Every finding on record at Walnut Grove Care & Rehab Center

On 02/27/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #45 from verbal and psychosocial abuse. On 02/27/25 at 2:06 p.m., Resident #45 reported over the weekend staff blamed them for turning on the call light. Resident #45 stated CNA #1 came to their room to answer the call light and Resident #45 told CNA #1 they needed assistance with incontinent care. Resident #45 stated CNA #1 told them they were assisting another resident and would come back when they could. Resident #45 stated when CNA #1 returned they yelled at them and stated they would be there in a minute and to stay off the light. Resident #45 stated they had not activated the call light again, that CNA #1 had not turned the call light off from the first interaction. Resident #45 stated they were so upset they started crying. Resident #45 stated they called the nurses station and reported the occurrence to the charge nurse/ LPN #4. Resident #45 stated they were so upset they wanted to leave the facility. On 02/27/25 at 2:12 p.m., the administrator stated on Monday 02/24/25, CNA #2 tattle-tailed on about three things, one of which were concerns about CNA #1 regarding verbal abuse over the weekend. The administrator stated it was reported CNA #1 wasn't very nice to Resident #45. The administrator stated they did not interview the resident or conduct an investigation. On 02/27/25 at 2:19 p.m., charge nurse/LPN #4 stated Resident #45 reported the incident to them and the resident was so upset they started crying. The LPN stated they removed CNA #1 from the resident's hall and placed them on another hall. LPN #4 stated they had not heard anything more regarding the incident. LPN #4 stated they should have reported the incident to the administrator and did not. There was no documentation the incident occurred. There were no progress notes, no staff or resident interviews, and there was no incident report submitted to the Oklahoma Department of Health. On 02/27/25 at 7:41 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 02/27/25 at 8:01 p.m., the administrator, DON, and regional RN were notified of the presence of an immediate jeopardy situation related to Resident #45 not being free from verbal abuse. The IJ template was provided to the administrator. On 02/27/25 at 8:47 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read, Walnut Grove IJ Abatement 02/27/25. Resident #45 was interviewed by Social Services on 2/27/25 and was offered counseling to help [them] with this situation. The resident states [they] feel safe, and very secure, it was just the one incident that made [them] feel disrespected. On 2/27/25 the Administrator self-reported to the state of Oklahoma. On 2/27/25 Certified Nursing Assistant #1 was placed on suspension pending investigation. On 2/27/25 all residents in the facility were interviewed by Director of Nursing and Administrator for any concerns or reports of rude behavior by CNA #1 while [they] were taking care of them. With no concerns found. On 2/27/25 the Regional Nurse Consultant interviewed staff that worked with Certified Nursing Assistant #1, no concerns were noted apart from Certified Nursing Assistant #2. On 2/27/25 All staff educated by Regional Nurse Consultant and Director of Nursing on the Policy for abuse and neglect and importance of notifying supervisor immediately of any allegations. No staff member will work until they are educated. All new employees will be educated on Abuse and Neglect policy. On 2/27/25 Regional Nurse Consultant educated the Administrator on the policy of Abuse and Neglect and reporting any allegations to the State of Oklahoma per education of timelines and doing an immediate investigation. All completed on 02/27/25 [at 8:47] p.m. Signed by the administrator. On 02/27/25 at 8:47 p.m., the IJ was lifted when all components of the plan of removal were completed. The deficient practice remained at a level of no actual harm with a potential for more than minimal harm. Based on record review and interview, the facility failed to protect a resident's right to be free from verbal abuse for 1 (#45) of 16 sampled residents reviewed for abuse. The administrator identified 59 residents who resided in the facility. Findings: On 02/27/25 at 2:06 p.m., Resident #45 reported over the weekend, staff blamed them for turning on the call light. Resident #45 stated CNA #1 came to their room to answer the call light and Resident #45 told CNA #1 they needed assistance with incontinent care. Resident #45 stated CNA #1 told Resident #45 they were assisting another resident and would come back when they could. Resident #45 stated when CNA #1 returned they yelled at them and stated they would be there in a minute and to stay off the light. Resident #45 stated they had not activated the call light again, that CNA #1 had not turned the call light off from the first interaction. Resident #45 stated they were so upset that they started crying. Resident #45 stated they called the nurses station and reported the occurrence to the charge nurse/ LPN #4. Resident #45 stated they were so upset they wanted to leave the facility. Resident #45 had diagnoses which included cognitive communication deficit, need for assistance with personal care and generalized anxiety. An admission MDS assessment, dated 12/10/24, showed Resident #45 was cognitively intact with a BIMS of 15, but was dependent on staff for bathing, lower body dressing, transfers, and toileting hygiene. The assessment showed Resident #45 required max assist with bed mobility, moderate assistance with upper body dressing. The assessment showed walking did not occur. On 02/27/25 at 2:12 p.m., the administrator stated on Monday 02/24/25, CNA #2 tattle-tailed on about three things, one of which were concerns about CNA #1 regarding verbal abuse over the weekend. The administrator stated it was reported CNA #1 wasn't very nice to Resident #45. The administrator stated they did not interview the resident or investigate in any way. On 02/27/25 at 2:19 p.m., charge nurse/LPN #4 stated Resident #45 reported the incident to them and the resident was so upset they started crying. The LPN stated they removed CNA #1 from the resident's hall and placed them on another hall. LPN #4 stated they had not heard anything more regarding the incident. LPN #4 stated they should have reported the incident to the administrator and did not. On 02/27/25 at 3:54 p.m., CNA #1 stated they worked on B hall for about 30 minutes. They stated there were a lot of call lights and they told Resident #45 they would get to them as fast as they could. CNA #1 stated Resident #45 kept hitting the call light, they were busy and Resident #45 became upset. CNA #1 stated they walked out. CNA #1 stated the nurse moved them to E hall. On 02/27/25 at 3:57 p.m., CNA #2 stated they were not there at the time the incident actually occurred, but was informed by evening shift that CNA #1 made Resident #45 cry and also had an attitude with Resident #215. CNA #2 stated they went to talk to Resident #45 and they identified CNA #1 as the staff that made them cry. CNA #2 stated they told the administrator about the incident on Monday morning and the administrator stated they would handle it. On 02/27/25 at 6:58 p.m., Resident #215 whom resided on E hall, stated they received good care Monday through Friday, but the weekends were terrible. Resident #215 stated last weekend a staff member told them they were short on staff and to stay off the call light. Resident #215 was unable to remember the staff members name. Resident #215 stated the staff member then left and did not even help them. Resident #215 stated, When they sent the [other staff] in here they were good to me. Resident #215 stated they did not know who to tell so they did not report it. Resident #215 stated the staff member did not return to their room, but they did not want to use the call light when that staff member was there.

