Every finding on record at Warr Acres Nursing Center

Based on observation, record review, and interview, the facility failed to ensure the floor of the walk in freezer was clean and free of debris for 1 of 1 freezers observed. The administrator identified 56 residents received their food from the kitchen. Findings: On 04/21/25 at 11:31 a.m., the walk-in freezer was observed. The left side, on the floor at the entrance of the freezer was a small clear bowl with a dried orange substance inside. There was a moderate to large amount of brown and orange debris on the floor and at the edge where the floor and the wall meet. To the right, on the floor under the metal rack, were three food items and a bag of unidentified substance. There was also moderate amount of brown and orange debris on the floor and at the edge where the floor and the wall meet. An undated policy Sanitation Inspection, read in part, Daily: Food service staff shall inspect refrigerators/coolers, freezers. On 04/21/25 at 11:32 a.m., the certified dietary manager stated they were the one to clean and they cleaned it last Monday. On 04/22/25 at 1:50 p.m., the administrator stated the freezer should be cleaned weekly other than wiping out for spills.

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were without debris particles for 1 (#2) of 1 sampled resident reviewed for respiratory services. The DON identified five residents received oxygen in the facility. Findings: On 04/21/25 at 12:58 p.m., Resident #2's oxygen concentrator filter was observed to have moderate amount of dust particles both within the filter and hanging off of the filter. An undated policy Oxygen Concentrator, read in part, Follow manufacturer recommendations for the frequency of cleaning filters. A care plan, revised 06/24/24 showed the resident used oxygen. A physicians, order dated 08/18/24 showed to change oxygen tubing weekly on Sunday night and clean oxygen concentrator filter under running water and pat dry. A significant change resident assessment, dated 02/26/25, showed the resident used oxygen. On 04/21/25 at 1:53 p.m., the DON stated they would have to look at the policy and procedure for the cleaning of the filter. The stated they expect their staff to look at the filters on the concentrators and all equipment to keep them clean. The DON was shown the concentrator filter. They stated, that was a lot of dust, not much air was going to get through there.

Based on observation, record review, and interview, the facility failed to ensure a resident assessment was accurately coded for 1 (#2) of 15 sampled residents reviewed for resident assessments. The DON identified four residents with catheters resided in the facility. Findings: On 04/21/25 at 1:00 p.m., Resident #2 was observed in bed and no catheter was observed. An undated policy titled Conducting an Accurate Resident Assessment, read in part, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies residents strengths to maintain or improve medical status, functional abilities, and psychosocial status. Resident #2's order summary, dated 06/03/22 through 04/23/25, showed diagnoses which included hypokalemia, right below the knee amputation, and major depressive disorder. The MDS indicators (information generated from the MDS of a residents condition) showed catheter. A significant change resident assessment, dated 02/26/25, showed H0100 A section of the MDS marked Yes. It indicated an indwelling catheter had been or was in place. Per the guidelines in the resident assessment instrument used for coding the MDS showed there was a seven day look back period to capture a resident with a catheter. There was no documentation in the progress notes of a catheter for the month of February 2025. A resident care plan, dated 03/11/25, did not show a catheter. Resident #2's order summary for active and discontinued orders from admission to current were reviewed and did not show orders for catheter placement. On 04/21/25 at 1:01 p.m., Resident #2 stated they never had a catheter of any type. On 04/23/25 at 11:04 a.m., certified nurse aide #1 stated Resident #2 was incontinent and had not had a catheter in pace. On 04/23/25 at 11:14 a.m., licensed practical nurse #1 stated Resident #2 was incontinent of urine and had not had a catheter in place. On 04/23/25 at 11:17 a.m., the DON stated they determine the coding for a catheter on the MDS by going to the resident and assessing them to see their needs. The DON stated Resident #2 never had a catheter and did not know how it was coded that way. The DON stated they saw the catheter marked on the matrix (a facility specific document that shows what residents have certain diagnoses that need monitoring) when they were gathering the documents for survey. The DON stated the MDS was not accurate.

Based on observation, record review, and interview, the facility failed to ensure medications were secure/locked when not attended for 1 (Hall 300) of 2 medication carts observed. The administrator identified 57 residents resided in the facility. Findings: On 04/23/25 at 11:06 a.m., a medication cart was observed unlocked and unattended on hall 300 next to room [ROOM NUMBER]. An undated policy Medication Storage, read in part, All drug and biologicals will be stored in a locked compartment .During medication pass, medication must be under the direct observation of the person administering medication or locked in the medication storage area/cart. On 04/23/25 at 11:08 a.m., CMA #1 returned to the cart. They stated the cart was not locked. CMA #1 stated the cart was to be locked when they walked away.

Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 27 opportunities were observed with three errors. The total medication error rate was 11.11%. The Executive Director identified 50 residents resided in the facility. Findings: Resident #7 had diagnoses which included Alzheimer's disease, anxiety disorder, hypertension, and GERD. A Physician's Order, dated 01/14/22, documented may crush tablets and/or open capsules unless contraindicated. A Physician's Order, dated 04/17/23, documented suction oropharynx every one hour as needed for aspiration. A Physician's Order, dated 06/14/23, documented regular diet, pureed texture, nectar (mildly thick) consistency, related to Alzheimer's disease. A Physician's Order, dated 09/01/23, documented Resident #7 was to receive omeprazole 20 mg delayed release one capsule by mouth daily for GERD. On 01/04/24 at 9:13 a.m., RN #1 was observed opening olanzapine 5 mg tablet from Resident #47's medication card and put it in their hand to administer to Resident #7. RN #1 was asked to verify the medication they popped into their hand. RN #1 reviewed the medication card and disposed of the medication they had just popped. On 01/04/24 at 9:15 a.m., RN #1 was observed opening levothyroxine 175 mg tablet from Resident #24's medication card and put it in their hand to administer to Resident #7. RN #1 was asked to verify the medication they popped into their hand. RN #1 reviewed the medication card and disposed of the medication they had just popped. On 01/04/24 at 9:17 a.m., RN #1 was observed crushing Resident #7's medications including the omeprazole capsule while still intact and administered it to the Resident by mouth in oatmeal. On 01/04/24 at 9:20 a.m., Resident #7 pushed half of the crushed omeprazole capsule out of their mouth and RN #1 picked it up and disposed of it. On 01/04/24 at 10:07 a.m., RN #1 stated they were to read the medication label and make sure it matched the order before opening the medication to administer to the resident. They stated they got nervous during medication administration observations. On 01/04/24 at 10:10 a.m., RN #1 stated some of Resident #7's capsules could be crushed, and the resident could spit out the capsule after they ate the medication inside it. On 01/04/24 at 10:12 a.m., RN #1 stated residents who were given capsules with swallowing difficulties might choke and aspirate or keep it in their mouth and eventually spit it out. On 01/04/24 at 12:10 p.m., the DON stated they could not see Resident #7 being able to swallow a capsule. On 01/04/24 at 12:15 p.m., the ADON stated the staff were supposed to read the medication administration record and ensure the order matched the medication label from the pharmacy.

Based on observation, record review and interview, the facility failed to ensure blood pressure and pulse were monitored as ordered for three (#7, 23, and #36) of six residents observed during medication administration. The Executive Director identified 50 residents resided in the facility. Findings: 1. Resident #7 had diagnoses which included Alzheimer's disease, anxiety disorder, hypertension, and GERD. A Physician Order, dated 09/01/22, documented lanoxin 125 mcg give one tablet by mouth one time a day for Afib, hold if pulse was below 60. On 01/04/24 at 9:05 a.m., RN #1 was observed typing the blood pressure and pulse of Resident #7 into the Resident's medication administration record without being observed taking the blood pressure and pulse, or reviewing any documentation for the information. 2. Resident #23 had diagnoses which included essetial hypertention. A Physician Order, dated 08/16/23, documented cozaar 50 mg give one tablet by mouth one time a day related to essential hypertension. Notify physician if the systolic was greater than 145 or less than 105 or diastolic was greater than 90 or less than 65. Notify the physician if pulse was greater than 96 or less than 56. On 01/04/24 at 8:43 a.m., RN #1 was observed typing the blood pressure and pulse of Resident #23 into the Resident's medication administration record without being observed taking the blood pressure and pulse, or reviewing any documentation for the information. 3. Resident #36 had diagnoses which included essential hypertension. A Physician Order, dated 10/15/23, documented lisinopril 10 mg give one tablet by mouth one time a day related to essential hypertension. Notify physician if the systolic was greater than 145 or less than 105 or diastolic was greater than 90 or less than 65. Notify the physician if pulse was greater than 96 or less than 56. On 01/04/24 at 8:52 a.m., RN #1 was observed typing the blood pressure and pulse of Resident #36 into the Resident's medication administration record without being observed taking the blood pressure and pulse, or reviewing any documentation for the information. On 01/04/24 at 10:04 a.m. RN #1 stated they checked the blood pressure and pulse of Residents #7, #23, and #36 around 6:35 a.m. They stated they memorized them because the residents had heart problems. On 01/04/24 at 10:15 a.m., RN #1 stated they usually memorized the blood pressures or wrote them on their palm or a piece of paper if they knew they would forget. On 01/04/24 at 12:14 p.m., the ADON stated staff were supposed to assess vital signs right before administering medications.

Based on record review and interview, the facility failed to allow the resident council to meet without staff present. The Executive Director identified 50 residents resided in the facility. Findings: Documents titled Resident Council Minutes identified staff as present for the following dates: 12/06/22, 01/26/23, 03/22/23, 04/24/23, 05/23/23, 06/08/23, 07/18/23, 08/24/23, 09/13/23, 10/10/23, 11/15/23, and 12/12/23. On 01/03/24 at 2:46 p.m., the Resident Council Representative stated they had been told a staff member had to be present at all council meetings. On 01/03/24 at 3:03 p.m., the Activities Director stated the facility wanted a staff member present at all council meetings. On 01/04/24 at 3:01 p.m., the Executive Director stated the Resident Council had never requested to have a meeting without staff present. The Executive Director stated staff was present to maintain order during the meetings.

Based on observation, record review and interview, the facility failed to ensure: a. the call light was in reach for two (#2 and #41) of 24 sampled residents observed during initial pool; and b. a resident's bed was positioned to allow them to watch TV comfortably for one (#41) of three sampled residents reviewed for accommodation of needs. The Executive Director identified 50 residents resided in the facility. Findings: A Facility Accommodation of Needs policy, dated 02/23, read in part, .The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom .Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible . The Call Lights: Accessibility and Timely Response policy, dated 2023, read in part, .Staff will ensure the call light is within reach of resident and secured, as needed . 1. Resident #2 had diagnoses which included muscle weakness and conversion disorder with seizures or convulsions. Resident #2's quarterly resident assessment, dated 12/11/23, documented Resident #2 was cognitively intact and dependent on staff for activities of daily living. On 01/02/24 at 2:01 p.m., Resident #2 stated they used their call light to call for help. They pointed to the call light cable from the wall and stated they could not see it. The call light was observed on the floor by the dresser out of Resident #2's reach. On 01/02/24 at 2:14 p.m., RN #3 came in to check on the resident. They did not put the call light in reach prior to leaving Resident #2's room. On 01/02/24 at 2:16 p.m., RN #3 stated Resident #2 was able to use their call light. They stated the call light was not in reach of Resident #2. RN #3 placed the call light within reach of Resident #2. 2. Resident #41 had diagnoses which included personal history of transient ischemic attack and transient paralysis. On 01/02/24 at 2:19 p.m., Resident #41 stated they were waiting for staff to change them. Resident #41 was observed moving their wheelchair to the foot of their bed looking for their call light. The call light was not located by the resident. On 01/02/24 at 2:25 p.m., RN #2 entered the room and asked Resident #41 where their call light was. RN #2 looked over the bed, moved the curtain, then pulled the call light cord from the end of the bed around the privacy curtain and placed it on the resident's bed. RN #2 stated the resident was not able to get out of bed on their own and the call light had not been in reach of Resident #41. RN #2 stated the call light was actually up under the blankets. On 01/02/24 at 2:53 p.m., Resident #41 stated they could not see their TV ok. They stated, I twist my neck to see it. They stated their family stated no wonder their neck hurt because they had to twist it to see the TV. They stated when Resident #13 was willing to pull their curtain, they could see Resident #13's TV, but they couldn't see their own. Resident #41 stated their family had complained about the location of the TV and bed. Resident #41's left side of bed was observed placed against the wall. The TV was observed across the room at approximately a 90 degree angle from the head of the resident's bed. The resident would have to turn their head completely to the right side to view the TV. On 01/23/24 at 11:14 a.m., LPN #1 stated the facility treated each resident as this was their home. They stated staff tried to accommodate each resident's needs. On 01/23/24 at 11:15 a.m., LPN #1 stated how a resident's room was set up depended on the situation. They stated Resident #41's roommate Resident #13 had a walker. They stated it was hard for Resident #13 to maneuver their walker around Resident #41's bed when it was turned the other way towards the TV. They stated they did whatever was easier for the residents. On 01/23/24 at 11:16 a.m., LPN #1 stated Resident #41's bed used to be facing the TV. On 01/23/24 at 11:17 a.m., LPN #1 stated Resident #41's family had complained about the room set up. LPN #1 stated they explained to the family that they didn't want Resident #13 to fall because they couldn't get around Resident #41's bed. LPN #1 stated the family member had come in at times and rearranged the room themselves, but staff would go in and put it back because it was too crowded. On 01/23/24 at 11:18 a.m. LPN #1 walked into Resident #41 and Resident #13's room. LPN #1 stated Resident #41 would only be able to visualize the TV laying on their right side. LPN #1 stated Resident #13 had cleaned up the room quite a bit since the last time it was changed. They stated Resident #13 had an excessive amount of personal items in the room. 48344

Based on observation, record review and interview the facility failed to: a. provide incontinent care in a manner to prevent cross contamination for one (#41) of two sampled residents observed receiving incontinent care; and b. ensure staff did not touch medication with their bare hands for one (RN#1) of three staff observed during medication pass. The Executive Director identified 50 residents resided in the facility. Findings: A facility Hand Hygiene policy, dated 2023, read in part, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under the conditions listed in .the attached table .Hands are visibly soiled .After handling contaminated objects .Before and after handling clean or soiled dressings, linens .during resident care, moving from a contaminated body site to a clean body site . 1. Resident #41 had diagnoses which included personal history of transient ischemic attack and transient paralysis. Resident #41's Quarterly Resident Assessment, dated 12/22/23, documented the resident was frequently incontinent of urine and always incontinent of bowel. On 01/02/24 at 2:28 p.m., RN #2 and CNA #1 entered Resident #41's room and donned gloves. CNA #1 opened the resident's disposable which was saturated with loose brown stool. CNA #1 sprayed toilet paper with total body body cleanser and wiped stool off of the resident several times. The CNA began searching through the drawers of Resident #41's bedside table with the same gloves used during incontinent care stating they were looking for wipes. RN #2 obtained wipes from the bathroom and handed them to CNA #1. CNA #1 used the wipes to clean stool from the resident. CNA #1 placed a new disposable brief under the resident and attached it with the same pair of gloves. There was brown bowel observed on the nondisposable pad under the resident which was left under the resident. CNA #1 pulled down the resident's gown, pulled the blanket up over the resident, handed them the call light, and raised the resident's head of bed with the controller all with the same pair of gloves. CNA #1 removed their gloves, and washed their hands with soap and water. On 01/02/24 at 2:40 p.m. CNA #1 was asked to observe the nondisposable pad left under the resident to see if they had bowel present on the pad. On 01/02/24 at 2:41 p.m., CNA #1 observed the pad and stated they didn't know if it was bowel because the pads were stained sometimes. On 01/02/24 at 2:44 p.m., CNA #1 replaced the soiled disposable pad with a new pad. On 01/02/24 at 2:49 p.m., CNA #1 stated every time they worked with a resident, they were to wash their hands afterwards when they removed their gloves. They stated they also had the option to sanitize their hands. They stated staff should sanitize their hands after providing incontinent care before touching clean items. On 01/04/24 at 8:38 a.m., the DON stated staff were to perform hand hygiene before and after care. They stated staff were to wear gloves anytime they were in contact with body fluids. They stated staff should perform hand hygiene before and after putting on gloves. 2. On 01/04/24 at 8:43 a.m., RN #1 was observed popping medications into their bare hands to be administered to Resident #23 during medication pass. On 01/04/24 at 8:52 a.m., RN #1 was observed popping medications into their bare hands to be administered to Resident #36 during medication pass. On 01/04/24 at 9:05 a.m., RN #1 was observed popping medications into their bare hands to be administered to Resident #7 during medication pass. On 01/04/24 at 10:06 a.m., RN #1 stated they were supposed to wash hands between patients. On 01/04/24 at 12:16 p.m., The ADON stated the policy for passing medications was to wear gloves when touching medications. 49701

