Every finding on record at Tulsa Center for Rehabilitation and Healthcare

Based on observation, record review, and interview, the facility failed to ensure dignity was maintained while residents were assisted with meals for 1 (#2) of 3 sampled residents reviewed for dignity.The administrator identified eight residents who were dependent on staff for eating.Findings:On 05/14/26 at 12:30 p.m., LPN #3 was observed standing while assisting Resident #2 with the noon meal.A quarterly assessment, dated 04/22/26, showed Resident #2 had a BIMS score of 10 which indicated moderate cognitive impairment. The assessment showed Resident #2 was dependent on staff for eating.On 05/14/26 at 12:50 p.m., LPN #3 stated staff should sit while assisting residents with eating to maintain dignity when dining.On 05/14/26 at 1:10 p.m., the DON stated staff should be seated next to the resident they were assisting to ensure dignity with dining.

Based on observation, record review, and interview, the facility failed to maintain infection control for residents with indwelling urinary catheters for 1 (#5) of 3 sampled residents reviewed for infection control.The administrator identified 11 residents with indwelling urinary catheters.Findings:On 05/14/26 at 11:00 a.m., CNA #3 and LPN #3 were observed to transfer Resident #5 from their bed to their wheelchair using a mechanical lift. CNA #3 was observed to place the catheter drainage bag on the floor. CNA #3 was observed to run over the catheter drainage bag with the wheel of the mechanical lift. CNA #3 was observed to slide the catheter bag along the floor from the front of the wheelchair to the back of the wheelchair.An annual assessment, dated 04/02/26, showed Resident #5 had a BIMS score of 15 which indicated intact cognition. The assessment showed Resident #5 had an indwelling urinary catheter and was dependent on staff for transfer from bed to chair.On 05/14/26 at 11:08 a.m., CNA #3 stated catheter bags should not be placed on the floor.On 05/14/26 at 11:10 a.m., LPN #3 stated catheter drainage bags should not be placed on the floor, slid along the floor, or ran over with the wheel of the mechanical lift.On 05/14/26 at 1:10 p.m., the DON stated catheter drainage bags should always be kept off the floor.

Based on observation, record review, and interview, the facility failed to ensure the call light system was functioning for 3 (#4, 6, and #8) of 5 sampled residents reviewed for functioning call lights. The administrator identified 121 residents resided at the facility.On [DATE] at 5:24 a.m., the call lights in room [ROOM NUMBER] and room [ROOM NUMBER] were observed to be on in the hallway. The call light alert box at the nurses' station was observed to show cord out for room [ROOM NUMBER] and room [ROOM NUMBER]. On [DATE] at 10:50 a.m., the call light box for room [ROOM NUMBER] was observed to be missing. Bare wires were observed to hang from the wall where it had been located.A policy titled Call Lights: Accessibility and Timely Response, dated 2025, read in part, Assure the facility is adequately equipped with a call light at each residents' bedside.Staff will report problems with a call light or call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.A Call Box Check Log, dated [DATE] through [DATE], showed rooms [ROOM NUMBER] had missing call light boxes.On [DATE] at 10:50 a.m., Resident #6 stated their call light did not work and there had been issues with it for several weeks. On [DATE] at 11:01 a.m., CNA #6 stated they knew room [ROOM NUMBER] and room [ROOM NUMBER]'s call lights did not work. They stated they were not aware the call lights in room [ROOM NUMBER] and room [ROOM NUMBER] did not work and was not sure if the residents had other ways to let them know they needed something. CNA #6 stated they usually checked on everyone frequently and residents would yell at them if they needed something.On [DATE] at 11:16 a.m., the maintenance supervisor stated there had been ongoing issues with the call light boxes requiring repairs and replacements, with several call light boxes missing. On [DATE] at 1:30 p.m., the DON stated there were ongoing issues with call lights. The DON stated residents were provided whistles or bells if their call lights did not work. The DON stated they were not sure which lights were not working.

Based on record review and interview, the facility failed to ensure residents were free from abuse for 1 (#5) of 3 sampled residents reviewed for abuse. The administrator identified 125 residents resided in the facility. Findings:An undated facility policy titled Abuse and Neglect Policy and Procedure, read in part, Identify, assess, care-plan, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care or are totally dependent on staff. Monitor the resident for early warning signs or any changes that would trigger abuse behavior and reassess strategies on a regular basis. An undated admission record showed Resident #5 had diagnoses which included violent behavior, dementia, depression, mood disorder, anxiety, and conduct disorder. An Incident Report Form, dated 10/27/25, showed Resident #5 threw soda on CNA #2 who threw a drink back in Resident #5's face. The form showed as CNA #2 was walking down the hall they were heard saying Ya'll better get ahold of that [explicit language]. I don't even play like that. CNA #2 was immediately suspended pending investigation and terminated on 10/30/25.A care plan for Resident #5, dated 01/11/26, showed the resident had the potential to demonstrate behaviors such as yelling out, swinging at staff and residents, cussing, and making racial slurs toward staff. A quarterly assessment for Resident #5, dated 01/11/26, showed the resident had a brief interview for mental status score of 7, which indicated they were moderately impaired for daily decision making. An in-service form titled Abuse In-service sign in sheet, dated 02/07/26 was provided by the administrator.On 02/24/26 at 11:30 a.m., the administrator provided a form titled QAPI [quality assurance and performance improvement] AGENDA, dated 11/20/25, which showed topics: a. falls with and without injury,b. infection,c. wounds -pressure ulcers,d. outstanding reportables,e. abuse and neglect,f. laboratory,g. performance improvement plans,h. quality measures, and i. staffing and retention. On 02/26/26 at 2:00 p.m., the administrator stated Resident #5 was known to be combative, yelled, and called staff racial slurs and vulgar names. The administrator stated they explained to CNA #2, they could not react to the resident's behavior by throwing things at them and they terminated CNA #2. The administrator stated they presented an in-service regarding abuse for all staff on 02/09/26.On 02/26/26 at 3:00 p.m., receptionist #1 stated they saw Resident #5 sitting near CNA #2 in the common room. Receptionist #1 stated CNA #2 was charting on an iPad when Resident #5 suddenly threw a can of soda at CNA #2. Receptionist #1 stated CNA #2 immediately jumped up and threw the soda can back into Resident #5's face. Receptionist #1 stated CNA #2 walked off down the hall stating, Yall better get that [explicit language], I don't even play like that. Receptionist #1 stated they immediately reported the incident to the administrator.On 03/02/26 at 1:11 p.m., Resident #5 stated they have not had a staff member throw a drink at them or abuse them. On 03/03/26 at 9:47 a.m., during a phone interview, CNA #2 stated they were at a table feeding residents when Resident #5 began calling them racial names. CNA #2 stated they turned their back to Resident #5. CNA #2 stated when they turned back around Resident #5 threw their drink at them. CNA #2 stated they had a bowl in their hand and the drink hit the bowl knocking it to the table spilling all the other cups on the table. CNA #2 stated some of the drinks splashed on Resident #5 causing the resident to start yelling CNA #2 had thrown a drink at them.

Based on record review and interview, the facility failed to ensure daily weights were obtained according to physician orders for 1 (#1) of 3 sampled residents reviewed for daily weights.The administrator identified 114 residents resided in the facility. Findings:A 24-hour skin assessment, dated 09/05/25 at 8:11 p.m., showed Resident #1 had bilateral lower extremity pitting edema and weeping of the right leg.A review of the vitals tab in the facility electronic health record showed on 09/06/25 Resident #1 weighed 256.3 pounds and on 09/23/25 Resident #1 weighed 273.2 pounds. Daily weights were not obtained in the month of September after an order was received from the hospital for daily weights on 09/23/25.A review of the vitals tab in the facility electronic health record showed on 10/14/25 Resident #1 weighed 267.5 pounds. Daily weights were not obtained in the month of October.A comprehensive assessment, dated 09/15/25, showed Resident #1 had a brief score for mental illness of 15 which indicated the resident was cognitively intact for daily decision making. The assessment showed diagnoses which included coronary artery disease, hypertension, peripheral vascular disease, respiratory failure, ischemic cardiomyopathy, and a history of coronary artery bypass graft.Hospital discharge orders, dated 09/23/25, showed discharge instructions to weigh Resident #1 daily and to notify the physician if a gain of three pounds or more in 48 hours or less. A physician visit note, dated 09/24/25, showed Resident #1 was seen by the APRN for a chronic care follow-up after hospital readmission. The note showed the current weight of 273 pounds and a previous weight of 256 pounds on 09/06/25. The note showed this was a gain of 17 pounds. There were no new orders.A review of October 2025 active orders for Resident #1 showed no orders to weigh daily or to restrict fluid intake.A progress note, dated 10/09/25 at 10:35 a.m., showed the left arm of Resident #1 was red and swollen with clear liquid drainage. The note showed an order was received for an antibiotic for seven days.A care plan, revised 10/14/25, showed cellulitis to the left upper extremity with risks for complications. The care plan showed a problem for peripheral vascular disease with interventions to include elevating the edematous extremity to promote venous return. The care plan did not show an intervention to weigh Resident #1 or to restrict their fluid intake.A progress note, dated 10/15/25, showed Resident #1 called 911 themself to go to the hospital due to cellulitis in their arm. A hospital clinical update, dated 10/15/25, read in part, CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS: 60 y.o. [year old] [sex omitted] presents to [hospital name withheld] for further evaluation of fluid overload. Per patient report [Resident #1] has been having increasing swelling in [their] lower extremities as well as [their] left upper extremity over the last 7 to 10 days. Patient also has admitted shortness of breath and orthopnea [shortness of breath while lying down]. Patient also admits to decreased appetite .Due to [their] increased swelling at the nursing home family called 911 from nursing home for patient to be taken from nursing home to ER [emergency room] for further evaluation and treatment. In the emergency department patient with chest x-ray concerning for pulmonary congestion [a condition where fluid accumulates in the lungs] and worse left sided atelectasis [a partial or complete collapse of the lung tissue] .Due to elevated troponin [lab test which indicates damage to the heart muscle or indicates heart failure] and BNP [brain natriuretic peptide is a hormone the heart releases when it is under stress, like heart failure] concern patient congestive heart failure exacerbation.A hospital Clinical Update, dated 10/22/25, showed Resident #1 was admitted to the hospital on [DATE] with a principal problem of congestive heart failure exacerbation and a weight of 291.45 pounds. The clinical update showed the last hospital weight on 09/23/25 was 273.81 pounds. This was a gain of 6% in one month.On 10/24/25 at 9:41 a.m., licensed practical nurse #1 stated the protocol for monitoring fluid overload was to weigh daily at the same time. They stated they would expect to obtain daily weights on residents with CHF or if bilateral edema was noted.On 10/24/25 at 9:47 a.m., the DON stated the nurse management entered the hospital discharge orders. They stated the best practice for monitoring fluid overload was intake and output monitoring and weights. The DON stated they would typically obtain weights for residents who had a diagnosis of CHF, but not always, if it were well controlled.On 10/24/25 at 10:41 a.m., the DON stated they did not show a diagnosis of CHF for Resident #1 and did not have a justified reason to obtain daily weights or intake and output volumes.On 10/24/25 at 10:23 a.m., the APRN stated the best practice for monitoring fluid overload for a resident with CHF would depend on how controlled they were, but if they were not controlled then they would order daily weights then weekly weights, and trend shortness of breath or edema. They stated they had noted Resident #1 had gained weight, but did not feel it was fluid overload. The APRN stated Resident #1 was hypotensive (low blood pressure) and they did not have room to go up on their diuretic medications. They stated the weights probably still should have been obtained. They stated they were made aware of the swelling and draining and that was when they ordered antibiotics.

Based on record review and interview, the facility failed to ensure a resident diagnosed with diabetes mellitus, who was ordered a routine blood test to monitor blood sugar levels, received the test for 1 (#2) of 5 sampled residents reviewed for unnecessary medications.The DON stated 60 residents at the facility had diabetes and all had their A1C tested at least annually.Findings:A facility policy titled Laboratory Services and Reporting, dated 07/2025, read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.A face sheet, dated 08/01/25, for Res #2 showed the resident had diagnosis of diabetes mellitus.A physician's medication order, dated 08/01/25, showed Res #2 was to be administered Lantus Solostar (a brand of insulin) 100 units/ml. The order showed Res #2 was to receive 5 units of the insulin in the morning and 27 units in the afternoon.A physician's lab order, dated 10/04/24, showed Res #2 was to have a blood sample collected for an A1C test that would show the resident's average blood sugar level over the previous 3 months. The order showed the A1C test was to be conducted every February, May, August, and November.On 08/21/25 at 10:20 a.m., the administrator was asked to provide Res #2's A1C test results. The administrator stated they had searched the resident's records and had not found A1C test results for 02/2025. They stated they had thought at the time the dialysis company had been collecting those labs, so they had not.On 08/21/25 at 1:07 p.m., the ADON was asked if the A1C test results for Res #2 had been collected and tested. The ADON stated they had found the A1C test results for each month except for 02/2025. The ADON stated they had spoken with the contracted dialysis company that month and they believed the dialysis staff were going to perform the A1C test. The ADON stated that was why they did not collect the blood sample for testing. They stated in the end, Res #2's A1C was not collected as ordered for February 2025. The ADON stated the residents A1C was not tested again until May 2025.

Based on observation, record review and interview the facility failed to ensure medications were secure for 1 of 3 carts on the Southeast Hall. The DON identified 108 residents resided in the facility. Findings:On 08/20/25 at 10:47 a.m., a green capsule in a plastic medication cup was observed sitting on top of the medication cart unattended on the Southeast Hallway. A Policy dated 04/2018, titled Medication Storage In The Facility, read in part, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 08/20/25 at 10:54 a.m., LPN # 2 stated they had left the medication on top of the medication cart. LPN # 2 stated they had intended to administer it to a resident but forgot. They stated leaving the medication unattended on the cart could result in the wrong resident taking the medication and could cause a medication error. They stated it should not have been left out on top of the cart and should have been secured inside the cart.

Based on observation, record review, and interview, the facility failed to ensure staff were compliant with Infection prevention protocols during the provision of tracheostomy care for 1 (#5) of 5 residents reviewed for infection control procedures. The administrator identified 3 residents with a tracheostomy resided in the facility. On 08/20/25 at 12:48 p.m., LPN #1 was observed to provide tracheostomy care for Res #5. After starting care, LPN #1 discovered supplies needed were not available in the room, LPN #1 removed their gloves and gown and left the room. On 08/20/25 at 1:15 p.m., LPN #1 returned to the room with supplies and donned a gown and gloves in the room. LPN #1was not observed to sanitize their hands. LPN #1 then opened a pair of sterile gloves, removed the gloves they had on and donned sterile gloves. LPN #1 was not observed to sanitize their hands between glove changes. LPN #1 then opened supplies, opened an alcohol wipe and wiped off inner cannula with the alcohol wipe. LPN #1 cleaned the area around the tracheostomy site and placed the inner cannula. LPN #1 was not observed to change gloves between cleaning the site and placing the inner cannula. While wearing the same gloves, LPN #1 removed the old collar, cleaned the area around the site, opened a new collar, removed a pen from a pocket of their uniform, and labeled the collar. LPN #1 then placed the new collar, gathered up the trash and left the room. A physician order for Res #5, dated 01/30/25, showed enhanced barrier precautions were required related to tracheostomy care. A Hand Hygiene policy dated June 2025 showed a table for when hand sanitizing should occur. The table included:1. Before applying and after removing personal protective equipment (PPE), including gloves. 2. Before and after handling clean or soiled dressings. 3. After handling items potentially contaminated with blood, bodily fluids, secretions. On 08/21/25 at 2:44 p.m., the DON stated hand washing or sanitizing should occur before starting a procedure, between glove changes, and when the procedure was over.

Based on record review and interview, the facility failed to report an allegation of abuse to the OSDH within two hours for one (#4) of four sampled residents reviewed for abuse. The administrator reported the census was 104. Findings: A facility policy titled Abuse, Neglect, and Exploitation, revised 10/2023, read in parts, Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #4 had diagnoses which included quadriplegia and generalized anxiety disorder. An Incident Report Form, dated 08/10/24, documented around midnight on 08/10/24, Resident #4 and their significant other were having a physical altercation in the resident's room and the police were called. The inbound notification documented the report was received by the OSDH on 08/10/24 at 4:13 p.m. On 12/27/24 at 2:00 p.m., the administrator stated allegations of abuse should be reported to the OSDH within two hours.

Based on record review and interview, the facility failed to use a gait belt for one (#3) of three residents who were sampled for assist with transfers. The administrator identified 106 resident resided in the facility. Findings: Resident #3 had diagnoses which included dementia and amputation of left lower leg. An Incident Report Form, dated 09/24/24, documented staff was assisting the resident with a transfer without using a gait belt. The resident suffered a right knee abrasion. On 10/16/24 at 2:46 p.m., the administrator stated the staff member had been suspended, then terminated, due to not following the facilities standards regarding the use of gait belts during transfers. They stated the incident had been added to the QA on 10/01/24, re-education had been provided to the direct care staff on 10/01/24, and weekly monitoring of the use of gait belts during transfers was begun on 10/01/24, and is still ongoing with a completion date of monitoring of 11/15/24. Documentation of QA, education, and monitoring was provided by the administrator. On 10/17/24 at 11:18 a.m., the DON stated all current direct care staff were educated on 10/01/24. New staff continue to be educated on hire that all assisted transfers are to use a gait belt, and the employee is provided with a gait belt at that time. They stated each resident has a number code on their door that designates the level of assistance required by each resident.

Based on observation, record review, and interview, the facility failed to ensure sufficient dietary staff to provide alternative meals. The Administrator identified 109 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: An Alternative Menu, undated, documented the following alternatives were available for lunch and supper: loaded baked potatoes, chef salad, bologna and cheese sandwich, turkey and cheese sandwich hot or cold, ham and cheese sandwich hot or cold, grilled cheese sandwich, cheese burger with fries or chips and side salad, peanut butter and jelly sandwich, and three different soups. A Dietary Schedule, dated February 26th through 29th, 2024, documented four to six employees were scheduled. A Dietary Schedule, dated March 1st through 17th, 2024, documented three to six employees were scheduled. On 03/17/24 at 10:37 a.m., Resident #47 stated they would turn in their alternative meal request for supper shortly after lunch. Resident #47 stated there had been times the dietary staff told the residents they couldn't cook any alternatives because there wasn't enough staff. Resident #47 stated at other times, dietary staff stated the only alternative was a peanut butter and jelly sandwich. Resident #58 agreed with Resident #47's statements. On 03/17/24 2:35 p.m., Resident #73 stated when there wasn't enough dietary staff the only alternative meal was peanut butter sandwiches. On 03/18/24 at 1:41 p.m., the CDM was talking with Resident #47. Resident #47 asked the CDM why alternative meals were not provided as ordered. CDM stated the alternative meals were limited when there weren't enough staff . On 03/18/24 at 1:54 p.m., the CDM stated their corporation stated while dietary was short staffed to just offer peanut butter and jelly sandwiches as an alternative. The CDM stated they only offer peanut butter and jelly sandwiches. The CDM stated the last time the kitchen was short staffed was last Friday or Saturday. On 03/18/24 at 3:25 p.m., the Administrator stated they have only offered peanut butter and jelly sandwiches recently because there had been a few dietary staff out for personal reasons. On 03/18/24 at 3:42 p.m., the CDM stated seven people a day were needed to be adequately staffed.

Based on observation, record review, and interview, the facility failed to ensure alternative meals were provided for three (#47, 48, and #73) of three sampled residents reviewed for meal service. The Administrator identified 109 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube. Findings: An Alternative Menu, undated, documented the following alternatives were available for lunch and supper: loaded baked potatoes, chef salad, bologna and cheese sandwich, turkey and cheese sandwich hot or cold, ham and cheese sandwich hot or cold, grilled cheese sandwich, cheese burger with fries or chips and side salad, peanut butter and jelly sandwich, and three different soups. On 03/17/24 at 10:37 a.m., Resident #47 stated they would turn in their alternative meal request for supper shortly after lunch. Resident #47 stated there had been times the dietary staff told the residents they couldn't cook any alternatives. Resident #47 stated at other times, dietary staff stated the only alternative was a peanut butter and jelly sandwich. Resident #58 agreed with Resident #47's statements. On 03/17/24 2:35 p.m., Resident #73 stated recently the only alternative meal was peanut butter sandwiches. On 03/18/24 at 1:41 p.m., the CDM was talking with Resident #47. Resident #47 asked the CDM why alternative meals were not provided as ordered. CDM stated when there weren't enough staff the alternative meals were limited. On 03/18/24 at 1:54 p.m., the CDM stated they only offer peanut butter and jelly sandwiches at times. On 03/18/24 at 3:25 p.m., the Administrator stated they didn't have a policy regarding meal alternatives. She stated they have an alternative menu the residents can order from. She stated they have only offered peanut butter and jelly sandwiches recently.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one resident (#58) of six sampled resident reviewed for medications. The Administrator stated 109 residents resided in the facility. Findings: A Medication Ordering and Receiving from Pharmacy, policy read in part, .Reorder medications four days in advance of need .to ensure adequate supply is on hand . Resident #58 had diagnoses which included epilepsy, unspecified, not intractable, without status epilepticus. A care plan problem for seizures, dated 03/01/24, documented Resident #58's was to be administered medications as ordered. A controlled drug disposition report, dated 02/09/24, documented 60 doses of phenobarbital 64.8 mg had been delivered to the facility for the use of Resident #58. The report documented the last dose of the original 60 doses was signed out on 03/18/24 at 6:00 p.m. A medication administration record, dated 03/01/204 through 03/20/24, documented a dose of phenobarbital 64.8 mg was scheduled to be administered to Resident #58 on 03/19/24 between 5:30 a.m. and 6:30 a.m. The record documented the medication was not available to be administered to the resident. A medication administration record, dated 03/01/204 through 03/20/24, documented Resident #58 did not receive the AM or PM doses of phenytoin sodium 200 mg on 03/18/24. It documented the medication was not available. A controlled drug disposition report, dated 03/19/24, documented six doses of phenobarbital 64.8 mg had been delivered to the facility for the use of Resident #58. The report documented the first dose of the original six was signed out on 03/19/24 at 7:59 p.m. A progress note, dated 03/19/24 at 10:36 p.m., documented Resident #58 stated they had two seizures. It documented the resident was sent to the hospital per the resident's request. A progress note, dated 03/20/24 at 2:28 a.m., documented Resident #58 returned to the facility with a diagnosis of seizure like activity and a new order for phenytoin sodium 200 mg twice a day. It documented this was the current dose for the medication. On 03/20/24 at 1:34 p.m., CMA #1 stated Resident #58 had run out of phenobarbital 64.8 mg on 03/18/24 and it was ordered. They stated six doses of the medication arrived on 03/19/24. On 03/20/24 at 2:03 p.m., the ADON was shown Resident #58's March medication administration record and was asked if the medications had been administered as ordered. They stated, No.

Based on record review and interview, the facility failed to ensure an assessment was transmitted timely for one (#87) of two sampled assessments reviewed for accuracy. The Administrator identified 109 residents resided in the facility. Findings: A Face Sheet, documented Resident #87 expired [DATE]. A Death In Facility assessment, dated [DATE], documented In Progress. On [DATE] at 1:23 p.m., MDS Coordinator #2 stated they double check assessments at the end of each month to ensure resident assessments were completed. They stated they were unsure the time frame for ensuring a Death In Facility assessment was completed but they were usually completed within 48 hours. On [DATE] at 1:23 p.m., MDS Coordinator #2 reviewed Resident #87's assessment and stated it showed it was still in progress. They reviewed the assessment and stated there was a warning they needed to clear before it was finalized. They stated they didn't know why it wasn't caught with there double check procedure. They stated the assessment was completed but had not been submitted timely.

Based on observation and interview, the facility failed to ensure a shower stall and curtain was clean for one of one shower rooms observed. The Administrator identified 109 residents resided in the facility. Findings: On 03/17/24 at 10:15 a.m., the southeast shower room was observed. The middle shower stall was the only one with a shower curtain. The shower walls had hard water stains, and an area of black substance in the grout on the floor next to the wall. The substance was able to be scratched off. The shower curtain was observed to have brown and orange stains scattered from the top to the bottom of the curtain. On 03/20/24 at 9:48 a.m., Housekeeper #1 stated shower rooms were cleaned everyday. The shower room was observed. The same hard water stains and black substance in the grout was observed. The shower curtain had the same stains. On 03/20/24 at 9:58 a.m., Housekeeping supervisor stated shower rooms should be cleaned every day. She stated they monitored the shower rooms two to three times a day. She stated she didn't know the process for ensuring shower curtains were cleaned. She was made aware of the observations on 03/17/24 and 03/20/24 and was asked if the room had been adequately cleaned. She stated, No.

