Every finding on record at Thunder Care and Rehabilitation

Based on record review and interview, the facility failed to protect residents from neglect and abuse for 2 (#1 and #10) of 4 sampled residents reviewed for neglect and abuse. The administrator identified 115 residents resided in the facility. Findings:An Abuse and Neglect policy, revised 08/12/22, read in part, It is the policy of this facility to maintain an abuse free environment.Mental abuse includes but is not limited to abuse that is facilitated or caused by nursing home staff threatening, demeaning.1.A Quarterly assessment, dated 09/20/25, showed Resident #1 had diagnoses of spina bifida and quadriplegia and a brief interview for mental status score of 12 indicating moderate cognitive impairment. The assessment showed Resident #1 was totally dependent upon staff for all of their care. A Behavior note, dated 09/16/25 at 5 p.m., showed Resident #1 was assisted from the courtyard back into the facility and Resident #1 was extremely mad and screaming loudly at CNA #2 stating they had been outside for over an hour waiting for someone to check on them. Resident #1 stated they would leave that place, nobody liked or cared for them in the facility. RN #1 discovered Resident #1 was mad because CNA #6 on the previous shift took them outside and never returned to bring them back inside. On 10/15/25 at 1:27 p.m., Resident #1 stated they asked to go outside close to 3:00 p.m. shift change, and staff did come outside for smoke time, but they did not check on Resident #1. Resident #1 stated the staff did complete every two-hour check which was when they were found and brought back into the facility at approximately 4:40 p.m.On 10/16/25 at 11:53 a.m., CNA #6 stated they told Resident #1 they only had seven minutes left in their shift when CNA #6 took Resident #1 outside as requested. CNA #6 stated they told CNA #2 Resident #1 was outside during report.On 10/16/25 at 3:29 p.m., CNA #2 stated they were not told Resident #1 was outside and did not know until they were doing every two-hour check and found Resident #1 outside in the courtyard.2. A Quarterly assessment, dated 08/04/25, showed Resident #10 had diagnoses of Guillain-Barre syndrome and obesity, had a brief interview for mental status score of 15 indicating they were cognitively intact. The assessment showed Resident #10 was totally dependent upon staff for bathing, dressing, bed mobility, transfers, and toileting.A Behavior note, dated 10/10/25 at 10:05 p.m., showed that CNA #7 told the nurse it was the last time Resident #10 was going to threaten them. The nurse asked Resident #10 what happened and Resident #10 stated they had asked CNA #7 to clean their buttcrack and CNA #7 responded aggressively yelling can you give me a minute? Resident #10 told CNA #7 not to yell at them like they were one of their [expletive] kids. CNA #7 stated they could be the age of one of their (expletive) kids, (expletive)! Resident #10 stated they would have someone beat CNA #7's (expletive) since Resident #10 was unable to get up. CNA #7 stated they would like to see Resident #10 try.A Final Incident Report Form, dated 10/10/25, showed CNA #7 did speak to Resident #10 in an inappropriate manner and was suspended from assignment. Resident #10 was assessed for distress and would continue to be monitored for distress. Two CNAs confirmed they had witnessed CNA #7 yell and used foul language toward Resident #10. The allegation was substantiated, and CNA #7 was terminated on 10/15/25.On 10/15/25 at 1:18 p.m., Resident #10 stated they were just recently in a verbal altercation, where CNA #7 had called them a (expletive), and told Resident #10 they were going to have someone beat them up. Resident #10 stated CNA #7 yelled at me like I was one of their kids, but [CNA #7] was fired.On 10/16/25 at 10:44 a.m., the administrator stated they were notified of the verbal altercation. CNA #7 was suspended pending investigation and had since been terminated. The administrator stated when they questioned CNA #7 over the phone, they did not deny any of the allegation. The administrator stated staff wrote witness statements after the incident and resident interviews were done.

Based on record review and interview, the facility failed to maintain an effective pest control program.The administrator identified 115 residents resided in the facility.Findings:A Pest Control policy, revised May 2008, read in part, this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.A Service Inspection Report, dated 07/24/25, showed cockroach activity was found in room [ROOM NUMBER]'s dresser. The cockroaches were physically removed from the room.A Service Inspection Report, dated 07/31/25, showed light cockroach activity was found in room [ROOM NUMBER] and 405. The cockroaches were physically removed from the room.A Service Inspection Report, dated 08/20/25, showed two baby cockroaches were found in the broom closet. The cockroaches were physically removed from the room.A Service Inspection Report, dated 08/28/25, showed 10 cockroaches were physically removed from a dresser in room [ROOM NUMBER].A Service Inspection Report, dated 09/09/25, showed 10 cockroaches were physically removed from a dresser in room [ROOM NUMBER]. The report showed activity was found behind the refrigerator and underneath baseboards in the kitchen.A Service Inspection Report, dated 09/24/25, showed room [ROOM NUMBER] and 117 had some cockroach activity. One cockroach was removed from room [ROOM NUMBER] and five cockroaches were physically removed from room [ROOM NUMBER]. rooms [ROOM NUMBER] were also treated for cockroaches.On 10/15/25 at 1:18 p.m., Resident #10 stated their room (room [ROOM NUMBER]) was just sprayed due to finding a bed bug in their bed. On 10/15/25 at 1:27 p.m., Resident #1 stated they had seen cockroaches in their room (room [ROOM NUMBER]) about a week ago. On 10/15/25 at 1:38 p.m., CNA #2 smirked, shook their head, and then stated yes there were cockroaches.On 10/16/25 at 11:02 a.m., the administrator stated some residents hoard stuff or kept their stuff in cardboard boxes but get mad when staff tried to help them declutter. The administrator stated the pest guy came out every time they called them and it was not always in the same area, and it was an effective pest control program as a whole, but they had to stay on top of residents that hoard.

Based on record review and interview, the facility failed to assess a resident after a fall for 1 (#9) of 6 sampled residents reviewed for assessing, monitoring and intervening for a resident with a change in condition.The administrator identified 115 residents resided in the facility.Findings:An Assessing Falls and Their Causes policy, revised March 2018, read in part, If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Obtain and record vital signs as soon as it is safe to do so.If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Notify the residents attending physician and family in an appropriate time frame.A quarterly assessment, dated 08/11/25, showed Resident #9's brief interview for mental status at a 13, indicated they were cognitively intact. The assessment also showed that Resident #9 had a diagnosis of history of stroke, had impairments on one side of their body, and was dependent upon staff for toileting, dressing, transferring, bathing, bed mobility, and personal hygiene. A Health Status note, dated 09/21/25 at 4:38 p.m., showed Resident #9 was transported to the ER related to patient self-reported they rolled out of bed last night and hit left ribs. Resident reported left sided pain and coffee brown emesis.There was no documentation of the fall anywhere in the medical record. A Health Status note, dated 09/23/25 at 2:57 p.m., showed Resident #9 returned to the facility from the hospital with a diagnosis of gastrointestinal bleed.On 10/15/25 at 1:42 p.m., RN #1 stated they sent the resident out because they had complained about pain. RN #1 stated they were not aware of the fall until the resident told them about it.On 10/16/25 at 2:39 p.m., the administrator stated they had investigated the fall and spoke with CNA #4 and #5 that worked during the time frame of the fall. The administrator stated CNA's #4 and #5 stated Resident #9 did fall out of bed and they put them back in bed. CNA's #4 and #5 told the administrator LPN #2 was in the room when they moved the resident back to their bed. The administrator stated they told LPN #2, they were supposed to do an incident report, and then the administrator terminated the LPN #2 probably on the 22nd of September for failing to complete an incident report and follow procedures.

Based on record review and interview, the facility failed to administer medication as the physician ordered for 1 (#2) of 3 sampled residents reviewed for medication administration.The administrator identified 115 residents resided in the facility. Findings:An Administering Medications policy, revised April 2019, read in part, medications are administered in accordance with prescriber orders, including any required time frame.An Order Recap Report showed levothyroxine Sodium Oral Tablet 150 MCG for hypothyroidism was ordered to be started on 07/24/25 and was not discontinued until 10/08/24 when the resident discharged .A July medication administration record showed blank areas on 07/26/25 and 07/27/25.On 10/16/25 at 3:18 p.m., the quality coordinator stated they could not find a reason why the 07/26/25 and 07/27/25 levothyroxine dose was not given, but it should have been.

This CMS-2567 was amended following an administrative review conducted on 09/05/2025. ER on [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect residents from Res #1's sexual abuse.Res #1 had a known history of sexually inappropriate behaviors and there was no evidence the facility had assessed or investigated to identify the potential risk to other residents related to Res #1's behaviors.On 08/05/25 at 2:49 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 08/05/25 at 3:07 p.m., the COO and the corporate nurse consultant were notified of the presence of an IJ situation related to residents not being free from Res #1's sexual abuse. The IJ template was provided to the COO.On 08/06/25 at 2:49 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The facility plan of removal, read in part, Thunder Care and Rehab [address withheld] Survey Date/IJ Date 08/05/25. Completion Date of Removal 08/06/25. Time of Completion 3:00 p.m. Immediate Plan of Removal Noncompliance.Due to sexual and physical abuse toward another resident and staff members, [Res] #1 was placed on one on one staffing on 8-4-2025 and placed in a private room on 8-5-2025. [They] will remain on 1 on 1 staffing and in a private room until placement in a psych facility or a facility suited to meet [their] needs can be found.ALL facility employees were in-serviced over the abuse and neglect policy, reporting abuse and neglect to the administrator/Abuse coordinator immediately for investigation and steps to be taken to immediately address the situation to protect the patients. Completion of in-service was on 8-5-25 at 1730 hrs [5:30 p.m.]. Administrator/Abuse Coordinator and Director of Nursing were in-serviced by COO over facility abuse and neglect policy and implementing the policy as written to identify an allegation of abuse and documenting such on the OSDH 283 form. This will ensure all allegations of abuse are investigated as such and the abuse protocols are followed immediately in order to protect patients. In-service completed on 8-5-2025 at 1730 hrs [5:30 p.m.].Facility will develop and implement a PIP plan that requires daily review of all incidents and progress notes to ensure all allegations of abuse and neglect have been reported as required by state, federal regulations and appropriate actions taken to protect patients from further concerns. Pip Plan will also require Care Plans to be reviewed and updated to include all changes implemented due to a behavior and/or allegation of abuse. Will be implemented by 8-6-2025, by 2:30 p.m.All PIP plan audits will be reviewed at QA meeting on 8-6-2025 by 3:00 p.m.PIP plan Audits will continue weekly and presented at QA meeting weekly until further determination of any changes needed.All cognitive residents were interviewed on 8-6-2025 to ensure no other abuse and neglect had been observed and not reported as stated in the facility abuse and neglect policy. All interviews have been completed as of 8-6-2025 at 12:30 p.m. No further allegations of physical or sexual abuse was identified in interviews.If any allegations are made proper steps to follow facility abuse and neglect policy will be taken and interventions put in place. Care plans will be reviewed and updated.All residents had skin assessments to assess for any injuries completed as 8-6-2025 by 1:00 p.m. No injuries of unknown origin were found.On 08/07/25 at 12:33 p.m., after all staff members had been in-serviced, resident interviews and skin assessments were reviewed, care plans and performance improvement projects were initiated with ongoing auditing, the immediacy was lifted, effective 08/06/25 at 3:00 p.m. The deficient practice remained at an isolated level with the potential for more than minimum harm.Based on record review and interview the facility failed to ensure residents were free from sexual abuse for 2 (#2 ad #3) of 3 sampled residents reviewed for abuse. Residents #2 and #3 were touched inappropriately by Resident #1 and the facility had no interventions to protect them and all residents from the sexual abuse. The DON identified 118 residents resided in the facility. Findings:A policy titled Abuse, dated 08/12/22, read in part, It is the policy of this facility to maintain an abuse free environment.Sexual Abuse- including any gesture, verbal or physical that is threatening, degrading, lewd or lascivious in nature.A behavior progress note, dated 06/05/25, showed Res #3 was in the dining room and reported Res #1 grabbed Res #3's hand and placed it in their pants. The note showed Res #1 said they only wanted to play and attempted to grab the nurse's breast voicing they wanted to play. Res #1's care plan, updated 06/06/25, had no interventions in place to address Res #1's behavior. A behavior note, dated 06/08/25, showed Res #1 stating to a certified nurse aide I'm going to fill you up with cum. You want some? The note showed Res #1 stated in dining room You hungry? then started pointing towards their genital area.A behavior note, dated 06/08/25, showed Res #1 asked a nurse Can I [explicit] you. The note showed the nurse intervened and told the resident that was inappropriate. A behavior note, dated 06/08/25 at 10:30 p.m., showed Res #1 continued to make sexual comments to staff and trying to make them touch their genitals and trying to touch them. A behavior note, dated 07/06/25 showed Res #1 had exhibited inappropriate sexual behaviors towards the nurse assisting them with their meal stating multiple times to the nurse (explicit language).A behavior note, dated 07/08/25, showed the Res #1 was inappropriate with the hospice nurse.A physician order, dated 07/12/25, showed the Res #1 was started on Medroxyprogesterone (a progestin) 20 milligrams in the mornings for high-risk heterosexual behaviors.A behavior note, dated 07/20/25, showed the weekend nurse supervisor witnessed Res #1 standing next to Res #2's geriatric chair in dining room groping them in the genital area over the top of their blanket. Res #1 was immediately removed from dining room and moved to area outside nurses' station to complete noon meal. Res #1 was placed on 30 minute checks by staff. The note showed the weekend charge stated they notified the administrator, ADON, and DON.A behavior note, dated 07/30/25, showed Res #1 was sitting at the common table on the South hall after supper. The note showed Res #1 was talking about wanting to have sex with a young member of the opposite sex and they wanted them brought to their room so they could (explicit) them. The note showed Res #1 was taken to their room. A face sheet, dated 08/07/25, showed Res #1 had diagnoses which included high risk heterosexual behaviors and bipolar disorders.On 08/04/25 at 3:11 p.m., LPN #1 was asked if this behavior was a form of abuse. LPN #1 stated, I did not witness it, it was reported to me.On 08/04/25 at 3:06 p.m. the DON reported the administrator was the abuse coordinator for the facility.

Based on record review and interview, the facility failed to ensure residents were bathed as scheduled for 2 (#4 and #5) of 5 sampled residents reviewed for assistance with activities of daily living. The DON reported 118 residents resided in the facility. Findings: 1.An annual assessment, dated 05/15/25, showed Res #4's cognition was intact.Res #4's bath sheets showed the resident missed three of three opportunities for a shower from 08/01/25 to 08/06/25.A diagnoses report, dated 08/06/25, showed Res #4 had diagnoses which included epilepsy and morbid obesity.On 08/06/25 at 1:41 p.m., Res #4 reported they had problems getting their showers like they should. The resident reported they were supposed to be on Monday, Wednesday, and Friday and they had not had a shower this month. On 08/06/25 at 2:35 p.m., ADON #2 stated they were unable to locate bath sheets for the month of August. 2.Res #5's bath sheets showed the resident missed three of three opportunities for a shower from 08/01/25 to 08/06/25.A diagnoses report, dated 08/06/25, showed Res #5 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction.On 08/06/25 1:41 p.m., Res #5 reported they had problems getting their showers like they should. The resident reported they were supposed to be on Monday, Wednesday, and Friday and had not had a shower this month. On 08/06/25 at 2:35 p.m., ADON #2 stated they were unable to locate bath sheets for the month of August.

Based on record review and interview, the facility failed to report an allegation of abuse to the OSDH within two hours for 1 (#1) of 3 sampled residents reviewed for abuse.The DON reported 118 residents resided in the facility.Findings:A facility Abuse Policy, dated 08/12/22, read in part, All incidents and allegations involving abuse or results in serious bodily injury is required to be reported within 2 hours.An order summary report, dated 08/04/25, showed Res #1 had diagnoses which included bipolar disorder and anxiety.A behavior note, dated 06/05/25, showed that it was reported by Res #6 that Res #1 grabbed Res #3's hand and placed the resident's hand in Res 1's pants. Res #1 was informed their behavior was inappropriate in the dining room and Res #3 was married. Res #1 voiced they did not know the resident was married and they only wanted to play. Res #1 was redirected and when a staff member of the opposite sex was feeding them, Res #1 reached up and grabbed at the staff member voicing they wanted to play. Res #1 was taken back to their room.On 08/04/25 at 3:06 p.m., the DON reported an incident report should have been completed and OSDH should have been notified within two hours.

Based on record review and interview, the facility failed to ensure the care plan was revised for 1 (#1) of 6 sampled residents reviewed for care plans.The DON reported 118 residents resided in the facility. Findings: A behavior note, dated 06/05/25, showed that it was reported by Res #6 that Res #1 grabbed Res #3's hand and placed their hand in Res #1's pants. Res #1 was informed their behavior was inappropriate in the dining room and Res #3 was married. Res #1 voiced they did not know Res #3 was married and they only wanted to play. Res #1 was redirected and when a staff member was feeding them. Res #1 reached up and grabbed at the staff member and voiced, they wanted to play. Res #1 was taken back to their room.A care plan, revised on 06/06/25, showed the incident on 06/05/25 with no intervention put in place.An order summary report, dated 08/04/25, showed Res #1 had diagnoses of bipolar disorder and anxiety.On 08/04/25 at 2:34 p.m., minimum data set #1 reported the care plan should have been revised with an intervention.

Based on record review and interview, the facility failed to conduct a thorough investigation after a allegation of abuse for 1 (#1) of 3 sampled residents reviewed for abuse.The DON reported 118 residents resided in the facility.Findings: An Abuse Policy, dated 08/12/22, read in part, Any allegation of abuse will be investigated by the Administrator and the Director of Nursing.A behavior note, dated 06/05/25, showed it was reported by Res #6 that Res #1 grabbed Res #3's hand and placed Res #3's hand in Res #1's pants. Res #1 was informed their behavior was inappropriate in the dining room and Res #3 was married. Res #1 voiced they did not know Res #3 was married and they only wanted to play. Res #1 was redirected and when a staff member was feeding them. Res #1 reached up and grabbed at the staff member voicing they wanted to play. Res #1 was taken back to their room.An order summary, dated 08/04/25, showed Res #1 had diagnoses which included bipolar disorder and anxiety.On 08/04/25 at 3:06 p.m., the DON reported they did not investigate the incident.

Based on record review and interview, the facility failed to implement their abuse policy by reporting within two hours an allegation of abuse for 1 (#3) of 3 sampled residents reviewed for abuse.The DON reported 118 residents resided in the facility. Findings:A facility Abuse Policy, dated 08/12/22, read in part, All incidents and allegations involving abuse or results in serious bodily injury is required to be reported within 2 hours.A behavior note, dated 06/05/25, showed it was reported by Res #6 that Res #1 grabbed Res #3's hand and placed the resident's hand in Res #1's pants. Res #1 was informed their behavior was inappropriate in the dining room and Res #3 was married. Res #1 voiced they did not know the resident was married and they only wanted to play. Res #1 was redirected and when a staff member of the opposite sex was feeding them. Res #1 reached up and grabbed at the staff member voicing, they wanted to play. The resident was taken back to their room.An order summary report, dated 08/04/25, showed Res #1 had diagnoses which included bipolar disorder and anxiety.On 08/04/25 at 3:06 p.m., the DON reported they were notified of the incident. The DON reported the administrator told staff to take Res #1 back to their room and the DON instructed staff to put in a note and to continue to monitor behaviors. The DON reported a facility related Incident form should have been completed within two hours and OSDH should have been notified.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the use of bed rails prior to installation for 1 (#79) of 1 sampled resident reviewed for bed rails. The administrator identified six residents used bed rails. Findings: On 04/21/25 at 11:22 a.m., bed rails were observed to be up on both sides of Resident #79's bed. On 04/23/25 at 10:00 a.m., bed rails were observed to be up on both sides of Resident #79's bed. An undated policy titled Bed Safety and Bed Rails reads in part, 3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 6. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. Use of Bed Rails: 6. The resident assessment to determine risk of entrapment includes, but is not limited to: a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medication(s); e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. condition; j. communication; k. mobility (in and out of bed); and l. risk of falling. An admission assessment, dated 02/24/25, showed Resident #79 had a BIMS summary score of three, which indicated the resident was severly impaired in cognition for daily decision making. On 04/23/25 at 1:46 p.m., the administrator stated the resident did not have an assessment done prior to having bed rails, but should have.

Based on observation, record review, and interview, the facility failed to ensure: a. a resident had a physician order for an indwelling urinary catheter; and b. a resident with an indwelling urinary catheter received services to help prevent urinary tract infections for 1 (#101) of 1 sampled resident reviewed for urinary catheters. The administrator identified three residents with an indwelling urinary catheter. Findings: On 04/21/25 at 11:25 a.m., Res #101 was observed lying in bed with eyes closed. An indwelling urinary catheter with medium yellow urine was observed hooked to the bedframe. On 04/23/25 at 9:09 a.m., Res #101 was observed sitting in a reclined geriatric chair. An indwelling urinary catheter was observed hooked to the chair. A diagnoses report, dated 08/08/24, showed Res #101 had a diagnosis of benign prostatic hyperplasia without lower urinary tract symptoms. A care plan, dated 08/09/24, showed Res #101 used disposable briefs due to urinary incontinence. The care plan showed to monitor and change the brief every two hours and as needed. There was no documentation of an indwelling catheter on the care plan. A quarterly assessment, dated 02/16/25, showed Res #101 had a BIMS score of 11 and was moderately cognitively impaired. The assessment showed Res #101 required partial to moderate assistance with toileting and was always incontinent of urine. A nurse note, dated 03/24/25, showed Res #101 returned to the facility from the hospital with an indwelling catheter in place. There was no physician order for an indwelling urinary catheter found in the medical record. There was no documentation related to urinary catheter maintenance or infection prevention interventions documented in the medical record or the care plan. On 04/21/25 at 11:30 a.m., Res #101 stated they did not know why they needed a catheter. They stated they did not know if the staff cared for the catheter regularly. On 04/23/25 at 9:12 a.m., LPN #1 stated Res #101 returned to the facility from the hospital with the catheter. They stated they were not sure why the catheter was still in place. LPN #1 was asked what care was provided to ensure prevention of urinary tract infections. They stated catheter care was generally performed every shift by a nurse when a resident had a catheter. LPN #1 stated a physician order and care interventions should have been documented in the medical record. They stated there was no way to know if Res #101 had received regular care and maintenance of the catheter since nothing had been documented. On 04/23/25 at 10:55 a.m., the DON stated any resident with an indwelling urinary catheter should have a physician order which specified a medical diagnosis, catheter size, and catheter care interventions every shift and as needed. They stated Res #101 returned from the hospital with the catheter, but they were not sure why they still required the catheter. The DON stated a physician order and care interventions should have been documented in Res #101's plan of care. They stated the resident had not been assessed for removal of the catheter.

Based on observation and interview, the facility failed to ensure all components of the daily staffing information was posted for 2 of 2 observations. The administrator reported 127 residents resided in the facility. Findings: On 04/22/25 at 8:50 a.m., a daily staffing schedule was observed in a glass case on the North hall. The schedule was dated 04/22/25 and did not contain the census or the actual hours worked. On 04/23/25 at 8:42 a.m., a daily staffing schedule was observed in a glass case on the North hall. The schedule was dated 04/23/25 and did not contain the census or the actual hours worked. On 04/24/25 at 12:05 p.m., the administrator reported they did not know the census and actual hours worked had to be on the schedule.

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 1 (#124) of 6 residents sampled for timely administration of medications. The administrator identified 127 residents resided in the facility. Findings: An undated administration time document showed the morning medication pass was from 7:00 a.m. to 11:00 a.m. A policy titled Administering Medications, revised 04/2019, read in part, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescribe orders, including any required time frame. Physician orders for Resident #124, dated 04/20/25, showed to administer the following: a. pristiq (an antidepressant) 50 mg in the morning for depression, b. clozapine (an antipsychotic) 200 mg two times a day for schizophrenia, c. rilutek (benzothiazole drug) 50 mg two times a day for bipolar disorder, d. naltrexone (opioid antagonist) 50 mg in the morning for opioid abuse. An April 2025 Medication Administration Audit Report, showed: a. clozapine was given on 04/21/25 at 12:28 p.m., b. pristiq and naltrexone were given on 04/21/25 at 12:31 p.m., and c. rilutex was given on 04/21/25 at 12:32 p.m. On 04/23/25 at 2:36 p.m., the DON stated the last time these medications were scheduled to be given was 11:00 a.m. On 04/23/25 at 2:37 p.m., the DON stated the 04/21/25 a.m. medications were given late. The DON stated they should have been given by 11:00 a.m.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were utilized for a resident with a wound for 1 (#79) of 1 sampled resident reviewed for wound care. The DON identified 18 residents received wound care. Findings: On 04/23/25 at 9:52 a.m., RN #1 was observed to provide wound care for Resident #79. RN #1 was not observed to utilize a gown during wound care. Signage was not observed near the resident's room. A policy titled Enhanced Barrier Precautions, dated April 2024, read in part, EBP's employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following .wounds. An admission assessment, dated 02/24/25, showed Resident #79 had a stage four pressure ulcer and a BIMS summary score of three, which indicated the resident was severly impaired in cognition for daily decision making. On 04/23/25 at 10:15 a.m., RN #1 stated EBP included a gown and gloves. RN #1 stated they should have worn a gown for wound care. On 04/23/25 at 10:44 a.m., the DON stated a gown and gloves should be worn for wound care.

