Every finding on record at The Highlands at Owasso

Based on observation, record review, and interview, the facility failed to ensure privacy was provided during wound care for 1 (#13) of 3 sampled residents reviewed for wound care. The administrator identified 84 residents resided in the facility. Findings: On 08/31/26 at 10:00 a.m., LPN #1 was observed to provide wound care for Resident #13 without shutting the door or pulling the curtain. An undated policy titled Dignity, read in part, 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. An admission form for Resident #13, dated 08/12/24, showed the resident had diagnoses which included atherosclerotic heart disease, depression, lupus, and a traumatic brain injury. A quarterly assessment for Resident #13, dated 05/30/26, showed the resident was moderately cognitively impaired with a BIMS score of 12. On 08/31/26 at 10:48 a.m., LPN #1 stated to provide privacy during wound care for Resident #13 they should have closed the door. LPN #1 stated they forgot to close the door because someone was behind them. On 08/31/26 at 11:00 a.m., the DON stated the door should be closed during resident care or procedures.

Based on observation, record review, and interview, the facility failed to maintain a homelike environment for 1 (#12) of 3 sampled residents reviewed for a clean, comfortable, and homelike environment. The administrator identified 84 residents resided in the facility. Findings: On 08/28/26 at 9:50 a.m., CMA #1 was observed yelling loudly down the hallway to another employee. Resident #12 asked CMA #1 to not yell. CMA #1 told Resident #12 they could yell if they needed to. Resident #12 again asked CMA #1 to not yell and again CMA #1 told Resident #12 they could yell if they needed to. An admission form for Resident #12, dated 08/21/24, showed the resident had diagnoses which included cerebral palsy, hypertension, chronic kidney disease, epilepsy, depression, mild intellectual disabilities, and ulcerative chronic proctitis with fistula. A quarterly assessment for Resident #12, dated 05/24/26, showed the resident was moderately cognitively impaired with a BIMS score of 8. On 08/28/26 at 9:53 a.m., CMA #1 stated it was the resident's home, and they should not be yelling down the hallways, especially after a resident asked them not to. On 08/28/26 at 10:15 a.m., Resident #12 stated they did not like it when the staff yelled in the hallways, especially when they did not feel good. On 08/28/26 at 10:28 a.m., the DON stated there should not be yelling in the hallways. They stated it was not conducive to a homelike environment. The DON stated the staff should have acknowledged the resident's request and stopped yelling.

Based on observation and interview the facility failed to ensure a resident had a privacy curtain for 1 (#5) of 3 sampled residents rooms reviewed for privacy. The administrator identified 84 residents resided in the facility.Findings: A quarterly assessment for Resident #5, dated 07/22/26, showed the resident was moderately cognitively impaired with a BIMS score of 12. On 08/26/26 at 2:14 p.m., Resident #5's room was observed to not have a privacy curtain to provide privacy between them and their roommate during care. On 08/26/26 at 2:15 p.m., Resident #5 stated they did not have a privacy curtain in their room, and it was embarrassing when they had to have incontinent care done. Resident #5 stated their roommate could see everything. 08/26/26 at 2:30 p.m., the administrator stated they did not know why there was not a privacy curtain in the room but there should be.

A past noncompliance immediate Jeopardy situation was determined to exist effective [DATE] related to the facility's failure to ensure residents were free from significant medication errors. Based on record review and interview, the facility failed to ensure:a. the correct resident was identified before administering medications; andb. a resident was free from significant medication errors for 1 (#1) of 3 sampled residents reviewed for medication administration.The ADON identified 88 residents received medications from the facility. Findings:Resident #1's face sheet from their electronic health record showed they were admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, hyperlipidemia, hypertension, and person history of a traumatic brain injury.A quarterly assessment for Resident #1, dated [DATE], showed the resident's cognition was significantly impaired with a brief score for mental illness score of 03. The assessment showed Resident #1 was taking and antidepressant, an opioid, an antiplatelet, and an anti-convulsant. The assessment did not show Resident #1 rejected care. Resident #1's vital signs taken from their electronic health record, dated [DATE] at 8:03 a.m., showed their blood pressure was 147/76 and their pulse was 83 beats per minute.A nurses note for Resident #1, dated [DATE], showed at 8:00 a.m. LPN #4 was notified by an unidentified CMA, Resident #1 was administered medications that were intended for Resident #2, their roommate. The note showed at 8:40 a.m. Resident #1 was diaphoretic, lethargic, pale, had cyanosis around the lips, labored breathing, and was unresponsive. The note showed EMS transferred Resident #1 to the hospital around 9:00 a.m.A final facility reported incident to the Oklahoma State Department of Health, dated [DATE], showed CMA #4 administered the wrong medication to Resident #1 due to CMA #4 asked Resident #1 if their name was Resident #2's name. Resident #1 replied yes and CMA #4 administered Resident #1 medications prescribed to Resident #2 in error. The report showed CMA #4 notified LPN #4 who assessed Resident #1, notified the medical director, and sent Resident #1 to the hospital for increased labored respirations.Hospital records for Resident #1, dated [DATE], showed the resident was treated at the hospital due to being administer the wrong medications. The note showed Resident #1 was diagnosed as hypotensive, bradycardia, and asystole (cardiac arrest). The hospital record showed Resident #1 was administered Narcan and epinephrine by EMS. The record showed Resident #1 was pronounced expired on [DATE] at 9:50 a.m.EMS records for Resident #1, dated [DATE], showed EMS arrived at the facility and was informed by the facility staff, Resident #1 was administered the wrong medications 40 minutes prior to EMS's arrival to the facility. The report showed the facility reported amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride were administered to Resident #1 in error. The report showed Resident #1 was lethargic and showed signs of sinus bradycardia with arrythmia 40 - 70 beats bpm (beats per minute), had shallow respirations, and cardiac arrest protocol were initiated. The EMS report showed Resident #1 was administered Narcan and epinephrine by EMS.Physician active orders for Resident #1, dated [DATE], showed the resident had an order for amlodipine 5 mg for hypertension and to hold the medication if the systolic blood pressure was less than 115 or heart rates was less than 50. The orders did not show they were prescribed aldactone, baclofen, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, and potassium chloride.On [DATE] at 3:22 p.m., the medical director stated the medication labetalol 300 mg administered in error could have caused Resident #1 to expire. On [DATE] at 12:55 p.m., CMA # 4 stated on [DATE] around 8:00 a.m. they administered Resident #1 the medications prescribed to Resident #2 due to Resident #1 identifying themselves as being Resident #2. CMA #4 stated when they were administering Resident #2's medications, they became aware they administered Resident #1 the wrong medications. CMA #4 stated, they notified LPN #4 who notified the physician of the medication administration error. CMA #4 stated the wrong medications were administered because they were unfamiliar with the residents and Resident #1 misrepresented their identity during medication administration.On [DATE] at 1:12 p.m., LPN #4 stated CMA #4 notified them Resident #1 was administered Resident #2's medication in error due to Resident #1 identified themselves as being Resident #2. LPN #4 stated they notified the physician of the medication error. They stated around 8:40 a.m. Resident #1 became clammy, had low respirations, and no verbal response. They called 911 and Resident #1 was transported to the hospital. On [DATE] at 1:45 p.m., the ADON stated they were notified on [DATE] at 8:47 a.m. by LPN #4 Resident #1 was administered Resident #2's medications in error. They stated LPN #4 reported to them Resident #1's respirations were 6 respirations per minute and Resident #1 was unresponsive. The ADON stated the medication administration error occurred due to CMA #4 asking Resident #1 if they were Resident #2 who replied, yes. The ADON stated Resident #1 missed 11 medications that were prescribed to them and only received Resident #2's medications. They stated CMA #4 failed to identify the correct resident as they were trained. They stated three of the 11 significant medications Resident #1 received in error which were prescribed for Resident #2 were as follows:a. amlodipine 10 mg (a vasodilator which lowered blood pressure) one tablet by mouth one time a day, hold if SBP was less than 110 on [DATE],b. lisinopril 40 mg (an ace inhibitor used to lower blood pressure) one tablet by mouth one time a day, hold if SBP was less than 115 on [DATE], andc. labetalol 300 mg (beta blocker used to lower high blood pressure) one tablet by mouth one time a day, hold if SBP was less than 115 and heart rate is less than 50 on [DATE].On [DATE] at 2:00 p.m., the DON stated they were informed on [DATE] at 8:01 a.m., Resident #1 was administered Resident #2's medications in error. The DON stated at 8:47 a.m. Resident #1 was sent to the hospital because they were declining. They stated Resident #1's photo in the health record should have been used to identify Resident #1 during medication administration due to Resident #1's cognition and hearing impairment.On [DATE] at 2:35 p.m., the medical director stated they reviewed Resident #1's EMS and hospital records dated [DATE]. They stated Resident #1's blood pressure was 90/50 and EMS gave them Narcan and epinephrine. The medical director stated labetalol, amlodipine, and lisinopril all lowered the blood pressure. The medical director stated the epinephrine was administer by EMS with labetalol could have cause an acute cardiac event.On [DATE] at 2:45 p.m., resident representative #1 stated they were notified on [DATE] by LPN #4 Resident #1 was administered the wrong medications. They stated this should have never happened because Resident #1 had dementia. Resident representative #1 stated Resident #1 expired as a result of the medication administration error. On [DATE] at 3:39 p.m., the owner of the facility stated they felt the three doses of epinephrine given to Resident #1 resulted in the death of the resident.The immediacy was removed effective [DATE] after the facility's QAPI committee put measures in place to prevent recurrence. The following actions were taken:a. on [DATE], a QAPI meeting was conducted. The facility IDT (interdisciplinary team) team reviewed their medication administration policy and procedures to ensure the policies and procedures in place would keep residents safe,b. the QAPI committee put in place in-service education by the DON and ADON on [DATE] for all staff administering medications which covered the topic of medication administration policies and procedures which included identifying the correct resident when administering medications, andc. the QAPI committee put in place bi-weekly visual audits of staff administering medications to ensure they were following medication administration policies and procedures. The facility provided documentation showing:a. They observed medication aides and nursing staff to ensure they were identifying the correct resident during medication pass,b. medication aide's certifications,c. medication aide skills check offs,d. nursing licenses were reviewed to ensure accurate training, ande. CMA # 4 was suspended immediately on [DATE] and self-terminated. Multiple CMA's and nursing staff from multiple shifts were observed and interviewed to ensure they had the proper skills and knowledge to ensure they were identifying the appropriate resident during medication pass and administering the appropriate medications as prescribed by a physician.

Based on observation, record review, and interview, the facility failed to safely transfer a resident using a mechanical lift for 1 (#2) of 4 sampled residents reviewed for the safe use of a mechanical lift for transfers. The ADON identified 14 residents utilized a mechanical lift for transfers. Findings:On 01/07/26 at 2:21 p.m., Resident #2 was observed in their room, sitting in their recliner. Resident #2 was dressed and their call light was in reach. An undated facility policy titled Safe Lifting and Movement of Residents, read in part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Staff responsible for direct resident care will be trained in the use of manual (gait,/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving resident when necessary, only staff will documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents.Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings.A quarterly assessment for Resident #2, dated 10/02/25, showed Resident #2 was severely impaired in cognition with a BIMS score of 5 and was dependent on others for most activities of daily living (including positioning and transfers).A care plan for Resident #2, revised 11/24/25, showed Resident #2 required the assistance of two or more staff members and a mechanical lift for transfers. A nurse's progress note for Resident #2, dated 12/06/25, showed Resident #2 slipped from the sling and fell during a mechanical lift transfer from the bed to the chair. The progress note showed the resident was transferred to the hospital for further evaluation due to routinely receiving blood thinners and Resident #2 complaining of head pain. The progress note showed there were two CNAs present who witnessed the fall and stated the resident hit their head on the floor. A state reportable incident report, dated 12/06/25, showed Resident #2 slipped and fell from the lift during a mechanical lift transfer. The incident report, read in part, Upon investigation, the nurse aids were attempting to ambulate [transfer] the resident in the lift and failed secure [their] back far enough on the lift [sling] per the guidance of our policies and procedures. This resulted in [Resident #2] falling from the top right of the sling and hitting [their] head onto the ground .The facility believes the CNAS neglected to secure the resident properly on the sling which led to the fall. A nurse's progress note for Resident #2, dated 12/06/25, showed Resident #2 had a small subdural hematoma requiring hospitalization. An in-service sign in sheet, dated 12/06/25, showed 102 staff members from the nursing department received an in-service on the lift machine and use of the lift machine for positioning and transfers. A QAPI meeting sign in sheet, dated 12/06/25, showed the QAPI team met to review lift use related to Resident #2.A PIP, dated 12/06/25 and revised 12/08/25, showed the facility goal was to ensure all lifts and slings were in working condition, all nursing staff providing direct care were educated and properly trained to use the lift and properly position and use the sling. The PIP showed the following steps completed:a. audited all residents using a mechanical lift to ensure proper care planning and overall appropriateness for mechanical devices;b. ordered new slings to make sure all residents had their own sling;c. in-serviced all nursing staff on appropriate use of mechanical lifts/slings;d. required all nursing staff to demonstrate competency on using the lift by demonstrating it on administrative staff;e. performed staff questionnaire on proper use of the lift; andf. created a log to routinely audit staff to visually check to see if staff were appropriately using the mechanical lifts. A nurse's progress note for Resident #2, dated 12/09/25, showed Resident #2 returned to the facility. An audit tool, dated 12/10/25 through 01/28/26, showed 17 staff members were monitored during a resident transfer to ensure they used the lift properly. On 01/15/26 at 2:30 p.m., the ADON stated Resident #2 fell during a lift transfer from the bed to the chair. The ADON stated CNA #4 and CNA #5 performed the lift transfer and one was on new hire orientation, but was not a new CNA. The ADON stated to determine what happened, the two CNAs reenact the transfer with the ADON posing as the resident. The ADON stated it was immediately obvious the CNAs had not properly positioned the sling which left the resident without trunk support. The ADON stated since the resident was without trunk support and could not hold themselves up while in the sling, the resident fell from the sling. The ADON stated they in-serviced staff on fitting/positioning a sling for a resident and use of a mechanical lift. The ADON stated the in-service included each staff member performing a return demonstration of a mechanical lift transfer on a member of the administration. The ADON stated all residents using a mechanical lift for transfers were checked to ensure they had the proper sling, slings were repaired/replaced if needed, and care plans accurately reflected the resident's needs. The ADON stated the quality assurance team performed random audits of mechanical lift transfers which they planned to continue. The ADON stated prior to the incident, their staff received instruction on mechanical lift transfers on hire, were in-serviced at least annually on mechanical lift transfers and reviewed/evaluated on mechanical lift transfers during their competency reviews.

Based on record review and interview, the facility failed to ensure that medications were given as ordered for 1 (#16) of 7 sampled residents reviewed for physician's orders.The administrator identified 83 residents resided in the facility. Findings:A hospital discharge medication list for Resident #16, dated 01/09/26, showed Resident #16 was to continue taking furosemide (a diuretic medication) 60 mg by mouth every day.A physician's order for Resident #16, dated 01/09/26, showed that Resident #16 was to take furosemide 40 mg by mouth every day.An admission assessment for Resident #16, dated 01/16/26, showed Resident #16 had a BIMS score (a test for cognition) of 12, which indicated moderate cognitive impairment, and received a diuretic medication.On 01/22/26 at 10:00 a.m., Resident #16 stated at the hospital they were taking 60mg of furosemide every day and since they had been admitted to the facility, they were only receiving 40 mg a day.On 01/22/26 at 12:20 p.m., the ADON stated Resident #16's discharge order from the hospital indicated they were to receive 60 mg of furosemide daily, but the nurse had mistakenly entered 40 mg daily.