Based on observation, record review and interview, the facility failed to ensure food items were properly dated and labeled in the walk in cooler and refrigerator located in the kitchen. The Executive Director identified 50 residents resided in the facility. Findings: The facility Food Receiving and Storage policy, revised 12/08, read in part, .Food shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated . On 01/02/24 at 1:05 p.m., Cook #1 stated staff should date and label all food items. On 01/02/24 at 1:19 p.m., the following items were observed in the refrigerator next to the tray line: a. two pitchers with blue lids which contained liquid with no date or label present; b. three pitchers with red lids which contained liquid with no date or label; c. one 46 ounce open container of Thick and Easy kiwi strawberry flavor with no open date; Cook #1 stated the pitchers of fluids were prepared for the meal service and did not contain a date or label on them. They stated the Thick and Easy was usually dated when they came in, but not when they opened it. On 01/02/24 at 1:22 p.m., the following items were observed in the walk in cooler: a. two pies with no label or date; b. a clear plastic gallon sized bag containing a pink substance with cream cheese and another unidentified word written on it. The bag was dated 12/19; c. raw meat product in a plastic bag in a metal bowl with no label present; d. three bags of a pink colored sliced meat product with no label; e. a package of circular sliced meat product with a use by date 10/26/23 and a handwritten label lunch meat and 12/2 then illegible after the two; f. two packages of pink colored circular sliced meat product with no label and a use by date 10/26/23; g. one package of pinkish brown sliced meat product with no label and a use by date 10/26/23; h. one package of white circular sliced meat product with a blue green substance growing on the bottom of it and no label present; i. six packages of sliced meat product with varying degrees of browning with no label present; j. two unlabeled bags of meat product one with no date and one with 12/30 written on it. Neither bag had a label. On 01/02/24 at 1:30 p.m., Cook #1 identified the gallon sized plastic bag as cream cheese with strawberry and stated We should have thrown away. Cook #2 stated the pies did not have a date or label present. Cook #2 identified the raw meat in the metal bowel as chicken with no date or label. Cook #2 stated the date was 01/02 because they had taken it out to use for the chicken [NAME] but did not need it. Cook #2 stated the other two bags of meat product were also chicken and did not contain a date or label. Cook #2 stated they had pulled the items from the freezer that morning. Cook #2 stated the white sliced meat was turkey, the large sliced meat was ham steak, the light pink was salami, and the brownish pink was bologna. They stated they did not contain labels and they were going to throw them in the trash because they had been sitting there awhile. Cook #2 stated the blue green substance was probably mold. Cook #2 stated they had removed three of the larger sliced meet products from the freezer yesterday. They stated they usually didn't label the meat because they just know what it was.

Based on record review and interview, the facility failed to ensure baseline care plans were developed within 48 hours of admission for one (#21) of 15 sampled residents reviewed for care plans. The Executive Director identified 50 residents resided in the facility. Findings: Resident #21 was admitted to the facility on [DATE] with diagnoses which included multiple fracture of pelvis with stable disruption of pelvic ring, fracture of lower end of right radius, dementia without behaviors, anxiety disorder, major depressive disorder, psychotic disturbance, and mood disturbance. A baseline care plan was not initiated until 11/21/23. On 01/23/24 at 11:43 a.m., MDS Coordinator #1 stated that might have been when they were out. They stated the care plan should have been completed within 48 hours of admission.

Based on record review and interview, the facility failed to ensure adequate supervision was provided during an out of facility appointment for one (#25) of five sampled residents reviewed for accidents. The Executive Director identified 50 residents resided in the facility. The DON identified 16 residents were at risk for elopement in the facility. Findings: Resident #25 had diagnoses which included dementia, psychotic disturbance, and disorganized schizophrenia. An initial State reportable, dated 09/21/23, with incident date 09/21/23, documented missing resident. It documented the Administrator was contacted around 9:00 a.m. and informed by Resident #25's niece and a VA representative that Resident #25 had been walking the hallways unattended. The Resident was transported to the VA clinic that morning for an eye appointment. A final State reportable, dated 09/26/23, with incident date 09/21/23, documented missing resident. It documented Resident #25's niece called the facility the night before at 7:30 p.m. to inform them the Resident's appointment was cancelled. Resident #25 was picked up from the VA by the ADON. Resident #25's quarterly resident assessment, dated 09/27/23, documented the Resident had severe cognitive impairment and exhibited wandering behavior. Resident #25's care plan for wandering, dated 12/26/23, documented, a. wanders about unaware of their safety, b. sometimes seek to leave the facility, and c. is considered an elopement risk. On 01/04/24 at 8:33 a.m., Resident #25 was observed walking up and down hall 400. A wander guard was observed on their left wrist. On 01/24/24 at 11:18 a.m., the DON stated if a resident had severe cognitive impairment, the family accompanied the resident to their appointment or the facility provided staff to accompany the resident. On 01/24/24 at 11:21 a.m., the DON stated Resident #25 was assessed as an elopement risk and a wander guard was provided for them. On 01/24/24 at 11:27 a.m., the DON stated the incident at the VA posed a safety concern due to Resident #25's cognitive status.

Based on observation, record review and interview, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one (RN #1) of one licensed staff observed during medication pass. The Executive Director identified 50 residents resided in the facility. The Executive Director identified four RNs and 12 LPNs were employed by the facility. Findings: 1. Resident #7 had diagnoses which included Alzheimer's disease, anxiety disorder, hypertension, and GERD. A Physician's Order, dated 01/14/22, documented may crush tablets and/or open capsules unless contraindicated. A Physician Order, dated 09/01/22, documented lanoxin 125 mcg give one tablet by mouth one time a day for Afib, hold if pulse was below 60. A Physician's Order, dated 04/17/23, documented suction oropharynx every one hour as needed for aspiration. A Physician's Order, dated 06/14/23, documented regular diet, pureed texture, nectar (mildly thick) consistency, related to Alzheimer's disease. A Physician's Order, dated 09/01/23, documented Resident #7 was to receive omeprazole 20 mg delayed release one capsule by mouth daily for GERD. On 01/04/24 at 9:05 a.m., RN #1 was observed typing the blood pressure and pulse of Resident #7 into the Resident's medication administration record without being observed taking the blood pressure and pulse, or reviewing any documentation for the information. On 01/04/24 at 9:13 a.m., RN #1 was observed opening olanzapine 5 mg tablet from Resident #47's medication card and put it in their hand to administer to Resident #7. RN #1 was asked to verify the medication they popped into their hand. RN #1 reviewed the medication card and disposed of the medication they had just popped. On 01/04/24 at 9:15 a.m., RN #1 was observed opening levothyroxine 175 mg tablet from Resident #24's medication card and put it in their hand to administer to Resident #7. RN #1 was asked to verify the medication they popped into their hand. RN #1 reviewed the medication card and disposed of the medication they had just popped. On 01/04/24 at 9:17 a.m., RN #1 was observed crushing Resident #7's medications including the omeprazole capsule while still intact and administered it to the Resident by mouth in oatmeal. On 01/04/24 at 9:20 a.m., Resident #7 pushed half of the crushed omeprazole capsule out of their mouth and RN #1 picked it up and disposed of it. On 01/04/24 at 10:10 a.m., RN #1 stated some of Resident #7's capsules could be crushed, and the resident could spit out the capsule after they ate the medication inside it. On 01/04/24 at 10:12 a.m., RN #1 stated residents who were given capsules with swallowing difficulties might choke and aspirate or keep it in their mouth and eventually spit it out. On 01/04/24 at 12:10 p.m., the DON stated they could not see resident #7 being able to swallow a capsule. On 01/04/24 at 12:15 p.m., the ADON stated the staff were supposed to read the medication administration record and ensure the order matched the medication label from the pharmacy. 2. Resident #23 had diagnoses which included essential hypertension. A Physician Order dated 08/16/23, documented cozaar 50 mg give one tablet by mouth one time a day related to essential hypertension. Notify physician if the systolic was greater than 145 or less than 105 or diastolic was greater than 90 or less than 65. Notify the physician if pulse was greater than 96 or less than 56. On 01/04/24 at 8:43 a.m., RN #1 was observed typing the blood pressure and pulse of Resident #23 into the Resident's medication administration record without being observed taking the blood pressure and pulse, or reviewing any documentation for the information. 3. Resident #36 had diagnoses which included essential hypertension. A Physician Order, dated 10/15/23, documented lisinopril 10 mg give one tablet by mouth one time a day related to essential hypertension. Notify physician if the systolic was greater than 145 or less than 105 or diastolic was greater than 90 or less than 65. Notify the physician if pulse was greater than 96 or less than 56. On 01/04/24 at 8:52 a.m., RN #1 was observed typing the blood pressure and pulse of Resident #36 into the Resident's medication administration record without being observed taking the blood pressure and pulse, or reviewing any documentation for the information. On 01/04/24 at 10:04 a.m. RN #1 stated they checked the blood pressure and pulse of Residents #7, #23, and #36 around 6:35 a.m. They stated they memorized them because the residents had heart problems. On 01/04/24 at 10:15 a.m., RN #1 stated they usually memorized the blood pressures or wrote them on their palm or a piece of paper if they knew they would forget. On 01/04/24 at 12:14 p.m., the ADON stated staff were supposed to assess vital signs right before administering medications. 4. On 01/04/24 at 8:58 a.m., RN #1 was observed to have left the medication cart on hall 200 unlocked while delivering medications to a resident on the memory care unit. On 01/04/24 at 10:07 a.m., RN #1 stated the medication cart should always be locked.

Based on observation and interview, the facility failed to ensure one (hall 200) of three medication carts were locked. The DON identified three medication carts were utilized in the facility. Findings: On 01/04/24 at 8:58 a.m., RN #1 was observed to have left the medication cart on hall 200 unlocked while delivering medications to a resident on the memory care unit. On 01/04/24 at 10:07 a.m., RN #1 stated the medication cart should always be locked.

Based on observation and interview, the facility failed to remove an excessive amount of lint for three of three dryers observed in the laundry room for lint. The Executive Director identified 50 residents resided in the facility. Findings: On 01/03/24 at 12:00 p.m., excessive lint was observed in the lint compartment floor and lint catcher in all three dyers. The Housekeeping Supervisor stated they last cleaned the lint compartments at 6:00 a.m. On 01/03/24 at 12:02 p.m., the Housekeeping Supervisor stated the lint compartments were cleaned every two hours. They stated it was a fire hazard if lint compartments and lint catchers were not cleaned. The Housekeeping Supervisor provided a cleaning log that documented the lint compartments were cleaned hourly. On 01/03/24 at 2:28 p.m., the Housekeeping Supervisor stated they could tell by the amount of lint observed the lint compartments were not cleaned at 6:00 a.m. They stated they were too embarrassed to acknowledge it to the surveyor during the laundry room observation.

Based on record review and interviews the facility failed to report allegations of abuse timely to the OSDH (Oklahoma State Department of Health) for one (#2) of four sampled residents reviewed for allegations of abuse. The regional clinical systems nurse identified 43 residents resided in the facility. Findings: A facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, documented when reports of abuse/neglect/exploitation occur the appropriate agencies will be notified no later than 24 hours after the discovery of the incident . if the events cause serious bodily injury the allegation will be reported within 2 hours . obtain statements from direct care staff .suspend the accused employee pending completion of the investigation .report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service. On 01/19/22 at 3:15 p.m., the regional clinical systems nurse was asked if an investigation should have been completed and CNA #1 reported to the nurse aide registry. She reported that the investigation should have been completed, sent to the appropriate agencies and the CNA should have been reported to the nurse aide registry.

Based on interview and record review, the facility failed to report allegation of abuse to the state nurse aide registry for one (#2) of four residents sampled for abuse. The regional clinical systems nurse identified 43 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 01/08/2020, documented the resident's cognition was intact, had no behaviors, and required extensive assistance with activities of daily living. On 01/19/22 at 1:52 p.m., the ADON was asked if an investigation should have been completed and CNA #1 reported to the nurse aide registry. He reported that the investigation should have been completed, sent to the appropriate agencies and the CNA should have been reported to the nurse aide registry. On 01/19/22 at 3:15 p.m., the regional clinical systems nurse was asked if an investigation should have been completed and CNA #1 reported to the nurse aide registry. She reported that the investigation should have been completed, sent to the appropriate agencies and the CNA should have been reported to the nurse aide registry.

Based on observation, interview, and record review, the facility failed to complete a thorough investigation of abuse for one (#2) of four residents sampled for abuse. The regional clinical systems nurse identified 43 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 01/08/20, documented the resident's cognition was intact, had no behaviors, and required extensive assistance with activities of daily living. A review of the state reports dated 03/21 through 05/21 did not include any investigations of allegations of abuse. On 01/19/22 at 10:39 a.m., the resident was resting in bed with eyes open. The resident was clean and dressed appropriately. The resident was asked how staff treated her. She reported there was an issue with a certain staff member in the past making fun of the way another resident talked and it really upset her. She reported she was so upset she called her family and told them about it. She reported her family said they called the police about it. She was asked if the staff member continued to work after the incident was reported and she reported the staff member worked again a couple of days later. She was asked who the staff member was and when this happened. She reported it was April or May of last year and the staff member's name was CNA #1. The resident was asked if she reported it to any other staff about the incident. She reported she had told the nurse but couldn't remember which one. She reported CNA #1 was always rude and abusive to the residents and the administrator knew about it. On 01/19/22 at 12:30 p.m., incident reports were reviewed with no reports found for 03/21 through 05/21. Documentation showed there was resident abuse questionnaires dated for 04/26/21 and 04/28/21 but no investigation was found. The questionnaires named CNA #1 for putting a resident to bed to fast, not giving her the choice of what she wanted to wear, and putting diapers on her that were to big. The questionnaire also reported CNA #1 had also complained about other residents to them and having to take care of them. No investigation reports were found for April 2021. On 01/19/22 at 1:52 p.m., the ADON was asked if an investigation had been completed. The ADON reported he called the former DON and she stated she had done the report. The ADON reported he was not able to locate the paperwork. On 01/19/22 at 3:15 p.m., the regional clinical systems nurse was asked if a thorough investigation should have been completed. She reported a thorough investigation should have been completed.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse for one (#2) of four residents sampled for abuse. The regional clinical systems nurse identified 43 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 01/08/20, documented the resident's cognition was intact, had no behaviors, and required extensive assistance with activities of daily living. A review of the state reports dated 03/21 through 05/21 did not include any investigations of allegations of abuse. On 01/19/22 at 10:39 a.m., the resident was resting in bed with eyes open. The resident was clean and dressed appropriately. The resident was asked how staff treated her. She reported there was an issue with a certain staff member in the past making fun of the way another resident talked and it really upset her. She reported she was so upset she called her family and told them about it. She reported her family said they called the police about it. She was asked if the staff member continued to work after the incident was reported and she reported the staff member worked again a couple of days later. She was asked who the staff member was and when this happened. She reported it was April or May of last year and the staff member's name was CNA #1. The resident was asked if she reported it to any other staff about the incident. She reported she had told the nurse but couldn't remember which one. She reported CNA #1 was always rude and abusive to the residents and the administrator knew about it. On 01/19/22 at 12:30 p.m., incident reports were reviewed with no reports found for 03/21 through 05/21. Documentation showed there was resident abuse questionnaires dated for 04/26/21 and 04/28/21 but no investigation was found. The questionnaires named CNA #1 for putting a resident to bed to fast, not giving her the choice of what she wanted to wear, and putting diapers on her that were to big. The questionnaire also reported CNA #1 had also complained about other residents to them and having to take care of them. On 01/19/22 at 1:52 p.m., the ADON was asked if an investigation had been completed. He reported he called the former DON and she reported it was completed and it should be in the book. He reported we could call the former DON and asked her about it. He reported he had not yet found a report on this incident. On 01/19/22 at 2:50 p.m., no investigation could be found for the allegations against CNA #1. Business office employee provided time sheet for CNA #1. She was asked if CNA #1 was fired or quit. She reported CNA #1 just stopped showing up for work. She was asked if CNA #1 would have continued to be employed if she had kept coming to work. She reported CNA would have still been employed.