On 02/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #1 from sexual abuse. Resident #1 was observed in Resident #2's bed. Resident #2 was observed by staff to have their hand down Resident #1's pants and was observed to suck on Resident #1's breast. Resident #1 was severely cognitively impaired for daily decision making and had not been evaluated for the capacity to consent to a sexual relationship. Resident #2 was cognitively intact for daily decision making. Resident #1 was known to wander in the facility and enter other resident rooms, as well as, seek out Resident #2. A progress note, dated 12/03/24, showed Resident #2 was laying in bed with Resident #1 and they were redirected. A progress note, dated 12/11/24, showed another resident informed a CNA Resident #2 had Resident #1 on their bed, in their room, Resident #1's shirt was up, and Resident #2's hand was down their pants. The incident was not identified as sexual abuse by the facility. A progress note, dated 01/27/25 at 3:46 p.m., showed Resident #1 entered another resident's room unwelcomed and was redirected. On 02/10/25 at 4:42 p.m., Resident #1 was observed entering another resident's room. On 02/11/25 at 11:39 a.m., CNA #1 stated they observed Resident #2 on top of Resident #1 in Resident #2's bed on 12/11/24. CNA #1 stated they observed Resident #2's hand down Resident #1's pants and Resident #2 was sucking on Resident #1's breast. A progress note, dated 02/11/25 at 12:00 p.m., showed Resident #1 was attempting to grab at and touch male residents in the dining room. The note showed Resident #1 attempted to sit on the lap of a resident of the opposite sex. On 02/11/25 1:23 p.m., Resident #1 was observed entering another resident's room. On 02/11/25 at 1:35 p.m., Resident #1 was observed entering another resident's room. On 02/11/25 at 2:56 p.m., CNA #2 stated they observed Resident #2 attempting to coerce Resident #1 into sexual activity on 12/11/24. CNA #2 stated they observed Resident #2 touching Resident #1's breast. On 02/11/25 at 3:38 p.m., the administrator stated Resident #1 wandered and routinely sought out Resident #2. On 02/11/25 at 4:00 p.m., the DON stated they were not aware of Resident #1 and Resident #2 laying in bed together on 12/03/24. They stated Resident #1 wandered and required redirection from staff. The DON stated since the incident on 12/11/24, Resident #2 was discharged from the facility and staff were to keep a watch on Resident #1 and redirect as needed. On 02/11/25 at 4:22 p.m., the administrator stated since 12/03/24 when Resident #1 and Resident #2 were laying in bed together they were redirecting Resident #1 from wandering. On 02/11/25 at 5:51 p.m., the administrator stated the facility had not evaluated or assessed Resident #1 for consent to enter into a sexual relationship. The administrator stated due to Resident #1's impaired cognition they were unable to have a conversation regarding consent for a sexual relationship. On 02/11/25 at 9:08 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/11/25 at 9:19 p.m., the administrator, COO, and the corporate MDS coordinator were notified of the presence of an immediate jeopardy situation related to Resident #1 not being free from sexual abuse. The IJ template was provided to the administrator and the COO. On 02/13/25 at 1:50 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Thunder Care and Rehab [address withheld] Survey Date/IJ date 2/11/2025 9:19 p.m. Completion Date of Removal 2/12/25 Immediate Plan of Removal Noncompliance Resident #1 has been placed on 1 on 1 staffing due to continuous wandering throughout the facility to ensure [they] is not in threat of abuse or neglect. Team is currently evaluating further needs to ensure steps to be taken long term for [their] individual needs and placement in a facility that can meet [their] needs. Until such a facility can be found or further options explored by team to ensure no abuse and neglect can occur due to [their] wandering and searching out the opposite sex, [they] will remain on 1 on 1 staffing. All current residents have been reviewed for any wandering issues that may place them at risk for Abuse and Neglect and steps taken to ensure each individual based on their needs are protected. After a review of the state reportable completed 12-12-2024, an amended follow up report has been completed on 2-11-25 to include further information that was reported to the state surveyor by a CNA stating that Resident #2 was witnessed laying on top of Resident #1 in [their] bed, while on top of [them] it was reported that [they] were witnessed sucking on [their] breast with [their] hand down [their] pants. This information was not all reported to the Administrator/Abuse Coordinator at the time of the incident, [they were] not informed of all this information until the State Surveyor relayed this information to [them]. All staff are being in-serviced over Abuse and Neglect Procedure. All information has been updated and updated to OSDH, APS, Police, PCP, and Family notified. We are currently interviewing all parties that were working at the time of the incident to determine why new information has arisen that was not reported at time of incident. We will report further information from all parties involved.Resident #2 was placed on 1 on 1 staffing at time of incident and placed in [hospital name withheld] hospital on 12-12-2024 and returned on 01-14-2025 and discharged to another facility on January 15th, 2025. All staff on the shift as of 11:17 p.m. on 2/11/2025 were in-services at that time over the abuse and neglect policy and reporting all abuse and neglect to the administrator/Abuse coordinator immediately for investigation and steps to be taken to immediately address the situation to protect the patients. ALL facility employees have been in-serviced over the abuse and neglect policy, reporting abuse and neglect to the administrator/Abuse coordinator immediately for investigation and steps to be taken to immediately address the situation to protect the patients. Completion of in-service was 2-12-25 at 3:30pm All employees on the shift at 11:17 p.m. on 2/11/2025 were interviewed at that time to ensure no other abuse and neglect had been observed and not reported as stated in the facility abuse and neglect policy. ALL facility employees have been interviewed to ensure no other abuse and neglect situations had been observed and not reported at [sic] stated in the facility abuse and neglect policy. Completion of the interviews were done on 2-12-25 at 5:30pm All residents were interviewed to ensure no other abuse and neglect had been observed and not reported as stated in the facility abuse and neglect policy. Completion of the interviews were done on 2-12-25 at 5:30pm Administrator/Abuse Coordinator was in-serviced by COO over facility abuse and neglect policy and implementing the policy as written in order to identify an allegation of sexual abuse and documenting such on the OSDH 283 form on 2-11-25. This will ensure all allegations of abuse are investigated as such and the abuse protocols are followed. On 02/14/25 at 2:35 p.m., the IJ was lifted when all components of the plan of removal were completed. The deficient practice remained at a level of potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 (#1) of 3 sampled residents who were reviewed for abuse. The administrator identified 118 residents who resided in the facility. Findings: 1. On 02/10/25 at 4:42 p.m., Resident #1 was observed walking into another resident's room, on the 200 hall, then exited less than one minute later. On 02/11/25 at 1:23 p.m., Resident #1 was observed entering another resident's room, on the 100 hall, exited less than a minute later and walked to the 200 hall, then the 300 hall. Resident #1 had diagnoses which included mild intellectual disabilities. An Abuse policy, dated 08/12/22, read in part, It is the policy of this facility to maintain an abuse free environment.SEXUAL ABUSE - including any gesture, verbal or physical that is threatening, degrading, lewd or lascivious in nature. A progress note, dated 11/09/24 at 9:40 p.m., showed Resident #1 was observed walking and pacing around the facility, and entering other residents' rooms. A quarterly MDS assessment, dated 11/23/24, showed the resident was severely impaired in cognition for daily decision making and wandered daily. A progress note, signed by the administrator, dated 12/01/24 at 12:04 p.m. and documented as a late entry on 12/12/24 at 12:05 p.m., showed Resident #1 walked around the facility. A progress note, signed by the administrator, dated 12/02/24 at 2:05 p.m. and documented as a late entry on 12/12/24 at 12:05 p.m., showed Resident #1 walked around the facility and entered other residents' rooms. A progress note, signed by the administrator, dated 12/03/24 at 1:06 p.m. and documented as a late entry on 12/12/24 at 12:09 p.m., showed Resident #1 walked around the facility. A progress note, dated 12/03/24 at 2:25 p.m., showed Resident #1 seemed to be seeking out to be around another resident of the opposite sex and kept going to that resident's room. The note showed Resident #1 and Resident #2 laid in Resident #2's bed together and neither resident was engaged in any type of sexual activity. A progress note, dated 12/03/24 at 9:03 p.m., showed Resident #1 was ambulating in the hallways. A progress note, dated 12/11/24 at 10:50 p.m., showed Resident #1 continued to seek out another resident of the opposite sex and was found in resident room again. The note showed Resident #1 was redirected out of the other resident's bed/room. A physician's order, dated 12/12/24, showed staff were to monitor the location, behavior, and general mood for Resident #1 in progress notes every hour. The ODH form 283 incident report, showed an incident dated 12/12/24, and identified Resident #1 and Resident #2. The incident report was identified as Inappropriate Behaviors. The incident report showed on 12/11/24 another resident alerted two CNAs and a RN that Resident #1 and Resident #2 had gone into Resident #2's room. The incident report showed Resident #1 and Resident #2 were in Resident #2's bed when staff arrived and Resident #2 was attempting to possibly stroke [Resident #1's] breasts, nothing down [their] pants or on any other areas of [Resident #1] nor [Resident #2's] body. The incident report showed staff guided Resident #1 out of Resident #2's room and due to the difference in cognition the facility preferred to keep the two residents separated and 15 minute checks were implemented. A care plan, showed it was created on 12/13/24 and showed Resident #1 wandered aimlessly and staff were monitoring Resident #1 to ensure the separation between the resident and another resident of the opposite sex. A progress note, dated 01/27/25 at 3:46 p.m., showed Resident #1 entered another resident's room unwelcomed and was redirected. 2. Resident #2 had diagnoses which included unspecified psychosis. A care plan, updated 06/10/24, showed Resident #2 was witnessed going in other residents' rooms and was observed by the DON and ADON to peek into another resident's room from the courtyard. A progress note, dated 12/03/24 at 2:25 p.m., showed a resident of the opposite sex seemed to be seeking out to be around Resident #2 and kept going to Resident #2's room. The note showed Resident #2 and a resident of the opposite sex had laid in Resident #2's bed together and staff redirected them. An annual MDS assessment, dated 12/07/24, showed Resident #2 was cognitively intact for daily decision making and did not exhibit behaviors. A progress note, signed by the DON, dated 12/11/24 at 11:00 p.m., showed another resident alerted two CNAs and a RN that Resident #1 and Resident #2 had gone into Resident #2's room. The note showed Resident #1 and Resident #2 were in Resident #2's bed when staff arrived and Resident #2 was attempting to possibly stroke [Resident #1's] breasts, nothing down [their] pants or on any other areas of [Resident #1] nor [Resident #2's] body. The note showed staff guided Resident #1 out of Resident #2's room and due to the difference in cognition the facility preferred to keep the two residents separated and 15 minute checks were implemented. A progress note, signed by LPN #1, dated 12/11/24 at 11:06 p.m., showed another resident had notified a CNA Resident #2 had a resident of the opposite sex on Resident #2's bed with the other resident's shirt up and Resident #2's hand down the other resident's pants. The note showed the CNA removed Resident #2 away from the other resident and called for the nurse. The note showed the nurse then moved Resident #2 into a room closer to the nurses station and placed Resident #2 on 15 minute checks. The note showed the DON was contacted. A care plan, dated as initiated on 12/12/24, showed the resident had a behavior problem and was found in bed with a resident of the opposite sex. The interventions, read in part, Intervene as necessary to protect the rights and safety of others. A progress note, dated 12/12/24 at 4:41 p.m., showed Resident #2 was discharged from the facility. A progress note, dated 01/14/25 at 3:25 p.m., showed Resident #2 was readmitted to the facility. A progress note, dated 01/15/25 at 11:31 a.m., showed Resident #2 was discharged to another long term care facility. On 02/11/25 at 11:39 a.m., CNA #1 stated on 12/11/24 another resident had approached the nurses station and informed RN#1, CNA #2 and themselves Resident #2 had led Resident #1 to Resident #2's room. CNA #1 stated they immediately went to Resident #2's room and they observed Resident #2 in their bed, on top of Resident #1. CNA #1 stated Resident #1's legs were apart, Resident #2 had their hand down Resident #1's pants, and Resident #2 was sucking on Resident #1's breast. CNA #1 stated they were the first staff member to enter Resident #2's room and they removed Resident #2 from Resident #1 and CNA #2 and RN #1 were right behind them. CNA #1 stated they guided Resident #1 out of Resident #2's room. CNA #1 stated they reported what they had observed to RN #1. CNA #1 stated no one from the facility had interviewed them about the incident. They stated RN #1 stated they would notify the administrator. CNA #1 stated after the incident on 12/11/24, Resident #2 was placed in a room closer to the nurses station so staff could watch them. They stated Resident #1 used to wander all day and all night, but had recently been wandering less at night, and the staff had to keep a good eye on them. On 02/11/25 at 1:36 p.m., CMA #1 stated Resident #1 wandered all the time, would go into other residents' rooms, and required redirection. During the interview, CMA #1 stated, just like that and redirected Resident #1 from another resident's room on the 200 hall. On 02/11/25 at 1:39 p.m., CNA #3 stated Resident #1 wandered and they had to redirect them from other residents' rooms frequently. On 02/11/25 at 1:47 p.m., RN #1 stated on 12/11/24 they were at the nurses station and another resident notified them they had seen Resident #1 enter Resident #2's room. RN #1 stated they were the third person to enter Resident #2's room. RN #1 stated the first staff member to enter the room was CNA #1. They stated CNA #1 reported to them Resident #2 was on top of Resident #1 in Resident #2's bed, but Resident #2 had their pants on. RN #1 stated that was all they remembered and the surveyor needed to review the incident report and progress note they had completed for further details. RN #1 stated they moved Resident #2 to a room closer to the nurses station and notified the administrator immediately. On 02/11/25 at 2:56 p.m., CNA #2 stated another resident had notified CNA #1, RN #1, and themselves Resident #1 was in Resident #2's room. CNA #2 stated the three staff members went to Resident #2's room. CNA #2 stated they observed Resident #2 attempting to coerce Resident #1 into sexual activity. CNA #2 stated they observed Resident #2 touching Resident #1's breast and reported the observation to RN #1. CNA #2 stated the staff were notified to monitor Resident #1 due to their wandering and wandering into other residents' rooms. On 02/11/25 at 3:16 p.m., RN #1 stated they had not documented the incident between Resident #1 and Resident #2. They stated LPN #1 had documented a progress note. On 02/11/25 at 3:17 p.m., LPN #1 stated they were on the East hall doing treatments on 12/11/24, and when they returned to the nurses station, RN #1 had notified them of the incident between Resident #1 and Resident #2. LPN #1 stated they notified the administrator of the incident. They stated they informed the administrator of what the CNAs had observed. LPN #1 stated they reported to the administrator Resident #1 was in Resident #2's room and Resident #2 basically was about to get on top of [Resident #1]. LPN #1 stated they did not know exactly what had happened, but the CNAs had reported Resident #2 was on top of Resident #1 in Resident #2's bed and they had heard Resident #2 may have had their hands down Resident #1's pants, but they had not gotten the full story. LPN #1 stated they had documented what was reported to them and what they had reported to the administrator. On 02/11/25 at 3:28 p.m., the DON stated they were made aware of the incident on 12/11/24, between Resident #1 and Resident #2, the following morning when they had arrived to work. The DON stated they had determined what had happened between Resident #1 and Resident #2 from the incident report documented by the administrator and what RN #1 had reported to them. They stated RN #1 had reported Resident #1 and Resident #2 were laying in bed together. The DON stated they thought the administrator had investigated the incident. On 02/11/25 at 3:38 p.m., the administrator stated on 12/11/24 staff had reported they observed Resident #1 walk into Resident #2's room with them. The administrator stated they were told three staff walked into Resident #2's room and found Resident #1 laying in Resident #2's bed. They stated staff had taken Resident #1 to their own room and moved Resident #2 closer to the nurses station. The administrator stated they had determined what had happened between Resident #1 and Resident #2 by what RN #1 had reported to them. The administrator stated RN #1 reported to them they had entered Resident #2's room first, followed by CNA #2, then CNA #1 had arrived last. The administrator was asked how they differentiated between inappropriate behavior and an allegation of abuse. They stated Resident #1 would seek out Resident #2 and due to Resident #1 having impaired cognition for daily decision making it was inappropriate behavior. The administrator stated Resident #1 had not been assessed for the ability to consent to a sexual relationship because Resident #1 was unable to have conversation with the staff. The administrator stated their investigation of the incident on 12/11/24 consisted of what RN #1 had reported to them. The administrator stated Resident #1 still wandered into other residents' rooms and staff were to redirect them. On 02/11/24 at 4:22 p.m., the administrator stated staff were notified to redirect Resident #1 after they were found in bed with Resident #2 on 12/03/24. On 02/11/25 at 5:17 p.m., Resident #1's POA stated the administrator had reported to them a resident of the opposite sex was going after Resident #1 in a sexual manner approximately three weeks ago. The POA stated the administrator had reported to them a resident of the opposite sex had grabbed Resident #1's breasts, but they had transferred that resident from the facility. On 02/11/25 at 6:56 p.m., the DON stated the resident of the opposite sex referenced in Resident #1's care plan was related to Resident #2. On 02/11/25 at 8:21 p.m., the administrator stated they were the abuse coordinator for the facility.

On 02/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement the abuse policy and procedure to identify an incident of sexual abuse. Resident #1 was observed in Resident #2's bed. Resident #2 was observed by staff to have their hand down Resident #1's pants and was observed to suck on Resident #1's breast. Resident #1 was severely cognitively impaired for daily decision making and had not been evaluated for the capacity to consent to a sexual relationship. Resident #2 was cognitively intact for daily decision making. Resident #1 was known to wander in the facility and enter other resident rooms, as well as, seek out Resident #2. The abuse protocol was not implemented by the facility and was not identified or investigated as an allegation of sexual abuse. A progress note, dated 12/03/24, showed Resident #2 was laying in bed with Resident #1 and they were redirected. A progress note, dated 12/11/24, showed another resident informed a CNA Resident #2 had Resident #1 on their bed, in their room, Resident #1's shirt was up, and Resident #2's hand was down their pants. The incident was not identified as sexual abuse by the facility. The ODH form 283 incident report, showed an incident dated 12/12/24, and identified Resident #1 and Resident #2. The incident report was identified as Inappropriate Behaviors. The incident report showed that on 12/11/24 another resident alerted two CNAs and a RN that Resident #1 and Resident #2 had gone into Resident #2's room. The incident report showed Resident #1 and Resident #2 were in Resident #2's bed when staff arrived and Resident #2 was attempting to possibly stroke [Resident #1's] breasts, nothing down [their] pants or on any other areas of [Resident #1] nor [Resident #2's] body. The incident report showed staff guided Resident #1 out of Resident #2's room and due to the difference in cognition the facility preferred to keep the two residents separated and 15 minute checks were implemented. A progress note, dated 01/27/25 at 3:46 p.m., showed Resident #1 entered another resident's room unwelcomed and was redirected. On 02/10/25 at 4:42 p.m., Resident #1 was observed entering another resident's room. On 02/11/25 at 11:39 a.m., CNA #1 stated they observed Resident #2 on top of Resident #1 in Resident #2's bed on 12/11/24. CNA #1 stated the observed Resident #2's hand down Resident #1's pants and Resident #2 was sucking on Resident #1's breast. A progress note, dated 02/11/25 at 12:00 p.m., showed Resident #1 was attempting to grab at and touch male residents in the dining room. The note showed Resident #1 attempted to sit on the lap of a resident of the opposite sex. On 02/11/25 1:23 p.m., Resident #1 was observed entering another resident's room. On 02/11/25 at 1:35 p.m., Resident #1 was observed entering another resident's room. On 02/11/25 at 2:56 p.m., CNA #2 stated they observed Resident #2 attempting to coerce Resident #1 into sexual activity on 12/11/24. CNA #2 stated they observed Resident #2 touching Resident #1's breast. On 02/11/25 at 3:38 p.m., the administrator stated Resident #1 wandered and routinely sought out Resident #2. On 02/11/25 at 4:00 p.m., the DON stated they were not aware of Resident #1 and Resident #2 laying in bed together on 12/03/24. They stated Resident #1 wandered and required redirection from staff. The DON stated that since the incident on 12/11/24, Resident #2 was discharged from the facility and staff were to keep a watch on Resident #1 and redirect as needed. On 02/11/25 at 4:22 p.m., the administrator stated since 12/03/24 when Resident #1 and Resident #2 were laying in bed together they were redirecting Resident #1 from wandering. On 02/11/25 at 5:51 p.m., the administrator stated the facility had not evaluated or assessed Resident #1 for consent to enter into a sexual relationship. The administrator stated due to Resident #1's impaired cognition they were unable to have conversation regarding consent for a sexual relationship. On 02/11/25 at 9:08 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/11/25 at 9:19 p.m., the administrator, COO, and the corporate MDS coordinator were notified of the presence of an immediate jeopardy situation related to not implementing the abuse policy and procedure for Resident #1. The IJ template was provided to the administrator and the COO. On 02/13/25 at 1:50 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in parts, Thunder Care and Rehab [address withheld] Survey Date/IJ date 2/11/2025 9:19 p.m. Completion Date of Removal 2/12/25 Immediate Plan of Removal Noncompliance After a review of the state reportable completed 12-12-2024, an amended follow up report has been completed on 2-11-25 to include further information that was reported to the state surveyor by a CNA stating that resident #2 was witnessed laying on top of resident #1 in [their] bed, while on top of [them] it was reported that [they] were witnessed sucking on [their] breast with [their] hand down [their] pants. This information was not all reported to the Administrator/Abuse Coordinator at the time of the incident, [they were] not informed of all this information until the State Surveyor relayed this information to [them]. All staff are being in-serviced over Abuse and Neglect Procedure. All information has been updated and updated to OSDH, APS, Police, PCP, and Family notified. We are currently interviewing all parties that were working at the time of the incident to determine why new information has arisen that was not reported at time of incident. We will report further information from all parties involved. Resident #2 was placed on 1 on 1 staffing at time of incident and placed in [hospital name withheld] hospital on 12-12-2024 and returned on 01-14-2025 and discharged to another facility on January 15th, 2025. All staff on the shift as of 11:17 p.m. on 2/11/2025 were in-services at that time over the abuse and neglect policy and reporting all abuse and neglect to the administrator/Abuse coordinator immediately for investigation and steps to be taken to immediately address the situation to protect the patients. ALL facility employees have been in-serviced over the abuse and neglect policy, reporting abuse and neglect to the administrator/Abuse coordinator immediately for investigation and steps to be taken to immediately address the situation to protect the patients. Completion of in-service was 2-12-25 at 3:30pm All employees on the shift at 11:17 p.m. on 2/11/2025 were interviewed at that time to ensure no other abuse and neglect had been observed and not reported as stated in the facility abuse and neglect policy. ALL facility employees have been interviewed to ensure no other abuse and neglect situations had been observed and not reported at [sic] stated in the facility abuse and neglect policy. Completion of the interviews were done on 2-12-25 at 5:30pm All residents were interviewed to ensure no other abuse and neglect had been observed and not reported as stated in the facility abuse and neglect policy. Completion of the interviews were done on 2-12-25 at 5:30pm Administrator/Abuse Coordinator was in-serviced by COO over facility abuse and neglect policy and implementing the policy as written in order to identify an allegation of sexual abuse and documenting such on the OSDH 283 form on 2-11-25. This will ensure all allegations of abuse are investigated as such and the abuse protocols are followed.Resident #1 has been placed on 1 on 1 staffing due to continuous wandering throughout the facility to ensure she is not in threat of abuse or neglect. Team is currently evaluating further needs to ensure steps to be taken long term for [their] individual needs and placement in a facility that can meet [their] needs. Until such a facility can be found or further options explored by team to ensure no abuse and neglect can occur due to [their] wandering and searching out the opposite sex, [they] will remain on 1 on 1 staffing. All current residents have been reviewed for any wandering issues that may place them at risk for Abuse and Neglect and steps taken to ensure each individual based on their needs are protected. On 02/14/25 at 2:35 p.m., the IJ was lifted when all components of the plan of removal were completed. The deficient practice remained at a level of potential for more than minimal harm. Based on observation, record review and interview, the facility failed to ensure the abuse policy and procedure was implemented for 1 (#1) of 3 sampled residents who were reviewed for abuse. The administrator identified 118 residents who resided in the facility. Findings: 1. On 02/10/25 at 4:42 p.m., Resident #1 was observed walking into another resident's room, on the 200 hall, then exited less than one minute later. On 02/11/25 at 1:23 p.m., Resident #1 was observed entering another resident's room, on the 100 hall, exited less than a minute later and walked to the 200 hall, then the 300 hall. Resident #1 had diagnoses which included mild intellectual disabilities. An Abuse policy, dated 08/12/22, read in parts, SEXUAL ABUSE - including any gesture, verbal or physical that is threatening, degrading, lewd or lascivious in nature.IDENTIFICATION: Staff will be trained to identify potential signs of abuse and to report same to the charge nurse.INVESTIGATION: Any allegation of abuse will be investigated by the Administrator and the Director of Nursing. The Administrator and Director of Nursing will, as a minimum: a. Review the resident medical record looking for events leading up to the incident. b. Interview the person(s) reporting the incident. c. Interview any witnesses to the incident. d. Interview the resident (if cognitive ability permits); e. Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident if necessary.All forms of Abuse, including resident to resident abuse, resident to family/visitor, or staff must be reported to the charge nurse who then must report to the Director of Nursing and the Administrator. A progress note, dated 11/09/24 at 9:40 p.m., showed Resident #1 was observed walking and pacing around the facility, and entering other residents' rooms. A quarterly MDS assessment, dated 11/23/24, showed the resident was severely impaired in cognition for daily decision making and wandered daily. A progress note, signed by the administrator, dated 12/01/24 at 12:04 p.m. and documented as a late entry on 12/12/24 at 12:05 p.m., showed Resident #1 walked around the facility. A progress note, signed by the administrator, dated 12/02/24 at 2:05 p.m. and documented as a late entry on 12/12/24 at 12:05 p.m., showed Resident #1 walked around the facility and entered other residents' rooms. A progress note, signed by the administrator, dated 12/03/24 at 1:06 p.m. and documented as a late entry on 12/12/24 at 12:09 p.m., showed Resident #1 walked around the facility. A progress note, dated 12/03/24 at 2:25 p.m., showed Resident #1 seemed to be seeking out to be around another resident of the opposite sex and kept going to that resident's room. The note showed Resident #1 and Resident #2 laid in Resident #2's bed together. The note showed neither resident was engaged in any type of sexual activity. A progress note, dated 12/03/24 at 9:03 p.m., showed Resident #1 was ambulating in the hallways. A progress note, dated 12/11/24 at 10:50 p.m., showed Resident #1 continued to seek out another resident of the opposite sex and found in resident room again. The note showed Resident #1 was redirected out of the other resident's bed/room. The ODH form 283 incident report, showed an incident dated 12/12/24, and identified Resident #1 and Resident #2. The incident report was identified as Inappropriate Behaviors. The incident report showed that on 12/11/24 another resident alerted two CNAs and a RN that Resident #1 and Resident #2 had gone into Resident #2's room. The incident report showed Resident #1 and Resident #2 were in Resident #2's bed when staff arrived and Resident #2 was attempting to possibly stroke [Resident #1's] breasts, nothing down [their] pants or on any other areas of [Resident #1] nor [Resident #2's] body. The incident report showed staff guided Resident #1 out of Resident #2's room and due to the difference in cognition the facility preferred to keep the two residents separated and 15 minute checks were implemented. The ODH form 283 showed the administrator was the person who completed the incident report. A care plan, showed it was created on 12/13/24 and showed Resident #1 wandered aimlessly and staff were monitoring Resident #1 to ensure the separation between resident and another resident of the opposite sex. A progress note, dated 01/27/25 at 3:46 p.m., showed Resident #1 entered another resident's room unwelcomed and was redirected. 2. Resident #2 had diagnoses which included unspecified psychosis. A care plan, updated 06/10/24, showed Resident #2 was witnessed going in other residents' rooms and was observed by the DON and ADON to peek into another resident's room from the courtyard. A progress note, dated 12/3/24 at 2:25 p.m., showed a resident of the opposite sex seemed to be seeking out to be around Resident #2 and kept going to Resident #2's room. The note showed Resident #2 and a resident of the opposite sex had laid in Resident #2's bed together and staff redirected them. An annual MDS assessment, dated 12/07/24, showed Resident #2 was cognitively intact for daily decision making and did not exhibit behaviors. A progress note, signed by the DON, dated 12/11/24 at 11:00 p.m., showed another resident alerted two CNAs and a RN that Resident #1 and Resident #2 had gone into Resident #2's room. The note showed Resident #1 and Resident #2 were in Resident #2's bed when staff arrived and Resident #2 was attempting to possibly stroke [Resident #1's] breasts, nothing down [their] pants or on any other areas of [Resident #1] nor [Resident #2's] body. The note showed staff guided Resident #1 out of Resident #2's room and due to the difference in cognition the facility preferred to keep the two residents separated and 15 minute checks were implemented. A progress note, signed by LPN #1, dated 12/11/24 at 11:06 p.m., showed another resident had notified a CNA that Resident #2 had a resident of the opposite sex on Resident #2's bed with the other resident's shirt up and Resident #2's hand down the other resident's pants. The note showed the CNA removed Resident #2 away from the other resident, called for the nurse, Resident #2 was moved into a room closer to the nurses station, and placed Resident #2 on 15 minute checks. The note showed the DON was contacted. A care plan, dated as initiated on 12/12/24, showed the resident had a behavior problem and was found in bed with a resident of the opposite sex. The interventions, read in part, Intervene as necessary to protect the rights and safety of others. A progress note, dated 12/12/24 at 4:41 p.m., showed Resident #2 was discharged from the facility. A progress note, dated 01/14/25 at 3:25 p.m., showed Resident #2 was readmitted to the facility. A progress note, dated 01/15/25 at 11:31 a.m., showed Resident #2 was discharged to another long term care facility. On 02/11/25 at 11:39 a.m., CNA #1 stated on 12/11/24 another resident had approached the nurses station and informed RN #1, CNA #2, and themselves Resident #2 had led Resident #1 to Resident #2's room. CNA #1 stated they immediately went to Resident #2's room and they observed Resident #2 in their bed, on top of Resident #1. CNA #1 stated Resident #1's legs were apart, Resident #2 had their hand down Resident #1's pants, and Resident #2 was sucking on Resident #1's breast. CNA #1 stated they were the first staff member to enter Resident #2's room and they removed Resident #2 from Resident #1 and CNA #2 and RN #1 were right behind them. CNA #1 stated they guided Resident #1 out of Resident #2's room. CNA #1 stated they reported what they had observed to RN #1. CNA #1 stated no one from the facility had interviewed them about the incident. They stated RN #1 stated they would notify the administrator. CNA #1 stated after the incident on 12/11/24, Resident #2 was placed in a room closer to the nurses station so staff could watch them. They stated Resident #1 used to wander all day and all night, but had recently been wandering less at night, and the staff had to keep a good eye on them. On 02/11/25 at 1:36 p.m., CMA #1 stated Resident #1 wandered all the time, would go into other resident's rooms, and required redirection. During the interview, CMA #1 stated, just like that and redirected Resident #1 from another resident's room on the 200 hall. On 02/11/25 at 1:39 p.m., CNA #3 stated Resident #1 wandered and they had to redirect them from other resident's rooms frequently. On 02/11/25 at 1:47 p.m., RN #1 stated on 12/11/24 they were at the nurses station and another resident notified them they had seen Resident #1 enter Resident #2's room. RN #1 stated they were the third person to enter Resident #2's room. RN #1 stated the first staff member to enter the room was CNA #1. They stated CNA #1 reported to them Resident #2 was on top of Resident #1 in Resident #2's bed, but Resident #2 had their pants on. RN #1 stated that was all they remembered and the surveyor needed to review the incident report and progress note they had completed for further details. RN #1 stated they moved Resident #2 to a room closer to the nurses station and notified the administrator immediately. On 02/11/25 at 2:56 p.m., CNA #2 stated another resident had notified CNA #1, RN #1, and themselves that Resident #1 was in Resident #2's room. CNA #2 stated the three staff members went to Resident #2's room. CNA #2 stated they observed Resident #2 attempting to coerce Resident #1 into sexual activity. CNA #2 stated they observed Resident #2 touching Resident #1's breast and reported the observation to RN #1. CNA #2 stated the staff were notified to monitor Resident #1 due to their wandering and wandering into other residents' rooms. On 02/11/25 at 3:16 p.m., RN #1 stated they had not documented the incident between Resident #1 and Resident #2. They stated LPN #1 had documented a progress note. On 02/11/25 at 3:17 p.m., LPN #1 stated they were on the East hall doing treatments on 12/11/24, and when they returned to the nurses station, RN #1 had notified them of the incident between Resident #1 and Resident #2. LPN #1 stated they notified the administrator of the incident. They stated they informed the administrator of what the CNAs had observed. LPN #1 stated they reported to the administrator that Resident #1 was in Resident #2's room and that Resident #2 basically was about to get on top of [Resident #1]. LPN #1 stated they did not know exactly what had happened but the CNAs had reported that Resident #2 was on top of Resident #1 in Resident #2's bed and they had heard Resident #2 may have had their hands down Resident #1's pants but they had not gotten the full story. LPN #1 stated they had documented what was reported to them and what they had reported to the administrator. On 02/11/25 at 3:28 p.m., the DON stated they were made aware of the incident on 12/11/24, between Resident #1 and Resident #2, the following morning when they had arrived to work. The DON stated they had determined what had happened between Resident #1 and Resident #2 from the incident report documented by the administrator and what RN #1 had reported to them. They stated RN #1 had reported Resident #1 and Resident #2 were laying in bed together. The DON stated they thought the administrator had investigated the incident. On 02/11/25 at 3:38 p.m., the administrator stated on 12/11/24 staff had reported they observed Resident #1 walk into Resident #2's room with them. The administrator stated they were told three staff walked into Resident #2's room and found Resident #1 laying in Resident #2's bed. They stated staff had taken Resident #1 to their own room and moved Resident #2 closer to the nurses station. The administrator stated they had determined what had happened between Resident #1 and Resident #2 by what RN #1 had reported to them. The administrator stated RN #1 reported to them they had entered Resident #2's room first, followed by CNA #2, then CNA #1 had arrived last. The administrator was asked how they differentiated between inappropriate behavior and an allegation of abuse. They stated Resident #1 would seek out Resident #2 and due to Resident #1 having impaired cognition for daily decision making they addressed the incident as inappropriate behavior. The administrator stated Resident #1 had not been assessed for the ability to consent to a sexual relationship because Resident #1 was unable to have conversation with the staff. The administrator stated their investigation of the incident on 12/11/24 consisted of what RN #1 had reported to them and no other staff or resident interviews were conducted. The administrator stated Resident #1 still wandered into other residents' rooms and staff were to redirect them. The administrator reviewed the ODH form 283 and was asked why the abuse policy had not been implemented. The administrator stated they had not implemented the abuse policy because Resident #1 willingly sought out Resident #2. On 02/11/24 at 4:22 p.m., the administrator stated staff were notified to redirect Resident #1 after they were found in bed with Resident #2 on 12/03/24. On 02/11/25 at 5:17 p.m., Resident #1's POA stated approximately 3 weeks ago, the administrator had reported to them a resident of the opposite sex was going after Resident #1 in a sexual manner. The POA stated the administrator had reported to them a resident of the opposite sex had grabbed Resident #1's breasts, but they had transferred that resident from the facility. On 02/11/25 at 6:56 p.m., the DON stated the resident of the opposite sex referenced in Resident #1's care plan was related to Resident #2. On 02/11/25 at 8:21 p.m., the administrator stated they were the abuse coordinator for the facility.