Based on record review and interview, it was determined the facility failed to secure medications for 1 (#13) of 5 sampled residents reviewed for medication storage.The administrator identified 83 residents received medications in the facility. Findings:A physician's order for Resident #13, dated 11/06/25, showed Resident #13 received zinc oxide 20% external paste topically to the sacrum and buttocks every shift for skin integrity. A nurse's progress note for Resident #13, dated 11/06/25, showed Resident #13 had a stage II pressure ulcer to their coccyx with redness to the surrounding tissue. The progress note showed the nurse cleaned the wound, dried the wound, and applied a zinc cream and a padded dressing to the wound. A nurse's progress note for Resident #13, dated 11/09/25 at 9: 00 a.m., showed when the nurse entered Resident #13's room, they observed the resident mixing zinc oxide paste in with their oatmeal. The progress note showed Resident #13 responded yes when asked if they ate some of the oatmeal mixture. A comprehensive assessment for Resident #13, dated 11/13/25, showed Resident #13 had a BIMS of 15, which indicated the resident was cognitively intact. The assessment showed Resident #13 had no skin issues and had ointment or medication applied to areas of their body other than their feet.On 01/22/26 at 10:55 a.m., the MDS coordinator stated it was reported Resident #13 ate zinc oxide paste that was left at their bedside. The MDS coordinator stated the facility was unable to determine who left the zinc oxide paste at bedside. The MDS coordinator stated it was inappropriate to leave medications unattended at bedside for Resident #13.On 01/22/26 at 11:20 a.m., the ADON stated they were notified Resident #13 possibly ate zinc oxide cream that was left at the bedside. The ADON stated they were unable to determine who left the cream at bedside but immediately sent out an in-service via phone and as part of their monthly in-service.

Based on observation, record review, and interview, the facility failed to provide medically appropriate dental services for 1 (#1) of 3 sampled residents reviewed for dental services.The administrator identified 83 residents resided in the facility. Findings:On 01/07/26 at 2:21p.m., Resident #1 was observed in bed with a denture cup at bedside. A social service progress note for Resident #1, dated 10/23/24 at 2:09 p.m., showed the guardian for Resident #1 provided contact information and wanted the resident to receive dental services. The progress note showed the guardian wanted Resident #1 to be assessed and fitted for dentures. Review of the clinical record did not show Resident #1 had been assessed and fitted for dentures. An e-mail provided by the social service director, dated 11/04/25, showed Resident #1 had impressions made for upper and lower dentures.An e-mail provided by the social service director, dated 11/18/25, showed Resident #1 received upper and lower dentures. The e-mail showed Resident #1's denture fitting needed no adjustment. An e-mail provided by the social service director, dated 01/15/26, showed Resident #1 had their dentures adjusted for comfort and given instructions on care of their dentures.On 01/07/26 at 2:21 p.m., Resident #1 stated their dentures were in their denture cup. On 02/02/26 at 1:30 p.m., the social service director stated they started working at the facility in June of 2025 and was not aware the resident requested dentures. The social service director stated there was no documentation in the clinical record regarding dental services for Resident #1, but they were able to find where the dental provider communicated with the facility regarding dental services for Resident #1. The social service director stated they did not know why the information was not part of the resident's clinical record. The social service director stated they did not know why it was more than a year before the resident received their dentures.

Based on record review and interview, the facility failed to ensure the DON had not worked as a charge nurse when the facility census was above 60 residents and failed to ensure the DON worked 40 hours each week. The Administrator stated the facility had a census greater than 90 residents for 36 days from 04/01/25 to 05/06/25. Findings: An undated policy titled Director of Nursing Services (DNS), read in part, The DNS may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The policy also showed the DON was to work at least 40 hours a week. On 05/06/25 the facility administrator provided the survey team a document titled Highland's Daily Census that showed each date on and between 04/01/25 and 05/06/25 having had a daily census greater than 90 residents. On 05/06/25 at 12:19 p.m., the DON was asked if they were the director of nursing for the facility. The DON stated they were the director of nursing of record. The DON stated they generally work every Tuesday, Wednesday, and Thursday on 12-hour shifts. The DON stated their primary duty was as the charge nurse working on the halls. The DON stated they also do things like assist the pharmacist with medication destruction when needed. They stated they had been the director of nursing of record for about one month. The DON stated the company that owns the facility was currently advertising the DON position. On 05/06/25 at 1:07 p.m., the administrator was asked who the DON was and what their duties. They stated the current DON had been in that position for about 5 to 6 weeks and worked as the DON as well as a charge nurse. They stated the current DON was appointed the director of nursing of record so they could assist in the destruction of medications with the pharmacist. The administrator was asked what they knew of current regulations regarding a DON's requirement for weekly hours devoted to DON duties and a DON working as a charge nurse. They stated they were not aware of any regulations in those areas.

Based on record review and interview, the facility failed to ensure a water management plan to prevent waterborne pathogens had been implemented. The administrator reported 95 residents reside at the facility. Findings: A facility policy titled Legionella Water Management Program, dated September 2022, read in part, As part of the infection prevention control program, our facility has a water management program, which is overseen by the water management team. The document also showed: a. There was a water management team consisting of the infection preventionist, the administrator, the medical director or their designee, the director of maintenance, and the director of environmental services; b. A detailed description and diagram of the water system in the facility which would show areas of the system that could encourage growth and spread waterborne bacteria, and c. Specific measures would be used to control the introduction or spread of Legionella including a system to monitor the effectiveness of the control measures. On 05/06/25 at 4:24 p.m., when asked to provide the facilty waterborne pathogen plan as described in their policy, the administrator stated the facility did not have a waterborne pathogen committee or a diagram of the facility that would show where waterborne pathogens could grow. They stated the water management team had never been formed. They stated they had also not tested the facilities water for pathogens.

Based on record review and interview, the facility failed to ensure residents were provided with a Notice of Medicare Non-Coverage at least two days prior to the end of skilled services for 2 (#99 and #100) of 3 sampled residents reviewed for beneficiary notices. The administrator identified 46 residents who had been discharged from skilled services from 11/06/24 through 05/06/25. Findings: An undated policy titled Policy on Issuing Notice of Medicare Non-Coverage (NOMNC), read in part, The NOMNC must be delivered at least two days before Medicare-covered services are scheduled to end. A Notice of Medicare Non-Coverage form for Resident #99 showed the resident's skilled services would end on 12/19/24. The form further showed the resident signed the form on 12/18/24 which one day prior to the end of services. A Notice of Medicare Non-Coverage form for Resident #100 showed the resident's skilled services would end on 01/24/25. The form further showed the resident signed the form on 01/23/25 which was one day prior to the end of services. On 05/06/25 at 11:47 a.m., the SSD was asked to explain the process of providing residents with the Notice of Medicare Non-coverage, form. They stated the forms were for residents that were receiving skilled services paid by Medicare and informed them of the date coverage for those services would end. They stated the form was to be given to the residents at least two days prior to the end date. They stated the form was to inform the residents of their rights to appeal for the coverage to continue it they chose to do so. The SSD was asked to look at the NOMNC forms for Res #99 and Res #100 for any irregularities. They stated each of the forms were given one day prior to the end of services instead of the two days that were required. They stated they had not followed policy.

On 04/18/25, a past non-compliance situation was determined to exist related to the facility's failure to provide supervision to protect residents. An Incident Report, dated 02/25/25, showed Resident #165 got out of the building and was found a mile away from the facility by police. Resident #165 was returned to the facility where the resident signed out of the facility against medical advice (AMA). On 04/09/25 Resident #165 eloped and was located a half mile away from the facility on a four-lane busy road. Resident #165's care plan did not address interventions of exit seeking behaviors on 02/16/25 and was not updated until 04/09/25 with interventions. Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent elopement for 1 (#165) of 3 sampled residents reviewed for elopement. The administrator identified 96 residents reside in the facility. Findings: On 04/27/25 at 12:45 p.m., the doors of the building were visually observed to be closed and locked. The alarm system indicated it was armed. A Hospital Discharge Summary, dated 02/24/25, showed Resident #165 was alert and aware. A facility Medical Diagnoses report, dated 02/24/25, showed Resident #165 had a diagnosis of encephalopathy. An Incident Report, dated 02/25/25, showed Resident #165 was admitted to the facility on [DATE] for skilled services. The report showed Resident #165 was discovered not in the facility on 02/25/25 at 12:25 p.m. The report showed Resident #165 was found at 1:13 p.m. by local law enforcement. A progress note, dated 02/25/25 at 11: p.m., showed the resident requested to go outside and was directed to the enclosed outside area of the facility. On 05/05/25 at 12:13 p.m. LPN #2 stated they had initially observed Resident #165 in the common outside area that was enclosed. Later the resident was observed through a window on the outside grounds of the building. LPN #2 stated administration was notified immediately and staff went to look for the resident. They stated the police and corporate personal were notified. LPN #2 stated they called Resident #165's first contact and notified them Resident #165 was missing. They stated the resident was found by local law enforcement and returned to the facility. LPN #2 stated Resident #1 was missing from the facility for approximately 50 minutes. When Resident #1 was returned to the facility, they stated they did not want to stay at the facility, they wanted to go home. LPN #2 stated prior to the resident's hospital stay the resident lived alone in the area. LPN #2 stated they explained to the resident the importance of receiving their medications and they could not be discharged with the PICC line in place and this line was needed for the prescribed antibiotics. LPN#2 stated Resident #165 was insistent they were going home and to take out the PICC line. LPN #2 stated an RN removed the PICC line and the resident signed out AMA. On 05/05/25 at 1:42 p.m., the administrater stated Resident #165 was reported to be missing and staff immediately looked for the resident. They stated other staff checked the doors leading to the outside to ensure they were locked and secure. The administrator stated local police were notified as well as the resident's contacts. They stated when Resident #165 was returned to the facility, Resident #165 reported someone had let them out. The administrator stated they thought a visitor might have let the resident out. The administrator stated corrective actions were immediately put in place after the elopement. Notices were placed on the inside and outside of the front doors reminding visitors not to let others out of the facility and the codes to the front doors were changed. The administrator stated the staff were educated on elopement, locked doors, and the importance of knowing where residents were in the building. The administrator stated monitoring was begun to ensure all doors were locked and the alarm system was in working order. He stated the incident was addressed and still ongoing in QAPI meetings. On 05/06/25 at 9:11 a.m. the administrator stated they were notified Resident #165 was seen outside of the building on 02/26/25 at 12:25 p.m. and was found by local law enforcement at 1:13 p.m. He stated the resident told the police they were walking home. On 05/06/25 at 10:02 p.m., the administrator provided documentation of the QAPI plan for the elopement dated 02/27/25, a copy of the 02/25/25 inservices for the staff regarding the elopement, and a copy of the ongoing monitoring of the door alarms with a start date 02/25/25.

Based on observation and interview, the facility failed to ensure medications were secured in a locked medication cart for 1 (treatment cart #1) of 1 medication cart observed on the center hallway. The administrator identified 117 residents reside in the facility. Findings: On 04/28/25 at 2:02 p.m., treatment cart #1 was located across the hall from the nurses station and was observed to be unlocked and unattended. On 04/28/25 at 2:05 p.m., LPN #1 returned to the cart and locked it. They stated the cart should be locked when not in use to secure medications. On 04/30/25 at 1:00 p.m., the ADON stated all medication carts should be locked if the CMA or nurse was not at the cart.

Based on observation and interview, the facility failed to ensure kitchen staff members wore a beard guard for 1 (cook #1) of 1 staff members observed for beard guards. The administrator identified 95 residents received meals prepared by the kitchen. Findings: On 04/28/25 at 1:29 p.m., an intital tour of the kitchen was conducted. [NAME] #1 was observed preparing food without wearing a beard guard. On 04/28/25 at 1:35 p.m., [NAME] #1 stated they did not know the facility policy regarding wearing beard guards, no one had told them they had to wear one. They stated the facility did not have any beard guards. On 04/28/25 at 2:32 p.m., the administrator stated they should have been wearing a beard guard.

Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were utilized during medication administration for one (#16) for one resident sampled for medication administration. The administrator reported the census was 97. Findings: Resident #16 had diagnoses which included chronic pain syndrome and hypertension. A physician order, dated 09/05/24, documented Resident #16 was to receive oxycodone 20 mg (pain medication) every 6 hours as needed for breakthrough pain. On 01/15/25 at 11:45 a.m., CMA #1 was observed administering Resident #16's oxycodone. CMA #1 punched the medication out of the card into their bare hand and then placed the medication in the medication cup. On 01/15/25 at 11:47 a.m., CMA #1 stated the medication should have been punched out of the card directly into the medicine cup without touching it. On 01/15/25 at 11:54 a.m., LPN #1 stated medication should not be touched with a bare hand. On 01/15/25 at 4:01 p.m., the ADON stated medication should be punched out of the card directly into the cup and should not be touched.

Based on observation, record review, and interview, the facility failed to ensure the call light system was functioning for one (#5) of one resident whose call light was tested . The administrator reported the census was 97. Findings: An undated policy titled Answering the Call Light, read in parts, Ensure the call light is plugged in and functioning at all times .Report all defective call lights to the nurse supervisor promptly. Resident #5 had diagnoses which included heart failure and anxiety disorder. On 01/15/25 at 10:00 a.m., Resident #5 stated that their call light did not work and that it had not worked in several months. They also stated that if they needed help, they would have their roommate activate their call light. Resident #5 then pressed the button to activate their call light and the light outside their door did not illuminate. On 01/15/25 at 11:54 a.m., LPN #1 was shown Resident #5's call light was not functioning. They stated they were unaware the call light was not functioning, and they would inform maintenance. 01/15/25 at 12:14 p.m., the maintenance supervisor stated call lights had been an ongoing issue in the facility. They stated the call system was wireless and required batteries. They further stated they did not conduct routine testing of the call system or scheduled replacement of the batteries.

Based on record review and interview, the facility failed to accurately transcribe admission orders as written and failed to acquire medications within four hours for one (#2) of five sampled residents whose clinical records were reviewed for pharmacy services. The DON identified 99 residents who resided in the facility. Findings: Resident #2 had diagnoses which included chronic obstructive pulmonary disease, depressive episodes, and dementia with mood disturbance. A hospital history and physical, dated 10/11/24, read in parts, Assessment/Plan .Depression/anxiety - PRN Xanax [alprazolam] [benzodiazepine medication]. The history and physical documented the resident was to continue taking alprazolam 1mg by mouth every six hours if needed. The facility admission orders, dated 10/11/24, documented Xanax 1mg every 6 hours to be given routinely, and Nuvigil 150mg to be given daily. The controlled drug receipt record/disposition forms for Nuvigil (CNS stimulant) 150mg tablets and Xanax 1mg tablets documented the medications were first delivered on 10/14/24. The medication administration record documented the resident received their first dose of Xanax 1mg on 10/15/24 at 12:00 a.m., then again at 6:00 a.m., 12:00 p.m., and 6:00 p.m. The medication administration record documented the resident received their first dose of Nuvigil 150mg on 10/15/24 at 12:00 p.m. On 12/12/24 at 5:10 p.m., CMA #1 stated they re-ordered medications early enough for the resident not to have an interruption in their medication treatment. The CMA stated they would order a medication only to find out the pharmacy did not send the medication. The CMA stated they would call the pharmacy and find out the medication required a written script. The CMA stated they would inform the nurse that an ordered medication required a script from the physician. On 12/12/24 at 5:20 p.m., LPN #1 stated the floor nurses received a copy of the new residents hospital discharge instructions, transcribed, and confirmed the orders with the physician before sending the orders to the pharmacy to fill. The LPN stated they usually received the admitted residents medications within four hours. The LPN stated they would not know a medication was not delivered until they compared what they received to the orders and contacted the pharmacy. The LPN stated if a medication required a written script from the physician, they would not know the pharmacy had not received the script until the medication did not arrive as expected. On 12/12/24 at 5:30 p.m., CMA #2 stated they had to contact the pharmacy if an ordered medication was not received to find out why the medication was not sent. The CMA stated the pharmacy did not send medications for a variety of reasons. The CMA stated the pharmacy did not contact the facility staff to inform them of the issue, but waited for the facility staff to contact them regarding the omission. The CMA stated that sometimes caused residents not to receive their medications as ordered. On 12/12/24 at 5:50 p.m., the DON reviewed the hospital discharge instructions for Resident #2, dated 10/11/24, and stated the order for Xanax appeared to have been transcribed in error as 1mg every six hours routine instead of as needed as the discharge instructions read. On 12/13/24 at 12:50 p.m., LPN #2 stated the floor nurses were responsible for admitting new residents. The LPN stated they received a text from the facility's admission coordinator stating the nurse would receive an admission. The LPN stated they would then review the hospital discharge instructions for medications, treatments, and other instructions, and transcribe the instructions into the admitting residents electronic medical record. The LPN stated that after they transcribed the orders, they would contact the facility's admitting physician, tell them the resident was in the facility, and the orders were entered from the resident's discharge records. The LPN stated they usually then received an OK from the physician. The LPN stated they did not read off the transcribed orders to the physician, and waited for pharmacy to notify them of any issues with the ordered medications. They stated if the pharmacist had concerns, the nurse would contact the physician with any needed changes to the order and usually received a simple verbal confirmation from the physician. The nurse stated the written script for Xanax and Nuvigil was sent on 10/14/24.