Based on observation and interview, the facility failed to ensure staff sanitized their hands between glove changes during wound care for two (#7 and #62) of two residents observed for wound care, and between residents when administering medications. The Resident Census and Conditions of Residents report, dated 09/06/23, documented four residents with pressure ulcers, and 99 residents who resided at the facility who received medications. Findings: 1. On 09/08/23 at 8:40 a.m., Resident #62 was observed for wound care. The wound nurse was observed to sanitize the over bed table using a Microkill cloth, removed gloves, moved trash can next to table, sanitized hands, placed wax paper on top of their sanitized cart, gathered their supplies, and locked their cart. The wound nurse obtained supplies and entered the room of Resident #62. The nurse sanitized their hands, opened packages, labeled and dated dressings, donned gloves, removed the dressing from the right hand of Resident #62, doffed gloves, and donned clean gloves. The wound nurse did not sanitize. The wound nurse then cleaned the wound. The nurse then doffed gloves, donned clean gloves, did not sanitize, applied calcium alginate, then bordered gauze. The nurse doffed their gloves and left the room to obtain more gloves, they did not sanitize their hands. When the nurse returned they sanitized their hands and donned clean gloves, removed the sock from the resident's left foot, and old dressing dated 9/7/23, doffed gloves, donned clean gloves, and did not sanitize their hands. The nurse then cleaned the wound twice. The nurse doffed and donned clean gloves and did not sanitize their hands. The nurse then applied the treatment, doffed and donned clean gloves, and did not sanitize their hands. On 09/11/23 at 3:13 p.m., Resident #7 was observed for wound care. The wound nurse sanitized their hands, gathered supplies, entered the resident's room and set up their field. The wound nurse donned clean gloves and verbalized the dressing had previously been removed by staff during incontinent care. The nurse then cleaned the wound. The nurse doffed their gloves, then donned clean gloves and did not sanitize their hands. The nurse applied the initialed and dated dressing and doffed their gloves, cleaned their area and left the room. On 09/11/23 at 3:31 p.m., the wound nurse was asked when they were to sanitize their hands when providing wound care. They stated before, in-between glove changes, and when finished. The nurse was asked if they had sanitized their hands between glove changes for both observed wound treatments. They stated, No. The nurse was asked why they did not sanitize between glove changes. They stated because they did not think about it. 2. On 09/12/23 at 8:44 a.m., CMA #1 was observed during medication administration. CMA #1 was observed to enter a resident room to obtain vital signs prior to medication administration. The resident was having difficulty with dizziness and CMA #1 informed the nurse who advised to hold medications until further instructed. CMA #1 did not sanitize their hands when they left the room and entered another resident room to obtain vital signs prior to administration of medications. CMA #1 returned to the cart, did not sanitize their hands, prepared medications for the resident, and returned to administer the medications. CMA #1 then returned back to the cart did not sanitize their hands, checked the electronic record and entered another resident room to obtain vital signs, returned to the cart and did not sanitize their hands prior to preparing medications for the resident. CMA #1 re-entered the resident room, administered the medications, and returned to their cart. CMA #1 was observed to not sanitize their hands. On 09/12/23 at 8:59 a.m., CMA #1 was asked when they were to sanitize their hands. They stated before medication administration, between residents, and if they touch anything in a resident room or a resident. The CMA stated they did not sanitize between residents.

Based on interview and record review, it was determined the facility failed to provide complete and informed advance notice of discharge from Medicare skilled services for three (#2, 16, and #146) of three residents who were reviewed for beneficiary protection notification. The Resident Census and Conditions of Residents report, documented 9 residents who had been discharged from Medicare skilled services in the last six months. Findings: 1. Resident #2 was admitted to Medicare Part A skilled services on 03/26/23. The resident was discharged from skilled services on 03/26/23. The resident had benefit days of skilled service coverage remaining at the time of discharge. Resident #2 continued at the facility for long term care. Review of the notice of Medicare non-coverage revealed the facility initiated the discharge from Medicare Part A services due to no progress with therapy. The form documented Resident #2 did not receive an SNF ABN Form CMS-10055 due to Resident #2 did not want continued services. 2. Resident #16 was admitted to Medicare Part A skilled services on 03/17/23. The resident was discharged from skilled services on 06/24/23. The resident had one day of skilled service coverage remaining at the time of discharge. Resident #16 continued at the facility for long term care. Review of the notice of Medicare non-coverage revealed, the facility had not provided Resident #16 with a NOMNC CMS-10123 or an ABN Form CMS-10055. 3. Resident #146 was admitted to Medicare Part A skilled services on 03/10/23. The resident was discharged from skilled services on 04/13/23. The resident had Medicare Part A Services benefit days remaining. Resident #146 continued at the facility for long term care. Review of the notice of medicare non-coverage revealed the facility had initiated the discharge from skilled services with benefit days remaining due to Resident #146 had met goals. The form documented a SNF ABN, Form CMS-10055 was not provided to the resident due to the resident stated they did not want continued services. A NOMNC CMS Form 10123 was provided. On 09/08/23 at 11:02 a.m., the RN case management specialist and traveling MDS coordinator, provided the SNF Beneficiary Protection Notification Reviews, and stated Resident #16 had one day remaining, but the facility thought, at the time of coming off skilled services, the resident had exhausted all 100 days. The RN was asked when it was determined Resident #16 had one skilled day remaining. They stated, they found out at the end of the month. On 09/08/23 at 11:38 a.m., the RN was asked who had initiated the discharge from skilled services for Resident #16. They stated they thought Resident #16 had used all 100 days so the facility initiated the discharge. The RN was asked why Resident #2 had not received an ABN. They stated they just did not give Resident #2 an ABN. They RN stated Resident#2 had informed them they did not want to do therapy anymore. The RN stated they should have given Resident #2 an ABN with Resident #146. The RN was asked why Resident #146 had not received an ABN when they stayed long term care after skilled services were discontinued per facility initiation. They stated Resident #146 had informed them they were not doing therapy anymore and had plateaued. The RN was asked where it was documented Resident #2 and #146 had stated verbally they did not want to continue therapy. The RN reviewed the EMR and stated on 04/11/23 Resident #146 had a progress note which had documented a conversation about the NOMNC but nothing was documented about the ABN. The RN reviewed the EMR for Resident #2 and stated they did not see any notes about the NOMNC or the ABN. The RN stated, They fell through the cracks.

Based on record review and interview, the facility failed to provide written information concerning the right to formulate an advance directive for two (#25 and #69) of three sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 99 residents resided at the facility. Findings: 1. Resident #25 was admitted with diagnoses which included acute respiratory failure and type two diabetes. Review of the clinical record revealed no documentation the resident had been provided information to formulate an advance directive. 2. Resident #69 was admitted with diagnoses which included type two diabetes and cardio obstructive pulmonary disease. Review of the clinical record revealed no documentation the resident had been provided information to formulate an advance directive. On 09/11/23 at 1:32 p.m., the administrator was asked to provide advance directives for Resident #25 and #69. The administrator stated they do not have an advanced directive for these residents, but are working on getting then.

Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. The Resident Census and Conditions of Residents form documented 76 residents who resided in the facility. Findings: Daily staffing reports were reviewed for 02/01/23 through 03/07/23. RN coverage was not documented for 03/04/23 and 03/05/23 On 03/07/23 at 2:30 p.m., the RDO was asked if they had RN coverage for the dates 03/04/23 and 03/05/23. The RDO stated they did not.

Based on record review and interview a past non-compliance situation in which the facility failed to ensure residents were administered medications according to physician orders, standards of nursing practice and the facility's medication policy and procedures to avoid medication errors. The Resident Census and Condition form identified 76 residents resided in the facility. Findings: A facility policy titled Medication Administration General Guidelines documented in part .Residents are identified before medication is administered using at least two resident identifiers . A medication error report, dated 08/29/22, documented resident #3 was given another resident's medications. A Facility Event Summary Report, dated 08/29/22, documented the DON was notified of the incident at 11:30 a.m. A physician order dated 08/29/22, at 11:40 a.m., ordered the resident to be sent to the hospital emergency room for evaluation and monitoring. The Facility Event Summary Report dated 08/29/22 documented the resident's Adult Protective Services state guardian was notified of the incident at 12:39 p.m. On 08/30/22, at 10:51 a.m., a hospital discharge summary documented in part .The patient was accidentally given the wrong medication .aspirin, Colace, multivitamin, Mucinex, Norvasc, cranberry juice, Lasix, Mobic, and potassium chloride .The resident was admitted for observation, given IV fluids and monitored. A Facility Event Summary Report, dated 08/30/22, at 3:41 p.m., documented the resident returned to the facility. On 03/07/22 at 1:15 p.m., the RDO was asked what action was taken as a result of the incident. They stated a full investigation was conducted, LPN #1 was suspended, and staff were educated. On 09/01/22, facility records documented an in service was conducted on medication administration policy for staff who administer medication.

On [DATE] at 7:24 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to implement the abuse policy to ensure employee background checks were completed. Documentation from OK Screen, dated [DATE], revealed CNA #1 had been disqualified from employment in LTC until [DATE] and had been a full time employee at the facility since [DATE]. CNA #2, CNA #3, Dietary aide #1, 2, 3, Dietary aide #4, and Transportation aide #1 were currently employed by the facility and had not received final clearance of background checks. On [DATE] at 7:30 p.m., the facility's administrator and Regional Director of Operations were made aware of the IJ situation related to the facility's failure to implement the abuse policy in regards to employee background checks. A plan of removal of the IJ situation was requested. A plan of removal was received on [DATE]. The facility was notified the immediacy was lifted as of [DATE] at 7:29 a.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of harm. The plan of removal documented: Plan of Removal F607 Please accept this POR as related to the Immediate Jeopardy called on [DATE] in relations to the failure to implement the Abuse policy regarding background checks for employees. Action Item: A root cause analysis was completed on [DATE] by the IDT to identify systemic issues .Date completed: [DATE] 1000pm central RCA of IJ regarding failure to implement the Abuse policy regarding the background checks for employees. Why was the employee screening for background checks not get completed in the entirety? The administrative team failed to ensure the process for OK screen was completed in its entirety. Why did the administrative team fail to monitor the process? The administrative team relied on the resource team to validate the process continued to be performed to the standard set for by Oklahoma State Department of Health. Why did the resource team fail to ensure the process was followed to the standard set for by Oklahoma State Department of Health? The resource team (consisted of two regional HR members and a HR specialist) completed a full audit of employee records in May of 2022. The full audit of the employee record included verification of OK screen approval, completed and signed application packet, EEOC form, Veteran form, completed and signed drug screen, completed and signed W-4, Completed and signed I-9, Copy of Drivers license and social security card, Signed wage deduction authorization, signed policy and procedure acknowledgment, initial and signed Senate Bill 9, resident rights acknowledgement, signed arbitration agreement, completed TB test, Completed Hep B, consent/declination, Completed emergency contact, signed job description, Signed new hirer orientation checklist, CPR certification for direct care staff, IV certification LVN if applicable, signed resident abuse and neglect P&P and proficiency testing. The resource team identified areas of the process that needed improvement through the record audit. The Human Resource Director was re-educated on the on boarding process, which includes OK Screen. The resource team completed the areas of improvement with the Human Resource Director. The resource team completed random follow up visits with the Human Resource Director. Follow up visits include but not limited to education on processes, assisting in addressing concerns, verification of new hirer process, assistance with recruiting and assistance with employee retention. No concerns were identified during the random follow up visits. The resource team than stopped the random visits and resumed quarterly visits with the center Human Resource Director. Routine visits from the resource team are scheduled quarterly and as needed. New hirer packet audits will be completed by the administrative team and the resource team per new hire. Why did the resource team resume quarterly visits? The resource team determined that the Human Resource Director was completing the on boarding process to include the OK Screen to the standards set forth by the Oklahoma State Department of Health. Why did the Human Resource Director stop completing the OK Screen to the standards set forth by the Oklahoma State Department of Health? The Human Resource Director began having performance issues which was noted by the administrative team. The Administrator addressed the Human Resource Director's performance and attendance issues on [DATE]. The Human Resource Director did not agree with the performance improvement plan and resigned without notice. Why did the Administrator address the Human Resource Directors performance issues? The Administrator attempted to correct the center employee's poor performance, to maintain the integrity of the department, ensure policies were implemented and staffing concerns were addressed appropriately. How did the Administrator address the immediate opening of the Human Resource Director position? The current Business Office Manager offered to assist with on boarding new hirers. She had experience from her previous employment. She audited the current employee files on [DATE] and noted concerns with the on boarding process related to OK screen completion. The BOM notified the administrative team, and the resource team was than notified. The administrative team and the BOM initiated a performance improvement plan and began the process to complete the OK Screen. Thirty of the thirty-seven OK Screens were completed prior to [DATE]. This event could have been prevented if the process was completed through OK Screen. If the employee was entered and registered to our center in OK screen, we would have received a notification from OK Screen notifying the center of the barring of employment. The center would have than terminated the employee per our abuse policy. Action Item: The resource team (HR/compliance, Nursing and operational resources) re-educated the BOM, HR assistant and the administrative team on [DATE] on the on boarding process. The on boarding process includes the completion of the OK screen, prior to the employee starting employment .Date Completed: [DATE] 5pm central Action Item: The BOM and HR assistant completed a full audit of all employee records on [DATE]. The resource team assisted in the audit to verify the completion of the audit and the accuracy of the audit .Date Completed: [DATE] 12:00pm central Action Item: POR reviewed in the Adhoc QAPI on [DATE] by the IDT, Root Cause Analysis was validated, and action plan from [DATE] will be updated .Date Completed: [DATE] 1:30pm central time Action Item: The administrative and the resource team will validate the on boarding process is complete. The on boarding process includes the OK Screen is complete prior to starting employment in the center. Each new hirer will be validated by the administrative team and or the resource team. This process has been initiated as of [DATE] and will continue until the center reaches substantial compliance. The HR/Compliance officer/Resource team will continue education with the HR assistant, education and validation of the new hirer process will include but not limited to the OK Screen process. The HR/Compliance officer/Resource team will complete monitoring Monday-Friday until substantial compliance is met .Date Completed: [DATE] 2:00pm central Action Item: Ten outstanding employees for OK screen will be completed by the BOM. The missing component for the completion is the finger printing process. The OK Screen has been completed up to the fingerprint process. Consents are on file for all ten staff members. Finger printing will be scheduled asap for the remaining nine employees missing fingerprints. One of the ten has been completed, seven of the ten have been scheduled for finger printing, one of the ten is pending confirmation of finger printing. One of the employees was termed on [DATE], related to the background check. Employees will not return to work after [DATE] at 8:30am central until the completed OK Screen is returned with the clearance letter .Date initiated: [DATE] 8:00am Based on record review and interview, the facility failed to implement their abuse policy for eight (CNA #1, 2, CNA #3, Dietary aide #1, 2, 3, Dietary aide #4, and Transportation aide #1) of eight employees who were hired by the facility and had not received final clearance of background checks upon hire; no letters were provided for provisional employment. Currently seven employees were working at the facility without completed background checks. The Daily Census Report, dated [DATE], identified 78 residents who resided in the facility. Findings: The Abuse Prevention Program policy, dated [DATE], read in part, .As part of the resident abuse prevention program, the administration will: 1. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. Had a finding entered in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. Had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property . On [DATE] at 4:13 p.m., the assistant BOM informed the surveyors that the facility had confirmation from an audit, conducted [DATE], that CNA #1 currently working at the facility was ineligible to work in LTC. The assistant BOM was asked to provide documentation of background checks for eight employees. Review of the eight employee files revealed: CNA #1 was a full time employee and had been hired by the facility on [DATE]. OK Screen documentation, dated [DATE], revealed CNA #1 was disqualified from working in LTC facilities until [DATE]. Review of the punch detail for CNA #1 revealed they had actively worked in the facility with the last documented shift as the night shift on [DATE]. The employee was terminated on [DATE]; CNA #2 was a current full time employee, hired [DATE]. The OK Screen background check was initiated on [DATE]; CNA #3 was hired as a full time employee on [DATE]. The OK Screen background check was initiated on [DATE]; Dietary aide #1 was a current full time employee, hired [DATE]. The OK Screen background check was initiated on [DATE]; Dietary aide #2 was a current full time employee, hired [DATE]. The OK Screen background check was initiated on [DATE]; Dietary aide #3 was a current full time employee, hired [DATE]. The OK Screen background check was initiated on [DATE]; Dietary aide #4 was a current part time employee, hired [DATE]. The OK Screen background check was initiated on [DATE]; and Transportation aide #1 was a full time employee, hired [DATE]. The OK Screen background check was initiated on [DATE]. On [DATE] at 5:12 p.m., the administrator stated employee files were being audited off and on between doing other things since [DATE]. The administrator was asked what the protocol was for hiring new employees. They stated they ran background checks before the employee began working in the facility. The administrator stated they had identified some things were wrong with the employee files and they began the audit in [DATE]. The administrator stated they had been notified CNA #1 was not eligible to work in LTC and terminated CNA #1 at approximately 10:00 a.m. on [DATE]. On [DATE] at 10:33 a.m., the administrator was asked who was responsible to train human resources/BOM employees to ensure they were aware of the facility's protocol to complete background checks. The administrator stated the facility human resources employees/BOM were trained by corporate personnel. On [DATE] at 11:01 a.m., an interview with the Regional Human Resource director provided results of an internal facility audit of employee files performed in the facility in May of 2022 by the corporate human resource department, and stated the lack of completed background checks had not been identified at that time. On [DATE] at 3:44 p.m., the disqualification for employment in LTC facilities, due to a barrier in effect for CNA #1, was verified during an interview with an OK Screen employee. The OK Screen employee stated CNA #1 was not listed in their system as employed, with this facility/any other long term care facility. On [DATE] at 4:53 p.m., the BOM was asked where provisional letters of employment were located. The BOM stated they did not have any provisional letters of employment. As of [DATE] at 7:00 p.m., documentation of completed OK screen background checks had not been provided by the facility for: A. CNA #2 [DATE]-[DATE] (406 days) B. CNA #3 [DATE]-[DATE] (387 days) C. Dietary aide #1 [DATE]-[DATE] (261 days) D. Dietary aide #2 [DATE]-[DATE] (8 years and 309 days) E. Dietary aide #3 [DATE]-[DATE] (140 days) F. Dietary aide #4 [DATE]-[DATE] (119 days) G. Transportation aide #1 [DATE] -[DATE] (147 days)

On 11/10/22 at 10:07 p.m., an immediate jeopardy (IJ) was identified and verified by the Oklahoma State Department of Health (OSDH). The facility failed to implement their infection control policy and procedure to ensure residents were protected from the transmission and spread of a communicable disease. The facility failed to cohort residents with the same test result; don appropriate PPE when entering an airborne isolation precaution room; ensure employees were properly trained to administer COVID-19 testing; and effectively track, trend, and educate staff with the results of COVID-19 testing for positive and negative residents. This system failure increased the risk of severe illness or death. On 11/10/22, the facility was notified and a plan of removal (POR) was requested on 11/10/22 at 10:24 p.m. By the survey exit date of 11/15/22 at 4:30 p.m., an acceptable plan of removal had not been received. The immediacy remains. Based on record review, observation, and interview, the facility failed to: a. implement and maintain an effective infection control program to ensure residents were protected from the transmission and spread of a communicable disease; b. cohort residents with the same COVID-19 status in the same room; c. don appropriate PPE when entering an airborne isolation precaution room; and d. ensure employee was properly trained to administer a COVID-19 test and effectively track, trend, and educate staff with the results of COVID-19 positive and negative residents for one of one employee files reviewed for education. The Resident Census and Conditions of Residents form documented 76 residents resided in the facility. Findings: A Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents policy, revised September 2021, read in part, .Residents with signs and symptoms of COVID-19 are identified and isolated to help control the spread of infection to other residents, staff and visitors .A COVID-19 care unit (which may be a dedicated floor, unit, wing or cluster of rooms at the end of a hallway) has been established to cohort and manage the care of residents with confirmed [CONDITION(S)]-CoV-2 infection .Residents who are close contacts 1. Unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection are placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. Staff caring for them use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). 2. Fully vaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection wear source control and are tested . The CDC Infection Control Guidance, updated Sept. 23, 2022, read in parts, .Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection .The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with [CONDITION(S)]-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing . A. Review of the facility's undated Matrixcare Infection Tracker revealed resident #5 and resident #6 roomed together and tested positive for COVID-19 on different dates; resident #3 and resident #4 roomed together and tested positive on different dates; resident #10 and resident #11 roomed together and resident #10 had tested positive for COVID-19 while resident #11 had tested negative. The tracker documented the following: Resident #6 tested positive for COVID-19 on 11/01/22 and remained in room SE85 with a non-COVID-19 positive roommate, Resident #5. Resident #6's projected end date for isolation was 11/11/22. Resident #5 tested positive for COVID-19 on 11/04/22 and remained in room SE85 with a COVID-19 positive roommate, Resident #6. Resident #5's projected end date for isolation was 11/14/22. Resident #3 tested positive for COVID-19 on 10/24/22 and remained in room SE80 with a non-COVID-19 positive roommate, Resident #4. Resident #3's projected end date for isolation was 11/04/22. Resident #4 tested positive for COVID-19 on 11/01/22 and remained in room SE80 with a COVID-19 positive roommate, Resident #3. Resident #4's projected end date for isolation was 11/11/22. Resident #10 rested positive for COVID-19 on 11/01/22 and remained in room SE71 with a non-COVID-19 roommate, Resident #11. Resident #10's projected end of isolation date was 11/11/22. Resident #11 tested negative for COVID-19 on 10/18/22, 10/21/22, 10/25/22, 10/28/22, 11/01/22, 11/04/22, and 11/08/22 but remained in room SE71 with a COVID positive roommate, Resident #10. The infection tracker identified 10 residents who were positive for COVID-19. On 11/12/22 at 9:22 a.m., during State monitoring, CNA #3 was asked if COVID-19 positive and COVID-19 negative residents were roomed together. They stated yes, the residents in room SE85 had continued in the same room even though Resident #6 tested positive for COVID-19 on 11/01/22 and their roommate, Resident #5, remained negative until 11/04/22. On 11/13/22 at 9:33 a.m., during monitoring, CNA #10 stated to the surveyor that Resident #5 had passed away, and was found without vital signs at 9:10 a.m. Resident #5 hospice nurse note, dated 11/02/22 at 10:08 a.m., read in parts, .This patient on service for primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .V/S B/P 93/60, P-83, R-18, T-97.4 . Resident #5 hospice nurse note, dated 11/02/22 at 2:04 p.m., read in parts, .PRN visit made for weakness .PT [patient] stated he stays in bed away from everyone because he does not want to get covid . B. On 11/09/22 at 4:15 p.m. resident #3 was observed in the southeast hall, near the entrance to the isolation room for resident #4 who was positive for COVID-19. LPN #1 stated Resident #3 also resided in the room with Resident #4. Resident #3 did not have a mask or any other PPE on and no staff were observed to ask the resident to don a mask or PPE or instruct the resident in the need for / use of PPE. On 11/09/22 at 4:15 p.m., LPN #1 was observed to have facial hair which was composed of a mustache and long beard. LPN #1 was observed to wear a surgical mask, don a gown and gloves and enter the isolation room for resident #4 who was positive for COVID-19. LPN #1 did not don an N95 mask nor a face shield. On 11/09/22 at 4:15 p.m., LPN #1 was asked if resident #3 was in isolation. They stated no. On 11/09/22 at 4:15 p.m., LPN #1 pointed to room [ROOM NUMBER] and stated there was another room where one resident had tested positive and the other resident continued to test negative and had not been moved from room [ROOM NUMBER]. LPN #1 stated resident #10 tested COVID-19 positive on 11/01/22 and their roommate, Resident #11 (tested COVID-19 negative) would come and go from the isolation room. On 11/09/22 at 4:28 p.m., Resident #3 was observed to wander into room SE75, an isolation room. CMA #1 was observed to enter the room wearing an N95 mask and gloves, and assist the resident back out of the room. CMA #1 did not wear a gown or face shield. On 11/09/22 at 4:30 p.m., CMA #1 was observed to sanitize their hands and don gloves and gown before entering the same isolation room at the end of the hall to provide the resident with medications. CMA #1 did not wear a face shield. On 11/09/22 at 7:25 p.m., CMA #1 wore an N95 mask and was observed to don gloves and gown. CMA #1 did not wear a face shield when they entered the room. CMA #1 stated resident #3 was asleep in bed A. CMA #1 stated resident #4 (COVID-19 positive resident) was in bed B. On 11/09/22 at 10:45 p.m., CNA #1 was observed to wear a surgical mask, face shield, gloves, and gown to enter room SE85. The Resident #3 in SE85A was resting in bed with their eyes closed. CNA #1 was observed in a COVID-19 positive room with a surgical mask on. On 11/09/22 at 11:40 p.m., the DON was asked why Resident #3, (a non-COVID-19 positive resident and wanderer), resided in the same room as Resident #4, (a COVID-19 positive resident) in isolation. The DON looked at the resident roster and stated Resident #3 did not reside in the room with Resident #4. The DON was asked to confirm Resident #3 was not in the room with Resident #4. The DON was observed to don an N95 mask, gloves, and gown before entering the isolation room for Resident #4 (a COVID-19 positive resident). The DON did not wear a faceshield or goggles. The DON stared at both beds occupied by Resident #3 and Resident #4 before doffing the PPE and exiting the room. The DON asked ADON #3 why Resident #3 (a non-COVID-19 positive resident) was not in the room listed on the room roster. ADON #3 stated the resident had never been in the room listed on the room roster. On 11/09/22, the room roster documentation reflected Resident #3 (a non-COVID-19 positive resident) was residing in room SE76B. Resident #3 was observed asleep in room SE80A throughout the evening hours and night. On 11/10/22 at 11:55 p.m., four of the six isolation carts on the southeast hall were observed to not have face shields. The DON was asked why there were no face shields on four of the six isolation carts. The DON entered the southeast hall and checked the availability of face shields, finding faceshields in an isolation cart at the beginning of the hall, near the nurses' station and at the very end of the hall but none in the four other isolation carts located in between. The DON stated they just had not been restocked. The DON was observed to look in the southeast office, and a few of the storage rooms for face shields. The DON stated they knew there was a box of face shields somewhere but did not know where they were located. On 11/10/22 at 12:15 a.m., corporate consultant #1 stated they needed to see for themselves who resided with Resident #10 (a COVID-19 positive resident). The corporate consultant was wearing only a surgical mask and walked down the hall to the resident's room. Without donning any more PPE, the corporate consultant entered the isolation room for Resident #10 and stared at the occupied beds. The corporate consultant exited the room and was asked why they had not donned PPE. The corporate consultant stated they were just entering the room to look at the resident and not provide care. The corporate consultant was asked when they expected their nursing staff to don PPE. The corporate consultant stated the staff were to don PPE prior to entering the resident's room. The corporate consultant stated they understood what the surveyor was intending with the question but reiterated they had just stepped in for a minute to identify who each resident was in the room. On 11/10/22 at 12:15 a.m., the corporate consultant stated Resident #11 had tested COVID-19 positive on 11/04/22. The corporate consultant stated the COVID-19 negative result documented for 11/04/22 was in error. The corporate consultant stated they remembered the testing because the resident had left the facility alone and tested positive when they returned. The corporate consultant #1 was asked if the resident tested positive on 11/04/22, why were they tested negative again on 11/08/22. They stated the person entering the batch testing results simply forgot to unclick the resident's name before saving the results. The corporate consultant was asked if the testing results were documented in error twice, how did the facility ensure the other documented testing results were accurate. The corporate consultant asked if the surveyor wanted the facility to test the residents now. The surveyor responded that it was after midnight and most residents were asleep. The corporate consultant stated it would not take long to test the roughly 19 residents left who had not tested COVID-19 positive in the last 90 days. On 11/10/22 at 2:20 a.m., ADON #3 stated Resident #3 tested negative for COVID-19 at 2:10 a.m.; Resident #4 tested negative for COVID-19 at 2:14 a.m.; and Resident #11 tested negative for COVID-19 at 2:15 a.m. On 11/10/22 at 2:25 a.m., ADON #3 was observed to wear an N95 mask over medium length facial hair. The ADON was observed to walk down the SE hall and enter an isolation room (SE71) without donning any further PPE. The ADON was observed to exit the room shortly after, carrying a culture swab for COVID-19 testing in their ungloved hand. The ADON stated they had tested Resident #10. The ADON entered an office on the southeast hall and applied the culture swab to the testing card before adding approximately five drops of reagent. The ADON was asked how long before the test was complete. They stated the results were immediate and could be read as soon as the reagent was observed to cover the sponge/testing window. In less than two minutes, ADON #3 stated the resident tested negative. Review of the BinaxNOW COVID-19 AG product insert documented to read results in the window 15 minutes after closing the card. On 11/10/22 at 2:45 a.m., the DON was asked what the facility policy was regarding PPE when entering a COVID-19 positive room. The DON stated the staff should don gloves, gown, mask, and face shield. The DON was asked to clarify what type of mask to wear when entering a COVID-19 positive room. The DON stated the staff were to wear an N95 mask. The DON was asked why the staff were observed to wear surgical masks when entering a COVID-19 positive isolation room. The DON stated the staff should be wearing N95 masks. The DON was asked if an N95 was effective for someone with facial hair. The DON stated the nurse was to have shaved. The DON was asked why LPN #1 was assigned to a hall with COVID-19 positive residents when the LPN had obvious facial hair. The DON stated they did not know who made the assignments. The DON was asked who monitored to ensure the staff were wearing appropriate PPE and the necessary PPE was available for use. The DON stated the Infection Preventionist was responsible to monitor staff to ensure proper use of PPE and check the isolation carts for adequate PPE supplies. The DON was asked why the observations of improper use of PPE and a limited availability of supplies. The DON stated they did not know. Review of the facility's Matrix for Providers form, received on 11/10/22, documented no residents with an infection of COVID-19. On 11/10/22 at 1:21 p.m., observations were made of Resident #4, who was COVID-19 positive, and Resident #3, who was COVID-19 negative, resided in the same room. LPN #1 was observed to don gloves and a gown to enter the resident's room. LPN #1 did not don an N95 mask or face shield/goggles. Signs on the resident's door indicated droplet transmission based precautions. C. On 11/10/22 at 4:32 p.m., the IP was asked what the facility's testing policies/protocols were. They stated they had not seen the policies. The IP was asked if they had been trained to perform the test. They stated yes they had been trained at a previous facility by an RN but not at this facility. The IP was asked what PPE was required to be worn when the COVID-19 test was administered. They stated gloves and a surgical mask or an N95. The IP was asked if they had been fit tested for an N95. They stated no. The IP was asked if they knew the CDC guidance for the COVID-19 testing procedure. They stated they had in the past but did not anymore. The IP was asked if they knew where to find the information. They stated no. The IP was asked if they had performed COVID-19 tests at the facility. They stated yes, on 11/08/22, and was scheduled to perform the tests again on 11/11/22. The IP was asked how they determined who required testing. They stated from a list of who had not tested positive in the last 90 days located on a white board in the office. The IP was asked what PPE was required to enter a resident's room that was positive for COVID-19. They stated gloves, face shield, gown, and an N95 mask or surgical mask if fully vaccinated. On 11/10/22 at 5:28 p.m., the DON was asked who administered COVID-19 tests in the facility. They stated the IP nurse, a medical records employee, and others could assist with prep and setup of the test. The DON was asked who had been trained to administer COVID-19 tests. The DON stated the IP and the medical records employee. The DON was asked who provided the training for the medical records employee. They stated they did not know, the training had been completed prior to the DON's employment at the facility. The DON was asked if they had observed the medical records employee administer the test. They stated yes, the medical records employee had tested the DON for COVID-19. The DON was asked how the facility cohorted residents. They stated positive with positive and negative with negative. On 11/10/22 at 7:44 p.m., CMA #1 was asked if they had been tested for COVID-19 at the facility. They stated yes by the IP on 11/04/22. CMA #1 stated the IP allowed them to self test. CMA #1 was asked what they meant by self test. CMA #1 stated they were able to test themselves for COVID-19. CMA #1 was asked if they had knowledge of positive and negative residents housed in the same room. They stated yes, they treated both as if they were positive and wore full PPE when they entered their room. The CMA was asked what she considered full PPE. She stated gloves, gown, N95 mask, and face shield. CMA #1 was asked if they felt the facility administered proper infection, prevention, and control practices. Review of the facility's Abbott BinaxNOW COVID-19 Ag Card - Training Checklist, for the medical records employee revealed the checklist was dated and signed by the IP on 08/16/22. The checklist did not provide documentation which indicated that the IP had completed the training and had competently performed specimen collection, storage, and handling or sample preparation, test procedure for quality control and patient testing. The facility did not provide a training checklist for the current IP.