Based on record review and staff interviews, it was determined the facility failed to notify the resident's physician and representative for changes in skin integrity for one (#1) of four sampled residents reviewed for notification. The facility identified 52 residents who resided in the facility. Findings: Resident #1 was admitted with [DIAGNOSES REDACTED]. On 03/18/21 at 1:24 p.m., licensed practical nurse (LPN) #1 was asked when did she take care of the resident. She stated she was transferred from the quarantined hall to her hall on 03/01/21. She was asked to describe the condition of the resident. She stated the resident had blisters on both of her legs. She was asked to describe the blisters. She stated there was one long, intact blister on the top of the resident's right thigh, one long, opened blister on the top of the left thigh and one opened blister under the left thigh. LPN #1 went on to state another blister had formed on the inner thigh the following day. She thought it was the right inner thigh but wasn't sure. She was asked if there was documentation she could refer to. She stated she didn't document it. She was asked if the physician had been notified. She stated she couldn't remember. At 3:07 p.m.,the assistant director of nursing was asked if he was aware of the blisters the resident had on her upper legs. He stated he wasn't. After reviewing the documentation, he was asked if the physician and the resident's representative was notified of the blisters. He stated he didn't find any documentation they were.

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to assess and monitor a resident after the resident was found with an abnormally moving left femur bone, with no known cause for the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. The facility failed to conduct a thorough initial assessment after the injury and failed to conduct ongoing assessments and monitoring related to the potential of complications from the injury. The facility also failed to notify the physician when an ordered X-Ray of the resident's leg was unable to be obtained and failed to obtain physician's orders [REDACTED]. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to assess and monitor the resident. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . The immediate jeopardy was removed on 08/13/18 at 3:21 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to: ~ assess and monitor one (#13) of two sampled residents who were reviewed for injuries of unknown origin. Resident #13 was found with an abnormally moving left femur bone. The facility did not conduct an initial assessment after the injury was noted and they did not conduct ongoing assessments and monitoring related to the potential for complications from the injury. ~ notify the physician when an ordered X-Ray of the resident's leg was unable to be obtained and failed to obtain physician's orders [REDACTED].#13) of two sampled residents who were reviewed for injuries of unknown origin. The facility identified 88 residents who resided at the facility. Findings: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A nurse's note, dated 08/06/18 at 12:21 p.m., documented, .Mobile x-ray technician unable to perform x-ray adequately so called (family member) back to make her aware and her response was to wait until hospice nurse comes out and evaluate and they'll (sic) go from there, resident has no signs of indication of pain . A shift report note, for the 6-2 shift on 08/06/18, documented, .Possible fx lt. hip. In bed only . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. A shift report note, for the shift from 10 p.m. on 08/06/18 to 6:00 a.m. on 08/07/18, documented, .hip does not look fx . A nurse's note, dated 08/07/18 at 11:54 a.m., documented, .Informed by staff pt has an issue with leg upon assessment this nurse noted pt lying in bed on left side when repositioned no c/o pain. Pt has leg has abnormal movement of femur bone, no discoloration, no open area, no active bleeding noted. As in prior message family has been made aware of above. Please reference previous note. Pt has no s/s of pain, no s/s of distress noted. Cont with HOB elevated and staff given pt supp for breakfast as she verbally refuses meals . A shift report note, for the 6-2 shift on 08/07/18, documented, .(no) s/s of pain. Kept comfortable. (No) discoloration to (left) leg . A hospice aide visit note, dated 08/08/18 and untimed, documented, .Pt broke leg . Review of the clinical record revealed no documentation the resident's leg was thoroughly assessed at the time the injury was first noted. There was no documentation to show the facility assessed and monitored the leg for complications from 08/06/18 through 08/08/18. There was no documentation to show the physician was notified of the inability to obtain the ordered x-ray or for further orders to direct the resident's care. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 stated CNA #4 reported to her that the weekend aide (CNA #3) had told her that when she turned the resident, she heard her leg pop. CNA #2 was asked if the resident's leg looked disconnected on 08/06/18, when she first observed the resident. She stated, Yes. She stated she saw the resident's leg first at 2:00 p.m., when making rounds. CNA #2 was asked to describe the resident's leg on this day. She stated it was swollen and it took two people to turn the resident now. She stated, Her leg looks like it is dangling. She was asked if the resident was in pain. She stated she had been informed the resident was receiving [MEDICATION NAME] every two hours. She stated the resident was out of it so she did not know whether she felt it or not. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked if the physician was notified they could not get the x-ray. She stated, Yes. She was asked where that was documented. She stated, It's probably not documented. She stated she just assumed the nurse documented. She stated she should not assume. The DON was asked what the hospice nurse had said when she visited the resident. She stated the hospice nurse came in after they were not able to get the x-ray and said they would keep the resident comfortable like the family preferred. She was asked who gave the orders to do nothing. She stated the family did not want the resident sent to the emergency room . The DON was asked where it was documented the family and physician were notified the x-ray could not be obtained. She stated, I guess some of the documentation got lost. She stated the nurse should have called the doctor. She stated, I don't see where she noted that. The DON was asked where the orders were to continue palliative care and not do anything else. She stated, There's not one. The DON was asked to describe the resident's leg today. She stated, I don't really know. It's swollen. She was asked if there were any other descriptors. She stated there was no warmth or discoloration when she saw it. The DON was asked where she obtained the information she put on the state reportable incident report. She stated from the staff and hospice nurse. She was asked if she had done an assessment of the resident's leg. She stated, I looked at it. She was asked who completed the assessment of the leg when she and the ADON saw it on 08/06/18. She stated the ADON had completed the assessment. She was asked if she allowed the LPN ADON to complete the assessment. She stated she had observed her completing the assessment. The DON was asked if she touched the resident's leg. She stated, No. She stated she did not want to hurt the resident. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. She was asked what happened when the staff moved the resident. She stated, Well, you have to still care for her. The DON was asked what kind of ongoing assessments and monitoring were occurring related to the resident's left leg. She made no comment. On 08/08/18 at 6:16 p.m., the physician was asked if he had been notified of the inability to obtain the ordered x-ray. He stated he had never heard of a radiology company not being able to obtain an x-ray. He was asked if the facility had told him that on 08/06/18. He stated he would remember that. He stated he had been at the facility on 08/06/18 and had seen the resident. He stated he had not noted any concern with resident #13. He stated she had been covered with her bed linens and he had moved all her extremities. He stated he might not have noted a concern with her leg. He was asked again if the facility had notified him of not obtaining the x-ray. He stated he was not sure and he would need to look into that. At 6:52 p.m., the physician stated the resident was on hospice services, so he would not have sent her out for treatment. He was asked if he had been given the opportunity to make that decision and provide further orders for the resident's care. He made no reply. The physician stated he had talked with his nurses and they had not been notified of the inability to obtain the ordered x-ray. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] .

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to assess and monitor a resident after the resident was found with an abnormally moving left femur bone, with no known cause for the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. The facility failed to conduct a thorough initial assessment after the injury and failed to conduct ongoing assessments and monitoring related to the potential of complications from the injury. The facility also failed to notify the physician when an ordered X-Ray of the resident's leg was unable to be obtained and failed to obtain physician's orders [REDACTED]. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure to assess and monitor the resident. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . The immediate jeopardy was removed on 08/13/18 at 3:21 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to: ~ assess and monitor one (#13) of two sampled residents who were reviewed for injuries of unknown origin. Resident #13 was found with an abnormally moving left femur bone. The facility did not conduct an initial assessment after the injury was noted and they did not conduct ongoing assessments and monitoring related to the potential for complications from the injury. ~ notify the physician when an ordered X-Ray of the resident's leg was unable to be obtained and failed to obtain physician's orders [REDACTED].#13) of two sampled residents who were reviewed for injuries of unknown origin. The facility identified 88 residents who resided at the facility. Findings: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A nurse's note, dated 08/06/18 at 12:21 p.m., documented, .Mobile x-ray technician unable to perform x-ray adequately so called (family member) back to make her aware and her response was to wait until hospice nurse comes out and evaluate and they'll (sic) go from there, resident has no signs of indication of pain . A shift report note, for the 6-2 shift on 08/06/18, documented, .Possible fx lt. hip. In bed only . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. A shift report note, for the shift from 10 p.m. on 08/06/18 to 6:00 a.m. on 08/07/18, documented, .hip does not look fx . A nurse's note, dated 08/07/18 at 11:54 a.m., documented, .Informed by staff pt has an issue with leg upon assessment this nurse noted pt lying in bed on left side when repositioned no c/o pain. Pt has leg has abnormal movement of femur bone, no discoloration, no open area, no active bleeding noted. As in prior message family has been made aware of above. Please reference previous note. Pt has no s/s of pain, no s/s of distress noted. Cont with HOB elevated and staff given pt supp for breakfast as she verbally refuses meals . A shift report note, for the 6-2 shift on 08/07/18, documented, .(no) s/s of pain. Kept comfortable. (No) discoloration to (left) leg . A hospice aide visit note, dated 08/08/18 and untimed, documented, .Pt broke leg . Review of the clinical record revealed no documentation the resident's leg was thoroughly assessed at the time the injury was first noted. There was no documentation to show the facility assessed and monitored the leg for complications from 08/06/18 through 08/08/18. There was no documentation to show the physician was notified of the inability to obtain the ordered x-ray or for further orders to direct the resident's care. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 stated CNA #4 reported to her that the weekend aide (CNA #3) had told her that when she turned the resident, she heard her leg pop. CNA #2 was asked if the resident's leg looked disconnected on 08/06/18, when she first observed the resident. She stated, Yes. She stated she saw the resident's leg first at 2:00 p.m., when making rounds. CNA #2 was asked to describe the resident's leg on this day. She stated it was swollen and it took two people to turn the resident now. She stated, Her leg looks like it is dangling. She was asked if the resident was in pain. She stated she had been informed the resident was receiving [MEDICATION NAME] every two hours. She stated the resident was out of it so she did not know whether she felt it or not. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked if the physician was notified they could not get the x-ray. She stated, Yes. She was asked where that was documented. She stated, It's probably not documented. She stated she just assumed the nurse documented. She stated she should not assume. The DON was asked what the hospice nurse had said when she visited the resident. She stated the hospice nurse came in after they were not able to get the x-ray and said they would keep the resident comfortable like the family preferred. She was asked who gave the orders to do nothing. She stated the family did not want the resident sent to the emergency room . The DON was asked where it was documented the family and physician were notified the x-ray could not be obtained. She stated, I guess some of the documentation got lost. She stated the nurse should have called the doctor. She stated, I don't see where she noted that. The DON was asked where the orders were to continue palliative care and not do anything else. She stated, There's not one. The DON was asked to describe the resident's leg today. She stated, I don't really know. It's swollen. She was asked if there were any other descriptors. She stated there was no warmth or discoloration when she saw it. The DON was asked where she obtained the information she put on the state reportable incident report. She stated from the staff and hospice nurse. She was asked if she had done an assessment of the resident's leg. She stated, I looked at it. She was asked who completed the assessment of the leg when she and the ADON saw it on 08/06/18. She stated the ADON had completed the assessment. She was asked if she allowed the LPN ADON to complete the assessment. She stated she had observed her completing the assessment. The DON was asked if she touched the resident's leg. She stated, No. She stated she did not want to hurt the resident. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. She was asked what happened when the staff moved the resident. She stated, Well, you have to still care for her. The DON was asked what kind of ongoing assessments and monitoring were occurring related to the resident's left leg. She made no comment. On 08/08/18 at 6:16 p.m., the physician was asked if he had been notified of the inability to obtain the ordered x-ray. He stated he had never heard of a radiology company not being able to obtain an x-ray. He was asked if the facility had told him that on 08/06/18. He stated he would remember that. He stated he had been at the facility on 08/06/18 and had seen the resident. He stated he had not noted any concern with resident #13. He stated she had been covered with her bed linens and he had moved all her extremities. He stated he might not have noted a concern with her leg. He was asked again if the facility had notified him of not obtaining the x-ray. He stated he was not sure and he would need to look into that. At 6:52 p.m., the physician stated the resident was on hospice services, so he would not have sent her out for treatment. He was asked if he had been given the opportunity to make that decision and provide further orders for the resident's care. He made no reply. The physician stated he had talked with his nurses and they had not been notified of the inability to obtain the ordered x-ray. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] .

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to investigate an injury of unknown origin when one resident was found with an abnormally moving left femur bone and there was no known causes for the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. The facility did not conduct an investigation into the reason for the injury. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure in investigating injuries of unknown origin. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . On 08/13/18 the Immediate Jeopardy situation was determined to continue due to the facilities failure to investigate an injury of unknown origin for another resident who was diagnosed with [REDACTED]. Resident #53 was admitted to the facility on [DATE] with no fractures. On 08/01/18, the resident was found to be restless and crying out in pain. The resident was found to have an acute [MEDICAL CONDITION] femur neck. No incidents and/or falls had been noted for the resident that could have caused the fracture. The facility did not conduct an investigation into the reason for the fracture. The OSDH verified the existence of the continuing Immediate Jeopardy situation. On 08/13/18 at 3:02 p.m., the Administrator was notified that the Immediate Jeopardy situation related to the facility's failure to investigate injuries of unknown origin was continuing and that an amended plan of removal was required. On 08/13/18 at 4:22 p.m., an amended plan of removal was received. The plan of removal documented, .1. Interim DON will review incident reports from (MONTH) 1st thru (MONTH) 13th to ensure any injuries of unknown origins have been identified and investigated. To be completed 8-13-18. 2. In-service to Administrator, Interim Director of Nursing and ADON on Reporting and Investigation of Injuries of Unknown Origins by (corporate registered nurse consultant name withheld). Completed on 8-13-18. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Stand up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 8-13-18. 4. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly Clinical QA meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. The immediate jeopardy was removed on 08/14/18 at 9:30 a.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to investigate injuries of unknown origin for two (#13 and #53) of two sampled residents who were reviewed for accidents. Resident #53 was diagnosed with [REDACTED]. Resident #13 was found with an abnormally moving femur bone with an unknown cause on 08/06/18. The facility identified 88 residents who resided at the facility. Findings: The facility's abuse prohibition standards of practice, revised 11/2017, documented, .Investigation: .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. Review of facility and clinical records revealed no documentation the injury was investigated as an injury of unknown origin. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. CNA #1 stated on 08/07/18, between 9:00 a.m. and 10:00 a.m., she was called to the DON's office and was asked about the incident. CNA #1 stated the DON kept saying, When she was put on the shower chair is when it must have happened. CNA #1 stated she was asked to write a statement about what she had observed. CNA #1 stated she felt that she was being blamed for the incident. She stated her co-worker, CNA #2, went to the DON and told her that another CNA, CNA #3, had told her on Saturday or Sunday (08/04/18 or 08/05/18), when the resident was turned in bed, she had heard something pop. CNA #1 stated she had been told no nurse had been notified of the pop. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. CNA #1 was asked when she first spoke with the DON about the incident. She stated, On Tuesday at about 10 o'clock. She stated the DON told her to hurry up and write a statement as she needed to report it to the state. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 stated CNA #4 reported to her that the weekend aide (CNA #3) had told her that when she turned the resident, she heard her leg pop. CNA #2 stated on 08/07/18, she went to the DON and told her what had been reported to her. She stated the DON had said it was possible it could have happened when the resident was being turned. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked where she obtained the information she put on the state reportable incident report. She stated from the staff and hospice nurse. She was asked if she had done an assessment of the resident's leg. She stated, I looked at it. She was asked who completed the assessment of the leg when she and the ADON saw it on 08/06/18. She stated the ADON had completed the assessment. She was asked if she allowed the LPN ADON to complete the assessment. She stated she had observed her completing the assessment. The DON was asked if she touched the resident's leg. She stated, No. She stated she did not want to hurt the resident. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. The DON was asked what kind of investigation into the injury of unknown origin had been done. She stated since the original incident report had been sent in, additional information had come to her attention. She stated she had sent in an addendum to the report. She was asked when that was done. She stated, Just a little bit ago. The DON was asked where she was with the investigation. She stated it was still ongoing as she was trying to get in touch with CNA #4. She stated CNA #4 was the one that said somebody on the weekend had heard a pop. The DON was asked if she had contacted every CNA who had worked with the resident since 08/04/18. She stated, No. She stated she wanted to know what CNA #4 was saying. She stated she had called CNA #4, but she would not return her calls. She stated she wanted to talk to CNA #4 before she talked with anyone else. She was asked if she knew which staff had worked with the resident since 08/04/18. She stated, No. She was asked if the facility had assignment sheets. She stated she could pull them. The DON was asked why the incident had not been reported to OSDH within two hours. The DON asked, When did it go to two hours? She stated she thought she had 24 hours to report the incident. The DON was asked why the information in the state reportable incident report did not accurately reflect the resident's condition, such as the left femur bone moving abnormally. She stated, I can't say it is fractured. I have to say what I see. On 08/08/18 at 4:35 p.m., CNA #2 was asked if she informed the DON of who had told her about the incident. She stated, Yes. She stated she had heard about the incident from CNA #4 and that CNA #3 had told CNA #4 about it. She stated, I even told her who (CNA #4) had heard it from. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] . 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/09/18, documented the resident was moderately impaired in cognitive skills for daily decision making; required extensive assistance with bed mobility and transfers; and had no falls since the last assessment. The resident's care plan, updated 07/09/18, documented a problem related to the resident being at risk for injury related to falls. The goal was the resident would have no significant injury related to falls in the next 90 days. Approaches included to rule out medical complications [REDACTED]. A nurse's note, dated 08/01/18 at 12:32 p.m., documented, .CNA came and reported that (resident #53) was all over her bed crying out in pain, not able to understand what she was saying. When (resident #53)'s right leg was repositioned she had no complaint but when the left leg was repositioned she yelled out in pain. Made the charge nurse aware and requested that a x-ray be done on her left leg/hip . An x-ray report, with a fax date of 08/01/18, documented, .Views of the left hip were obtained. The visualized osseous structures demonstrate an acute complete slightly displaced left subcapital [MEDICAL CONDITION]. The femoral head remains articulated without evidence of dislocation . A state reportable incident report, with a fax date and time of 08/01/18 at 4:51 p.m., documented the resident had a certain injury. It was documented the report was a combined initial and final incident report. It was documented, .On 8/1/18 approx 1230 p.m. (resident #53) was in her bed and began complaining of pain in her left hip. An x-ray was ordered and it showed an acute complete slightly displaced left subcapital [MEDICAL CONDITION] without evidence of dislocation. (Resident #53) denied having a fall, she states she just started hurting .Was sent to ER and admitted to the hospital . A hospital history and physical report, dated 08/01/18 at 5:10 p.m., documented, .EMSA was told by patient's nurse at Warr Acres Nursing Home that she has been c/o of lef (sic) hip pain when moved. X-ray was performed and showed left hip fx. EMSA states that the facility does not have a documented fall. NH nurse told EMSA that they think it is a 'pathological break' .It is unknown as to whether or not patient actually suffered a fall, loss of consciousness or head injury . Review of facility and clinical records revealed no documentation the fracture was investigated as an injury of unknown origin. There was no documentation of any type of investigation. On 08/13/18 at 2:35 p.m., the administrator was asked to provide the investigation into the injury of unknown origin. He stated, There isn't one.