Based on observation and interview, the facility failed to serve hot foods at an appealing temperature. The DON identified 99 residents who ate meals prepared in the kitchen. Findings: On 12/11/24 at 12:45 p.m., Resident #4 stated they ate their meals in their room and the food was never hot and rarely warm. The resident stated some of the meals were not thoroughly cooked or were over-cooked/burnt, but were still served. On 12/11/24 at 1:00 p.m., Resident #6 stated the meals tasted bad and at times they felt the kitchen staff purposely sent food out they knew was not edible. On 12/11/24 at 4:50 p.m., the dietary manager stated the kitchen staff checked food temperatures before serving and checked the temperature of the meal cart once it was delivered to the residents' hall. On 12/11/24 at 5:40 p.m., the temperature gauge on the meal cart was observed to read 100 degrees Fahrenheit with the heating dial set to 145 degrees Fahrenheit. On 12/11/24 at 5:55 p.m., a test tray stored on the observed meal cart was received and food temperatures were taken with the dietary manager present. With multiple popcorn shrimp scored on the temperature probe, the temperature of the shrimp was 92 degrees Fahrenheit. The shrimp felt cold with a chewy texture, and covered in a damp/wet breading. The breading tasted bland and the shrimp had no flavor. On 12/11/24 at 5:55 p.m., the dietary manager stated that was not good, but they knew the food was hot when it left the kitchen.

Based on observation and interview, the facility failed to maintain an effective pest control program. The DON identified 99 residents in the facility. Findings: On 12/12/24 at 3:50 p.m., an environmental tour was conducted on the 400 hall. Evidence of roaches (droppings and dead roaches) was present along baseboards, near and under the refrigerator, on glue traps located in the corners of the room, storage drawers, and closets. Live roaches were observed in the corners nearest the bathroom door and near the heat/air unit in room [ROOM NUMBER] and 412. On 12/13/24 at 5:25 p.m., the corporate administrator stated the exterminator visited the facility monthly. The corporate administrator stated because of how the invoices were delivered, they were not sure if the administrator reviewed the recommendations the exterminator left on their invoices, but the exterminator responded quickly to any concerns the facility had related to vermin. The corporate administrator stated they would address the pest control issue immediately.

Based on record review and interview, the facility failed to ensure injuries of unknown origin were reported timely for one (#1) of three residents sampled for incidents. The ADON identified 80 residents who resided at the facility. Findings: An undated Abuse Investigation and Reporting policy, read in parts, .All reports of resident abuse, .and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies .All alleged violations .including injuries of an unknown source .will be reported by the facility Administrator, or his/her designee .immediately, but not later than: .twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Resident #1 admitted with diagnoses which included Chronic Lymphocytic Leukemia of B-cell type (a form of blood cancer). A progress note, dated 08/03/24, documented a large bruise to the right arm of Resident #1 was noted and the resident reported they did not know what caused the bruise. The note documented Resident #1 did not complain of pain or discomfort. A progress note, dated 08/04/24, at 4:00 p.m., documented Resident #1 reported that the bruising to their right upper arm was painful. The note documented the wound nurse was consulted, and Resident #1 stated they did not know what caused the bruise, but stated they did not fall. The note documented an x-ray order was obtained to rule out fractures or abnormalities. The note documented the results of the x-ray did not identify an acute fracture or dislocation. The note documented the wound nurse obtained an order for tramadol 50 mg every six hours as needed for pain. A late entry progress note, dated 08/05/24, at 7:40 a.m., documented a discussion with Resident #1 about the possibilities of how Resident #1 thought they had received the bruise. Resident #1 stated they may have bumped it on the door or the bed. The note documented the nurse had observed Resident #1 bump into the door in the past. A progress note, dated 08/05/24, at 6:50 p.m., documented the nurse had spoke with the family member of Resident #1 at the nursing station and the family member mentioned the bruise on the arm of Resident #1. The note documented they had informed the family member the facility was not sure of what caused the bruise, but they had completed an x-ray that resulted negative for abnormalities and an order for blood work on the next lab draw day in the morning. An ODH Form 283, dated 08/05/24, documented an allegation of abuse for Resident #1, who had a bruise shaped in the form of a hand to their upper extremity and an investigation had begun. A progress note, dated 08/06/24, at 4:47 a.m., documented the nurse was notified at the start of their shift to request an officer to the facility to obtain a statement from Resident #1 regarding the bruise to their right upper arm. The note documented an officer did come to the facility and spoke to Resident #1. A late entry progress note, dated 08/06/24, at 4:58 p.m., documented the nurse had spoke with Resident #1 after they were notified of a bruise on their arm. The note documented the nurse had asked what happened and Resident #1 stated, I do not know what happened, the only thing I can think of is that I bumped it while going to the bathroom or something. The note documented the nurse asked Resident #1 if anyone had hit them and they stated absolutely not. The note documented the nurse asked the roommate if they had witnessed anything regarding Resident #1 and the roommate stated no. On 08/08/24, at 1:20 p.m., Resident #1 stated they had woke up with the bruise on Monday and had no idea how it happened. Resident #1 stated they must have bumped it going to the bathroom, and stated no one had ever hurt them. Resident #1 stated they felt safe. On 08/09/24 at 11:09 a.m., the regional administrator stated the facility probably failed to notify of the incident as an injury of unknown origin. They stated when they were made aware it was brought to them as an abuse allegation and so that was what was reported.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to prevent falls for two (#3 and #5) of four residents reviewed for falls. Resident #5 experienced 22 falls since 05/03/19 resulting in an orbit fracture and a right [MEDICAL CONDITION]. The MDS nurse identified 72 resident who had experienced falls in the previous six months. 1. Resident #5 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. An undated care plan documented: .I am at risk for falls r/t poor memory/cognition, weakness, history of falls with fracture, use of [MEDICAL CONDITION] medications . Goal I will be free from falls through next review . Interventions . Alert my family and doctor of falls. Check on me to ensure that I am safe. Keep my call light available and encourage me to use it to obtain assistance. Provide assistance with transfers . An admission assessment, dated 04/16/19, documented the resident's cognition was severely impaired, the resident required limited assistance with activities of daily living, was occasionally incontinent of bladder, frequently incontinent of bowel, and had experienced one fall in the month prior to admission. An update to the care plan dated 05/03/19, documented, 2019 I fell .5/3/2019: trying to get myself into my w/c . Sign placed in my room to remind me to 'Call don't fall'. A nurse's note, dated 05/11/19 at 5:25 a.m., documented, CNA called this nurse to resident's room. Observed resident sitting on her bottom in the floor next to the left side of her bed .no injury noted .Resident stated she was trying to get to her w/c and went down when asked what happened . An update to the care plan, dated 05/11/19, documented, .2019 I fell .5/11/2019: trying to get to my w/c . Check on me every 2 hours to ensure I am safe . A nurse's note, dated 05/27/19 at 6:44 p.m., documented, @ 1830 (6:30 p.m.) Resident observed in room beside bed on buttocks with feet spread out, call light in reach, yellow skid socks on feet, w/c locked and in place, resident stated bed moved away from her, bed not locked and was at angle at this time .no injuries observed . An update to the care plan, dated 05/28/19, documented, 2019 I fell .5/28/2019: r/t bed being unlocked . Ensure that my bed is locked at all times . A nurse's note, dated 06/10/19 at 2:09 a.m., documented, This nurse saw res on floor from hallway. Res was laying on the floor on her L side at the foot of her bed facing her bathroom. Her brief was saturated, pants were pulled down below hips. Resident unable to describe what happened, stated 'I just fell , I don't know'. When asked if res was tryin to get to bathroom, res stated 'I guess so' Bed was set to lowest position, top rails up and locked, call light within reach .no injuries noted at this time . A nurse's note, dated 06/10/19 at 4:45 p.m., documented, Resident observed prone position on floor in resident room, not responding, off and on drifting to sleep, not able to stay awake, Laceration to left lateral side of face .left eye swollen not able to open .ambulate (sic) took to (hospital name deleted) . An update to the care plan, dated 06/10/19, documented: .2019 I fell .6/10/2019: trying to get to the bathroom. 6/10/2019: shortly after son left. I was coming from the restroom . Keep my door open and peak (sic) in on me each time you pass by the door . Please remind my family to let staff know when they leave . A nurse's note, dated 06/11/19 at 12:56 a.m., documented, Resident currently out of facility, admitted to hospital due to injuries sustained during fall. A nurse's note, dated 06/12/19 at 11:45 a.m., documented, Resident admitted to SNF .orbit Fracture laceration to left side of face, able to ambulate with assistance to bed with help of staff and (ambulance staff), needs extensive help to transfer, weak and confused . A nurse's note, dated 06/16/19 at 11:16 a.m., documented, At 1100 .CNA stated she observed a resident outside sitting on the ground. This SN approached resident who was bleeding form (sic) the bridge of the nose. SN asked resident if she fell out of her w/c. As w/c was near her person. Resident did not speak. SN called 911 .possible head injury .Fire Dept arrived, stating taking Pt to (hospital) . A nurse's note, dated 06/16/19 at 4:00 p.m., documented the resident was on her way back to the facility with no new orders. The resident had no fractures or bleeds, and the laceration had derma bond on it. A nurse's note, dated 06/23/19 at 3:00 p.m., documented, Resident observed in supine position in bathroom surrounded by blood at head, responding & alert to self, this nurse and one other nurse assessed and held pressure to head wound that was approx. 1.5 inches, ambulance called, resident assisted to stretcher and talking to us and crying on the way out . A nurse's note, dated 06/29/19 at 12:29 p.m., documented, Pt had a fall approx @ 0920. It was witnessed by a CM[NAME] Pt had been laying in recliner by nurses station with legs propped up with a blanket on her. I had walked by patient 5-10 minutes before incident and she had her eyes closed and appeared to be asleep. Pt had nonskid socks on. She was seen standing up by recliner and wheelchair, CMA ran to assist pt, but pt fell right as she got to her. Pt was sitting on her buttocks with L arm leaning on the side of recliner. She did not hit her head .When asked if experiencing any pain, she pointed to her L upper arm. No sign of injury was noted. When I checked on patient five minutes later and asked if she was feeling ok she stated yes . An update to the care plan, dated 06/29/19, documented, 2019 I fell .6/29/2019: I am very confused and impulsive and fell after getting out of my recliner on my own and standing beside it . All interventions in place continue. A nurse's note, dated 07/07/19 at 3:03 p.m., documented, Resident yelling and shouting 'they are going to blow this place up, no one cares, You wait and see.' resident hitting staff and yelling at other residents, trying to get outside away from bomb per resident, [MEDICATION NAME] given per PRN, resident fell at door trying to get outside . A nurse's note, dated 07/07/19 at 6:00 p.m., documented, Resident in chair in lobby, stood up and fell on Right hip, resident assisted to chair and one on one supervision till calm down .C/O right hip pain, states is hurting, Xray ordered for STAT . A nurse's note, dated 07/07/19 at 6:04 p.m., documented, Resident slide from w/c trying to get out of the building thinking per resident that the building was to blow up, insisted to help get us out, resident has no injuries . An update to the care plan, dated 07/07/19, documented, 2019 I fell .7/7/19 x 2: I was convinced that the building was going to blow up and got up and fell Staff sat with me and gave medication to calm my anxiety. An X-ray of the right hip, dated 07/14/19, documented, The right hip demonstrates a slightly displaced [MEDICAL CONDITION] femur in the subcapital portion .Impression: slightly displaced subcapital [MEDICAL CONDITION] hip . A nurse's note, dated 07/14/19 at 9:56 p.m., documented, Resident has possible fracture and displacement per xray, Dr (name deleted) informed and ordered to be sent hospital . A Consultation Report from the hospital, dated 07/15/19, documented, .History of Present Illness .a patient at the Highlands in Owasso currently admitted after a fall at her facility. She was found in the ED to have a right displaced femoral neck fracture .I recommend operative treatment. They understand and agree . A nurse's note, dated 07/21/19 at 6:50 p.m., documented, Resident arrived @ 1300 (1:00 p.m.) via stretcher, WBAT, Abduction pillow between BLE .Staples to Right Hip veered (sic) by dry dressing . A nurse's note, dated 07/27/19 at 9:40 p.m., documented, Resident observed on floor next to bed laying and yelling for help, fell trying to get into bed, assessing resident C/O right hip pain, resident started on neuro and put into bed, not able to tell what happened .Doctor ordered fall mat to be placed and xray of right hip . An update to the care plan, dated 07/27/19, documented, 2019 I fell .7/27/19 got out of bed and fell . Reduce risk of injuries from falls. A nurse's note, dated 07/30/19 at 4:47 p.m., documented, On this date at approximately 1600 (4:00 p.m.) patient was observed with her bottom sitting on the edge of a swivel rocking recliner in the common area. Patient was asked to please slide back in the chair while this nurse was in route to help. Patient slid off the edge of the chair down on her buttock then over on to her left side hitting her head . A nurse's note, dated 07/30/19 at 10:30 p.m., documented, pt states 'someone get me up' .pt transferred from floor to chair via 2 person assist, first aid given, noted a goose egg and skin tear to the L temple .pt transported via (ambulance) to (hospital) . An update to the care plan, dated 07/30/19, documented, 2019 I fell .7/30/19 got p (sic) out of recliner and fell in common area. Resident has no safety awareness r/t advanced dementia. Staff are unable to prevent falls d/t impulsive and unable to fully follow direction. Staff will in the future place interventions to reduce risk of injuries r/t falls . Reduce risk of injuries from falls. A nurse's note, dated 07/31/19 at 2:54 p.m., documented, .continues with abrasion to her left forehead that has a single steri-strip . An undated care plan, documented, I have advanced dementia and am confused and impulsive with no safety awareness. For this reason falls are inevitable. I am at risk for injuries r/t my falls. Goal I will have no injuries r/t falls through next review. Interventions Continue to reduce risk of falls as much as possible by following Fall interventions. An update to the care plan, dated 08/22/19, documented, .2019 8/22 non injury fall got up out of recliner after waking up .Continue current interventions. A nurse's note, dated 08/29/19 at 4:15 p.m., documented, This nurse witnessed resident sitting on the floor in front of her wheelchair. Legs outstretched and hands on the floor .Resident has on socks, however not slip resistant socks .Resident cannot describe incident . An update to the care plan, dated 08/29/19, documented, .2019 .8/29: non injury fall, attempted to ambulate alone .continue current interventions. A nurse's note, dated 09/06/19 at 11:20 a.m., documented, This nurse observed resident sitting on bottom at the end of recliner .X-ray being obtained . An update to the care plan, dated 09/06/19, documented, .2019 9/6: slid out of recliner attempting to get up .Continue interventions. A nurse's note, dated 09/09/19 at 11:26 p.m., documented, Resident was observed attempting to stand from her wheelchair using the railing on the wall. Resident began to slide down the wall obtaining a skin tear on her left arm . A nurse's note, dated 09/09/19 at 11:55 p.m., documented, This nurse was called to residents room. Resident observed sitting on the floor next to bed. Bed in lowest position, wearing regular socks, brief dry. No injuries noted at this time . An update to the care plan, dated 09/09/19, documented: .2019 .9/9: I fell . I have a UTI. No injury. 9/9: Non injury fall I have UTI .Continue my treatment of [REDACTED]. Encourage me to wear my hip protectors . Encourage me to wear my safety helmet . A nurse's note, dated 09/10/19 at 1:37 p.m., documented, @ approx 1115, this nurse called to resident's room by (PT Staff) who stated that resident was in the floor .Upon entering resident's room this nurse observed resident laying on her left side parallel to her bed with head at the foot of the bed and feet pointing toward the head of her bed. Foot of recliner was up. When asked what happened resident stated 'I fell ' . An update to the care plan, dated 09/10/19, documented, .2019 .9/10: Non injury fall attempting to ambulate .Continue interventions. A nurse's note, dated 09/11/19 at 7:13 p.m., documented, Staff came to this nurse to report pt on the floor. Pt often attempts to stand without assistance. Fall was unwitnessed however multiple staff heard the fall. Pt was found on the floor, laying on her back in the seating area near the nurses station .Pt complaining of her right ankle and right hip hurting. X-rays ordered . An update to the care plan, dated 09/11/19, documented, .2019 .9/11: non injury fall, UTI continues . No new interventions were identified. An undated care plan documented, I have had an actual fall with serious injury Poor Balance, Poor communication/comprehension, Unsteady gait Goal I will resume usual activities without further incident through the review date. Interventions Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Pharmacy consult to evaluate medications. A nurse's note, dated 09/28/19 at 4:28 a.m., documented, Resident follow up on non injury fall on 9/27/19 . A nurse's note, dated 10/08/19 at 8:56 a.m., documented, This nurse was notified of pt laying in the floor in her room. This nurse and 2 CNAs went in pt's room to find her sitting on her bottom, in the floor. Pt states 'I've been scooting all over the place, my legs don't work' .No apparent injuries noted . On 10/08/19 at 10:47 a.m., the DON was asked how the staff/facility respond to unwitnessed falls. She stated the nurse assesses the resident, calls the doctor and the family and sends the resident to the hospital if needed. She stated we review what happened to determine interventions. She stated we do a risk assessment. Every time someone has an unwitnessed injury they do an investigation. She stated they look at the environment, equipment, check the resident's vital signs and look at the overall picture. She was asked if she could show the surveyor documentation of an investigation. She stated possibly. No investigations of falls were provided. At 12:00 p.m., the DON reported the resident had fallen this morning from a wheelchair she was not supposed to have. She stated the wheels were not locked. She stated she should be in a Broda chair. She was asked who is responsible for interventions to prevent falls. She stated, all staff. At 12:21 p.m., there was no sign observed in the resident's room that said Call don't fall. 2. Resident #3 had [DIAGNOSES REDACTED]. An undated care plan, documented, I am at risk for falls related to my fall history, weakness, and unsteady gait . Goal I will be free from falls through next review . Interventions/Tasks Alert my family and doctor of falls. Check on me to ensure that I am safe. Keep my call light available and encourage me to use it to obtain assistance. Notice my falling star when you pass by me and ensure that I am safe and not trying to get up or doing something that my (sic) cause me to fall. Provide assistance with transfers . 01/10/2018: sign placed in my room to remind me and staff to be sure my non slip socks are on . A progress note, dated 01/03/19, documented the resident was found on the floor in front of his bed. An update to the care plan for falls, documented, .2019 I fell : 1/3 trying to go to the bathroom w/o assist . 1/3/2019: Therapy to work on strengthening. Placed on bowel and bladder program . A progress note, dated 04/02/19 at 9:34 p.m., documented the resident had been found on the floor between a chair and an ottoman. No injury was documented. An update to the care plan for falls, documented, .2019 I fell : 4/2 slid out on my regular chair in room . 4/02/2019: Be sure my one way slide device is under me in my chair . An update to the care plan for falls, documented, .2019 I fell : .4/14 trying to get something from cabinet in bathroom . Interventions/Tasks . 4/14/2019: Please help to keep my room nd (sic) bathroom clutter free. 4/14/2019: Room will be rearranged and decluttered. 4/14/2019 Therapy to eval and treat for strengthening . A progress note, dated 04/28/19 at 10:05 p.m., documented the resident was found on the floor in front of a recliner. No injury was documented. A progress note, dated 05/11/19 at 10:10 p.m., documented the resident had been found on the floor with his feet on a recliner. No injury was documented. An update to the care plan for falls, documented, .2019 I fell : 5/11 getting in recliner . 5/11/2019: Maintenance to ensure recliner is working appropriately . A progress note, dated 05/19/19 at 2:17 a.m., documented the resident had been found in the process of sliding from his chair to the floor and was assisted to the ground by a staff member. No injury was documented. An update to the care plan for falls, documented, .2019 I fell : 5/19 slid out of chair . 5/19/2019: Sign placed to remind staff to be sure my one way slide device is in my chair and gets moved with me into whatever chair I am sitting in . A progress note, dated 05/25/19 at 3:37 a.m., documented the resident was found on the floor in front of a recliner. No injury was documented. A care plan intervention, dated 05/25/19, documented, UA and Chest Xray done with no abnormal results. Current interventions reviewed and will continue. An update to the care plan for falls, documented, .2019 I fell : 5/28 incontinent episode . 5/28/2019: Staff to increase checks on me for incontinent/toileting needs . A quarterly assessment, dated 07/14/19, documented the resident was severely impaired cognitively, required extensive assistance with transfers, locomotion, personal hygiene, and toilet use, was frequently incontinent of bowel and bladder, and had experienced two or more falls since admission. On 10/03/19 at 9:11 a.m., the resident was observed returning to his room from the dining room. Observations of his room found a sign to remind staff to use a non skid device in the resident's chair. No device was found under the resident or in another chair. At 10:30 a.m., the room was checked for the presence of a sign to remind the resident to wear non skid socks. No sign was observed. The resident was observed sitting in a wheelchair in front of a television. The non skid device for his chair was not observed in the wheelchair or recliner. A progress note, dated 10/06/19 at 1:30 a.m., documented the resident was found on the floor next to a recliner and the resident had acquired a skin tear on his forehead. On 10/07/19 at 9:52 a.m., the resident's family member reported he had fallen over the weekend. She stated that staff had not been answering the resident's call light for the past two weeks or more. At 10:10 a.m., the resident was observed in his room. He was sitting in his recliner and had a dark area located on his left upper forehead. CNA #5 was asked how long she had worked with the resident. She stated she had worked at the facility for three months and with the resident routinely during that time. She was asked if the resident had been using a one way slide device in the resident's chairs. She stated she had not seen one. CNA #6 was asked how long she had worked with the resident. She stated two months. She was asked if she had observed a one way slide device used in the resident's chairs. She stated she had not. At 10:20 a.m., the resident daughter stated the call light outside the resident's room was not working. She pushed the button and a small red light located on the wall came on but the light on the ceiling outside the resident's doorway did not activate. At 1:12 p.m., LPN #8 was asked how long she had worked with the resident. She stated one month. She was asked to search the resident's room for the non skid device used in the resident's chairs. She stated she was not sure what it looked like and that she had been told therapy was looking for it. CNA #5 informed LPN #8 that the device was a blue pad. No such device was found in the room. At 1:26 p.m., the resident was observed in his wheelchair. The call light button was observed approximately seven feet away under the covers of a made-up bed. The administrator was observed walking near-by and asked to enter the room and push the call-light button. He pulled on the call light's cable until the button itself was retrieved into his hand. He pushed the button and the red light on the wall came on but the ceiling light outside the resident's door did not activate. The administrator was asked if the resident would have been able to utilize the call light system. He stated he would not. On 10/08/19 at 7:49 a.m., LPN #9 was asked how long she had worked with the resident. She stated for two months. She was asked if she had ever observed the resident to have a one way slide device available to use in that time. She stated she had not seen one.