On 09/15/22 at 5:53 p.m., an Immediate Jeopardy (IJ) was identified and verified by the Oklahoma State Department of Health (OSDH). The facility was notified at 6:10 p.m., of the Immediate Jeopardy regarding the treatment and services to prevent/heal pressure ulcers for three (#3, 9, and #10) of three sampled residents who were reviewed with pressure ulcers. The facility failed to administer treatment/services to prevent infection and the development of new pressure ulcers. The facility failed to identify pressure ulcers, ensure physician notification was made and documented, ensure treatment orders were in place for each wound, ensure treatments were followed per physician order, and ensure all nursing staff received education regarding recognizing signs and symptoms of infection. A Plan of Removal (POR) was received on 10/04/22. The facility was notified on 10/06/22 at 2:48 p.m. the immediacy was lifted as of 10/04/22 at 5:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of harm. The Plan of Removal documented: Plan of Removal Pressure ulcers Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/15/22 for Treatment/services to prevent infection and development of new pressure ulcers. Action Items 1: All residents had a skin assessment completed by nursing staff by 9/16/22 at 8:00pm central time. Weekly skin assessments will be completed by the staff nurse and verified by charge nurse and/or ADON. Skin assessments are completed on all residents weekly. Skin assessments are documented in Matrix. Skin assessments populate in Matrix on the scheduled day of the skin assessment. The nurse completing the skin assessment, documents in Matrix and is required to electronically signed in the electronic medical record. The wound report tool will be reviewed weekly by the resident at risk team. The resident at risk team consists of nurses, operators, social services and dietary. The review will consist of completion of skin assessments and the condition of the wounds. Recommendations of the team will be addressed by the nurse. The nurse will contact the medical director and or physician to review changes and implement orders as needed DON/ADON(s), charge nurses, and wound nurse(s) were educated on facility wound care policy and procedures by Regional Clinical Nurse RN/DON/ADON/Unit Manager Completed on 10/4/22 5:00 pm Central Time Regional Clinical Nurse, RN will begin rounding with wound nurse x2 weekly. RN Regional Nurse 2 is assigned as the backup regional nurse in the center to cover the regional clinical nurse that is assigned to this center, shall they not be available. Wound round reports will be reviewed by the DON and ADONs during the daily clinical meeting which is conducted daily-7 days a week. Wound reports will be reviewed/verified by Clinical Resource Nurse, RN/DON/ADON/Unit Manager each day following daily clinical meeting, which is conducted 7 days a week. Action Item 2: All resident admission assessments were reviewed for completion on 9/15/22 by 9:45pm central time by Corporate Resource Nurse(s) RN. Regional Nurse Manager, RN/DON/ADON/Unit Manager will review all admits and readmits daily during morning clinical meeting for accuracy and completeness. Nurses were re-educated on pressure ulcers, interventions, assessments, Braden scale, documentation, completing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The RN Corporate Resource Nurse(s)/DON/ADON/Unit Manager will complete the education. Nurses, C.N.A and CMA's received education regarding the recognition of signs and symptoms of infection, areas of skin concern, change of condition/status, how to communicate concerns with charge nurse, ADON and/or physician. The Nurses were also educated on physician orders, electronic medication entry into the EMAR. The regional nurse manager education team consisted of seven regional nurse managers, RN. Re-education was completed with 1-2 staff members at a time. The wound module is part of the Matrix training. For Nurses/C.M.A./C.N.A. and other non-clinical staff came in before their shift started, during their shift and stayed after their shift. The staff that are unavailable due to not being scheduled for various reasons and or not answering their phone will be re-educated prior to working their next shift. Completed on 10/4/22 5:00 pm Central Time Action Item 3: Residents receiving IV antibiotics were reviewed to ensure antibiotic orders have been followed as prescribed by the RN Clinical Resource Nurse(s) concerns identified during this review will be addressed by DON/ADON/Unit Manager to include the nurse involved and documented on audit tool in POR Binder completed on 10/4/2022 5:00 pm Central Time. Any new antibiotic orders and changes to antibiotic orders will be reviewed by the DON/ADONs during the morning clinical meeting, and the nurse manager on the weekend. If an order has not been followed the policy/procedure for a missed medication will be completed. This includes an event observation and notification to the family and physician. Regional Nurse Manager, RN will validate all new antibiotic orders daily. RN Regional Nurse 2 is assigned as the backup regional nurse in the center to cover the regional clinical nurse that is assigned to this center, shall they not be available. Action Item 4: Resident #3 has been in the hospital for wound management since 9/2/22. The Corporate Resource Nurse, RN obtained a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Both residents returned to the facility same day without new orders. Action Item 5: Follow up wounds, and antibiotic treatment reviews will be held by the Administrator and DON during the weekly Resident at Risk Team on Wednesdays at 3:00pm CST. Regional Director of Operations will review Administrators/DON Resident at Risk findings weekly. Review will be kept in the POR/POC binder. Review consists of the meeting occurring and the residents at risk were reviewed. All Resident at Risk documentation and actions will be presented to the QAPI Committee monthly. The center does not use agency staff, if the center utilizes agency staff or hires new staff, staff will complete the appropriate education prior to working on the floor. Education will be completed by the Regional Nurse Manager, RN/DON, RN/Nurse manager RN/LPN. Completed on 10/4/22 5:00 pm Central Time Based on observation, record review, and interview, the facility failed to identify pressure ulcers, ensure physician notification was made and documented, ensure treatment orders were in place for each wound, ensure treatments were followed per physician order, and ensure all nursing staff received education regarding recognizing signs and symptoms of infection for three (#3, 9, #10) of three residents identified with pressure ulcers. The Resident Census and Conditions of Residents form identified eight residents had pressure ulcers. Findings: A Prevention of Pressure Injuries policy, dated May 2022, read in parts, .Monitoring .Evaluate, report and document potential changes in the skin .Review the interventions and strategies for effectiveness on an ongoing basis . 1. Resident #3 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note, dated 08/01/22 at 1:30 p.m., documented Resident #3 had a stage II pressure injury from a lengthy stay on a toilet at home, skin tears to left lower shin area, and lower right forearm. Review of the resident's clinical record did not reveal an admission assessment had been completed or a skin assessment prior to 08/12/22. A facility Wound Management report, dated 08/12/22, documented a deep tissue injury of 11 x 6 cm to the right buttock was identified. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 08/25/22, documented Resident #3 was at risk for pressure ulcer due to moisture. The goal for Resident #3 was documented as the resident was to have intact skin without evidence of redness, irritation, maceration, or open areas. The approach documented to check incontinence pads frequently (every 2-3 hours) and change as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a discharge return anticipated assessment dated [DATE], documented Resident #3 was discharged to the hospital. A hospital Trauma Surgery Consult Note, dated 09/07/22, read in parts, .[Resident #3] is a 74 y.o. male who presents with stage 4 decubitus sacral wound. Impression and Plan: Infected stage IV sacral wound 1. Agree with antibiotics per primary team 2. Plan to proceed to OR for I&D of sacral wound 09/08/22 .Infectious disease has requested that we obtain a culture of the wound . On 09/12/22 at 10:05 a.m., wound nurse #2 was asked about Resident #3's skin. They stated on admission the resident had wounds on their shin and arm. The wound nurse stated the deep tissue injury developed at the facility, but on admission there was only excoriation and it was treated with barrier cream and not open. Wound nurse #2 was asked how Resident #3's wounds progressed. They stated they had done the original skin check on admission. The wound nurse was asked where the original skin check was documented. They stated it was documented in wound manager. The wound nurse stated they were alerted by the nurse on 09/12/22 when the new deep tissue injury was in the system and it was not small, it was at least 14 centimeters across. On 09/13/22 at 10:35 a.m., the wound nurse #1 was asked about the skin condition on admission for Resident #3. They stated on the day after admit a small blanchable area was noted and treated with barrier cream. Wound nurse #1 stated they did not document clear skin and only documented by exception. Wound nurse #1 stated on 09/12/22 they received a text to evaluate the skin condition for Resident #3 and noted a DTI to the sacrum. Wound nurse #1 was asked if skin assessments had been completed between 08/01/22 and 08/12/22. They stated they did not know. Wound nurse #1 was asked how often skin assessments were to be completed. They stated weekly. Wound nurse #1 was asked when they had last observed the sacrum of Resident #3. They stated they had seen it the day Resident #3 went to the hospital and noted necrosis and deterioration. Wound nurse #1 stated the wound had opened up with drainage and an odor was present, but not foul. Wound nurse #1 was asked how the physician was involved in treatment changes. They stated, He is notified, being we are both certified he trusts our judgement. On 09/13/22 at 11:31 a.m., ADON #1 was asked who performed the admission assessment. They stated the floor nurse would be responsible. ADON #1 was asked how it could be determined who completed the admission process. They stated there should have been an admission note entered under the observation tab of the clinical record. On 09/14/22 at 11:24 a.m., RNM #1 was asked when admission skin assessments were to be completed. They stated on the day of admission. RNM #1 was asked if an admission assessment had been completed for Resident #3. They stated one should have been completed and documented in the clinical record. RNM #1 stated the wound nurse had completed the admission skin assessment but had not documented in the clinical record. 2. Resident #9 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was provided that the order had been reviewed by the physician or medical director. A facility Wound Management note, dated 07/31/22, identified the sacral wound at a stage III with measurements of 1.5 x 2 x 1 cm. The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/04/22, the facility documented a measurement of 1.5 x 2 x 1 cm for the stage III sacrum. A wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing treatment plan was not implemented. On 08/31/22, the facility documented the sacral wound measurement as 1.5 x 1.5 x 1 cm and was unstageable with undermining of 2.6 cm, no direction of the undermining was documented. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/07/22, the facility documented the sacral wound measurement as 1.4 x 1.3 x 0.7 cm, was unstageable and undermining of 2.1 cm. No direction of the undermining was documented. A wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was discussed with the wound nurse and the wound was stable from the prior exam. Measurements were provided of 1.4 x 1.3 x 0.1 cm with tunneling of 1 cm at 12:00 and 2:00. A wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing treatment plan was not implemented. On 09/13/22 at 5:36 p.m., wound nurse #1 and wound nurse #2 were observed to administer wound treatments to Resident #9. During the treatment two additional wounds were present that had not been previously identified, according to physician orders. Both wounds were treated by wound nurse #1. The first unidentified wound was to the sacrum. The second unidentified wound was to the left lateral side, proximal to the last rib. The wound measured 1 x 1 cm, with a crescent shaped wound directly under the circular wound. They were red in color and unblanchable. They were located where the resident had previously been laying on their peg tube. On 09/13/22 at 6:12 p.m., wound nurse #1 was asked what wounds were treated. They stated the sacral wound and the back of the head, but the back of the head had healed and they needed to resolve it in the system. Wound nurse #1 stated the hip excoriation was not as bad the day before and a new area on Resident #9's side was identified today. The wound nurse was asked if there were any other new areas noted. They stated the excoriation. The wound nurse was asked where it was documented. They stated they would have to check the list of things to do. The wound nurse was asked what was on the treatment order for the new open area to the sacrum. The nurse stated nothing was documented or entered in the clinical record yet. On 09/15/22 a 12:39 p.m., the DON with RNM #1 present, was asked who provided wound treatment orders. The DON stated the wound doctor and the medical director. The DON was asked how orders were received from the wound doctor. The DON stated they were not sure. RNM #1 stated the wound doctor made recommendations and the medical director reviewed them. RNM #1 stated if the medical director approved the orders they were entered in the electronic system, if the orders were not approved they would automatically delete from the system. On 09/16/22 at 10:29 a.m., RNM #1 with the administrator present, stated wound nurse #1 had identified the new wounds for Resident #9, but had not entered them in the electronic system so they technically were not identified due to no treatment orders. A wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment order was not implemented. On 09/21/22 at 2:03 p.m., the medical director was asked how the wound doctor's orders/recommendations were addressed. The medical director stated they deferred to the wound physicians as they were general surgeons and their recommendations were considered orders that the medical director just signed. 3. Resident #10 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 08/23/22, documented to prevent/heal pressure sores and skin breakdown by providing treatment as ordered. No interventions were listed on the care plan. The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The order frequency was changed on 09/13/22 for wound care to be provided on Monday, Wednesday, and Friday. No documentation was provided in the clinical record with explanation for the change in the frequency or of communication with the physician. On 09/13/22 at 10:35 a.m., wound nurse #1 and wound nurse #2 were asked how the physician was involved with wound care. They stated they notified the physician. The nurses were asked why wound treatments were changed from daily to Monday, Wednesday, and Friday for Resident #10. They stated, Since we are both certified wound nurses, he trusts our judgement. On 09/13/22 at 2:17 p.m., Resident #10 stated their wound dressings were completed daily. The dressings were observed to be dated 09/12/22. The coccyx dressing appeared to have pulled away from the wound, leaving it partially exposed. The resident stated they were taking antibiotics to fight an infection in their wounds on their buttocks and coccyx. On 09/14/22 at 4:18 p.m., wound nurse #2 was observed to provide treatments to the wounds for Resident #10. A foul odor was detected when wound nurse #2 removed the dressing from the ischial and sacral wounds. During the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound nurse #2 stated they would inform the physician of the slough and biofilm in the ischial and sacral wound beds and the previously unidentified wounds. The wound nurse did not state the odor of the wounds would be reported to the physician. On 09/15/22 at 12:39 p.m., the DON with RNM #1 present, was asked who provided wound treatment orders. The DON replied the wound doctor and the medical director. The DON was asked how orders were received from the wound doctor. The DON stated they were not sure. The RNM #1 stated the wound doctor made recommendations and the medical director reviewed them and if the medical director approved the orders they were entered in the electronic system, if the orders were not approved they would automatically delete from the system.

On 09/28/22 at 9:38 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to report an allegation of abuse one (#1) when the DON failed to report an allegation of abuse which was reported to them by Resident #1. Resident #1 reported to the DON, with witnesses present, that LPN #1 was making fun and laughing at the resident. The DON failed to report the alleged abuse to the administrator. On 09/28/22 at 9:46 p.m., the facility's administrator, Regional Nurse Manager #1, the Chief Operating Officer, and the corporate Survey Focus Coordinator was made aware of the IJ situation related to the facility's failure to implement the abuse policy. A plan of removal of the IJ situation was requested. A plan of removal was received on 10/04/22 and accepted on 10/06/22. The facility was notified the immediacy was lifted as of 10/04/22 at 5:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of isolated harm. The plan of removal documented: Plan of Removal F609 The facility failed to have a system in place which ensured all the allegations of abuse, neglect, exploitation and/or mistreatment are thoroughly investigated, and measures were immediately put into place to prevent further abuse/neglect. Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/28/2022, for abuse reporting/investigating. Action Item: The DON, the nurse and the C.N.A. were suspended on 9/28/22 pending investigation of incident. The DON then stated she was self-terminating. Person Responsible: Regional Nurse Manager Timeline for completion: 10/4/22 5:00 pm Central Time Action Item: Review self-reports from previous 30 days to determine if the investigation has been completed thoroughly. No deficient practice was noted, all investigation were completed and reported to the Oklahoma Department of Health timely. Documentation of this review is in the POR binder. Person Responsible: Chief Operating Officer/Regional Nurse Manager/Administrator Timeline for completion: 10/4/22 5:00 pm Central Time Action Item: Education of all staff with return demonstration via posttest on abuse prevention, abuse reporting timely, abuse investigation and neglect policies; resident rights and the grievance process and all staff not present will be provided education to starting next shift. All staff will complete abuse skills competency and return demonstration before their next scheduled working shift. Person Responsible: Administrator/Regional Nurse Manager/Unit Manager Timeline for completion: 10/4/22 5:00 pm Central Time Action Item: Safe surveys will be completed with all residents that are interviewable; responsible parties will be phone interviewed for all residents that are not interviewable and those residents will be assessed for signs of physical or psychosocial distress. Person Responsible: Regional Nurse Manager/ ADON/Unit Manager Timeline for completion: 10/4/22 5:00 pm Central Time Action Item: Review of all nurses notes from prior 7-day period to identify any allegations of abuse that were not reported timely. Review of grievance log for the past 30 days. Three allegations were noted from the nurse note review. Zero allegations were noted from the grievance review. The Regional Nurse Manager reported the allegations from the nurse notes to the Administrator. The administrator self-reported the three allegations to the Oklahoma Department of Health on 9/28/22. Person Responsible: Regional Nurse Manager/ADON/Unit Manager/Administrator Timeline for completion: 10/4/22 5:00 pm Central Time Action Item: Ad hoc QAPI to review POR, and effectiveness with the IDT to include the medical director. Medical Director notified by the Regional Nurse Manager of the Immediate Jeopardy and the physician and family member was notified for the resident. The review will be documented in the POR Binder. Any revisions or changes will be addressed and reevaluated with findings addressed in QAPI meeting. Person Responsible: Regional Nurse Manager/DON/ADON/Unit Manager Timeline for completion: 10/4/22 5:00 pm Central Time Action Item: Regional Director of Operations/COO will review the POR to tick and tie the audit tools to validate the POR has been completed and all allegations are investigated and reported timely. Person Responsible: Regional Director of Operations/COO /SFC/RNM Timeline for completion: 10/4/22 5:00 pm Central Time Please accept our plan of removal and lift the jeopardy effective 10/4/2022 . Based on record review, observation, and interview, the DON failed to report an allegation of abuse to the administrator for one (#1) of ten sampled residents who were reviewed for abuse. The Resident Census and Conditions of Residents form identified 100 residents resided in the facility. Findings: The Abuse Prevention Program policy, dated June 2021, read in parts, .The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures .An alleged violation of abuse .will be reported immediately, but not later than: Two [2] hours if the alleged violation involves abuse .The Administrator is the Abuse Prevention Coordinator. In the absence of the Administrator the Director of Nursing will serve in this capacity . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON's employee record documented the Abuse and Neglect Policy and Procedure was signed by the DON upon hire on 08/15/22. An annual assessment, dated 08/17/22, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making. On 09/27/22 at 4:30 p.m., The resident stated they asked the DON if they were going to do anything about LPN #1 laughing at and making fun of them. Resident #1 stated the DON stated there was nothing they could do about it. On 09/27/22 at 4:56 p.m., They were asked if they had reported the allegation. The DON stated they had not reported the allegation because they had only heard a conversation between EMSA personnel and the resident. The DON stated, I left it at that because I didn't hear it myself. They stated they had instructed the resident to report the allegation to the state surveyors on Monday. The DON was asked if they had received training regarding abuse. They stated they did not think so but maybe they did when they were hired. They were asked what the types of abuse were. The DON stated verbal, physical, and mental. They were asked if the resident's allegation of the nurse making fun of and laughing at Resident #1 was an allegation which required further investigation. The DON stated they did not know because they had not witnessed the incident. The DON was asked if they had asked the resident or staff for further details regarding the allegation. They stated no. The DON stated they should have gotten a statement but they did not know what the facility's policy was. On 10/04/22 at 9:58 a.m., the administrator was asked what the facility's protocol was if a resident reported an allegation of abuse to a staff member. They stated staff were to immediately report the allegation to the administrator, the employee's supervisor, or the DON. The administrator was asked why the allegation of abuse was not reported to them by the DON per facility protocol. The administrator stated that was their question also. They stated when they asked the DON they had not gotten an answer. The administrator was asked what the time frame was for reporting allegations of abuse. They stated any allegation was to be reported immediately.