Based on observation, record review, and interview, the facility failed to ensure the low temperature warewasher had the appropriate amount of chemical to sanitize dishes for the facility. The administrator identified 55 residents ate meals from the kitchen. Findings: On 02/24/25 at 11:26 a.m., the CDM was observed using test strips for sanitizer in the low temperature warewasher and the sanitizer was not pumping through to release the chemical into the warewasher. An undated chemical company instruction manual, read in part,Test paper must read at least 50 parts per million. A policy titled Warewasher revised date 12/18/24, read in part, The dish machine, if low temp, shall use a detergent, a rinse drying agent, and a sanitizer .The sanitizing temperature to activate the sanitizer per manufactuers' instructions .Low temperature dish machine log Sanitizer greater than 50 part per million. On 02/24/25 at 11:27 a.m., the CDM stated the sanitizer was reading 25 ppm and it should be at 50 ppm.

Based on record review and interview, the facility failed to ensure a resident had access to their trust account money on nights and weekends for 1 (#1) of 1 sampled resident reviewed for access to their trust account money. The BOM identified 12 residents who had money in the trust account. Findings: An undated Policy and Procedure of Resident Trust Fund, read in part, The management of the trust shall be managed by the business office or it's designees and ensure that proper accounting principals are followed .but not to exclude State and Federal regulations. A review of the trust account ledgers for Resident #1 contained no entries of money being withdrawn at night or on the weekends. On 02/24/25 at 12:26 p.m., Resident #1 reported over the weekend they wanted a coke and was told they did not have any money. On 02/27/25 at 10:04 a.m., the BOM stated they worked at the facility Monday through Friday. They stated if residents wanted money they would need to request it from them on Friday and keep it on their person. They stated the facility did not keep petty cash. They stated, I guess they wouldnt when asked directly how residents would get their money if they wanted it at night or on the weekends. On 02/27/25 at 10:17 a.m. RN #1 stated they worked Tuesday through Saturday and they did not deal with the money. They stated if a resident asked for money on the weekend, they would have to contact the BOM. They stated if a resident requested money on a Friday, they would have to keep it on their person.

Based on record review, and interview, the facility failed to report an allegation of abuse to the state agency for 1 (#45) of 1 sampled resident reviewed for abuse. The administrator identified 59 residents resided in the facility. Findings: An undated Abuse Prevention Program policy, undated, read in part, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator .The Administrator is the Abuse Coordinator .IF YOU SUSPECT ABUSE .Notify a Supervisor/Nurse Immediately .Notify the Administrator and Director of Nursing .The Administrator or designee utilizing the state specific Incident Reporting System will immediately notify the Department of Health by the Incident Reporting System .Investigation .All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .All personnel must promptly report any incident or suspected incident of abuse, mistreatment or neglect, including injuries of unknown origin. Resident #45 had diagnoses which included cognitive communication deficit, need for assistance with personal care and generalized anxiety. An admission MDS assessment, dated 12/10/24, showed Resident #45 was cognitively intact with a BIMS of 15, but was dependent on staff for bathing, lower body dressing, transfers, and toileting hygiene. The assessment showed Resident #45 required max assist with bed mobility, moderate assistance with upper body dressing. The assessment showed walking did not occur. On 02/27/25 at 2:06 p.m., Resident #45 reported over the weekend, staff blamed them for turning on the call light. Resident #45 stated CNA #1 came to their room to answer the call light and Resident #45 told CNA #1 they needed assistance with incontinent care. Resident #45 stated CNA #1 told Resident #45 they were assisting another resident and would come back when they could. Resident #45 stated when CNA #1 returned they yelled at them and stated they would be there in a minute and to stay off the light. Resident #45 stated they had not activated the call light again, that CNA #1 had not turned the call light off from the first interaction. Resident #45 stated they were so upset that they started crying. Resident #45 stated they called the nurses station and reported the occurrence to the charge nurse/ LPN #4. Resident #45 stated they were so upset they wanted to leave the facility. On 02/27/25 at 2:12 p.m., the administrator stated on Monday 02/24/25, CNA #2 tattle-tailed on about three things, one of which were concerns about CNA #1 regarding verbal abuse over the weekend. The administrator stated it was reported CNA #1 wasn't very nice to Resident #45. The administrator stated they did not interview the resident or conduct an investigation. On 02/27/25 at 2:19 p.m., charge nurse/LPN #4 stated Resident #45 reported the incident to them and the resident was so upset they started crying. The LPN stated they removed CNA #1 from the resident's hall and placed them on another hall. LPN #4 stated they had not heard anything more regarding the incident. LPN #4 stated they should have reported the incident to the administrator and did not.

Based on record review, and interview, the facility failed to investigate an allegation of abuse for 1 (#45) of 1 sampled resident reviewed for abuse. The administrator identified 59 residents resided in the facility. Findings: There was no documentation that this incident even occurred. There were no progress notes, no staff or resident interviews, no facility-initiated report provided to Oklahoma Department of Health. An undated Abuse Prevention Program policy, undated, read in part, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .All personnel must promptly report any incident or suspected incident of abuse, mistreatment or neglect, including injuries of unknown origin. Resident #45 had diagnoses which included cognitive communication deficit, need for assistance with personal care and generalized anxiety. An admission MDS assessment, dated 12/10/24, showed Resident #45 was cognitively intact with a BIMS of 15, but was dependent on staff for bathing, lower body dressing, transfers, and toileting hygiene. The assessment showed Resident #45 required max assist with bed mobility, moderate assistance with upper body dressing. The assessment showed walking did not occur. On 02/27/25 at 2:06 p.m., Resident #45 reported over the weekend, staff blamed them for turning on the call light. Resident #45 stated CNA #1 came to their room to answer the call light and Resident #45 told CNA #1 they needed assistance with incontinent care. Resident #45 stated CNA #1 told Resident #45 they were assisting another resident and would come back when they could. Resident #45 stated when CNA #1 returned they yelled at them and stated they would be there in a minute and to stay off the light. Resident #45 stated they had not activated the call light again, that CNA #1 had not turned the call light off from the first interaction. Resident #45 stated they were so upset that they started crying. Resident #45 stated they called the nurses station and reported the occurrence to the charge nurse/ LPN #4. Resident #45 stated they were so upset they wanted to leave the facility. On 02/27/25 at 2:12 p.m., the administrator stated on Monday 02/24/25, CNA #2 tattle-tailed on about three things, one of which were concerns about CNA #1 regarding verbal abuse over the weekend. The administrator stated it was reported CNA #1 wasn't very nice to Resident #45. The administrator stated they did not interview the resident or conduct an investigation. On 02/27/25 at 2:19 p.m., charge nurse/LPN #4 stated Resident #45 reported the incident to them and the resident was so upset they started crying. The LPN stated they removed CNA #1 from the resident's hall and placed them on another hall. LPN #4 stated they had not heard anything more regarding the incident. LPN #4 stated they should have reported the incident to the administrator and did not.