On 08/31/17, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent falls and to implement interventions to aid in the prevention of falls. Resident #106 had a fall on 07/11/17 that resulted in a fractured right hip that required surgical repair. No interventions were put in place to prevent future falls. In addition the facility failed to prevent accident hazards in the resident's environment when the resident's oxygen tubing was observed coiled around her feet and wallker as the resident was ambulating from the bathroom. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 1:25 p.m., the DON was informed of the IJ regarding falls and that a plan of removal was required. She was informed this placed the facility in an extended survey. At 4:03 p.m., an acceptable plan of removal was received from the DON. The plan of removal documented: Plan of removal 08/31/17 SUPERVISION TO PREVENT ACCIDENTS RELATED TO FALLS 2:50 PM Having (name deleted), CNA sit with resident (name deleted) until portable oxygen concentrator can either be serviced to work appropriately or a new one arrive to the facility. If it does not arrive by 7 PM a different staff member will sit with resident (name deleted) and that will be documented. There will be documentation and sign in to document who sat with the resident until her portable oxygen arrives. (Resident name deleted) has agreed for the portable oxygen concentrator to be placed on her walker, and that she will use it at all times and take walker with her everywhere she goes. 3:22 PM Administrative nurses: (name deleted), LPN, (name deleted), LPN, (name deleted), LPN, (name deleted), LPN, and (name deleted), LPN, will participate in completing a Fall Risk Evaluation for all current residents. (name deleted), RN will sign off on the completed Fall Risk Evaluations. These will be complete by 8:30 PM. Put in place 'Falling Star Program.' Falling stars will be placed on resident's doors who flag as a high risk or have falls in the past 3 months. All will be complete by 9 PM on 8/31/17. IN-SERVICE TO ALL STAFF (Name deleted), RN DON will begin In-service at 4:20 PM for employees currently here for, at 5:00 PM an in-service will be held for all staff. During the rest of the evening we will in-service staff that was not able to come at 5. (Name deleted) will conduct in-service at 5 pm. (Name deleted), (Name deleted), (name deleted) LPN, and (Name deleted) will be in-serviced, and then help to inservice other staff as they come in. In-service will contain the following information: Falling Star Program Policy and those with stars on their door are high risk for falls. All staff should check on those people as you pass by the room for safety. Facility Fall Policy Care Plans and the location of them Keep Oxygen tubing up off floor and out of residents way Looking in rooms as you pass by to prevent a possible fall Incident Reports and the appropriateness of fall interventions Make sure (Resident name deleted) has her portable oxygen and walker with her at all times. Make sure she has a working battery, and that the back up battery is charging. All staff will be in-serviced by 12:00 midnight on 08/31/17, excluding the employees who are sick or out of town on vacation. These staff will be in-serviced before there(sic) next shift. Any staff that is PRN or Agency will be in-serviced before they work again. List of Employees that will not be in-serviced on 8/31/2017 due to illness or they are out of town. (Name deleted)- In Stillwater, OK at school- is supposed to work this Saturday (Name deleted)- works at Macy distributing company- work tomorrow 9/1/17 @ 6am (Name deleted)- works another job in sand spring does not get off til 10pm tonight, works next 9/2/17 @ 6am weekend doubles (Name deleted)- was at school (Name deleted)- works another job, works tonight at 10pm (Name deleted)- is in Oklomugee(sic), OK will come in 9/1/17 at 10am to be inserviced (Name deleted)- is in OK city PRN (Name deleted)- out of town in Lincoln City PRN Also, a list will be attached of PRN employees not yet inserviced. PRN staff not yet inserviced as of 10:30 PM on 9/2/17 ~(Name deleted) done ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) ~(Name deleted) Addendum: Resident said she likes to sit in her wheelchair sometimes when she is going to be out of her room for long periods or go far distances. She likes to use her normal E-tank on the back of her chair so that she will not have to switch anything back and forth. She will use the short tubing, and switch back to her Portable oxygen upon return to her room. This has been careplanned. Addendum: (Name deleted) LPN, MDS will be doing in-service as well. Addendum: 8/31/2017 - fall risk evals complete at 7:30 PM 8/31/2017 - Falling stars placed of(sic) the residents that are high fall risk and those having a fall in the last 3 months complete 8PM 8/31/2017 - 97 Staff members in-serviced by midnight on 8/31. 9/1/2017 Portable Concentrator arrived at 9:06 AM and began charging. 9/1/2017 Portable Concentrator brought to resident and resident educated on new machine at 12:06, and placed on resident at 12:11 PM. Staff were interviewed on 09/05/17 in regard to their knowledge of the fall inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 09/02/17 at 6:12 a.m., when all components of the plan of removal and addendums had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for five (#69, #87, #106, #142, and #177) of seven sampled residents who had experienced falls; and ~ ensure the environment was free of accident hazards for one (#106) of seven sampled residents who had experienced falls. Resident #106 had a fall on 07/11/17 with no fall interventions initiated to prevent future falls. The resident sustained [REDACTED]. In addition, the facility failed to ensure accident hazards were not present in the resident's environment when the resident's oxygen tubing was observed coiled around the resident's feet and walker as the resident was ambulating from her bathroom. The facility identified 53 residents who were at high risk for falls. Findings: An updated fall policy, documented, .Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .if underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified and will re-evaluate the continued relevance of current interventions . 1. Resident #106 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 12/03/16, documented, Focus .I have had a fall and have imnpaired vision and am at risk for future falls .Goal .I will be free from falls through next review .Interventions .Remind me to use call light and wait for assistance for transfers and ambulation .Keep my belongings in a reachable area .Keep my room clutter free and well lit due to my impaired vision .Keep my walker in reach when I am in bed or chair .Provide assistance with transfers and ambulation as needed .Check on me to ensure that I am safe .Encourage me to call for assistance when moving about with my oxygen .Encourage me to use my walker to ambulate even for short distances . Encourage neighbor to go to bed at an earlier hour. Also to ask for assistance when feeling tired .Check for othostatic hypotension and report to DR .Encourage neighbor to sit for a minute before coming to standing position .Assist me to keep my room clutter free . An incident report, dated 02/23/17 at 6:50 a.m., documented, .resident noted standing in front of her room, her hair, face and clothes bloody .Resident stated she had gone into the bathroom .she fell when trying to get out of the bathroom, that she did not remember how she fell .Immediate action taken .cleaned resident up, called EMSA, notified family and Dr. (name deleted) .Injuries report post incident .hematoma .face .laceration .top of scalp .IDT met to discuss. Staff to wake neighbor at night and encourage her to go to the restroom with the assistance of the staff member . A fall risk evaluation, with an effective date of 02/23/17 at 0650 (6:50 a.m.), documented, .Score: 12 .moderate Risk .Reason for Assessment .recent falls .History of falls within last six months .multiple falls .Medications taken more than 3 x/week, including prn's .antihistamines .diuretics .narcotic's (sic) .psychotropic's (sic) .Gait analysis .exhibits loss of balance while standing .uses an assistive device, e.g. cane, walker, etc . A care plan, updated 02/23/17, documented, Focus: I have had a fall and have impaired vision and am at risk for future falls .Goal: I will be free from falls through next review .Interventions: .Please wake my (sic) up during the night and encourage me to go to the restroom with your assistance . The care plan did not address the fall that had occurred on 02/23/17. A fall risk evaluation, with an effective date of 02/26/17 at 01:38 (1:38 a.m.), documented, .Score: 12 .moderate risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .antihistamines .diuretics .hypoglycemic agents .narcotic's (sic) .psychotropic's (sic) .gait analysis .exhibits loss of balance while standing .uses an assistive device, e.g. cane, walker, etc . An incident report, dated 02/26/17 at 1:38 a.m., documented, .resident sitting in floor in front of recliner. Recliner is an electrical chair and was raised in upright position. Resident states that she hit her left temporal on the floor but was sitting on bottom when this nurse entered room .resident states that she was getting up to go to the bathroom and just slid out of her chair .Immediate action taken .assisted resident up to feet and back into her recliner, denies any injuries or new pain .will continue neuro checks .Unit Manager reports that neighbor told him, she fell asleep and accidentally hit remote on her recliner and was tossed from her lift chair .also told wound nurse and other nurseing (sic) staff this .no injuries observed .IDT met to discuss. Staff to ensure recliner control is pinned up away from, neighbor being able to accidentally hit control but still be able to reach it intentionally. On side of chair arm . A care plan, updated 02/26/17, documented, .Keep my recliner control pinned on side of arm of my recliner . The care plan did not address the fall that occurred on 02/26/17, the resident's toileting needs, or the resident sliding out of her recliner. An annual assessment, dated 05/21/17, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required supervision with bed mobility, supervision with transfers, walking in the room, walking in the corridor, toileting, and personal hygiene, used a walker for mobility, received oxygen therapy, had [DIAGNOSES REDACTED]. A fall risk evaluation, dated 05/26/17, documented, .Score: 12 .moderate risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .antihistamines .diuretics .hypoglycemic agents .narcotic's(sic) .psychotropic's(sic) .gait analysis .exhibits loss of balance while standing .uses an assistive device, e.g. cane, walker, etc . An incident report, dated 05/26/17, documented, .alerted by staff that resident fell on to the floor in her bathroom. Resident got up on her own, skin tear x2 to (R) upper arm, one measures 4cm and top one measures 2.5cm, slight redness noted to the (L) middle of back. Resident declines any ER eval and says, 'I am not hurt.' .says that she slipped in the bathroom and hit her (R) upper arm and (L) mid back .Immediate action taken .cleansed skin tear to (R) upper arm w/SNS, pat dry, applied TAO, covered w/non stick pad, wrapped w/soft gauze & secured w/tape .staff to encourage and assist resident to have appropriate footwear/nonslip footwear on for all ambulation . A care plan, updated 05/26/17, documented, .Encourage and assist me to have appropriate footwear/nonslip footwear for all ambulation . The care plan did not address the fall that occurred on 05/26/17, or the resident's toileting needs. An incident report, dated 06/04/17 at 12:45 a.m., documented, .found down in patient room against the wall. Pt stated that she fell , while trying to walk to the bathroom. Upon assessment there was a small lump discovered on the back of her head to the right of the occipital bone and there is a cut on her R ring finger .orders were given to send the patient out for an eval. Pt refused, (resident's daughter, name deleted) agreed with her mother .Immediate action taken .the cut was bandaged .Dr.(name deleted) and the pt's daughter (name deleted), were notified .post investigation it appears that resident was likely drowsy after her night medications. Resident educated that after taking night medications she is to ask for assistance to ambulate/transfer, resident agrees . A care plan, updated 06/04/17, documented, .Remind me to ask for assistance when I am so tired after taking my night medications . The care plan did not address the fall that occurred on 06/04/17, or the resident's toileting needs. A fall risk evaluation, dated 07/05/17, documented, .Score: 12 .moderate risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .diuretics .hypoglycemic agents .narcotic's (sic) .psychotropic's (sic) .gait analysis .exhibits loss of balance while standing .strays off the straight path of walking .uses an assistive device, e.g. cane, walker, etc . An incident report, dated 07/05/17 at 1:15 p.m., documented, .resident fell in hallway from her doorway landing onto her right side. Resident c/o pain to her stomach and lower back, wiping her face moaning/groaning. Shoes slid onto feet, heels not all the way in. Resident stated she got dizzy and tripped over her oxygen tubing .Immediate action taken .head to toe completed .no injuries noted @ this time .PRN Morphine given .resident assisted herself up to sitting position .encourage resident to ask for assist to ensure shoes are on properly, reducing the risk of future falls . A care plan, updated 07/05/17, documented, .Encourage me and assist me to have my shoes on properly before ambulating . The care plan did not address the fall that occurred on 07/05/17, the resident's dizziness, or the oxygen tubing the resident stated had caused her to trip and fall. A fall risk evaluation, dated 07/11/17, documented, .Score: 16 .high risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .diuretics .antihypertensives .NSAID'S .narcotic's (sic) .sedatives/Hypnotic's (sic) .gait analysis .uses short discontinuous steps and/or shuffling steps .exhibits jerking or instability when making turns .uses an assistive device, e.g. cane, walker, etc .wears poorly fitting shoes .decrease in muscle coordination . An incident report, dated 07/11/17 at 4:30 p.m., documented, .guy delivering oxygen alerted this nurse that she fell . Upon entering room I observed resident lying flat on her back by her table, shoes off, walker to her right side fallen over on floor. Resident c/o hitting head. Small hematoma to R occipital lobe. Resident said the guy knocked and said he is delivering her oxygen and she turned to look and fell .Immediate action taken .head to toe completed, small hematoma with redness to R occipital lobe, bruise/blood blister to top of R wrist .10/10 hips with movement. ROM performed x4 c/o hurting to hip/pelvis. No internal/external rotation to extremity .assisted resident x2 lift onto chair. Initiated Neuro Checks. Notified Dr.