On 09/16/22 at 3:00 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to identify, implement, monitor, and modify interventions to prevent a severe weight loss. Resident #9 experienced a severe weight loss of 16.26% in one month and the facility failed to monitor weights, monitor enteral feeding, and implement interventions. On 09/16/22 at 3:18 p.m., the facility's administrator, Regional Director of Operations, Regional Nurse Manager #1, Regional Nurse Manager #2, and the DON was made aware of the IJ situation related to the facility's failure to prevent severe weight loss. A plan of removal of the IJ situation was requested. A plan of removal was received on 10/04/22 and accepted on 10/05/22. The facility was notified the immediacy was lifted as of 10/04/22 at 5:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of isolated harm. The plan of removal documented: Plan of Removal significant weight loss Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/16/22 for residents who received enteral feeding and weight loss. Action Item 1: Resident #9 was immediately re-assessed by RN Clinical Resource Nurse for proper tube feeding procedures and proper positioning, deficient practice corrected. All residents with enteral feedings were weighed between 9/15/22 and 9/17/22. Corporate Resource Nurse(s) RN, reviewed enteral feeding resident weights for significant weight loss and variances on 9/17/22 completed by 5:00pm central time Residents receiving tube feedings with weight variance were placed on a weekly weight schedule x4 weeks by the Corporate Resource Nurse(s), RN on 9/17/22 completed on 10/4/22 5:00 pm Central Time DON/Regional Nurse Manager, RN will review Dietitian enteral feeding recommendations on day received. Enteral feeding recommendations will be transmitted to the resident physician for review/approval within 24 hours of receipt. Any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON/Regional Nurse Manger will review the previously mentioned on the weekends. Weekly weights will be reviewed by the DON/Regional Nurse Manager, RN during the morning clinical meeting. Weights are completed by the designated CNA. Weights are documented by Nurse Manager in Matrix, weights are entered by every Thursday by 5:00 pm. DON/Regional Nurse Manager will review the weight process the following day and the regional nurse/regional nurse 2 will validate the process. Follow up weekly weight reviews will be held by the Administrator & DON every Wednesday at 3:00pm central time with the Resident at Risk Team in the clinical management office. Identified residents at risk will be reviewed for interventions, recommendations by the team/physician. Regional Director of Operations will review Administrator & DON Resident at Risk team findings weekly. This will be reviewed in QAPI for process improvement. All Residents at Risk documentation and action(s) taken will be presented to the QAPI Committee monthly. Action Item 2: Nursing staff was educated by Corporate Resource Nurse(s) on significant weight loss, interventions, physician notifications, entering physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Education was completed with 1-2 staff members at a time. The wound module is part of the Matrix training. For Nurses/C.M.A./C.N.A. and other non-clinical staff came in before their shift started, during their shift and stayed after their shift. The staff that are unavailable due to not being scheduled for various reasons and or not answering their phone will be educated prior to working their next shift. The RN Corporate Resource Nurse(s)/DON or Unit Managers will complete the education. Clinical staff-Nurses, CNAs, and CMAs was educated on repeated meal refusals, repeated meal intake of less than 50%, recognition of signs of decreased appetite and signs of weight loss by RN Clinical Resource Nurse(s). Education for nurses completed on 10/4/22 5:00 pm Central Time. The RN Corporate Resource Nurse(s)/DON or Unit Managers will complete the education. The regional nurse manager education team consisted of seven regional nurse managers, RN. Education was completed with 1-2 staff members at a time. The wound module is part of the Matrix training. For Nurses/C.M.A./C.N.A. and other non-clinical staff came in before their shift started, during their shift and stayed after their shift. The staff that are unavailable due to not being scheduled for various reasons and or not answering their phone will be educated prior to working their next shift. The center does not use agency staff, if the center utilizes agency staff or hires new staff, staff will complete the appropriate education prior to working on the floor. Education will be completed by the Regional Nurse Manager, RN/DON, RN/Nurse manager RN/LPN. Please accept our plan of removal and lift the jeopardy effective 10/4/2022 . Based on observation, record review, and interview, the facility failed to assess, monitor, and intervene for one (#9) of three residents sampled for weight loss. This resulted in the resident experiencing a severe weight loss of 16.26% in one month. The Regional Nurse Manager #1 identified seven residents with significant weight loss. Findings: The Enteral Nutrition policy, dated November 2018, read in parts, .Adequate nutritional support through enteral nutrition is provided to residents as ordered .The nurse confirms that orders for enteral nutrition are complete . The Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol policy, dated September 2017, read in parts, .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time .The staff will report to the physician significant weight gains or losses . Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Weight Variance Report, dated 03/15/22 through 09/15/22, documented the latest weight for Resident #9 was 99.2 pounds on 08/16/22. No weight was documented for September 2022. The Medication Administration Record, dated 08/01/22 through 08/31/22, did not document any orders for continuous or bolus tube feeding. The MAR documented the resident was NPO. A Resident Progress Note, dated 08/18/22, read in part, .CBW: 99.2# .NPO. [MEDICATION(S)] 1.5 @40ml x22hr providing 1320kcal, 56g pro, 668ml fluid. Flushes 200cc q 6 hours (1200ml fluid). Tolerating feeds .EEN: 1115kcal, 40-50g pro, 1350-1575ml fluid .likely not meeting adequate intake with continuing decline. Rec 1. Increasing [MEDICATION(S)] 1.5 @ 55ml x 22hr Providing 1815kcal, 77g pro, 919 free H2O. Will continue to monitor. The progress note was signed by the registered dietician. Review of the clinical record did not reveal the physician had addressed the dietary progress note. A Daily Census Report, dated 08/30/22, was provided to the survey team as a list of weights for September 2022 by RNM #1. RNM #1 stated at the end of the month they printed a daily census report, which was provided to the nurse aide who was responsible for obtaining weights, for the following month. Resident #9 was not on the list. A Resident Progress Note, dated 08/31/22 at 3:34 p.m., documented the resident had returned from the hospital. The note read in part, .will administer feeds as per orders . A Resident Progress Note, dated 08/31/22 at 6:44 p.m., documented the nurse attempted to hook the resident to the feeding pump but the pump gave an error message and another pump could not be located. A Resident Progress Note, dated 08/31/22 at 7:07 p.m., documented the physician had been made aware the feeding pump was not functional and orders were received for [MEDICATION(S)] 1.5 240ml via peg tube four times per day, flush with 100ml of water, and to resume continuous feeding orders once another pump was obtained. An admission assessment, dated 09/04/22, documented the resident was severely impaired in cognition for daily decision making, weight loss/gain was not experienced or unknown, and they had a feeding tube. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Dietary flow sheet .Enteral Formula Pump Administration: [MEDICATION(S)] 1.5 to run at 40 Ml/Hour for 22 hours per day . The order was dated 08/26/22 through 09/01/22. The Medication Administration Record, dated 09/01/22 through 09/22/22, documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR did not reveal documentation the resident had received the Glucerna 1.2 from 09/01/22 - 09/16/22. On 09/13/22 at 8:23 a.m., the resident was observed in bed. The feeding pump was observed to be off. A bottle of Glucerna was hanging on the feeding pump. The bottle had a hand written date of 09/01 or 09/11, the day was smudged. The bottle contained 400 cc of formula. On 09/13/22 at 4:16 p.m., the resident was observed in bed. The feeding pump was observed to be off with no formula hanging. On 09/15/22 at 9:51 a.m., the feeding tube was not connected. The resident was observed in bed with the enteral feeding pump infusing at 40 cc/hr. The end of the feeding tube was observed to not be connected to the resident and was infusing under the resident's bed. A pool of light tan liquid was observed on the floor, at the end of the feeding tube. On 09/15/22 at 10:54 a.m., the enteral feeding pump was observed infusing at 40 cc/hr. The end of the feeding tube was observed to be under the resident's bed. A pool of light tan liquid, was observed from the hallway on the floor at the end of the feeding tube. On 09/15/22 at 11:48 a.m., the enteral feeding pump was observed infusing at 40 cc/hr. The end of the feeding tube was observed to be under the resident's bed. A pool of light tan liquid, was observed from the hallway on the floor at the end of the feeding tube. On 09/15/22 at 12:15 p.m., the enteral feeding pump was observed infusing at 40 cc/hr. The end of the feeding tube was observed to be under the resident's bed. A pool of light tan liquid, was observed from the hallway on the floor at the end of the feeding tube. On 09/15/22 at 1:32 p.m., the enteral feeding pump was observed infusing at 40 cc/hr. The end of the feeding tube was observed to be under the resident's bed. A pool of light tan liquid, was observed from the hallway on the floor at the end of the feeding tube. The enteral feeding pump documented the resident had received 1778 cc and had received 1103 cc of fluid. On 09/15/22 at 2:02 p.m., observed LPN in room. LPN #1 was asked what care they were providing to Resident #9. They stated they were changing the enteral tube feeding set, water, and formula. The LPN pulled the blankets off of the resident and observed the tube was not connected. The LPN was asked about the area of the floor at the end of the feeding tube. They stated the floor appeared wet. LPN #1 was asked how long the resident's tube feeding had not been infusing into the resident. They stated the CNAs had repositioned the resident about one hour ago and they may have unhooked it at that time. The LPN stated the resident was repositioned every two hours. LPN #1 was asked how they knew what the resident's enteral feeding physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They were asked if they had administered bolus enteral feedings. LPN #1 stated no. On 09/15/22 at 2:14 p.m., CNA #1 was asked about the resident's tube feeding. They stated the tube feeding had been leaking. They stated the feeding pump said the formula was running but the resident wasn't getting any food. They were asked when they had noticed the tube feeding was leaking. They stated around 11:00 a.m. CNA #1 was asked if they had notified anyone about the enteral feeding not infusing. They stated LPN #2. On 09/15/22 at 2:18 p.m., RNM #1 was asked when weights were obtained. They stated monthly weights were obtained the first few days of the month, upon return from the hospital, and as needed. RNM #1 was asked where the weights were documented. They stated they were documented on paper then added to the electronic clinical record under vital signs. RNM #1 was asked why the weight for Resident #9 had not been obtained upon return from the hospital on 08/31/22 or the monthly weight for September 2022. They reviewed the list of monthly weights and stated they did not know. RNM #1 was asked for the resident's current weight. On 09/15/22 at 3:47 p.m., CNA #1 obtained the weight for Resident #9 via mechanical lift. The weight was observed and reported as 82.94 pounds. This weight indicated a 16.26% weight loss in one month. On 09/15/22 at 4:16 p.m., LPN #2 was asked if anyone had reported any issues with Resident #9's enteral feeding not infusing. They stated not that they remembered. They were asked if they had provided care to Resident #9. They stated they had worked on the resident's hall for a few hours but had not provided care to the resident. LPN #2 stated the nurse who had been assigned to the hall wanted a different hall so they covered until another nurse took over. On 09/16/22 at 9:28 a.m., a bottle of Glucerna was observed to be connected to the enteral feeding pump. The bottle of Glucerna, dated 09/15/22 at 2:05 (a.m. or p.m. was not indicated), was observed to contain 600 cc of formula. The pump was observed to be set at 40 cc/hr with a 100 ml water flush. The pump read the resident had been fed 222 ml. On 09/16/22 at 10:53 a.m., RNM #1 was asked where continuous and bolus enteral feedings were documented. They stated on the MAR. They reviewed the electronic record and stated the orders for the enteral tube feeding was listed on the dietary flow sheet. RNM #1 contacted the IT department and asked how nurses were able to see the resident's tube feeding orders when it was documented on the dietary flow sheet. RNM #1 stated the nurses were not able to see the resident's enteral feeding orders when they were located on the dietary flow sheet. RNM #1 stated there was not a place to document the administration of the enteral tube feeding administration on the dietary flow sheet. RNM #1 was asked where bolus enteral feedings from 09/01/22 through 09/16/22 were documented for Resident #9. They stated on the electronic MAR. They reviewed the MAR and was asked how often the resident had received a bolus enteral feeding. RNM #1 stated, Zero. RNM #1 was asked how tube feeding was monitored to ensure the resident had received enteral feeding as ordered by the physician to maintain nutrition and prevent weight loss. They stated there was no way to know the enteral feeding had been administered as ordered by the physician. RNM #1 stated they did not know if anyone had monitored. On 09/21/22 at 2:03 p.m., the medical director was asked how they received and addressed dietary recommendations from the dietician. They stated there was a system in place and it was a part of a continuous quality assurance. The medical director stated the recommendations were placed in a folder for them to sign. The medical director was asked how they were aware of weights to monitor for significant weight loss. The medical director stated they reviewed monthly weights. On 09/21/22 at 3:21 p.m., RNM #1 was asked how residents' weights were monitored to ensure significant/severe weight loss was identified. They stated they had a book where weights were documented before they were placed in the electronic clinical record. RNM #1 stated the weights were inaccurate because sometimes the residents were weighed with the mechanical lift and sometimes the wheel chair weight had not been deducted.

On 09/16/22 at 3:00 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to prevent aspiration with proper positioning for residents who received enteral nutrition. Resident #3 was found to be lying supine by the treatment nurses with continuous enteral feeding infusing. As a result of lying supine, the resident was transferred to the hospital and was diagnosed with aspiration pneumonia. Resident #9 was observed lying supine with a continuous tube feeding infusing. On 09/16/22 at 3:18 p.m., the facility's administrator, Regional Director of Operations, RNM #1, RNM #2, and the DON was made aware of the IJ situation related to the facility's failure to prevent aspiration pneumonia with proper positioning of residents who received enteral tube feeding. A plan of removal of the IJ situation was requested. A plan of removal was received on 10/05/22 and accepted on 10/06/22. The facility was notified the immediacy was lifted as of 10/04/22 at 5:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of isolated harm. The plan of removal documented: Plan of Removal Tube feeding Please accept this Plan of Removal as a credible allegation of compliance for the immediate jeopardy initiated on 9/16/22 for adequate nutritional tube feeding and administrating tube feedings. Action Items: Resident #9 was immediately assessed by the Clinical Resource Nurse, RN for proper tube feeding procedures and proper positioning, deficient practice corrected. Resident #3 was transported to the hospital on 9/2/22 and remains an in patient. Other residents with enteral feedings were reviewed for proper tube feeding and proper positioning per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Charge nurse/ADON/nurse manager will monitor all residents who receive enteral feedings to ensure the correct formula, rate, and correct positioning of residents q shift daily by visual inspection and document in EMR. Nursing documentation will be reviewed and validated during daily morning clinical meetings by the DON and ADON for each hall assignment. The nurse manager/ADON will complete the assigned duties previously mentioned above, on the weekend. Night shift nurse manager/charge nurse LVN will complete the assigned duties previously mentioned above daily. Verification of reviews conducted during daily morning clinical meeting of nursing documentation by DON/ADON will be conducted by the Administrator & Regional Nurse Manager, RN every Wednesday at 3:00pm CST with the Resident at Risk Team in the clinical management office. Dietitian enteral feeding recommendations and enteral physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON/Regional Nurse Manager, RN will review Dietitian enteral feeding recommendations on day received. Enteral feeding recommendations will be transmitted to the resident physician for review/approval within 24 hours of receipt. Any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents with enteral feedings were weighed by 9/18/22 by the designated CNA Weights are documented by the nurse manger in Matrix, weights are entered by every Thursday by 5pm.The DON/ADON/Unit Manager will review the weight process the following day and the regional nurse/regional nurse 2 will validate the process. Corporate Resource Nurse(s) reviewed enteral feeding resident weights for significant weight loss and variances on 9/27/22 completed by 5:00pm central time. Follow up reviews will be held by the Administrator and DON every Wednesday at 3:00pm CST with the Resident at Risk Team in the clinical management office. Regional Director of Operations will review Administrator and Don Resident of Risk Team findings for identified concerns and will address immediately and take to QAPI for further follow up. POR will tick and tie the audit tools to validate the POR has been completed and all allegations are investigated and reported timely. All Residents at Risk documentation and action(s) taken will be presented to the QAPI Committee monthly. RN, LPN, C.N.A., and CMA was educated by Corporate Resource Nurse(s) on significant weight loss, interventions, physician/nurse notifications, proper enteral feeding positioning, signs of acute respiratory failure, signs of aspiration pneumonia, and severe [CONDITION(S)]. RN's and LPNs were educated on the proper rate, formula, flushes, entering orders into the electronic medical record, change of condition, to include physician and family notifications. The regional nurse manager education team consisted of seven regional nurse managers, RN. Education was completed with 1-2 staff members at a time. Education is housed in the POR binder. Completed on 10/4/22 5:00 pm Central Time The center does not use agency staff, if the center utilizes agency staff or hires new staff, staff will complete the appropriate education prior to working on the floor. Education will be completed by the Regional Nurse Manager, RN/DON, RN/Nurse manager RN. Completed on 10/4/22 5:00 pm Central Time Please accept our plan of removal and lift the jeopardy effective 10/4/2022 . Based on observation, record review, and interview, the facility failed to ensure residents who received enteral feedings were positioned in a manner to prevent aspiration for two (#3 and #9) of three sampled residents who were reviewed with enteral feedings. The Resident Census and Conditions of Residents form identified six residents who received nutrition by tube feeding. Findings: The Enteral Nutrition policy, dated November 2018, read in parts, .Risk of aspiration is assessed by the nurse and provider .Risk of aspiration may be affected by .Improper positioning of the resident during feeding . 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan, dated 08/23/22, documented the resident had a feeding tube and the goal was the resident will experience no complications. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge assessment, dated 09/02/22, documented Resident #3 had a feeding tube. A hospital record, dated 09/02/22 at 7:59 p.m., read in part, .presents from nursing home for concern of possible aspiration. Per report wound care nurse came to see patient around 1800 [6:00 p.m.] he was lying flat with the tube feeding bad [sic] open and finished and patient was hypoxic in the 60's and does not normally wear oxygen . A hospital record, dated 09/02/22 at 8:32 p.m., read in part, .does have very severe rhonchi and wet cough .most likely mucous plug or aspiration pneumonitis . A nurse note, dated 09/03/22 at 6:30 p.m., documented the resident had a change in condition which was noted when the wound care nurse had went into the room to treat his wound. The resident's oxygen saturation was 73%. The oxygen saturation was rechecked after the administration of five liters of oxygen via nasal cannula and was 95%. The resident was sent to the hospital. The note documented the physician and family were notified of the change of condition and was transferred to the hospital at 7:10 p.m. A hospital record, dated 09/05/22, read in part, .RLL pneumonia - suspected aspiration . On 09/13/22 at 10:05 a.m., wound nurse #2 was asked what the resident's position was when they had entered to provide wound care on 09/02/22. They stated the resident was lying flat in bed. They were asked if the resident's enteral feeding was infusing. They stated yes. Wound nurse #2 was asked who was responsible to ensure residents who received enteral feedings were positioned in a manner to prevent aspiration. They stated the charge nurse. On 09/13/22 at 10:35 a.m., wound nurse #1 was asked what the resident's position was when they had entered the room to provide wound care. The wound nurse stated the resident was supine and they had asked wound nurse #2 if the tube feeding was infusing and wound nurse #2 stated it was infusing and turned it off. Wound nurse #1 stated the resident was lethargic, confused, and had a wet cough. On 09/13/22 at 11:03 a.m., the room of Resident #3 was observed to have signs on the wall next to their bed that read the resident can not be flat in bed, NPO precaution, and the resident must be at least 30 degrees in bed. 2. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 09/04/22, documented the resident was severely impaired in cognition for daily decision making, weight loss/gain was not experienced or unknown, and they had a feeding tube. A care plan, updated 09/13/22, read in part, .Elevate HOB 30 degrees . On 09/15/22 at 2:50 p.m., Resident #9 was observed lying flat in bed on their left side. The head of the resident's bed was elevated, however, the resident was positioned in the fetal position in the middle/end of the bed. The enteral feeding was observed to be infusing at 40cc/hr. Resident #9's room was across from the nurses desk and the door to the room was open. On 09/15/22 at 2:55 p.m., CNA #1 was observed to enter the resident's room and asked if the resident was okay. RNM #2 looked into the resident's room. The resident did not answer and the CNA exited the room. On 09/15/22 at 2:58 p.m., RNM #2 entered the room, observed the enteral feeding pump, and exited the room. On 09/15/22 at 3:04 p.m., RNM #2 entered the resident's room and exited after a few seconds. On 09/15/22 at 3:10 p.m., ADON #1 and CNA #1 entered the resident's room. ADON #1 stated they were going to provide oral care and reposition the resident higher in bed. ADON #1 exited the room to obtain gloves. On 09/15/22 at 3:12 p.m., RNM #2 looked into the resident's room. The resident was observed to be lying flat in their bed and the enteral feeding was observed to infuse at 40cc/hr. On 09/15/22 at 3:15 p.m., ADON #1 was observed to provide oral care. The resident was observed to be lying flat in their bed with the tube feeding infusing. On 09/15/22 at 3:19 p.m., CNA #1 entered the resident's room with a mechanical lift and joined ADON #1. CNA #1 raised the bed up higher. On 09/15/22 at 3:22 p.m., CNA #1, ADON #1, CNA #2, CNA #3, and Regional Nurse Manager #2 were in the resident's room. ADON #1 had removed a loose dressing from the resident's sacral area. The resident was observed to have had a bowel movement and ADON #1 and CNA #1 positioned the resident slightly more toward the head of the bed and began providing incontinent care. The resident was observed to continue to lie flat with the enteral tube feeding infusing. Regional Nurse Manager #2 exited the room. On 09/15/22 at 3:27 p.m., ADON #1 was asked at what angle the resident was positioned. They stated, Maybe 15-20 degrees. CNA #1 lowered the head of the bed until it was flat. The resident continued to lie flat in bed. On 09/15/22 at 3:36 p.m., the incontinent care and bedding change was completed. The resident was observed to be supine during the care. The enteral feeding pump was observed to be on hold at this time. CNA #1 and CNA #2 were observed to stand by the enteral feeding pump. ADON #1 was observed to be on the opposite of the bed from the enteral feeding pump since 3:15 p.m. On 09/15/22 at 3:39 p.m., ADON #1 exited the room and CNA #1 was asked who put the enteral feeding pump on hold. They stated they had just placed the pump on hold. They were asked why they had placed the enteral feeding pump on hold. They stated they knew it was supposed to be on hold due to the position of the resident. On 09/15/22 at 3:49 p.m., CNA #1, CNA #2, and CNA #3 had completed resident care and positioned the resident at a 30 degree angle in bed. On 09/15/22 at 4:09 p.m., ADON #1 was asked how resident's who received continuous enteral nutrition were to be positioned. They stated their head was to be elevated 30 degrees. They were asked why they were to be positioned at a 30 degree angle. They stated to prevent aspiration pneumonia. ADON #1 was asked why Resident #9 was not positioned in a manner to prevent aspiration pneumonia. They stated they had observed the angle of the head of the bed. They stated they did not look at the resident's position. The ADON #1 was asked why the enteral feeding was not held during the provision of care until 3:36 p.m. They stated they told CNA #1 to place the pump on hold. They were asked if a 15-20 degree angle was sufficient to prevent aspiration. They stated no. On 09/16/22 at 12:20 p.m., the resident was observed in bed with the enteral feeding infusing at 40cc/hr. The resident's torso was observed to be angled at approximately ten degrees. On 09/16/22 at 12:25 p.m., LPN #2 was asked what position the resident was to be in to prevent aspiration when the enteral feeding was infusing. They stated the resident's head needed to be elevated and the resident was to be kept comfortable. They were asked when the last time they had assessed Resident #9. They stated approximately 30 minutes ago. They were asked at what angle the resident was positioned. They observed the resident and stated, Not quite high enough, I'm not good on numbers. Not very much, not even ten degrees. LPN #2 was asked why the resident was not positioned in a manner to prevent aspiration. They stated they had the resident a little higher earlier. They were asked at what angle had they positioned the resident. LPN #2 stated, I don't know. I'm not good at degree numbers. On 09/16/22 at 12:27 p.m., LPN #2 walked down the hall to pass meal trays. They did not reposition the resident. On 09/16/22 at 12:34 p.m., RNM #1 and RNM #3 were asked what angle residents who received enteral feedings were to be placed to prevent aspiration. RNM #1 stated 30 degrees. They were asked what angle Resident #9 was positioned. They observed the resident and RNM #3 stated approximately ten degrees. RNM #1 and RNM #3 were informed of the observations of the resident not positioned to prevent aspiration and was asked why the resident was not positioned in a manner to prevent aspiration. RNM #1 stated the staff were not paying attention. On 09/24/22 at 8:44 a.m., CNA #5 was asked what angle the resident needed to be to prevent aspiration. CNA #5 stated 90 degrees. They were asked what position the resident was currently in. They stated about 30 degrees. On 09/24/22 at 8:46 a.m., Resident #9 was observed lying in bed at approximately a 15 degree angle. RNM #3 was asked at what angle the resident was positioned. They stated approximately 20 degrees. They stated the resident at times would slide down in bed and if they elevated the foot of the bed that may help with positioning. RNM #3 stated they were going to check the resident's orders. On 09/24/22 at 9:08 a.m., RNM #3 and the DON entered the resident's room and repositioned the resident. The DON was asked what angle the resident was to be positioned to prevent aspiration. They stated 30 degrees.