Based on observation, record review and interview, the failed failed to ensure medication carts were secured when not in use for 2 of 7 medication carts observed. The administrator identified 59 residents resided in the facility. Findings: On 02/27/25 at 8:33 p.m., medication carts for halls A/B and E/F and on the North side of the nursing station were observed unlocked and unattended with keys in the lock. On 02/27/25 at 8:34 p.m., nursing was staff observed sitting at the nurses station and medication carts A/B and E/F were observed unlocked and unattended. An undated Medication Storage in the Facility policy, read in part,Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On 02/27/25 at 8:35 p.m., the licensed practical nurse #3 stated medication carts A/B and E/F were supposed to be locked and attended by staff who were assigned to the medication carts. On 02/28/25 at 11:06 a.m., the director of nursing stated it was policy for medication carts A/B and E/F to be attended to and locked at all times.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and EBP were followed during the administration of medications. The administrator identified seven residents required enhanced barrier precautions. Findings: On 02/25/25 at 8:41 a.m., LPN #3 was observed providing crushed medications through a PEG tube to a resident that required EBP. LPN #3 washed their hands and wore gloves, but did not wear a gown while providing care to the indwelling device. An Enhanced Barrier Precautions policy, copyright date 2025, read in part, Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resistant organisms .This facility utilizes Enhanced Barrier Precautions .as a strategy to decrease transmission of CDC [Centers for Disease Control and Prevention]-targeted and epidemiologically important MDROs when Contact Precautions do not apply .Enhanced Barrier Precautions: An infection control intervention designed to reduce transmissions of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Indications .Wounds and/or indwelling medical devices even if the resident is not know to be infected or colonized with an MDRO .Indwelling devices include, but are not limited to, feeding tubes. On 02/25/25 at 8:46 a.m., LPN #3 stated EBP included a gown, gloves, and a mask. They stated they would have worn a gown if they would have thought about it. They stated they were not wearing a gown while providing medication through a percutaneous endoscopic gastrostomy tube. On 02/26/25 4:51 p.m., the DON stated they would have to look up the actual policy, but essentially a gown, gloves, and mask should be worn when the resident had something contagious.

Based on record review and interview, the facility failed to ensure baths were provided as care planned for one (#2) of four sampled residents reviewed for ADL (activities of daily living) assistance. A facility resident report, dated 07/24/24, documented 61 residents resided in the facility. Findings: A facility ADL Care Bathing policy, dated 07/21/22, read in part, Nursing staff will assist in bathing Residents to promote cleanliness and dignity. A care plan focus, dated 06/16/24, read in part, BATHING/SHOWERING: Offer Bathing/Showering twice weekly and as necessary. Resident #2's bathing records were reviewed. Documentation stated the resident was offered baths 2 of 14 dates between 06/30/24 and 07/13/24. Of the two days the resident was offered baths, documentation indicated they had a bath on 07/02/24 and refused a bath on 07/11/24. On 07/25/24 at 9:33 a.m., CNA #1 stated they were assigned to work with Resident #2 that day. They stated after a bath was offered, they inform the charge nurse if the resident was given a bath or if they refused. They stated they then put the information in the resident electronic medical record (EMR). On 07/25/24 at 9:39 a.m., CNA #2 stated they inform the charge nurse after offering baths and then chart in the EMR if the resident was bathed or if they refused. On 07/25/24 at 9:46 a.m. the assistant director of nursing (ADON) stated after offering a bath to a resident the aides fill out a bath sheet and document in the electronic medical record. The ADON reviewed Resident #2's EMR and stated the button the aides would click to open the area of the EMR to document was not in the chart. They stated the aides would not be able to chart bathing in the EMR without that button. They reviewed the resident's bathing records and stated the resident had not received the required number of baths in the first two weeks of July 2024. On 07/25/24 at 10:54 a.m. ADON stated the staff had not documented if the resident had or had not received all the baths that had been care planned. They stated the staff had not followed facility policy regarding bathing and documentation.

Based on observation and interview, the facility failed to properly inform visitors and staff of residents who were in isolation on transmission based precautions for three (#13, 19, and #48) of three sampled residents who tested positive for COVID. The IP identified 22 residents who tested positive for COVID. Findings: The Infection Control Manual, dated 5/11/23, read in part, .An isolation notice will be placed in plain view outside the entrance to the isolation/quarantine room . On 10/17/23 at 9:30 a.m., a white cross or plus sign was observed on the doors to Res #13, 19 and #48's rooms. On 10/18/23 at 8:00 a.m., a large letter Q was observed on the doors to Res #13, 19 and #48's rooms. The resident roster documented Res #13, 19 and #48 tested positive for COVID on 10/10/23. On 10/18/23 at 2:00 p.m., the corporate nurse reported the white cross was a plus sign meaning the residents were COVID positive and the letter Q was for quarantine, but acknowledged there would be no way for a visitor to know what the white plus sign or letter Q meant.

Based on observation and interview, the facility failed to ensure food was labeled and stored in a sanitary manner. The Resident Census and Conditions of Residents, dated 10/17/23, documented 57 residents receive their meals from the kitchen. Findings: A Refrigerator Storage policy, dated February 2010, read in part, .label all leftovers with recipe name and date (month, day, year) of storage. Discard refrigerated leftovers after 48 hours . On 10/17/23 at 9:30 a.m., an intial tour of the kitchen was conducted. The following was found in the refrigerator: a. Bologna in a ziplock bag dated 09/23. b. An unlabeled zip lock bag of hot dogs. c. Chopped eggs in a ziplock bag dated 9/4. d. Rice in a ziplock bag date 9/4. e. An unlabeled zip lock bag of a green herb. f. Cheese in a zip lock bag dated 10/7. g. An unlabeled bag of deli meat that was open and leaking juices onto a tray containing other food items. On 10/17/23 at 10:02 a.m., the dietary manager reported the refrigerator was a mess. The dietary manager reported refrigerator food storage was their responsibility and they hadn't had time to get to it due to staffing changes in the kitchen.