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to investigate an injury of unknown origin when one resident was found with an abnormally moving left femur bone and there was no known causes for the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. The facility did not conduct an investigation into the reason for the injury. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure in investigating injuries of unknown origin. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . On 08/13/18 the Immediate Jeopardy situation was determined to continue due to the facilities failure to investigate an injury of unknown origin for another resident who was diagnosed with [REDACTED]. Resident #53 was admitted to the facility on [DATE] with no fractures. On 08/01/18, the resident was found to be restless and crying out in pain. The resident was found to have an acute [MEDICAL CONDITION] femur neck. No incidents and/or falls had been noted for the resident that could have caused the fracture. The facility did not conduct an investigation into the reason for the fracture. The OSDH verified the existence of the continuing Immediate Jeopardy situation. On 08/13/18 at 3:02 p.m., the Administrator was notified that the Immediate Jeopardy situation related to the facility's failure to investigate injuries of unknown origin was continuing and that an amended plan of removal was required. On 08/13/18 at 4:22 p.m., an amended plan of removal was received. The plan of removal documented, .1. Interim DON will review incident reports from (MONTH) 1st thru (MONTH) 13th to ensure any injuries of unknown origins have been identified and investigated. To be completed 8-13-18. 2. In-service to Administrator, Interim Director of Nursing and ADON on Reporting and Investigation of Injuries of Unknown Origins by (corporate registered nurse consultant name withheld). Completed on 8-13-18. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Stand up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 8-13-18. 4. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly Clinical QA meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. The immediate jeopardy was removed on 08/14/18 at 9:30 a.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to investigate injuries of unknown origin for two (#13 and #53) of two sampled residents who were reviewed for accidents. Resident #53 was diagnosed with [REDACTED]. Resident #13 was found with an abnormally moving femur bone with an unknown cause on 08/06/18. The facility identified 88 residents who resided at the facility. Findings: The facility's abuse prohibition standards of practice, revised 11/2017, documented, .Investigation: .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. Review of facility and clinical records revealed no documentation the injury was investigated as an injury of unknown origin. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. CNA #1 stated on 08/07/18, between 9:00 a.m. and 10:00 a.m., she was called to the DON's office and was asked about the incident. CNA #1 stated the DON kept saying, When she was put on the shower chair is when it must have happened. CNA #1 stated she was asked to write a statement about what she had observed. CNA #1 stated she felt that she was being blamed for the incident. She stated her co-worker, CNA #2, went to the DON and told her that another CNA, CNA #3, had told her on Saturday or Sunday (08/04/18 or 08/05/18), when the resident was turned in bed, she had heard something pop. CNA #1 stated she had been told no nurse had been notified of the pop. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. CNA #1 was asked when she first spoke with the DON about the incident. She stated, On Tuesday at about 10 o'clock. She stated the DON told her to hurry up and write a statement as she needed to report it to the state. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 stated CNA #4 reported to her that the weekend aide (CNA #3) had told her that when she turned the resident, she heard her leg pop. CNA #2 stated on 08/07/18, she went to the DON and told her what had been reported to her. She stated the DON had said it was possible it could have happened when the resident was being turned. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked where she obtained the information she put on the state reportable incident report. She stated from the staff and hospice nurse. She was asked if she had done an assessment of the resident's leg. She stated, I looked at it. She was asked who completed the assessment of the leg when she and the ADON saw it on 08/06/18. She stated the ADON had completed the assessment. She was asked if she allowed the LPN ADON to complete the assessment. She stated she had observed her completing the assessment. The DON was asked if she touched the resident's leg. She stated, No. She stated she did not want to hurt the resident. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. The DON was asked what kind of investigation into the injury of unknown origin had been done. She stated since the original incident report had been sent in, additional information had come to her attention. She stated she had sent in an addendum to the report. She was asked when that was done. She stated, Just a little bit ago. The DON was asked where she was with the investigation. She stated it was still ongoing as she was trying to get in touch with CNA #4. She stated CNA #4 was the one that said somebody on the weekend had heard a pop. The DON was asked if she had contacted every CNA who had worked with the resident since 08/04/18. She stated, No. She stated she wanted to know what CNA #4 was saying. She stated she had called CNA #4, but she would not return her calls. She stated she wanted to talk to CNA #4 before she talked with anyone else. She was asked if she knew which staff had worked with the resident since 08/04/18. She stated, No. She was asked if the facility had assignment sheets. She stated she could pull them. The DON was asked why the incident had not been reported to OSDH within two hours. The DON asked, When did it go to two hours? She stated she thought she had 24 hours to report the incident. The DON was asked why the information in the state reportable incident report did not accurately reflect the resident's condition, such as the left femur bone moving abnormally. She stated, I can't say it is fractured. I have to say what I see. On 08/08/18 at 4:35 p.m., CNA #2 was asked if she informed the DON of who had told her about the incident. She stated, Yes. She stated she had heard about the incident from CNA #4 and that CNA #3 had told CNA #4 about it. She stated, I even told her who (CNA #4) had heard it from. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] . 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/09/18, documented the resident was moderately impaired in cognitive skills for daily decision making; required extensive assistance with bed mobility and transfers; and had no falls since the last assessment. The resident's care plan, updated 07/09/18, documented a problem related to the resident being at risk for injury related to falls. The goal was the resident would have no significant injury related to falls in the next 90 days. Approaches included to rule out medical complications [REDACTED]. A nurse's note, dated 08/01/18 at 12:32 p.m., documented, .CNA came and reported that (resident #53) was all over her bed crying out in pain, not able to understand what she was saying. When (resident #53)'s right leg was repositioned she had no complaint but when the left leg was repositioned she yelled out in pain. Made the charge nurse aware and requested that a x-ray be done on her left leg/hip . An x-ray report, with a fax date of 08/01/18, documented, .Views of the left hip were obtained. The visualized osseous structures demonstrate an acute complete slightly displaced left subcapital [MEDICAL CONDITION]. The femoral head remains articulated without evidence of dislocation . A state reportable incident report, with a fax date and time of 08/01/18 at 4:51 p.m., documented the resident had a certain injury. It was documented the report was a combined initial and final incident report. It was documented, .On 8/1/18 approx 1230 p.m. (resident #53) was in her bed and began complaining of pain in her left hip. An x-ray was ordered and it showed an acute complete slightly displaced left subcapital [MEDICAL CONDITION] without evidence of dislocation. (Resident #53) denied having a fall, she states she just started hurting .Was sent to ER and admitted to the hospital . A hospital history and physical report, dated 08/01/18 at 5:10 p.m., documented, .EMSA was told by patient's nurse at Warr Acres Nursing Home that she has been c/o of lef (sic) hip pain when moved. X-ray was performed and showed left hip fx. EMSA states that the facility does not have a documented fall. NH nurse told EMSA that they think it is a 'pathological break' .It is unknown as to whether or not patient actually suffered a fall, loss of consciousness or head injury . Review of facility and clinical records revealed no documentation the fracture was investigated as an injury of unknown origin. There was no documentation of any type of investigation. On 08/13/18 at 2:35 p.m., the administrator was asked to provide the investigation into the injury of unknown origin. He stated, There isn't one.

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to prevent neglect when they did not investigate an injury of unknown origin for a resident who was found with an abnormally moving left femur bone, with no known cause for the injury. The facility neglected to notify the physician of the inability to obtain an ordered x-ray and obtain further orders for the care of the resident. The facility neglected to conduct an assessment at the time the injury was identified and neglected to conduct ongoing assessments related to the potential of complications from the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's neglect in the care of resident #13. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . The immediate jeopardy was removed on 08/13/18 at 3:21 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to prevent neglect when they did not investigate an injury of unknown origin, notify the physician of the inability to obtain an ordered x-ray and for further treatment orders, conduct a thorough inital assessment of the injury, and conduct continued assessments and monitoring for complications for one (#13) of two sampled residents who were reviewed for injuries of unknown origin. Resident #13 was found with an abnormally moving femur bone with an unknown cause on 08/06/18. The facility identified 88 residents who resided at the facility. Findings: The facility's abuse prohibition standards of practice, revised 11/2017, documented, .Investigation: .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A nurse's note, dated 08/06/18 at 12:21 p.m., documented, .Mobile x-ray technician unable to perform x-ray adequately so called (family member) back to make her aware and her response was to wait until hospice nurse comes out and evaluate and they'll (sic) go from there, resident has no signs of indication of pain . A shift report note, for the 6-2 shift on 08/06/18, documented, .Possible fx lt. hip. In bed only . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. A shift report note, for the shift from 10 p.m. on 08/06/18 to 6:00 a.m. on 08/07/18, documented, .hip does not look fx . A nurse's note, dated 08/07/18 at 11:54 a.m., documented, .Informed by staff pt has an issue with leg upon assessment this nurse noted pt lying in bed on left side when repositioned no c/o pain. Pt has leg has abnormal movement of femur bone, no discoloration, no open area, no active bleeding noted. As in prior message family has been made aware of above. Please reference previous note. Pt has no s/s of pain, no s/s of distress noted. Cont with HOB elevated and staff given pt supp for breakfast as she verbally refuses meals . A shift report note, for the 6-2 shift on 08/07/18, documented, .(no) s/s of pain. Kept comfortable. (No) discoloration to (left) leg . A hospice aide visit note, dated 08/08/18 and untimed, documented, .Pt broke leg . Review of the clinical record revealed no documentation the resident's leg was thoroughly assessed at the time the injury was first noted. There was no documentation to show the facility assessed and monitored the leg for complications from 08/06/18 through 08/08/18. There was no documentation to show the physician was notified of the inability to obtain the ordered x-ray or for further orders to direct the resident's care. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. CNA #1 stated on 08/07/18, between 9:00 a.m. and 10:00 a.m., she was called to the DON's office and was asked about the incident. CNA #1 stated the DON kept saying, When she was put on the shower chair is when it must have happened. CNA #1 stated she was asked to write a statement about what she had observed. CNA #1 stated she felt that she was being blamed for the incident. She stated her co-worker, CNA #2, went to the DON and told her that another CNA, CNA #3, had told her on Saturday or Sunday (08/04/18 or 08/05/18), when the resident was turned in bed, she had heard something pop. CNA #1 stated she had been told no nurse had been notified of the pop. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. CNA #1 was asked when she first spoke with the DON about the incident. She stated, On Tuesday at about 10 o'clock. She stated the DON told her to hurry up and write a statement as she needed to report it to the state. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 stated CNA #4 reported to her that the weekend aide (CNA #3) had told her that when she turned the resident, she heard her leg pop. CNA #2 stated on 08/07/18, she went to the DON and told her what had been reported to her. She stated the DON had said it was possible it could have happened when the resident was being turned. CNA #2 was asked if the resident's leg looked disconnected on 08/06/18, when she first observed the resident. She stated, Yes. She stated she saw the resident's leg first at 2:00 p.m., when making rounds. CNA #2 was asked to describe the resident's leg on this day. She stated it was swollen and it took two people to turn the resident now. She stated, Her leg looks like it is dangling. She was asked if the resident was in pain. She stated she had been informed the resident was receiving [MEDICATION NAME] every two hours. She stated the resident was out of it so she did not know whether she felt it or not. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked if the physician was notified they could not get the x-ray. She stated, Yes. She was asked where that was documented. She stated, It's probably not documented. She stated she just assumed the nurse documented. She stated she should not assume. The DON was asked what the hospice nurse had said when she visited the resident. She stated the hospice nurse came in after they were not able to get the x-ray and said they would keep the resident comfortable like the family preferred. She was asked who gave the orders to do nothing. She stated the family did not want the resident sent to the emergency room . The DON was asked where it was documented the family and physician were notified the x-ray could not be obtained. She stated, I guess some of the documentation got lost. She stated the nurse should have called the doctor. She stated, I don't see where she noted that. The DON was asked where the orders were to continue palliative care and not do anything else. She stated, There's not one. The DON was asked to describe the resident's leg today. She stated, I don't really know. It's swollen. She was asked if there were any other descriptors. She stated there was no warmth or discoloration when she saw it. The DON was asked where she obtained the information she put on the state reportable incident report. She stated from the staff and hospice nurse. She was asked if she had done an assessment of the resident's leg. She stated, I looked at it. She was asked who completed the assessment of the leg when she and the ADON saw it on 08/06/18. She stated the ADON had completed the assessment. She was asked if she allowed the LPN ADON to complete the assessment. She stated she had observed her completing the assessment. The DON was asked if she touched the resident's leg. She stated, No. She stated she did not want to hurt the resident. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. She was asked what happened when the staff moved the resident. She stated, Well, you have to still care for her. The DON was asked what kind of ongoing assessments and monitoring were occurring related to the resident's left leg. She made no comment. The DON was asked what kind of investigation into the injury of unknown origin had been done. She stated since the original incident report had been sent in, additional information had come to her attention. She stated she had sent in an addendum to the report. She was asked when that was done. She stated, Just a little bit ago. The DON was asked where she was with the investigation. She stated it was still ongoing as she was trying to get in touch with CNA #4. She stated CNA #4 was the one that said somebody on the weekend had heard a pop. The DON was asked if she had contacted every CNA who had worked with the resident since 08/04/18. She stated, No. She stated she wanted to know what CNA #4 was saying. She stated she had called CNA #4, but she would not return her calls. She stated she wanted to talk to CNA #4 before she talked with anyone else. She was asked if she knew which staff had worked with the resident since 08/04/18. She stated, No. She was asked if the facility had assignment sheets. She stated she could pull them. The DON was asked why the incident had not been reported to OSDH within two hours. The DON asked, When did it go to two hours? She stated she thought she had 24 hours to report the incident. The DON was asked why the information in the state reportable incident report did not accurately reflect the resident's condition, such as the left femur bone moving abnormally. She stated, I can't say it is fractured. I have to say what I see. On 08/08/18 at 4:35 p.m., CNA #2 was asked if she informed the DON of who had told her about the incident. She stated, Yes. She stated she had heard about the incident from CNA #4 and that CNA #3 had told CNA #4 about it. She stated, I even told her who (CNA #4) had heard it from. On 08/08/18 at 6:16 p.m., the physician was asked if he had been notified of the inability to obtain the ordered x-ray. He stated he had never heard of a radiology company not being able to obtain an x-ray. He was asked if the facility had told him that on 08/06/18. He stated he would remember that. He stated he had been at the facility on 08/06/18 and had seen the resident. He stated he had not noted any concern with resident #13. He stated she had been covered with her bed linens and he had moved all her extremities. He stated he might not have noted a concern with her leg. He was asked again if the facility had notified him of not obtaining the x-ray. He stated he was not sure and he would need to look into that. At 6:52 p.m., the physician stated the resident was on hospice services, so he would not have sent her out for treatment. He was asked if he had been given the opportunity to make that decision and provide further orders for the resident's care. He made no reply. The physician stated he had talked with his nurses and they had not been notified of the inability to obtain the ordered x-ray. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] .