On 09/28/22 at 9:38 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to prevent abuse for one (#1) when the facility failed to ensure Resident #1 was not humiliated when LPN #1 made fun of them and laughed at them in a demeaning and humiliating way. The nurse stated the statement made by Resident #1 to EMSA, regarding the nurse refusing to provide suction, was Bullshit, was laughing while walking out of the room, and began talking and laughing with other staff in the hallway regarding Resident #1's statements to EMSA. On 09/28/22 at 9:46 p.m., the facility's administrator, Regional Nurse Manager #1, the Chief Operating Officer, and the corporate Survey Focus Coordinator was made aware of the IJ situation related to the facility's failure to prevent abuse. A plan of removal of the IJ situation was requested. A plan of removal was received on 10/04/22 and accepted on 10/06/22. The facility was notified the immediacy was lifted as of 10/04/22 at 5:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of isolated harm. The plan of removal documented: Plan of Removal F600 The facility failed to prevent abuse. Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/28/2022, for implementing the abuse policy. Action Item: The DON, the nurse and the C.N.A. were suspended on 9/28/22 pending investigation of incident. The DON than stated she was self-terminating. Person Responsible: Regional Nurse Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Education to all staff on the centers abuse prevention program, recognizing signs and symptoms of abuse/neglect, abuse reporting timely, abuse investigation and neglect policies; resident rights and SLP Compliance Program with emphasis on Professional Conduct and all staff not present will be provided education to starting of next shift. All staff will complete abuse skills competency and posttest and or return demonstration, resident rights and grievance posttest and return demonstration before next shift. Person Responsible: Administrator/DON/ADON/Unit Manager/Regional Nurse Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Review self-reports from previous 30 days to determine if the investigation has been completed thoroughly. No deficient practice was noted, all investigation were completed and reported to the Oklahoma Department of Health timely. Documentation of this review is in the POR binder. Person Responsible: Chief Operating Officer/Administrator/Regional Nurse Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Safe surveys will be completed via questionnaire with all residents that are interviewable; responsible parties will be phone interviewed for all residents that are not interviewable and those residents were interviewed for signs of physical or psychosocial distress and documented. Any allegations of abuse coming from the interviews were reported to the Oklahoma Department of Health. All allegations of abuse are reviewed in morning meeting and investigation initiated immediately upon notification with reportable submitted to the Oklahoma Department of Health. 1. Psychosocial harm was assessed through resident interviews for interviewable residents and residents that are not interviewable with families to evaluate and determine physical and emotional abuse. 2. Non-interviewable residents had skin assessments completed with no concerns of physical harm identified. Families were contacted for signs of psychosocial concerns, with none identified. 3. Staff re-education and monitoring will be completed routinely and as needed to prevent abuse and ensure proper reporting of all allegations. 4. Any revisions or changes will be addressed and reevaluated with findings addressed in QAPI meeting. Follow up reviews will be held by the Administrator and DON every Wednesday at 3:00pm CST with the Resident at Risk Team in the clinical management office. Regional Director of Operations will review Administrator and Don Resident of Risk Team findings for identified concerns and will address immediately and take to QAPI for further follow up. POR will tick and tie the audit tools to validate the POR has been completed and all allegations are investigated and reported timely. Person Responsible: Regional Nurse Manager/ ADON/DON/Unit Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Review of all nurses notes from prior 7-day period to identify any allegations of abuse that were not reported timely. Review of grievance log for the past 30 days. Three allegations were noted from the nurse note review. Zero allegations were noted from the grievance review. The Regional Nurse Manager reported the allegations from the nurse notes to the Administrator. The administrator self-reported the three allegations to the Oklahoma Department of Health on 9/28/22. Person Responsible: Regional Nurse Manager/DON/ADON/Unit Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Ad hoc QAPI to review POR, and effectiveness with the IDT to include the medical director. Screening, Training, Prevention, Identification, Investigation, Protection and Reporting/response Person Responsible: Regional Nurse Manager/Regional Director of Operations/DON/ADON/Unit Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Regional Director of Operations/COO will review the POR to tick and tie the audit tools to validate the POR has been completed by 10/4/22. Person Responsible: Regional Director of Operations/Additional RDO/COO Completed on 10/4/22 5:00 pm Central Time Please accept our plan of removal and lift the jeopardy effective 10/4/2022 . Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for one (#1) of ten sampled residents who were reviewed for abuse. The Resident Census and Conditions of Residents form identified 100 residents resided in the facility. Findings: The Abuse Prevention Program policy, dated June 2021, read in parts, .Our residents have the right to be free from abuse .Our center will not condone any form of resident abuse . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 08/17/22, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making. The Employee Time Card, dated 09/16/22 through 09/30/22, documented LPN #1 worked from 09/24/22 through 09/27/22. The employee was not suspended until 09/29/22. On 09/27/22 at 4:30 p.m., Resident #1 stated on 09/24/22 they had called EMSA to suction them because the nurse had suctioned them and the resident felt it was ineffective. The resident stated while EMSA was present LPN #1 offered them a breathing treatment but the resident was not confident the nurse would return to remove the breathing treatment when it was completed because the nurse was unreliable. The resident stated the DON offered to stay and provide a breathing treatment and suction and LPN #1 left the room. Resident #1 stated EMSA was in the room and they heard LPN #1 laughing at and making fun of the resident when LPN #1 had left the room. The resident stated EMSA personnel #1 stated, They're out there making fun of him. Laughing at him. The resident stated they asked the DON if they were going to do anything about LPN #1 laughing at and making fun of them. Resident #1 stated the DON stated there was nothing they could do about it. On 09/27/22 at 4:56 p.m., the DON was asked if they had provided any care to Resident #1 on 09/24/22. The DON stated they had provided a breathing treatment and suctioning while EMSA was present. The DON was asked if they overheard staff laughing at or making fun of Resident #1. The DON stated the resident told them the nurse was making fun of them and giggling at them. They were asked if they had reported the allegation. The DON stated they had not reported the allegation because they had only heard a conversation between EMSA personnel and the resident. The DON was asked if the resident had asked them to do something about the nurse laughing at and making fun of them. The DON stated LPN #1 was not an employee of the facility and worked for agency. The DON stated they had instructed the resident to report the allegation to the state surveyors on Monday. The DON stated, I left it at that because I didn't hear it myself. The DON was asked if they had received training regarding abuse. They stated they did not think so but maybe they did when they were hired. They were asked what the types of abuse were. They stated verbal, physical, and mental. The DON was asked if the resident's allegation of the nurse making fun of and laughing at him was an allegation which required further investigation. They stated they did not know because they had not witnessed the incident. The DON was asked if they had asked the resident or staff for further details regarding the allegation. They stated no. The DON stated they should have gotten a statement but they did not know what the facility's policy was. On 09/28/22 at 4:25 p.m., EMSA personnel #2 was asked about the run made on 09/24/22 for Resident #1. They stated they had gotten a call a resident with a [CONDITION(S)] needed suctioning. They stated when they arrived LPN #1 began defending themselves and as the nurse walked out of the resident's room the nurse began laughing at the resident and was heard in the hall laughing and talking to other staff about Resident #1. They stated LPN #1 was bashing the resident the whole time and was disrespectful to the resident. EMSA personnel #2 stated the resident was crying. EMSA personnel #2 was asked what they meant by bashing. They stated when they first arrived the staff were gathering to find out what was going on, laughing, and talking about the resident. They were asked what the LPN #1 said about the resident. EMSA personnel #2 stated the LPN #1 told the other staff the resident had said LPN #1 had refused to suction them and that was bullshit. They stated the nurse was repeating what the resident had said and mocked the resident. They stated another nurse (DON) had entered the room and heard Resident #1 talking to them about the allegation. EMSA personnel #2 stated they notified the nurse they were not okay with how LPN #1 had treated the resident. EMSA personnel #2 stated the nurse agreed with EMSA filing a report on the incident. On 09/28/22 at 6:22 p.m., LPN #1 was asked what had happened when EMSA came to the facility on [DATE] for Resident #1. LPN #1 stated they had suctioned the resident but they requested deeper suctioning. They stated they offered the resident a breathing treatment. The resident stated they wanted a second opinion and the DON discussed the breathing treatment with the resident and provided it. LPN #1 stated when EMSA arrived and entered the room, the resident had called LPN #1 a liar and was incompetent. LPN #1 stated they smirked and walked out of the resident's room, leaving the resident with the two EMSA personnel. LPN #1 was asked if they had laughed at or made fun of the resident. They stated they had only smirked. LPN #1 stated the DON had told them they were laughing at the resident. LPN #1 stated they told the DON they had just smirked. On 09/28/22 at 7:00 p.m., Resident #1 was asked how it made them feel when LPN #1 laughed at and made fun of them on 09/24/22. They stated they cried. They stated it made them feel like they did not matter and that their life and health was a joke. The resident stated, She kept it going throughout the days. They stated the other staff knew what happened and it was embarrassing. On 09/29/22 at 1:58 p.m., the administrator stated during their investigation of the allegation involving Resident #1 the DON self-terminated when they were suspended, pending the investigation. They stated they suspended CNA #4 because they were involved in laughing and making fun of the resident. On 10/04/22 at 9:58 a.m., the administrator was asked how staff were made aware of the abuse protocol. They stated they provided inservices and also provided one on one education as needed. The administrator was asked how the facility protected residents from abuse. They stated if they received an allegation of abuse they immediately suspended the employee pending investigation. They were asked what the facility's policy was if a resident reported an allegation of abuse to a staff member. They stated they were to immediately report the allegation to them, the employee's supervisor, or the DON. The administrator was asked why the abuse policy was not implemented when the DON had received an allegation of abuse from Resident #1 on 09/24/22. They stated they did not know. The administrator stated they had asked the DON why they had not implemented the policy and the DON reported to them they had not heard the laughing at and making fun of the resident directly.

On 09/28/22 at 9:38 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to implement their abuse policy for one (#1) when the DON failed to identify abuse when Resident #1 was humiliated when LPN #1 made fun of them and laughed at them in a demeaning and humiliating way. The nurse stated the statement made by Resident #1 to EMSA regarding the nurse refusing to provide suctioning was Bullshit, was laughing while walking out of the room, and began talking and laughing with other staff in the hallway, regarding Resident #1's statements to EMSA. On 09/28/22 at 9:46 p.m., the facility's administrator, Regional Nurse Manager #1, the Chief Operating Officer, and the corporate Survey Focus Coordinator was made aware of the IJ situation related to the facility's failure to implement the abuse policy. A plan of removal of the IJ situation was requested. A plan of removal was received on 10/04/22 and accepted on 10/06/22. The facility was notified the immediacy was lifted as of 10/04/22 at 5:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of isolated harm. The plan of removal documented: Plan of Removal F607 The facility failed to implement their abuse policy. Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/28/2022, for implementing the abuse policy. Action Item: The DON, the nurse and the C.N.A. was suspended on 9/28/22 pending investigation of incident. The DON than stated she was self-terminating. Person Responsible: Regional Nurse Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Education to all staff on the centers abuse prevention program, recognizing signs and symptoms of abuse/neglect, abuse reporting timely, abuse investigation and neglect policies; resident rights and SLP Compliance Program with emphasis on Professional Conduct and all staff not present will be provided education to starting of next shift. All staff will complete abuse skills competency and posttest and or return demonstration, resident rights and grievance posttest and return demonstration before next shift. Person Responsible: Administrator/DON/ADON/Unit Manager/Regional Nurse Manager/Director of Clinical Practice Completed on 10/4/22 5:00 pm Central Time Action Item: Review self-reports from previous 30 days to determine if the investigation has been completed thoroughly. No deficient practice was noted, all investigation were completed and reported to the Oklahoma Department of Health timely. Documentation of this review is in the POR binder. Person Responsible: Chief Operating Officer/Administrator Completed on 10/4/22 5:00 pm Central Time Action Item: Safe surveys will be completed with all residents that are interviewable; responsible parties will be interviewed to determine if the responsible party believes the resident has suffered psychological harm, all residents that are un-interviewable will have a skin assessment to assess for physical harm. Person Responsible: Regional Nurse Manager/ADON/DON/Unit Manager Completed on 10/4/22 5:00 pm Central Time Action Item: Review of all nurses notes from prior 7-day period to identify any allegations of abuse that were not reported timely. Review of grievance log for the past 30 days. Three allegations were noted from the nurse note review. Zero allegations were noted from the grievance review. The Regional Nurse Manager reported the allegations from the nurse notes to the Administrator. The administrator self-reported the three allegations to the Oklahoma Department of Health on 9/28/22. Person Responsible: Regional Nurse Manager/DON Completed on 10/4/22 5:00 pm Central Time Action Item: Ad hoc QAPI to review POR, and effectiveness with the IDT to include the medical director. Screening, Training, Prevention, Identification, Investigation, Protection and Reporting/response. The review will be documented in the POR Binder. Any revisions or changes will be addressed and reevaluated with findings addressed in QAPI meeting. Person Responsible: Regional Nurse Manager/DON/Regional Director of Operations Completed on 10/4/22 5:00 pm Central Time Action Item: Regional Director of Operations/COO will review the POR to tick and tie the audit tools to validate the POR has been completed by 10/4/22. Person Responsible: Regional Director of Operations/Additional RDO/COO Completed on 10/4/22 5:00 pm Central Time Please accept our plan of removal and lift the jeopardy effective 10/4/2022 . Based on record review, observation, and interview, the facility failed to identify abuse and implement the abuse policy for one (#1) of ten sampled residents who were reviewed for abuse. The Resident Census and Conditions of Residents form identified 100 residents resided in the facility. Findings: The Abuse Prevention Program policy, dated June 2021, read in parts, .The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures .As part of the resident abuse prevention program, the administration will: Develop and implement polices and procedures to aid our Center in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Protect residents during abuse investigations .The Administrator is the Abuse Prevention Coordinator. In the absence of the Administrator the Director of Nursing will serve in this capacity .During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the Administrator . Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON's employee record documented the Abuse and Neglect Policy and Procedure was signed by the DON upon hire on 08/15/22. An annual assessment, dated 08/17/22, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making. On 09/27/22 at 4:30 p.m., Resident #1 stated they heard LPN #1 laughing at and making fun of them when LPN #1 left the room. The resident stated they asked the DON if they were going to do anything about LPN #1 laughing at and making fun of them. Resident #1 stated the DON stated there was nothing they could do about it. On 09/27/22 at 4:56 p.m., The DON was asked if the resident had asked them to do something about the nurse laughing at and making fun of Resident #1. They stated they had instructed the resident to report the allegation to the state surveyors on Monday. The DON stated, I left it at that because I didn't hear it myself. The DON was asked if they had received training regarding abuse. They stated they did not think so but maybe they did when they were hired. On 10/04/22 at 9:58 a.m., the administrator was asked how the facility protected residents from abuse. They stated if they received an allegation of abuse they immediately suspended the employee pending the investigation. The administrator was asked why the abuse protocol was not implemented when the DON had received an allegation of abuse from Resident #1 on 09/24/22. They stated they did not know. The administrator stated they had asked the DON why they had not implemented the policy and the DON reported to them they had not heard the laughing at and making fun of the resident directly.

Based on observation, record review, and interview, the facility failed to ensure effective administration to prevent multiple system failures. The Resident Census and Conditions of Residents form identified 100 residents who resided in the facility. Findings: a. ensure resident funds were conveyed within 30 days of death; b. ensure a homelike environment; c. ensure residents were free from abuse; d. ensure the abuse policy was implemented; e. ensure an abuse allegation was reported; f. ensure medications and treatments were administered per the physicians' orders; g. identify pressure ulcers, ensure pressure ulcers did not worsen, ensure physician notification was made and documented, admission skin assessments were conducted, identify the signs of wound infections, and ensure wound treatments were provided; h. ensure a resident did not experience severe weight loss; i. ensure residents who received enteral nutrition were positioned in a manner to prevent aspiration; j. ensure medications were available; k. ensure meals were served at palatable temperatures; and l. ensure care concerns were identified, and good faith attempts were made to correct identified issues through the QA/QAPI program. On 09/21/22 at 3:21 p.m., RNM #1 was asked who was responsible to monitor to ensure quality of care concerns were identified and corrected. They stated RNMs, DON, and ADONs. RNM #1 was asked why QA/QAPI plans had not been effective. They stated once a concern had been corrected, the care area was removed from the list of concerns. RNM #1 was asked if administration would have been aware of quality of care concerns identified by the survey team if effective monitoring was in place. They stated yes. On 09/21/22 at 4:55 p.m., RNM #1 was asked what type of oversight had been provided for quality of care concerns. RNM #1 stated they could not say effective oversight had been provided.

Based on record review and interview, the facility failed to ensure an effective governing body which was involved and engaged during a time of instability of staff in administrative roles. The Resident Census and Conditions of Residents form identified 100 residents resided in the facility. Findings: A Quality Assurance and Performance Improvement Program policy, dated August 2019, read in parts, .Quality Assurance and Performance Improvement is a continuous process towards quality management .Quality Assurance and Performance Improvement [QAPI] builds upon traditional quality assurance methods by emphasizing the organization and systems. QAPI incorporates systems, programs, clinical practice, and clinical development driving system integrations and inter-program coordination through organized leadership oversight .The QAPI Committee provides leadership and guidance for ongoing continuous quality and performance improvement .QAPI is facilitated through leadership oversight . A Quality Assurance and Performance Improvement [QAPI] Program - Governance and Leadership policy, dated March 2020, read in parts, .The governing body is responsible for ensuring that the QAPI program: Is implemented and maintained to address identified priorities .Is sustained through transitions of leadership and staffing . A Governing Body policy, dated July 2021, read in part, .The governing body is responsible and accountable for the QAPI program . The facility had deficient practice cited in regards to pharmacy services on the survey dated 07/13/22 and the survey dated 08/04/22. The facility was unable to correct this deficient practice by the correction dates the facility identified on the plan of corrections. The facility had deficient practice cited in regards to abuse/neglect, pressure ulcers, homelike environment, and palatable food on the survey dated 08/04/22. The facility was unable to correct these deficient practices by the correction dates the facility identified on the plan of corrections. The facility had deficient practice in regards to abuse/neglect, implementation of the abuse policy, reporting of abuse, pressure ulcers, significant weight loss, and tube feeding at the level of Immediate Jeopardy during the current survey. On 09/15/22, an IJ situation was identified and verified in pressure ulcers. On 09/16/22, IJ situations were identified and verified in significant weight loss and tube feeding. On 09/28/22, IJ situations were identified and verified in abuse/neglect, implementation of the abuse policy, and reporting abuse. By the survey exit on 10/04/22 at 1:00 p.m., the IJ situations continued at a level of Immediate Jeopardy until 10/04/22 at 5:00 p.m. On 09/21/22 at 3:49 p.m., the Regional Director of Operations was asked how long they had been employed by the facility. They stated approximately one month. They stated they were in a newly identified position. The Regional Director of Operations was asked if they had identified concerns related to pressure ulcers, significant weight loss, or tube feedings. They stated when they first started the facility had new staff in leadership positions. The Regional Director of Operations stated they barely had clinical morning meetings and they had to start with the basics. On 09/21/22 at 4:55 p.m., RNM #1 was asked what type of oversight had been provided for quality of care concerns. They stated they could not say effective oversight had been provided. On 09/22/22, the Regional Director of Operations provided the survey team a list of members of the governing body as requested. The list identified the governing body consisted of the Regional [NAME] President/Regional Director of Operations, the medical director, and the CEO.

Based on record review and interview, the facility failed to ensure an effective QA/QAPI program to correct identified quality deficiencies. The Resident Census and Conditions of Residents form identified 100 residents resided in the facility. Findings: A Quality Assurance and Performance Improvement Program policy, dated August 2019, read in parts, .Quality Assurance and Performance Improvement is a continuous process towards quality management .Quality Assurance and Performance Improvement [QAPI] builds upon traditional quality assurance methods by emphasizing the organization and systems. QAPI incorporates systems, programs, clinical practice, and clinical development driving system integrations and inter-program coordination through organized leadership oversight .The QAPI Committee provides leadership and guidance for ongoing continuous quality and performance improvement .QAPI is facilitated through leadership oversight . The facility had deficient practice cited in regards to pharmacy services on the survey dated 07/13/22 and the survey dated 08/04/22. The facility was unable to correct this deficient practice by the correction dates the facility identified on the plan of corrections. The facility had deficient practice cited in regards to abuse/neglect, pressure ulcers, homelike environment, and palatable food on the survey dated 08/04/22. The facility was unable to correct these deficient practices by the correction date the facility identified on the plan of correction. The facility had deficient practice in regards to abuse/neglect, implementation of the abuse policy, reporting of abuse, pressure ulcers, significant weight loss, and tube feeding at the level of Immediate Jeopardy during the current survey. On 09/15/22, an IJ situation was identified and verified in pressure ulcers. On 09/16/22, IJ situations were identified and verified in significant weight loss and tube feeding. On 09/28/22, IJ situations were identified and verified in abuse/neglect, implementation of the abuse policy, and reporting abuse. By the survey exit on 10/04/22 at 1:00 p.m., the IJ situations continued at a level of Immediate Jeopardy until 10/04/22 at 5:00 p.m. On 09/21/22 at 2:03 p.m., the medical director was asked how they were involved to ensure appropriate plans and interventions to prevent repeated system failures were implemented. They stated they could not speak to things that had not been brought to their attention. On 09/21/22 at 3:21 p.m., RNM #1 was asked how often QA meetings were conducted. They stated monthly. RNM #1 was asked what the facility had implemented to provide a good faith attempt to correct identified deficiencies. They stated they used their QAPI program, quality measure reports, and every department reviewed the QAPI plan. RNM #1 was asked who was responsible to monitor to ensure quality of care concerns were identified and corrected. They stated regional nurse managers, DON, and ADONs. RNM #1 was asked if prior to the survey if the QA/QAPI committee had identified quality deficiencies. They stated they identified concerns with wounds and weight loss. RNM #1 was asked how they monitored for effective corrective actions for wounds and weight loss. RNM #1 stated they joined the treatment nurses during wound care rounds and reviewed reports during clinical meetings. They were asked if the QA/QAPI plans had been effective. RNM #1 stated no. RNM #1 was asked why the QA/QAPI plans had not been effective. They stated once a concern had been corrected the care area was removed from the list of concerns.

On 07/28/22 at 7:05 p.m., an Immediate Jeopardy (IJ) situation was identified and verified with the Oklahoma State Department of Health (OSDH). The facility failed to ensure the pain management of resident #15 during the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During the pressure wound treatments the resident displayed verbal and nonverbal expressions of pain and the wound nurse failed to stop the treatment and treat the resident's pain. Notification of IJ was provided to the facility at 7:13 p.m. with a request for a Plan of Removal. ***The immediacy was removed for 08/04/22 at 3:20 p.m. when the last resident skin assessment was completed, leaving the deficient practice at an isolated harm. Notification of immediacy removal date and time made to the administrator on 08/04/22 at 4:24 p.m. On 07/29/22 at 12:15 p.m., an acceptable plan of removal was received as follow: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on July 28th, 2022 for Pressure Ulcer and Pain Action Item: All residents will have a skin assessment completed. All Residents with wounds will be assessed/reassessed and wound assessment documented as well as review of treatment orders resident specific. Physician is evaluating all residents pain management. All residents will be assessed/reassessed for pain and provided subsequent pain management per physician recommendations and will be provided resident specific treatment. Assess and review interventions. Staff will audit wound care treatments per shift for completion of treatment, pain assessment, interventions needed and physician notification as needed to address wounds and pain concerns. Person Responsible: Nursing Timeline for Compliance: 7/30/22 8:00pm CST Action Item: Resident #15 was sent to Emergency Department for Treatment and evaluation of wounds and pain. A low air loss mattress will be in place upon his return and to any resident that has been identified as needing a low air / treatment specific mattress. Note of noncompliance: Resident is non compliant with diabetic treatment; resident is non-compliant with Hemodialysis. Person Responsible: Nursing Timeline for compliance: 7/29/22 5:00pm CST Action Item: All Nurses will receive an in-service on pressure ulcers, interventions, assessments, and treatments. All direct care staff will be in-serviced on pain recognition, policy and procedures related to pain recognition, assessment, and appropriate intervention. Wound Treatment Nurse will be educated on how to assess for pain and proper interventions of a resident experiencing pain during wound treatments by the Corporate Resource Nurse. Person Responsible: Corporate Resource Nurse/DON Timeline for Compliance: 7/30/22 8:00pm CST Based on record review, observation, and interview, the facility failed to ensure pain management during pressure wound treatments for one (#15) of one resident observed during pressure wound treatment. The Resident Census and Conditions of Residents form, dated 07/20/22, documented 11 residents with pressure ulcers. Findings: A policy titled, Wound Care, revised June 2022, read in part, .For example, the resident may have PRN order for pain medication to be administered prior to wound care . A policy title, Pain Assessment and Management, revised July 2022, read in parts, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .Pain management is a multidisciplinary care process .Assessing the potential for pain; Recognizing the presence of pain; Identifying the characteristics of pain; Addressing the underlying causes of the pain . Resident #15 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's Care Plan, revised 04/21/22, documented a category for pain with interventions to administer pain meds as ordered, establish causative factors and ways to alleviate them, and monitor pain. The care plan did not address pain associated with pressure ulcers and treatment. A Physician's Order, dated 06/19/22, documented to perform a wound treatment pain evaluation once a day on the first shift. A Physician's Order, dated 07/27/22, documented to give one tablet of [MEDICATION(S)]/acetaminophen 7.5/325 mg every six hours routinely. This order had previously been PRN. No documentation was in the clinical record to indicate a reason for the change to routine. Resident #15's physician orders did not have any orders for break through pain such as PRN pain medication. Resident #15's TAR, dated July 2022, documented to monitor pain during wound treatment once a day. The TAR documented out of ten opportunities, three were blank, five were documented as zero pain, two were documented as not administered with reasons as other and drug/item unavailable. On 07/28/22 at 12:28 p.m., the wound nurse was observed to prepare wound treatments for resident #15's six pressure ulcer wounds. The nurse obtained supplies from the cart and entered the resident room. On 07/28/22 at 12:31 p.m., the wound nurse informed resident #15 the wound treatment was to be done. At no point prior to beginning the treatment did the wound nurse assess resident #15's pain. On 07/28/22 at 12:41 p.m., during the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 cried out again in pain when the wound nurse packed gauze with Santyl to the wound bed. After the wound was dressed, the wound nurse, on the side of the bed closest to the wall, and the CNA turned resident #15 toward the wall. Resident #15 yelled out, This hurts me! The nurse replied to the resident, I know it hurts, I'll let the nurse know when we leave here to try and get you some pain medicine. The resident was grabbing the sheet and pad with his right hand making a fist and yelled out, I had cake yesterday. The statement was in response to a question asked earlier by the CNA assisting the wound nurse. The wound nurse continued the treatment to resident #15's multiple wounds until completed. At 1:31 p.m., when the wound nurse had completed the treatments to resident #15's wounds, and was outside of the resident's room, the wound nurse was asked when the resident's pain would be addressed. The wound nurse stated they try to let the nurse and CMA know but because, You wanted to see him, we did it first. The wound nurse added, I should have let the nurses down here know. On 07/28/22 at 2:32 p.m., CMA #5 was asked what time resident #15 received pain medication. The CMA stated about a half hour after the wound treatment. The CMA stated the resident was in real bad pain, he kept saying, I'm in pain. The CMA was asked if the nurse had ever asked before the wound treatment to treat the resident's pain. They stated no. CMA #5 was asked why the pain medication was given if the medication had not been requested by the wound nurse. The CMA stated it was scheduled to be given. On 07/28/22 at 2:38 p.m., LPN #5 was asked if the wound nurse communicated with them about resident #15's pain. They stated no. LPN #5 was asked how the resident's pain was. They stated the pain medication had been changed to routine and the management of resident #15's pain had improved. The LPN was asked if the pain medication was effective. They stated it was a little better since the medication was made routine. The LPN was asked what the protocol was if a resident had pain during wound treatment. LPN #5 stated we should call the doctor and get them something. On 07/28/22 at 4:06 p.m., LPN #5 was asked why they had documented Resident #15's pain as a zero on the TAR for the wound treatment. They stated they had documented prior to the dressing change. No other explanation was provided. On 07/28/22 at 5:35 p.m., resident #15 was asked to rate their pain during the wound treatment. The resident stated a 10 on a zero to 10 scale. On 07/29/22 at 2:57 p.m., CNA #4 was asked if they had assisted with Resident #15's wound treatments before 07/28/22. They stated no. The CNA was asked if the resident had complained of pain prior to the wound treatment. They stated yes, Resident #15 had and was treated with pain medication at 12:30 p.m., prior to the wound treatment. CNA #4 was asked if the drainage from the wound was typical. They stated it was a lot and stated they did not know when the dressing had been changed previously. On 08/04/22 at 5:56 p.m., the DON was asked what their expectations were of pain management during wound treatments. The DON stated to manage the pain and document. The DON was asked what if the resident did not have a PRN pain medication. The DON stated to call the doctor and get an order.