(name deleted), (name deleted) Unit Manager, (name deleted) DON, POA (name deleted) & (name deleted) LPN .Level of Pain: Numerical: 10 .hospice .Injuries report post incident .fracture .Mental Status: .Notes: acute right intertrochanteric hip fracture .Post investigation it appears that resident was a little drowsy at the time of fall. Resident's pain meds adjusted r/t drowsiness. Dr. will re-evaluate as needed r/t increased or decreased pain and drowsiness . A nurse's note, dated 07/11/17, documented, Received XRay results .acute right intertrochanteric hip fracture. Notified Dr. (name deleted), received orders to send to emergency room .(name deleted) POA present in room, notified of results .(Ambulance) contacted and arrived @ 1950 (7:50 p.m.) exited @ 2005 (8:05 p.m.). Resident medicated with Morphine d/t c/o pain R hip 10/10 @ 1834 (6:34 p.m.) Lorazepam @ 1932 (7:32 p.m.) . A care plan, updated 07/11/17, documented, .Pain meds decreased until further evaluation by physician due to drowsiness . The care plan did not address the fall that occurred on 07/11/17. A fall risk evaluation, dated 07/19/17, documented, .Score: 17 .high risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .diuretics .antihypertensives .NSAID'S .narcotic's (sic) .gait analysis .exhibits loss of balance while standing .strays off the straight path of walking .require hands-on assistance to move from place to place .decrease in muscle coordination . An incident report, dated 07/19/17 at 6:07 a.m., documented, .I heard loud hit and picture frame fell off the wall. She started hollering out, I immediately went into her room and observed her lying on her right side with her entire recliner on its right side with legs extended out. Resident lying her head on chair right by her outer door. Resident said she has to pee and was rocking herself to get up and it fell over .Immediate action taken .head to toe completed, previous bruising and skin tears to R hip, lower back, inner/outer right thigh from previous fall/surgery to R hip. Dark bruising to right outer knuckles purple in color. ROM WNL. No hematoma or bruising to head @ this time .8/10 R hip/back .Admin routine medication to help with pain/anxiety. Obtained STAT X-ray R hip. Notified Dr.(name deleted), (name deleted) DON, POA(name deleted) .taken to hospital .No .resident educated not to rock back and forth in her chair and therapy to work with her on more effective ways to get up . A care plan, updated 07/19/17, documented, .Remind me to not rock back and forth to get up out of chair. Also to continue working with therapy on moire effective ways to rise from my chair . The care plan did not address the fall that occurred on 07/19/17, or the resident's toileting needs. A significant change assessment, dated 07/24/17, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required limited assistance with bed mobility, walking in the room, walking in the corridor, and personal hygiene, extensive assistance with transfers and toileting, used a walker and a wheelchair for mobility, received oxygen therapy, had a [DIAGNOSES REDACTED]. A fall risk evaluation, dated 07/28/17, documented, .Score: 19 .high risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .diuretics .hypoglycemic agents .antihypertensives .NSAID'S .narcotic's (sic) .psychotropic's (sic) .gait analysis .exhibits loss of balance while standing .strays off the straight path of walking .requires hands-on assistance to move from place to place .decrease in muscle coordination . An incident report, dated 07/28/17 at 10:25 p.m., documented, .resident was on floor laying on left side facing door .nurse ask (sic) resident what happed (sic) .resident responded, 'I grabbed my oxygen cord and lost balance and I'm ok, get me off this floor, please.' .skin intact, no bruising at this time, improper foot wear, and medication change had occurred earlier in day .Immediate action taken .resident was reminded and encouraged to use call light .resident encouraged to keep walker with her while ambulating and ensure steady balance prior to reaching for something . A care plan, updated 07/28/17, documented, .Encourage me to keep my walker with me while ambulating and ensure steady balance before reaching for things . The care plan did not address the fall that occurred on 07/28/17, or the oxygen tubing the resident stated had caused her to trip and fall. A fall risk evaluation, dated 08/02/17, documented, .Score: 14 .moderate risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .diuretics .antihypertensives .NSAID'S .narcotic's (sic) .gait analysis .exhibits loss of balance while standing .uses short discontinuous steps and/or shuffling steps .uses assistive device, e.g. cane, walker, etc .decrease in muscle coordination . An incident report, dated 08/02/17 at 11:00 a.m., documented, .Walking down corridor and I looked in residents room and she is sitting on her buttocks in bathroom with her walker in front of her with O 2 (sic) tubing wrapped around one leg of her walker. Resident denies hitting head, no hematoma noted. Call light not pressed for assistance. Socks noted to bilateral feet. Resident stated, 'I have to pee, get me up, I'm not waiting.' .Immediate action taken .head to toe completed, no new injuries noted @ this time .7/10 R hip. No internal/external rotation, ROM WNL. Assisted resident x2 onto toilet, notified Dr.(name deleted), POA(name deleted), DON (name deleted) .taken to hospital .No .Educate and remind resident to put the slack of her tubing up on furniture to help prevent tripping . A care plan, updated 08/02/17, documented, .Educate and remind me to put slack of oxygen tubing up on furniture so not in floor in walking path . The care plan did not address the fall that occurred on 08/02/17, or the resident's toileting needs. A fall risk evaluation, dated 08/05/17, documented, .Score: 13 .moderate risk .reason for assessment request .recent falls .history of falls within last six months .multiple falls .medications taken more than 3 x/week, including prn's .diuretics .hypoglycemic agents .antihypertensives .benzodiazepines .narcotic's (sic) .gait analysis .exhibits loss of balance while standing .uses assistive device, e.g. cane, walker, etc .decrease in muscle coordination . An incident report, dated 08/05/17 at 4:30 p.m., documented, .Found resident on the floor, lying on her right side with her right hand stuck under the hutch. Tried several times to wake the resident up. Placed a pillow under her head. No head injuries noted. Took resident BS and got a reading of 33. Got one glucagon kit and administered. Checked the residents (sic) body out and didn't notice any injuries at this time. Waited 15 min. Resident still not alert, moved head some and opens eyes but does not respond. Called residents (sic) name several times. Recheck her sugar again and got a BS 32. Administered a 2nd glucagon kit and notified Dr. (name deleted) office. Received order to send her out. Called 911 and reported information. Notified (name deleted) residents (sic) daughter of what happened .EMS arrived and started an IV and took her out via stretcher .(name deleted) hospital notified and reported no injuries noted at this time but resident is unconscious and had Right hip surgery previously, which is the side she fell on . Also reported that the fall was unwitnessed. Unknown if resident hit her head, but no bruises abrasions or other injury to head .residents (sic) sliding scale decreased and closer monitoring of blood sugar . A care plan, updated 08/05/17, documented, .Sliding scale decreased and close r (sic) monitoring of FSBS . The care plan did not address the fall that occurred on 08/05/17, how they would monitor finger stick blood sugars more closely, and who would monitor finger stick blood sugars. A 14 day scheduled assessment, dated 08/20/17, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required limited assistance with bed mobility, limited assistance with walking in the room, walking in the corridor, toileting, and personal hygiene, used a walker and a wheelchair for mobility, received oxygen therapy, had [DIAGNOSES REDACTED]. On 08/28/17 at 10:30 a.m., the resident was observed sitting at the table in her room with the O2 nasal cannula on. The O2 tubing was observed strung across to the other side of the room, lying on the floor by the resident's recliner. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. At 2:15 p.m., the resident was observed sitting in the recliner in her room with the O2 nasal cannula on. The O2 tubing was observed lying on the floor by the resident's recliner. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. At 4:30 p.m., the resident was observed sitting at the table in her room with the O2 nasal cannula on. The O2 tubing was strung across to the other side of the room, lying on the floor by the resident's recliner. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. On 08/29/2017 at 11:35 a.m., the resident was observed sitting in a recliner in her room, taking a breathing treatment. The O2 tubing was observed lying on the floor in front of her chair. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. The resident's wheelchair was observed across the room from the resident. At 2:08 p.m., the resident was observed in her room sitting in her recliner with the foot rest up. The O2 tubing was observed lying on the floor in front of her recliner below the foot rest. The resident's wheelchair was observed approximately three feet from the recliner. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. At 3:51 p.m., the resident was observed sitting at the table in her room with the O2 nasal cannula on. The O2 tubing was observed strung across to the other side of the room, lying on the floor by the resident's recliner. She was watching television by herself, eating some food. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. On 08/30/2017 at 1:49 p.m., the resident was observed sitting at the table in her room with the O2 nasal cannula on. The O2 tubing was observed strung across to the other side of the room, lying on the floor by the resident's recliner. No staff were observed in the room assisting to keep the O2 tubing off the floor and out of the way of the resident's feet. At 2:26 p.m., CNA #6 was asked if she was familiar with the resident 's care. She stated, Yes. She was asked how she knew what interventions or assistance were needed for the resident to prevent falls. She stated, There are none that I can think of to tell you. She likes to keep her door closed, but we are supposed to make sure the door is open so we can peek in at her when we walk by. She was asked what she was looking for when she walked by and peeked in the room. She stated, We were told to make sure she is not on the floor and that there is nothing on the floor in her path to the bathroom or anywhere else in the room. She was asked if that included the oxygen tubing. She stated, Yes. She was asked if the resident called for assistance. She stated, Sometimes she calls if she needs help, but most of the time she feels like she can do it on her own and then she falls. She was asked if she was instructed after each fall on what interventions were to be put in place to help prevent the resident from falling. She stated, No, not really, we're just told to keep an eye on her to make sure she's not on the floor and that her floor is clear for her to walk around without tripping. At 2:45 p.m., LPN #7 was asked if she was familiar with the resident 's care. She stated, Yes, she has a history of falls and recent falls. She was asked what interventions were in place to prevent future falls. She stated, We encourage her to press her call light and ask for assistance. She was asked if the resident used her call light. She stated, She will tell you that she will not use her call light. We have put signs on her walker that say 'Call don't fall,' and she rips them up and throws them away. The LPN was asked if the resident required assistance with walking. She stated, She uses a walker, but she doesn't use the walker properly. She won't lock her brakes. I have taught her the proper way to ambulate with it, but she still does it her own way, and then she falls. The LPN was asked how they ensured the resident was safe from falling. She stated, I try to go in there frequently and check on her. She was asked what she was looking for when she checked on the resident. She stated, I check to see if she's up or sitting slumped over in her chair. I watch for her oxygen tubing to make sure that the

