE (moves all extremities) - WNL (within normal limits) (No) c/o pain or distress. (No) apparent injuries. Oriented to self only (x1)." On the document titled "Conclusion and Interventions of Incident" it documented, "List interventions in Place to Prevent incident: Has no restraint - will try bed alarm. List Interventions Needed to Prevent Recurrence: Keep needed items w/in (within) reach." A check mark was next to "Educate Resident." There were no apparent injuries. The Incident/Accident Report dated 04/24/10, at 12:45 a.m., documented the resident was in her room, bed rails were present and were up, and the height of the bed was adjustable and was down. It further documented, "Describe exactly what happened...Check resident after bed alarm went off. Resident laying on abdomen small bruise slightly raised to (R) temporal area. Confused/disoriented... Additional comments and/or steps taken to prevent recurrence: Cont. to monitor frequently low bed c (with) soft floor mat c bed alarm instructed resident to use call light." It also documented the resident had a bruise to the right side of her head and was sent to the emergency room . The ER report dated 04/24/2010, documented, ..."evaluated for a forehead contusion, eccymosis." The Incident/Accident Report dated 06/28/10, at 6:50 p.m., documented the resident was in the common room and was alert and confused. It further documented, "Describe exactly what happened...Resident was in geri chair - personal alarm attached - resident crawled out geri chair & fell on to floor...Additional comments and/or steps taken to prevent recurrence: (blank)." It also documented she had a 2.5 cm (centimeter) laceration to her right temporal area with 5 stitches, a 2 cm skin tear to her left upper arm and an abrasion to her right lower leg. She was sent to the emergency room . The Incident/Accident Report dated 08/28/10, at 1:30 a.m., documented the resident was in her room, was confused, disoriented, bedrails were present and were up on a low bed, and she had abrasions to her right elbow and right knee. It further documented, "Describe exactly what happened...Resident on floor. Laying on (R) side. Abrasion to (R) knee & 1 cm to (R) elbow...Additional comments and/or steps taken to prevent recurrence: Half rail up for safety. Turn Q 2 (hours) Personal alarms in place. The Incident/Accident report dated 11/21/10 at 3:30 a.m., documented the resident was disoriented and bed rails were present and were up. It further documented, "Describe exactly what happened...Rsdt. (up) (with) agitation & (increased) anxiety - fell out of bed - getting a lge. hematoma to (R) side of forehead - Would not let me get V/S...Additional comments and/or steps taken to prevent recurrence: Put in G/chair - place at nurses station for visual view." She was sent to the emergency room . The report sent to the Oklahoma State Department of Health (OSDH) documented, "Patient has a low bed c (with) mat on floor. Causative factors: bed was not put in lowest position p (after) bed check. Staff counseled & safety precautions put into place." On 12/07/10, during the noon meal, the resident was observed sitting at a table in the dining room, in her G/C waiting to be fed. Observed on the resident's (R) forehead was a light greenish bruise with a scab in the center. The restorative aide (RA), sitting beside the resident was asked what had caused the bruise. The RA stated, "She's a Houdini. She can get out of anything." The RA reported the resident had fallen out of her bed. On 12/07/10 at 1:30 p.m., the resident was observed in her room, in bed, with bed rails up on both sides. The bed rails were approximately 3 feet long. The resident had approximately 24 inches, at the top and bottom of her bed that was not covered by the bed rail. The bed rails sat in the center of her bed. The resident was awake and asked for help to get up into the G/C, which was at the end of her bed. The ADON was asked for an assessment for the bed rails and the G/C. The ADON reported the bed rails and the G/C had not been considered a restraint, so they had not completed an assessment. At 2:00 p.m., the ADON was interviewed regarding the resident's falls with the bed rails up. The ADON reported they were called half rails, but fit in the center of the bed. The ADON was asked when the centered "half" rails had been put into place. The ADON reported the first bed rails were true half rails and only fit on the top quarter of the bed. The new centered "half" rails had been put on the resident's bed after the August fall, to prevent further falls. On 12/07/10 at 3:00 p.m., the DON was interviewed. He was informed of the resident's bed with centered side rails. He was shown the incident reports of the resident coming out of the bed with the centered rails up which had resulted in injuries. The DON reported he had thought the centered bed rails were a problem and he would get the bed rails removed from the center of the resident's bed. On 12/07/10 at 4:00 p.m., the resident's centered rails were removed. A new low bed was put in place and a mat was on the floor. The DON said no rails would be put on her bed. During the three day survey, the resident was observed to always be placed in a G/C, when out of bed. An incident report had documented the resident had fallen out of the G/C in June, with injury. The only intervention was a personal alarm to be placed on the resident while in the G/C. On 12/08/10 at 10:00 a.m., the RA was asked why the resident was always in a G/C when out of bed. The RA reported she had first been in a wheelchair with tippers on the back wheels and a pommel cushion in the W/C. When the resident had started tipping backwards and then falling forward, they were afraid she was going to throw herself out of the W/C. They then placed the resident in a G/C, so she could still come out of her room to socialize. On 12/09/10 at 9:00 a.m., the resident was observed in the lobby reclined in a regular recliner. The resident was observed to be in a comfortable position. The RA reported the resident would be placed in the recliner, instead of the G/C, to sit up in the lobby.