Based on record review and interview, the facility failed to ensure a resident's representative was notified of a medication change for one (#1) of three sampled residents reviewed for notification. The administrator identified 109 residents resided in the facility. Findings: Resident #1 was admitted to the facility with diagnoses which included cerebral palsy, autistic disorder, and spastic quadriplegic cerebral palsy. A physician's order, dated 08/01/24, documented permethrin external cream 5%, apply to entire body topically, leave on and wash off after 8 hours. The resident's record was reviewed and contained no documentation the resident's representative was notified of the new order. On 10/08/24 at 12:27 p.m., licensed practical nurse #1 stated they did not remember if they notified the resident's representative of the new order.

Based on observation, record review, and interview, the facility failed to ensure a proper bed bath was provided for one (#3) of two sampled residents observed receiving bed a bath. The Administrator identified 105 residents resided in the facility and 79 residents needed assistance with bathing. Findings: Resident #3 had a diagnosis of obesity. Resident #3's admission resident assessment, dated 05/03/24, documented Resident #3 had moderate cognitive impairment and they were dependent on another person for bathing. Resident #3's care plan for self-care deficit, dated 05/01/24, documented the Resident required staff participation with bathing. On 07/26/24 at 9:49 a.m., Resident was observed receiving a bed bath. On 07/26/24 at 9:53 a.m., There were no washcloths left to continue the Resident's bed bath. CNA #3 stepped out of the room to get more washcloths. CNA #1 and CNA #2 each had a washcloth in their hands. They both reused the washcloths by dipping them back into the soapy wash basin one time to wash the Resident. On 07/26/24 at 10:00 a.m., CNA #3 cleaned Resident #3's upper peri area one time at request with one wash cloth. They did not wipe between the Residents' labia. On 07/26/24 at 10:02 a.m., There were no washcloths left to continue the Resident's bed bath. CNA #3 stepped out of the room to get more washcloths. CNA #1 and CNA #2 each had a washcloth in their hands. They both reused the washcloths by dipping them back into the clean water basin one time to rinse the Resident. Resident #3 was turned to their right side. On 07/26/24 at 10:07 a.m., CNA #3 stated they were done with the bed bath and should get the nurse to do Resident #3's wound care. CNA #3 was asked if they cleaned the Resident's labia at their request. They stated, yes once. They stated they did not clean the Resident's peri area correctly. On 07/26/24 at 10:09 a.m., Resident #3 was laid on their back. CNA #3 cleaned between the Resident's labia with a washcloth. The washcloth had a blood stain and a string of blood clot. CNA #3 continued to clean the Residents peri area. On 07/26/24 at 10:13 a.m., Resident #3 stated they were on their menstrual cycle. On 07/26/24 at 10:36 a.m., CNA #3 stated the process was to clean resident's top to bottom including proper cleaning of female residents peri area during bed bath. On 07/26/24 at 10:40 a.m., CNA #1 and CNA #2 stated they should not have reused the washcloths. They stated the washcloths were considered dirty and should be discarded after each use.

Based on record review and interview, the facility failed to ensure resident's were treated with dignity and respect for one (#1) of three sampled residents. The ADON reported 98 residents resided in the facility. Findings: Res #1 admitted to the facility with diagnoses of intellectual disability disorders, bipolar, and anxiety. An admission assessment, dated 07/19/23, documented the resident's was severely impaired with cognition. A state incident report, dated 01/23/24, documented a staff member grabbed the resident and took her back to her room and sat her down on the bed because she was trying to hit them. A care plan, dated 01/25/24, documented the resident had the potential to demonstrate physical and verbal behaviors. On 01/30/24, the administrator reported the staff member had been terminated and an in-service was held regarding how to respond to resident behaviors.

On 05/06/20, an Immediate Jeopardy situation was determined to exist related to the facility's failure to implement infection prevention and control practices to prevent the development and transmission of COVID-19. The facility failed to perform appropriate screening of visitors and staff, failed to implement transmission based precautions and the use of PPE, failed to isolate known residents with COVID-19, failed to quarantine residents exposed to COVID-19, failed to quarantine residents with unknown status due to return admissions from the hospital and offsite [MEDICAL TREATMENT], and failed to provide thorough education to staff to ensure appropriate and safe care was provided to residents. The facility identified one resident who had passed in the hospital, six residents residing in the facility and seven staff who had all tested positive for COVID-19. One resident and 29 staff had test results still pending. OSDH verified the existence of the Immediate Jeopardy Situation. At 5:25 p.m., the DON was informed of the IJ related to the failure to implement infection prevention and control practices. A plan of removal for the IJ situation was requested. The DON was working as nursing staff for residents on the floor on the evening shift. No other administrative personnel were present in the facility at the time. At 8:36 p.m., an acceptable plan of removal was provided by the DON. The plan of removal documented, May 6, 2020 Hillcrest Nursing Center 2120 N. Broadway (NAME) OK Plan of Removal 1. Staff member is placed at front door monitoring station to ensure staff, and essential visitors are properly monitored upon entrance into the community. Front lobby and monitoring station are disinfected with approved product. 2. Evaluation is completed to include temperatures and sign/symptom are checked on all residents, staff, and persons in community at present. 3. Residents identified with positive test received this date are moved to an area of the community designated for contained isolation unit. This unit is contained by door closure at each end of the specified unit. The closed doors are identified by signage to indicate Isolation Precautions Required Past this Point, with instruction for application of PPE before entering. PPE is located at the entrance points of the contained unit. 4. Residents with exposure, return admits from hospital, and [MEDICAL TREATMENT] are placed in private rooms on quarantine unit with PPE placed outside of rooms. 5. Areas designated as contained isolation unit and quarantine unit are cleansed and disinfected with approved product; cleaning will be completed with increased frequency during each shift. Common areas within the community are cleansed and disinfected with increased frequency of high touch areas. 6. Staff are educated regarding manned front entrance monitoring and appropriate monitoring required every entry into facility, Proper use, location and application of PPE to include instruction of PPE use while assisting residents on contained isolation unit and quarantine unit, residents with potential exposure, and all other units within community, and cleaning and disinfecting requirements. Staff are educated regarding personal protection outside of facility to limit exposure and signs/symptoms to report to supervising staff for determination of absence from work necessary. This plan of removal will be in compliance May 6, 2020 by 11:59 pm. On 05/07/20 at 4:05 p.m., the documentation of the education provided to the staff was reviewed. No dates or times of when the education was provided were documented. No signatures were provided confirming the education was received by the staff. There were 61 staff members on the list, 21 were documented as having received a phone call, seven no answer, one busy, one quit, 12 left messages, six were blank and 13 were documented as having received the education in person. No written documentation was provided to the staff regarding the education. On 05/07/20 from 4:20 p.m. to 5:40 p.m., staff were observed working in the COVID unit without appropriate masks to protect against contracting COVID-19. Staff was observed to carry soiled trash, without the removal of gloves or shoe covers, from the COVID unit through the hallways and out the front entry of the facility to dispose of the trash. Staff reported they had not been provided any biohazard bags for soiled waste or cleaning and disinfectant supplies. Staff were unaware of the COVID negative status and infection control measures required to provide safe care for resident #3, who had refused to change rooms and remained on the COVID positive unit. Staff was unable to verify they had been educated and understood the components documented in the plan of removal. At 5:53 p.m., the DON was informed the IJ would not be removed due to the facility's failure to provide appropriate PPE to staff working the COVID unit, failure to implement appropriate transmission based precautions, failure to ensure appropriate environmental cleaning, failure to identify the status and care of resident #3 and failure to thoroughly educate staff. A plan of removal for the IJ situation was requested. The DON was working on the floor. No other administrative personnel were present in the facility at the time. At 7:59 p.m., an acceptable plan of removal was provided by the DON. The plan of removal documented, May 7, 2020 Hillcrest Nursing Center 2120 N. Broadway (NAME) OK Plan of Removal 1. All staff working the (sic) in the Contained Isolation Unit (COVID unit) will be provided and wear N95 mask and be fit tested prior to working. 2. Staff members currently working on the COVID unit have been verbally educated regarding infection control procedures when leaving the COVID unit; staff have been instructed on proper removal of PPE waste products from the COVID unit to utilize the exterior key pad exit door located on the unit for removal of trash; PPE soiled disposal will be placed in biohazard bags and properly sealed before removal from the COVID unit. 3. Facility will provide a housekeeping cart on the unit during this time of quarantine for housekeeping cleansing and disinfecting with instruction to staff for proper use of equipment, disinfectant supplies, and biohazard. 4. COVID negative resident choosing to remain in his room has been identified by placement of signage and staff educated. 5. Education will be provided to staff to include: - PPE application, removal, disposal - Laundry services - Dining services - Infection Control based precautions within and outside the unit - Cleansing and disinfecting This plan of removal will be in compliance May 8, 2020 by 5:00 pm. On 05/08/20 at 5:20 p.m., the DON stated she was typing the written part of the education to have been provided to the staff. She stated she was working the floor as the charge nurse at the same time. She was asked if all the staff had been educated. The DON stated no. She was asked if anything had been signed by those who had been educated. She stated no. At 6:30 p.m., the DON was unable to provide documentation of the education provided to staff. Staff was unable to verify they had been educated or understood the components documented in the plan of removal. At 6:40 p.m., the DON was informed the IJ would not be removed due to the facility's failure to thoroughly educate staff. A plan of removal for the IJ situation was requested. No other administrative personnel was present in the facility at the time. At 6:53 p.m., an acceptable plan of removal was provided by the DON. The plan of removal documented, May 8, 2020 Hillcrest Nursing Center 2120 N. Broadway (NAME) OK Plan of Removal 1. Education will be provided to staff to include: - PPE application, removal, disposal - Laundry services - Dining services - Infection Control based precautions within and outside the unit - Cleansing and disinfecting This plan of removal will be in compliance May 8, 2020 by 11:59 pm. On 05/09/20, interviews were conducted with a total of six employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and they understood the information provided. The IJ was removed as of 05/08/20 at 11:59 p.m., when all components of the plan of removal had been completed. Based on observation, record review and interview, it was determined the facility failed to: ~ ensure proper infection prevention and control practices were implemented to prevent the development and transmission of COVID-19; ~ ensure residents wore face masks when out of their rooms; ~ perform appropriate screening of visitors and staff; ~ implement transmission based precautions and the use of PPE; ~ isolate known residents with COVID-19; ~ quarantine residents exposed to COVID-19 and residents with unknown status due to return admissions from the hospital and offsite [MEDICAL TREATMENT]; ~ provide appropriate environmental cleaning; ~ sanitize the dietary cart after being inside of the COVID positive unit, and dispose of trays and plates from the COVID positive unit appropriately; and ~ failed to provide thorough education to staff to ensure appropriate and safe care to residents. Seven residents and seven staff members were known to have contracted COVID-19. The facility identified 81 residents who resided in the facility. Findings: On 05/06/20 at 2:30 p.m., observations were made at the entrance to the facility. A screening desk was set up at the door with a thermometer and binder. No one was stationed at the screening desk to instruct or monitor visitors who had entered into the facility. Staff, with knowledge of the front door code, would open the door for others. At 2:35 p.m., the housekeeping supervisor stated there were residents positive for COVID-19 who had just been wandering around the facility without masks. As resident #1 approached, he stated she was positive for COVID-19. Resident #1 was observed to wander around the front entrance without wearing a mask. At 2:36 p.m., the staff was asked who was in charge. The housekeeping supervisor stated no one was in charge. The DON was out but would be back. From 2:36 p.m. to 2:50 p.m., resident #1 was observed to wander away and come back up to the front entrance. She had a surgical mask and was observed to cover and uncover her mouth with the mask. The resident was then observed to rub the mask all over the sign-in binder used for staff and visitors. Multiple staff would frequently attempt to redirect her and ask her to wear the mask. She was not observed to keep the mask on. At 2:50 p.m., the DON was observed to enter the facility. As she and another staff attempted to take their temperatures, an outside provider entered the facility. The provider asked them to allow her to sign in, then went on into the facility without taking her temperature or completing the screening process. At 2:55 p.m., resident #2 was observed self propelling his wheelchair in the hallway and to the lobby by the front entrance. He was observed wearing a surgical mask below his nose. The mask was observed to have been soiled. At 3:00 p.m., the DON stated they had received results of the COVID-19 testing on the residents and some of the staff. She stated the administrator, assistant administrator and ADON had all tested positive which left just her. The DON also stated she had to cover the shift and work the floor. The DON stated they currently had six residents in the facility who were positive for [MEDICAL CONDITION]. She stated two of them were wanderers. She continued to explain they had not made a plan for what they would do if residents who wandered were positive. The DON stated she was not sure she could have contained them because it would have gone against their rights. She was asked if she allowed residents, who were positive for [MEDICAL CONDITION], to wander around the facility putting others at risk, would that not have been against all the other residents rights to a safe environment. The DON stated she had not thought of it that way but yes. The DON was asked if the staff had been using PPE when caring for the residents who had COVID-19. She stated no, but they had it in the administrators office. At 4:42 p.m., a staff member was observed to have used the door code then walk into the facility without the screening process having been conducted. At 5:00 p.m., a staff member was observed as she assisted a resident in his wheelchair back into the facility after being transported. The screening process was not observed to have been conducted. At 5:15 p.m., PPE was observed to have been brought out to the hall. Staff had been working to designate a COVID unit for the six residents who were positive for COVID-19. Resident #3, who was negative for [MEDICAL CONDITION], refused to move from his room and would also remain on the unit. At 5:24 p.m., a staff member was observed to use the code to the front entrance and open the door for another staff member. The screening process was not observed to have been conducted. At 5:25 p.m., the DON was asked if the residents who returned from the hospital and residents who were new admissions had been quarantined to one area and monitored for 14 days due to their risk from outside exposure. She stated no. The DON was asked if the residents who received treatments outside of the facility, such as [MEDICAL TREATMENT], were on isolation precautions due to their risk from outside exposure. She stated they had two residents on [MEDICAL TREATMENT] but no, they had not been put on isolation precautions. The DON was asked if they had a plan for where they would provide a quarantined area in the facility. She stated no. Multiple residents were observed out of their rooms without masks on during observations on 05/06/20. At 6:33 p.m., after an enclosed unit was designated for the positive COVID-19 residents, staff was heard yelling in the hallway. They were attempting to redirect resident #1 back to the COVID unit. Staff was heard yelling in the hall to get the resident back to the unit. On 05/07/20 at 3:05 p.m., the DON arrived to the facility. The COO, who had been there for part of the day left the facility. The DON stated she had worked the night shift after she had covered the evening shift the day before and had just arrived for the day. At 4:05 p.m., the documentation of the education provided to the staff was reviewed. No dates or times of when the education was provided were documented. No signatures were provided confirming the education was received by the staff. There were 61 staff members on the list, 21 were documented as having received a phone call, seven no answer, one busy, one quit, 12 left messages, six were blank and 13 were documented as having received the education in person. No written documentation was provided to the staff regarding the education. At 4:12 p.m., the maintenance director was asked if he had received recent education. He stated last night, about all that. At 4:16 p.m., LPN #1 stated she had received education the night before regarding the isolation lock down and PPE. At 4:20 p.m., CNA #1 was observed to exit the COVID unit wearing a surgical mask, gloves, shoe covers and holding a bag of trash. She was asked if she had an N95 or higher-level respirator she wore when providing care to the residents who had COVID-19. She stated she had no idea about that, this mask was all they provided to her. CNA #1 proceeded to carry the trash, with the gloves and shoe covers still on, throughout the hallways and out the front door of the facility to dispose of the trash. At 4:25 p.m., the DON was asked if staff had been provided N95 masks and the PPE needed to protect themselves and the residents when providing care. The DON stated when the administrator had stated over the phone that he had the PPE ready to go she had assumed it was all there and had not checked it. She was asked if staff had been educated on PPE and the difference in the types of masks. The DON stated no, it was on her. At 4:30 p.m., CNA #2 stated, when the in-service was provided they said nothing about the masks. At 4:31 p.m., RN #1 stated he had little kids at home, he was very worried. At 4:32 p.m., LPN #1 stated, they were saying we would have to share the masks. She then stated, should they not have provided us with everything we needed to know. At 5:04 p.m., outside the unit, signs had been posted on the doors to indicate it was the COVID unit. Two CNAs were observed to have been working the unit. No signs were observed outside the room of resident #3 to indicate he was negative for COVID-19. At 5:06 p.m., CNA #1 stated they had not been provided any biohazard bags for soiled waste or cleaning and disinfectant supplies. At 5:17 p.m., CNA #1 was unsure about the care to have been provided to resident #3, who was negative for COVID-19 but had refused to move rooms and chose to remain on the unit. As she questioned how his care differed, CNA #3 stated she had not been made aware that resident #3 was negative or there was any difference in the care to have been provided to him. The staff had not been educated on the precautions to have been implemented when providing care, including the use of new PPE each time. At 5:30 p.m., the DON was asked if the same nurse was assigned to cover the regular hall and the COVID unit. She stated no, she (the DON) was to work the floor again. Multiple residents were observed out of their rooms without masks on during observations on 05/07/20. At 6:03 p.m., the DON stated, they did have a discussed plan for what they would have done. On 05/08/20 at 5:20 p.m., the DON was observed typing at her computer. She was asked if all the staff had been educated regarding the components documented in the plan of removal. She stated no, she was still typing it. She had worked until 1:30 a.m. and was back early this morning but had not been able to finish. The DON stated she was currently working the floor as the charge nurse. She was asked if anything had been signed by those who had been educated. She stated no. There were no other administrative staff in the building. At 6:02 p.m., the dietary cart was observed outside the doors of the COVID unit. The cart had multiple trays and Styrofoam dishware with partially eaten food on it. A resident was observed to approach the cart. As he went to touch the plates on the top of the cart the DON stopped him and he was redirected. At 6:06 p.m., in the COVID unit CMA #1 was observed wearing an N95 mask over his beard. The CMA was not wearing any eye protection. He was asked if he had been fit tested for the N95 mask. He stated no. He was asked if he had been educated to wear a face shield when providing care to a resident who was positive for COVID-19 until he was able to be tested . He stated no. CMA #1 was asked if he received any education on what to do with the dietary cart and trays following a meal, including discarding of the food and sanitizing the cart and trays before it left the unit. He stated the kitchen had told him to just push the cart outside the doors and leave it but he questioned it because of the possible contamination. At 6:10 p.m., RN #1 was asked if he was the only nurse on the schedule. He stated the DON would work the floor. The RN stated corporate could have sent the DON help but they do not. At 6:40 p.m., the DON stated she understood the importance of the education and how it was needed to provide appropriate and safe care to the residents. Multiple residents were observed out of their rooms without masks on during observations on 05/08/20.