On 07/26/22 at 5:31 p.m. an Immediate Jeopardy situation was identified and verified through the Oklahoma State Department of Health (OSDH) regarding neglect of the facility to ensure medical social services for Resident #10. Resident #10 presented to the facility a request from his cancer specialist, for a dental evaluation for clearance to begin [CONDITION(S)] and [CONDITION(S)] to prevent the spread of cancer, on admission and two follow up visits on 04/05/22 and 07/18/22. The requests were unfulfilled by the facility. Resident #10 went five months without the requested dental evaluation. This neglect prevented Resident #10 from beginning his [CONDITION(S)] and [CONDITION(S)] treatment and put the resident at increased risk for the spread of cancer. An acceptable Plan of Removal (POR) was submitted on 07/27/22 at 10:53 a.m. with notification made to the Administrator at 10:54 a.m. The POR was provided as follows: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on July 26th, 2022, for neglect and Medical social needs. Action Item: All residents will be reviewed for medical social services's needs. Interviews with the residents/responsibility[sic] party to assess for immediate medical social service's[sic] needs. Record review will be completed within 48 hours to assess medical social service needs. Person Responsible: Nursing and administration Timeline for completion: 7/27/22 by 1600 cst Action Item: Resident number ten will be scheduled for a follow up dental appointment for clearance related to [CONDITION(S)]. Person Responsible: Nursing and Administration scheduled his dental appointment for 8/23/22. The center is continuing to try to schedule an appointment sooner. The center will notify the Oncologist that the dental appointment has been scheduled and the the center continues to try to schedule an earlier appointment. Timeline for completion: 7/27/22 by 1600 cst Action Item: Medical Social Services will be monitored by Nursing and Administration until a Director of Social Services is in place. Monitoring will consist of the nurse managers reviewing all appointment follow up paperwork. Appointments will be made and transported by the transportation position. The Administrator and the nursing administration will review the completion of the process. Person Responsible: Administration/DON/Regional Nurse Manager Timeline for completion: 7/27/22 by 1600 cst Action Item: The Administrator/DON/ Corporate resource social worker will re- inservice all staff on appointment process, follow up services required, neglect and documentation/notification of these services. Person Responsible: Administrator/DON/ Corporate resource social worker Timeline for completion: 7/27/22 by 1600 cst On 07/27/22 at 5:21 p.m., the immediacy was lifted upon the scheduling of Resident #10's dental appointment and in-services/education for staff, on meeting the social services needs of the residents, leaving the deficient practice at a level of isolated harm. Based on record review, observation, and interview, the facility failed to ensure medical social services scheduled and followed through with an appointment for clearance to receive [CONDITION(S)]/[CONDITION(S)] for one (#10) of three residents reviewed for medical social services. The Resident Census and Conditions of Residents form, documented 96 residents reside at the facility. Findings: Resident #10 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of right kidney, [CONDITION(S)], and cutaneous [CONDITION(S)] of right ear (skin cancer). A Progress Note, dated 02/22/22, documented social services had left messages with the Indian clinic and the cancer specialist office regarding authorization for [CONDITION(S)] treatment with no response. The note documented resident #10's case worker informed the [NAME] had done an authorization, and another message was left for the cancer specialist. No follow up was documented in the clinical record. A Progress Note, dated 03/22/22, read in part, .No outside referrals needed at this time. The note was signed by social services. No other notes were documented by social services. An Oklahoma Cancer Specialists and Research Institute document titled, Established Patient History and Physical, dated 04/05/22, documented resident #10 was seen by their cancer specialist. It read in parts, .He has not yet undergone his dental evaluation .Dental evaluation ASAP . This request was unfulfilled by the facility. On 07/18/22 resident #10 was seen by their cancer specialist who had requested a dental evaluation, a third time. This request was again unfulfilled by the facility. On 07/20/22 at 10:05 a.m., resident #10 stated they were first diagnosed with cancer three years ago. The resident stated they had not been to the dentist to be cleared for [CONDITION(S)] and [CONDITION(S)]. Resident #10 stated they had surgery to remove the skin cancer near their right ear prior to entering the facility and was to be cleared for treatment by a dentist. The resident stated their [CONDITION(S)]/[CONDITION(S)] was scheduled to begin in April 2022. The resident stated four appointments had been scheduled and canceled by his representative because the facility did not have transportation to get them to the dentist. On 07/21/22 at 10:11 a.m., resident #10's representative stated the number of dental appointments that had been scheduled and canceled were three. The representative stated they were surprised Resident #10 was able to get to the cancer specialist appointment on 07/18/22. They stated the facility told them they did not have transportation. The clinical record did not indicate Resident #18 had been to an appointment on 07/18/22. No documentation was found in the clinical record that indicated conversations with the representative or the resident. No documentation was found in the clinical record that attempts had been made to utilize outside resources for transportation of the resident to the dentist. On 07/21/22 at 10:33 a.m., LPN #3 was asked if Resident #10 had been to an appointment recently. They stated resident #10 had been to the cancer specialist on the 18th. They stated they only knew because the resident had informed them of the visit. The LPN stated residents should be signed out when leaving the facility. The LPN checked the sign out book, but resident #10 was not signed out that day. LPN #1 referred to the nurse that worked the 18th. On 07/21/22 at 10:45 a.m., LPN #4 stated they had worked resident #10's hall the 18th, but did not remember if the resident went out of the facility. The LPN stated the resident would have been signed out by transportation. The LPN stated the transportation person was new and may not have signed out the resident because it was their first day. On 07/21/22 at 11:00 a.m., the medical records person confirmed resident #10 was taken to an appointment on the 18th. They stated the nurse was to enter a progress note. MR was asked if Resident #10 brought back any record of the appointment. They stated yes but they had not scanned it into the system yet. On 07/26/22 at 10:37 a.m., MR stated the facility had no social services staff. They stated themselves and the HR person had been tag teaming social services for the past several months since there was no social services person. The MR staff person was asked if they were aware resident #10 had a follow up appointment in a month with their cancer specialist. They stated no, after they scanned in the paperwork it was given to the nurse who was to notify of any appointments or follow ups and chart on it. This was neglected to be completed. On 07/26/21 at 12:31 p.m., Resident #10's cancer specialist stated resident #10's care and treatment had been compromised due to not getting his treatments for cancer post surgery. The doctor stated it had been four months since a dental clearance was requested. The doctor stated the skin cancer had been removed but without [CONDITION(S)]/[CONDITION(S)] it could come back. The doctor stated they like to do treatments within one to two months after surgery. The doctor stated the neglect of the facility to ensure Resident #10 was cleared by a dentist for [CONDITION(S)]/[CONDITION(S)] delayed the treatment and put Resident #10 at risk for the cancer to return and spread. On 07/26/22 at 3:53 p.m., the RRN #2 was asked how long social services had been empty. They stated one had been hired, but only worked one day and quit last Wednesday. They stated the corporate social worker had been in and out of the facility. The RRN was asked who assistedwith social services when the corporate social worker was not present. They stated, I'm assuming MR was helping. Other than than I don't know. The RRN was asked who documented or scheduled follow up appointments. They stated the nurse should document on the resident's calendar. The RRN was asked if their system worked. They stated, We know it's broken.

On 07/26/22 at 5:31 p.m. an Immediate Jeopardy situation was identified and verified through the Oklahoma State Department of Health (OSDH) regarding neglect of the facility to ensure medical social services for Resident #10. Resident #10 presented to the facility a request from his cancer specialist, for a dental evaluation for clearance to begin [CONDITION(S)] and [CONDITION(S)] to prevent the spread of cancer, on admission and two follow up visits on 04/05/22 and 07/18/22. The requests were unfulfilled by the facility. Resident #10 went five months without the requested dental evaluation. This neglect prevented Resident #10 from beginning his [CONDITION(S)] and [CONDITION(S)] treatment and put the resident at increased risk for the spread of cancer. An acceptable Plan of Removal (POR) was submitted on 07/27/22 at 10:53 a.m. with notification made to the Administrator at 10:54 a.m. The POR was provided as follows: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on July 26th, 2022, for neglect and Medical social needs. Action Item: All residents will be reviewed for medical social services's needs. Interviews with the residents/responsibility[sic] party to assess for immediate medical social service's[sic] needs. Record review will be completed within 48 hours to assess medical social service needs. Person Responsible: Nursing and administration Timeline for completion: 7/27/22 by 1600 cst Action Item: Resident number ten will be scheduled for a follow up dental appointment for clearance related to [CONDITION(S)]. Person Responsible: Nursing and Administration scheduled his dental appointment for 8/23/22. The center is continuing to try to schedule an appointment sooner. The center will notify the Oncologist that the dental appointment has been scheduled and the the center continues to try to schedule an earlier appointment. Timeline for completion: 7/27/22 by 1600 cst Action Item: Medical Social Services will be monitored by Nursing and Administration until a Director of Social Services is in place. Monitoring will consist of the nurse managers reviewing all appointment follow up paperwork. Appointments will be made and transported by the transportation position. The Administrator and the nursing administration will review the completion of the process. Person Responsible: Administration/DON/Regional Nurse Manager Timeline for completion: 7/27/22 by 1600 cst Action Item: The Administrator/DON/ Corporate resource social worker will re- inservice all staff on appointment process, follow up services required, neglect and documentation/notification of these services. Person Responsible: Administrator/DON/ Corporate resource social worker Timeline for completion: 7/27/22 by 1600 cst On 07/27/22 at 5:21 p.m., the immediacy was removed leaving the deficient practice at a level of isolated harm. Based on record review, observation, and interview, the facility failed to ensure medical needs were not neglected for one (#10) of six residents sampled for neglect. The facility failed to ensure Resident #10 was assessed and reviewed for clearance to receive [CONDITION(S)] and [CONDITION(S)] to reduce the risk of the spread of cancer. The Resident Census and Conditions of Residents form, dated 07/20/22, documented 96 residents reside at the facility. findings: Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note, dated 02/22/22, documented social services had left messages with the Indian clinic and the cancer specialist office regarding authorization for [CONDITION(S)] treatment with no response. The note documented resident #10's case worker, with the Indian Nation had informed the facility, the [NAME] had done an authorization, and another message was left for the cancer specialist. There was no documentation in the clinical record an appointment had been scheduled or that Resident #10 had been evaluated by a dentist. A Progress Note, dated 03/22/22, read in part, .No outside referrals needed at this time. The note was signed by social services. No other notes were documented by social services. A document titled, Oklahoma Cancer Specialists and Research Institute Established Patient History and Physical, dated 04/05/22, read in parts, .Patient presents today for re-evaluation for [CONDITION(S)] therapy anterior review results of most recent PET scan. He has not yet undergone his dental evaluation .Dental evaluation ASAP . There was no documentation in the clinical record Resident #10 had the dental evaluation to be cleared for [CONDITION(S)], or that an appointment had been scheduled. A document titled, Oklahoma Cancer Specialists and Research Institute Established Patient History and Physical, dated 07/18/22, read in parts, .[CONDITION(S)] 2014 .Cutaneous [CONDITION(S)] of the right ear S/P surgical resection with neck dissection 11/1/2021 .Plan .Waiting on dental clearance to start further adjuvant therapy .Follow-up in 1 month . There was no documentation in the clinical record Resident #10 had the dental evaluation to be cleared for [CONDITION(S)], or that an appointment had been scheduled. On 07/20/22 at 10:05 a.m., resident #10 stated they had not been to the dentist to be cleared for [CONDITION(S)] and [CONDITION(S)]. Resident #10 stated they had surgery to remove the skin cancer near their ear prior to entering the facility and was to be cleared for treatment by a dentist. The resident stated appointments had been scheduled by their representative and canceled because the facility did not have transportation to get them to the dentist. On 07/21/22 at 10:11 a.m., resident #10's representative stated the number of dental appointments that had been scheduled and canceled were three. The representative stated they were surprised Resident #10 was able to get to the cancer specialist appointment on July 18th because the facility told them they did not have transportation. On 07/21/22 at 10:33 a.m., LPN #3 stated Resident #10 had been to the cancer specialist on the 18th. They stated they only knew because the resident had informed them of the visit. The LPN stated residents should be signed out when leaving the facility. The LPN checked the sign out book, but resident #10 was not signed out that day. LPN #1 referred to the nurse that worked the 18th. On 07/21/22 at 10:45 a.m., LPN #4 stated they had worked Resident #10's hall the 18th, but did not remember if the resident went out of the facility. The LPN stated the resident would have been signed out by transportation. The LPN stated the transportation person was new and may not have signed out the resident because it was their first day. LPN #4 was asked if there would be any other documentation of Resident #10's visit. They stated no. LPN #4 was asked who scheduled the resident appointments. They stated social services scheduled appointments. The LPN was asked who scheduled appointments when there was no social services. They stated they did not know. On 07/21/22 at 11:00 a.m., the medical records person confirmed Resident #10 was taken to an appointment on the 18th. MR was asked where it was documented. They stated the nurse was to enter a progress note. MR was asked if Resident #10 had returned with any records of the appointment. They stated yes but they had not scanned it into the system yet. There was no documentation in the clinical record the resident had an appointment on the 18th. On 07/26/22 at 10:37 a.m., MR stated nobody was doing social services. They stated themselves and the HR person had been tag teaming social services for the past several months since there was no social services person. The MR staff person was asked if they were aware Resident #10 had a follow up appointment in a month with their cancer specialist. They stated no, after they scanned in the paperwork it was given to the nurse who was to notify of any appointments or follow ups and chart on it. There was no documentation in the clinical record the resident had a follow up appointment or that an appointment had been scheduled. On 07/26/21 at 12:31 p.m., Resident #10's cancer specialist stated resident #10's care and treatment had been compromised due to not getting their treatments for cancer post surgery. The doctor stated it had been four months since a dental clearance was requested. The doctor stated the skin cancer had been removed but without [CONDITION(S)]/[CONDITION(S)] it could come back. The doctor stated they like to do treatments within one to two months after surgery. The doctor stated delaying the treatment had put resident #10 at risk for the cancer to return and spread. The doctor stated it was unknown if the cancer had spread at this point in time. On 07/26/22 at 3:53 p.m., the RRN #2 was asked how long the social services position had been empty. They stated one had been hired, but only worked one day and quit last Wednesday. They stated the corporate social worker had been in and out of the facility. The RRN was asked who had assisted with social services when the corporate social worker was not present. They stated, I'm assuming MR was helping. Other than that, I don't know. The RRN was asked who documented or scheduled follow up appointments. They stated the nurse should document on the resident's calendar. The RRN was asked if their system worked. They stated, We know it's broken.

On 07/28/22 at 7:05 p.m., an Immediate Jeopardy (IJ) situation was identified and verified with the Oklahoma State Department of Health (OSDH). The facility failed to ensure pressure ulcer management to promote healing and prevent new or worsening pressure ulcers for resident #15. The wound nurse failed to follow physician orders and failed to provide pressure wound treatments daily as ordered by the physician for Resident #15. Notification of IJ was provided to the facility at 7:13 p.m. with a request for a Plan of Removal. On 07/29/22 at 12:15 p.m., an acceptable plan of removal was received as follows: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on July 28th, 2022 for Pressure Ulcer and Pain Action Item: All residents will have a skin assessment completed. All Residents with wounds will be assessed/reassessed and wound assessment documented as well as review of treatment orders resident specific. Physician is evaluating all residents pain management. All residents will be assessed/reassessed for pain and provided subsequent pain management per physician recommendations and will be provided resident specific treatment. Assess and review interventions. Staff will audit wound care treatments per shift for completion of treatment, pain assessment, interventions needed and physician notification as needed to address wounds and pain concerns. Person Responsible: Nursing Timeline for Compliance: 7/30/22 8:00pm CST Action Item: Resident #15 was sent to Emergency Department for Treatment and evaluation of wounds and pain. A low air loss mattress will be in place upon his return and to any resident that has been identified as needing a low air / treatment specific mattress. Note of noncompliance: Resident is non compliant with diabetic treatment; resident is non-compliant with Hemodialysis. Person Responsible: Nursing Timeline for compliance: 7/29/22 5:00pm CST Action Item: All Nurses will receive an in-service on pressure ulcers, interventions, assessments, and treatments. All direct care staff will be in-serviced on pain recognition, policy and procedures related to pain recognition, assessment, and appropriate intervention. Wound Treatment Nurse will be educated on how to assess for pain and proper interventions of a resident experiencing pain during wound treatments by the Corporate Resource Nurse. Person Responsible: Corporate Resource Nurse/DON Timeline for Compliance: 7/30/22 8:00pm CST The immediacy was removed for 08/04/22 at 3:20 p.m. when the last resident skin assessment was completed, leaving the deficient practice at an isolated harm. Notification of immediacy removal date and time made to the administrator on 08/04/22 at 4:24 p.m. Based on record review, observation, and interview, the facility failed to assess, monitor, obtain and provide pressure wound treatments to prevent infection/maggots for two (#11 and #15) of eight residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form, dated 07/20/22, documented 11 residents with pressure ulcers resided at the facility. Findings: A facility policy titled, Wound Care, revised June 2022, read in parts, .guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure .Review the resident's care plan to assess for any special needs of the resident .resident may have PRN orders for pain medication to be administered prior to wound care . 1. Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's Care Plan, revised 04/21/22, documented a category as pressure ulcer and listed four wounds; Unstageable to right thigh/lower right buttock,left buttock,Stage 3 Sacrum. The care plan documented a goal that the resident's wounds will decrease in size, with five interventions in place. The interventions listed were: follow facility skin care protocol, preventative measures, report to charge nurse any skin redness or breakdown immediately, treatment as ordered, and turn and reposition every two hours and prn. The resident's care plan did not address resident pain during the wound treatments or prior to wound treatments. The number of wounds and locations of wounds were incorrect and incomplete. A [NAME] Initial Wound Evaluation and Management Summary, dated 04/21/22, documented wound site one, a stage four pressure wound of the left ischium, with moderate purulent drainage and measurements (length x width x depth) 9.9 x 5.4 x 2 cm. The wound covered a surface area of 53.46 cm squared with undermining of 7 cm at 7 o'clock with 100% necrotic tissue. The wound was documented to have an odor. Wound site two, an unstageable pressure wound of the right ischium, with light sero-sanguinous drainage and measurements 5.7 x 7 x 0.2 cm. The wound covered a surface area of 39.90 cm squared with no undermining documented and 100% necrotic tissue. This wound was documented to have an odor. Wound site three, an unstageable, full thickness pressure wound of the sacrum, with moderate sero-sanguinous drainage and measurements 4.4 x 4.6 x 0.3 cm. The wound covered a surface area of 20.24 cm squared with no undermining documented. The wound was documented to have an odor with 70% slough and 30% granulation of the wound bed. Wound site four, an unstageable, full thickness pressure wound of the left hip, with light sero-sanguinous drainage and measurements 5.5 x 5.3 x not measurable cm. The wound covered a surface area of 29.15 cm squared with no odor or undermining documented. The wound was documented to be 100% thick devitalized necrotic tissue. The wounds #1 through #4 were documented to have a dressing treatment plan to apply Dakins (sodium hypochlorite) solution twice daily for 30 days and to apply a sterile gauze sponge twice daily for 30 days then apply a Dakins soaked gauze, wet to moist, twice daily. A secondary dressing of ABD pad twice daily for 30 days. Wound site five, an unstageable, full thickness, pressure wound of the left heel, with light sero-sanguinous drainage and measurements 5.5 x 6.8 x not measurable cm. The wound covered a surface area of 37.40 cm squared with an odor. The wound was documented to have 90% thick adherent black necrotic tissue and 10% thick adherent devitalized necrotic tissue. The dressing plan for the wound was documented as to apply Santyl once daily for 30 days, cover with gauze island border dressing once a day for 30 days. Recommendations to off-load wounds, reposition per facility protocol, and provide a low air loss mattress. No other [NAME] wound evaluations or visit notes were provided. The wound doctor's wound treatment orders and recommendations were not followed or put in place. Resident #15 was sent out to the hospital 04/22/22 due to a low blood pressure reading of 88/54. The resident did not return to the facility until 05/19/22, due to wound infections, per hospital discharge summary and facility progress notes. A Progress Note, dated 05/22/22 at 8:58 p.m., documented Resident #15 was seen by the wound doctor and the LPN. The note documented the LPN observed the resident was not able to answer questions due to an altered mental status. The note documented the resident was under three blankets and blood was pooling under the wound vacuum dressing, when the dressing was removed, blood was pulsating from multiple areas. The wound doctor ordered the resident be sent to the emergency room for evaluation. No documentation was provided of the wound doctors visit that day. A hospital document titled, ED to Hosp-Admission, dated 05/23/22, read in parts, .Acute blood loss [CONDITION(S)] .[CONDITION(S)], due to unspecified organism, unspecified whether acute organ dysfunction present .[CONDITION(S)], unspecified site, unspecified type .Sacrum: 7 x 10 x 2.5 cm to fascia [length x width x depth], L trochanter: 9.5 x 5 x 5.5 cm to bone, L ischium: 10.5 x 8 x 4 cm to bone (biopsy and cx), R ischium: 11 x 5 x 3.5 cm to fascia .Portion of bone from left ischium for pathology and culture . Resident #15's MAR, dated June 2022, documented Resident #15 was in house 06/16/22 to 06/20/22. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date of the assessment was 06/20/22, the order was open ended. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders were in place for wound treatments from 06/16/22 until 06/19/22. The wound treatment orders for the left posterior thigh, left buttock, and left shin were not ordered until 06/20/22. A Progress Note, dated 06/16/22 at 12:05 a.m., documented Resident #15 returned to the facility skilled with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note, dated 06/19/22 at 10:33 p.m., documented Resident #15 had received wound care provided by the wound nurse and an RN. A Progress Note, dated 06/19/22 at 10:41 p.m., documented IV antibiotics arrived to start in the morning. A Progress Note, dated 06/20/22 at 4:52 a.m., documented received IV antibiotics. A Progress Note, dated 06/20/22 at 11:43 a.m., documented Resident #15 was send to the hospital to be dialized. A hospital document titled, ED to Hosp-Admission, dated 06/20/22, read in parts, .Chief complaint needs [CONDITION(S)] .Patient not able to provide history .the patient only moans answers .did respond to the positive when asked about abdominal pain .CT abdomen pelvis without contrast .Pelvis .large bilateral soft tissue defects consistent with decubitus ulcers overlying both ischium, coccyx and the left greater trochanter. Cortical bone is exposed to the air at each of these sites .Osteomyeitis cannot be excluded on the basis of this examination .On initial laboratory test however he is noted to have a white blood cell count of 24, uptrending from his prior on discharge .also noted to have [CONDITION(S)] with a heart rate of 116 .CT of abdomen pelvis was performed which shows findings as above with severe decubitus ulcers in signs of concerning for [CONDITION(S)] .Admit to inpatient status .for the following reasons: Transient [CONDITION(S)] in the setting of end-stage [CONDITION(S)] with [CONDITION(S)], recent hospitalization for [CONDITION(S)] and multiple decubitus ulcers requiring IV antibiotics, follow-up lab, follow-up cultures, serial clinical exams necessitate inpatient hospitalization to monitor for symptoms condition, loss of function, loss of life .Sacrum: 15 x 11.5 x 1.3 cm; tunnel at 12:00 to 2 cm;depth to fascia/bone (probable [CONDITION(S)]) over lower sacrum, L trochanter: 10.5 x 5.5 x 2.5 cm; tunnel at 12:00 14 cm; depth to necrotic fascia and bone ([CONDITION(S)]), large purulent drainage cultured, Left ischium: 14 x 7 x 2.5 cm; tunnel at 12:00 7 cm; depth to bone ([CONDITION(S)]), Right ischium: 10 x 5.5 x 2.2 cm, tunnel at 12:00 8 cm; depth to fascia .Extensive wounds, worsening with current measure; ischial wounds and sacral wounds nearly confluent at SQ level with intact skin bridges; diffuse coagulapathic type bleeding from surfaces due to antiplatelet use .Is been about 5 weeks since last operation and wounds are clinically deteriorating . A Facility Wound Summary Report, dated 06/26/22 to 07/26/22, documented Resident #15 wounds as identified on 06/16/22 with measurements (L x W x D) (cm): a. Sacrum 6.5 x 13.5 x 4 with most recent observation date/time as 06/16/22 8:29 a.m. b. Right hip 9.4 x 9.3 x 5.8 06/16/22 8:36 a.m. c. Right buttock 9.2 x 11.1 x 5.7 06/16/22 at 8:32 a.m. d. Left buttock 7.5 x 7.2 x 4 06/16/22 at 8:31 a.m. e. Left heel 8 x 7.5 06/19/22 6:57 p.m. f. Left shin 9 x 2.3 06/16/22 at 6:56 p.m. Wound nurse notes, dated 07/27/22, documented Resident #15's wounds as: a. Sacrum 8.7 x 15.7 x 6.4 with tunnel at 12:00 2 cm b. Right hip 10.8 x 11.4 x 6.4 c. Right buttock 10.8 x 12.9 x 7.1 d. Left buttock 8.2 x 9.4 x 6.7 e. Left heel 6 x 7.25 f. Left shin 8 x 3.25 No other assessments were provided by the facility. A Progress Note, dated 07/19/22 at 2:40 p.m., documented Resident #15 returned to the facility. Resident #15's Physician's Orders, dated 07/19/22, documented to administer Santyl (a debridement wound treatment) 250 u/gm one application once a day; a wound treatment order: Left foot (left 1st, 2nd, 3rd toe) Clean with normal saline/wound cleanser, apply: providine cover with primary dressing: gauze, secure with Kerlix (a brand of roll gauze) and tape once a day; a wound treatment order: Left shin, clean with wound cleanser/normal saline, apply: Santyl, cover with primary dressing: soft silicone dressing once a day; a wound treatment order: unstageable pressure injury to left heel, clean with normal saline/wound cleanser, apply: Santyl, cover with primary dressing: soft silicone bordered heel dressing, secure with Kerlix and tape once a day; and a wound treatment order: left ischial and left surgical trochanter, clean with normal saline/wound cleanser, apply: Santyl, cover with primary dressing: soft silicone dressing once a day. Resident #15's Physician's Orders, dated 07/20/22, documented: a wound treatment order: left posterior thigh, clean with normal saline/wound cleanser, apply: Santyl, cover with primary dressing: gauze, then soft silicone bordered dressing once a day; a wound treatment order: right hip/ischium, clean with wound cleanser/NS apply: Santyl, cover with primary dressing: silicone bordered dressing once a day; a wound treatment order: sacrum, clean with Vashe wound cleanser/normal saline, apply: Santyl, cover with primary dressing: Kerlix roll gauze and soft silicone bordered dressing once a day; to administer [MEDICATION(S)] 500 mg IV once a day every other day to end on 07/21/22; and documented to administer [MEDICATION(S)] 0.9% sodium chloride piggyback; 1 gram/50 mL; IV once a day with a stop date of 07/21/22 for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's treatment administration record, dated 07/01/22 through 07/28/22, documented the resident was in house from 07/19/22 to 07/28/22. The [MEDICATION(S)] was not administered as ordered on 07/20/22, with no explanation provided. The date of 07/20/22 was blank. The treatment record also had blanks for the [MEDICATION(S)] on the dates of 07/20/22 and 07/21/22 with no explanation provided. The Santyl order was documented as not done four out of eight opportunities. The reasons provided were blank, drug/item unavailable, or [CONDITION(S)]. The wound treatment order for the left posterior thigh was documented as six missed opportunities out of eight. The reasons/comments were documented the same as above. The wound treatment order for the left buttock ordered to be completed daily appeared on the TAR twice for the dates the resident was present in the facility. Both dates were documented as completed on 07/19/22 and 07/20/22. The wound treatment order for the left foot, left shin, right hip/ischium, sacrum, and left ischial and left surgical trochanter, were all documented as seven missed opportunities out of eight. The wound treatment pain evaluation, ordered daily, was documented as five missed opportunities out of ten, with five dates documented with a pain value of zero on a scale of zero to ten. On 07/28/22 at 12:28 p.m., the wound nurse was observed to provide pressure wound treatments to resident #15's six pressure ulcers. Upon entry to the room, the wound nurse failed to assess for pain of the resident prior to administering the treatments. The resident was observed to not be on a low air loss mattress to prevent pressure ulcers or promote healing. The resident was observed to be flat on his back with nothing to prevent the heel from being in contact with the mattress. Upon removal of the dressings the dates of the removed dressings were observed to be 07/26/22. The wound nurse was observed to not clean the wounds in an aseptic manner or with regard to the residents comfort. The nurse cleaned the heel quickly and in a rough manner in continuous circles with gauze. The left lateral shin wound was cleaned roughly, with gauze moving quickly and continuously from left to right and right to left. The wound nurse was not observed to change gloves between removing a dirty dressing, cleaning the wounds, or applying a new dressing. Observations were made of the resident expressing pain, both verbally and non-verbally during the dressing changes that went unaddressed by the wound nurse until the resident was rolled to the left side and stated to the nurse, This hurts me. The wound nurse then stated to the resident, I know, I'll let the nurse know when I leave to see if we can get some pain meds for you. The dressing to the resident's sacrum was observed to be saturated with a pink tinged drainage that was observed to have leaked through the dressing, the residents brief, incontinence pad, draw sheet, and through to the fitted sheet on the resident's bed. This dressing was observed to have a faded date of 07/26/22. The resident wounds to the ischiums, sacrum, and hip were observed to be tunneled and deep. The wounds to resident #15's heel and left lateral shin were observed to have black eschar with unknown depth. An odor was observed to come from the wounds, it is unknown which wounds had an odor. On 07/28/22 at 1301, the wound nurse was asked if the dressings were completed. They stated yes. The nurse was asked to step out into the hall. The nurse was asked when the wound treatments were ordered to be changed. They stated the last they had checked they were ordered to be completed on Monday, Wednesday, and Friday. The wound nurse was asked if they had confirmed the orders prior to completing the treatments that day. The nurse stated no. The nurse was asked to confirm and verify the frequency of the wound treatments. The nurse stated they were ordered daily. The nurse was asked if the treatments had been completed as ordered. The nurse stated no. On 08/04/22 at 5:56 p.m., the DON was asked what their expectations were of the wound nurse when performing pressure wound treatments. The DON stated they expected the wound nurse to follow the physician orders. 2. Resident #11 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was discharged to the hospital due to altered mental status and [CONDITION(S)]. A Facility Wound Summary Report, dated 06/26/22 to 07/26/22, documented Resident #11 wounds (L x W x D) (cm): a. Skin tear - R, Plantar foot full thic identified 06/02/22 at 10:51 a.m. 1.2 x 0.5 most recent observation 06/10/22 11:00 a.m. b. Pressure Ulcer stage III identified 05/10/22 Left calf initial size 4 x 3 x 0.1, current size 1.8 x 2.2 x 0.1 last observed 06/10/22. c. Pressure Ulcer stage III identified 05/10/22 Right calf initial size 8 x 4 x 0.1, current size 12.2 x 5 x 0.1 last observed 06/13/22. d. Pressure Ulcer stage III identified 05/10/22 Left knee initial size 1 x 1, current size 0.7 x 0.7 x 0.1 last observed 06/13/22. e. Pressure Ulcer stage identified 07/03/22 Right bottom of foot current size 5.2 x 4 x 0.4 last observed 07/03/22. No other wound assessments were provided by the facility. A Physician's Order, dated 03/22/22 to 07/22/22, documented a wound treatment order: right medial calf, cleanse with normal saline, pat dry apply collagen with silver, cover with calcium alginate and a dry dressing change every day for 30 days morning. A Physician's Order, dated 05/06/22 to 07/22/22, documented a wound treatment order: left medial ankle, apply skin prep daily once a day morning. A Physician's Order, dated 05/10/22 to 07/22/22, documented a wound treatment order: left lateral calf, clean with normal saline/wound cleanser, apply alginate calcium, cover with bordered island gauze once a day morning. A Physician's Order, dated 05/10/22 to 07/22/22, documented a wound treatment order: right medial calf, clean with normal saline/wound cleanser, apply alginate calcium and collagen sheet with silver, cover with gauze island dressing, once a day morning. A Physician's Order, dated 05/15/22 to 07/22/22, documented a wound treatment order: right lateral calf, clean with normal saline/wound cleanser, apply: alginate calcium, collagen powder, apply once daily for 30 days: moisten lightly with normal saline, cover with primary dressing: border island dressing once a day morning. A Physician's Order, dated 06/16/22 to 07/22/22, documented a wound treatment order: left, lateral knee, clean with normal saline/wound cleanser, apply: collagen sheet and calcium alginate, cover with primary dressing: foam dressing once a day on Mon, Wed, Fri morning. A Physician's Order, dated 06/16/22 to 07/22/22, documented a wound treatment order: left lateral calf, clean with normal saline/wound cleanser, apply alginate calcium AG, cover with foam dressing, once a day on Mon, Wed, Fri; shift 1. A Physician's Order, dated 06/16/22 to 07/22/22, documented a wound treatment order: sacrum, apply barrier cream every shift am pm. A Physician's Order, dated 07/03/22 to 07/22/22, documented a wound treatment order: right bottom foot, clean with normal saline/wound cleanser, apply Santyl, cover with adhesive gauze once a day shift 1. Resident #11's TAR, dated 07/01/22 to 07/31/22, documented the resident was in house 07/01/22 to 07/19/22 and 07/19/22 to 07/22/22. The wound treatment to the right bottom foot, ordered daily, was documented as 13 missed opportunities out of 19. The wound treatment to the left lateral knee, ordered Monday, Wednesday, and Friday was documented as six missed opportunities out of seven. The wound treatment to the left lateral calf, ordered Monday, Wednesday, and Friday was documented as five missed opportunities out of seven. The wound treatment to the right calf, ordered Monday, Wednesday, and Friday was documented as five missed opportunities out of seven. A facility reported incident form, OSDH 283, dated 07/20/22 documented allegations of neglect and read in part, .maint director did not show up to work this morning and sent a text saying someone had maggots in his wounds and this was why he was leaving . Review of hospital medical records titled, ED to Hosp-Admission (Current), dated 07/22/22, read in parts, .Clinically the patient has numerous bilateral lower extremity ulcerations most notably in necrotic right plantar forefoot ulceration initially with visible maggots that were washed out and left medial ankle ulcerations to level of bone with concern for underlying osteomylitis [bone infection] .Patient is at risk of major [CONDITION(S)] due to this presentation. We will consider bilateral lower extremity ulcer debridements with bone biopsies to guide long-term IV antibiotic therapy per infectious disease recommendations if positive for osteomylitis as long as his limbs are deemed viable/salvageable from a peripheral perfusion standpoint based on cardiology's recommendations . On 08/04/22 at 5:56 p.m., the DON was asked what their expectations were of the wound nurse when performing pressure wound treatments. The DON stated they expected the wound nurse to follow the physician orders and infection prevention protocol. The DON was asked if wound treatments were occurring if maggots were found in a residents wound. They stated no.