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the physician was notified of new and existing pressure ulcers. Resident #3 was admitted to the facility on [DATE] with a Stage III pressure ulcer. Wound care was not provided at the facility until [DATE]. The physician was not aware of the Stage III and then Stage IV pressure ulcer and an additional pressure ulcer until [DATE]. The resident developed multiple Stage III, Stage IV and unstageable pressure ulcers and infected pressure ulcers. The IJ situation was verified with the Oklahoma State Department of Health. At 4:50 p.m., the administrator and facility owner were informed of the IJ situation regarding physician notification. On [DATE] at 6:45 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: We will educate nurses on evaluating skin upon admission, notifying the physician of any pressure ulcers and documenting in PCC as well as following all physician orders as prescribed. Nurses will be educated by [DATE] at 11 pm. All new nurses and agency nurses will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. We will educate certified nurses aides on reporting on the shwer sheets all bruises, reddened areas, open areas and rashes even if you feel they have been reported previously. Certified Nurses Aides will be educated by [DATE] at 11 pm. All new CNAs and agency CNAs will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. Nursing Administration will be educated on the wound nurse or designee to evaluate skin at least monthly and to notify physician of all pressure ulcers found and documented on weekly skin log. Nursing Administration will be educated by [DATE] at 11pm. All new administrative nurses will be educated upon hire. Any staff unreachable will be educated prior to begin of next shift. On [DATE] at 10:52 a.m., CNA #17 was observed providing care to residents. The CNA was asked if she received an inservice from the facility on the topic of wounds. She stated she had worked on [DATE] and today and had not received an inservice either day. On [DATE] at 12:05 p.m., CNA #18 was observed assisting a resident to the dining room. The CNA was asked if she received an inservice from the facility on the topic of wounds. She stated she had not been inserviced by the facility on any topic. She stated she received her inservices through her employer agency. On [DATE] at 4:00 p.m., an amended plan of removal for the IJ situation was received from the facility. The plan of removal documented: We will educate nurses on evaluating skin upon admission, notifying the physician of any pressure ulcers and documenting in PCC as well as following all physician orders as prescribed. Nurses will be educated by [DATE] at 11 pm. All new nurses and agency nurses will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. We will educate certified nurses aides on reporting on the shwer sheets all bruises, reddened areas, open areas and rashes even if you feel they have been reported previously. Certified Nurses Aides will be educated by [DATE] at 11 pm. All new CNAs and agency CNAs will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. Nursing Administration will be educated on the wound nurse or designee to evaluate skin at least monthly and to notify physician of all pressure ulcers found and documented on weekly skin log. Nursing Administration will be educated by [DATE] at 11pm. All new administrative nurses will be educated upon hire. Any staff unreachable will be educated prior to begin of next shift. The IJ was removed on [DATE] at 9:25 a.m., when all components of the plan of removal were completed. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to notify the physician of residents' pressure ulcers; obtain physician orders for wound care and treatments; and ensure dietary recommendations were relayed to the physician for protein supplementation and nutritional support to aid in the healing of pressure ulcers for one (#3) of three residents who were reviewed for new and worsening pressure ulcers. Resident #3 was admitted to the facility on [DATE] with a Stage III pressure ulcer. Wound care was not provided at the facility until [DATE]. The physician was not notified of the Stage III pressure ulcer until [DATE], and the Stage III pressure ulcer had deteriorated to a Stage IV and the resident had acquired an additional unstageable pressure ulcer. The resident developed multiple Stage III, Stage IV and unstageable pressure ulcers and infected pressure ulcers. This had the potential to affect all 99 residents who resided in the facility. Findings: A hospital's wound ostomy nurse consult note for resident #3, dated [DATE], documented, .Consulted for coccyx wound present on admission .Wound Assessment: Mid sacrum opened wound measures 2.2 x 1.8 x 0.2 cm. Wound bed red. Macerated edges. Edges attached, defined. Small amount lf (sic) serosanguinous drainage .Recommendations: Cleanse wound to mid sacrum with normal saline. Apply silver Calcium alginate to cover wound bed M,W,F, apply Allevyn dressing to cover wound. Change allevyn on Monday and Thursday and prn soiling . A hospital's nutrition assessment, dated [DATE], documented, .Consult received for non-healing wound .Pt experienced N/V, diarrhea, and poor appetite 2 weeks PTA (prior to admission) per Physician .Interventions/Recommendations: Will add renal restrictions to current diet order. Will send Nepro supplement BID to increase calorie and protein intake. Continue anti-emetics as needed; N/V affecting PO intake .Wounds: mid sacrum open wound . A hospital Cardiology Consult Note, dated [DATE], documented the resident had a Stage 3 ulcer of the sacral region. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admit note, dated [DATE], documented a new hospital dressing covering a pressure ulcer on the coccyx. There was no documentation the dressing was removed and the wound assessed. There was no documentation of physician notification of the pressure ulcer. The skilled nurses notes, dated [DATE] through [DATE], documented a pressure ulcer to the coccyx. There was no documentation of physician notification of the pressure ulcer. The Skin Condition Evaluation sheet, dated [DATE], documented the resident had redness to her abdominal fold and a pressure ulcer on her coccyx. There was no documentation of physician notification of the pressure ulcer. A skilled nurse's note, dated [DATE], documented, .Skin Concerns: redness to abdominal fold, Stage III to coccyx . There was no documentation of physician notification of the pressure ulcer. A physician's progress note, dated [DATE], did not document any skin or wound concerns. A skilled nurse's note, dated [DATE], documented, .Skin Concerns: Stage II to coccyx and redness to abdominal fold . The five day assessment, dated [DATE], documented the resident had modified independence in cognition for daily decision making, ambulated and dressed herself with limited one per assistance, required supervision for eating, was continent of urine, and occasionally incontinent of bowel. The assessment documented the resident weighed 143 pounds, had moisture associated skin damage, received pressure reducing devices for the chair and bed, was on a turning/repositioning program, and received pressure ulcer care. The assessment documented the resident had one Stage I pressure ulcer. A physician's progress note, dated [DATE], did not document any skin or wound concerns. A Skin Condition Evaluation sheet, dated [DATE], documented the resident had a stage II pressure ulcer on her coccyx. There was no documentation of physician notification of the pressure ulcer. On [DATE], the resident was sent to the emergency room for lethargy. The hospital discharge sheet, dated [DATE], documented, Skin Condition .Pressure Ulcer .Other Breakdown .Stage III coccyx, diabetic L toe . The admit/readmit screener, dated [DATE], documented the resident was admitted from an acute care hospital, had a stage III pressure ulcer to her coccyx, and a stage II pressure ulcer to her left toe(s). There was no documentation of physician notification of the pressure ulcer. The Skin Condition Evaluation sheet, dated [DATE], documented the resident had a stage III pressure ulcer on the coccyx. There was no documentation of physician notification of the pressure ulcer. The Medication Administration Record [REDACTED]. A review of the Physician's Order Summary documented there was no pressure ulcer/wound care or dietary protein supplement ordered for the resident in [DATE]. The skilled nurses' notes, dated [DATE] through [DATE], documented the resident had a stage III pressure ulcer on her coccyx. There was no documentation of wound care or dressing change. There was no documentation of physician notification of the pressure ulcer. A physician's progress note, dated [DATE], did not document any skin or wound concerns. A skilled nurse's note, dated [DATE], documented the resident had a stage II pressure ulcer on her coccyx. There was no documentation of physician notification of the pressure ulcer. The Skin Condition Evaluation sheet, dated [DATE], documented the resident had a stage III pressure ulcer to her coccyx, and a pressure ulcer to the left great toe. There was no documentation of physician notification of the pressure ulcer. The comprehensive assessment, dated [DATE], documented the resident had a stage II and a stage III pressure ulcer. The assessment documented the resident weighed 144 pounds, had pressure reducing devices for the chair and bed, was on a turning/repositioning program, received pressure ulcer care, received an application of nonsurgical dressings, and the applications of ointments/medications. There was no documentation of physician notification of the pressure ulcer. The skilled nurses' notes, dated [DATE] and [DATE], documented a small wound to the resident's left great toe. There was no documentation of physician notification of the pressure ulcer. An administrative progress note, dated [DATE] and signed by wound nurse #1, documented, .pain in back . There was no documentation of pressure ulcers, wound care, dressing changes, or physician notification. The skilled nurses' notes, dated [DATE] and [DATE], documented the resident had a pressure ulcer on her coccyx and another on her left great toe. There was no documentation of physician notification of the pressure ulcer. A skilled nurse's note, dated [DATE], documented the resident had a pressure ulcer on her coccyx and another on her left great toe. There was no documentation of physician notification of the pressure ulcer. The 14-day assessment, dated [DATE], documented the resident had modified independence in cognition for daily decision making, required one person physical assist with eating, weighed 142 pounds, had a stage III pressure ulcer and moisture associated skin damage. It documented the resident received a pressure reducing devices for the chair and bed, was on a turning/repositioning program, received pressure ulcer care, and received applications of nonsurgical dressings and ointments/medications. There was no documentation of physician notification of the pressure ulcer. A physician's progress note, dated [DATE], did not document any skin or wound concerns. A skilled nurse's note, dated [DATE], documented the resident had a pressure ulcer to her coccyx. There was no documentation of wound care or dressing change. There was no documentation of physician notification of the pressure ulcer. The Skin Condition Evaluation sheet, dated [DATE], documented the resident had a pressure ulcer to her coccyx. There was no documentation of physician notification of the pressure ulcer. A skilled nurse's note, dated [DATE], documented the resident had a pressure ulcer to her coccyx and to her left great toe. There was no documentation of physician notification of the pressure ulcers. The skilled nurses' notes, dated [DATE] through [DATE], documented a pressure ulcer to her coccyx. There was no documentation of wound care or dressing change. There was no documentation of physician notification of the pressure ulcer. A physician's progress note, dated [DATE], did not document any skin or wound concerns. A physician's progress note, dated [DATE], did not document any skin or wound concerns. The Skin Condition Evaluation sheet, dated [DATE], documented the resident had a pressure ulcer to her coccyx. There was no documentation of wound care or dressing change. There was no documentation of physician notification of the pressure ulcer. The skilled nurses' notes, dated [DATE] and [DATE], documented the resident had a wound to her bottom. There was no documentation of physician notification of the pressure ulcer. A review of the Physician's Order Summary documented there was no pressure ulcer/wound care or dietary protein supplement ordered for the resident in [DATE]. The resident was discharged to the hospital on [DATE] for altered mental status. The hospital history and physical, dated [DATE], documented, .Physical examination: There is a stage 4 ulcer of the sacrum with associated [MEDICAL CONDITION] .assessment: Stage 4 coccyx ulcer. [MEDICAL CONDITION] of the coccyx .Severe protein calorie malnutrition .Plan: Patient is admitted for IV antibiotics and wound care. Will continue protein and nutritional supplement . The hospital discharge summary, dated [DATE], documented, .Discharge Diagnoses: [REDACTED].Discharge Instruction: The patient is being discharged back to skilled care for continued wound care .Laboratory data showed .[MEDICATION NAME] was 7.6 indicating severe protein-calorie malnutrition . The resident was readmitted to the facility on [DATE] from an acute long term care hospital. The admit/readmit screener, dated [DATE], documented the resident was admitted from a long term acute care facility, had a stage II pressure ulcer on the left toe(s), and a stage IV pressure ulcer to the sacrum. A skilled nurse's note, dated [DATE], documented, .Skin Concerns: right medial upper leg, and coccyx pressure ulcer . A physician's progress note, dated [DATE], documented the resident had an ulcer on the coccyx and to see wound care notes. The wound care physician's note, dated [DATE], documented, .She presents with a stage 4 pressure wound coccyx of at least 10 days duration. There is heavy serous exudate .Stage 4 Pressure Wound Coccyx .Wound size (L x W x D): 3.8 x 4.0 x 1.5 cm .Undermining: 1.0 cm at 1 o'clock .Exudate: Heavy Serous .Yellow Necrotic: 30% .Granulation tissue: 70% .Procedure: .Wound of the Left, First Toe .Wound Size: 0.5 x 4.0 x 0.3 cm .Exudate: Moderate Serous .Yellow necrotic: 100% . A laboratory test performed on [DATE], documented the resident's Total Protein was 5.9L with a reference range of 6XXX,[DATE].1, and her [MEDICATION NAME] was 2.6L with a reference range of 3XXX,[DATE].1. The comprehensive assessment, dated [DATE], documented the resident was moderately impaired in cognition, weighed 185 pounds and had two stage IV pressure ulcers. The largest pressure ulcer measured 3.5 x 5.0 x 1.0 cm. A dietary progress note, dated [DATE], documented, .Weight / Wound / Hospice Review: at risk for skin break down, metabolic issues .AEB the review of physician orders, meds, and labs; noted -Pressure ulcer to coccyx. Non healing incision of Left outer calf; Has wound vac; Bruising to right chest and breast and right arm remains from admitted ; noted on Theragram, [MEDICATION NAME], Folic Acid, Ca, Tums, Insulin; ht 68 in; wt 182.5#: BMI 29.5; wt loss of 20.5# in one month; 38.7# wt gain since [DATE]; Avg Weekly meal intake % showed; 76%, 83%, 79%, 88% respectively; feeds self; refuses medications at times; refused to go to the hospital; diet is CCHo/ RCS reg, reg; INTERVENTION: ADD PROSTAT 30ML BID- MAY PUT IN SPRITE OR JUICE TO ENHANCE FLAVOR; [MEDICATION NAME] 1 PKG IN 8 OZ WATER BID; Goal - to provide protein for wound healing . A review of the Physician's Order Summary documented the [MEDICATION NAME] was ordered on [DATE]. There was no documentation that the Prostat was ordered. The resident's electronic medical record was reviewed. There was no documentation the physician was informed of the dietician's recommendation for Prostat 30ml BID. On [DATE], a [MEDICATION NAME] laboratory test was performed with results of 5.8 with a reference range of ,[DATE]. On [DATE] at 7:50 a.m., the administrator was asked when did the facility determine there were any concerns related to pressure ulcers. She stated it was the end of the year or beginning of the new year. She was asked how did the facility first identify the concern. She stated the wound log had not been turned in. She was asked if the facility had identified any concerns with the notification of pressure ulcers to physician and facility staff. She stated no. She stated the facility had not been aware of the resident's pressure ulcer until her return to the facility on [DATE]. She stated she had been informed the pressure ulcer was a new hospital acquired pressure ulcer. On [DATE] at 10:35 a.m., the ADON was asked who was responsible for notifying the physician of any new or worsening pressure ulcers. He stated the nurse who found the pressure ulcer was responsible for notifying the physician. He was asked where they would chart physician notification. He stated in the progress notes. A physician's order, dated [DATE] at 11:44 a.m., documented the resident was to receive 30ml of Promod three times a day for supplement. On [DATE] at 1:40 p.m., LPN #1 was asked when did she first notice resident #3 had a pressure ulcer. She stated she did not remember. She was asked if she removed the dressing and observed the condition of the skin under the dressing on admission. She stated she could not remember if she removed the dressing but her first recollection of the condition of the resident's skin around the coccyx was the skin was beefy red and peeling but still blancheable. She was asked what treatment was provided to the pressure ulcer on the coccyx. She stated she applied house stock barrier cream to the site and contacted the wound care nurse for further instructions. She was asked where she documented the treatment. She stated she did not document the treatment. She was asked where she documented she contacted the wound nurse for further instructions. She stated she did not document she had contacted the wound nurse. She was asked when the physician was notified of the resident's pressure ulcer. She stated she could not state specific dates. She was asked where she documented the physician was contacted regarding the resident's pressure ulcer. She stated she documented it in the progress notes or in the scanned documents. She was shown the skilled nurse's note, dated [DATE], and asked about the stage III pressure ulcer it documented. She stated, I don't stage wounds. Must have been an error. Always been told only a wound doctor or nurse could stage a wound. She was asked what the protocol was when a resident was admitted with a pressure ulcer. She stated, If no wound orders, notify the physician of the wound and admission. Notify the wound nurse and consult with the wound doctor. She was asked if the protocol was followed for resident #3. She stated, I'm not sure. She was asked if she had contacted the wound nurse and physician, how long would she wait for wound orders before again notifying the wound nurse and physician for orders. She stated she had recontacted the wound care nurse and was assured the resident's wounds were addressed. She was asked if there were any orders for wound care then. She stated she did not remember. On [DATE] at 2:00 p.m., the administrator was asked what the protocol was for a resident admitted with a pressure ulcer. She stated the admitting nurse documented on the admit/readmit screener. She was asked who monitored the documentation for resident concerns such as pressure ulcers. She stated the DON and wound nurse was to monitor. She stated the DON and wound nurse were no longer employed with the facility. She stated the facility had weekly wound reports which were not part of the medical record but she had been unable to locate them. She stated the new protocol was for the new wound nurse to perform an assessment as soon as practical for every admit or readmit and also monthly on every resident. On [DATE] at 3:05 p.m., the MDS coordinator was asked when did the facility first start treating the resident's pressure ulcers. She stated there were no wound care orders before [DATE]. She was asked when the resident received protein supplements. She stated, The [MEDICATION NAME] was ordered on [DATE] by the dietician and confirmed by the nurse on [DATE]. It was discontinued on [DATE] when she went to the hospital and was never resumed. The Promod wasn't started until today. On [DATE] at 3:15 p.m., the primary care physician was asked when he was notified of the resident's pressure ulcer on the coccyx. He stated he would have to review the physician's progress notes for the resident to be sure. He reviewed the physician's progress notes for the resident and stated he was notified of the coccyx wound on [DATE]. He was asked if that was the first he was made aware of the pressure ulcer. He stated he would have to look at the hospital records since the resident had been back and forth from the hospital several times. He reviewed the hospital records and stated [DATE] was the first he was aware of the pressure ulcer. On [DATE] at 5:00 p.m., the wound physician was asked what interventions the resident received to promote wound healing. She stated the resident received nutritional support with additional protein and vitamin supplements along with wound physician's visits, wound care, and monitoring. She was asked when she was notified of the resident's wounds. She stated she was informed of the resident and assessed the wounds on [DATE]. She was asked if she was aware the resident had a sacral pressure ulcer on initial admission to the facility. She stated no. On [DATE] at 5:00 p.m., LPN #1 was asked if she was the nurse who admitted the resident on [DATE]. She stated yes. She was asked where she obtained the admitting order for the resident. She stated the obtained the admitting orders from the hospital orders. She stated the facility often received discharge notes or packets with orders to continue. She was asked if she assessed the pressure ulcer on admission. She stated her standard of practice was to remove dressings unless there was a physician's order not to remove but she could not remember if she had removed the resident's dressing on the sacral pressure ulcer. She was asked about the multiple entries in the resident's electronic medical record where she documented a stage II to III pressure ulcer in October and [DATE]. She stated those entries were typing errors where she must have been thinking of another resident. She stated she usually did not stage a wound unless a physician or wound nurse had previously staged the wound. She was asked who she notified of the pressure ulcer. She stated, Notified wound nurse like I was suppose to. She was asked where she documented it. She stated, Usually document in the progress notes but didn't with her and I know if it's not documented, it's not done. She was asked who would contact the physician. She stated she expected the wound nurse to contact the physician. She was asked how long she anticipated it would take for the wound nurse to contact the physician. She stated she thought it would take no more than a few hours. She was asked if when she had observed there was still no wound care orders, what did she do. She stated she contacted the wound nurse again and was told the wound physician would see the resident. She was asked where she documented the conversation with the wound nurse. She stated she did not document the conversation with the wound nurse. She stated she was out sick for awhile and when she returned in late October, she asked about the resident's wound care and was told by the wound nurse that the resident was being treated. She stated she did not chart the conversation. She was asked to describe the progression of the sacral pressure ulcer. She stated the first she recalled of the wound was it was red, blanchable, and peeling or sloughing was present. She stated the wound got worse after one of the hospitalization s but she could not remember which. She was asked if she contacted the physician regarding the progression of the pressure ulcer. She stated she did not remember but did not think so since the resident was to be seen by the wound care physician. She was asked if she notified anyone else of the pressure ulcers. She stated she wanted to say yes but was not sure. On [DATE] at 5:05 p.m., resident #3's wounds were observed with the wound physician and wound nurse. All dressings were removed and wound sites measured. A new unstageable pressure ulcer was present on the left hip. The left big toe was assessed at 1.5cm x 1.5cm and scabbed over. The left outer calf wound was observed to be irregular in shape and a mix of yellow necrotic and pale pink colored wound bed. The left heel was measured at 7.0 cm x 5.0 cm and black in color. The left plantar foot wound measured 2.0cm x 3.0cm and was black in color. The right stump wound measured 0.4cm x 0.5cm and had a pale pink wound bed. The right medial stump measured 0.5cm x 1.0cm and was black in color. The coccyx wound was unstageable with yellow and black eschar wound bed and red raised edges and measured 14.0cm x 9.0cm. There were small areas of white in the wound bed which appeared to be bone. On [DATE] at 7:25 p.m., the ADON was asked how did the resident's documented pressure ulcer go without treatment from the original admitted in October and through hospitalization s which documented the pressure ulcer. He stated, We dropped the ball big time. The resident expired in the facility on [DATE] at 1:45 a.m.