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to prevent neglect when they did not investigate an injury of unknown origin for a resident who was found with an abnormally moving left femur bone, with no known cause for the injury. The facility neglected to notify the physician of the inability to obtain an ordered x-ray and obtain further orders for the care of the resident. The facility neglected to conduct an assessment at the time the injury was identified and neglected to conduct ongoing assessments related to the potential of complications from the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's neglect in the care of resident #13. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . The immediate jeopardy was removed on 08/13/18 at 3:21 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to prevent neglect when they did not investigate an injury of unknown origin, notify the physician of the inability to obtain an ordered x-ray and for further treatment orders, conduct a thorough inital assessment of the injury, and conduct continued assessments and monitoring for complications for one (#13) of two sampled residents who were reviewed for injuries of unknown origin. Resident #13 was found with an abnormally moving femur bone with an unknown cause on 08/06/18. The facility identified 88 residents who resided at the facility. Findings: The facility's abuse prohibition standards of practice, revised 11/2017, documented, .Investigation: .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A nurse's note, dated 08/06/18 at 12:21 p.m., documented, .Mobile x-ray technician unable to perform x-ray adequately so called (family member) back to make her aware and her response was to wait until hospice nurse comes out and evaluate and they'll (sic) go from there, resident has no signs of indication of pain . A shift report note, for the 6-2 shift on 08/06/18, documented, .Possible fx lt. hip. In bed only . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. A shift report note, for the shift from 10 p.m. on 08/06/18 to 6:00 a.m. on 08/07/18, documented, .hip does not look fx . A nurse's note, dated 08/07/18 at 11:54 a.m., documented, .Informed by staff pt has an issue with leg upon assessment this nurse noted pt lying in bed on left side when repositioned no c/o pain. Pt has leg has abnormal movement of femur bone, no discoloration, no open area, no active bleeding noted. As in prior message family has been made aware of above. Please reference previous note. Pt has no s/s of pain, no s/s of distress noted. Cont with HOB elevated and staff given pt supp for breakfast as she verbally refuses meals . A shift report note, for the 6-2 shift on 08/07/18, documented, .(no) s/s of pain. Kept comfortable. (No) discoloration to (left) leg . A hospice aide visit note, dated 08/08/18 and untimed, documented, .Pt broke leg . Review of the clinical record revealed no documentation the resident's leg was thoroughly assessed at the time the injury was first noted. There was no documentation to show the facility assessed and monitored the leg for complications from 08/06/18 through 08/08/18. There was no documentation to show the physician was notified of the inability to obtain the ordered x-ray or for further orders to direct the resident's care. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. CNA #1 stated on 08/07/18, between 9:00 a.m. and 10:00 a.m., she was called to the DON's office and was asked about the incident. CNA #1 stated the DON kept saying, When she was put on the shower chair is when it must have happened. CNA #1 stated she was asked to write a statement about what she had observed. CNA #1 stated she felt that she was being blamed for the incident. She stated her co-worker, CNA #2, went to the DON and told her that another CNA, CNA #3, had told her on Saturday or Sunday (08/04/18 or 08/05/18), when the resident was turned in bed, she had heard something pop. CNA #1 stated she had been told no nurse had been notified of the pop. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. CNA #1 was asked when she first spoke with the DON about the incident. She stated, On Tuesday at about 10 o'clock. She stated the DON told her to hurry up and write a statement as she needed to report it to the state. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 stated CNA #4 reported to her that the weekend aide (CNA #3) had told her that when she turned the resident, she heard her leg pop. CNA #2 stated on 08/07/18, she went to the DON and told her what had been reported to her. She stated the DON had said it was possible it could have happened when the resident was being turned. CNA #2 was asked if the resident's leg looked disconnected on 08/06/18, when she first observed the resident. She stated, Yes. She stated she saw the resident's leg first at 2:00 p.m., when making rounds. CNA #2 was asked to describe the resident's leg on this day. She stated it was swollen and it took two people to turn the resident now. She stated, Her leg looks like it is dangling. She was asked if the resident was in pain. She stated she had been informed the resident was receiving [MEDICATION NAME] every two hours. She stated the resident was out of it so she did not know whether she felt it or not. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked if the physician was notified they could not get the x-ray. She stated, Yes. She was asked where that was documented. She stated, It's probably not documented. She stated she just assumed the nurse documented. She stated she should not assume. The DON was asked what the hospice nurse had said when she visited the resident. She stated the hospice nurse came in after they were not able to get the x-ray and said they would keep the resident comfortable like the family preferred. She was asked who gave the orders to do nothing. She stated the family did not want the resident sent to the emergency room . The DON was asked where it was documented the family and physician were notified the x-ray could not be obtained. She stated, I guess some of the documentation got lost. She stated the nurse should have called the doctor. She stated, I don't see where she noted that. The DON was asked where the orders were to continue palliative care and not do anything else. She stated, There's not one. The DON was asked to describe the resident's leg today. She stated, I don't really know. It's swollen. She was asked if there were any other descriptors. She stated there was no warmth or discoloration when she saw it. The DON was asked where she obtained the information she put on the state reportable incident report. She stated from the staff and hospice nurse. She was asked if she had done an assessment of the resident's leg. She stated, I looked at it. She was asked who completed the assessment of the leg when she and the ADON saw it on 08/06/18. She stated the ADON had completed the assessment. She was asked if she allowed the LPN ADON to complete the assessment. She stated she had observed her completing the assessment. The DON was asked if she touched the resident's leg. She stated, No. She stated she did not want to hurt the resident. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. She was asked what happened when the staff moved the resident. She stated, Well, you have to still care for her. The DON was asked what kind of ongoing assessments and monitoring were occurring related to the resident's left leg. She made no comment. The DON was asked what kind of investigation into the injury of unknown origin had been done. She stated since the original incident report had been sent in, additional information had come to her attention. She stated she had sent in an addendum to the report. She was asked when that was done. She stated, Just a little bit ago. The DON was asked where she was with the investigation. She stated it was still ongoing as she was trying to get in touch with CNA #4. She stated CNA #4 was the one that said somebody on the weekend had heard a pop. The DON was asked if she had contacted every CNA who had worked with the resident since 08/04/18. She stated, No. She stated she wanted to know what CNA #4 was saying. She stated she had called CNA #4, but she would not return her calls. She stated she wanted to talk to CNA #4 before she talked with anyone else. She was asked if she knew which staff had worked with the resident since 08/04/18. She stated, No. She was asked if the facility had assignment sheets. She stated she could pull them. The DON was asked why the incident had not been reported to OSDH within two hours. The DON asked, When did it go to two hours? She stated she thought she had 24 hours to report the incident. The DON was asked why the information in the state reportable incident report did not accurately reflect the resident's condition, such as the left femur bone moving abnormally. She stated, I can't say it is fractured. I have to say what I see. On 08/08/18 at 4:35 p.m., CNA #2 was asked if she informed the DON of who had told her about the incident. She stated, Yes. She stated she had heard about the incident from CNA #4 and that CNA #3 had told CNA #4 about it. She stated, I even told her who (CNA #4) had heard it from. On 08/08/18 at 6:16 p.m., the physician was asked if he had been notified of the inability to obtain the ordered x-ray. He stated he had never heard of a radiology company not being able to obtain an x-ray. He was asked if the facility had told him that on 08/06/18. He stated he would remember that. He stated he had been at the facility on 08/06/18 and had seen the resident. He stated he had not noted any concern with resident #13. He stated she had been covered with her bed linens and he had moved all her extremities. He stated he might not have noted a concern with her leg. He was asked again if the facility had notified him of not obtaining the x-ray. He stated he was not sure and he would need to look into that. At 6:52 p.m., the physician stated the resident was on hospice services, so he would not have sent her out for treatment. He was asked if he had been given the opportunity to make that decision and provide further orders for the resident's care. He made no reply. The physician stated he had talked with his nurses and they had not been notified of the inability to obtain the ordered x-ray. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] .

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician of the inability to obtain an x-ray for a resident who had suffered an injury of unknown origin. The resident was found with an abnormally moving left femur bone and there was no known cause for the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure in notifying the physician. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . The immediate jeopardy was removed on 08/13/18 at 3:21 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to notify the physician of the inabilitiy to obtain an ordered x-ray for one (#13) of two sampled residents who were reviewed for injuries of unknown origin. The resident was found with an abnormally moving femur bone with an unknown cause on 08/06/18. The facility identified 88 residents who resided at the facility. Findings: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A nurse's note, dated 08/06/18 at 12:21 p.m., documented, .Mobile x-ray technician unable to perform x-ray adequately so called (family member) back to make her aware and her response was to wait until hospice nurse comes out and evaluate and they'll (sic) go from there, resident has no signs of indication of pain . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. A nurse's note, dated 08/07/18 at 11:54 a.m., documented, .Informed by staff pt has an issue with leg upon assessment this nurse noted pt lying in bed on left side when repositioned no c/o pain. Pt has leg has abnormal movement of femur bone, no discoloration, no open area, no active bleeding noted. As in prior message family has been made aware of above. Please reference previous note. Pt has no s/s of pain, no s/s of distress noted. Cont with HOB elevated and staff given pt supp for breakfast as she verbally refuses meals . A hospice aide visit note, dated 08/08/18 and untimed, documented, .Pt broke leg . Review of the clinical record revealed no documentation the physician was notified of the inability to obtain the ordered x-ray or for further orders to direct the resident's care. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 was asked if the resident's leg looked disconnected on 08/06/18, when she first observed the resident. She stated, Yes. She stated she saw the resident's leg first at 2:00 p.m., when making rounds. CNA #2 was asked to describe the resident's leg on this day. She stated it was swollen and it took two people to turn the resident now. She stated, Her leg looks like it is dangling. She was asked if the resident was in pain. She stated she had been informed the resident was receiving [MEDICATION NAME] every two hours. She stated the resident was out of it so she did not know whether she felt it or not. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked if the physician was notified they could not get the x-ray. She stated, Yes. She was asked where that was documented. She stated, It's probably not documented. She stated she just assumed the nurse documented. She stated she should not assume. The DON was asked what the hospice nurse had said when she visited the resident. She stated the hospice nurse came in after they were not able to get the x-ray and said they would keep the resident comfortable like the family preferred. She was asked who gave the orders to do nothing. She stated the family did not want the resident sent to the emergency room . The DON was asked where it was documented the family and physician were notified the x-ray could not be obtained. She stated, I guess some of the documentation got lost. She stated the nurse should have called the doctor. She stated, I don't see where she noted that. The DON was asked where the orders were to continue palliative care and not do anything else. She stated, There's not one. The DON was asked to describe the resident's leg today. She stated, I don't really know. It's swollen. She was asked if there were any other descriptors. She stated there was no warmth or discoloration when she saw it. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. She was asked what happened when the staff moved the resident. She stated, Well, you have to still care for her. On 08/08/18 at 6:16 p.m., the physician was asked if he had been notified of the inability to obtain the ordered x-ray. He stated he had never heard of a radiology company not being able to obtain an x-ray. He was asked if the facility had told him that on 08/06/18. He stated he would remember that. He stated he had been at the facility on 08/06/18 and had seen the resident. He stated he had not noted any concern with resident #13. He stated she had been covered with her bed linens and he had moved all her extremities. He stated he might not have noted a concern with her leg. He was asked again if the facility had notified him of not obtaining the x-ray. He stated he was not sure and he would need to look into that. At 6:52 p.m., the physician stated the resident was on hospice services, so he would not have sent her out for treatment. He was asked if he had been given the opportunity to make that decision and provide further orders for the resident's care. He made no reply. The physician stated he had talked with his nurses and they had not been notified of the inability to obtain the ordered x-ray. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] .