Based on record review, and interviews, it was determined the facility failed to ensure two (#4 and #12) of five sampled residents who experienced a change in condition were assessed, monitored and had interventions implemented. Resident #4 had complaints of nausea, vomiting and abdominal pain for five days before notifying the physician. Resident #12 was assessed to have a weak thready pulse, no detectable blood pressure, temperature of 100 degrees Fahrenheit and had [DIAGNOSES REDACTED]. There was no documentation of thorough continued assessments with new and appropriate interventions for the change in conditions. Findings: 1. Resident #4 had [DIAGNOSES REDACTED]. The annual assessment, dated [DATE], documented the resident's cognition was moderately impaired, was able to understand others and could be understood. The resident had an ostomy and was always continent of bladder. The assessment did not indicate the resident had any pain. The care plan, documented he was at risk for adverse reaction related to polypharmacy. The interventions included Monitor for possible signs and symptoms of adverse drug reaction . fatigue, incontinence, agitation, lethargy, confusion .constipation, and gastric upset. The care plan also documented the resident was on [MEDICATION NAME], for [MEDICAL CONDITION]. The interventions included, .Suspect toxicity and report to the physician if any of the following occur: Anorexia, nausea, vomiting, diarrhea, or visual disturbances . A nurse's note, dated [DATE] at 1:42 p.m., documented, Res continues to have his [MEDICAL CONDITION] and [MEDICAL CONDITION] which are patent and intact. There are collection bags applied to his abdominal wall for waste collection which are near empty as of the time of this entry . Res continues to insist on taking care of and replace the items himself as needed .Will continue to observe. There was no documented assessment of the resident after the collection bag was noted to be near empty. A nurse's note, dated [DATE] at 9:42 p.m., documented, Resident continues to be on observation for his [MEDICAL CONDITION] and [MEDICAL CONDITION] which are both patent and intact. Resident refuses cares from staff for maintenance of these items, and insists on performing his own self cares. Resident c/o n/v since earlier this morning after breakfast, which he did not eat lunch. I informed CMA that resident needs something for n/v [MEDICATION NAME] given at 1600 (4:00 p.m.). The note was documented by LPN #2. A review of the MAR for ,[DATE], did not contain an administration record of [MEDICATION NAME] being administered on [DATE]. A physician's orders [REDACTED]. Prior to the [DATE] order, the [MEDICATION NAME] had been discontinued in ,[DATE]. A nurse's note, dated [DATE] at 10:31 p.m., documented, Resident continues to be on observation for his [MEDICAL CONDITION] which is patent and intact .Resident c/o n/v, [MEDICATION NAME] 4mg given PO this evening. A nurse's note, dated [DATE] at 11:09 p.m., documented, Resident continues to be on observation for his [MEDICAL CONDITION] which is patent and intact. Resident refuses cares from staff for maintenance of these items, and insists on performing his own self cares. Resident c/o n/v, [MEDICATION NAME] 4mg given PO this evening. A nurse's note, dated [DATE] at 2:00 p.m., documented, Res continues to have his [MEDICAL CONDITION] and [MEDICAL CONDITION] which are patent and intact. There are collection bags applied to his abdominal wall for waste collection which are near empty as of the time of this entry . A nurse's note, dated [DATE] at 9:32 p.m., documented, Resident continues to be on observation for his [MEDICAL CONDITION] which is patent and intact. Resident refuses cares from staff for maintenance of these items, and insists on performing his own self cares. Resident c/o n/v, and abdominal discomfort, which CMA gave him [MEDICATION NAME] 4mg given PO. The MAR for [DATE] to [DATE] documented [MEDICATION NAME] was administered only once on [DATE]. A nurse's note, dated [DATE] at 2:27 p.m., documented, Res continues to have his [MEDICAL CONDITION] and [MEDICAL CONDITION] which are patent and intact. There are collection bags applied to his abdominal wall for waste collection which are near empty as of the time of this entry . There was no documentation the facility completed an assessment of the resident's current condition of continued nausea, abdominal discomfort and low bowel output in the [MEDICAL CONDITION]. A physician's progress note, dated [DATE] at 2:10 p.m., documented, .Nursing reports resident denies, SOB, chest pain, N/V/D . The progress note was signed by the nurse practitioner. A nurse's note, dated [DATE] at 4:35 p.m., documented, Resident lying in bed with eyes open, which I asked resident how he was feeling he stated pain to his LLQ, which he rated a 5 with slight tenderness to touch, bowel sound is hypoactive. I noted green emesis in the trash can on the left side of his bed. B/P ,[DATE], P.77, T. 97.3, R.18 02 sat. 97% on room air. (Name deleted) N/P notified that resident state's he has n/v after breakfast in the mornings for several days. Received order for ultrasound of the abdomen to r/o impaction, labs for CBC,CMP, [MEDICATION NAME] spray for soreness to his throat for vomiting, which he is now hoarse, and also [MEDICATION NAME] topical gel 50mg/ml (1ML) and if resident has noted emesis is dark or old blood noted may send resident out this evening. ADON, notified of orders, which she suggested X-ray of Abdomen this evening. Mobil x-ray was notified, which I was informed resident needs to be NPO for 8 hours for an ultrasound, but they will be out to do the x-ray . The nurse's note did not indicate the nurse practitioner ordered an x-ray, but did order the ultra sound. The facility had identified a change in condition on [DATE] and did not notify the physician until [DATE], six days after the change was first noted. A physician's orders [REDACTED]. The physician also ordered [MEDICATION NAME] (a non narcotic pain medication) 50 mg every four hours as needed for pain. A second order, dated [DATE], entered by LPN #2, documented the resident was to have an x-ray of the abdomen to rule out an impaction. A review of the MAR for [DATE] and [DATE] documented the resident received one dose of [MEDICATION NAME] and one dose of [MEDICATION NAME] on each day. The resident rated the pain on [DATE] as 10 on a scale of 1:10; and 8 on [DATE]. There was no documentation the facility had completed the ultra sound as ordered by the N/P or regarding the change in order to an x-ray. An x-ray report, dated [DATE], documented, .history .stomach function .significant findings .abdomen x-ray .Mild to moderate colonic ileus. Moderate stool. No bowel obstruction. Bone soft tissue are unremarkable. A nurse's note, dated [DATE] at 11:36 p.m., documented, Resident continues to have his [MEDICAL CONDITION] and [MEDICAL CONDITION] which are patent and intact. There are collection bags applied to his abdominal wall for waste collection which are near empty as of the time of this entry. Resident continues to insist on taking care of and replace the items himself as needed. Noted no emesis this evening, but x-ray of abdomen was done and faxed, but I have no excess (sic) to receive report. A nurse's note, dated [DATE] at 2:50 p.m., documented, ARNP texted x-ray report for res this AM. ARNP ordered Fleets Enems's (sic) until clear. Order entry done, TARS printed off and placed into book, pharmacy faxed and called in the order. Fleets has not been delivered to the facility as of the time of this entry. Res has had no periods of emesis this shift. Res has remained in his room, in his bed, for the duration of this shift .refused to eat his breakfast and lunch meals. Res's 1100 hour FSBS done as ordered, but sliding scale insulin not given due to res's refusal to eat his lunch. Will continue to observe. The note was documented by LPN #1. A physician's orders [REDACTED].insert 1 unit rectally one time a day for constipation. Administer one enema PRN and repeat until clear then DC order. The order was given by the nurse practitioner. A nurse's note, dated [DATE] at 5:58 p.m., documented, Resident continues to have his [MEDICAL CONDITION] and [MEDICAL CONDITION] which are patent and intact. Resident continues to insist on taking care of and replace the items himself as needed. Noted no emesis this evening, awaiting for fleets enema from pharmacy. A nurse's note at 8:00 p.m., documented, Fleets enema given rectally as ordered with slight discomfort noted via resident which resident was positioned to his left side. [MEDICATION NAME] spray, 2 sprays given to the back of residents throat for hoarseness and topical [MEDICATION NAME] gel applied to bilateral wrist for nausea. No BM noted at this time, only small amount of tanish to brown liquid stool noted in [MEDICAL CONDITION] bag. A nurse's note, dated [DATE] at 2:24 p.m., documented, Administered fleet enema, resident tolerated well, resident alert and oriented, sleepy most of the morning, replaced [MEDICAL CONDITION] bag. no sign of distress. There was documentation the facility assessed the effectiveness/output following the administration of the fleet enema. A review of the MAR for ,[DATE], documented the resident was only administered a fleet enema on [DATE] and [DATE]. There was no documentation the facility assessed the resident to ensure he was cleared prior to the fleet enema being discontinued. A nurse's note, dated [DATE] at 3:00 p.m., documented, Res has laid in his bed for the duration of this shift. Res has his FSBS performed, but no insulin was administered by this nurse as res has refused to eat his breakfast and lunch meals. Res has appeared to have been asleep for most of this shift. No stool is showing as output in res's [MEDICAL CONDITION] bag. Res is ordered to be NPO after midnight as res is scheduled for an abdominal US in the AM. Will continue to observe. There was no documentation to indicate the facility assessed the resident after there was no stool output in the [MEDICAL CONDITION] bag, or notified the physician there was no output in the [MEDICAL CONDITION] bag, continued refusal of meals and the insulin not being administered. A nurse's note, dated [DATE] at 2:21 p.m., documented, Res has laid in his bed for the duration of this shift. Res has his FSBS performed, but no insulin was administered by this nurse as res is NPO this AM until abdominal US is completed. Res has appeared to have been asleep for most of this shift. No stool is showing as output in res's [MEDICAL CONDITION] bag. Will continue to observe. There continued to be no documentation of an assessment and the physician being notified of the absence of stool. A note at 7:42 p.m., documented, Resident in bed on the duration of the shift . There was no documentation of the resident's output at the time of the note. A nurse's note, dated [DATE] at 7:30 a.m., documented, Called to residents room by CN[NAME] Resident noted to be laying on his right side. Resident would not respond. Extremities cool to touch, however chest and abdomen were warm. No pulse noted. Resident noted to be a full code. Resident repositioned and CPR initiated immediately. [DATE] called and fire department arrived. Fire department took over CPR and intubated resident. Defibrillator attempted without success. EMS arrived on scene and stated to cease CPR . A review of the ADL sheets for ,[DATE], documented the resident's bowel incontinence should be checked once every shift. There was no documentation of any checks on 14 out of 27 shifts from [DATE] to [DATE]. On [DATE] at 8:10 a.m., a confidential interview was conducted with a resident. The resident stated Resident #4 had passed away and had been complaining of an upset stomach for over a week. On [DATE] at 1:45 p.m., LPN #1 stated the resident was not having bowel movements like he normally did. He stated he did not see any assessments of the resident which would include checking for bowel sounds. He verified the doctor was notified through the nurse practitioner on [DATE] and she had ordered an ultra sound. He stated an ultra sound could not be completed right away so an x-ray was done. He stated when the x-ray results were obtained the nurse practitioner ordered fleet enemas until the resident was cleared. He stated he did not see any assessments or documentation to indicate the resident had been cleared and the enemas could be discontinued. When asked about the number of fleet enemas the resident received, he stated two. After reviewing the resident's clinical record he stated, That's not good. The enemas should have been continued. He stated he did not see anything to indicate the resident's physician was notified of the nausea, vomiting and abdominal pain until six days after it had started. He then stated the physician should have been notified when the resident continued to have no bowel output after the fleet enemas had started. At 2:54 p.m., the DON stated the physician should have been notified prior to [DATE] when the resident started having little output, and abdominal pain with nausea and vomiting. She stated she would need to look and see if there were any additional assessments and would provide any documentation she had. She then stated the resident did have an x-ray, but she did not know there was an ultra sound ordered on [DATE]. She confirmed the ultra sound was never completed. On [DATE] at 9:40 p.m., the nurse practitioner stated she did not know the resident was having any problems of abdominal pain, nausea and vomiting until they called her on [DATE] in the afternoon. She stated when she was in to see the resident on the same day, the nurses did not report any problems. She stated she did not realize they did not complete the ultra sound as ordered and they should have. She reviewed the nurses notes about the [MEDICAL CONDITION] being empty with no signs of bowel movements and stated they should have contacted her because the fleets were no working. She then stated she did not know only two fleet enemas were administered. She stated the resident was ordered chlorseptic because his throat was sore from the nausea and vomiting. At 10:20 a.m., the DON stated all assessments and notifications would be in the nurses notes. She stated she had provided all documentation and assessments on the resident that could be found. She stated she would look again to see if there were any assessments for bowel sounds or additional information she missed. At 2:02 p.m., the DON stated she had nothing more to provide and the facility should have assessed the resident better. She stated she called to find out about the ultrasound once she knew, but it still was not completed. She then stated she did not find any documentation the resident had been assessed and was cleared prior to the enemas being stopped. At 3:55 p.m., LPN #2 stated the order for [MEDICATION NAME] was obtained after the resident was provided the medication. She stated the CMA stated he had some on the cart and the next day she realized there was no order. She then stated the order was obtained one day after the first dose was administered. She stated she did not assess the resident further because when he was having little to no output, she thought someone else had emptied the [MEDICAL CONDITION]. She then stated the resident had an x-ray instead of an ultrasound because she was told to get an x-ray. The LPN was asked if she consulted with the physician about the order for the x-ray. She stated she just put the order in the system and did not call. She confirmed the physician had not ordered the x-ray but she was told by the facility nursing supervisor to have it done. She stated the resident had been having a decline over the previous week and she thought he should have been sent out. She stated she did not notify the physician until there was a concern noted on [DATE]. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated [DATE], documented the resident was rarely/never understood; had modified independence in cognitive skills for daily decision making; required supervision with personal hygiene; and required extensive assistance with transfers, dressing, toileting and bathing. The care plan, last updated on [DATE], documented: ~[MEDICAL CONDITION] r/t history of chronic embolism and [MEDICAL CONDITION] .Signs/symptoms .of [MEDICAL CONDITION] are leg pain that is worse when standing or walking, leg swelling, warm/red leg . ~Altered Endocrine System .Monitor/document/report to MD - PRN s/sx of [MEDICAL CONDITION]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, slurred speech .s/sx of [MEDICAL CONDITION] .deep laboured breathing .stupor . ~Anticoagulation Therapy .Monitor/document/report to MD - PRN s/sx of anticoagulation complications .lethargy, SOB .sudden changes in mental status, significant or sudden changes in v/s . ~Altered Cardiovascular Status r/t Hypertension .Monitor/document/report to MD - PRN any s/sx .shortness of breath, excessive sweating, changes in cap refill, colour/warmth of extremities . A physician's orders [REDACTED]. A physician's progress note, dated [DATE], documented, .Per nursing, no issues or concerns .fair appetite with fluid intake .Respiratory: (-) dyspnea, (-) cough, (-) Cough productive of sputum, (-) Hemoptysis, (-) wheezing. Cardiovascular: (-) chest pain, (-) palpitations, (-) dyspnea at rest, (-) dyspnea with activity .Exam .lungs are clear . A nurse's note, dated [DATE] at 3:38 a.m., documented, .resting in bed with eyes closed, resp regular and non-labored .no s/s of acute distress . A nurse's note at 9:57 a.m. documented, The resident has been having fever with the temperature of 100 Fahrenheit .appears to be congested, with productive cough and tachypnea. Her blood pressure could not be measured because of febrile and thready pulse. Chest X ray has been requested . An untimed physician's orders [REDACTED]. A nurse's note at 3:00 p.m. documented, Results of chest x-ray findings the heart is normal in size and lungs are clear, no pleural effusion, no acute fracture or pneumothorax . A nurse's note at 8:58 p.m., documented, .resting well with eyes open respirations even and non-labored . A nurse's note dated [DATE] at 12:03 a.m., documented, .observed that the resident has labored breathing .took her last breath, then CPR started immediately. Called 911 . The resident expired in the facility. The clinical record did not contain documentation the resident had been fully assessed with [REDACTED]. The results of her vital signs were not documented in the clinical record. There was no documentation the resident's FSBS had been obtained/attempted. The clinical record did not contain documentation the resident was re-assessed/monitored, or the physician was notified for further instructions when the results of the chest x-ray were received at 3:00 p.m. On [DATE] at 2:30 p.m., a nurse's note, dated [DATE] at 9:57 a.m., was reviewed with LPN #3. She was asked if she had provided care for the resident. She stated, Yes. She was asked if she had notified the physician of the change of condition. She stated, I think I did, but I don't remember. LPN #3 was asked who ordered the chest x-ray. She stated, I called the x-ray facility to come. I consulted with other nurses and was told to call for the x-ray, that there was already an order. LPN #3 was asked when the resident was assessed/found to be congested, and had a thready pulses, were vital signs assessed. She stated, We tried. The pulse was thready and difficult to get. I didn't know their policy or protocol so I consulted with another nurse. The other nurse also tried to get the blood pressure and pulse and was not able to get it. LPN #3 was asked how/where the pulse was attempted. She stated, The wrist. She was asked why the resident was not sent to the hospital. She stated, I had that on my mind. I had been talked to by management and told by my supervisor do not do that so often. At 3:30 p.m., the DON was asked what protocol should have been placed for the resident's change of condition. She stated, We notify the physician and the family. She was asked where would the information be documented. She stated In the progress notes. The DON was asked what information would be expected of the nurses to report to the physician/provider. She stated the information given to the physician would be specific to what was going on with the resident. She was asked if the facility had standing orders, i.e. x-rays. She stated, We can't have standing orders. The DON was asked what occurred based on the notes, and referred to the note, dated [DATE] at 9:57 a.m. She stated, I knew she was not feeling well. The nurse does the assessment and vitals, then calls the doctor, gets an order and has the chest x-ray done. The doctor signs everything in PCC. The DON was asked how much assessment would be expected to be obtained with a change of condition. She stated, I would expect a pulse with an actual number, and another person to try to get the blood pressure. The DON was asked if she had ever told the nurses to not send a resident to an emergency department or hospital. She stated she had told them verbally to notify her before they send out a resident. If they were in the middle of a code situation, then do it and contact her after. She (resident #12) was not in a code. If they were calling the doctor and getting orders, it should be documented what they informed the physician. The DON was asked if the information would have been documented in another area. She stated I do not know where else it would be. The DON was asked if a follow-up should have been initiated and the physician notified when the chest x-ray was negative with consideration to the resident's [DIAGNOSES REDACTED]. She was asked if a chest x-ray would determine why a blood pressure could not be obtained. She had no comment. At 4:10 p.m., the DON stated she had no additional documentation of assessments or notifications.

On 10/10/19 at 4:45 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide supervision to prevent accident hazards. Resident #41 was admitted to the facility with an order to not consumve anyting by mouth and received all nutrition via a peg tube due [MEDICAL CONDITION] pneumonites related to the inhalation of food and vomit. The resident was a known wanderer seeking out food in residents room. The resident was observed entering a residents room undetected by staff and was consuming pretzels from a night stand. Staff were unaware of this until he had left the room and was found to have pretzels in his mouth. At 5:12 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility's failure to ensure an NPO resident who wandered the facility seeking out food was provided adequate supervision. On 10/10/19 at 5:39 p.m., the administrator provided the survey team with an acceptable plan of removal. The facility's plan of removal documented the following: Plan of Removal Place cited resident 1:1 until alternate placement can be found. Identify any other resident that wanders that is NPO. Re-educate all staff regarding supervision of wandering residents who are NPO and redirecting them from others rooms and food items. Re-educate all staff to notify administrator and/or DON of any resident who is NPO that is observed wandering into other residents room and/or obtaining food items. No staff will be allowed to work until re-education is complete. Completion-10/10/19 at 2200 (10:00 p.m.). On 10/14/19 and 10/15/19, interviews were conducted with a total of 18 employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and they understood the information provided. The resident was observed to have 1:1 staffing on both days. On 10/15/19 at 9:45 a.m., the DON informed the IJ had been removed as of 10/10/19 at 10:00 p.m. The deficient practice remained at a level of potential for harm at a pattern. Based on observation, record review and interviews, it was determined the facility failed to ensure an NPO resident who wandered the facility seeking out food was provided adequate supervision for one (#41) of two sampled residents reviewed for accident hazards. Resident #41 was admitted to the facility and not able to have anything by mouth and received all nutrition via a peg tube due [MEDICAL CONDITION] pneumonites due to inhalation of food and vomit. The resident was a known wanderer seeking out food in residents room. The resident was observed entering a residents room undetected from staff and was consuming pretzels from a night stand. Staff were unaware of this until he had left the room and was found to have pretzels in his mouth. The facility identified one additional resident who was NPO and wandered the facility. Findings: Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Transdisciplinary Screen, dated 03/27/19, documented, .[DIAGNOSES REDACTED].no fluids by mouth . A care plan, updated 05/12/19, documented, Focus .5/12/19 The resident has, a behavior problem r/t trying to eat off peers meal trays. The resident has a peg tube and is NPO until evaluated by speech therapy Goal The resident, will have no evidence of behavior problems by review date interventions .anticipate and meet needs .assist resident to develop more appropriate methods to express feelings appropriately .If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. A care plan, dated 05/15/19, documented, Focus The resident has a swallowing problem r/t Swallowing assessment results .Goal The resident will not have injury related to aspiration .Interventions .10/14/19 Eternal feed order as needed .All staff to be informed of resident; special dietary and safety needs .Monitor for shortness of breath, choking, labored respirations, lung congestion . A quarterly assessment, dated 06/18/19, documented the resident's cognition was severely impaired and received all nutrition via a bolus peg tube. The assessment further documented the resident required one person extensive asssistance with transfers and was able to get around on his own in the wheelchair. The assessment documented the resident had [DIAGNOSES REDACTED]. The assessment did not document the resident wandered the facility and he had no behaviors. A physician's progress note, dated 07/03/19, documented .07/03/19 .Patient is not adhering to n.p.o. status. Patient cannot eat whatever he wants whenever he wants, patient currently has PEG tube and PEG tube feedings . A nurse's note, dated 08/06/19 at 10:12 p.m., documented, .Resident up in w/c most of the shift, Resident had to be redirected multiple times to stay out of other residents room . A history and physical note, dated 08/09/19, documented, .PMHx .[MEDICAL CONDITION] affecting right dominant side, [MEDICAL CONDITION], severe protein calorie malnutrition, [DIAGNOSES REDACTED], pmeumonitis for inhalation of food . A nurse's note, dated 08/12/19 at 9:07 p.m., documented, .resident continue with bolus feeding of TWO cal formula and flushes as directed. peg tube patent, no vomiting, HOB elevated. peg tube site cleaned and apply dry dressing. resident up on wheelchair and continue to go into peers room and searching for food to eat. continue to redirect resident about his NPO status . A care plan focus, dated 08/17/19, documented, Resident has a behavioral hx of digging in trash and attempts to eat items in trash, removing items from other peers' rooms Focus .Resident has a Peg tube for all nutritional and medication needs. Resident has orders for 2 cal hn 4x daily with 175 ml flush. A nurse's note, dated 08/23/19 at 11:21 p.m., documented, .continue to redirect resident out of peers room and on his NPO status . A care plan focus, dated 08/23/19, documented, continue to redirect resident out of peers room and on his NPO status . A nurse's note, dated 08/30/19 at 6:35 p.m., documented, .Late Entry: Note Text: Head to toe assessment: Resident AOx1, unable to make needs known . Assisted by staff with transfer and able to propels self in w/c . wander along hall way and into other residents rooms, redirected by staff . A nurse's note, dated 08/31/19 at 12:54 p.m., documented, .resident up on wheelchair, continue to wander into peers room, continue to redirect resident . A behavior note, dated 09/22/19 at 4:00 p.m., documented, .During rounds resident found in his bed with a empty coffee cup. Unknown if resident obtained this cup with fluids in it or not. Resident does have a slight cough & trying to move some phlegm out of his throat area. Resident shows no s/s of distress noted at this time. A second behavior note at 6:27 p.m., documented, .Resident found in his room up in w/c with his back to the door. Nurse noted that resident was eating chips from a bag. When nurse attempted to take the bag from resident he became upset. When nurse finally obtained the bag it was empty. Nurse is unaware if the bag was empty when he obtained it. Resident did not show any s/s of distress or choking. Moved resident into lobby area to be watched by staff. A nurse's note, dated 09/22/19 at 7:20 p.m., documented, . Peg tube focus charting continues. Resident cont on bolus peg feeding as directed with Two CAL,peg patent. peg site clean dry and intact and care done as directed and resident tolerated well. Assisted by staff with ADL. Resident up in w/c most of shift ambulating through out hallway. A nurse's note, dated 09/24/19 at 11:04 p.m., documented, .Res remains on a check and change Q2 hours and PRN. Res continues to self ambulate in his WC ad lib and mostly goes into other res's room in search of food and fluids to drink. Redirection minimally effective. Will continue to observe. A nurse's note, dated 09/27/19 at 8:27 p.m., documented, .resident continue to go into peers rooms and eat off their dinner tray, continue to redirect resident on NPO status . A nurse's note, dated 09/28/19 at 11:42 a.m., documented, . resident continue to go into peers rooms and eat off their meal tray, continue to redirect resident on NPO status . A social service note, dated 09/30/19 at 10:12 a.m., documented, .Resident continues to be a full code status. Resident is on a NPO diet and gets all nutrition via peg tube. Resident is wheelchair bound and is able to propel himself. No social service needs at this time. The Behavior Monthly Flowsheet for 09/2019, documented the resident roams from room to room seeking food. The resident had these behaviors documented 27 times from the 21st through the 30th. A history and physical note, dated 10/02/19, documented, .Exam .GI +BS, nontender to palpation, peg tube . A nurse's note, dated 10/02/19 at 1:40 p.m., documented, .Res continues to self ambulate in his WC ad lib during the day time. He mostly goes in and out of other's rooms in search of food and drinks to orally consume . Res continues to be on a check and change Q2 hours and he is repositioned while in bed as well. Will continue to observe. The Behavior Monthly Flowsheet for 10/2019, documented the resident wandered looking for food. The resident had these behaviors documented nine times from the first through the tenth. On 10/10/19 at 3:30 p.m., the resident was observed in his wheelchair self propelling himself down hall 100 near room [ROOM NUMBER]. There were no staff observed on the hall. The resident propelled himself into the room, got his wheelchair caught on the edge of bed A and then proceeded to the night stand. The resident took a container of mini pretzels off the night stand closest to bed A, opened them and started eating them. The door to the room was open and the resident was visible from the hall. At 3:37 p.m., the resident continued to be in the room eating the pretzels as LPN #2 walked by the room down the hall to an adjacent room. She then turned back and went by the room a second time. The nurse did not look in the room each time she went by. The resident remained in the room eating the pretzels. At 3:39 p.m., the resident put the lid back on the container of pretzels and placed it on the floor. He then started to propel himself to the doorway to exit the room. As the resident was almost to the door another resident went by looked in and saw him and shouted very loudly, You are not allowed in there, you need to get out. She repeated this several times then went to the nurses station telling a CNA the resident was not to be in the room. By the time the resident had told the CNA the resident had propelled himself out the door and was going towards the nurses station. The CNA was over heard telling the concerned resident that Resident #41 was not in the room he was in the hallway. The CNA did not investigate the concern of the resident. Two CNAs and LPN #2 were then observed to come down the hall passing the resident outside the doorway and did not stop to check on the resident and/or redirect the resident away from the room. At 3:42 p.m., the ADON approached the resident who was having a hard time propelling himself down the hall through the double doors outside room [ROOM NUMBER]. She was talking to the resident and was assisting him. At 3:46 p.m., the ADON said very loudly, You can not have those. She then attempted to swipe his mouth in attempts of getting the pretzels out. The resident was pulling away and resisting the ADON. The administrative assistant came by as the ADON continued to make attempts at getting the pretzels and stated, You dropped most of them down the hallway. At 3:47 p.m., the DON approached the resident and said she wanted to listen to his lungs and attempted to get the resident to comply with going back to his room to be checked. The resident refused several times as the DON repeatedly stated she needed to check his lungs. The resident finally agreed and allowed her to take him back to his room. At 3:50 p.m., the ADON stated the resident could not have any food because he was an NPO peg tube feeder. She was asked where the pretzels came from. She stated, I have no clue where he got the pretzels from. When asked if he had a history of [REDACTED]. At 3:54 p.m., the DON was observed talking with the resident in the room. She stated over and over to the resident he could not do that (get food and eat it) because he could get pneumonia. She then stated to the resident he could get very sick and he responded he had pneumonia. At 3:57 p.m., the resident then pulled out some pretzels that were in his wheelchair seat and attempted to eat them. The DON got the pretzel from the resident and cleaned off the remaining ones in the seat of the wheelchair. She placed the pretzels into the residents trash can, checked his lungs, washed her hands then left the room. At 3:59 p.m. the DON stated the resident had a stroke and it affected his swallowing. She then stated all he wants to do is eat. She stated he had a swallow study that he did not pass and he can not have anything by mouth. She then stated, Once in a while he will go around and if it is accessible (food) he will grab it and eat it. She then stated she has gone over the risk and he repeated them back to her. She was asked where the resident received the pretzels from. She stated, I don't know where he got them from, they just told me he has them. She then stated the resident was NPO and that she was not sure if he had any problems with aspiration. At 4:05 p.m., LPN #2 stated she did not know the resident was in room [ROOM NUMBER]. She stated she was the charge nurse responsible for the room. She then stated she was not aware of the resident having any food or that there was a problem with him having food. At 4:50 p.m., CNA #1 stated the resident looked for food because he was NPO. She then stated he will seek out food throughout the whole facility, but was not aware of anytime the resident actually wandered in a resident's room and got food. She then stated she was not aware of the resident being in room [ROOM NUMBER] and getting pretzels from the room. She confirmed she was working on that hall and never saw the resident in the room when she passed by. She then stated she was the person who told the concerned resident he was not in the room because he was in the hall. When asked if she ever checked on the resident after being told he could not be in the room. She stated the resident did not have to be closely supervised and was checked on like all other residents. She then stated she was not normally working on the hall or with resident #41 and did not know to watch him closely. At 4:50 p.m., LPN #4 stated he knew resident #41 wandered the halls and always seemed to know where he was going. The nurse then stated he never had any complaints of him wandering into other rooms and did not think he would. At 4:57 p.m. LPN #3 stated the resident had a peg tube and wanders the facility. She then stated the resident will go in and take other resident's food and he knows where to go and get the food. She then stated the resident was not monitored closely when on her hall and that she did not know about the other halls. At 4:57 p.m., CNA #2 stated she works on hall 200 but she knew of a man from the North hall (Resident #41) that went in and out of resident's rooms. She then stated she did not know why he was going into the rooms.