Based on observation, record review, and interview, the facility failed to assess residents for the continued need for indwelling urinary catheters for one (#2 ) of two sampled residents reviewed for an indwelling urinary catheter. The Resident Census and Conditions of Residents, dated 10/17/23, documented four residents who had an indwelling urinary catheter. Findings: Res #2's medical record documented diagnoses which included neuromuscular dysfunction of the bladder. Res #2 was readmitted to the facility from the hospital on 09/10/23, the re-admission nursing note, dated 09/10/23, documented Res #2 had an indwelling urinary catheter in place upon re-admission. A significant change resident assessment, dated 09/17/23, documented Res #2 had an indwelling urinary catheter in place. On 10/17/23 at 10:45 a.m. and throughout the survey, Res #2 was observed to have an indwelling urinary catheter in place. There was no documentation Res #2 had been assessed for the continued need for their indwelling urinary catheter. On 10/18/23 at 3:30 p.m., the corporate Nurse reported they were not aware the residents needed to be assessed for the continued use of an indwelling urinary catheter if they had a diagnosis to justify why a urinary catheter was needed. The corporate nurse reported Res #2 had not been assessed for the continued use of their indwelling urinary catheters.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#34) of 25 sampled residents whose assessments were reviewed for accuracy. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: Res #34 was admitted to the facility on [DATE] with diagnoses of frontotemporal neurocognitive disorder, major depressive disorder, post-traumatic stress disorder, sleep apnea, and hypertension. An MDS assessment, dated 09/13/23, documented the resident's cognition was moderately impaired. The MDS documented the resident had non-alzheimer's dementia. On 10/23/23 at 11:30 a.m., MDS #1 reported the assessment was inaccurate.

Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#48) of four sampled residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: Res #48 was admitted to the facility on [DATE] with a diagnosis of impulse disorder. The resident's EHR documented the resident was diagnosed with delusion disorders on 05/11/22. The EHR did not contain documentation that OHCA had been contacted regarding a new mental health diagnosis On 10/24/23 at 12:00 p.m., the MDS coordinator reported she didn't know that the state needed to be contacted regarding new mental health diagnosis.

Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#54) of five sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents, dated 10/17/23, documented a census of 61 residents. Findings: A Comprehensive Interdisciplinary Plan of Care policy, dated July 2018, read in part, .Comprehensive Interdisciplinary Plan of Care will be developed and implemented no later than 21 days following the admission . Res #54 was admitted on [DATE] with diagnoses which included dementia, gastrostomy, neuromuscular dysfunction of the bladder and frontotemporal neurocognitive disorder. An admission resident assessment for Res #54 was completed on 09/15/23 which documented the resident received nutrition through a PEG tube, had an indwelling urinary catheter, and required extensive assistance with ADL's. A comprehensive care plan for Res #54 was not developed. On 10/23/23 at 11:45 a.m., the MDS Coordinator reported there was no comprehensive care plan for Res #54. The MDS Coordinator reported the comprehensive care plan was late and should have been done.

Based on record review and interview, the facility failed to complete a discharge summary for two (#58 and #59) of two closed records reviewed. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: 1. Res #58 was admitted to the facility on [DATE] and had diagnoses which included right femur fracture, heart failure, and hypothyroidism. An admission assessment, dated [DATE], documented the resident was moderately cognitively impaired and required extensive assistance with most ADLs. A progress note, dated [DATE] at 11:42 a.m., documented the resident was found unresponsive in wheelchair and CPR was immediately initiated. The note documented the resident was transported via EMS to the hospital. A progress noted, dated [DATE] at 1:17 p.m., documented the resident was deceased at the hospital. There was no documentation of a discharge summary found in the medical record. 2. Res#59 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, schizophrenia, dementia, and depressive disorders. A nurse's note, dated [DATE] at 11:30 p.m., documented the resident was yelling in pain, pointing to the left hip. The note documented the resident stated they was hurting real bad and had been medicated recently. The note documented the resident was sent to the hospital. The resident was admitted to the hospital. The clinical record contained no discharge summary. On [DATE] at 10:20 a.m., the DON stated a discharge summary for Res #58 and Res #59 was not completed but should have been.

Based on observation, record review, and interview, the facility failed to provide nail care for a resident who was unable to carry out activities of daily living for one (#35) of 25 sampled residents. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: Res #35 was admitted to the facility with diagnoses of anorexia, cerebrovascular disease, dysphagia, and cerebral infarction. An annual assessment, dated 07/17/23, documented the resident required extensive assist with all ADL's. On 10/18/23 at 10:07 a.m., Rest #35 was observed resting in bed with eyes open. The resident's fingernails were observed to be long and starting to curve back under, nail polish was observed to missing from most of the nails. On 10/24/23 at 9:50 am the resident's fingernails were observed to be long and starting to curve back under, fingernail polish was observed to be missing from most of the nails. On 10/24/23 at 9:54 a.m., CNA #1 was asked who was responsible for the resident's nail care. CNA #1 reported another CNA was. On 10/24/23 at 9:57 a.m., LPN #1 reported the CNA's are responsible for nail care as long as the resident was not a diabetic. On 10/24/23 at 10:02 a.m., the DON reported the CNA's are responsible for the resident's nail care as long as they were not diabetic.

Based on record review and interview, the facility failed to implement a physician agreed upon pharmacist MRR recommendation for one (#31) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 61 residents resided in the facility. Findings: A policy with regard to timeliness of pharmacist recommendation and response, dated 07/01/19, documented the physician and/or director of nursing are requested to acknowledge and act upon recommendation within 30 calendar days of the consultant pharmacist's drug regimen review/recommendation. Res #31 had diagnoses which included heart failure, acquired absence of leg below the knee, and atherosclerotic heart disease. An admission assessment, dated 04/01/23, documented Res #31 was cognitively intact and required extensive assistance with most ADLs. A pharmacist MRR, dated 08/01/23, read in part, .Based on current CDC recommendations and new CMS recommendations for opioid use disorder, opioid doses greater than 50 MME/day, or an ordered combination of benzodiazepines and an opioid: Please consider adding the following order/protocol to this patient's medical record. Narcan nasal liquid 4 mg/0.1 ml for overdose .Administer one spray in one nostril one time. May repeat in alternating nostrils every 2-3 minutes until responsive or EMS arrives . The MRR documented the physician's agreement to the recommendation. The physician's response was undated. There was no documentation of physician ordered Narcan in Res #31's medical record. On 10/23/23 at 2:00 p.m., the DON stated the physician agreed MRR dated 08/01/23 for adding Narcan to the resident's medication regimen was never implemented but should have been per policy.