On 08/08/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician of the inability to obtain an x-ray for a resident who had suffered an injury of unknown origin. The resident was found with an abnormally moving left femur bone and there was no known cause for the injury. Resident #13 was admitted to the facility on [DATE] with no fractures. On 08/06/18, the resident was found with an abnormally moving left femur bone. No incidents and/or falls had been noted for the resident that could have caused the injury. At 4:52 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 5:08 p.m., the administrator and director of nursing were notified of the IJ situation related to the facility's failure in notifying the physician. On 08/09/18 at 9:57 a.m., an acceptable plan of removal was provided. The plan of removal documented, .2. On 08/08/18 skin and pain assessments were started on 100% of the in-house residents and will be completed by 08/09/18 to ensure no further injuries of unknown origin. Complete head to toe assessments and pain assessments will be completed by the ADON, MDS Coordinators and Charge Nurses, in accordance to facility standard of practice. The physician and responsible party will be notified of any new injuries if identified with orders as indicated. MDS Coordinators, Interim DON and ADON were reeducated by the Regional MDS Manager and Administrator on 08/08/18. Training included documentation of Changes of condition, assessment, investigation of injuries of unknown origin, communication with attending physician of assessments of injuries of unknown origin and Abuse and Neglect Standard of Practice related to investigation of injury of unknown origin. Re-education was started on 08/08/18 by the Interim DON and ADON for all Licensed Nurses currently employed. Training will include documentation of assessment, assessment injuries of unknown origin, investigation of injury of unknown origin and communication with attending physician of injuries of unknown origin. Abuse and Neglect Standard of Practice re-education was started on 8/08/18 by the Administrator and will be completed by end of day 8/9/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on the above plan by DON/ADON. 3. Interim DON, ADON, MDS nurse and Administrator will review incident reports, 24 hour report and Daily Nurses Notes at the Daily Clinical Start up meeting to ensure that documentation, investigation and notifications are through (sic) and complete as of 08/09/18. Weekly skin assessments will be reviewed by Interim DON/ADON during weekly clinical QA Meeting for 4 weeks and monthly for 2 months to ensure no injuries of Unknown Origin are identified. 4. Administrator will have an off cycle QA Meeting with QA Committee and Medical Director by 08/09/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 5. Investigation regarding (resident #13), injury of unknown origin is ongoing at this time. staff are being interviewed and witness statements are being obtained. Staff are being in-serviced related to Abuse/Neglect, Physician Notification, Resident assessment and Investigation related to injury of unknown origin. Physician has been requested to visit (resident #13) and visit is scheduled for 8-9-18. Head to toe skin assessments and pain assessments have been completed on all residents currently in facility . The immediate jeopardy was removed on 08/13/18 at 3:21 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to notify the physician of the inabilitiy to obtain an ordered x-ray for one (#13) of two sampled residents who were reviewed for injuries of unknown origin. The resident was found with an abnormally moving femur bone with an unknown cause on 08/06/18. The facility identified 88 residents who resided at the facility. Findings: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 06/21/18, documented the resident was severely impaired in cognitive skills for daily decision making; required extensive assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene; and was dependent on staff for eating. It was documented the resident had no functional limits in range of motion and was always incontinent of bowel and bladder. It was also documented the resident rarely understood others. The resident's care plan, updated 06/26/18, documented a problem related to a self care deficit. It was documented the resident required total assistance with activities of daily living and had contractures of her upper and lower extremities. The goal was the resident would maintain the highest practical level of independence over the next 90 days. Approaches included to use one staff for bed mobility, toileting, eating, and personal hygiene and one to two staff for transfers. A nurse's note, dated 08/06/18 at 11:18 a.m., documented, .This nurse was called to shower by residents hospice aid and and (sic) adnormality (sic) was brung (sic) to my attention lt leg looked out of place and swollen upon touch no signs that would indicate pain, resident is and (sic) hospice patient, called physician and obtained stat order to x-ray lt hip and lt leg, called (family member name withheld) and made her aware of finding and the P[NAME], resident do not show any facial expressions that indicate pain . A hospice aide visit note, dated 08/06/18 and untimed, documented, .Leg thigh .unusual . A nurse's note, dated 08/06/18 at 12:21 p.m., documented, .Mobile x-ray technician unable to perform x-ray adequately so called (family member) back to make her aware and her response was to wait until hospice nurse comes out and evaluate and they'll (sic) go from there, resident has no signs of indication of pain . A state reportable incident report, with a fax date and time of 08/07/18 at 11:41 a.m., documented the report was a combined initial and final report. It was documented the resident had sustained an injury of unknown source, and the physician, family, legal representative, and Adult Protective Services had been notified. The report documented, .At approx 11 am on 8/6/18, Hospice CNA called Charge Nurse to the shower room. (Resident #13) presented with a raised area to her left leg, area is not discolored or warm to touch. (Resident #13) did not show s/s of pain when area was touched. Spoke with staff, area was not noticed until today when Staff CNA and Hospice CNA were getting (resident #13) ready for shower (undressed). Charge nurse called family to talk about getting an x-ray, family stated they did not want anything done as long as she is not having pain. Hospice was notified of family's decision . (Resident #13) is an 89 yo female .with dx of dementia, protein calorie malnutrition, [MEDICAL CONDITION], GERD, anxiety, [MEDICAL CONDITIONS] delusions. (Resident #13) is total care for ADL's with 1-2 person assist. Her BIMS is 99, this shows the progression of her dementia. (Resident #13) doesn't speak much and when she does her speech is garbled. (Resident #13) is unable to make needs known . Nursing will continue to monitor for s/s of pain since (resident #13) is not very verbal. Staff and Hospice will continue to provide palliative care for (resident #13) and support to the family. The incident report was signed by the Director of Nursing. The incident report did not accurately reflect the resident's condition. A nurse's note, dated 08/07/18 at 11:54 a.m., documented, .Informed by staff pt has an issue with leg upon assessment this nurse noted pt lying in bed on left side when repositioned no c/o pain. Pt has leg has abnormal movement of femur bone, no discoloration, no open area, no active bleeding noted. As in prior message family has been made aware of above. Please reference previous note. Pt has no s/s of pain, no s/s of distress noted. Cont with HOB elevated and staff given pt supp for breakfast as she verbally refuses meals . A hospice aide visit note, dated 08/08/18 and untimed, documented, .Pt broke leg . Review of the clinical record revealed no documentation the physician was notified of the inability to obtain the ordered x-ray or for further orders to direct the resident's care. On 08/08/18 at 1:40 p.m., CNA #1 was asked if she was familiar with resident #13. She stated yes. She stated she worked Monday through Friday and was off on the weekends. She was asked if she had any knowledge of any incident with resident #13. She stated on Monday 08/6/18, she and the hospice aide decided to shower the resident because she was wet. She stated when they sat her down on the shower chair, they noticed her left upper leg was very swollen. She stated the resident sometimes made noises when they got her up, but she did not on this day. She stated the resident did moan when she was seated on the shower chair. CNA #1 stated they sent for the nurse. She stated the nurse came and looked at the resident and said they would get an x-ray. She stated they were unable to get an x-ray because the resident's legs were contracted. CNA #1 stated the nurse called for the hospice nurse to come, and she did. She stated the hospice nurse took a picture of the resident's leg and stated she was going to send it to the hospice doctor. CNA #1 stated the resident's family member was called. She stated they were told to leave the resident in bed and to keep her dry. On 08/08/18 at 2:05 p.m., CNA #1 was asked to show the surveyor the resident's left leg. The leg was observed to be enlarged. CNA #1 was asked if it was larger than normal. She stated, Yes. She stated, It was bigger than this on Monday (08/06/18). CNA #1 attempted to reposition the resident. The resident moaned in pain when the left leg was moved. The left thigh bent abnormally, abducting slightly, when it was moved. On 08/08/18 at 2:31 p.m., CNA #2 was asked what knowledge she had of the incident with resident #13. She stated when she came to work on 08/06/18 for the evening shift, it was reported to her the resident's leg was messed up. She stated around 8:00 p.m. on that evening, CNA #4 came in and asked her if she knew what had happened to the resident's leg. CNA #2 stated she asked CNA #4 if she had observed the resident's leg. CNA #2 stated she told the CNA #4 the leg looked disconnected. CNA #2 was asked if the resident's leg looked disconnected on 08/06/18, when she first observed the resident. She stated, Yes. She stated she saw the resident's leg first at 2:00 p.m., when making rounds. CNA #2 was asked to describe the resident's leg on this day. She stated it was swollen and it took two people to turn the resident now. She stated, Her leg looks like it is dangling. She was asked if the resident was in pain. She stated she had been informed the resident was receiving [MEDICATION NAME] every two hours. She stated the resident was out of it so she did not know whether she felt it or not. On 08/08/18 at 4:03 p.m., the DON was asked what happened to the resident's leg. She stated, We don't really know. She stated around 11:00 a.m. on 08/06/18, she and the ADON were called to look at the resident. She stated they went to the shower room and were shocked the resident was not feeling anything. She stated they tried to do an x-ray but could not get it. She stated, She (resident #13) isn't in pain. She stated they called the family, and the family did not want anything done as long as the resident was not having pain. The DON was asked when she first became aware there was something wrong with the resident's leg. She stated, On Monday. She stated they had heard a rumor the weekend CNA heard a pop. She stated she called CNA #2 and CNA #2 had informed her of who the person was that had told her about the weekend CN[NAME] The DON stated the hospice aide had come to her on this day and informed her the resident's leg had not been like that before. The DON stated, I think it's pathological. She stated, We are keeping her comfortable because that is her wishes. The DON was asked to describe how the resident's leg was on 08/06/18. She stated, It had a big hump right here (pointing to the upper thigh). She stated the leg was swollen and had a baseball or softball sized raised area. She stated, It was not warm or painful when (ADON) touched it. She was asked if they attempted to move the leg. She stated no. She stated they agreed to get an x-ray. The DON was asked if the physician was notified they could not get the x-ray. She stated, Yes. She was asked where that was documented. She stated, It's probably not documented. She stated she just assumed the nurse documented. She stated she should not assume. The DON was asked what the hospice nurse had said when she visited the resident. She stated the hospice nurse came in after they were not able to get the x-ray and said they would keep the resident comfortable like the family preferred. She was asked who gave the orders to do nothing. She stated the family did not want the resident sent to the emergency room . The DON was asked where it was documented the family and physician were notified the x-ray could not be obtained. She stated, I guess some of the documentation got lost. She stated the nurse should have called the doctor. She stated, I don't see where she noted that. The DON was asked where the orders were to continue palliative care and not do anything else. She stated, There's not one. The DON was asked to describe the resident's leg today. She stated, I don't really know. It's swollen. She was asked if there were any other descriptors. She stated there was no warmth or discoloration when she saw it. The DON was asked to read the nurse's note, dated 08/06/18 at 11:18 a.m., when it was documented the leg looked out of place and the nurse's note, dated 08/07/18 at 11:54 a.m., when it was documented there was abnormal movement of the femur bone. She stated, I was not aware of that. She stated, I didn't see abnormal movement of the femur. She was asked what happened when the staff moved the resident. She stated, Well, you have to still care for her. On 08/08/18 at 6:16 p.m., the physician was asked if he had been notified of the inability to obtain the ordered x-ray. He stated he had never heard of a radiology company not being able to obtain an x-ray. He was asked if the facility had told him that on 08/06/18. He stated he would remember that. He stated he had been at the facility on 08/06/18 and had seen the resident. He stated he had not noted any concern with resident #13. He stated she had been covered with her bed linens and he had moved all her extremities. He stated he might not have noted a concern with her leg. He was asked again if the facility had notified him of not obtaining the x-ray. He stated he was not sure and he would need to look into that. At 6:52 p.m., the physician stated the resident was on hospice services, so he would not have sent her out for treatment. He was asked if he had been given the opportunity to make that decision and provide further orders for the resident's care. He made no reply. The physician stated he had talked with his nurses and they had not been notified of the inability to obtain the ordered x-ray. A physician's progress note, dated 08/09/18, documented, .Impressions: [MEDICAL CONDITION] .