On 04/03/19 at 1:04 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) related to the facility's failure to provide supervision and protection from resident to resident aggressive behaviors for one (#26) of one sampled resident who had aggressive behaviors. The clinical record documented eighteen occurrences of the resident's aggressive behaviors between 01/31/19 and 04/03/19. At 1:28 p.m., the facility administrator and director of nurses (DON) were notified of the IJ situation and were asked to provide a plan of removal. At 2:06 p.m., the administrator provided an acceptable plan of removal. The facility's plan of removal documented: Plan for removal of immediacy for IJ Cited resident placed on 1:1 (one staff member was assigned to stay with the resident at all times). Cited resident will be sent out to (Local hospital) for psych (psychiatric) eval (evaluation). Cited resident will be 1:1 upon her return indefinitely. Education will be provided to the staff regarding cited resident being 1:1 upon her return. No oncoming staff will work until inservice is complete. A review of current residents that have had aggressive behaviors in the past 30 days will be evaluated for further intervention. Completion: 4/3/19 at 5pm. On 04/04/19 at 10:10 a.m., the administrator was informed the IJ had been lifted, as of 04/03/19 at 5:00 p.m. after interviews were conducted with nine facility staff and the facility documentation was reviewed to indicate the plan of removal was completed. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, record review and interview, it was determined the facility failed to provide supervision and protection of residents to prevent aggressive behaviors exhibited by one (#26) of one sampled resident who displayed aggressive behaviors. The administrator identified one additional resident who had exhibited aggressive behaviors in the past 30 days. The census for the facility on 04/02/19 was 106. Findings: Resident #26 had [DIAGNOSES REDACTED]. The care plan, dated 10/09/18, documented the resident had behavior problems related to aggressive and verbal behaviors. Interventions included: ~ Report episodes of escalating behavior to the nurse for immediate intervention - 10/11/18; ~ Document escalating mood/actual behavior and report to the psychiatric consultants - 10/11/18. ~ Initiate 1:1 for behaviors as needed for [MEDICAL CONDITION] - 10/11/18; ~ Assist the resident to develop more appropriate methods to express feelings -01/09/18; ~ If reasonable, discuss the behaviors with the resident. Explain/reinforce why the behavior was inappropriate and/or unacceptable - 01/09/18; ~ Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert her attention, remove her from the situation and take to an alternate location - 01/09/18; ~ Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes -01/09/18. The annual assessment, dated 01/04/19, documented the resident's cognition was severely impaired, was independent with ambulation, the resident's behaviors put the resident and others at significant risk for physical injury and significantly intruded on the privacy and activities of others. An incident report, dated 01/31/19 at 11:35 a.m., documented the resident was observed to walk up to resident #28 and hit her on her left upper arm while the resident was seated in the dining room. A handwritten note at the bottom of the page documented an intervention to encourage resident #26 to eat in her assigned dining room. A psychiatric physician's progress note, dated 01/31/19, documented the resident was starting to hit residents and staff again. On 01/31/19 the care plan was updated with place the resident on close observation and redirect if the resident becomes hostile. An incident report, dated 02/14/19 at 1:10 p.m., documented a nurse observed the resident walking down the hallway. The resident balled up her fist and started hitting another resident who was confined to a wheelchair. The nurse attempted to redirect the resident to her room but the resident refused to be redirected and ran away from the staff member. The hand written interventions at the bottom of the page documented to provide 1:1 and to contact the resident's psychiatric consultant. An incident report, dated 02/15/19 at 10:40 a.m., documented resident #8 reported the resident had approached him while he was seated in his wheelchair in the hallway and hit him on his left shoulder. The nurse documented she had observed the resident backing away from residents #8 and #27 and leaving the area. The report also documented resident #26 yelled threats and profanities at resident #8 and resident #27 during the assault. No new interventions were documented on the report. An incident report, dated 02/17/19 at 11:24 p.m., documented the resident had entered another resident's room and was attacking the resident. The report documented the nurse attempted to remove the resident from the other resident's room when the resident started hitting the nurse multiple times. One of the blows hit the nurse's nose which caused it to bleed. The report documented 911 was called and the resident was transferred to a local emergency room . The hand written interventions at the bottom of the page documented to provide 1:1 and to contact the resident's psychiatric consultant. An incident report, dated 02/18/19 at 6:37 p.m., documented the resident entered the room of resident #27 and started kicking her. The report documented the resident was told to stay in her room. No new interventions were documented on the report. An incident report, dated 02/18/19 at 7:09 p.m., documented there was an incident in the room of resident #5. The only documented information on the form was there were no injuries. No new interventions were documented. The clinical record contained no additional information about the incident. An incident report, dated 02/18/19 at 10:39 p.m., documented a resident to resident incident occurred involving resident #26. The report contained documentation of no injuries: however, no additional information or new interventions were documented. The clinical record contained no additional information about the incident. An incident report, dated 02/22/19 at 7:45 a.m., documented a nurse heard shouting and yelling. When she checked on the outburst she was told resident #26 had entered another resident's room; when resident #26 was asked to leave the room she attacked the other resident. The report documented the other resident was noted to have bruising and complained of pain to her left eye. The hand written interventions on the bottom of the page documented the resident was moved to a different room on another hall, staff were to contact the resident's psychiatric physician and anticipate the resident's needs. A psychiatric progress note, dated 02/26/19, documented, Nursing staff reports the resident continues to hit staff and peers for no reason. She was sent out on 02/15/19 for hitting two other residents but came back almost immediately. Continue to titrate her mood stabilizers interchangeably. With her [MEDICAL CONDITION]'s disease progressing rapidly, it is unclear how effective medication changes will be for behavior issues. An incident report, dated 03/11/19 at 1:50 p.m., documented a resident to resident contact, which involved resident #26, had occurred in a hallway. The report also documented the resident was transferred to a local emergency room . The hand written interventions on the bottom of the page documented to place resident #26 on 1:1, redirect as needed, and contact the resident's psychiatric physician. A nurse's note, dated 03/11/19, documented resident #5 was leaving a friend's room when resident #26 came up to her and started hitting her. An incident report, dated 03/14/19 at 1:00 p.m., documented resident #26 had hit another resident in the dining room. The report also documented the resident was put on 1:1, 911 was called and she was transported to a local emergency room . The hand written interventions on the bottom of the page documented to inform the psychiatric physician, redirect and obtain a psychiatric evaluation. Another incident report, dated 03/14/19 at 3:00 p.m., documented the resident had hit resident #29 while they were in the lobby. No new interventions were documented and there was no documentation regarding if the resident was still on 1:1. A nurse's note, dated 03/14/19 at 3:56 p.m., documented the resident had been transferred to a local emergency room at 3:35 p.m. An incident report, dated 03/19/19 at 3:35 p.m., documented the resident was in the dining room and started hitting a staff member multiple times. The typed interventions on the report were to place the resident on 1:1 and send her to a local emergency room for evaluation. The hand written interventions at the bottom of the page documented to redirect and inform the psychiatrist of behaviors. An incident report, dated 03/21/19 at 8:00 a.m., documented the resident had entered the hallway with no clothing on the lower half of her body. When the nurse attempted to redirect the resident, she started hitting the nurse multiple times. The resident was transported to a local emergency room and the mental health physician was notified. The report documented the psychiatrist issued a new order for a medication change. An incident report, dated 03/21/19 at 10:17 p.m., (no documentation if this was a late entry) documented during dinner resident #26 hit another resident. The resident was redirected back to her hall/dining room away from the other resident. The typed interventions on the report documented staff were to redirect away from other residents when signs and symptoms of agitation were present and develop a one on one activity plan. The hand written interventions at the bottom of the page documented to create activity plan, notify psychiatric services, and monitor behaviors. An incident report, dated 03/25/19 at 1:00 p.m., documented the resident entered the dining room, approached another resident and started hitting her. The resident was sent to a local emergency room for evaluation. The hand written interventions at the bottom of the page documented; 1:1, notify the psychiatric consult for behavioral evaluation. An incident report, dated 03/26/19 at 8:46 p.m., documented the resident approached another resident in the hall way and began hitting her. The hand written interventions at the bottom of the page documented nursing staff intervened, 1:1 and redirected. An incident report, dated 03/30/19 at 11:15 a.m., documented the resident started hitting a nurse multiple times, even as the nurse was moving away from the resident. The nurse was hit on her arms, head, and face. Her glasses were knocked off her face. The report documented a new order was received from the psychiatrist to increase the dose of one of her medications and to send the resident to a local emergency room for evaluation due to hitting another resident. The report documented the resident returned at 12:50 p.m., with no new orders. The hand written interventions at the bottom of the page documented 1:1, psychiatric behavioral services and medication evaluation. An incident report, dated 04/01/19 at 8:30 a.m., documented the resident entered a resident's room and started hitting the two residents who resided in the room. The resident's were struck multiple times in the face, head, chest and back. The resident was observed running out of the residents' room. The report documented the resident was transported to a local emergency room for evaluation and treatment. The resident was returned to the facility at 1:20 p.m. with no new orders. The report also documented the psychiatrist issued a new order to increase the dose of a mood stabilizer medication. The hand written interventions at the bottom of the page documented to place on 1:1 for 2 hours then reevaluate, notify psychiatric consultant for medication changes, and to send to a local emergency room . On 04/02/19 at 9:00 a.m., residents #27 and #5 were interviewed. They stated resident #26 had been very aggressive. They added the resident had entered their room yesterday (04/01/19) morning and attacked both of them. They stated they were yelling for help. Staff intervened and removed the resident to another area. They stated they have been told, by staff, to stay in their rooms; but, that doesn't help because the resident enters their room, verbally threatens to kill them, and hits them. They further added they had told the director of nurses (DON) and the administer but no one had done anything about protecting them from the resident. Resident #5 was observed to be a double above the knee [MEDICAL CONDITION]. Both residents stated they were dependent on a wheelchair for transportation. During the interview it was observed the resident was pacing back and forth in the hall outside the room. She would look in every time she walked by the door. The resident was ambulating independently without supervision. At 9:30 a.m., the DON was interviewed about the resident's aggressive behaviors. She stated the resident had a history of [REDACTED]. She added they had tried everything to prevent the behaviors. She stated the resident had entered a residents' room yesterday (04/01/19) and had started hitting both of the roommates. A nurse's note, dated 04/02/19 at 12:45 p.m., documented a nurse witnessed the resident hit resident #27 four or five times in the back while the resident was seated in her wheelchair. The note documented the resident was redirected to sit down at the dining table. At 3:10 p.m., resident #27 reported that earlier today, at 2:00 p.m., she was at the nurses' station talking to the charge nurse when resident #26 came up behind her and started hitting her in the back. The resident added the staff started watching the resident after that. The resident said, I'm uncomfortable leaving my room. I can't even have a conversation with my nurse, we aren't safe anywhere, but she can go anywhere and do anything. That isn't fair. They don't do anything to protect us. At 3:45 p.m., resident #5 was asked if she was afraid of the resident. She said, Oh yes! Everyone is. At 3:47 p.m., resident #30 was asked if he had seen another resident hit other residents. He stated he had but he was not afraid because she only hit residents that were weaker than she was. At 3:49 p.m., resident #8 was asked if he had seen another resident hit other residents. He stated he had but he was not afraid because if she came near him he would deck her. At 3:50 p.m., the activity director was asked if she had ever seen resident #26 hit other residents. She stated she had. She was asked if it had been effective to try to counsel the resident on more appropriate ways to express her feelings. She stated it was not; all you could do, to protect others, was to physically remove her from the area. She was asked if activities provided a diversion for the resident. She stated the resident was not able to focus well enough to participate in activities. At 4:02 p.m., the administrator and corporate nurse were interviewed about the resident to resident aggression. They stated resident #26 was currently on 1:1. They were asked how long the resident would be on 1:1. They stated the resident would be on 1:1 for two hours then they would reevaluate her and if she was not exhibiting behaviors they would remove the 1:1. They were asked what they were going to do to protect the other residents. They stated they didn't know what else they could do; they added mental health services had advised them the resident was maximized out on her medications; we have changed her to a private room; and we have gone through all of the interventions. They stated it didn't do any good to send her to the hospital for evaluation because the resident would be sent right back; no other facility will accept her. They were asked if they had conducted an investigation and/or evaluation in an effort to determine what causative factors would exacerbate the resident's behaviors, per the care plan intervention. They stated they didn't know what would set her off. They stated they are in the process of scheduling a care plan meeting with mental health providers, the resident's private physician, the resident's daughter and the facility staff: however, they were having trouble getting everyone's schedule coordinated. At 4:30 p.m., CNA #2 was observed providing 1:1 with the resident. He was asked if he had been advised about why he was providing 1:1 for the resident. He stated he had not been informed but he knew the resident had a history of [REDACTED]. He was asked if he knew how long the resident was to be placed on 1:1. He stated he didn't know. He was asked if anyone had advised him of interventions to be initiated. He stated he was told to keep an eye on the resident and get her to her room if necessary. He was asked if other residents were afraid of the resident. He stated on one occasion he had observed a resident leave the dining room and she had stated she was afraid of the resident and would not return to the dining room until the resident was gone. He stated he was new to the facility and did not know the name of the resident who left the dining room. On 04/03/19 at 8:07 a.m., resident #27 stated she was visiting with the laundry supervisor in the hall, when resident #26 came up behind her and started hitting her on the back. The resident stated the laundry supervisor tried to redirect resident #26 but resident #26 turned on her and started hitting her in the face. She stated staff intervened and removed the resident from the area. At 8:09 a.m., charge nurse #2 was interviewed. She stated she had heard shouting coming from down the hall; she walked toward the shouting and saw resident #26 walking away from resident #27 and the laundry supervisor. Resident #26 was removed to her room and a certified nurse aide (CNA) was assigned to stay with her. She was asked how long the resident would been on 1:1. The nurse stated the resident would be reevaluated at the end of two hours. She stated resident #27 and the laundry supervisor were assessed for injuries; she stated no injuries were noted. She added she phoned the psychiatric consultant and lab tests were ordered. No additional orders were given. The charge nurse was asked if the resident was on 1:1 at the beginning of her shift. She stated she was not. She was asked what interventions had been initiated to prevent the resident's behaviors. She stated snacks were offered, activities weren't effective, and the resident would be placed on 1:1 when behaviors occurred. She was asked if verbally counseling the resident about her behaviors was effect during a behavior. She said, It was not. It is like she is in her own zone. I've been hit trying to redirect her. She added she had told other residents to stay in their rooms and to stay away from the resident when she was roaming around. At 8:15 a.m., the laundry supervisor was interviewed. She stated she was standing in the hall, outside the laundry room visiting with resident #27, when resident #26 walked up behind resident #27 and started hitting her. She added she tried talking to the resident; asking her not to hit the resident; and trying to calm her down. She stated the resident turned on her and started yelling profanities hitting her in the chest. She further stated staff members had to redirect the resident to a different location. A nurse's note, dated 04/03/19 at 8:49 a.m., documented the psychiatrist was notified of the resident's behavior this morning. New orders were issued to obtain lab tests. The note also documented the physician was informed the resident had been placed on 1:1 for 2 hours and then was to be reevaluated by a nurse. At 9:37 a.m., resident #29 was asked if she was afraid of any of the other residents. She stated she was afraid, very afraid, of resident #26. She was asked how the facility protected her from the resident. She stated they don't; she isn't protected; a guy at my table made sure she did not hit me anymore. She did not provide information as to how the male resident had provided protection. At 10:30 a.m., CNA #4 was asked if other residents were afraid of resident #26. She identified five residents who were afraid of the resident, she added maybe more. The CNA stated the resident will just walk up to other residents and start hitting them, for no reason. She added the facility had not advised her of any interventions to protect the other residents. She stated she had advised the other residents to stay away from the resident. I don't know what will set the resident off. She further added that resident #5 will ask her to get ice from the ice chest, located at the nurses' station, because the resident was afraid the resident would be in the area. We have been told to redirect resident #26, give her a snack, and take her to her room when she has behaviors.

Based on record review and interview, it was determined the facility failed to ensure staff correctly transferred a resident to prevent a fall with injury for one (#6) of three sampled residents reviewed for falls. The facility identified 14 residents who required a lift for transfers. Findings: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 10/23/18, documented the resident's cognition was moderately impaired, required extensive assistance with transfers. A nurse's note, dated 11/21/18 at 3:20 p.m. documented, Incomplete documentation .RESIDENT FAMILY VISITING LAST PM AROUND 1800 (6:00 p.m.) (RESIDENT #6) REQUESTED CNA (certified nurse aide) TO GET BEDPAN BUT FAMILY WANTED HIM TO GET UP AND UTILIZE THE BSC (bedside commode). CNA GOT ASSISTANCE FROM CMA (certified medication aide) TO TRANSFER RESIDENT TO TOILET WHILE FAMILY WAIT IN HALLWAY. (RESIDENT #6) BECAME WEAK AND DEADWEIGHT PER CNA/CMA REPORT. THEY ATTEMPTED TO LOWER HIM TO HIS KNEES BUT WERE UNABLE TO HOLD HIS WEIGHT AND HE DROPPED ONTO HIS KNEES. CMA RETRIEVED NURSE, (name-deleted), AND THE THREE OF THEM HOISTED HIM UP AND INTO BED. CHARGE NURSE, (name-deleted) REPORTS HE HAD A PORTION OF SKIN THAT WAS SCUFFED FROM LEFT KNEE BUT JUST THE TOP LAYER. NO OPEN AREAS. HE REPORTED TO (name-deleted nurse), (PER CONVERSATION WITH NAME-DELETED NURSE) THAT ONCE HE WAS IN BED HE DID NOT HURT ANYWHERE. (Name-deleted nurse) REPORTED THAT SHE CHECKED ON HIM AGAIN AND HE DID NOT REPORT PAIN AND THERE WAS NO BRUISING OR REDNESS. A nurse's note, dated 11/21/18 at 3:30 p.m. documented, Late entry: At approx (approximately) 1800 (6:00 p.m.) I was called to Res. (resident) room where I found him on knees next CMA . A nurse's note, dated 11/21/18 at 10:11 p.m., documented, On 11/20/2018 called to the room of Resident by my CNA found resident on floor on knees and CMA beside him helped Resident in bed, noticed a couple of abrasions on knee area no bleeding, Resident stated he was better now that he was in bed and off floor. An investigation note, dated 11/21/18, documented an interview was conducted with the licensed practical nurse (LPN) present after the fall. The note documented the LPN noted the resident on his knees and some abrasion type areas were noted to both knees. The note documented a representative from the [MEDICAL TREATMENT] clinic was interviewed. The representative stated the resident did not appear to be feeling well and the residents left knee was noticeably swollen. The resident was sent to the emergency room for further evaluation. A nurse's note, dated 11/26/18 at 9:33 p.m., documented, Resident returned from (a local hospital) with immobilization brace for left distal femur fracture, will check q (every) shift for skin irritation . There was no documentation in the clinical record to indicate a thorough assessment was performed after the fall. There was no documentation a pain assessment or a fall risk assessment was conducted prior to the fall. There was no care plan provided which was developed before 12/06/18 to indicate the level of assistance with activities of daily living required by the resident. A final incident report faxed to the Oklahoma State Department of Health (OSDH), documented and incident date of 11/21/18 with resident #6. The report documented the resident received assistance of two staff members to transfer to a bedside commode. The resident was lowered to the floor. The preceding nurse nurse stated the resident did not complain of pain and slept well through the night. The report documented the resident was assisted to [MEDICAL TREATMENT] at approximately 9:30 a.m. and at approximately 1:00 p.m., the resident's daughter reported the resident complained of knee discomfort and [MEDICAL CONDITION] was noted. The staff were provided a training on proper transferring with the assistance of the therapy department and use of a non-mechanical lift. Another final report faxed to OSDH, documented an investigation was conducted for an injury of unknown origin and the incident date was unknown. The report documented the resident returned from the hospital on [DATE] where he had been since 11/21/18. The hospital reported the resident had a left distal femur fracture. The report documented the resident was sent to the emergency room due to the resident was not feeling well at [MEDICAL TREATMENT] and was complaining of knee pain. An X-ray was obtained which showed a left distal femur fracture. An interview was conducted with the [MEDICAL TREATMENT] center and was negative for any incident which occurred while he was there. The two staff providing the transfer were reeducated on transfer techniques and using the mechanical lift. The nursing staff were reeducated on reviewing the kardex before transferring a resident to provide proper technique. On 03/18/19 at 3:20 p.m., LPN #2 was asked how much assistance the resident required with transfers. She stated he was a two person assist or required a lift. She further stated she could not remember if the CNAs used a lift. On 03/19/19 at 8:45 a.m., LPN #1 was asked about the fall for resident #6. She reviewed the clinical record and stated there was no documentation the resident was assessed after the fall. The fall should have been documented in a health status note when it happened, what happened and the status of the resident. She was asked if she could locate a pain assessment or fall risk assessment which was completed on admission to the facility. She stated no. The LPN was asked what level of assistance the resident required. She stated he required a lift for transfers. He was very weak from the [MEDICAL TREATMENT] and was hardly able to transfer in the wheelchair. She was asked if an incident report had been completed. After reviewing the clinical record she stated she could not see one. The LPN was asked if she could locate in the clinical record any directions to inform staff of the level of care needed. She stated no.

Based on record review and interviews, it was determined the facility failed to ensure pain was sufficiently managed for one (#1) of three sampled residents who were reviewed for pain management. The facility identified 102 residents who resided in the facility. This resulted in the resident expressing suicidal ideation's and an admission to a geriatric psychiatric facility. Findings: Resident #1 had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 10/23/17, documented the resident had a potential risk for episodes of pain related to chronic pai[DIAGNOSES REDACTED]. Staff was to administer pain medication and evaluate the effectiveness of pain interventions. This was to include alleviating symptoms and the resident's satisfaction with the results. Staff was to identify, record and treat conditions which may increase pain or discomfort. They were to monitor, record and report any signs or symptoms of pain, including non-verbal pain such as mood changes or behaviors. An annual assessment, dated 10/27/18, documented the resident's cognition was intact and had pain almost constantly that had made it hard for him to sleep at night in the last 5 days, received an opoid medication for seven of seven days in the look back period. A pain assessment, dated 12/11/18 documented the resident stated he had pain which was almost constantly that made it hard to sleep at night and limited his day to day activities. A quarterly assessment, dated 01/27/19, documented the resident's cognition was moderately impaired, had frequent pain and received an opioid seven of the seven days in the look back period. A physician's telephone order, dated 02/26/19, documented the resident was to be administered a [MEDICATION NAME] 5% twice a day to his back. A pharmacy 'Order Fill History', documented an order date of 02/27/19 for the [MEDICATION NAME]. The pharmacy had responded a [DIAGNOSES REDACTED]. An order summary, dated 02/28/19, documented the order was changed to aspercreme/[MEDICATION NAME] 4% two times a day for back pain. A nurse's note, dated 02/28/19, documented the order for [MEDICATION NAME] was not applied because the medication was not in the facility. A nurse's note, dated 03/01/19 at 12:04 p.m., documented the resident was having suicidal ideation's related to not having an order for [REDACTED]. The facility was sending the resident out to be evaluated and treated as indicated for suicidal ideation. A nurse's note, dated 03/01/19 at 1:29 p.m., documented the resident was transported from the facility to a geriatric psychiatric facility for further evaluation. A pharmacy 'Order Fill History', dated 03/05/19, documented the medication order for the [MEDICATION NAME] was rejected due to requiring prior authorization. On 03/14/19 at 10:41 a.m., the assistant director of nursing was asked why the resident had suicidal ideation's on 03/01/19. She stated he was upset because his pain patches were not in. She was asked if anyone assessed him for pain when he had complaints of pain. She stated it looked like no one had, it was not documented.