Based on interview, and record review, the facility failed to provide sufficient staff for 11 of 183 shifts reviewed. The administrator reported a census of 61 residents. Findings: A staffing schedule, dated February 2022, documented on 02/12/22 and 02/26/22, 10 of 11 required staff members were on duty, and on 02/27/22 eight of 11 required staff members were on duty. A staffing schedule, dated March 2022, documented on 03/03/22, 03/04, 03/06, 03/08, 03/16, 03/20, 03/27, 03/30/22, three of four required staff members were on duty. On 05/05/22 at 9:14 a.m., CNA #2 reported they had worked short handed. On 05/05/22 at 10:07 a.m., LPN #1 reported they had worked short staffed. On 05/05/22 at 10:44 a.m., the administrator reported in March 2022 there were eight night shifts with three staff members on duty, and in February 2022 day shift was short staffed on three shifts. The administrator reported in February 2022, there were two days with 10 staff and one day with eight staff. The administrator reported the shifts should have been fully staffed.

Based on observation and interview, the facility failed to ensure pureed diets were prepared in a sanitary manner for seven (#55, 41, 31, 59, 210, 35, and #44) of seven residents reviewed for a pureed diet. The Resident Census and Condition, dated 05/03/22, documented seven residents received a pureed diet. Findings: a. On 05/03/22, from 10:15 a.m. to 10:28 a.m, Cook #1, stirred pureed carrots with spatula and placed spatula onto unsanitized surface three consecutive times. b. On 05/03/22 at 10:28 a.m., Cook #1 touched their face mask, eye glasses, and shirt, then plated pureed food without performing hand hygiene. On 05/03/22 at 10:33 a.m., Cook #1 reported the spatula was placed on an unsanitized surface and hand hygiene wasn't performed prior to plating pureed food. On 05/03/22 at 10:35 a.m., the dietary manager and registered dietician reported the pureed food had been prepared in an unsanitary manner.

Based on record review and interview, the facility failed to ensure one (#20) of 61 residents had the right to receive visitors of the resident's choosing. The Resident Census and Conditions of Residents, dated 05/03/22, documented 61 residents resided in the facility. Findings: On 05/02/22 at 11:46 a.m., Res #20 reported FM #1 had been banned from visiting by the administrator since 04/22/22. A Resident/Patient Concern Report, dated 04/22/22, signed by the administrator, read in parts, .was yelling down the hall, someone better get down here and help my mother.continued to be beligerent, refused to come and talk about the situation . Stated Res #20 had the call light on for an hour. Staff was afraid to enter the room due to (FM #1's) behavior. LPN charge nurse called police due to FM#1's threatening behavior. Police came and FM #1 was banned from facility .called FM #2 to inform them what had happened. FM #2 said FM #1 tends to be a hot head. Encouraged FM #2 to come to me if they have any more concerns. On 05/03/22 at 10:44 a.m., during a phone interview, FM #2 reported they felt it would be safe for family FM #1 to visit Res #20. FM #2 reported FM #1 being banned from visiting Res #20 was detrimental to the resident. FM #1 reported they had not been contacted by the facility regarding the incident since 04/22/22. On 05/03/22 at 2:40 p.m., the administrator reported on 04/22/22 she was in her office and heard FM #1 yelling and cursing at the staff. She reported she left her office to try to assist in the situation. The administrator reported the LPN on duty phoned the police because the staff was afraid of FM #1. The administrator reported the police asked if she wanted FM #1 banned from the facility and she agreed. The administrator reported FM #1 had not visited Res #20 since 04/22/22. The administrator reported she had not followed up with Res #20 or the family since the incident. On 05/03/22 at 4:00 p.m., the administrator reported the facility did not have a policy for visitor restriction.