On 03/28/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have competent nursing staff to care for residents with pressure ulcers. The resident was admitted to the facility on [DATE] with one stage II pressure ulcer on the right buttock that measured 5 cm x 4 cm, per hospital records dated 03/12/18. The resident was sent to the hospital on [DATE]. Hospital records documented upon arrival to the hospital, the resident was found to be in septic shock, most likely from a stage IV sacral decubitus ulcer. The ulcer was found to measure 7.6 cm x 7.8 cm, with the distal sacrum and proximal coccyx exposed, and osteo[DIAGNOSES REDACTED] could not be excluded. The resident subsequently required intravenous antibiotic treatment of [REDACTED]. At 12:13 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 12:17 p.m., the administrator and Director of Nursing were notified of the IJ situation related to the facility's failure to have competent nursing staff to care for a resident with pressure ulcers. On 03/29/18 at 12:07 p.m., an acceptable plan of removal, with addendum, was provided. The plan of removal documented, On 03/28/18 an Immediate Jeopardy was called by the surveyor due to concerns in the areas of Pressure Ulcer assessment and treatment and Nurse Competency. Based on the concerns identified, the following plan of action was implemented. Resident was admitted on [DATE] with a stage 4 pressure to his sacrum. Treatment orders were obtained on 03/13/18 but the nurse failed to code the order correctly and the treatment did not fire to the electronic TAR therefore it was not documented as being completed. On 03/15/18 the orders were changed and the treatment was documented correctly. On 03/20/18 orders were changed again but resident was discharged to the hospital. On return from the hospital the treatment orders did not get transcribed. Resident discharged from facility on 03/23/18. 1. On 03/28/18 skin assessments were started on 100% of the residents and will be completed by 12am 03/29/18. Complete head to toe assessments will be completed by the Director of Nurses (DON) ADON, MDS Coordinators and Charge Nurses. In accordance to facility standard of practice. The physician and responsible party will be notified of any new skin problems if identified with treatment orders for wound obtained and transcribed appropriately. Director of Nursing and ADON were reeducated by the Divisional Quality Manager on 03/28/18. Training will include documentation, assessment, proper staging of pressure areas, measurement and management of pressure and non-pressure areas and communication with attending physician and/or wound care physician with any changes in wound condition and receiving and transcribing treatment orders appropriately. Re-education was started on 03/28/18 by the DON and ADON for all Licensed Nurses currently employed. Training will include documentation, assessment, proper staging of pressure areas, measurement and management of pressure and non-pressure areas and communication with attending physician and/or wound care physician with any changes in wound condition and receiving and transcribing treatment orders appropriately. Reeducation will be completed by 8am 03/29/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on above plan. All current resident's orders were reviewed for proper coding and transcription on 3/28/18 by the DON and corrections made if indicated. All resident's charts were checked by medical Records for telephone orders written to ensure they were transcribed and coded accurately in the Electronic Record and will be completed by 5pm on 03/28/18. 2. DON, ADON, MDS nurse and Administrator will review Treatment Administration Record for all Pressure Ulcers at the Daily Clinical Start up meeting to ensure that documentation is accurate as of 03/29/18. All new treatment orders written will be reviewed by DON and/or ADON during Daily clinical Meeting to ensure proper transcription and coding. Weekly skin assessments will be reviewed by DON/ADON during weekly Clinical QA Meeting for 4 weeks and monthly for 2 months to ensure compliance starting 03/29/18. 3. Administrator will have an off cycle QA Meeting with QA Committee and Medical director by 03/29/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 4. Addendum to Plan 3/29/18 at 12:02 Re-education was started on 03/29/18 by the DON and ADON for all Licensed Nurses currently employed. Training will include documentation, assessment, proper staging of pressure areas, measurement and management of pressure and non-pressure areas and communication with attending physician and/or wound care physician with any changes in wound condition and receiving and transcribing treatment orders appropriately. Reeducation will be completed by 03/29/18 . The immediate jeopardy was removed on 03/29/18 at 4:15 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ ensure staff was competent in caring for two (#1 and #4) of four sampled residents who had pressure ulcers. The facility identified six residents as having pressure ulcers; and ~ ensure staff was competent in caring for one (#4) of three sampled residents whose records were reviewed and who developed respiratory concerns. The facility identified 83 residents as residing at the facility. Findings: 1. A hospital physical therapy note, dated 03/12/18 at 2:21 p.m., documented, .Skin inspection .findings: Pressure Stage 2 .Wound Management .Wound #1 location: Coccyx .Size: 5 cm x 4 cm .Date Measured: 03/12/18 .Description: Opaque wound base, light pink/red around the edge .Type of Drainage: None .Wound Type consistent with: Pressure Stage 2 .Margins: Irregular .Odor N (none) .Wound 1: Irrigation/Cleaning Normal saline & gauze Dressing Contact Layer: Skin Prep: [MEDICATION NAME] AG .(Secondary) Dressing: [MEDICATION NAME] .Comment: [MEDICATION NAME] AG/[MEDICATION NAME] .Some granulation to sacral pressure ulcer w/ minimal drainage, will benefit from skilled PTWC (physical therapy wound care) to progress healing .Therapist Recommendation for discharge: Skilled Nursing Facility . A hospital nurse's note, dated 03/12/18 at 3:18 p.m., documented, .Patient discharge to Warr Acres Nursing Home . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted for skilled services for strengthening and mobility. A skilled nurse's note, dated 03/12/18 at 8:06 p.m., documented, .Received (sic) resident in unit vai (sic) stretcher .Residnet (sic) is a times 2 assist with adls and transfers .Resident scrotal area is escoriated (sic) .Protective cream applied. Coccyx is red and irritated. Resident was repositioned . A wound assessment report; dated 03/12/18, untimed, and electronically signed by the DON; documented, .Date of Assessment .3/12/2018 .Wound Type .pressure .Wound Location .Coccyx; unstageable wound with eschar, order for santyl .Date wound identified .312/2018 .Present upon admission .yes .Assessment Occasion .Admission . It was documented the ulcer was unstageable due to slough/eschar, had no drainage, had no infection, and there was no pain with wound/treatment. It was documented the ulcer measured 7.5 cm x 6.0 cm x 0.0 cm, had 100% eschar on the wound bed, and had well defined borders. It was documented the surrounding skin was normal. It was documented the physician was in the facility and was notified of the pressure ulcer and the responsible party was notified. It was documented, .Treatments .Pending treatment orders . Review of admission orders [REDACTED] Review of the resident's undated baseline care plan revealed no documentation the resident had any skin concerns. It was marked the resident needed to be turned and repositioned as a skin breakdown intervention. The baseline care plan was not signed by a facility staff member or the resident/ resident representative. A physician's telephone order, dated 03/13/18, documented, .Cleanse sacrum (with) normal saline. Pat dry. Apply Santyl to wound bed. Apply [MEDICATION NAME] and cover (with) [MEDICATION NAME] daily . Skilled nurses' notes, dated 03/13/18 at 6:05 a.m. and 9:04 p.m., documented the resident's skin was warm and dry. There was no documentation related to the pressure ulcer. Review of treatment sheets, dated 03/13/18, revealed no documentation the pressure ulcer treatment was completed as ordered. There was no entry with instructions for the treatment on the treatment sheet. A skilled nurse's note, dated 3/14/18 at 10:17 a.m., contained no documentation related to the pressure ulcer. Review of treatment sheets, dated 03/14/18, revealed no documentation the pressure ulcer treatment was completed as ordered. Skilled nurses' notes, dated 03/15/18 at 2:07 a.m. and 12:27 p.m., contained no documentation related to the pressure ulcer. Review of treatment sheets, dated 03/15/18, revealed no documentation the pressure ulcer treatment of [REDACTED]. A physician's telephone order, dated 03/15/18 and untimed, documented, .Venelex Ointment, Apply Ointment to wound on sacrum every shift until healed . A skilled nurse's note, dated 03/15/18 at 9:32 p.m., documented, .Being turned every 2 hours d/t wound on sacrum. New order for Venelex ointment to sacrum. Rated pain 7/10 on buttocks . Treatment sheets, dated 03/15/18, documented the Venelex was applied at 10:00 p.m. Treatment sheets, dated 03/16/18, documented Venelex ointment was applied to the pressure ulcer three times daily. The treatment sheets documented, .A Pressure ulcer of sacral region, stage 2 . A skilled nurse's note, dated 03/16/18 at 12:36 p.m., documented, .He has a stage 3 on left glute and area was cleansed and treatment applied . Treatment sheets, dated 03/17/18 through 03/19/18, documented Venelex was applied to the pressure ulcer three times daily. A five day, pay per service assessment, dated 03/19/18, documented the resident was severely cognitively impaired; required extensive assistance for bed mobility, transfers, locomotion, dressing, and personal hygiene; was frequently incontinent of urine and always incontinent of bowel; and had one unstageable pressure ulcer with slough or eschar present. It was documented the resident received dressings and ointments or medications for the ulcer. A nurse's note, dated 03/20/18 at 4:15 a.m., documented, .(12:15 a.m.) Resident alert and oriented per verbal stimuli and noted moaning/groaning states his 'stomach is hurting so bad.' Peg tube noted with drain dressing soaked with brown colored feeding around peg tube site. Vitals noted 100/62, (heart rate) 122, (respirations) 22, t = 102.2 axillary with O2 sat 84% on RA. Resident denies any shortness of breath. O2 at 3l/bnc applied at this time. Noted productive cough but resident states there is nothing coming up. Informed resident not to swallow the secretions that he is coughing up. Peg tube site cleansed and dressing applied. PRN pain medication given after 240 cc residual noted of browninsh (sic) colored feeding. (11:30 p.m.) feeding held. MD notified of resident status and condition changes and order to sent (sic) resident to ER for evaluation and treatment .Transported out of facility via stretcher with EMT x 4 at (1:50 a.m.) . Review of treatment sheets, dated 03/20/18 at 6:00 a.m., documented the Venelex treatment was not applied. A skilled nurse's note, dated 03/20/18 at 12:19 p.m., documented, .Assessment complete . There was no documentation of when the resident returned to the facility or what had occurred with the resident while out of the facility. Review of treatment sheets, dated 03/20/18 at 2:00 p.m. and 10:00 p.m., revealed no documentation the resident received the Venelex treatment to the pressure ulcer. A physician's telephone order, dated 03/20/18 and untimed, documented, .DC Venelex to Coccyx. Clean coccyx (with) wound cleanser, pat dry apply Santyl to wound bed, cover (with) dry dressing, change daily . Treatment sheets, dated 03/20/18, had no documentation the pressure ulcer treatment of [REDACTED]. There was not an entry on the treatment sheet with instructions for the Santyl treatment. The resident's comprehensive care plan, dated 03/20/18, documented a problem related to impaired skin integrity. It was documented, .was admitted with scrotal excoriation and an unstageable coccyx wound, the wound bed is covered with escsar (sic) . The goal was the area on the coccyx would decrease in size and be free of infections through the next review date. Approaches included to use a draw sheet to prevent friction and shearing and to treat the ulcer with Santyl daily. Treatment sheets, dated 03/21/18 and 03/22/18, had no documentation the pressure ulcer treatment was completed as ordered by the physician. A skilled nurse's note, dated 03/22/18 at 9:19 a.m., documented, .Resident refused care and medictions (sic) stating 'leave me alone.' Encouraged resident to turn from side-to-side often for skin integrity, resident refuses at this time . Treatment sheets, dated 03/23/18, had no documentation the pressure ulcer treatment was completed as ordered by the physician. Review of the clinical record revealed no documentation the resident received a treatment for [REDACTED]. There was no documentation the pressure ulcer was assessed after 03/13/18. The clinical record documented inconsistent skin assessments, staging, and locations of the pressure ulcer. There was no documentation the resident was seen by the facility's consultant wound doctor. A skilled nurse's note, dated 03/23/18 at 7:24 p.m., documented, .Resident's family called supervisor and asked us to send resident to (hospital name withheld) for eval and treatment. Did not state what it was in reference to. We got him ready and sent him out per family request and he has not returned as yet . A hospital history and physical report, dated 03/23/18 at 9:18 p.m., documented, .Stage IV sacral decubitus ulcer .surrounding necrosis . A hospital progress note, dated 03/24/18 at 9:33 a.m., documented, .Problem List 1. Pneumonia 2.[MEDICAL CONDITION] .Impression .Septic shock on admission from most likely stage 4 decub ulcer on admission .Stage 4 decub ulcer .Plan .Continue IV Vanc and [MEDICATION NAME] at this point for both Decub ulcers and HCAP .ordered CT (computerized tomography) .to look at the decub ulcer extent . A hospital CT scan, dated 03/26/18 at 5:50 p.m., documented, .Findings: .There is a large sacral decubitus ulcer measuring approximately 7.6 cm x 7.8 cm .The underlying distal sacrum and proximal coccyx appear to be exposed. A tiny amount of overlying soft tissue may be present. This ulcer is new compared to the prior exam. The distal sacrum underlying the ulcer does not appear significantly changed compared to the prior exam. The visualized osseous structures are demineralized .Impression .New, large sacral decubitus ulcer with the underlying distal sacrum appearing almost exposed by the wound. A trace amount of overlying soft tissue may separate the cortex from the wound. However, given the possible exposure of the underlying sacrum, osteomyeolitis is not excluded . On 03/28/18 at 9:33 a.m., LPN #1 was asked who was responsible for completing skin assessments when a resident was admitted to the facility. She stated the admitting nurse completed the initial skin assessment and then documented the assessment in the electronic record on the wound manager screen. She was asked when that was done. She stated it was completed on admission. LPN #1 was asked how the assessment was completed. She stated when the resident came to the facility, a head to toe assessment was done. She stated if there were any wounds, it was documented and put into the initial nursing note. She stated the very first nursing note should have the skin condition documented. LPN #1 was asked what was done if a resident was admitted with a pressure ulcer, but there were no orders for a treatment for [REDACTED]. She was asked who was responsible for transcribing the order received. She stated the that completed the admission should do the transcription. She stated there was supposed to be some one who went through the chart to verify orders were transcribed. She stated that was where some breakdown in the system was happening. LPN #1 was asked what the process was for ensuring physician orders were added to medication and treatment sheets, as indicated. She stated that was done in the computer system. She stated that once the orders were entered into the computer, they automatically appeared on the medication or treatment sheets. LPN #1 was asked how often pressure ulcer assessments were completed. She stated, Once a week. She was asked who completed those assessments. She stated various nurses, depending on what shift they were working. She stated the assessments were assigned out over the different shifts. LPN #1 was asked where the pressure ulcer assessments were documented. She stated they were documented on the skin assessment sheets and were kept in the report book all month. She stated they were then taken out and placed in the resident's charts. She was asked to provide the skin assessments for resident #4. She obtained the report book, looked through the book, and looked through the resident's clinical record. No skin assessments were located. LPN #1 was asked who completed pressure ulcer treatments. She stated the charge nurses did. She was asked what training she had in pressure ulcer care. She stated the only training she had was being a nurse for [AGE] years. She stated she had no specialized training. She was asked if the facility had provided any inservice education related to pressure ulcers. She stated, No as far as I can remember. She was asked how long she had been employed by the facility. She stated a time frame over one year. LPN #1 was asked if resident #4 had a pressure ulcer upon admission to the facility. She stated, Yes. She was asked how that was addressed on the resident's baseline care plan. She reviewed the care plan and stated the only thing that was documented was to turn and reposition the resident. She stated it did not reflect the current pressure ulcer, any treatments, or the fact the resident had a specialty mattress. LPN #1 was asked what treatment orders were in place for the resident's pressure ulcer. She stated she believed Santyl was initially ordered but then in was changed to Venelex or vice versa. She stated, I'm not sure why. She stated, It was closed, eschared over. She stated the resident was very combative and would not let the nurses do anything. She stated, I don't know if that is charted. LPN #1 was asked when the order for the Santyl treatment was obtained. She stated 03/13/18. She was asked if the ulcer was treated with the Santyl, as ordered by the physician. She reviewed the treatment sheets and stated, It's not there. She reviewed the nursing medication administration sheets and stated, I don't see it on there. She was asked if she had treated the pressure ulcer with Santyl as ordered. She stated, I never did. She was asked why she did not. She stated, it did not show up and wasn't on my report. LPN #1 was asked to describe the resident's pressure ulcer. She stated it was pretty good size. She stated it was almost perfectly round and was complete eschar, She was asked if the facility had a wound care doctor. She stated, Yes. She stated the wound care doctor had been at the facility on 03/20/18 but did not see the resident. She was asked why the resident was not seen by the wound care doctor. She stated if there had been no treatment orders and the ulcer had not been reported on, the wound care doctor would not know to see the resident. LPN #1 was asked if she had knowledge these orders were not carried out prior to the survey. She stated, Yes. She was asked if she had taken that information to anyone. She stated, Yes. She was asked if anything had been done after that. She stated, No. LPN #1 was asked why the pressure ulcer treatment had been changed to Venelex on 03/15/18. She stated, I have no idea. She stated a reason had not been documented. She was asked if there was Santyl in the facility. She stated, Yes. She stated she did not understand why it would not have been documented on the treatment sheets. She was asked if the resident received the Venelex treatment as ordered. She stated, Yes. She stated she did that treatment herself on the days she was at work. LPN #1 was asked why the Santyl was re-ordered on [DATE]. She stated it was her belief the MDS coordinator had asked about it and had wanted to look at the pressure ulcer. She stated that was when they, she and the MDS coordinator, had taken the concern to the DON. She stated she believed that was when it was changed. She was asked if the resident had received that treatment, as ordered by the physician. She stated, I don't know. She was asked if it was documented. She reviewed the treatment sheets. LPN #1 was asked again if the resident received the Santyl treatment as ordered. She stated, No, I don't think so. LPN #1 was asked why the resident did not receive the pressure ulcer treatments as ordered by the physician. She stated, The only thing I can tell you is there is a huge communication problem. She stated no one was verifying orders were put into the computer or verifying orders showed up on the treatment sheets. LPN #1 was asked to describe the pressure ulcer at the time the resident went back to the hospital on [DATE]. She stated it had not changed at all on the day she had observed it last, which would have been 03/22/18. She was asked what interventions had been implemented to care for the pressure ulcer. She stated, Having him stay off it. She stated the resident could turn side to side. She stated, That's all I know of, except for a specialty mattress. She was asked what kind of specialty mattress the resident had. She stated, Maybe just a mattress with bevels. She stated she did not know what kind. On 03/28/18 at 10:21 a.m., the MDS coordinator was asked if she had spoke with LPN #1 regarding the resident's pressure ulcer. She stated she had asked for clarification. She stated she had needed to see the wound sheet and see the actual dressing. She was asked what she had determined the treatment to be. She stated she would have to look at the note. She stated she was getting some clarification and went and looked at the wound. She was asked if she had talked with the DON. She stated, Yes. She was asked what the conversation with the DON was about. She stated she needed clarification on the pressure ulcer. She was asked what clarification she needed. She stated what type of treatment was actually getting done to the wound. She was asked what date it was she spoke with the DON. She stated it would have been the date of the assessment. On 03/28/18 at 10:25 a.m., the DON was asked how she monitored the facility's pressure ulcer system. She stated weekly skin sheets were completed and a weekly report was done for any pressure ulcer above a stage II. She stated, I knew he was coming in, so I measured myself and put it into the system. She stated pressure ulcers were talked about every morning during a meeting. The DON was asked how she monitored to ensure treatments were completed as ordered by the physician. She stated that in the computer system, a treatment would show up red if they were not done. She stated they communicated well with the nurses. She stated they tried to set treatments for the morning shift. She stated the computer software would not allow you to close it (finalize) if there was no documentation. She was asked how she monitored to ensure physician orders were put into the computer system. She stated they went through orders every morning. The DON was asked why resident #4 did not receive the pressure ulcer treatments as ordered by the physician. She stated, My understanding is they didn't want it to open. She stated the resident was really hospice appropriate. She was asked where that information was documented. She stated, It probably isn't documented. She stated there was no order for Santyl. The surveyor provided the order for the DON's review. The DON was asked why the wound assessment, dated 03/12/18 and signed electronically by herself, documented measurements, a treatment of [REDACTED]. She stated she did not do the wound assessment. She stated, I did a nurses' note on him. She was asked where that was documented. She reviewed the clinical record and stated she could not find the note. The DON was asked what the admitting nurse's documentation noted about the resident's skin. She sated, Coccyx is red, oh dear. She was asked if the resident received the Santyl treatment, as ordered on [DATE]. She reviewed the treatment sheets and stated, No, he didn't. It's not on there at all. She was asked why the Venelex was ordered on [DATE]. She stated, I don't know. She stated she would have to ask the nurse why. The DON was asked why the treatment was changed back to Santyl on 03/20/18. She stated, I don't know. She was asked if the resident received that treatment. She stated, That order wasn't process either. The DON was asked who completed the wound assessment on 03/12/18 if she did not. She stated, I must have had it (the computer screen) open or something. She stated the admitting nurse must have done it. She stated she looked at the resident the following day (03/13/18). She was asked where that documentation was. She stated, I remember on him I wrote a note. The DON was asked if she had any knowledge the resident had not received his pressure ulcer treatments, as ordered by the physician, prior to this day. She stated, No, I did not. The DON was asked when she had observed the resident's pressure ulcer. She stated the day after his admission. She stated, It was my understanding we were leaving it alone. If we opened it, it would be a mess. She stated, I was not aware of (the order for) Santyl at all. The DON was asked if she had observed the pressure ulcer again. She stated she did not know if she had or not. She was asked if the wound doctor had seen the resident. She stated she did not think so. She then stated she thought she had looked at it to measure it on 03/20/18 with the nurse because she was concerned about the ulcer. She was asked why she did not check the orders and treatments if she was concerned about the ulcer. She stated she wanted to make sure the ulcer was not infected. She stated if it opened up, there would be a mess. The DON was asked at what time was it not appropriate to treat a pressure ulcer. She stated when a person was as sick as resident #4 was. She stated the resident needed hospice services. She was asked if the resident was receiving hospice services. She stated, No. She was asked how the physician was involved in making a decision not to treat the resident's pressure ulcer. She stated she had talked with the doctor's office but did not know who it was she had talked with. She was asked if the family had been involved in making that decision. She stated the facility had not talked with the family. The DON was asked if there was a physician's order for hospice services. She stated, No. 2. A hospital wound care evaluation report, dated 01/15/18, documented resident #1 had the following pressure ulcers: ~ a suspected deep tissue injury to the left trochanter that measured 10 cm x 4 cm by 0.1 cm. It was documented, .pink-red open ulcer black slough-eschar purple .4 cm x 1.5 cm area in center that is dark tissue, 2nd area just posterior to trochanter Stage 1 or possible DTPI that in deep red that is intact and 8 cm x 4 cm .; ~ a stage II pressure ulcer to the left upper arm that measured 14 cm x 4 cm x 0.1 cm; and ~ an abrasion to the top of the left shoulder that was scabbed. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 01/24/18 at 7:35 p.m., documented, .Admit .Pt has wounds to left hipt (sic), left upper FA, back of neck, coccyx reddened .To right ankle red/purple scar noted. To pts. right heel bandage noted . A skilled nurse's note, dated 01/25/18 at 2:46 a.m., documented, .wounds .wound care .Resident has drsg intact to left heel . A skilled nurse's note, dated 01/25/18 at 6:18 p.m., documented, .pts. wounds covered to left upper FA, left hip, neck . Review of the resident's clinical record, from 01/24/18 through 01/30/18, revealed no documentation the resident received any treatments to the pressure ulcers. There were no physician orders for treatments, and there was no documentation the pressure ulcers had been assessed when the resident was admitted to the facility. An admission assessment, dated 01/31/18, documented the resident was cognitively intact, required extensive assistance with bed mobility and transfers, and had one stage I pressure ulcer and one unstageable pressure ulcer. The resident's care plan, dated 01/31/18, documented a problem related to impaired skin integrity. It was documented the resident was admitted with a left lateral thigh wound and left heel blister. The goal was the areas would show signs of healing and be free of infection within 30 days. Approaches included to complete skin assessments quarterly and as needed; nurse documentation weekly and as needed on any aspects of wound healing; and a wound care consultation. A wound assessment report, dated 01/31/18, documented the resident had a blister on the left heel. It was documented the blister measured 4.0 cm x 4.5 cm and was present on admission. It was documented there was no drainage or infection. Another wound assessment report, dated 01/31/18, documented the resident had an open wound to the left, rear thigh. It was documented the wound measured 2.2 cm x 7.0 cm x 0.0 cm, had no drainage, and no signs of infection. It was documented the wound had slough and was present upon admission. Physician's orders, dated 01/31/18 and untimed, documented, .Vit C 500 mg caplet. Take one P.O. BID .Zinc 50 mg capsule. Take 2 capsules by mouth twice a day .Wound Care Consult .Santyl Ointment. Cleanse wound to (left) hip c N.S. Pat dry. Apply Santyl to the wound bed .Silverdene .Apply a thin layer of silverdene peri-wound bed and cover with [MEDICATION NAME]. Skin Prep to (right) heel q shift .Cleanse (left) shoulder c N.S. Pat dry. Apply [MEDICATION NAME] and cover (with) a band aid once daily . Review of treatment sheets, dated 01/31/18, revealed no documentation the resident received the treatments, except the application of skin prep to the right heel. Treatment sheets, dated 02/01/18 through 02/05/18, documented the resident received the treatments as ordered. A wound care specialist initial evaluation, dated 02/06/18, documented: ~ there w (TRUNCATED)