On 02/14/17, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who were admitted with a pressure ulcer were identified as having a pressure ulcer and appropriate assessment and medical and nutritional interventions were provided to ensure a resident with a pressure ulcer was able to heal and did not develop additional pressure ulcers. Resident #3 was admitted to the facility on [DATE] with a Stage III pressure ulcer that was not assessed at the facility until 12/07/16. Wound care was not provided at the facility until 12/05/17. The physician was not aware of the Stage III and then Stage IV pressure ulcer and an additional pressure ulcer until 12/06/16. The Dietician was not aware the resident had pressure ulcers until 12/27/16. The resident developed multiple Stage III, Stage IV and unstageable pressure ulcers and infected pressure ulcers. The IJ situation was verified with the Oklahoma State Department of Health. At 4:50 p.m., the administrator and facility owner were informed of the IJ situation regarding pressure ulcers. On 02/14/17 at 6:45 p.m., a plan of removal for the IJ situation was received from the facility. The plan of removal documented: We will educate nurses on evaluating skin upon admission, notifying the physician of any pressure ulcers and documenting in PCC as well as following all physician orders [REDACTED]. All new nurses and agency nurses will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. We will educate certified nurses aides on reporting on the shower sheets all bruises, reddened areas, open areas and rashes even if you feel they have been reported previously. Certified Nurses Aides will be educated by 2/15/2017 at 11 pm. All new CNAs and agency CNAs will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. Nursing Administration will be educated on the wound nurse or designee to evaluate skin at least monthly and to notify physician of all pressure ulcers found and documented on weekly skin log. Nursing Administration will be educated by 2/15/17 at 11pm. All new administrative nurses will be educated upon hire. Any staff unreachable will be educated prior to begin of next shift. On 02/16/17 at 10:52 a.m., CNA #17 was observed providing care to residents. The CNA was asked if she received an inservice from the facility on the topic of wounds. She stated she had worked on 02/15/17 and today and had not received an inservice either day. On 02/16/17 at 12:05 p.m., CNA #18 was observed assisting a resident to the dining room. The CNA was asked if she received an inservice from the facility on the topic of wounds. She stated she had not been inserviced by the facility on any topic. She stated she received her inservices through her employer agency. On 02/16/17 at 4:00 p.m., an amended plan of removal for the IJ situation was received from the facility. The plan of removal documented: We will educate nurses on evaluating skin upon admission, notifying the physician of any pressure ulcers and documenting in PCC as well as following all physician orders [REDACTED]. All new nurses and agency nurses will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. We will educate certified nurses aides on reporting on the shwer sheets all bruises, reddened areas, open areas and rashes even if you feel they have been reported previously. Certified Nurses Aides will be educated by 2/16/2017 at 11 pm. All new CNAs and agency CNAs will be educated prior to providing care. Any staff unreachable will be educated prior to begin of next shift. Nursing Administration will be educated on the wound nurse or designee to evaluate skin at least monthly and to notify physician of all pressure ulcers found and documented on weekly skin log. Nursing Administration will be educated by 2/16/17 at 11pm. All new administrative nurses will be educated upon hire. Any staff unreachable will be educated prior to begin of next shift. The IJ was removed on 02/17/17 at 9:25 a.m., when all components of the plan of removal were completed. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to prevent the development of pressure ulcers and to provide the necessary treatment and services to promote healing of pressure ulcers including the failure to: ~ assess the resident's pressure ulcers; ~ provide wound care; ~ notify the physician of the resident's pressure ulcers; ~ ensure the dietician was aware of the resident's skin breakdown; and ~ follow up on dietary recommendations for protein supplementation and nutritional support to aid in the healing of pressure ulcers for one (#3) of three residents who were reviewed for new and worsening pressure ulcers. Resident #3 was admitted to the facility on [DATE] with a Stage III pressure ulcer which was not assessed at the facility until 12/07/16. The physician was not notified of the Stage III pressure ulcer until 12/06/16, and the Stage III pressure ulcer had deteriorated to a Stage IV and the resident had acquired an additional unstageable pressure ulcer. Wound care was not provided at the facility until 12/05/17. The resident developed multiple Stage III, Stage IV and unstageable pressure ulcers and infected pressure ulcers The facility identified 20 residents who received care for pressure ulcers. Findings: A facility policy, dated 11/07/14 and titled Skin Breakdown Prevention, documented, .To strive to prevent skin breakdown for residents/neighbors that do not have skin breakdowns and to develop safeguards that will decrease the possibility of wound not healing. Although The Highlands does recognize that not all wounds are preventable due to issues with circulation, terminal illness, nutrition and other issues, we will strive to provide the appropriate interventions to reduce or prevent skin breakdown .1. A skin evaluation will be performed by the Charge Nurse or Admission Nurse and reviewed by the Director of Nursing upon admission. 2. A Braden Scale will be performed upon admission and quarterly thereafter or as skin condition changes. The interventions listed on the Braden Scale form will be utilized by nursing as part of the individual plan of care unless contraindicated medically. 3. Skin evaluations will be performed by the Charge Nurse or Wound Nurse on a weekly basis and placed in the treatment book. Interventions will be implemented at the time the skin issue is discovered. 4. Nurse aides will observe/inspect skin anytime care is provided for changes and or skin breakdown, and report findings to the Charge Nurse. A shower sheet will be completed with all showers/baths indicating the condition of the resident's skin. The form will be given to the Charge Nurse who will begin appropriate interventions and bring the form to morning nursing meeting. 5. If a resident is determined to be at high risk for skin breakdown, the Dietary Consultant will be notified for possible recommendations. 6. Skin Breakdown Prevention will be reviewed at all QAPI Committee meetings . An attached sheet, titled Tips for Proper Head to Toe Assessment, documented, .Provide privacy and conduct assessment in a well lite (sic) area. Expose entire skin surface. Start top to bottom, left to right. Check all folds, pits, cracks, and crevices. This includes .peri area, gluteal folds .butt crack .heels .etc. CNA to be observant of skin conditions when providing all manner of care including incontinent care, toileting, showers, ADL's, am/hs care. Look for bruising, reddened areas, rash, open areas .After the proper thorough head and toe assessment is complete make sure you document your findings on all appropriate forms . A hospital's wound ostomy nurse consult note for resident #3, dated 10/10/16, documented, .Consulted for coccyx wound present on admission .Wound Assessment: Mid sacrum opened wound measures 2.2 x 1.8 x 0.2 cm. Wound bed red. Macerated edges. Edges attached, defined. Small amount lf (sic) serosanguinous drainage .Recommendations: Cleanse wound to mid sacrum with normal saline. Apply silver Calcium alginate to cover wound bed M,W,F, apply Allevyn dressing to cover wound. Change allevyn on Monday and Thursday and prn soiling . A hospital's nutrition assessment, dated 10/10/16, documented, .Consult received for non-healing wound .Pt experienced N/V, diarrhea, and poor appetite 2 weeks PTA (prior to admission) per Physician .Interventions/Recommendations: Will add renal restrictions to current diet order. Will send Nepro supplement BID to increase calorie and protein intake. Continue anti-emetics as needed; N/V affecting PO intake .Wounds: mid sacrum open wound . A hospital Cardiology Consult Note, dated 10/11/16, documented the resident had a Stage 3 ulcer of the sacral region. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admit note, dated 10/12/16, documented a new hospital dressing covering a pressure ulcer on the coccyx. There was no documentation the dressing was removed and the wound assessed. There was no documentation of physician notification of the pressure ulcer. This note was signed by LPN #1. The admit/readmit screener, dated 10/12/16, documented the resident was admitted from an acute care hospital. The only documented skin concern was abdominal redness. There was no documentation of the stage III sacral pressure ulcer The skilled nurses' notes, dated 10/13/16 through 10/15/16, documented a pressure ulcer to the coccyx. There was no documentation of wound care or dressing change. There was no documentation of physician notification of the pressure ulcer. These notes were signed by LPN #1. The Skin Condition Evaluation sheet, dated 10/14/16, documented the resident had redness to her abdominal fold and a pressure ulcer on her coccyx. A skilled nurse's note, dated 10/17/16, documented, .Skin Concerns: redness to abdominal fold, Stage III to coccyx . This note was signed by LPN #1. A physician's progress note, dated 10/18/16, did not document any skin or wound concerns. A skilled nurse's note, dated 10/19/16, documented, .Skin Concerns: Stage II to coccyx and redness to abdominal fold . This note was signed by LPN #1. The five day assessment, dated 10/19/16, documented the resident had modified independence in cognition for daily decision making, ambulated and dressed herself with limited one per assistance, required supervision for eating, was continent of urine, and occasionally incontinent of bowel. The assessment documented the resident weighed 143 pounds, had moisture associated skin damage, received pressure reducing devices for the chair and bed, was on a turning/repositioning program, and received pressure ulcer care. The assessment documented the resident had a stage I pressure ulcer. A physician's progress note, dated 10/20/16, did not document any skin or wound concerns. A Skin Condition Evaluation sheet, dated 10/21/16, documented the resident had a stage II pressure ulcer on her coccyx, a skin tear to the back of the left hand, and an abrasion to the outer left forearm. On 10/23/16, the resident was sent to the emergency room for lethargy. The hospital laboratory results, dated 10/23/16, documented the resident had a low [MEDICATION NAME] at 3.0 g/dL (reference range 3.8-4.8) and a low Total Protein at 6.2 g/dL (reference range 6.4-8.2). The hospital laboratory results, dated 10/24/16, documented the resident had a low [MEDICATION NAME] at 2.6 g/dL and a low Total Protein at 5.4 g/dL. A monthly facility dietary note, dated 10/24/16, documented, .Neighbors Diet .CC/RCS Regular Diet .Neighbor is on a CC/RCS Regular Diet, IDT will meet and discuss and will continue to monitor neighbor at this time . The hospital laboratory results, dated 10/28/16, documented the resident had a low [MEDICATION NAME] at 2.2 g/dL and a low Total Protein at 4.8 g/dL. The hospital discharge sheet, dated 10/28/16, documented, Skin Condition .Pressure Ulcer .Other Breakdown .Stage III coccyx, diabetic L toe . The hospital Discharge Summary, dated 10/28/16, documented the resident was hypoglycemic and hypotensive on admission. The Discharge Summary also documented: .Procedures and Results . LLE arterial doppler - mild ASVD . The admit/readmit screener, dated 10/28/16, documented the resident was admitted from an acute care hospital, had a stage III pressure ulcer to her coccyx, a stage II pressure ulcer to her left toe(s), and a skin tear to her left upper arm. There was no documentation of physician notification of the pressure ulcer. The Skin Condition Evaluation sheet, dated 10/28/16, documented the resident had a stage III pressure ulcer on the coccyx and an abrasion to the left upper arm. The medication administration record (MAR) and treatment administration record (TAR), for October 2016, did not document the resident received any wound care or nutritional protein supplement. A review of the physician's orders [REDACTED]. The skilled nurses' notes, dated 10/31/16 through 11/03/16, documented the resident had a stage III pressure ulcer on her coccyx. There was no documentation of wound care or dressing change. A physician's progress note, dated 11/03/16, did not document any skin or wound concerns. A skilled nurse's note, dated 11/04/16, documented the resident had a stage II pressure ulcer on her coccyx. The Skin Condition Evaluation sheet, dated 11/04/16, documented the resident had a stage III pressure ulcer to her coccyx, a pressure ulcer to the left great toe, and a skin tear to her upper left arm. The comprehensive assessment, dated 11/04/16, documented the resident required extensive one person assist in ambulation and transfers, was continent of bowel and bladder, and had a stage II and a stage III pressure ulcer. The assessment documented the resident weighed 144 pounds, had pressure reducing devices for the chair and bed, was on a turning/repositioning program, received pressure ulcer care, received an application of nonsurgical dressings, and the applications of ointments/medications. The skilled nurses' notes, dated 11/05/16 and 11/06/16, documented a small wound to the resident's left great toe. An administrative progress note, dated 11/06/16 and signed by wound nurse #1, documented, .pain in back . There was no documentation of pressure ulcers, wound care, or dressing changes. The skilled nurses' notes, dated 11/07/16 and 11/08/16, documented the resident had a pressure ulcer on her coccyx and another on her left great toe. A skilled nurse's note, dated 11/10/16, documented the resident had a pressure ulcer on her coccyx and another on her left great toe. The 14-day assessment, dated 11/10/16, documented the resident had modified independence in cognition for daily decision making, required extensive two person assist in ambulation and dressing, required one person physical assist with eating, was continent of urine, and occasionally incontinent of bowel. The assessment documented the resident weighed 142 pounds, had a stage III pressure ulcer and moisture associated skin damage. It documented the resident received pressure reducing devices for the chair and bed, was on a turning/repositioning program, received pressure ulcer care, and received applications of nonsurgical dressings and ointments/medications. A physician's progress note, dated 11/10/16, did not document any skin or wound concerns. A skilled nurse's note, dated 11/11/16, documented the resident