On [DATE], an Immediate Jeopardy situation was determined to exist in regard to the facility's failure to follow their 'Emergency Care', policy and procedure to initiate CPR when a resident was found to be without V/S and had a full code status. The facility failed to ensure all direct care staff had knowledge of the facility's procedure for identifying residents CPR status. The facility failed to ensure their policy and procedure had been revised to address current CPR status identification utilized by the facility. On [DATE] at 4:00 p.m., the Oklahoma State Department of Health was notified and the Immediate Jeopardy situation was verified. At 4:15 p.m., the Administrator and the DON were informed of the IJ situation. On [DATE] at 5:00 p.m., a plan of removal was accepted. The plan of removal documented the following: "Plan of correction: 1. All residents will be identified as either a DNR or Full Code. This will be posted on the inside of the residents' room closet door. 2. The card will state which one the resident requested. (DNR or FULL CODE) 3. Each staff will be immediately educated on this procedure until all personnel giving care have been made aware of this system. 4. The MDS Coordinator will be in charge of identifying what option the resident requests and providing information to all staff as the policy states. 5. Director of Nurses will monitor on a weekly basis for current residents and on an individual basis as new residents are admitted . 6. Charge Nurses will be educated immediately on this system of identification and the need to start CPR on any resident who is full code. This teaching will be done either in person or by phone. Charge Nurses will not be allowed to work until they have been made aware of this system. DNR/FULL CODE POLICY: All residents will be identified as to choice of code status upon admission and as needed. The resident's choice will be posted inside their closet door where staff can have easy access to their code status. All residents who have requested full code status will have CPR initiated immediately if found with no Blood Pressure or Pulse." The facility provided an 'Inservice Training Report', dated [DATE]. The inservice documented, "Educated on new policy of identification of DNR or full code status. Charge nurses educated to start CPR on any resident found c no BP/Pulse immediately." The last direct care staff had been inserviced on [DATE] at 10:25 p.m. The IJ was removed as of [DATE] at 10:25 p.m., after all direct care staff had been inserviced. The deficiency remained at a level of actual harm that was not immediate jeopardy, and was isolated. On [DATE], staff were interviewed regarding knowledge of issues addressed in the inservice. The staff were able to verbalize knowledge related to CPR status determination. Random resident rooms were observed to have their CPR status [REDACTED]. Based on record review, observation and staff interview, it was determined the facility failed to: a) Follow their policy and procedure by not initiating CPR when a resident had a full code status had been found without vital signs for one (#3) of one sampled deceased resident. The resident expired without CPR being administered. This had the potential to affect all 75 residents. b) Ensure all direct care staff had knowledge of the facility's current method of determining CPR status. This had the potential to affect all 75 residents. c) Ensure the facility's policy and procedure had been revised to address the current method of CPR status determination. This had the potential to affect all 75 residents. d) Ensure treatment had been obtained and provided in a timely manner, when complications related to an indwelling urinary catheter had occurred for one (#1) of one sampled resident with an indwelling urinary catheter. This caused harm to the resident by not obtaining and providing treatment in a timely manner, when bleeding and swelling had first been observed on [DATE]. Findings: The facility's policy/procedure titled 'Cardiopulmonary Resuscitation (CPR)' documented: "Basic Responsibility: Licensed nurse and any person in the facility capable of performing CPR Purpose: To ventilate and establish circulation on a resident with absences of respirations and pulse..." The facility's policy and procedure titled, "Emergency Care, General Guidelines for: Basic Responsibility: Licensed Nurse Purpose: 1. To provide emergency care to a resident in need of urgent service. 2. To prevent complications. Equipment: 1. Emergency telephone listing. 2. Medical record. 3. Emergency supplies as needed. Procedure: 1. Observe condition of all residents by making rounds as soon as nursing report is completed. 2. If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as necessary. 3. If attending physician is not available, call alternate physician. (If not available, contact physician(s) responsible for emergency care of residents, or arrange transportation to an appropriate facility for emergency care.) 4. Notify resident's family or responsible party of resident's condition. 5. If resident/family requests it, contact clergy of resident's religious denomination. 6. Always take report and record vital signs when a resident's condition has changed. 7. If a resident expires, initiate CPR unless ordered otherwise. Call paramedics. Call the attending physician or resident's family or responsible party, as appropriate. 8. Record details and exact time of condition change of resident, initiation of emergency procedure and resident's response to emergency care. 9. Record exact time physician was called and exact time physician responded to call. 10. Follow facility policy for notification of supervisors regarding resident's condition change, expiration or transfer. 11. Follow the facility procedure to notify the resident's representative. ..." 1. Resident #3 had [DIAGNOSES REDACTED]. A 14 day assessment, dated [DATE], documented the resident had moderately impaired cognition, required extensive assistance with bed mobility, transferring between surfaces, dressing, was not ambulatory, was frequently incontinent of bowel and always incontinent of bladder. On [DATE] at 9:53 p.m., a nurse's note documented, "Resident resting in bed ou closed, easily aroused by verbal stimuli. Resp even and unlabored. Skin w/d to touch. Incontinent of b&b, however, clean and dry at this time. cl and water within easy reach." On [DATE] at 1:37 a.m., a nurse's note documented, "Resting quietly c/l in reach no s/s of distress noted. Assist with ADL's." At 5:47 a.m., a nurse's note documented, "Res with no pulse, resp & pupils fixed. Dr. (Name deleted) notified and ordered to release res to funeral home. Notified res son & wants to come to the nh before funeral home notified." At 6:45 a.m., a nurse's note documented, "...funeral home here to pick up resident body at this time." The resident's care plan and current physician's orders [REDACTED]. The resident's medical record did not contain documentation of CPR being performed for the resident. On [DATE] at 9:45 a.m., the DON was interviewed. The DON was asked the resident's CPR status. The DON reported she thought the resident had been a DNR. The DON was asked if the resident had received CPR when she was discovered to be without vital signs. She reported she did not think so, because the staff would have told her about doing CPR. She further reported the staff would have told her when they reported the resident had expired. At 10:00 a.m., an attempt was made to contact LPN #1 who had been the charge nurse when the resident had been found with no vital signs. The LPN could not be reached. At 10:10 a.m., CNA #1 was contacted via telephone. The CNA had been assigned to provide care to the resident on the evening she expired. The CNA reported she made rounds at 3:30 a.m. She reported she had been in the resident's room at 4:00 a.m. The CNA reported the resident had been sweaty, but was not wet at that time. The CNA reported, "She told me, I love you." The CNA reported she had been making rounds at 5:00 a.m. At that time, the resident's roommate had turned on her call light, needing help with a bedpan. The CNA reported she looked around the privacy curtain and noticed the resident had "passed". She reported she then approached the resident and did a "sternal rub" and the resident did not respond. The CNA reported she then got the LPN charge nurse and the nurse did her "procedure" on the resident. The CNA was asked what the procedure had been. The CNA reported the procedure the LPN had performed was checking the resident's vital signs. The CNA was then asked if she knew the resident's CPR status. She reported the resident had been a DNR and no CPR had been done. The CNA was asked how did she determined which residents were full codes and which were DNRs. The CNA stated, "You'll have to ask my supervisor." On [DATE] at 11:15 a.m., interviews were conducted with direct care staff. Ten CNAs were interviewed and verbalized the facility system of the heart on the door as meaning full code. Three LPNs were interviewed and verbalized the facility system of the heart on the door as meaning full code. Two CMAs were interviewed and verbalized the facility system of the heart on the door as meaning full code. At 11:20 a.m., the DON was asked how the staff determined the CPR status for the residents. The DON reported there were heart stickers on the residents' doors by their names, that indicated to the staff the resident's CPR status. The DON then stated, "I am not sure if the heart means DNR or full code. I will have to find out." The DON then left and returned after talking to another nurse and reported the heart on the door meant full code. At 2:35 p.m., resident #3's physician was reached via phone call. The physician made no indication of the resident being a DNR. The physician reported the facility staff had contacted her between 5:00 and 6:00 a.m., and told her the resident was cold and her pupils were fixed and dilated. The physician reported at that time, she told them not to do CPR. At 3:00 p.m., phone calls were made to direct care staff for the night shift. Three CNAs were interviewed regarding the CPR status for residents. One of the three were able to verbalize the facility's system of the hearts on the residents' doors to indicate full code. Two of the CNAs had no knowledge of the facility's system. At 3:10 p.m., direct care staff for the evening shift were interviewed as followed: Five CNAs and two LPNs were interviewed and verbalized the facility system of the heart on the door as meaning full code. At 3:40 p.m., the DON was interviewed. The DON was asked when the facility had implemented the system of placing the hearts on the residents' doors to designate full code. The DON reported they had tried the system about two years ago and it had been unsuccessful. She reported they had begun trying the system for the second time, four months ago. The DON was then asked if the facility's policy and procedure had been revised to address the implementation of the heart system for identification of CPR status. The DON reported the policy and procedure had not been revised. 