On 05/12/22 at 5:40 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to identify, implement, monitor, and modify interventions to prevent a severe weight loss. Resident #3 experienced a severe weight loss of 25% and the facility failed to monitor weights, address meal refusals and implement interventions. At 5:55 p.m., the facility's administrator, assistant administrator, and DON was made aware of the IJ situation related to the facility's failure to prevent severe weight loss. A plan of removal of the IJ situation was requested. On 05/12/22 at 7:49 p.m., the administrator provided an acceptable plan of removal. The plan of removal documented, Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on May 12th, 2022 for neglecting to obtain weights for residents and provide proper nutritional intervention. 1. Action: To ensure identification of weight loss and risk for weight loss, center licensed nursing staff conducted and documented an audit of all center residents current weight and reviewed with IDT to include registered dietician. If new weight loss is noted during weekly or monthly weights, the attending physician, registered dietician, and nursing management will be notified to obtain orders as indicated and a change of care plan will be initiated. Actual weight loss and potential risk factors will be care planned to meet individual resident needs. Completion Timeline: Beginning May 12th, 2022 and ending May 13th, 2022. Responsible: Licensed Nurses/DON/RNM/RD 2. Action: Nursing Administration to conduct education with licensed nursing staff regarding: 1) Notification of nursing management upon identification of resident change in weight to include. 2) Inspection and documentation of weekly weights times 4 weeks upon admission, as recommended by RD/IDT, and monthly weights for all stable residents. Beginning May 12th, 2022 licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning May 12th, 2022 and ending May 13th, 2022. Responsible: [name removed], RN, Regional Nursing Manager; [name removed], RN, Director of Nursing 3. Action: Nursing Administration to conduct education with certified/temporary nursing assistants regarding notification of charge nurse upon identification of resident change in weight and/or meal intake percentage. Beginning May 12th 2022, certified/temporary nursing assistants (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning May 12th, 2022 and ending May 13th, 2022. Responsible: [name removed], RN, Regional Nursing Manager; [name removed], RN, Director of Nursing 4. Nursing Administration began auditing the electronic medical record of each resident to ensure weekly/monthly weights are scheduled to be performed by a licensed nurse. Completion Timeline: Beginning May 12th, 2022 and ending May 13th, 2022. Responsible: [name removed], RN, Regional Nursing Manager; [name removed], RN, Director of Nursing 5. Action: Beginning on May 12, 2022 and for the next 30 days, the Director of Nursing will utilize the Daily Clinical Meeting Process to validate charge nurse compliance with inspection, notification, and documentation of resident weights which are to be conducted upon admission and weekly and/or monthly thereafter. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning May 12th, 2022 and ending May 13th, 2022. Responsible: Administrator, Assistant Administrator, and Director of Nursing Action: Beginning on May 12, 2022 a significant change assessment was opened for resident. Completion timeline: Opened May 12, 2022 with completion in seven days. Responsible: MDS coordinator, Director of nursing Action: Resident care plan update to reflect interventions on May 12th, 2022, to reflect current status. To include weekly weights. Weight on 5/5/22 was 86.9 pounds, weight on 5/12/22 is 90 pounds. RD to assess additional supplements. Current supplements include fortified foods and a high protein calorie snack at 2pm. Completion timeline: Updated May 12, 2022. Responsible: MDS coordinator, Director of nursing Action: Labs ordered on May 12th, 2022 Completion timeline: Ordered on May 12th, 2022, to be drawn May 13th, 2022 Responsible: Director of Nursing, Physician Action: Change of Condition was completed on May 12, 2022. Change of condition notification includes the physician. Completion timeline: May 12th,2022 Responsible: Administrator, Director of Nursing. Action: QAPI meeting with physician and IDT will be completed 5/12/22 Completion timeline: May 12th, 2022 Responsible: Administrator, Director of Nursing On 05/16/22, interviews were conducted with a total of eleven employees who worked different shifts. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. On 05/16/22 at 10:30 a.m., the administrator was informed the IJ had been removed as of 05/13/22 at 8:35 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review, observation, and interview, the facility failed to assess, monitor, and intervene for one (#3) of five residents sampled for weight loss. This resulted in the resident having a severe weight loss of 25%. The assistant administrator identified six residents with significant weight loss. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission the resident was documented to weigh 112 pounds, with a resident stated baseline of 117 pounds. A review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the weight records for Resident #3 had no documented weights for 2021. Multiple weights were documented for 2020, the last weight in 2020 was documented on 10/20/20 as 119.5 pounds, with an average weight for 2020 as 108.27 pounds, and only one weight in 2022. The documented weight on 05/05/22 was 86.9 pounds. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No lab results were in the electronic record and no labs were provided by the facility before the end of the survey. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found or provided that this order was monitored by the facility. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan, dated 10/19/21 and last reviewed 11/04/21, documented an approach as the resident is noncompliant with letting staff obtain monthly weights or PRN weights. The care plan did not address any new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Medical Nutrition Therapy Assessment for Skilled Nursing Facilities, dated 05/03/22, completed by the dietician, documented Resident #3's intake of meals as refused 76%-100% of the time. Resident #3's intake of supplements was documented as 0%. On 05/12/22 at 11:53 a.m., Resident #3 was observed to be very thin and frail, with dry, flaky skin. The resident stated meals were provided but the staff either do not wake them or food was cold and unappealing. When attempts to request alternative meals were made, staff told them it had to be ordered by a certain time. Resident #3 stated meals were refused as well as oral supplements because they were rotten or spoiled. Resident #3 stated he did not receive a 2:00 p.m. snack each day. On 05/12/22 at 12:30 p.m., CMA #1 was asked how long they had provided care to Resident #3. The CMA stated several years. The CMA was asked if Resident #3 had refused meals. The CMA stated yes, Resident #3 refused two out of three meals a day and his supplements. The CMA stated Resident #3's niece will occasionally bring food for the resident. CMA #1 was asked who obtained resident weights. The CMA stated the CNAs because the facility no longer had a restorative aide. On 05/12/22 at 1:18 p.m., Resident #3 received an afternoon meal tray, the resident was in bed with eyes closed and the light off. No supplements were observed to be given to the resident. On 05/12/22 at 1:30 p.m., an attempt was made to speak to the dietary manager. The dietary manager stated they were too busy to answer questions. A meeting was requested after the meal was completed. The dietary manager did not attend. On 05/12/22 at 3:18 p.m., the DON was asked how weights were monitored. The DON stated they took over the weights and had received this month's weights but did not have baseline weights. The DON was asked what was done when a resident had a severe weight loss. The DON stated, the doctor should be notified, an [MEDICATION(S)] lab obtained, and the resident started on protein shakes. The DON was asked if resident #3 had a severe weight loss. The DON stated yes. The DON was asked if new interventions were started when the current weight was received. The DON stated nothing new was added, only a protein supplement drink was discontinued. The DON stated the physician was not notified of the weight loss for Resident #3 and should have been. The DON was asked if a significant change assessment or change in condition had been completed. The DON stated no, but should have been.

Based on record review, observation, and interview, the facility failed to ensure residents were free from accident hazards for one (#31) of two reviewed for falls. The facility failed to prevent a fall resulting in a leg fracture. The census and condition form documented a census of 121 residents. Findings: Res #31 had diagnoses which included muscle weakness, muscle wasting, unsteadiness on feet, and a fracture of the left leg. A quarterly assessment, dated 08/12/21, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident did not ambulate, required a mechanical lift for transfers, was frequently incontinent of bowel and bladder, and had no falls. A care plan, edited 10/22/21, documented in parts .I will need to be transferred using the total lift. Please ensure this is a bariatric lift . A incident report, dated 11/03/21, documented in parts .resident was with staff and transferring to bed, completing a stand pivot transfer, when resident became dizzy upon sitting on edge of bed and fell to the ground and heard a pop in the lower left leg. Resident was sent to the emergency department and was noted to have a fractured tibia on the left leg. A progress note, dated 11/03/21, documented in parts .A CNA came to the nurse and informed the nurse the resident had fallen. The nurse assessed the resident and the resident could not move her left ankle . A progress note, dated 11/03/21, documented the resident was readmitted back to the facility with a diagnoses of a fracture to the left ankle. A significant change assessment, dated 11/12/21, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident did not ambulate, required a mechanical lift for transfers, was frequently incontinent of bowel and bladder, and had no falls. On 02/15/22 at 7:40 a.m., Res#31 was observed lying in bed. Res #31 reported to have had a history of falls. Res #31 reported on 11/03/21, a CNA was in the room, stood Res #31 up from a motorized wheelchair, and while the CNA was moving the motorized wheelchair back, Res. #31 became dizzy and fell resulting in a left leg fracture. Res. #31 reported there was supposed to be two staff members present while transferring. Res. #31 reported staff members were supposed to use a mechanical lift while transferring. On 02/16/22 at 7:53 a.m., TNA #1 stated to have been employed at the facility greater than five months. TNA #1 stated Res #31 was to be transferred by a mechanical lift and to always make sure two staff members were present in the room during a transfer. On 02/16/22 at 07:56 a.m., TNA #2 stated to have been employed at the facility greater than four months and Res #31 had always required a mechanical lift during a transfer. On 02/16/22 at 7:58 a.m., LPN #2 stated to have been employed at the facility greater than two months and Res #31 required a mechanical lift. On 02/16/22 at 8:30 a.m., the facility Administrator was notified of a potential harm with substandard quality of care and expanding the survey. On 02/16/22 at 9:18 a.m., Res#31 was observed lying in bed. Res #31 reported on the day of the fall, CNA #1 was in the room preparing to help Res.#31 get in the bed. Res#31 stated CNA #1 helped the resident stand up, and while the resident was standing, CNA #1 was moving the motorized wheelchair backwards. Res #31 stated the CNA left the resident standing when the resident became dizzy and fell . Res #31 stated to have been sent to the emergency department and was diagnoses with a left lower tibia fracture above the left ankle. Res #31 stated there was no other staff in the room when the fall occurred. On 02/16/22 at 9:29 a.m., CNA #4 stated on 11/03/21 to have been in Res#31's room. CNA #4 stated the resident was ready to go to bed. CNA #4 stated to have stood the resident up from a motorized wheelchair, and while moving the chair backwards, Res #31 fell . CNA#4 stated there was no other staff member in the room. On 02/16/22 at 10:15 a.m., the point of care system (POC) was reviewed and documented in parts . was to be transferred by a mechanical lift or a physical transfer of two or more staff members . On 02/16/22 at 10:22 a.m., CNA #2 stated they followed the care plan for transfer assistance. On 02/16/22 at 10:00 a.m.,CNA #3 stated the care plan was followed for resident transfers, toileting, and resident care. On 02/16/22 at 10:05 a.m., CNA #4 stated the care plan was followed for resident transfers. On 02/16/22 at 10:10 a.m., CNA #5 stated the care plan was followed for transfer requirements. On 02/17/22 at 10:23 a.m., the DON stated a mechanical lift should have been used to transfer Res #31.

Based on observation, interview, and record review, it was determined the facility failed to intervene with a resident identified with a significant weight loss which received total nutrition via tube feeding for one (#5) of three sampled residents who were reviewed for weight loss and received nutrition via tube feeding. Resident #5 had a significant weight loss of 16.77% in 16 days. The facility identified eight residents who received nutrition via tube feeding and nine residents with unplanned significant weight loss. Findings: A policy titled, Weight Documentation, dated 05/01/14, documented, .DON (director of nursing)/designated nurse will review all weights to determine need for reweighs. Changes of 5 pounds or greater will be reweighed and verified by DON/designee. Reweighs will be completed within 24 hours .DON/designee will be responsible for reviewing residents' weights to determine significant weight loss/gain and initiate weekly weight plan/intervention as necessary. Physician, Consultant Dietitian, and resident/family (or responsible party) will be notified of significant weight loss/gain. (I.e. (sic) 5%-one month, 7.5%-3 months, 10%-6 months). Implement additional interventions or recommendations as made by notification . Resident #5 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/01/18, documented the resident was severely impaired in cognition, had received 51% or more of total calories via tube feeding, weighed 165 pounds with no weight loss documented. A care plan, dated 10/02/18, documented, .Problem: I am at risk for aspiration as I need a feeding tube due to [MEDICAL CONDITION] . Approach: Provide the formula at rate/time, for my feedings as my MD (Medical Doctor) has ordered .Review my labs and weight as ordered, report loss or abnormal levels . A dietitian progress note, dated 11/05/18, documented the resident had lost three pounds over a six month period and a current weight of 161.4 pounds. The resident received Glucerna 1.2 at a rate of 50 ml (milliliters) per hour to provide 1440 Kcals (kilocalorie) which calculated to meet 76% of the resident needs. A skin assessment, dated 11/18/18, identified an abrasion to the left buttocks which measured 2.5 cm (centimeter) x 1.7 cm x 0.1 cm. A lab report, dated 11/20/18, documented a low Pre-[MEDICATION NAME] of 13.5 (normal range 18.0 - 37.0). The physician had initialed the report and documented the resident to be administered a protein supplement. No documentation was found that the nursing staff had addressed the physician's response. A nurse progress note, dated 11/29/18, documented the attending physician had completed a wound assessment with no new orders. The assessment documented measurements of the abrasion to the left buttocks were unchanged from the initial assessment. A dietitian order, dated 12/03/18, documented to increase the rate of Glucerna to 60 ml per hour to provide 1728 Kcal in order to meet 100% of the resident needs for wound healing. On 12/04/18, the resident's weight was recorded as 161 pounds. Nurse progress notes were reviewed for 12/04/18 through 12/20/18 and revealed the abrasion to the left buttocks had not healed with three additional pressure ulcers identified. The clinical record documented the physician had completed an assessment of the resident on (MONTH) 4th, 6th, and 20th of (YEAR). On 12/20/18, the resident's weight was documented as 134 pounds which signified a significant weight loss of 16.77% in 16 days. A nurse note, dated 12/31/18, documented the attending physician had assessed the resident's wounds with no mention of weight loss. The clinical record documented the physician had completed wound assessments on (MONTH) 2nd and 7th, 2019 without mention of the resident's significant weight loss. On 01/08/19 at 8:59 a.m., the resident was observed in bed with Glucerna 1.2 infusing via tube feeding at 60 ml per hour. The resident was observed and appeared frail and emaciated. He did not respond to verbal stimuli and continued with a fixed stare. Physician orders, dated 01/08/19, documented the following to be infused via tube feeding: Glucerna 1.2 continuous at 60 ml/hr, to provide 1440 ml /1728 calories of formula per day. The order also requested a protein supplement of 90 ml to be administered via feeding tube three times daily. On 01/11/19, the resident's weight was documented as 132.6 which signified an additional 1% weight loss in 22 days. On 01/15/19 at 4:10 p.m., LPN (licensed practical nurse) #4 was asked the process for obtaining weights and monitoring for weight loss. She stated the restorative aide and dietary manager obtained weights. She stated the unit manager reviewed the weights and if a weight loss was noted the dietitian, physician, and family would be notified. She was asked if resident #5's weight loss was identified. She stated the resident was on weekly weights and the dietitian had reviewed his clinical record within the last two weeks. She was asked if interventions were initiated regarding the resident's weight loss. She stated she did not know if any adjustments or interventions had been initiated. She was asked who was responsible to initiate interventions for identified weight loss. She stated the physician or the dietitian. She was asked if the physician had been contacted. She referred to the clinical record and stated she did not see any documentation that the physician had been notified. At 4:19 p.m., the dietary manager and restorative aide were observed obtaining weights. The dietary manager was asked what the time frame was to obtain weights. She stated they were started on Mondays and finished on Tuesday. She was asked what the facility process was regarding the review of weights. She stated she reviewed the weights then entered the readings into the computer. She was asked what the process was if significant weight loss was identified. She stated the nursing department and the dietitian would be notified. She was asked if she had reported the resident's significant weight loss. She stated as soon as the weight loss was identified she reported it to the the nurse and dietitian. She was asked if the dietitian had left any documentation regarding the residents whose clinical records were reviewed on 01/14/19. She provided a list from the dietician which documented a list of residents with corresponding columns checked if reviewed for tube feeding, weight change, or renal concerns. Resident #5 was marked for tube feeding only. On 01/15/19 at 5:01 p.m., the resident was observed in bed with the tubing connected to the formula disconnected from the resident's feeding tube. The 1000 ml container of Glucerna 1.2 was observed to have 700 ml (milliliters) of formula remaining. The label documented the container of formula had been started at 12:01 a.m. on 01/15/19 which revealed the resident had not received the nutrients as ordered. At 5:13 p.m., LPN #5 was asked to observed the resident and the Glucerna container with the surveyor. She was asked how long the Glucerna 1.2 had been disconnected. She stated the resident was up at shift change and was returned to bed about 3:30 p.m. She stated it may have been disconnected when the resident was transferred from the bed to the chair. She stated it would have been reconnected if he had been in his room. She stated if the resident was taken out of his room the tube feeding was disconnected and the pump remained in the room. She was asked what time the resident was placed in his chair. She stated she thought it was about 1:00 p.m. She was asked why the resident had only received 300 ml of formula since midnight. She stated she did not know. She checked the pump and informed the surveyor that 173 ml of formula had infused. She stated 200 ml of water had been administered via tube feeding since the pump had last been cleared. She was asked how often the pump was cleared of infusion information. She stated at the end of the shift the nurse will zero out the information and document the I/O (intake and output) for the resident. She was asked if there had been any interventions initiated regarding the resident's weight loss. She stated the resident now received a protein supplement via tube feeding. A dietitian order from her review on 01/14/19, dated as a late entry on 01/15/19, documented a new tube feeding order. The order was to increase Glucerna 1.2 to 75 ml per hour to provide 2160 Kcal. to exceed established nutritional needs. The 90 ml protein supplement was to be continued three times daily via tube feeding. She documented the resident's ideal body weight was 75.5 Kg (166.1 pounds). At 5:30 p.m., LPN #4 and #6 stated they had some clarification regarding the resident and tube feeding. LPN #6 stated she had started a container of Glucerna 1.2 at noon today but the container had already been labeled for 12:01 a.m. On 01/16/19 at 9:25 a.m., LPN #6 was asked who was responsible for initiating a tube feeding. She stated the nurses. She was asked how the formula containers were labeled. She stated the containers were stored in the supply room and each time a new container was initiated the nurse completed the label with the resident's name, formula rate, date, time, and initials of the nurse initiating the feeding. The resident's I/O (intake/output) documentation, dated 01/01/19 through 01/15/19, revealed gaps in daily shift charting, inaccurate calculation of sum total of daily intake, and nine of the 15 days reviewed the resident had received less than the total amount of formula and supplement as ordered. On 01/16/19 at 2:06 p.m., the dietitian was asked how often she visited the facility. She stated usually two full days and one half day during the month. She was asked how her reviews were conducted. She stated she prioritized her list to include consults from the physician and/or nurse, reviewed the weight variances report. She stated she assessed high risk residents, those receiving tube feedings, residents with wounds, and new admissions. She was asked how she communicated her recommendations. She stated she documented any changes and reported those changes to the administrator and DON before leaving the facility. She was asked if she had reported any changes during her visit on 01/14/19. She stated yes but did not recall the residents' names. She was asked if she had addressed resident #5's weight loss after she had been notified by the dietary manager on 12/20/18. She stated she had visited the facility the next day, and the resident's weight had not been documented in the clinical record. She stated the dietary manager was not in the facility and could not be reached by phone. She stated she noted the resident had lost two or three pounds. She stated she had written an order to increase the formula from 50 ml to 60 ml per hour. She stated she had spoke to the resident's charge nurse and was informed that the resident did not have a weight loss. She was asked if she had followed up with the DON. She stated, No. She was asked if she had been informed that the resident had developed pressure ulcers. She stated she had not been notified. She was asked if she was aware that the resident's tube feeding was disconnected daily when staff took him out of his room. She stated she was not aware and that would have an effect on resident's caloric intake. She was asked how the physician was involved. She stated she did not have a face to face with any of the physicians, but they respected her decisions. Communication was conveyed through the DON. On 01/16/19 at 2:37 p.m., the DON was asked what the facility process was for identifying significant weight loss. She stated once the weights were obtained they were reviewed by the dietary manager and DON. She stated the physician and dietician would then be notified. She was asked if the dietitian had written orders regarding the resident's weight loss after her consult on 01/14/19. She stated she received the orders on 01/15/19. She was asked if staff had reported any physical changes regarding weight loss. She stated the resident did not look like he had lost weight and his clothing fit the same. She was informed that the resident's tube feeding had been observed disconnected on 01/15/19. She stated she was aware that staff disconnected the feeding when they provided care and during baths. She was asked if staff documented when they changed the containers of formula. She stated, No. She was asked who reviewed the I/O sheets especially for the resident receiving tube feedings to ensure accuracy. She stated the 3-11 nurse totals the daily amounts. The DON was asked if she had reviewed the I/O records. She stated no. She was asked if the physician had been notified of the resident's significant weight loss. She stated she would review the resident's clinical record for documentation. No documentation had been provided by the end of survey.