had a pressure ulcer to her coccyx. There was no documentation of wound care or dressing change. A monthly dietary note, dated 11/11/16, documented, .Neighbor is on a CC/RCS Regular Diet, Neighbor has lost some weight this month, IDT has met and discussed and will continue to monitor . There was no documentation the resident had a pressure ulcer or of the use of a protein supplement to aide the healing of a pressure ulcer. A Skin Condition Evaluation sheet, dated 11/11/16, documented the resident had a pressure ulcer to her coccyx and skin tears to her bilateral upper extremities. A skilled nurse's note, dated 11/12/16, documented the resident had a pressure ulcer to her coccyx and to her left great toe. The skilled nurses' notes, dated 11/14/16 through 11/18/16, documented a pressure ulcer to her coccyx. There was no documentation of wound care or dressing change. A physician's progress note, dated 11/15/16, did not document any skin or wound concerns. A physician's progress note, dated 11/17/16, did not document any skin or wound concerns. The nutrition assessment form, signed 11/18/16, documented the resident's skin was intact and recommended to continue current diet. The additional comments documented the resident had mild weight loss. There was no documentation of a protein supplement to aide in the healing of a pressure ulcer. The Skin Condition Evaluation sheet, dated 11/18/16, documented the resident had a pressure ulcer to her coccyx, redness to her groin, and multiple skin tears to her arms and hands. There was no documentation of wound care or dressing change. The skilled nurses' notes, dated 11/19/16 and 11/20/16, documented the resident had a wound to her bottom. The MAR and TAR, for November 2016, did not document the resident received any wound care or nutritional protein supplement. A review of the physician's orders [REDACTED]. The resident was discharged to the hospital on [DATE] for altered mental status. The hospital history and physical, dated 11/27/16, documented, .Physical examination: There is a stage 4 ulcer of the sacrum with associated [MEDICAL CONDITION] .assessment: Stage 4 coccyx ulcer. [MEDICAL CONDITION] of the coccyx .Severe protein calorie malnutrition .Plan: Patient is admitted for IV antibiotics and wound care. Will continue protein and nutritional supplement . The hospital discharge summary, dated 12/02/16, documented, .Discharge Diagnoses: [REDACTED].Discharge Instruction: The patient is being discharged back to skilled care for continued wound care .Laboratory data showed .[MEDICATION NAME] was 7.6 indicating severe protein-calorie malnutrition . The resident was readmitted to the facility on [DATE] from an acute long term care hospital. The admit/readmit screener, dated 12/02/16, documented the resident was admitted from a long term acute care facility, had a stage II pressure ulcer on the left toe(s), and a stage IV pressure ulcer to the sacrum. The Skin Condition Evaluation sheet, dated 12/02/16, documented the resident had a stage IV pressure ulcer on her coccyx, a pressure ulcer to the left great toe, and redness under her breasts bilaterally. A skilled nurse's note, dated 12/05/16, documented, .Skin Concerns: right medial upper leg, and coccyx pressure ulcer . A physician's progress note, dated 12/06/16, documented the resident had an ulcer on the coccyx and to see wound care notes. A wound care physician's note, dated 12/07/16, documented the resident received a multivitamin and protein supplement. It documented, .She presents with a stage 4 pressure wound coccyx of at least 10 days duration. There is heavy serous exudate .Stage 4 Pressure Wound Coccyx .Wound size (L x W x D): 3.8 x 4.0 x 1.5 cm .Undermining: 1.0 cm at 1 o'clock .Exudate: Heavy Serous .Yellow Necrotic: 30% .Granulation tissue: 70% .Procedure: Surgical excisional debridement of muscle .Indication: Remove necrotic tissue and establish the margins of viable tissue, remove thick adherent eschar and devitalized tissue .Description(:) Wound debrided via surgical excision and muscle removed along with necrotic tissue .Wound of the Left, First Toe .Wound Size: 0.5 x 4.0 x 0.3 cm .Exudate: Moderate Serous .Yellow necrotic: 100% .Procedure: Surgical excisional debridement of subcutaneous tissue .Indication Remove necrotic tissue and establish the margins of viable tissue .Residual necrosis: Present and scored .Description(:) Wound debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue . There was no documentation to indicate the resident was receiving a protein supplement. This was the first wound assessment documented in the facility. The skilled nurses' notes, dated 12/08/16 and 12/09/16, documented a stage IV pressure ulcer to her coccyx and a pressure ulcer to her great toe. The Skin Condition Evaluation sheet, dated 12/09/16, documented the resident had a stage IV pressure ulcer to the coccyx, a pressure ulcer to the left great toe, and redness under her breasts and abdominal folds. The five day assessment, dated 12/09/16, documented the resident had modified independence in cognition for daily decision making, did not ambulate, required extensive two person assist to dress, required set up and supervision for eating, and was frequently incontinent of urine and of bowel. The assessment documented the resident weighed 203 pounds, had one stage IV pressure ulcer, one unstageable pressure ulcer, moisture associated skin damage, had a pressure reducing device for the chair and bed, was on a turning/repositioning program, and received pressure ulcer care. A skilled nurse's note, dated 12/12/16, documented, .Skin Concerns: Laceration to outer left leg, pressure ulcer to coccyx, pressure ulcer to left great toe . The wound care physician's note, dated 12/13/16, documented the resident received a multivitamin and protein supplement. It documented the stage IV pressure ulcer to the coccyx measured 5.5 x 5.5 x 1.5 cm, had undermining of 1.0 cm at 1 o'clock, had heavy serous exudate, with 50% yellow necrotic tissue and 50% granulated tissue, and deteriorating wound progression. It documented the physician surgically debrided the subcutaneous tissue to remove the necrotic tissue and establish the margins of viable tissue. The note documented a wound of the left, first toe measuring 0.5 x 4.0 x 0.2 cm with moderate serous exudate, 100% yellow necrotic tissue, and no change in wound progression. It documented the physician debrided the wound via surgical excision and subcutaneous tissue was removed along with necrotic tissue. The note documented a wound of the left anterior lower leg which measured 3.5 x 3.5 x (not measurable) cm with light serous exudate and 100% granulated tissue. There was no documentation to indicate the resident was receiving a protein supplement. On 12/14/16, the resident was sent to the hospital for altered mental status. The hospital history and physical, dated 12/14/16, documented, .Pressure ulcer coccyx with [DIAGNOSES REDACTED] to the surrounding skin; ulcer with slough tip of L 1st toe; sutures L lower leg . The hospital laboratory results, dated 12/14/16, documented the resident had a urinary tract infection, her [MEDICATION NAME] was low at 2.4 g/dL, and her Total Protein was low at 5.1 g/dL. The resident returned to the facility on [DATE]. The admit/readmit screener, dated 12/19/16, documented the resident returned from an acute care hospital, had a stage II pressure ulcer on the left toe(s), a stage IV pressure ulcer on the sacrum, and a left outer calf surgical incision. The screener documented, .Inscision (sic) with sutures intact to left outer calf .Left great toe tip with dark hard stop (sic) . The Skin Condition Evaluation sheet, dated 12/19/16, documented the resident had a pressure ulcer to the coccyx, sutures in her left lower extremity, and bruising on her breast, chest, and right arm. The monthly dietary note, dated 12/20/16, documented, .Neighbor is on a CC/RCS Regular Diet, Neighbor has gained some weight this month, IDT has met and discussed and will continue to monitor at this time . The was no documentation of a dietary protein supplement to aide in the healing of pressure ulcers. The Skin Condition Evaluation sheet, dated 12/21/16, documented the resident had a coccyx wound measuring 3 x 1.5 x 0.2 cm and a wound on the front of the lower left leg measuring 1.5 x 0.4 cm. The wound care physician's note, dated 12/22/16, documented the resident received a multivitamin and protein supplement. It documented the stage IV pressure ulcer to the coccyx measured 4.0 x 5.5 x 1.5 cm, had undermining of 1.0 cm at 1 o'clock, had moderate serous exudate, with 50% yellow necrotic tissue and 50% granulated tissue, and the wound progression had improved. It documented the physician surgically debrided the subcutaneous tissue to remove the necrotic tissue and establish the margins of viable tissue. The note documented a wound of the left, first toe measuring 0.5 x 0.5 x 0.2 cm with moderate serous exudate, 100% yellow necrotic tissue, and no change in wound progression. It documented the physician debrided the wound via surgical excision and subcutaneous tissue was removed along with necrotic tissue. The note documented a wound of the left anterior lower leg which measured 3.5 x 3.5 x (not measurable) cm, had heavy serous exudate, and 100% granulated tissue. The note documented a wound on the right anterior knee which measured 0.2 x 0.2 x 0.1 cm with light serous exudate and 100% yellow necrotic tissue. There was no documentation to indicate the resident was receiving a protein supplement. The Skin Condition Evaluation sheet, dated 12/26/16, documented the resident had a pressure ulcer on the coccyx and a non-healing surgical site to the back of the lower left leg. The Skin/Wound Note, written by the wound care nurse, dated 12/27/16, documented, .Seen by wound doctor 12/22/16, stage IV to coccyx, 4.0cm x 5.5cm x 1.5cm, wound bed covered in 50% granulation tissue and 50% yellow necrotic slough, heavy serous exudate present, underming (sic) 1.0cm at 1 o'clock, peri wound is moist but not macerated and excoriated. wound (sic) was debrided via surgical excision removing necrotic tissue and establishing the margin of viable tissue, using topical [MEDICATION NAME] to control pain. unstageable (sic) to l. first toe, 0.5cm x 0.5cm x 0.2cm, wound bed covered in 100% yellow necrotic tissue. moderate serous exudate present, no pain/odor associated with wound. peri wound is dry and intact. laceration to l. anterior lower leg, 3.5cm x 3.5cm, wound bed covered in 100% granulation tissue, heavy serous exudate, no pain/odor associated with area. peri wound dry and intact. leg is has (sic) [MEDICAL CONDITION]. wound of r. anterior knee, 0.2cm x 0.2cm x 0.1cm, wound bed covered in 100% yellow necrotic tissue, light serous exudate present, no pain/odor noted to area, peri wound was dry and intact. wound was debrided via surgical excision removing necrotic tissue and establishing the margin of viable tissue using topical [MEDICATION NAME] to control pain. neighbor tolerated visit . The Skin Condition Evaluation sheet, dated 12/28/16, documented the resident had a pressure ulcer on her coccyx and a non-healing incision on the left outer calf. The wound care physician's note, dated 12/30/16, documented the resident received a multivitamin and protein supplement. It documented the stage IV pressure ulcer to the coccyx measured 3.5 x 5.5 x 1.0 cm, had undermining of 1.0 cm at 1 o'clock, had moderate serous exudate, with 40% yellow necrotic tissue and 60% granulated tissue, and wound progression had improved. It documented .Wound debrided via surgical excision and muscle removed along with necrotic tissue . The note documented a wound of the left, first toe measuring 0.6 x 0.8 x 0.2 cm with moderate serous exudate, 100% yellow necrotic tissue, and deteriorating wound progression. It documented the physician debrided the wound via surgical excision and subcutaneous tissue removed along with necrotic tissue. The note documented a wound of the left anterior lower leg measured 3.8 x 2.0 x (not measurable) cm, had heavy serous exudate, with 30% yellow necrotic tissue and 70% granulated tissue. It documented .Wound debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue . The note documented a wound on the right anterior knee had resolved. A laboratory test performed on 12/30/16, documented the resident's Total Protein was 5.9L with a reference range of 6.1-8.1, and her [MEDICATION NAME] was 2.6L with a reference range of 3.6-5.1. The Skin/Wound Note, dated 01/02/17, written by the wound care nurse, documented, .Wound doctor in and seen on 12/30/16 Coccyx wound is 3.5 x 5.5 x 1.0 cm surface area is 19.25 cm squared undermining at 1.0 cm at 1 o'clock. wound (sic) doctor used a curette and removed 40% yellow necrotic tissue and muscle removed and established the margins of viable tissue, removed thick adherent eschar and devitalized tissue. resident (sic) tolerated procedure well. Pain controlled with topical [MEDICATION NAME]. Wound of the left first toe 0.6 x 0.8 x 0.2 cm wound debrided with Curette and removed 100% yellow necrotic tissue and established the margins of viable tissue, removed thick adherent eschar and devitalized tissue. resident tolerated procedure well. wound of the left anterior lower leg 3.8 x 2.0 Heavy Serous Exudate. Wound doctor used a curette to remove 30% yellow necrotic tissue and subcutaneous tissue removed and established the margins of viable tissue, removed thick adherent eschar and devitalized tissue. Resident tolerated well. Wound of the right antior knee closed on 12/30/16. Vocalized understanding of process of wound and treatment changes . The Skin Condition Evaluation sheet, dated 01/02/17, documented the resident had a pressure ulcer on her coccyx and a surgical site on the back of the left lower leg. The Skin Condition Evaluation sheet, dated 01/04/17, documented the resident had a pressure ulcer on her coccyx and a non-healing incision on the left outer calf. On 01/04/17, a [MEDICATION NAME] laboratory test was performed with results of 4.8 with a reference range of 18-45. The nutrition assessment form, signed 01/05/17, documented the resident had a pressure ulcer on her coccyx, a non healing incision to the outer (left) calf, and upper and lower extremity weeping [MEDICAL CONDITION]. The dietician recommended to continue current diet. She documented, .refues (sic) lab draws, refused to go to hospital; PO is good; on Laxis (sic), Theragram, [MEDICATION NAME], folic acid and Vit c; mild wt loss noted after [MEDICATION NAME] added. PO intake adequate to meet est needs at this time; considering Hospice services . There was no documentation of a protein supplement to aide in the healing of the pressure ulcers. The wound care physician's note, dated 01/05/17, documented the resident received a multivitamin and protein supplement. It documented the stage IV pressure ulcer to the coccyx which measured 3.5 x 5.0 x 1.0 cm, had undermining of 1.0 cm at 1 o'clock, had moderate serous exudate, with 40% yellow necrotic tissue, 60% granulated tissue, and the improved wound progression. It documented .Wound debrided via surgical excision and subcutaneous tissue removed along with ne