Based on observation, record review and interview, it was determined the facility failed to ensure nutrition and fluids were administered as ordered via a percutaneous endoscopic gastrostomy (PEG) tube for two (#77 and #115) of three sampled residents who were reviewed for PEG feeding tube administration. This resulted in resident #77 being admitted to the hospital with [REDACTED]. The facility identified nine residents who received nutrition via a PEG tube. Findings: The facility policy for PEG tubes documented the PEG tube was to be flushed with 15 cubic centimeters (cc/ml) of water before, 5cc of water between medications and then 30 cc of water after the medications every shift. 1. Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan, dated 12/05/17, documented the resident was at risk for dehydration related to receiving all nutrition/hydration through the PEG tube. Interventions included to monitor and document the intake and output. A dietary note, dated 02/12/18 at 5:37 p.m., documented the resident was receiving [MEDICATION NAME] 1.5 @ 60 cc and hour and a flush of 40 cc of water which provided 2,040 cc of water for the tube feeding and flush only which meets 99% of her estimated fluid needs. A dietary note, dated 05/28/18 at 4:34 p.m., documented the previous two weights were questioned. The 05/2018 weight was more in line with the prior weights. There were no changes made to the tube feeding plan. The quarterly assessment, dated 09/13/18, documented the resident's cognition was severely impaired, received 51% or more calories and 501 cc or more fluid from the PEG tube. The physician's orders [REDACTED]. The resident was to receive 1,440 cc of [MEDICATION NAME] and 1,440 cc of free water in a 24 period to equal 2,880 cc/day. The intake record was reviewed. The intake was documented as follows: 09/01/18 - 1,960 cc 09/02/18 - 900 cc 09/03/18 - 2,640 cc 09/04/18 - 2,760 cc 09/05/18 - 2,600 cc 09/06/18 - 2,900 cc 09/07/18 - 3,000 cc 09/08/18 - 3,050 cc 09/09/18 - 2,100 cc 09/10/18 - 2,560 cc 09/11/18 - 2,560 cc 09/12/18 - 2,800 cc 09/13/18 - 2,800 cc 09/14/18 - 2,700 cc 09/15/18 - 2,800 cc 09/16/18 - 2,100 cc 09/17/18 - 2,500 cc 09/18/18 - 2,360 cc 09/19/18 - 2,360 cc 09/20/18 - 1,800 cc. A physician's progress note, dated 09/19/18, documented the resident was tolerating current medicines and treatments and the resident denied new symptoms or complications. A nurse's note, dated 09/20/18 at 9:11 a.m., documented laboratory results were abnormal and the primary care physician provided orders to send the resident to the emergency room for acute [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A hospital admission history and physical, dated 09/20/18 at 2:40 p.m., documented the resident was admitted with abnormal labs. The note documented the resident appeared to be severely dehydrated with a large free water deficit and will get dietary consult for tube feeding and free water. The note further documented the PEG tube was in place and did not appear to be well taken care of. A consultation report, dated 09/20/18, documented the reason for consultation was acute on [MEDICAL CONDITION] and [MEDICAL CONDITION]. The physician documented he was not sure what the feeding regimen at the nursing home was, but she looked clinically very dehydrated. The impression documented [MEDICAL CONDITION], acute kidney injury and unknown stage [MEDICAL CONDITION]. The plan documented to increase [MEDICATION NAME] water in the intravenous line, add water flushes through the PEG tube and consult with a dietitian for the feeding. A hospital discharge history and physical, dated 09/25/18 at 3:25 p.m., documented the dehydration with [MEDICAL CONDITION] had been resolved. The new diet after discharge would be [MEDICATION NAME] 1.5, five cans per day with a 210 free water flush after each can to be administered at 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m. and midnite .PATIENT MUST HAVE FREE WATER FLUSH WITH EACH CAN OF TUBE FEEDS . A nurse's note, dated 09/26/18 at 8:22 p.m., documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The note documented the tube feeding had changed to five cans of [MEDICATION NAME] 1.5 calories five times a day with 210 cc of free water flush after each feeding. The physician's orders [REDACTED]. The [MEDICATION NAME] carton documented 237 cc were in the carton. This would ensure the resident received 2,235 cc/day in fluid intake excluding fluid administered with medications. The intake sheet for 09/2018 documented the resident received the following fluid amounts in a 24 hour period: 09/27/18 - 2,047 cc 09/28/18 - 2,170 cc 09/29/18 - 2,150 cc 09/30/18 - 1,810 cc. The intake sheet for 10/2018 documented the resident received the following fluids in a 24 hour period: 10/01/18 - 2,560 cc 10/02/18 - 2,400 cc 10/03/18 - 2,430 cc 10/04/18 - 1,600 cc 10/05/18 - 537 cc 10/06/18 - 1,787 cc 10/07/18 - 2,040 cc 10/08/18 - 2,184 cc 10/09/18 - 2,330 cc 10/10/18 - 2,220 cc 10/11/18 - 2,450 cc 10/12/18 - 3,200 cc 10/13/18 - 1,420 cc 10/14/18 - 1,900 cc 10/15/18 - 2,100 cc 10/16/18 - 2,780 cc 10/17/18 - 2,000 cc 10/18/18 - 2,000 cc 10/19/18 - 1,200 cc 10/20/18 - 1,500 cc 10/21/18 - 1,920 cc 10/22/18 - 2,300 cc 10/23/18 - 600 cc. A dietary note, dated 10/06/18 at 6:56 a.m., documented the resident had a change in tube feeding and the registered dietician was not notified of the change in the tube feeding plan nor was a consult placed. The note documented the resident was to receive [MEDICATION NAME] 1.5, one can five times a day with a flush of 210 cc of water. The tube feeding will provide 1,950 cc for the tube feeding and the flush only plus receives additional water with medication. That will provide 2,400 cc of water meeting 100% of estimated fluid needs through tube feeding and flush only. On 10/23/18 at 7:44 a.m., the DON was asked if she had been asked to investigate the allegation of neglect concerning the tube feeding and flushes for resident #77. She stated she did. She was asked what type of investigation she conducted. She stated she investigated whether nurses provided PEG tube feedings correctly. She stated they were performing flushes before and after medications and one nurse was combining the feeding and flushes together. The DON stated she could not substantiate the allegation. She was asked for the documentation of interviews she conducted during her investigation. She stated she thought they were at home she would get them to us. The DON further stated she attempted to interview nursing staff that no longer worked at the facility. On 10/24/18 at 10:03 a.m., the DON was asked how much fluid the resident was to receive on a daily basis prior to her hospitalization . She stated if the pump was running at 60cc/hour, per the order, it would be a total of 1,440 cc in feeding. She stated if the resident received the 240 cc of flushes, it would be a total of 1,440 cc per day to equal 2,880 cc/day. The DON continued to state the resident was also to receive water with her medications, 15 cc before the medication, 5 cc between the medications and 30 cc after the medications. She stated looking at the treatment record, she was administered medication at least 5 times a day. The DON was asked what the total amount the resident should receive in fluids in a 24 hour period prior to her hospitalization . She stated based on the treatment record, if you count the medications, 3,395 cc per day. After reviewing the documentation, she was asked if the resident received her total fluid amount before the hospitalization in which she received a [DIAGNOSES REDACTED]. The DON provided documentation of the nurses who performed the administration of fluids. 09/28/18 1650 (4:50 p.m.) Conversation with registered nurse (RN) #2 .She was asked if she was familiar with resident. Yes of course, she was recently in the hospital for dehydration and altered mental status. Asked if she had any ideas about what might have caused dehydration. She was vomiting quite a lot right before she went to the hospital. Asked if she notified (Name-deleted physician), She stated Yes, a few times. Asked what he told her to do. give [MEDICATION NAME] check to make sure the HOB (head of bed) was up. Asked if HOB was always up: Yes, we always kept it around 45 (degrees) Asked if she ever did not give flushes. (RN #2) got offended and stated, Absolutely not! . (There was no documentation in the clinical record to indicate the resident had vomited.) A statement regarding licensed practical nurse (LPN) #1 documented, .She then administered crushed [MEDICATION NAME] via PEG followed by 15 ml water. Educated (LPN #1) on flushing with 30 ml of water after medication administration to clear the line of leftover residual powder . A statement regarding LPN #9 documented, .She states resident was vomiting frequently prior to hospitalization . She states [MEDICATION NAME] PRN (as needed) was being given. Resident with altered mental status the day sent to hospital, vomitus on gown in am. (10/20). Asked what she believes caused condition leading to hospitalization , she stated: I'm the the only one who gives the flushes. Asked her how she knows that: when I come on Monday the PEG tube has a lot of residual from feeding in it. It's not clear. Asked her if there was was any other factors she believed may have contributed to the residents dehydration: Her vomiting. Asked what she did about vomiting: I gave her [MEDICATION NAME]. Asked if she contacted (Name-deleted physician) about vomiting, she stated: yes, several times. I don't recall the dates. Asked what orders if any she received: continue [MEDICATION NAME]. Then the last day he said draw labs. Asked why X-Ray was obtained: I thought she might have aspiration pneumonia from the vomiting.Asked if she had told anyone other than (Name-deleted physician): NO.Asked if she told anyone of her suspicions of other nurses possibly not giving flushes: NO. then she retracted and said she complained about (name-deleted LPN) to everyone.Asked if she told (Name-deleted DON) she said NO. She never had time to listen . A documented note, dated 09/26/18 at 5:00 p.m., documented, Reviewed Hospital Documentation and resident chart. There is no documentation that would indicate a clear root cause of dehydration diagnosis. She does have a hx (history) of acute kidney injury. Chart shows being given [MEDICATION NAME] for nausea/vomiting pretty much daily. There is no documentation of conversation with PCP (primary care physician). There is some charting of PRN usage for N/V (nausea /vomiting) . On 10/24/18 at 11:32 a.m., LPN #9 was asked if she administered the free water flush every four hours as prescribed. She stated, yes she most of the time she administered the flushes with medications which were every four hours. She was asked if she documented the amount of fluids administered. She stated yes at the end of the shift. She stated she did not think the weekend staff were administering the free water flushes and she informed the DON. She was asked what the response was from the DON. She stated she did not say anything. The LPN was asked if she had any concerns with any other residents. She stated she would get report from the night nurse (LPN #10) who would inform her the feeding pumps for residents #77 and #115 would be off and not hooked up to the residents when she came on duty on Sunday nights. On 10/24/18 at 11:50 a.m., the physician was asked if he was informed the resident was receiving the as needed anti nausea medication on a daily basis. He stated no, he had ordered it as needed due to her [DIAGNOSES REDACTED]. The physician was asked if he was made aware the resident was experiencing vomiting prior to the hospitalization . He stated no, he sent her to the hospital due to the abnormal laboratory tests. He was asked if he was made aware the resident was not receiving the ordered amount of fluids each day. He stated no. At 1:11 p.m., the DON was asked how many milliliters (ml) were in the [MEDICATION NAME] carton. She stated there was 237 milliliters in the carton. At 2:44 p.m., the DON was asked how much fluid the resident was supposed to be administered via tube feeding and the flushes per day. After reviewing the clinical record, she stated she should be receiving 2,735 cc day. After reviewing the documentation of intake from 09/26/18 through 10/24/18, the DON was asked if the resident was currently receiving the correct amount of fluids on every shift. She stated, No. On 10/24/18 at 7:05 p.m., LPN #8 was observed to administer medications and the [MEDICATION NAME] via peg tube. LPN #8 was not observed to administer the 210 cc of free water after administering the medications and the [MEDICATION NAME] (tube feeding) as ordered by the physician. At 7:46 p.m., LPN #8 was asked if the resident had been administered all of her feedings for this shift. He stated yes. The LPN was asked to review the treatment administration record ( TAR) for the tube feeding and free water orders. He was asked why he did not administer the 210 cc of free water after administering the tube feeding. He stated today was the first time he had seen the order for the 210 cc flush. The LPN was asked if his initials were documented on 10/17/18 and 10/18/18 as having administered the [MEDICATION NAME] and the free water. He stated yes. He was asked since today was the first time he saw the order for the free water on the TAR, if he had administered the free water on those days. He stated, Honestly, probably not. 2. Resident #115 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 01/09/18, documented the resident had a peg tube for nutrition, hydration, medications and was to have nothing by mouth. The care plan documented the resident was dependent with tube feeding and water flushes and documented to follow the current physician's orders [REDACTED]. A physician's orders [REDACTED]. On 10/24/18 from 4:29 p.m. to 5:00 p.m., the resident was observed in his bed with the lights off. The tube feeding pump was turned off and unhooked from his PEG tube. One bag containing approximately 550 cc of [MEDICATION NAME] 1.5 and one bag containing approximately 350 cc of water was hanging on the pole. No staff members were observed providing care to the resident during this time. One staff member was observed stopping in the resident's doorway and looking in the room but did not provide care. At 5:03 p.m., LPN #8 was observed entering the resident's room. The LPN was asked if he was going to provide care to the resident. He stated yes. The LPN stated, For some reason his pump (feeding pump) is unhooked and turned off. The LPN checked for placement, checked for residual and flushed the peg tube before he hooked up the tubing and discovered the tubing was clamped. The LPN unclamped the tubing and primed the line and hooked up the tubing and started the pump. The LPN was asked what the numbers 2925 meant on the feeding pump. He stated that was the total volume infused and would be cleared during the night shift when they changed out the bags and syringes. On 10/25/18 at 11:09 a.m., the DON was asked why the resident's tube feeding pump was not hooked up and was turned off on 10/24/18. She stated she did not know why the tube feeding pump was turned off. She stated the certified nurse aide would put the pump on hold while they were providing care and the nurse would have to come back and turn the feeding pump back on. The DON was asked when the feeding pumps were cleared and the volume infused was recorded. She stated it should be done at the end of every shift. On 10/25/18 at 5:11 p.m., the resident was observed in the common area with visitors. He was not hooked up to his tube feeding pump.

On 09/26/18 an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision and interventions for a resident with a history of suicide attempts. The resident was admitted to the facility after an episode of depression and attempted suicide and had a history of [REDACTED]. At 4:55 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. At 5:12 p.m., the administrator, director of nursing (DON), the corporate nurse and the corporate representative were informed an IJ situation existed due to the facility's failure failure to provide supervision and interventions to prevent an attempted suicide for a resident with a history of suicide attempts. The resident was admitted to the facility after an episode of depression and an attempted suicide as well as had a history of [REDACTED]. At 7:20 p.m., an acceptable plan of removal was received from the corporate nurse. The plan of removal documented: Resident immediately placed on 30 minute checks by staff for 24 hours and continue to monitor hourly for new behaviors. Care plan updated to reflect past behaviors and current condition. Appropriate interventions per policy and procedure will be initiated as necessary when resident shows signs and symptoms of behaviors. Resident assessed by RN to assess for any suicidal ideation. All staff currently on duty in the facility will be educated face to face on Suicide Threat policy and procedure by 8:00 pm on 09/26/18. Remaining staff members currently being notified and in-serviced via phone call. Any remaining staff members that can not be reached at this time will be educated on this policy before being allowed to report to their shift for duty. Current nursing staffing reviewed and appropriate staffing is being provided to meet staffing and supervision needs and requirements. Sufficient staffing and supervision is reviewed prior to each shift for appropriate amount of staff to meet residents needs. If it is determined that current shift staffing is not appropriate- the prior shift staff members will remain on duty until the staffing and supervision level is deemed appropriate. Residents at risk for this same deficient practice will be identified by any change noted in behavior indicating self harm, will be addressed per physician order [REDACTED]. Compliance to be discussed in quality assurance meeting. Residents at risk will be identified through basic questionnaire to identify any immediate s/s (signs/symptoms) of depression and/or suicidal ideation. Concerns identified will be reported to the physician immediately. Consult for psychiatric evaluation Resident will be placed on one hour observation until resident is cleared by PCP (primary care physician) and/or physician. 09/27/18 at 5pm will be completed. Interviews were conducted with facility staff on 09/27/18. After the last staff member was interviewed and was able to verbalize knowledge of the facility's suicide policy and procedures and all questionnaires were reviewed, the IJ was removed on 09/27/18 at 11:12 a.m., when all inservices and questionnaires to identify potential residents had been completed. The deficient practice remained at an isolated level of harm. Based on observation, record review and interviews, it was determined the facility failed to ensure a resident with a known history of attempted suicide had adequate supervision to prevent further attempts of suicide for one (#5) of one sampled resident with a history of suicidal tendencies. The resident was left during an episode of breaking glass and was able to cut his wrist approximately three inches in length in an attempt to die. The facility did not identify any additional residents with a history of suicidal ideation's and or attempted suicides in the facility. Findings: A policy, titled Suicide Threats, documented, .Resident suicide threats shall be taken seriously and addressed appropriately .The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats .A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident .All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instruct to report changes in the resident's behavior immediately .As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated .Staff shall document details of the situation objectively in the resident's medical record . A History and Physical (H and P), dated 04/13/18, located in the clinical record for resident #5, documented, .source of information .the patient himself .as well as H and P dated (MONTH) 12. (YEAR) .reason for admission .depression and suicidal expressions . History of present illness .this patient is a [AGE] year-old male with a long history of mental health issues .has thoughts of death, dying, and suicide. Has thoughts of jumping off of the bridge or overdose .sometimes feels like go to sleep and never wake up . past psychiatric history .multiple psychiatric hospitalization s. Multiple suicide attempts and gestures in the past . A Consultation report, dated 04/14/18, documented, .chief complaint .depression .HPI (health protective information)/ Subjective .is a patient who is admitted to the psychiatric unit .He has been increasingly depressed and got suicidal . Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's baseline care plan, dated 05/05/18, did not addresses the resident's history of depression and suicide attempts. An admission assessment, dated 05/11/18, documented the resident's cognition was intact, was independent in all areas of activities of daily living and had no mood indicators or behaviors. A health status note, dated 07/11/18 at 1:53 p.m., documented, this nurse was informed by an aide on the hall that this resident was upset and had head butted and punched the picture in the hall. Upon arrival the nurse noted resident bleeding from forehead, leaning up against the wall .resident proceeded to throw a chair at the window and vending machine .was able to calm resident down enough to apply pressure to left hand cut from punching the picture on wall stated he was upset and homicidal . A care plan, dated 07/12/18, documented, Focus has behaviors and sudden outbursts at times. 07/11/8- head butted and punched the picture on the wall . Goal (Resident) will not have any major injuries from behaviors. (Resident) will not injure any staff or residents during outbursts . Interventions .psych consult as needed .redirect (Resident) as needed .social services visits as needed .Try to separate (Resident) from other residents to protect them from injury . There was no documentation the facility had a psychiatric consult and services provided to the resident after the 07/11/18 episode of the resident being homicidal and head butting and punching pictures on the wall that resulted in lacerations to the forehead and hand. This was the first time the facility had addressed the resident's behaviors of outburst, but still did not address the resident's history of attempted suicides. A review of the daily assignment sheet for 08/21/18 for the 11:00 p.m. through 7:00 a.m. shift, documented there were two licensed nurses and four certified nurse aides working at the time of the incident. Only one certified nurse aide was assigned to work on hall 400, the hall the resident resided on at the time of the attempted suicide. An incident report, dated 08/22/18 at 3:30 a.m., documented the resident was transferred to the hospital after cutting his left wrist with glass. The resident stated the resident was tired of life and his situation. It documented the resident stated, I am tired of life, I want to end it today. There were no documented witnesses to the incident and there were no documented interventions on the incident report. The section titled other information documented, He is a cutter and suicidal. An Emergency Department Report dated 08/22/18, documented, .Triage stated complaint left forearm laceration .time 04:17 (4:17 a.m.) .history .presents to the emergency department with chief complaint of left forearm self-inflicted wound. He says that tonight he was tired of people playing games with him and that he does not want to live anymore. He has a history of [MEDICAL CONDITION] disorder .he says that he was walking by a picture that was on the wall several times tonight and kept thinking about taking a piece of the glass and cutting his left arm. He did punch the picture and removed a shard of glass to cut his left forearm with . procedure .left forearm laceration repair the 3 cm (centimeters) laceration on the left forearm was anesthetized .the wound was repaired with 6 staples . A health status progress note, dated 08/22/18 at 7:19 a.m., documented, the resident had been transferred to the hospital due to cutting his left wrist with glass. Resident said he's tired and is (sic) situation. A care plan, dated 08/26/18, documented, Focus 8/22/2018 07:19 (7:19 a.m.) Health Status Note Text .Resident transferred by EMSA (emergency medical services authority) to hospital r/t (related to) cutting his left wrist with a glass. Resident said he's tired of life and is (sic) situation .The resident has the potential to demonstrate physical behaviors such (nothing was documented) . Goal .The resident will seek out staff/caregiver when agitation occurs . Interventions .analyze of key times, places, circumstances, triggers and what de-escaltes behavior and document .monitor q (every) shift document observed behavior and attempted interventions in behavior log .monitor/document/report to MD (medical doctor) of danger to self and others .psychiatric/Psychogeriatric consult as indicated .when the resident becomes agitated intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later . A Psychiatry Established Patient progress note, dated 08/29/18, documented, .Chief complaint .Pt (patient) was inpatient last week for cutting wrists. Pt states he was angered (secondary) to family issues and decided to punch picture frames as a result and used the glass to cut his wrist Nurses report .nursing staff reports disruptive behavior last week that included the patient punching and breaking glass of pictures on the walls then using the glass to cut his wrist. The patient was admitted to an inpatient facility . This was the only documented psychiatric visit since the resident had been admitted to the facility on [DATE]. On 09/26/18 at 2:00 p.m., the resident was asked about the incident on 08/22/18. He stated it was early in the morning and he had been walking up and down the halls busting out picture frames. He then stated he wanted to end his life so he took a sharp piece of glass and cut his left wrist. He was asked if there was anyone present when this was going on. He stated an aide talked to him when he was upset and agitated and he did not want to talk to her about it. He then stated the aide left and he was alone again. He stated once the aide was no longer around he picked up the glass and cut his wrist. The resident stated the facility knew he had problems and he had attempted to kill himself in the past. The resident was asked how many times he had attempted to harm or kill himself. He stated over the years a lot and he stated just prior to being admitted , he attempted to jump off a bridge and take some pills but was stopped by the police. He then stated he also had another time he was going up and down the hallway breaking pictures with his head and fist. He stated that time he cut his forehead and his hand. He was asked how long prior to actually cutting his wrist that the glass breaking occurred. He stated he wasn't sure but thought it was about three to four weeks before hand. He was asked if the facility provided any therapy or counseling to him since he had been admitted to the facility. He stated he did not see anyone until after he was back from the hospital in August. The resident's left wrist was observed with a scar that ran vertically along his wrist approximately three inches in length. He then stated they had to put in six staples to close the cut up. At 3:10 p.m., the corporate nurse was asked for all documentation currently not in the residents clinical record to include any psychiatric consults, care plan interventions and orders. She stated she would look for and provide any documentation. At 3:56 p.m., licensed practical nurse (LPN) #1 was asked about the night the resident cut his wrist. She stated they were short staffed that night and she had to go to the other end of the building to take care of some residents. She stated she did not know there was any problems until certified nurse aide (CNA) #1 came and got her. She stated when they got back the resident had cut his wrist and had to be sent to the emergency room . She then stated the resident kept saying he wanted to die and that he had been at the end of his tunnel. She was asked if the resident had any previous history of this kind of behavior. She stated this was the first time that he had done anything like this. She then stated she had been told after the incident the resident had a history of [REDACTED]. She was asked what interventions were in place to prevent the recurrence of the incident. She stated the best intervention would be to have more staff, but they were always not staffed well. At 4:42 p.m., CNA #1 was asked about the night the resident had attempted to kill himself. She stated the resident had been pacing the halls and was agitated. She stated she tried talking to the resident and he did not want to talk. She was asked if she continued to monitor the resident and his behavior. She stated she was the only aide on the hall and she had to take care of other residents. She then stated the nurse was on the opposite end of the building taking care of other residents. She was asked if she had notified the nurse of the behaviors. She stated again the nurse was on the other end and she was taking care of other residents. The aide stated she was in the bathroom when she heard a crash, when she came out the resident had broken a picture with glass. She then stated she did not know the resident very well and left him alone to go and get the nurse. She stated there was no one else working to stay with the resident, and when they returned he had cut his wrist. She was asked if the resident had a history of [REDACTED]. She then stated she didn't know of another times he attempted suicide. At 7:10 p.m. the corporate nurse stated they had no additional documentation to provide and everything had been provided.

On 09/26/18 an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure failure to ensure a resident received the necessary care and services, such as provide behavioral health services, for a resident with a history of suicide attempts. The resident was admitted to the facility after an episode of depression and attempted suicide and had a history of [REDACTED]. At 4:55 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. At 5:12 p.m., the administrator, director of nursing (DON), the corporate nurse and the corporate representative were informed an IJ situation existed due to the facility's failure failure to provide behavioral health services for a resident with a history of suicide attempts. The resident was admitted to the facility after an episode of depression and an attempted suicide as well as had a history of [REDACTED]. At 7:20 p.m., an acceptable plan of removal was received from the corporate nurse. The plan of removal documented: Resident immediately placed on 30 minute checks by staff for 24 hours and continue to monitor hourly for new behaviors. Care plan updated to reflect past behaviors and current condition. Appropriate interventions per policy and procedure will be initiated as necessary when resident shows signs and symptoms of behaviors. Resident assessed by RN (registered nurse) to assess for any suicidal ideation. All staff currently on duty in the facility will be educated face to face on Suicide Threat policy and procedure by 8:00 pm on 09/26/18. Remaining staff members currently being notified and in-serviced via phone call. Any remaining staff members that can not be reached at this time will be educated on this policy before being allowed to report to their shift for duty. Current nursing staffing reviewed and appropriate staffing is being provided to meet staffing and supervision needs and requirements. Sufficient staffing and supervision is reviewed prior to each shift for appropriate amount of staff to meet residents needs. If it is determined that current shift staffing is not appropriate - the prior shift staff members will remain on duty until the staffing and supervision level is deemed appropriate. Residents at risk for this same deficient practice will be identified by any change noted in behavior indicating self harm, will be addressed per physician order [REDACTED]. Compliance to be discussed in quality assurance meeting. Residents at risk will be identified through basic questionnaire to identify any immediate s/s (signs or symptoms) of depression and/or suicidal ideation. Concerns identified will be reported to the physician immediately. Consult for psychiatric evaluation Resident will be placed on one hour observation until resident is cleared by PCP (primary care physician) and/or physician. 09/27/18 at 5pm will be completed. Interviews were conducted with facility staff on 09/27/18. After the last staff member was interviewed and was able to verbalize knowledge of the facility's suicide policy and procedures and all questionnaires were reviewed, the IJ was removed on 09/27/18 at 11:12 a.m., when all inservices and questionnaires to identify potential residents had been completed. The deficient practice remained at an isolated level of harm. Based on observation, record review and interviews, it was determined the facility failed to ensure a resident with suicidal tendencies received the necessary care and services, such as behavioral health services, to aide in the prevention of further attempted suicides for one (#5) of one sampled residents reviewed for behavioral health services. Resident #5 did not receive psychological services and have supervision during an episode of depression with suicidal ideation which resulted in the resident cutting his left wrist with broken glass. The facility did not identify any additional residents with a history of suicidal ideation's and or attempted suicides in the facility. Findings: A policy, titled Suicide Threats, documented, .Resident suicide threats shall be taken seriously and addressed appropriately .The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats .A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident .All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instruct to report changes in the resident's behavior immediately .As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated .Staff shall document details of the situation objectively in the resident's medical record . A History and Physical, dated 04/13/18, located in the clinical record for resident #5, documented, .source of information .the patient himself .as well as H and P (History and Physical) dated (MONTH) 12. (YEAR) reason for admission .depression and suicidal expressions . History of present illness .this patient is a [AGE] year-old male with a long history of mental health issues .has thoughts of death, dying, and suicide. Has thoughts of jumping off of the bridge or overdose .sometimes feels like go to sleep and never wake up . past psychiatric history .multiple psychiatric hospitalization s. Multiple suicide attempts and gestures in the past . A Consultation report, dated 04/14/18, documented, .chief complaint .depression .HPI (health protected information)/ Subjective .is a patient who is admitted to the psychiatric unit .He has been increasingly depressed and got suicidal . The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's baseline care plan, dated 05/05/18, did not addresses the resident's history of depression and suicide attempts. An admission assessment, dated 05/11/18, documented the resident's cognition was intact, was independent in all areas of activities of daily living and had no mood indicators or behaviors. A health status note, dated 07/11/18 at 1:53 p.m., documented, this nurse was informed by an aide on the hall that this resident was upset and had head butted and punched the picture in the hall. Upon arrival the nurse noted resident bleeding from forehead, leaning up against the wall .resident proceeded to throw a chair at the window and vending machine .was able to calm resident down enough to apply pressure to left hand cut from punching the picture on wall stated he was upset and homicidal . A care plan, dated 07/12/18, documented, Focus has behaviors and sudden outbursts at times. 07/11/8 - head butted and punched the picture on the wall . Goal (Resident) will not have any major injuries from behaviors. (Resident) will not injure any staff or residents during outbursts . Interventions .psych consult as needed .redirect (Resident) as needed .social services visits as needed .Try to separate (Resident) from other residents to protect them from injury . There was no documentation the facility had a psychiatric consult and services provided to the resident after the 07/11/18 episode of the resident being homicidal and head butting and punching pictures on the wall that resulted in lacerations to the forehead and hand. This was the first time the facility had addressed the resident's behaviors of outburst, but still did not address the resident's history of attempted suicides. An incident report, dated 08/22/18 at 3:30 a.m., documented the resident was transferred to the hospital after cutting his left wrist with glass. The resident stated the resident was tired of life and his situation. It documented the resident stated, I am tired of life, I want to end it today. There were no documented witnesses to the incident and there were no documented intervention on the incident report. The section titles other information documented, He is a cutter and suicidal. An Emergency Department Report dated 08/22/18, documented, .Triage stated complaint left forearm laceration .time 04:17 (4:17 a.m.) .history .presents to the emergency department with chief complaint of left forearm self-inflicted wound. He says that tonight he was tired of people playing games with him and that he does not want to live anymore. He has a history of [MEDICAL CONDITION] disorder .he says that he was walking by a picture that was on the wall several times tonight and kept thinking about taking a piece of the glass and cutting his left arm. He did punch the picture and removed a shard of glass to cut his left forearm with . procedure .left forearm laceration repair the 3 cm (centimeters) laceration on the left forearm was anesthetized .the wound was repaired with 6 staples . A health status progress note, dated 08/22/18 at 7:19 a.m., documented, the resident had been transferred to the hospital due to cutting his left wrist with glass. Resident said he's tired and is (sic) situation. A care plan, dated 08/26/18, documented, Focus 8/22/2018 07:19 (7:19 a.m.) Health Status Note Text .Resident transferred by EMSA (emergency medical services authority) to hospital r/t (related to) cutting his left wrist with a glass. Resident said he's tired of life and is (sic) situation .The resident has the potential to demonstrate physical behaviors such (nothing was documented) . Goal .The resident will seek out staff/caregiver when agitation occurs . Interventions .analyze of key times, places, circumstances, triggers and what de-escalates behavior and document .monitor q (every) shift document observed behavior and attempted interventions in behavior log .monitor/document/report to MD (medical doctor) of danger to self and others .psychiatric/Psychogeriatric consult as indicated .when the resident becomes agitated intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later . A Psychiatry Established Patient progress note, dated 08/29/18, documented, .Chief complaint .Pt (patient) was inpatient last week for cutting wrists. Pt states he was angered (secondary) to family issues and decided to punch picture frames as a result and used the glass to cut his wrist Nurses report .nursing staff reports disruptive behavior last week that included the patient punching and breaking glass of pictures on the walls then using the glass to cut his wrist. The patient was admitted to an inpatient facility . This was the only documented psychiatric visit since the resident had been admitted to the facility on [DATE]. On 09/26/18 at 2:00 p.m., the resident was asked about the incident on 08/22/18. He stated it was early in the morning and he had been walking up and down the halls busting out picture frames. He then stated he wanted to end his life so he took a sharp piece of glass and cut his left wrist. He was asked if there was anyone present when this was going on. He stated an aide talked to him when he was upset and agitated and he did not want to talk to her about it. He then stated the aide left and he was alone again. He stated once the aide was no longer around he picked up the glass and cut his wrist. The resident stated the facility knew he had problems and he had attempted to kill himself in the past. He was asked how many times he had attempted to harm or kill himself. He stated over the years a lot and he stated just prior to being admitted he attempted to jump off a bridge and take some pills but was stopped by the police. He then stated he also had another time he was going up and down the hallway breaking pictures with his head and fist. He stated that time he cut his forehead and his hand. He was asked how long prior to actually cutting his wrist that they glass breaking occurred. He stated he wasn't sure but thought it was about three to four weeks before hand. He was asked if the facility provided any therapy or counseling to him since he had been admitted to the facility. He stated he did not see anyone until after he was back from the hospital in August. The resident's left wrist was observed with a scar that ran vertically along his wrist approximately three inches in length. He then stated they had to put in six staples to close the cut up. At 3:10 p.m., the corporate nurse was asked for all documentation currently not in the residents clinical record to include any psychiatric consults, care plan interventions, and orders. She stated she would look for and provide any documentation. At 3:56 p.m., licensed practical nurse (LPN) #1 was asked about the night the resident cut his wrist. She stated they were short staffed that night and she had to go to the other end of the building to take care of some residents. She stated she did not know there was any problems until certified nurse aide (CNA) #1 came and got her. She stated when they got back, the resident had cut his wrist and had to be sent to the emergency room . She then stated the resident kept saying he wanted to die and that he had been at the end of his tunnel. She was asked if the resident had any previous history of this kind of behavior. She stated this was the first time that he had done anything like this. She then stated she had been told after the incident the resident had a history of [REDACTED]. She was asked what interventions were in place to prevent the recurrence of the incident. She stated the best intervention would be to have more staff, but they were always not staffed well. At 4:42 p.m., CNA #1 was asked about the night the resident had attempted to kill himself. She stated the resident had been pacing the halls and was agitated. She stated she tried talking to the resident and he did not want to talk. She was asked if she continued to monitor the resident and his behavior. She stated she was the only aide on the hall and she had to take care of other residents. She then stated the nurse was on the opposite end of the building taking care of other residents. She was asked if she had notified the nurse of the behaviors. She stated again the nurse was on the other end and she was taking care of other residents. The aide stated she was in the bathroom when she heard a crash, when she came out the resident had broken a picture with glass. She then stated she did not know the resident very well and left him alone to go and get the nurse. She stated there was no one else working to stay with the resident, and when they returned he had cut his wrist. She was asked if the resident had a history of [REDACTED]. She then stated she didn't know of another times he attempted suicide. At 7:10 p.m. the corporate nurse stated they had no additional documentation to provide and everything had been provided.