Based on observation, interview, and record review, it was determined the facility failed to provide a pain medication as ordered by the physician and failed to report the pain medication was not available and intervene during episodes of pain for one (#1) of five sampled residents who were reviewed for pain. The facility did not provide [MEDICATION NAME], an opioid [MEDICATION NAME] pain medication, as ordered by the physician for 28 hours and 40 minutes after the order was changed. The resident was observed to be irritable with restless movements, arms drawn close to the chest in a guarding position, eyes wide, mouth open, and making a noise as if attempting to speak. The facility identified 33 residents who received pain management. Findings: A policy titled, Pain Assessment and Management, dated October 2010, documented, .'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain .Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .Possible Behavioral Signs of Pain .groaning .irritability .Guarding .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated .Report the following information to the physician or practitioner: Prolonged, unrelieved pain . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received all nutrients through a peg tube. A physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet .1 tab per gastric tube every 6 Hrs. as needed for Anxiety . A pain evaluation, dated 01/30/17, documented yes to the following nonverbal/noncognitive signs which would indicate the presence of pain: ~Facial Expressions: Grimacing/distorted face, frowning/scowling, and turned down mouth; ~Vocalizations: Moaning and grunting; and ~Body Actions/Observed Behaviors: Irritability. The evaluation documented medication for relief of pain. The pain evaluation documented pain medications were administered which included, [MEDICATION NAME] 10 mg every four hours and [MEDICATION NAME] 10 mg three times daily. The medication administered as needed was documented as [MEDICATION NAME] 600 mg one every six hours. The evaluation documented the resident was unable to express acceptable pain level. A quarterly assessment, dated 04/16/17, documented the resident was severely impaired for daily decision making, had limited ability to express his ideas and wants due to unclear speech, was totally dependent on staff for bed mobility, transfers, and all activities of daily living, had bilateral upper and lower extremity impairment, and was always incontinent of urine and bowel. The assessment documented the resident had received scheduled pain medication during the five day look back period. The assessment documented a pain assessment interview should not be conducted due to the resident was never/rarely understood. For staff assessment of pain, the assessment documented the resident had no indicators of pain or possible pain observed or documented in the last five days. A care plan, dated 04/16/17, documented, Problem/Need .Pain .chronic pain .has difficulty making his needs known, but tries to tell staff what he needs . Goal & Target date .will be comfortable and his pain level will not increase thru next review 07/16/17 . Approaches .Document location of pain, type of pain, and duration of pain and if relief was obtained .Medication for pain is not to be held or altered without physician order [REDACTED].The level of pain can be determined by using one of the following types of pain scale, numeric (0-10) pain scale or verbal description of pain .All staff will observe (Name withheld) for presence of pain .Report any diaphoresis, moaning, restlessness, grimacing or crying that may indicate pain to charge nurse .receives routine Oxycodon (sic) .Oxy IR Q4 (hours) routinely per peg tube . A physician's orders [REDACTED].Stat Order .[MEDICATION NAME] HCL Solution .10mg per peg Q 4 (hours) routinely .Pain . A physician's orders [REDACTED].[MEDICATION NAME] tablet; 600mg; Amount to administer: 600 mg; gastric tube .Every 6 hours-PRN .Pain . A physician's orders [REDACTED].transport to (Name withheld) ER for eval et tx . The resident returned to the facility from the emergency roiagnom on [DATE] with a pain medication order change. A physician's orders [REDACTED].[MEDICATION NAME] 5mg/5ml solution .Give 5 ml (5 mg total) by PT q 4 hours as needed for pain . On 06/13/17 at 2:00 p.m., the resident was observed in bed in his room. He attempted to speak when spoken to and was in no apparent distress. At 4:08 p.m., a skin check was completed with assistance from LPN #1 and the DON. LPN #1 stated the resident had been administered [MEDICATION NAME] approximately 20 minutes prior to completing the skin check. The resident tolerated the observation without any signs of pain or distress. An entry on a narcotic count sheet for [MEDICATION NAME] 5mg/5ml Solution, dated 06/14/17 at 6:40 a.m. documented the resident had received [MEDICATION NAME] 5ml. On 06/14/17 at 10:00 a.m., the resident was observed in the main common area in his Broda Chair, dressed, looking out the window, and in no apparent distress. An untimed entry on a narcotic count sheet for [MEDICATION NAME] 5mg/5ml Solution, dated 06/14/17, documented the resident received [MEDICATION NAME] 5ml. A physician's orders [REDACTED].[MEDICATION NAME] give 10 ml .gen pain . A review of the fax sent to the pharmacy requesting the physician's new order for [MEDICATION NAME] 10 mg [MEDICATION NAME] was completed. The fax documented the new prescription had been faxed on 06/14/17 at 10:10 a.m. An entry on a narcotic county sheet for [MEDICATION NAME] 5mg/5ml Solution, dated 06/14/17 at 5:40 p.m., documented [MEDICATION NAME] 5ml was signed out on the Narcotic Count Sheet but a line had been marked through the entry with a remark written that the medication had been discontinued and had not been given; The following entries were written on the back of a PRN Medication Flowsheet, dated 06/01/17 - 06/30/17: ~ On 06/14/17 at 5:40 p.m., [MEDICATION NAME] 600 mg x 1 via peg c/o pain (gen). There was no documentation of effectiveness. ~ On 06/15/17 at 2:50 a.m., [MEDICATION NAME] 600 mg per tube - gen pain. There was no documentation of effectiveness. ~ On 06/15/17 at 10:20 a.m., [MEDICATION NAME] 600 1 via peg c/o pain generalized. There was no documentation of effectiveness. No documentation was found to indicate the physician had been notified that [MEDICATION NAME] 10mg [MEDICATION NAME] had not been delivered to the facility. On 06/15/17 at 11:05 a.m., the resident was observed in bed in his room. His parents were at his bedside. As the surveyor entered the room the resident's father stated the resident was very restless. He stated, He has been like this ever since we got here. The resident was observed to be in constant movement appearing to be very restless. With his hands contracted he had his arms drawn up on his chest. As the surveyor approached the resident his eyes were very wide, his mouth open, and he was making a grunting and groaning sound. The surveyor asked the resident if he was hurting and with the same expression he made a grunting sound. The resident's father stated he was going to get the nurse. He left the room and returned in less than five minutes with the nurse. ADON #2 informed the resident's father that the physician had been in to see the resident on 06/14/17 and changed his pain medication order. He stated the medication had not been delivered to the facility so the resident had been receiving [MEDICATION NAME]. At 11:20 a.m., ADON #2 was asked what pain medication the resident had been getting prior to the physician's orders [REDACTED]. He stated, Oxy. He was asked what the resident had been receiving since the physician's orders [REDACTED]. He stated, [MEDICATION NAME]. He stated, We have a call into (physician's name withheld). He was asked why the medication had not been delivered to the facility. He stated it had something to do with insurance. He was asked if the physician had been notified. He stated no. At 11:35 a.m., the DON was asked when the pharmacy had informed the facility that the payor source had denied the prescription. She stated 06/14/17 at 3:20 p.m. The documentation was requested regarding the pharmacy informing the facility of the denial but documentation was never provided to the surveyor. The DON was asked if the physician had been informed of the pharmacy's report of payor source denial of the prescription. She stated, No. She was asked why the physician had not been notified that there would be a delay in the delivery of the new order for [MEDICATION NAME] 10mg [MEDICATION NAME]. She stated, This was the first I heard of all this.

Based on interview and record review, it was determined the facility failed to notify the physician of a new ordered pain medication being unavailable in the facility and ineffective results from administering a less effective pain medication for one (#1) of five sampled residents who were reviewed for pain. The facility did not provide [MEDICATION NAME], an opioid [MEDICATION NAME] pain medication, as ordered by the physician for 28 hours and 40 minutes after the order was changed. The resident was observed to be irritable with restless movements, arms drawn close to the chest in a guarding position, eyes wide, mouth open, and making a noise as if attempting to speak. The facility identified 33 residents who received pain management. Findings: A policy titled, Pain Assessment and Management, dated October 2010, documented, .'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain .Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .Possible Behavioral Signs of Pain .groaning .irritability .Guarding .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated .Report the following information to the physician or practitioner: Prolonged, unrelieved pain . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received all nutrients through a peg tube. A physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet .1 tab per gastric tube every 6 Hrs. as needed for Anxiety . A pain evaluation, dated 01/30/17, documented yes to the following nonverbal/noncognitive signs which would indicate the presence of pain: ~Facial Expressions: Grimacing/distorted face, frowning/scowling, and turned down mouth; ~Vocalizations: Moaning and grunting; and ~Body Actions/Observed Behaviors: Irritability. The evaluation documented medication for relief of pain. The pain evaluation documented pain medications were administered which included, [MEDICATION NAME] 10 mg every four hours and [MEDICATION NAME] 10 mg three times daily. The medication administered as needed was documented as [MEDICATION NAME] 600 mg one every six hours. The evaluation documented the resident was unable to express acceptable pain level. A quarterly assessment, dated 04/16/17, documented the resident was severely impaired for daily decision making, had limited ability to express his ideas and wants due to unclear speech, was totally dependent on staff for bed mobility, transfers, and all activities of daily living, had bilateral upper and lower extremity impairment, and was always incontinent of urine and bowel. The assessment documented the resident had received scheduled pain medication during the five day look back period. The assessment documented a pain assessment interview should not be conducted due to the resident was never/rarely understood. For staff assessment of pain, the assessment documented the resident had no indicators of pain or possible pain observed or documented in the last five days. A care plan, dated 04/16/17, documented, Problem/Need .Pain .chronic pain .has difficulty making his needs known, but tries to tell staff what he needs . Goal & Target date .will be comfortable and his pain level will not increase thru next review 07/16/17 . Approaches .Document location of pain, type of pain, and duration of pain and if relief was obtained .Medication for pain is not to be held or altered without physician order [REDACTED].The level of pain can be determined by using one of the following types of pain scale, numeric (0-10) pain scale or verbal description of pain .All staff will observe (Name withheld) for presence of pain .Report any diaphoresis, moaning, restlessness, grimacing or crying that may indicate pain to charge nurse .receives routine Oxycodon (sic) .Oxy IR Q4 (hours) routinely per peg tube . A physician's orders [REDACTED].Stat Order .[MEDICATION NAME] HCL Solution .10mg per peg Q 4 (hours) routinely .Pain . A physician's orders [REDACTED].[MEDICATION NAME] tablet; 600mg; Amount to administer: 600 mg; gastric tube .Every 6 hours-PRN .Pain . A physician's orders [REDACTED].transport to (Name withheld) ER for eval et tx . The resident returned to the facility from the emergency roiagnom on [DATE] with a pain medication order change. A physician's orders [REDACTED].[MEDICATION NAME] 5mg/5ml solution .Give 5 ml (5 mg total) by PT q 4 hours as needed for pain . On 06/13/17 at 2:00 p.m., the resident was observed in bed in his room. He attempted to speak when spoken to and was in no apparent distress. At 4:08 p.m., a skin check was completed with assistance from LPN #1 and the DON. LPN #1 stated the resident had been administered [MEDICATION NAME] approximately 20 minutes prior to completing the skin check. The resident tolerated the observation without any signs of pain or distress. An entry on a narcotic count sheet for [MEDICATION NAME] 5mg/5ml Solution, dated 06/14/17 at 6:40 a.m. documented the resident had received [MEDICATION NAME] 5ml. On 06/14/17 at 10:00 a.m., the resident was observed in the main common area in his Broda Chair, dressed, looking out the window, and in no apparent distress. An untimed entry on a narcotic count sheet for [MEDICATION NAME] 5mg/5ml Solution, dated 06/14/17, documented the resident received [MEDICATION NAME] 5ml. A physician's orders [REDACTED].[MEDICATION NAME] give 10 ml .gen pain . A review of the fax sent to the pharmacy requesting the physician's new order for [MEDICATION NAME] 10 mg [MEDICATION NAME] was completed. The fax documented the new prescription had been faxed on 06/14/17 at 10:10 a.m. An entry on a narcotic county sheet for [MEDICATION NAME] 5mg/5ml Solution, dated 06/14/17 at 5:40 p.m., documented [MEDICATION NAME] 5ml was signed out on the Narcotic Count Sheet but a line had been marked through the entry with a remark written that the medication had been discontinued and had not been given; The following entries were written on the back of a PRN Medication Flowsheet, dated 06/01/17 - 06/30/17: ~ On 06/14/17 at 5:40 p.m., [MEDICATION NAME] 600 mg x 1 via peg c/o pain (gen). There was no documentation of effectiveness. ~ On 06/15/17 at 2:50 a.m., [MEDICATION NAME] 600 mg per tube - gen pain. There was no documentation of effectiveness. ~ On 06/15/17 at 10:20 a.m., [MEDICATION NAME] 600 1 via peg c/o pain generalized. There was no documentation of effectiveness. No documentation was found to indicate the physician had been notified that [MEDICATION NAME] 10mg [MEDICATION NAME] had not been delivered to the facility. On 06/15/17 at 11:05 a.m., the resident was observed in bed in his room. His parents were at his bedside. As the surveyor entered the room the resident's father stated the resident was very restless. He stated, He has been like this ever since we got here. The resident was observed to be in constant movement appearing to be very restless. With his hands contracted he had his arms drawn up on his chest. As the surveyor approached the resident his eyes were very wide, his mouth open, and he was making a grunting and groaning sound. The surveyor asked the resident if he was hurting and with the same expression he made a grunting sound. The resident's father stated he was going to get the nurse. He left the room and returned in less than five minutes with the nurse. ADON #2 informed the resident's father that the physician had been in to see the resident on 06/14/17 and changed his pain medication order. He stated the medication had not been delivered to the facility so the resident had been receiving [MEDICATION NAME]. At 11:20 a.m., ADON #2 was asked what pain medication the resident had been getting prior to the physician's orders [REDACTED]. He stated, Oxy. He was asked what the resident had been receiving since the physician's orders [REDACTED]. He stated, [MEDICATION NAME]. He stated, We have a call into (physician's name withheld). He was asked why the medication had not been delivered to the facility. He stated it had something to do with insurance. He was asked if the physician had been notified. He stated no. At 11:35 a.m., the DON was asked when the pharmacy had informed the facility that the payor source had denied the prescription. She stated 06/14/17 at 3:20 p.m. The documentation was requested regarding the pharmacy informing the facility of the denial but documentation was never provided to the surveyor. The DON was asked if the physician had been informed of the pharmacy's report of payor source denial of the prescription. She stated, No. She was asked why the physician had not been notified that there would be a delay in the delivery of the new order for [MEDICATION NAME] 10mg [MEDICATION NAME]. She stated, This was the first I heard of all this.

Based on interview and record review, it was determined the facility failed to provide pharmacy services to ensure a pain medication was provided as ordered by the physician for one (#1) of five sampled residents who were reviewed for pain. The facility did not provide Norco, an opioid analgesic pain medication, as ordered by the physician for 28 hours and 40 minutes after the order was changed. The resident was observed to be irritable with restless movements, arms drawn close to the chest in a guarding position, eyes wide, mouth open, and making a noise as if attempting to speak. The facility identified 33 residents who received pain management. Findings: A policy titled, Pain Assessment and Management, dated October 2010, documented, .'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain .Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .Possible Behavioral Signs of Pain .groaning .irritability .Guarding .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated .Report the following information to the physician or practitioner: Prolonged, unrelieved pain . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received all nutrients through a peg tube. A physician's orders [REDACTED].Lorazepam 0.5 mg tablet .1 tab per gastric tube every 6 Hrs. as needed for Anxiety . A pain evaluation, dated 01/30/17, documented yes to the following nonverbal/noncognitive signs which would indicate the presence of pain: ~Facial Expressions: Grimacing/distorted face, frowning/scowling, and turned down mouth; ~Vocalizations: Moaning and grunting; and ~Body Actions/Observed Behaviors: Irritability. The evaluation documented medication for relief of pain. The pain evaluation documented pain medications were administered which included, Oxycodone 10 mg every four hours and Baclofen 10 mg three times daily. The medication administered as needed was documented as Ibuprofen 600 mg one every six hours. The evaluation documented the resident was unable to express acceptable pain level. A quarterly assessment, dated 04/16/17, documented the resident was severely impaired for daily decision making, had limited ability to express his ideas and wants due to unclear speech, was totally dependent on staff for bed mobility, transfers, and all activities of daily living, had bilateral upper and lower extremity impairment, and was always incontinent of urine and bowel. The assessment documented the resident had received scheduled pain medication during the five day look back period. The assessment documented a pain assessment interview should not be conducted due to the resident was never/rarely understood. For staff assessment of pain, the assessment documented the resident had no indicators of pain or possible pain observed or documented in the last five days. A care plan, dated 04/16/17, documented, Problem/Need .Pain .chronic pain .has difficulty making his needs known, but tries to tell staff what he needs . Goal & Target date .will be comfortable and his pain level will not increase thru next review 07/16/17 . Approaches .Document location of pain, type of pain, and duration of pain and if relief was obtained .Medication for pain is not to be held or altered without physician order [REDACTED].The level of pain can be determined by using one of the following types of pain scale, numeric (0-10) pain scale or verbal description of pain .All staff will observe (Name withheld) for presence of pain .Report any diaphoresis, moaning, restlessness, grimacing or crying that may indicate pain to charge nurse .receives routine Oxycodon (sic) .Oxy IR Q4 (hours) routinely per peg tube . A physician's orders [REDACTED].Stat Order .Oxycodone HCL Solution .10mg per peg Q 4 (hours) routinely .Pain . A physician's orders [REDACTED].Ibuprofen tablet; 600mg; Amount to administer: 600 mg; gastric tube .Every 6 hours-PRN .Pain . A physician's orders [REDACTED].transport to (Name withheld) ER for eval et tx . The resident returned to the facility from the emergency roiagnom on [DATE] with a pain medication order change. A physician's orders [REDACTED].Oxycodone 5mg/5ml solution .Give 5 ml (5 mg total) by PT q 4 hours as needed for pain . On 06/13/17 at 2:00 p.m., the resident was observed in bed in his room. He attempted to speak when spoken to and was in no apparent distress. At 4:08 p.m., a skin check was completed with assistance from LPN #1 and the DON. LPN #1 stated the resident had been administered Oxycodone approximately 20 minutes prior to completing the skin check. The resident tolerated the observation without any signs of pain or distress. An entry on a narcotic count sheet for Oxycodone 5mg/5ml Solution, dated 06/14/17 at 6:40 a.m. documented the resident had received Oxycodone 5ml. On 06/14/17 at 10:00 a.m., the resident was observed in the main common area in his Broda Chair, dressed, looking out the window, and in no apparent distress. An untimed entry on a narcotic count sheet for Oxycodone 5mg/5ml Solution, dated 06/14/17, documented the resident received Oxycodone 5ml. A physician's orders [REDACTED].Elixir give 10 ml .gen pain . A review of the fax sent to the pharmacy requesting the physician's new order for Norco 10 mg Elixir was completed. The fax documented the new prescription had been faxed on 06/14/17 at 10:10 a.m. An entry on a narcotic county sheet for Oxycodone 5mg/5ml Solution, dated 06/14/17 at 5:40 p.m., documented Oxycodone 5ml was signed out on the Narcotic Count Sheet but a line had been marked through the entry with a remark written that the medication had been discontinued and had not been given; The following entries were written on the back of a PRN Medication Flowsheet, dated 06/01/17 - 06/30/17: ~ On 06/14/17 at 5:40 p.m., Ibuprofen 600 mg x 1 via peg c/o pain (gen). There was no documentation of effectiveness. ~ On 06/15/17 at 2:50 a.m., Ibuprofen 600 mg per tube - gen pain. There was no documentation of effectiveness. ~ On 06/15/17 at 10:20 a.m., Ibuprofen 600 1 via peg c/o pain generalized. There was no documentation of effectiveness. No documentation was found to indicate the physician had been notified that Norco 10mg Elixir had not been delivered to the facility. On 06/15/17 at 11:05 a.m., the resident was observed in bed in his room. His parents were at his bedside. As the surveyor entered the room the resident's father stated the resident was very restless. He stated, He has been like this ever since we got here. The resident was observed to be in constant movement appearing to be very restless. With his hands contracted he had his arms drawn up on his chest. As the surveyor approached the resident his eyes were very wide, his mouth open, and he was making a grunting and groaning sound. The surveyor asked the resident if he was hurting and with the same expression he made a grunting sound. The resident's father stated he was going to get the nurse. He left the room and returned in less than five minutes with the nurse. ADON #2 informed the resident's father that the physician had been in to see the resident on 06/14/17 and changed his pain medication order. He stated the medication had not been delivered to the facility so the resident had been receiving Ibuprofen. At 11:20 a.m., ADON #2 was asked what pain medication the resident had been getting prior to the physician's orders [REDACTED]. He stated, Oxy. He was asked what the resident had been receiving since the physician's orders [REDACTED]. He stated, Ibuprofen. He stated, We have a call into (physician's name withheld). He was asked why the medication had not been delivered to the facility. He stated it had something to do with insurance. He was asked if the physician had been notified. He stated no. At 11:35 a.m., the DON was asked when the pharmacy had informed the facility that the payor source had denied the prescription. She stated 06/14/17 at 3:20 p.m. The documentation was requested regarding the pharmacy informing the facility of the denial but documentation was never provided to the surveyor. The DON was asked if the physician had been informed of the pharmacy's report of payor source denial of the prescription. She stated, No. She was asked why the physician had not been notified that there would be a delay in the delivery of the new order for Norco 10mg Elixir. She stated, This was the first I heard of all this.