2. Resident #1 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "...I have an indwelling F/C for DX urine retention...Intervention... monitor /record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns..." A quarterly assessment, dated [DATE], documented the resident had moderately impaired cognition, did not have any behaviors, required extensive assistance with bed mobility, transferring between surfaces, all ADL care, had an indwelling urinary catheter and was frequently incontinent of bowel. A nurse's note, dated [DATE] at 7:28 p.m., documented, "CNA noted blood at catheter insertion site. Nurse noted residents foreskin pulled back and the meatus and first part of the shaft were swollen. Insertion site had moderate amount of bleeding. Possibly from getting tugged on on when pants were being pulled off while assisting resident to bed. Pericare given and foreskin pulled back over penis. Cath strap placed on leg to secure catheter. Posterior area of meatus has a small split that is healed. Resident c/o tenderness to touch. PRN Tylenol given. Dr. (Name deleted physician) was faxed on this." LPN #2 was asked at that time if she could locate the fax documented as sent on [DATE], to the physician regarding the resident's problem. A nurse's note, dated [DATE] at 10:25 p.m., documented, "Nurse assessed, Scant amount of [MEDICAL CONDITION] noted to meatus, pericare given, foreskin pulled over penis. Odor from peri area noted. Catheter strap securing tubing. No blood in tubing or bag. No blood noted on meatus." There was no documentation in the medical record the physician had been informed of the odor from the resident's peri area. A nurse's note, dated [DATE] at 1:12 p.m., documented, "Resident has open area noted to posterior meatus. There is a light yellow area that has a spot on it...smaller than a dime and it is red around this area. No drainage noted. Tender to touch. Nurse cleansed with NS, applied TAO, Dr. (physician name deleted ) was faxed on this..." The nurse had treated the penis before obtaining a physician's orders [REDACTED]. A fax cover sheet, dated [DATE] at 2:09 p.m., documented, "Residents penis has an open area on his posterior meatus that is round and light yellow in color and also has a dark area on it, approx yellow area is smaller than a dime. No drainage, noted @ this time. Around the yellow area is red, area is also tender to touch. I cleansed this area c NS and applied TAO. Swelling is down from last week. May we cont c the tx as noted above daily, until healed, please advise." The fax had been sent to the physician on [DATE], which was a holiday. On [DATE], a day after the fax had been sent on a holiday to the physician's office, the physician had replied, "Yes, please." A nurse's note, dated [DATE] at 2:42 p.m., documented, "Residents penis enlarged at this time with unusual swelling. Penis also red at this time. F/C intact and draining clear yellow urine to gravity. POA consents to send to ER." A progress note, dated [DATE] at 9:13 a.m., documented the resident was going home from the hospital with Hospice services. On [DATE] at 10:50 a.m., the DON was interviewed. The DON was asked if it was acceptable to send faxes to the physician's office after hours and on holidays when the office was closed. The DON reported it is a usual procedure to fax doctors unless it is something "major", major meaning "life threatening." The DON was then asked if it was acceptable for the above medical issues. She reported the nurses should have contacted the physician by phone due to the office being closed. On [DATE] at 3:30 p.m., the DON was asked if the resident's POA had been been informed of the above medical issues. The DON reported the family was not notified of the blood, at the catheter insertion site or of the swollen penis. The DON reported the resident's friend was here everyday and knew, but the POA and family were not informed.. On [DATE] at 9:50 a.m., LPN #2 was asked if she had located the fax confirmation form documented as faxed to the physician on [DATE], regarding the blood at the catheter insertion site and the swelling of the penis. LPN #2 reported she was not able to locate the confirmation fax form.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure the physician was informed, in a timely manner, when blood had first been observed on 12/26/13, coming from an indwelling urinary catheter insertion site with noted swelling of the penis head and upper shaft for one (#1) of one sampled male resident with an indwelling urinary catheter. This caused actual harm to the resident by not ensuring treatment had been obtained in a timely manner. The resident had to be sent to the hospital on [DATE], related to complications involving the indwelling urinary catheter. b) Ensure the POA was informed, in a timely manner, when an incident/accident occurred which resulted in a fracture of a shoulder for one (#2) of three sampled residents who had experienced incidents. This had the potential to affect 39 residents who had experienced an incident/accident during the month of December 2013, per the DON. Findings: 1. Resident #1 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 8/20/13, documented, "...I have an indwelling F/C for DX urine retention...Intervention... monitor /record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns..." A quarterly assessment, dated 11/27/13, documented the resident had moderately impaired cognition, did not have any behaviors, required extensive assistance with bed mobility, transferring between surfaces, all ADL care, had an indwelling urinary catheter and was frequently incontinent of bowel. A nurse's note, dated 12/26/13 at 7:28 p.m., documented, "CNA noted blood at catheter insertion site. Nurse noted residents foreskin pulled back and the meatus and first part of the shaft were swollen. Insertion site had moderate amount of bleeding. Possibly from getting tugged on on when pants were being pulled off while assisting resident to bed. Pericare given and foreskin pulled back over penis. Cath strap placed on leg to secure catheter. Posterior area of meatus has a small split that is healed. Resident c/o tenderness to touch. PRN Tylenol given. Dr. (Name deleted physician) was faxed on this." LPN #2 was asked at that time if she could locate the fax documented as sent on 12/26/13, to the physician regarding the resident's problem. A nurse's note, dated 12/26/13 at 10:25 p.m., documented, "Nurse assessed, Scant amount of [MEDICAL CONDITION] noted to meatus, pericare given, foreskin pulled over penis. Odor from peri area noted. Catheter strap securing tubing. No blood in tubing or bag. No blood noted on meatus." There was no documentation in the medical record the physician had been informed of the odor from the resident's peri area. A nurse's note, dated 01/01/14 at 1:12 p.m., documented, "Resident has open area noted to posterior meatus. There is a light yellow area that has a spot on it...smaller than a dime and it is red around this area. No drainage noted. Tender to touch. Nurse cleansed with NS, applied TAO, Dr. (physician name deleted ) was faxed on this..." The nurse had treated the penis before obtaining a physician's orders [REDACTED]. A fax cover sheet, dated 01/01/14 at 2:09 p.m., documented, "Residents penis has an open area on his posterior meatus that is round and light yellow in color and also has a dark area on it, approx yellow area is smaller than a dime. No drainage, noted @ this time. Around the yellow area is red, area is also tender to touch. I cleansed this area c NS and applied TAO. Swelling is down from last week. May we cont c the tx as noted above daily, until healed, please advise." The fax had been sent to the physician on 01/01/14, which was a holiday. On 01/02/14, a day after the fax had been sent on a holiday to the physician's office, the physician had replied, "Yes, please." A nurse's note, dated 01/28/14 at 2:42 p.m., documented, "Residents penis enlarged at this time with unusual swelling. Penis also red at this time. F/C intact and draining clear yellow urine to gravity. POA consents to send to ER." A progress note, dated 02/04/14 at 9:13 a.m., documented the resident was going home from the hospital with Hospice services. On 02/05/14 at 10:50 a.m., the DON was interviewed. The DON was asked if it was acceptable to send faxes to the physician's office after hours and on holidays when the office was closed. The DON reported it is a usual procedure to fax doctors unless it is something "major", major meaning "life threatening." The DON was then asked if it was acceptable for the above medical issues. She reported the nurses should have contacted the physician by phone due to the office being closed. On 2/5/14 at 3:30 p.m., the DON was asked if the resident's POA had been been informed of the above medical issues. The DON reported the family was not notified of the blood, at the catheter insertion site or of the swollen penis. The DON reported the resident's friend was here everyday and knew, but the POA and family were not informed.. On 02/06/14 at 9:50 a.m., LPN #2 was asked if she had located the fax confirmation form dated 12/26/13, documented as faxed in the nurse's note to the physician regarding the blood at catheter insertion site and the swelling of the penis. LPN #2 reported she was not able to locate the confirmation fax form. 2. Resident #2's [DIAGNOSES REDACTED]. An annual assessment, dated 08/24/13, documented the resident had unclear speech, had severely impaired cognition, was totally dependent of staff for bed mobility, transferring between surfaces, bathing and was always incontinent of bowel and bladder. On 12/19/13 at 5:11 p.m., a nurse's note documented, "Resident in process of transfer from bed to shower chair, resident pulled away from CNA. CNA heard pop in left shoulder, no swelling or discoloration upon assessment, no change in ROM, resident not showing signs of pain at this time, will continue to monitor." At 6:00 p.m., a telephone physician's orders [REDACTED]." On 12/20/13 at 12:35 a.m., a nurse's note documented, "Mobile x-ray here awaiting results. Resident resting quietly no s/s distress." The x-ray results documented, "Mildly displaced [MEDICAL CONDITION] humeral shaft and humeral neck." At 6:46 a.m., a physician's notification form documented, "X ray result faxed to (Name deleted) physician." At 12:44 p.m., a nurse's note documented, "(Name deleted) POA notified of fx shoulder. States 'I will be out to see her later.' Thanked this nurse for letting her know." The POA had not been notified until the day after the incident. On 02/04/14 at 12:15 p.m., the resident was observed lying in her bed, being spoon-fed the lunch meal by a CNA. At 3:30 p.m., the DON was interviewed regarding incident. She reported the nurse had been given a written warning for not calling the resident's POA at the time of the incident.