On 08/07/17, a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision to prevent elopement of a resident who was known to have exiting behaviors. The resident was found in a park severely dehydrated and sunburned. The resident was transported to a local hospital in which he was admitted to the intensive care unit and placed on life support. The Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to provide adequate supervision to prevent elopement of a resident who was known to have exiting behaviors. On 08/08/17 at 3:00 p.m., the administrator was informed of the past noncompliance IJ related to the facility's failure to provide adequate supervision to prevent elopement of a resident who was known to have exiting behaviors. The facility put measures into place to prevent recurrence when staff had been inserviced related to elopement of residents and elopement drills to be held monthly. Pictures of residents at high risk for elopement were placed at each nursing station in the facility. An elopement book was kept at the front nursing station and had been updated. The key pad code for the main door had been changed on 07/17/17. The staff inservice was held on 07/31/17. The quality assurance (QA) meeting conducted on 07/17/17 documented, .QA committee recommends that staff is inserviced regarding Elopements, most wanted posters be placed at the nurses station as well as the elopement book updated. Key pad codes were changed and no smoking signs were placed at the front entrance to keep staff and residents from going out to an unsecured area to smoke. Elopement drills to be held during the in service monthly . The inservice conducted on 07/31/17, titled Teamwork-Elopement Drill-Elopement of Residents, documented, .The importance of keeping track of residents in the facility, staff demonstrated correct procedure for locating missing residents . On 08/07/17 and 08/08/17, staff were interviewed in regard to their knowledge of the inservice. Staff verbalized understanding of the inservice, to be aware of residents who are at risk for elopement and where they are at in the facility. Based on interview and record review, it was determined the facility failed to ensure a resident was provided with adequate supervision to prevent elopement for one (#3) of three sampled residents who were reviewed for elopement. Resident #3 suffered life threatening injuries and was admitted to the intensive care unit on life support with [DIAGNOSES REDACTED]. The facility identified seven residents who were at risk for elopement. Findings: The facility's policy and procedure for elopements documented, .staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .If an employee discovers that a resident is missing from the facility, he/she shall: .determine if the resident is out on an authorized leave or pass .if the resident was not authorized to leave, initiate a search of the building(s) and premises .if the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.) .provide search teams with resident identification information; and .Initiate an extensive search of the surrounding area . Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 05/27/17, documented the resident's cognition was severely impaired and was independent with all activities of daily living. The care plan, dated 06/01/17, documented the resident was at risk for elopement due to repeatedly wanting to go home and he had decreased awareness of safety. The goal documented the resident would not leave the facility unattended. The interventions documented, .assess (Resident #3) for fall risk .Codes to be changed on the doors to outside the facility if (Resident #3) gets outside .Distract (Resident #3) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .(Resident #3) picture and information will be placed in a book and be at nearby nurses station .Staff shall promptly report when (Resident #3) tries to leave the premises or is suspected of being missing to the charge nurse or DON (Director Of Nursing) . The treatment administration record (TAR) for 06/2017 and 07/2017 were reviewed for behavior monitoring. Wandering and elopement were not monitored on resident #3 for these two months. A social services note, dated 06/22/17 at 8:47 p.m., documented, Was alerted by a family member at 8:40 that resident was outside of the facility. This writer was easily able to redirect resident back into facility. Resident stated he was going to his ex-wife's house. Explained to the resident that it was to hot and dangerous on the highway, resident agreed and stated he was tired . A nursing progress note, dated 06/22/17 at 8:53 p.m., documented, Approx (approximately) 2043 (8:43 p.m.) was informed a family member saw res (resident) in the parking lot, staff was able to redirect res back into the building at approx. 2040(8:40 p.m.), this nurse last visualized res at approx. 2030 in north hall lobby. Res assisted to his room at this time .Res unable to recall where he was going but stated he was tired and ready for bed . A nursing progress note, dated 07/16/17 at 8:30 p.m., documented, Notified by staff nurse that resident is missing from facility. Internal and external search conducted and resident not found at facility at this time . At 8:45 p.m., a nursing note documented, Resident has eloped from facility and is currently at (name-deleted hospital) for eval (evaluation) and treat (treatment) . An incident report faxed to the Oklahoma State Department of Health, dated 07/16/17, documented, .(Resident #3) was noted to be missing from the facility - Police notified they stated that they had picked up a man matching his description and took him to the ER (emergency room ) for evaluation . On 07/16/17 at 7:10 p.m., an emergency department report documented, .male who presents to the emergency department with chief complaint of altered mental status. He was found in the park by a bystander with altered mental status .On arrival his identity was unknown found out that he was missing from a nursing home for several hours. He is found to be hyperthermic with elevated temperature and lack of sweating. He was out in the heat in the park. Symptoms have been severe and modified by time . Vital signs obtained documented at 7:15 p.m., the residents temperature documented to be 39.7 degrees Celsius (103.5 degrees Fahrenheit), pulse 118, respiration were at 30 breaths per minute. A physical exam documented the resident was not responding to verbal or painful stimuli .Pupils are pinpoint and mildly responsive .Mucous membranes are dry .He was given 2 L (liters) of normal saline .most likely hyperthermia due to being outside in the heat .Ice and fans were applied .sepsis is also a consideration so he was started on broad-spectrum antibiotics .Central line and (endotracheal) intubation was performed . A consultation report documented the reason for the consultation was due to altered mental status, respiratory failure, and mechanical ventilation. The history of present illness documented, .white mail, who was found down in a local park by some kids. He was brought in and found to be hyperthermic. he was intubated and was started on a cooling interventions. He is currently normal thermic, intubated .He has had a right subclavian central line placed .IMPRESSION:1. Heat stroke: Patient was found outside and temperatures well over 90. He also had a sunburn on his exposed skin areas He was found in a park by passerby, who called 911 .2. Respiratory failure PLAN: .The patient is obviously critically ill. His prognosis is guarded. An inservice sheet, dated 07/17/17, documented the staff were inserviced on elopement, wandering residents and a list of high risk residents will be posted on dry erase boards on each nurses station and the wonder book was kept at the west station by the nurses desk. A inservice sheet, dated 07/31/17, documented an inservice was provided to the staff for teamwork, elopement drill and elopement of residents. The importance of keeping track of residents in the facility. The staff demonstrated correct procedure for locating missing residents. On 08/08/17 at 8:45 a.m., licensed practical nurse (LPN) #2 was asked about the elopement for resident #3. She stated she was working the 3-11 shift. She stated she was in the process of performing finger stick blood sugars (FSBS). She stated when she was performing a FSBS on resident #3's roommate, she did not observe resident #3 to be in the room. She further stated around 6:00 p.m. or 7:00 p.m., another nurse told her resident #3 was not in the facility and the staff had looked every where in the facility. She stated she immediately called the assistant director of nursing (ADON) and started the procedure for missing residents. She was asked if she contacted the police. She stated yes. She further stated the police came to the facility after she notified them of the missing resident. The police stated they had found a man fitting the description of resident #3 and sent the resident to the emergency room . LPN #2 was asked if she was aware if resident #3 was an elopement risk. She stated no. At 8:50 a.m., registered nurse (RN) #1 was asked if he was familiar with resident #3. He stated he was aware the resident wandered and was a high risk for elopement. He further stated the resident had attempted to elope from the facility the month prior to the incident on 07/16/17. At 11:00 a.m., LPN #3 was asked if she was working the day resident #3 had eloped from the facility. She stated yes. She further stated she was the one who noticed the resident was missing. She was asked when she realized the resident was missing. She stated she was administering the evening medications and went to the room of resident #3's at 6:30 p.m., but the resident was not in his room. She stated she waited 15 minutes and then went back to the resident's room; he was not in his room. She stated her and certified nurses aides (CNAs) went from room to room to search for the resident. When the resident could not be found, she notified LPN #2 and she called 911. LPN #3 was asked if she knew if the resident was at risk for elopement. She stated yes. At 11:15 a.m., CNA #1 was asked if she was working on 07/16/17. She stated yes. She was asked if she knew resident #3. She stated yes. She was asked when the last time she had seen the resident in the facility on that day. She stated she observed the resident walking in the halls, but she did not remember the last time she had seen resident on that day. She was asked what time she left the facility that day. She stated 3:00 p.m. She was asked if she recalled if the resident was in the facility at that time. She stated she did not know. She was asked if the resident was an elopement risk. She stated, I don't know. At 11:30 a.m., CNA #2 was asked if he was working on 07/16/17. He stated yes. He was asked if he was familiar with resident #3. He stated yes. He was asked if he knew about the incident that occurred on that day. He was asked if he had seen the resident on that day in the facility. He stated he had observed the resident wandering in the halls. He was asked when the last time he observed the resident being in the facility on that day. He stated at 1:00 p.m. in the north hall of the facility. He continued to state he ended his shift at 3:00 p.m. that day. He was asked if he knew if the resident was at risk for elopement. He stated the resident did not exhibit any elopement behaviors, to his knowledge. At 11:39 a.m., the administrator was interviewed regarding the elopement of resident #3. She stated the resident was last seen about 1:00 p.m. on that day and another staff member had visualized resident at 2:15 and 2:30 p.m. She further stated the resident was found a couple of blocks from the facility, where there was a park. She was asked if the facility had called to check on the resident. She stated according to the emergency room , he was disoriented, so someone called the emergency medical services (EMS). They took him to the hospital which they admitted him. She further stated when the staff called the police, they stated the resident was picked up around 3:00 p.m. at the park. The administrator was asked what plan was put into place for the elopement incident that occurred on 07/16/17. She stated the resident was on the elopement risk list. She was asked how staff were informed of residents who were considered elopement risks. She further stated she had and inservice on elopement and elopement drill and the staff were told which residents were considered elopement risks. She continued to state there was an incident when residents would insist on smoking at the front of the facility. There were residents who would follow them out, which eventually led to a resident elopement. There was a sign placed at the front door to prohibit smoking at the front of the facility. The administrator continued to state there were posters placed at the nurses stations which showed the residents who were at risk for elopement. On 08/08/17 at 2:00 p.m., the ADON was shown the TAR for June and July 2017 on resident #3. She was asked if there was any monitoring for the resident's wandering behavior documented. She stated no. She was asked should there be monitoring for the wandering behavior. She stated yes. The ADON was then asked what interventions were put into place when resident #3 eloped from the facility. She stated for the elopement on 06/22/17, the codes were changed on the door and the resident's location was to be monitored frequently. She was asked what interventions were initiated for the incident on 07/16/17. She stated the front door code was changed again on 07/17/17. She continued to state the facility had started to post pictures of the residents who were at risk for elopement.

Based on observation, clinical record review, staff interviews and review of facility policy and procedures, it was determined the facility failed to consistently assess a resident's skin integrity for the development of wounds for one (#6) of four sampled residents, who were reviewed for wounds. This resulted in actual harm for resident #6 when the resident's skin integrity was not assessed timely and the resident developed an avoidable wound with necrotic tissue on 10/16/15. On 10/19/15 the resident's wound increased in size and there was a foul odor present. This had the potential to 52 residents identified by the facility who were at high risk for the development of impaired skin integrity. The facility identified seven residents with wounds. Findings: A facility policy titled, Resident Examination and Assessment, documented: Purpose .The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan . Physical Exam . 8. Skin: a. intactness; b. moisture; c. color; d. texture; and e. presence of bruises, pressure sores, redness, [MEDICAL CONDITION], rashes . Documentation The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data . A facility policy titled, Pressure Ulcer Risk Assessment, documented: Purpose .The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation . 1. Review the resident's care plan to assess for any special needs of the resident. 2. Review current Braden Scale or facility risk assessment tool . General Guidelines . 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor . Assessment . 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will perform routine skin inspections (with daily care). b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes . Identifying Residents at Risk . 4. [DIAGNOSES REDACTED]. .b. Urinary Incontinence c. [MEDICAL CONDITION]/[MEDICAL CONDITION] . f .[MEDICAL CONDITION] g. Diabetes . j. [MEDICAL CONDITION] . l. [MEDICAL CONDITION]/[MEDICAL CONDITION] . Steps in the Procedure . 4. Once inspection of skin is completed proceed to the Admission Assessment or Weekly Skin Integrity tool (depending on whether this is a new admission or an existing resident) and complete documentation findings. 5. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 6. Proceed to care planning and interventions individualized for the resident and there particular risk factors. 7. Notification (refer below to reporting). 8. Document the procedure. Documentation .The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment conducted (for example, Admission assessment, Weekly Skin Integrity tool). 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification and refusal. 9. Observations of anything unusual exhibited by the resident. 10. The signature and title (or initials) of the person recording the data. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration is noted. 12. Documentation in medical records addressing MD notification if new skin alteration noted with change of plan of care if indicated. 13. Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care if indicated . Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED].Weekly skin assessment once a day on Wed . A care plan, dated 03/17/15, documented, .Problem .I have fragile skin and am at risk for impaired skin integrity related to [MEDICAL CONDITION], incontinence, increased pressure, and routine use of [MEDICAL CONDITION] medications. I have preventative treatment in place . Goal .I will maintain or develop clean and intact skin . Approach . inspect my skin daily with care and bathing and report any changes to my physician and family . inspect my skin, head to toe, every week and document findings . notify my physician and family of any worsening of skin breakdown . staff to place wedge under my legs to float my heels . weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . A weekly skin report, dated 03/06/15 through 06/17/15, documented the resident's skin was assessed as clean, dry and intact weekly. A quarterly assessment, dated 06/19/15, documented the resident was severely impaired in cognitive skills for daily decision making. She required total assistance from staff with dressing, hygiene and bathing. She was at risk for the development of a pressure ulcer. She did not have any unhealed wounds or pressure ulcers present. She was always incontinent of bowel and bladder. A weekly skin report, dated 06/24/15 through 08/05/15, documented the resident's skin was assessed as clean, dry and intact weekly. A treatment administration record, dated August 2015, documented, .Weekly skin assessments- Wednesdays 3-11 (3:00 p.m. to 11:00 p.m.) . The treatment administration record was reviewed. There were two gaps for three opportunities to document a weekly skin assessment was conducted. A nursing progress note, dated 08/21/15, documented, Called to resident's room, noted gargling and labored breathing, vitals .82 % on room air, pulse 127 .(named physician #1) made aware .transport to (named hospital) . A nursing progress note, dated 09/04/15, documented, Resident readmitted to facility for LTC under the car (sic) of (named physician #2) from (named hospital). Transfer via stretcher. AOX1. Breathing even and unlabored. Lung sounds clear to auscultate. Bowel sounds present in all 4 quads. Incont of bowel and bladder. No S/S of discomfort noted. Skin intact. V/S stable . A physician's orders [REDACTED]. A physician's orders [REDACTED]. A treatment administration record, dated September 2015, documented, .Weekly skin assessments- Wednesdays 3-11 (3:00 p.m. to 11:00 p.m.) . Bilateral heels skin prep daily for prevention .Order date 09/04/15 . Skin prep to bilateral heels was documented from 09/04/15 through 09/30/15. Weekly skin checks were initialed as completed each Wednesday. There was no documentation which identified the findings from each weekly skin assessment. A treatment administration record, dated October 2015, documented, .Weekly skin assessments- Wednesdays 3-11 . Bilateral heels skin prep daily for prevention . Skin prep to bilateral heels was documented from 10/01/15 through 10/20/15. Weekly skin checks were initialed as completed each Wednesday. There was no documentation which identified any abnormal skin findings from each weekly skin assessment. There was no documentation of skin assessment findings in the clinical record since the nurse progress note from the resident's readmission to the nursing home on 09/04/15 which documented the resident's skin was intact through 10/15/15. A nursing progress note, dated 10/16/15, documented, (named CNA #6) found 2 wounds on resident L outer calf: #1 wound is 1 mm W x 1mm L x 0.3 mm D; wound #2 measures 1.5 mm wide x 3 mm L x 0.3 mm deep w/ black and yellow slough present; applied Santyl, dry dressing. Continues to have 4 (plus) [MEDICAL CONDITION]. Has air pressure relief mattress on bed since re-admit. Heels/LE are floated on pillows at all times. Call placed to daughter without answer. Call placed to (named physician #1) without return call. A physician's orders [REDACTED]. A nursing progress note, dated 10/19/15 at 9:32 a.m., documented, Wound rounds made resident has open area to left lower leg from pressure 8 x 4 x 0.3 cm has moderate amount of serous drainage with strong odor. Wound bed 100 % yellow slough, eschar noted also periwound red. Called wound doctor. New orders for PO antibiotic and [MEDICATION NAME] faxed to pharmacy. Nurse to call POA. Also has zero c/o pain at site. On air mat and turned Q 2 hours and pillows used for comfort. Treatment in place and has tolerated well. Will continue weekly skin checks and keep area clean and dry. A nursing progress note, dated 10/19/15 at 1:27 p.m., documented, Called POA (named POA) made aware of wound and treatent (sic) and that resident was placed on PO ABT. Told POA would call her after wound doctor saw . A nursing progress note, dated 10/20/15, documented, Resident started abt [MEDICATION NAME] for left leg infection . On 10/21/15 at 10:25 a.m., LPN #3 was observed as she provided the resident's wound care. The staff exhibited difficulty in moving the resident's lower extremities due to the resident's size. This required the surveyor to crouch down below the level of the bed in order to look up at the underside of the resident's left lower calf. The resident had a wound on her posterior left lower calf. The wound was approximately 8 centimeters in length by 4 centimeters in width. The wound bed was covered with yellow slough. The edges of the wound were pink and red. At 1:30 p.m., the ADON stated new wounds were discovered on the resident during the provision of care this morning. She stated two wounds were found on the resident's right lower leg. She then stated a wound was discovered above the resident's left lower calf. She stated the wound resembled a shear injury and she was unable to obtain a measurement of the shear injury. She stated the injury was observed to be approximately 3 centimeters wide by 3 centimeters in length. She further stated the resident's right hip was observed with a 1 centimeter wide by one centimeter in length open reddened area of skin with clear fluid weeping out. A nursing progress note, dated 10/21/15 at 12:47 p.m., documented, Nurse called this nurse to room. Resident has two areas to right lowere (sic) leg 1.5 x 1 x 0, 1 x 1 x 0 cm. Has zero drainage scabs noted. Also has abrasion to left upper leg above her wound possible shear. Refuses to let me measure at this time. Also has [MEDICAL CONDITION] to right hip. Clear fluid coming out .Called POA made aware of new wounds and treatments and new orders. States she is coming to see her tonight . On 10/22/15 at 8:17 a.m., the corporate administrator provided staff initiated treatment sheets, for weekly skin assessments and skin prep to bilateral heels daily, to the surveyors from September and October 2015. She then stated this is documentation which shows the resident's skin was assessed. She was notified the documentation only provided a staff members initials which documented the resident's skin was observed and no findings. She was then asked if the documentation she provided documented the findings from the skin assessment. She stated, No. They were charting by exception, I think. We went from (named charting provider) to (named charting provider) in September and have had some issues. At 9:35 a.m., a confidential interview was conducted with a staff member. She was asked if the resident's skin was assessed during application of skin prep to her bilateral heels daily. She stated no. She further stated the resident cries out and it's difficult to look at her legs. She then stated in order to observe the resident's legs the staff member has to crouch below the level of the bed and look up. She stated it requires at least two staff members to perform a head to toe skin assessment. She then stated the staff did not assess the resident's skin routinely. She stated, I think they signed it and went on. They didn't assess her skin and she's very high risk. On 10/22/15 at 9:00 a.m., LPN #3 was asked how often she applied the skin prep treatment to the resident's heels. She stated she had provided the care less than ten times, in the last couple of weeks. She was then asked if she was able to provide the wound treatment for [REDACTED]. You need assistance. She was asked if she observed other areas of the resident's skin when she applied the skin prep heel treatment. She stated she only observed the resident's heel during the treatment. She then stated, She's hard to treat. You try to get in and get done fast. She stated the resident had [MEDICAL CONDITION] in her legs and cries out often during care and her legs are very heavy and difficult to manage without causing the resident pain. She stated the resident's skin is observed as much as possible during incontinent care and bathing. The resident's skin is observed head to weekly during scheduled skin assessments. On 10/22/15 at 9:19 a.m., RN #1 was asked how often he applied the skin prep treatment to the resident's heels. He stated he provided the treatment every day he worked in September and October 2015. He was asked how many staff members does it take to provide the resident's care. He stated, Two people. I always take an aide with me. He was then asked what was the nurses aide's role during care. He stated the nursing aide holds the resident's leg up off the bed while he applied the skin prep to the resident's heels. He was asked if he was able to observe any others areas of the resident's skin while he provided the heel treatment. He stated, I concentrated on her heels. He further stated, I just placed prep on her heels. I didn't do a full skin assessment because she has to have one every week by the nurse assigned to this.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician of the emergence of a new wound and when there were changes in a wound, and obtain physician's orders for treatments to be provided to the wound for resident #1. The resident developed a wound to the right foot, with an infection [MEDICAL CONDITION], was sent to the hospital, and required an amputation of the right great toe, and then an amputation of the lower leg below the knee. The resident expired on [DATE]. At 7:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of the Immediate Jeopardy situation. At 7:45 p.m., the facility Administrator and Director of Nurses were informed of the IJ situation. A plan of removal for the immediate jeopardy was received and accepted at 8:35 p.m. on [DATE]. The plan of removal documented: "The plan of REMOVAL FOR IJ.............. Related to Failure to assess wound call the physician and to provide care and treatment to a wound. Our plan of removal will consist of the following: 1. Physician will be called and notified and orders will be received immediately when any wounds are found. If the wound care physician provides treatments and new orders for residents the primary physician will be called and informed of Wound physician and of orders received from that physician. All orders will be implement upon receiving orders from the physician. 2. Nursing Staff has been in-serviced on identifying, reporting contacting physician. Receiving and implementing orders. 3. A full skin sweep of EVERY RESIDENT in the building will be completed by 10 am on Thursday [DATE]. If any new wounds are found the physician will be contacted and orders received and implemented. 4. In-service of all nursing staff has been competed on [DATE] on identifying and reporting any wounds and receiving and implementing treatments. By 10 am [DATE]" The immediate Jeopardy was removed on [DATE] at 10:30 a.m., when the facility provided evidence that all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on observation, record review and interview, it was determined the facility failed to notify the physician of the emergence of a new wound and when there were changes in a wound, and obtain physician's orders for treatments to be provided to the wound for one (#1) of six sampled residents with skin conditions. This resulted in an immediate jeopardy situation for resident #1. The resident developed a wound to the right foot, with an infection [MEDICAL CONDITION], was sent to the hospital, and required an amputation of the right great toe, and then an amputation of the lower leg below the knee. The resident expired on [DATE]. This had the potential to affect 24 residents identified by the facility with skin breakdown. Findings: A facility policy titled, CONDITION CHANGE, RESIDENT, documented, "...To observe, record and report any condition change to the attending physician so proper treatment will be implemented..." A facility policy titled, Acute Condition Changes-Clinical Protocol, documented, "...Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician;.... At the next visit, the Physician will review the status of the condition change and document his/her evaluation, including the significance of the acute situation;..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan problem, dated [DATE], documented the resident was at risk for developing skin breakdown. Interventions included: "...Wound consult as ordered... Inspect and chart skin integrity every day Treatments and dressings as ordered per physician Inspect skin daily with and care and bathing, and report any changes to charge nurse Inspect skin complete body head to toe every week and document results Condition of each area of skin breakdown to be documented each day and with every treatment and/or dressing change Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Notify physician of any worsening of skin breakdown..." A weekly skin assessment sheet for [DATE], dated [DATE] (sic), documented the resident's skin was warm and dry and was not intact. No abnormalities were listed. A comprehensive assessment, dated [DATE], documented the resident could usually understand others and could usually make herself understood by others. The assessment also documented the resident required extensive one person assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene and bathing. The assessment documented the resident was non-ambulatory and a wheelchair was used for mobility. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident was at risk for developing pressure ulcers, had no pressure ulcers, and had no venous or arterial ulcers. For skin and ulcer treatments, the assessment documented the application of ointments/medications other than to feet. A care plan, dated [DATE], documented a problem of, "Skin, Fragile Potential for skin breakdown and infection. (Resident) gets skin tears and bruising easily. (Resident) has dry skin. Interventions included: "All staff to be aware of (resident's) skin fragility All staff to be instructed in skin protection techniques for repositioning and transferring resident Inspect skin with morning and evening care and when bathing Document each incident of bruising or skin tear, and tailor interventions to prevent further occurrences..." A weekly skin assessment, dated [DATE], documented the resident's skin was warm, dry and intact. A treatment sheet for [DATE], documented a new wound treatment added to the sheet on [DATE]. The treatment sheet entry documented, "Apply skin prep to R medial foot below grt (great) toe to callous QD (every day) [DATE]." There was no documentation of a new physician's order for this treatment on [DATE]. There was no documentation of an assessment of the area to the right foot. There was no documentation to show the physician was notified of the area to the right foot. A weekly skin assessment, dated [DATE], documented the resident's skin was warm, dry and intact. The February monthly physician's orders did not include an order for [REDACTED]. A treatment sheet for February 2013, documented a new wound treatment was added to the sheet on [DATE]. The treatment sheet entry documented, "Cleanse scab bed area to R medial foot below grt toe c NS, pat dry apply skin prep cover c 4x4, wrap c Kling secure c tape QD. [DATE]." There was no documentation of a new physician's order for this treatment on [DATE]. There was no documentation of an assessment of the area to the resident's right foot, which necessitated the need for a change in treatment. There was no documentation to show the physician was notified of the area to the right foot. A Pain Monitoring Tool, documented the resident was medicated on ,[DATE] at 9:10 a.m., with two [MEDICATION NAME] 325 mg, for complaints of pain in her right foot, rated as a 7. A nurse's note, dated [DATE] at 11:00 a.m., documented, "Upon skin eval plantar wound noted to R bottom medial foot. Open area 2 x 2 cm. 100% necrotic et dry 0 drainage 0 odor. Wound physician notified will visit @ 1400 (2:00 p.m.) today. N/O recd to wound culture..." A wound care physician's note, dated [DATE] at 2:10 p.m., documented "...Chief Complaint:...Plantar Ulcer History of present illness:...Patient who developed severe plantar ulcer in less than 24 hrs (hours) with associated [MEDICAL CONDITION] Assessment:...Wound Location (s): R Plantar...10.5 x 4 cm... Etiology (type) Other: infection...Exudate yes small Exudate Type Sero-Sanguinous Fleshy Peri Wound Tissue [DIAGNOSES REDACTED] Eschar yes Black Hard 20% of wound base...Problem List: 1. Plantar ulcer - with associated [MEDICAL CONDITION]: Incision made with fleshy discharge, cultures taken. Pain ,[DATE]. R/O Plantar necrotizing fascitis... Assessment/Plan: Send patient to ER for evaluation..." A nurse's note, at 2:45 p.m., documented, "(Ambulance company) and (MD name deleted) notified." A nurse's note, at 3:00 p.m., documented, "(Ambulance company) here to transfer to ER, transported to (hospital name deleted), family notified." A nurse's note, dated [DATE] at 3:00 p.m., documented, "Late Entry for [DATE] - 3 cm round scabbed area noted to medial aspect of ball of foot, @ base of great toe, 0 redness or drainage noted, will notify skin nurse to have wound doctor assess on Wednesday [DATE]." An untimed nurse's note, dated [DATE], documented, "Late Entry for [DATE] @ 1400 (2:00 p.m.), res noted c callus to R medial foot below grt toe, N/O skin prep QD, monitor." An untimed nurse's note, dated [DATE], documented, "Late Entry for [DATE] @ 1300 (1:00 p.m.) res noted c scab (dark in color) to R medial foot below grt toe, N/O for skin prep to area & wrap c 4 x 4 & Kling OD." The Emergency Department Report, from the hospital, dated [DATE], documented: "...HISTORY OF PRESENT ILLNESS: The patient was sent to the hospital via EMS for an infection in her right foot. It was unclear how long it has been going on. By report, it has been going on for about 4 or 5 days according to the family...SKIN: Otherwise clean, dry, and intact with a notable exception of her right foot ________ necrosis over a hammertoe on the left side over the medial aspect of the distal metatarsal on the right foot. There is [DIAGNOSES REDACTED]. There are some slightly hemorrhagic changes around the area of necrosis. There is [DIAGNOSES REDACTED] of the foot circumferentially around this area of a break in the skin. Her dorsalis pedis, femoral, and posterior tibial pulses are 2+. The History and Physical report from the hospital, dated [DATE], documented: "...Assessment and Plan: The patient is an [AGE] year-old woman. She has fairly severe dementia...so history is taken from the patient's (family member) and from the emergency room doctor. The patient's (family member)...said that her sister had been visiting the patient recently and said she had been having some trouble with not eating very well and has been more lethargic than usual for about the last 2 weeks...Skin:...On her left foot, she does have a very slight wound on the hammer toe on left foot...There is a little bit of surrounding [DIAGNOSES REDACTED]. On the right foot, though, there is significant [DIAGNOSES REDACTED] on most of the foot. The bottom of the foot has what appears to be a large hematoma. It is very dark-colored. There is a break in the skin on the dorsal aspect that when I press on the wound, it does leak liquid that is a mixture of some purulent-looking fluid along with a little bit of blood..." A Consultation Report completed by a podiatrist, dated [DATE], documented: "...History of Present Illness: This is an [AGE] year-old female who presents with an infected ulceration, right foot. Her (family member), (name deleted), states just made known of it on Sunday ([DATE])... Physical Examination: DERM: There appears to be ulceration started over the medial aspect of the head of the first metatarsal, right foot. She has extremely large bunion deformity with crossover second toe. She now has abscess extending into her arch about 6 or 7 cm and about 2 to 3 cm wide. It is a uneven border. The center portion has pus draining from it. Was able to cut through this approximately 3 to 4 cm. Also has [DIAGNOSES REDACTED] extending into her arch and onto the dorsum of her foot, but no [MEDICAL CONDITION] of her leg. Pulse is very difficult to palpate. Handheld Doppler reveals elongated monophasic pulses worse on the right than the left..." A Surgical Pathology report, dated [DATE], documented a [DIAGNOSES REDACTED]. A Surgical Pathology report, dated [DATE], documented, "...[DIAGNOSES REDACTED]. ...Procedure/Site: right great toe amputation..." A Discharge Summary, from the hospital, dated [DATE], documented, "...The decision was made to discharge the patient to LTAC for continuation of antibiotics and wound care..." A physician's order, written by LPN #2, dated [DATE], documented: "Clarification for [DATE]: Apply skin prep to R medial foot below grt toe to callous QD. Diagnosis: [REDACTED]. Clarification for [DATE]: Cleanse scabbed area to R medial foot below grt toe c NS, pat dry, apply skin prep, cover c 4x4, wrap c Kling, secure c tape QD. Diagnosis: [REDACTED]. An update to the care plan, dated [DATE], documented, "clarification for [DATE] - apply skin prep to medial foot (arrow down) grt toe to callous QD clarification [DATE] - cleanse scabbed area to R medial foot below grt toe c NS, pat dry apply skin prep, cover c 4x4, wrap c Kling secure c tape QD." An Operative Report, dated [DATE], documented the resident had a right [MEDICAL CONDITION]. On [DATE] at 2:14 p.m., the resident's nursing home physician was asked about the resident's wound on her right foot. He stated he was not aware the resident had a wound on her right foot. At 3:21 p.m., the wound care physician was asked when she was made aware of the wound to the resident's right foot. She stated she was made aware of the wound to the resident's right foot on [DATE]. At 3:30 p.m., the administrator was asked when she was made aware of a wound to the resident's right foot. She stated she was told in February on the day the resident was sent to the hospital. She stated the resident had a pin point area on her right foot. At 4:30 p.m., an interview was conducted with CNA #1 regarding resident #1 having a wound to her right foot. The CNA stated she had seen a wound on the resident's right foot. She stated the wound was a big huge blister like area with a hole, that looked mushy. She also stated the wound had heavy drainage. She stated the dressings had to be changed frequently. She stated she would ask LPN #2 to change the dressing and she would not change the dressing so she would ask LPN #1 to change the dressing. She stated the resident began to decline and became lethargic and would not eat. At 5:20 p.m., the facility wound care nurse was asked when she was aware the resident had a wound to her right foot. She stated she was made aware of the wound on [DATE]. At 5:30 p.m., LPN #3 was asked when she was aware the resident had a wound to her right foot. She stated she was made aware of the wound when she returned to work the week of [DATE]. At 6:14 p.m., LPN #1 was interviewed regarding the wound on the right foot of the resident. She stated she didn't know anything about her right foot. She stated she did apply skin prep to the resident's foot but she could not remember which foot it was. She stated the wound on the right foot looked like a small, round, scabbed, light black area. LPN #2 was the day shift nurse assigned to the hall where the resident resided and was responsible for the resident's care. LPN #2 no longer worked at the facility. A review of her file documented LPN #2 was disciplined on several occasions for not assessing residents, not documenting resident assessments and falling asleep at the desk. The facility provided documentation showing LPN #2 failed to assess other resident's skin or wounds for residents who were in her care. On [DATE] at 11:15 a.m., LPN #4 identified LPN #2 as the nurse who wrote an entry on the treatment sheet of the resident on [DATE] and [DATE]. LPN #4 also identified LPN #2 as the nurse who wrote clarification orders on [DATE], for treatments dated [DATE] and [DATE]. LPN #4 also identified LPN #2 as the nurse who documented late entry's in the nurses' notes, dated [DATE] for documentation that should have been written in the nurses' notes on [DATE] and [DATE]. On [DATE] at 2:03 p.m., LPN #2 was asked how the wound on the right foot of resident #1 presented. She stated it was a pin point black area on the resident's right foot. On [DATE] at 1:00 p.m., a family member of the resident was asked what was the date that the family became aware of the wound to the resident's foot. The family member stated the resident's foot was unwrapped on [DATE] by another family member. The family member stated she received a phone call on [DATE] from another family member who told her that their relative, who had just left the facility from visiting the resident, was very upset and stated that the resident's foot looked awful and they are going to have to cut her foot off. The family member stated she then called the facility on [DATE] and asked to speak to the resident's nurse. She stated when the nurse got on the phone she asked her what was going on with the resident's foot. She stated her relative told her that the resident's foot looked really bad and they were probably going to have to cut it off. She stated, the nurse said to her, "No it's really, really red, it definitely needs to be looked at, but it's not a huge issue, I don't think." The family member stated she called back that evening to see how the resident was doing and the nurse told her, the resident was doing fine, she was resting. The family member stated she called the facility the next morning on [DATE], and spoke with LPN #4 in regards to the resident's foot. She stated the nurse told her she was going to look at the resident's foot and call the wound doctor. She stated she would call her back and let her know something later. The family member stated LPN #4 called her back that afternoon and told her the wound doctor would be out on Wednesday to look at the resident's foot. The family member stated something must have transpired because she received a call that same day ([DATE]) at 2:00 p.m., from LPN #4 and she told her they were going to send the resident to the hospital because they felt like she needed IV antibiotics. The family member stated she told the nurse she would leave work at 3:30 to meet the resident at the hospital. The family member stated she left work at 3:30 p.m., and while she was in route to the hospital emergency room to meet the resident she received a phone call from the emergency room physician. She stated the physician stated there was a very big possibility they were going to have to amputate. The family member stated when she arrived at the hospital she went in to see the resident and pulled the sheet back to look at her foot because at that point she knew the resident's foot was not just really, really red like the nurse at the facility had told her. She stated the emergency room physician told her the resident's white blood cell count was greater than 31,000 and that she was septic from a staph infection. At 1:20 p.m., another family member was asked what day she unwrapped the resident's foot. She stated she couldn't remember the date, but it was the same day her relative reported to the first family member about how bad the resident's foot was. She stated the resident had a black area on half of her foot. She asked the nurse what happened to the resident's foot and what they were doing about it. She stated the nurse told her they were going to scrape the black part off of her foot because they did that kind of stuff right there in the facility. She stated she noticed the resident was not moving at all which was not normal for her.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to assess a wound, notify the physician of the emergence of a new wound and when there were changes in a wound, and obtain physician's orders for treatments to be provided to the wound for resident #1. The resident developed a wound to the right foot, with an infection [MEDICAL CONDITION], was sent to the hospital, and required an amputation of the right great toe, and then an amputation of the lower leg below the knee. The resident expired on [DATE]. At 7:40 p.m., the Oklahoma State Department of Health was notified and verified the existence of the Immediate Jeopardy situation. At 7:45 p.m., the facility Administrator and Director of Nurses were informed of the IJ situation, which constituted substandard quality of care. A plan of removal for the immediate jeopardy was received and accepted at 8:35 p.m. on [DATE]. The plan of removal documented: "The plan of REMOVAL FOR IJ.............. Related to Failure to assess wound call the physician and to provide care and treatment to a wound. Our plan of removal will consist of the following: 1. Physician will be called and notified and orders will be received immediately when any wounds are found. If the wound care physician provides treatments and new orders for residents the primary physician will be called and informed of Wound physician and of orders received from that physician. All orders will be implement upon receiving orders from the physician. 2. Nursing Staff has been in-serviced on identifying, reporting contacting physician. Receiving and implementing orders. 3. A full skin sweep of EVERY RESIDENT in the building will be completed by 10 am on Thursday [DATE]. If any new wounds are found the physician will be contacted and orders received and implemented. 4. In-service of all nursing staff has been competed on [DATE] on identifying and reporting any wounds and receiving and implementing treatments. By 10 am [DATE]" The immediate Jeopardy was removed on [DATE] at 10:30 a.m., when the facility provided evidence that all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on observation, record review and interview, it was determined the facility failed to assess a wound, notify the physician of the emergence of a new wound and when there were changes in a wound, and obtain physician's orders for treatments to be provided to the wound for one (#1) of six sampled residents with skin conditions. This resulted in an immediate jeopardy situation for resident #1. The resident developed a wound to the right foot, with an infection [MEDICAL CONDITION], was sent to the hospital, and required an amputation of the right great toe, and then an amputation of the lower leg below the knee. The resident expired on [DATE]. This had the potential to affect 24 residents identified by the facility with skin breakdown. Findings: A facility policy titled, Pressure Ulcer Risk Assessment, documented, "... 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a 'skin alert,' performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes..." A facility policy titled, Physician Medication Orders, documented, "...Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state... No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses... Orders must be written and maintained in chronological order..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan problem, dated [DATE], documented the resident was at risk for developing skin breakdown. Interventions included: "Provide measures to decrease pressure/irritation to skin: fleece pad, egg crate mattress, heel protectors. Keep skin clean and dry... Avoid hot water and irritating soaps Keep bed linen clean, dry, and free of wrinkles Assist resident to turn and reposition every two hours Position with pads and cushions to prevent pressure Wound consult as ordered... Inspect and chart skin integrity every day Treatments and dressings as ordered per physician Inspect skin daily with and care and bathing, and report any changes to charge nurse Inspect skin complete body head to toe every week and document results Condition of each area of skin breakdown to be documented each day and with every treatment and/or dressing change Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Notify physician of any worsening of skin breakdown." A weekly skin assessment, dated [DATE], documented the resident's skin was warm, dry and intact with a reddened area to the ball of the left foot below the great toe, and a treatment was in place. An update to the care plan, dated [DATE], documented, "cleanse area to ball of left foot below grt toe c DWC, pat dry, apply skin prep q shift." A weekly skin assessment sheet for [DATE], dated [DATE] (sic), documented the resident's skin was warm and dry and was not intact. No abnormalities were listed. A comprehensive assessment, dated [DATE], documented the resident could usually understand others and could usually make herself understood by others. The assessment also documented the resident required extensive one person assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene and bathing. The assessment documented the resident was non-ambulatory and a wheelchair was used for mobility. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident was at risk for developing pressure ulcers, had no pressure ulcers, and had no venous or arterial ulcers. For skin and ulcer treatments, the assessment documented the application of ointments/medications other than to feet. A care plan, dated [DATE], documented a problem of, "Skin, Fragile Potential for skin breakdown and infection. (Resident) gets skin tears and bruising easily. (Resident) has dry skin. Interventions included: "All staff to be aware of (resident's) skin fragility All staff to be instructed in skin protection techniques for repositioning and transferring resident Inspect skin with morning and evening care and when bathing Document each incident of bruising or skin tear, and tailor interventions to prevent further occurrences..." A weekly skin assessment, dated [DATE], documented the resident's skin was warm, dry and intact. A treatment sheet for [DATE], documented a new wound treatment added to the sheet on [DATE]. The treatment sheet entry documented, "Apply skin prep to R medial foot below grt (great) toe to callous QD (every day) [DATE]." There was no documentation of a new physician's order for this treatment on [DATE]. There was no documentation of an assessment of the area to the right foot. There was no documentation to show the physician was notified of the area to the right foot. A weekly skin assessment, dated [DATE], documented the resident's skin was warm, dry and intact. The February monthly physician's orders did not include an order for [REDACTED]. A treatment sheet for February 2013, documented a new wound treatment was added to the sheet on [DATE]. The treatment sheet entry documented, "Cleanse scab bed area to R medial foot below grt toe c NS, pat dry apply skin prep cover c 4x4, wrap c Kling secure c tape QD. [DATE]." There was no documentation of a new physician's order for this treatment on [DATE]. There was no documentation of an assessment of the area to the resident's right foot, which necessitated the need for a change in treatment. There was no documentation to show the physician was notified of the area to the right foot. A Pain Monitoring Tool, documented the resident was medicated on ,[DATE] at 9:10 a.m., with two [MEDICATION NAME] 325 mg, for complaints of pain in her right foot, rated as a 7. A nurse's note, dated [DATE] at 11:00 a.m., documented, "Upon skin eval plantar wound noted to R bottom medial foot. Open area 2 x 2 cm. 100% necrotic et dry 0 drainage 0 odor. Wound physician notified will visit @ 1400 (2:00 p.m.) today. N/O recd to wound culture..." A wound care physician's note, dated [DATE] at 2:10 p.m., documented "...Chief Complaint:...Plantar Ulcer History of present illness:...Patient who developed severe plantar ulcer in less than 24 hrs (hours) with associated [MEDICAL CONDITION] Assessment:...Wound Location (s): R Plantar...10.5 x 4 cm... Etiology (type) Other: infection...Exudate yes small Exudate Type Sero-Sanguinous Fleshy Peri Wound Tissue [DIAGNOSES REDACTED] Eschar yes Black Hard 20% of wound base...Problem List: 1. Plantar ulcer - with associated [MEDICAL CONDITION]: Incision made with fleshy discharge, cultures taken. Pain ,[DATE]. R/O Plantar necrotizing fascitis... Assessment/Plan: Send patient to ER for evaluation..." A nurse's note, at 2:45 p.m., documented, "(Ambulance company) and (MD name deleted) notified." A nurse's note, at 3:00 p.m., documented, "(Ambulance company) here to transfer to ER, transported to (hospital name deleted), family notified." A nurse's note, dated [DATE] at 3:00 p.m., documented, "Late Entry for [DATE] - 3 cm round scabbed area noted to medial aspect of ball of foot, @ base of great toe, 0 redness or drainage noted, will notify skin nurse to have wound doctor assess on Wednesday [DATE]." An untimed nurse's note, dated [DATE], documented, "Late Entry for [DATE] @ 1400 (2:00 p.m.), res noted c callus to R medial foot below grt toe, N/O skin prep QD, monitor." An untimed nurse's note, dated [DATE], documented, "Late Entry for [DATE] @ 1300 (1:00 p.m.) res noted c scab (dark in color) to R medial foot below grt toe, N/O for skin prep to area & wrap c 4 x 4 & Kling OD." The Emergency Department Report, from the hospital, dated [DATE], documented: "...HISTORY OF PRESENT ILLNESS: The patient was sent to the hospital via EMS for an infection in her right foot. It was unclear how long it has been going on. By report, it has been going on for about 4 or 5 days according to the family...SKIN: Otherwise clean, dry, and intact with a notable exception of her right foot ________ necrosis over a hammertoe on the left side over the medial aspect of the distal metatarsal on the right foot. There is [DIAGNOSES REDACTED]. There are some slightly hemorrhagic changes around the area of necrosis. There is [DIAGNOSES REDACTED] of the foot circumferentially around this area of a break in the skin. Her dorsalis pedis, femoral, and posterior tibial pulses are 2+. The History and Physical report from the hospital, dated [DATE], documented: "...Assessment and Plan: The patient is an [AGE] year-old woman. She has fairly severe dementia...so history is taken from the patient's (family member) and from the emergency room doctor. The patient's (family member)...said that her sister had been visiting the patient recently and said she had been having some trouble with not eating very well and has been more lethargic than usual for about the last 2 weeks...Skin...On her left foot, she does have a very slight wound on the hammer toe on left foot...There is a little bit of surrounding [DIAGNOSES REDACTED]. On the right foot, though, there is significant [DIAGNOSES REDACTED] on most of the foot. The bottom of the foot has what appears to be a large hematoma. It is very dark-colored. There is a break in the skin on the dorsal aspect that when I press on the wound, it does leak liquid that is a mixture of some purulent-looking fluid along with a little bit of blood..." A Consultation Report completed by a podiatrist, dated [DATE], documented: "...History of Present Illness: This is an [AGE] year-old female who presents with an infected ulceration, right foot. Her (family member), (name deleted), states just made known of it on Sunday ([DATE])... Physical Examination: DERM: There appears to be ulceration started over the medial aspect of the head of the first metatarsal, right foot. She has extremely large bunion deformity with crossover second toe. She now has abscess extending into her arch about 6 or 7 cm and about 2 to 3 cm wide. It is a uneven border. The center portion has pus draining from it. Was able to cut through this approximately 3 to 4 cm. Also has [DIAGNOSES REDACTED] extending into her arch and onto the dorsum of her foot, but no [MEDICAL CONDITION] of her leg. Pulse is very difficult to palpate. Handheld Doppler reveals elongated monophasic pulses worse on the right than the left..." A Surgical Pathology report, dated [DATE], documented a [DIAGNOSES REDACTED]. A Surgical Pathology report, dated [DATE], documented, "...[DIAGNOSES REDACTED]. ...Procedure/Site: right great toe amputation..." A Discharge Summary, from the hospital, dated [DATE], documented, "...The decision was made to discharge the patient to LTAC for continuation of antibiotics and wound care..." A physician's order, written by LPN #2, dated [DATE], documented: "Clarification for [DATE]: Apply skin prep to R medial foot below grt toe to callous QD. Diagnosis: [REDACTED]. Clarification for [DATE]: Cleanse scabbed area to R medial foot below grt toe c NS, pat dry, apply skin prep, cover c 4x4, wrap c Kling, secure c tape QD. Diagnosis: [REDACTED]. An update to the care plan, dated [DATE], documented, "clarification for [DATE] - apply skin prep to medial foot (arrow down) grt toe to callous QD clarification [DATE] - cleanse scabbed area to R medial foot below grt toe c NS, pat dry apply skin prep, cover c 4x4, wrap c Kling secure c tape QD." An Operative Report, dated [DATE], documented the resident had a right [MEDICAL CONDITION]. On [DATE] at 2:14 p.m., the resident's nursing home physician was asked about the resident's wound on her right foot. He stated he was not aware the resident had a wound on her right foot. At 3:21 p.m., the wound care physician was asked when she was made aware of the wound to the resident's right foot. She stated she was made aware of the wound to the resident's right foot on [DATE]. At 3:30 p.m., the administrator was asked when she was made aware of a wound to the resident's right foot. She stated she was told in February on the day the resident was sent to the hospital. She stated the resident had a pin point area on her right foot. At 4:30 p.m., an interview was conducted with CNA #1 regarding resident #1 having a wound to her right foot. The CNA stated she had seen a wound on the resident's right foot. She stated the wound was a big huge blister like area with a hole, that looked mushy. She also stated the wound had heavy drainage. She stated the dressings had to be changed frequently. She stated she would ask LPN #2 to change the dressing and she would not change the dressing so she would ask LPN #1 to change the dressing. She stated the resident began to decline and became lethargic and would not eat. At 5:20 p.m., the facility wound care nurse was asked when she was aware the resident had a wound to her right foot. She stated she was made aware of the wound on [DATE]. At 5:30 p.m., LPN #3 was asked when she was aware the resident had a wound to her right foot. She stated she was made aware of the wound when she returned to work the week of [DATE]. At 6:14 p.m., LPN #1 was interviewed regarding the wound on the right foot of the resident. She stated she didn't know anything about her right foot. She stated she did apply skin prep to the resident's foot but she could not remember which foot it was. She stated the wound on the right foot looked like a small, round, scabbed, light black area. LPN #2 was the day shift nurse assigned to the hall where the resident resided and was responsible for the resident's care. LPN #2 no longer worked at the facility. A review of her file documented LPN #2 was disciplined on several occasions for not assessing residents, not documenting resident assessments and falling asleep at the desk. The facility provided documentation showing LPN #2 failed to assess other resident's skin or wounds for residents who were in her care. On [DATE] at 11:15 a.m., LPN #4 identified LPN #2 as the nurse who wrote an entry on the treatment sheet of the resident on [DATE] and [DATE]. LPN #4 also identified LPN #2 as the nurse who wrote clarification orders on [DATE], for treatments dated [DATE] and [DATE]. LPN #4 also identified LPN #2 as the nurse who documented late entry's in the nurses' notes, dated [DATE] for documentation that should have been written in the nurses' notes on [DATE] and [DATE]. On [DATE] at 2:03 p.m., LPN #2 was asked how the wound on the right foot of resident #1 presented. She stated it was a pin point black area on the resident's right foot. On [DATE] at 1:00 p.m., a family member of the resident was asked what was the date that the family became aware of the wound to the resident's right foot. The family member stated the resident's foot was unwrapped on [DATE] by another family member. The family member stated she received a phone call on [DATE] from another family member who told her that their relative, who had just left the facility from visiting the resident, was very upset and stated that the resident's foot looked awful and they are going to have to cut her foot off. The family member stated she then called the facility on [DATE] and asked to speak to the resident's nurse. She stated when the nurse got on the phone she asked her what was going on with the resident's foot. She stated her relative told her that the resident's foot looked really bad and they were probably going to have to cut it off. She stated, the nurse said to her, "No it's really, really red, it definitely needs to be looked at, but it's not a huge issue, I don't think." The family member stated she called back that evening to see how the resident was doing and the nurse told her, the resident was doing fine, she was resting. The family member stated she called the facility the next morning on [DATE], and spoke with LPN #4 in regards to the resident's foot. She stated the nurse told her she was going to look at the resident's foot and call the wound doctor. She stated she would call her back and let her know something later. The family member stated LPN #4 called her back that afternoon and told her the wound doctor would be out on Wednesday to look at the resident's foot. The family member stated something must have transpired because she received a call that same day ([DATE]) at 2:00 p.m., from LPN #4 and she told her they were going to send the resident to the hospital because they felt like she needed IV antibiotics. The family member stated she told the nurse she would leave work at 3:30 to meet the resident at the hospital. The family member stated she left work at 3:30 p.m., and while she was in route to the hospital emergency room to meet the resident she received a phone call from the emergency room physician. She stated the physician stated there was a very big possibility they were going to have to amputate. The family member stated when she arrived at the hospital she went in to see the resident and pulled the sheet back to look at her foot because at that point she knew the resident's foot was not just really, really red like the nurse at the facility had told her. She stated the emergency room physician told her the resident's white blood cell count was greater than 31,000 and that she was septic from a staph infection. At 1:20 p.m., another family member was asked what day she unwrapped the resident's foot. She stated she couldn't remember the date, but it was the same day her relative reported to the first family member about how bad the resident's foot was. She stated she the resident had a black area on half of her foot. She asked the nurse what happened to the resident's foot and what they were doing about it. She stated the nurse told her they were going to scrape the black part off of her foot because they did that kind of stuff right there in the facility. She stated she noticed the resident was not moving at all which was not normal for her.