Based on record review, observation and staff interview, it was determined the facility failed to re-assess and treat a resident who complained of continuous pain after a fall for one (#3) of 10 sampled residents identified with pain. This failed practice resulted in harm to the resident. This had the potential to affect 77 residents identified by the 'Resident Census And Conditions Of Residents' report as being on a pain management program. Findings: 1. The admission assessment, dated 07/20/11, identified resident #3 as not experiencing pain. The resident was on PRN and routine pain medication. The December 2011, physician's orders [REDACTED]." No other pain medications had been prescribed at that time. On 12/04/11, at 7:30 a.m., an incident/accident report documented the resident slid out of her W/C and hit the floor on her (R) side. There were no apparent injuries documented. On 12/05/11, at 7:20 a.m., a nurse's note documented the resident was experiencing pain from her upper (L) groin and thigh area to her toes, and was refusing to move her lower extremities. When the resident had been moved she cried out in pain. The physician had been faxed to get an order for [REDACTED]. At 10:30 a.m., a nurse's note documented the physician faxed the facility an order for [REDACTED]. At 11:30 a.m., a nurse's note documented, "X-ray tech here..." At 8:00 p.m., a nurse's note documented the resident was complaining of pain to her (L) hip and (L) leg. The X-ray results were not back at that time. The routine 9:00 p.m., Tylenol was administered per the December MAR. On 12/06/11, at 8:30 a.m., a nurse's note documented the resident was complaining of pain to her (L) upper leg. A physician's progress note, dated 12/06/11, documented, "...fell out of her chair last week. Obtained X-ray - they were negative. No fracture...having pain in her (L) hip but no evidence of a break..." A physician's telephone order dated 12/06/11, documented, "[MEDICATION NAME] 100mg 1 PO BID x 7 days for a UTI." The lab results for the C&S, dated 12/07/11, documented the resident had a UTI from Escherichia coli. On 12/07/11, at 11:10 p.m., a nurse's note documented the resident complained of tenderness in her pelvic area with palpitation. The December MAR indicated [REDACTED]. On 12/08/11, at 11:00 p.m., a nurse's note documented the resident was complaining of pain on palpation, in her (L) pelvic region. The December MAR indicated [REDACTED]. On 12/09/11, at 7:40 a.m., a nurse's note documented the resident was experiencing generalized pain. The December MAR indicated [REDACTED]. At 5:45 p.m., a nurse's note documented the resident complained of, 'severe pain in lower abdomen and lower back'. The note also documented the resident had not eaten more than 20% at each meal that day. There was no documentation to show the resident was assessed for the severe pain. On 12/10/11, at 7:30 a.m., a nurse's note documented the resident was complaining of lower back pain. There was no documentation to show the resident was assessed for the pain. On 12/12/11, at 11:45 a.m., a nurse's note documented the resident complained of pain in her (L) leg and (L) hip. An X-ray was ordered by the physician for both hips and pelvis due to the resident's continued complaints of pain. The resident continued to complain of pain after the negative x-ray of 12/06/11. The facility failed to re-assess the resident for her continued complaints of pain until 12/12/11, when the physician ordered another x-ray and the source of the pain was identified. On 12/13/11, the X-ray results came back identifying a positive [MEDICAL CONDITION]. The physician ordered the resident to be sent to the ER for an evaluation of the fracture. The resident was admitted to the hospital for repair of the [MEDICAL CONDITION]. On 12/16/11, the resident was readmitted back to the nursing home from the hospital to the skilled unit. physician's orders [REDACTED].**Not to exceed 4gm/day. [MEDICATION NAME] 5mg/325 mg 2 PO Q 6 hours PRN DX: Severe Pain **Not to exceed 4gm/day." The Tylenol TID routinely administered and the Tylenol PRN had been D/C'd. A 5 day quarterly assessment, dated 12/22/11, identified the resident with a moderate cognition deficit, short and long term memory loss, and had frequent moderate pain, and was on a PRN pain medication. The current care plan documented the resident had pain from a recent L [MEDICAL CONDITION], the staff were to administer pain medication as ordered and notify her physician if her pain was not relieved by medication. On 02/29/12, at 5:15 p.m., the ADON was asked why the physician ordered [MEDICATION NAME] instead of another pain medication. The ADON said the physician felt like the resident's pain could be caused by a UTI since the hip and leg X-rays came back negative for a fracture. The ADON was then shown the December MAR. She was shown where the PRN Tylenol had never been given to the resident who continued to complain of pain. She was asked what should have been done. She said the nurses should have given the PRN Tylenol as ordered by the physician and if that did not work they should have called the physician for a stronger pain medication.