On 03/28/18, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have an effective system for the care of a resident with a pressure ulcer. The facility failed to implement medical interventions to promote the healing of pressure ulcers; conduct accurate and thorough pressure ulcer assessments; and ensure competent nursing staff to care for residents with pressure ulcers. The resident was admitted to the facility on [DATE] with one stage II pressure ulcer on the right buttock that measured 5 cm x 4 cm, per hospital records dated 03/12/18. The resident was sent to the hospital on [DATE]. Hospital records documented upon arrival to the hospital, the resident was found to be in septic shock, most likely from a stage IV sacral decubitus ulcer. The ulcer was found to measure 7.6 cm x 7.8 cm, with the distal sacrum and proximal coccyx exposed, and osteo[DIAGNOSES REDACTED] could not be excluded. The resident subsequently required intravenous antibiotic treatment of [REDACTED]. At 12:13 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 12:17 p.m., the administrator and Director of Nursing were notified of the IJ situation related to the facility's failures in caring for a resident with pressure ulcers. On 03/29/18 at 12:07 p.m., an acceptable plan of removal, with addendum, was provided. The plan of removal documented, On 03/28/18 an Immediate Jeopardy was called by the surveyor due to concerns in the areas of Pressure Ulcer assessment and treatment and Nurse Competency. Based on the concerns identified, the following plan of action was implemented. Resident was admitted on [DATE] with a stage 4 pressure to his sacrum. Treatment orders were obtained on 03/13/18 but the nurse failed to code the order correctly and the treatment did not fire to the electronic TAR therefore it was not documented as being completed. On 03/15/18 the orders were changed and the treatment was documented correctly. On 03/20/18 orders were changed again but resident was discharged to the hospital. On return from the hospital the treatment orders did not get transcribed. Resident discharged from facility on 03/23/18. 1. On 03/28/18 skin assessments were started on 100% of the residents and will be completed by 12am 03/29/18. Complete head to toe assessments will be completed by the Director of Nurses (DON) ADON, MDS Coordinators and Charge Nurses. In accordance to facility standard of practice. The physician and responsible party will be notified of any new skin problems if identified with treatment orders for wound obtained and transcribed appropriately. Director of Nursing and ADON were reeducated by the Divisional Quality Manager on 03/28/18. Training will include documentation, assessment, proper staging of pressure areas, measurement and management of pressure and non-pressure areas and communication with attending physician and/or wound care physician with any changes in wound condition and receiving and transcribing treatment orders appropriately. Re-education was started on 03/28/18 by the DON and ADON for all Licensed Nurses currently employed. Training will include documentation, assessment, proper staging of pressure areas, measurement and management of pressure and non-pressure areas and communication with attending physician and/or wound care physician with any changes in wound condition and receiving and transcribing treatment orders appropriately. Reeducation will be completed by 8am 03/29/18. Any nurse who is on vacation or leave of absence will not be allowed to work until education is received. All new nurses will receive education prior to working on the floor on above plan. All current resident's orders were reviewed for proper coding and transcription on 3/28/18 by the DON and corrections made if indicated. All resident's charts were checked by medical Records for telephone orders written to ensure they were transcribed and coded accurately in the Electronic Record and will be completed by 5pm on 03/28/18. 2. DON, ADON, MDS nurse and Administrator will review Treatment Administration Record for all Pressure Ulcers at the Daily Clinical Start up meeting to ensure that documentation is accurate as of 03/29/18. All new treatment orders written will be reviewed by DON and/or ADON during Daily clinical Meeting to ensure proper transcription and coding. Weekly skin assessments will be reviewed by DON/ADON during weekly Clinical QA Meeting for 4 weeks and monthly for 2 months to ensure compliance starting 03/29/18. 3. Administrator will have an off cycle QA Meeting with QA Committee and Medical director by 03/29/18. QA Committee will review above plan monthly for 3 months and make revisions if indicated. 4. Addendum to Plan 3/29/18 at 12:02 Re-education was started on 03/29/18 by the DON and ADON for all Licensed Nurses currently employed. Training will include documentation, assessment, proper staging of pressure areas, measurement and management of pressure and non-pressure areas and communication with attending physician and/or wound care physician with any changes in wound condition and receiving and transcribing treatment orders appropriately. Reeducation will be completed by 03/29/18 . The immediate jeopardy was removed on 03/29/18 at 4:15 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ perform initial and ongoing thorough skin and pressure ulcer assessments; ~ implement medical interventions to aid in the healing of pressure ulcers; and/or ~ obtain physician orders for pressure ulcer treatments in a timely manner for two (#1 and #4) of four sampled residents who had pressure ulcers. The facility identified six residents as having pressure ulcers. Findings: 1. A hospital physical therapy note, dated 03/12/18 at 2:21 p.m., documented, .Skin inspection .findings: Pressure Stage 2 .Wound Management .Wound #1 location: Coccyx .Size: 5 cm x 4 cm .Date Measured: 03/12/18 .Description: Opaque wound base, light pink/red around the edge .Type of Drainage: None .Wound Type consistent with: Pressure Stage 2 .Margins: Irregular .Odor N (none) .Wound 1: Irrigation/Cleaning Normal saline & gauze Dressing Contact Layer: Skin Prep: [MEDICATION NAME] AG .(Secondary) Dressing: [MEDICATION NAME] .Comment: [MEDICATION NAME] AG/[MEDICATION NAME] .Some granulation to sacral pressure ulcer w/ minimal drainage, will benefit from skilled PTWC (physical therapy wound care) to progress healing .Therapist Recommendation for discharge: Skilled Nursing Facility . A hospital nurse's note, dated 03/12/18 at 3:18 p.m., documented, .Patient discharge to Warr Acres Nursing Home . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted for skilled services for strengthening and mobility. A skilled nurse's note, dated 03/12/18 at 8:06 p.m., documented, .Received (sic) resident in unit vai (sic) stretcher .Residnet (sic) is a times 2 assist with adls and transfers .Resident scrotal area is escoriated (sic) .Protective cream applied. Coccyx is red and irritated. Resident was repositioned . A wound assessment report; dated 03/12/18, untimed, and electronically signed by the DON; documented, .Date of Assessment .3/12/2018 .Wound Type .pressure .Wound Location .Coccyx; unstageable wound with eschar, order for santyl .Date wound identified .312/2018 .Present upon admission .yes .Assessment Occasion .Admission . It was documented the ulcer was unstageable due to slough/eschar, had no drainage, had no infection, and there was no pain with wound/treatment. It was documented the ulcer measured 7.5 cm x 6.0 cm x 0.0 cm, had 100% eschar on the wound bed, and had well defined borders. It was documented the surrounding skin was normal. It was documented the physician was in the facility and was notified of the pressure ulcer and the responsible party was notified. It was documented, .Treatments .Pending treatment orders . Review of admission orders [REDACTED] Review of the resident's undated baseline care plan revealed no documentation the resident had any skin concerns. It was marked the resident needed to be turned and repositioned as a skin breakdown intervention. The baseline care plan was not signed by a facility staff member or the resident/ resident representative. A physician's telephone order, dated 03/13/18, documented, .Cleanse sacrum (with) normal saline. Pat dry. Apply Santyl to wound bed. Apply [MEDICATION NAME] and cover (with) [MEDICATION NAME] daily . Skilled nurses' notes, dated 03/13/18 at 6:05 a.m. and 9:04 p.m., documented the resident's skin was warm and dry. There was no documentation related to the pressure ulcer. Review of treatment sheets, dated 03/13/18, revealed no documentation the pressure ulcer treatment was completed as ordered. There was no entry with instructions for the treatment on the treatment sheet. A skilled nurse's note, dated 3/14/18 at 10:17 a.m., contained no documentation related to the pressure ulcer. Review of treatment sheets, dated 03/14/18, revealed no documentation the pressure ulcer treatment was completed as ordered. Skilled nurses' notes, dated 03/15/18 at 2:07 a.m. and 12:27 p.m., contained no documentation related to the pressure ulcer. Review of treatment sheets, dated 03/15/18, revealed no documentation the pressure ulcer treatment of [REDACTED]. A physician's telephone order, dated 03/15/18 and untimed, documented, .Venelex Ointment, Apply Ointment to wound on sacrum every shift until healed . A skilled nurse's note, dated 03/15/18 at 9:32 p.m., documented, .Being turned every 2 hours d/t wound on sacrum. New order for Venelex ointment to sacrum. Rated pain 7/10 on buttocks . Treatment sheets, dated 03/15/18, documented the Venelex was applied at 10:00 p.m. Treatment sheets, dated 03/16/18, documented Venelex ointment was applied to the pressure ulcer three times daily. The treatment sheets documented, .A Pressure ulcer of sacral region, stage 2 . A skilled nurse's note, dated 03/16/18 at 12:36 p.m., documented, .He has a stage 3 on left glute and area was cleansed and treatment applied . Treatment sheets, dated 03/17/18 through 03/19/18, documented Venelex was applied to the pressure ulcer three times daily. A five day, pay per service assessment, dated 03/19/18, documented the resident was severely cognitively impaired; required extensive assistance for bed mobility, transfers, locomotion, dressing, and personal hygiene; was frequently incontinent of urine and always incontinent of bowel; and had one unstageable pressure ulcer with slough or eschar present. It was documented the resident received dressings and ointments or medications for the ulcer. A nurse's note, dated 03/20/18 at 4:15 a.m., documented, .(12:15 a.m.) Resident alert and oriented per verbal stimuli and noted moaning/groaning states his 'stomach is hurting so bad.' Peg tube noted with drain dressing soaked with brown colored feeding around peg tube site. Vitals noted 100/62, (heart rate) 122, (respirations) 22, (temperature) = 102.2 axillary with O2 sat 84% on RA. Resident denies any shortness of breath. O2 at 3l/bnc applied at this time. Noted productive cough but resident states there is nothing coming up. Informed resident not to swallow the secretions that he is coughing up. Peg tube site cleansed and dressing applied. PRN pain medication given after 240 cc residual noted of browninsh (sic) colored feeding. (11:30 p.m.) feeding held. MD notified of resident status and condition changes and order to sent (sic) resident to ER for evaluation and treatment .Transported out of facility via stretcher with EMT x 4 at (1:50 a.m.) . Review of treatment sheets, dated 03/20/18 at 6:00 a.m., documented the Venelex treatment was not applied. A skilled nurse's note, dated 03/20/18 at 12:19 p.m., documented, .Assessment complete . There was no documentation of when the resident returned to the facility or what had occurred with the resident while out of the facility. Review of treatment sheets, dated 03/20/18 at 2:00 p.m. and 10:00 p.m., revealed no documentation the resident received the Venelex treatment to the pressure ulcer. A physician's telephone order, dated 03/20/18 and untimed, documented, .DC Venelex to Coccyx. Clean coccyx (with) wound cleanser, pat dry apply Santyl to wound bed, cover (with) dry dressing, change daily . Treatment sheets, dated 03/20/18, had no documentation the pressure ulcer treatment of [REDACTED]. There was not an entry on the treatment sheet with instructions for the Santyl treatment. The resident's comprehensive care plan, dated 03/20/18, documented a problem related to impaired skin integrity. It was documented, .was admitted with scrotal excoriation and an unstageable coccyx wound, the wound bed is covered with escsar (sic) . The goal was the area on the coccyx would decrease in size and be free of infections through the next review date. Approaches included to use a draw sheet to prevent friction and shearing and to treat the ulcer with Santyl daily. Treatment sheets, dated 03/21/18 and 03/22/18, had no documentation the pressure ulcer treatment was completed as ordered by the physician. A skilled nurse's note, dated 03/22/18 at 9:19 a.m., documented, .Resident refused care and medictions (sic) stating 'leave me alone.' Encouraged resident to turn from side-to-side often for skin integrity, resident refuses at this time . Treatment sheets, dated 03/23/18, had no documentation the pressure ulcer treatment was completed as ordered by the physician. Review of the clinical record revealed no documentation the resident received a treatment for [REDACTED]. There was no documentation the pressure ulcer was assessed after 03/13/18. The clinical record documented inconsistent skin assessments, staging, and locations of the pressure ulcer. There was no documentation the resident was seen by the facility's consultant wound doctor. A skilled nurse's note, dated 03/23/18 at 7:24 p.m., documented, .Resident's family called supervisor and asked us to send resident to (hospital name withheld) for eval and treatment. Did not state what it was in reference to. We got him ready and sent him out per family request and he has not returned as yet . A hospital history and physical report, dated 03/23/18 at 9:18 p.m., documented, .Stage IV sacral decubitus ulcer .surrounding necrosis . A hospital progress note, dated 03/24/18 at 9:33 a.m., documented, .Problem List 1. Pneumonia 2.[MEDICAL CONDITION] .Impression .Septic shock on admission from most likely stage 4 decub ulcer on admission .Stage 4 decub ulcer .Plan .Continue IV Vanc ([MEDICATION NAME]) and [MEDICATION NAME] at this point for both Decub ulcers and HCAP .ordered CT (computerized tomography) .to look at the decub ulcer extent . A hospital CT scan, dated 03/26/18 at 5:50 p.m., documented, .Findings: .There is a large sacral decubitus ulcer measuring approximately 7.6 cm x 7.8 cm .The underlying distal sacrum and proximal coccyx appear to be exposed. A tiny amount of overlying soft tissue may be present. This ulcer is new compared to the prior exam. The distal sacrum underlying the ulcer does not appear significantly changed compared to the prior exam. The visualized osseous structures are demineralized .Impression .New, large sacral decubitus ulcer with the underlying distal sacrum appearing almost exposed by the wound. A trace amount of overlying soft tissue may separate the cortex from the wound. However, given the possible exposure of the underlying sacrum, osteomyeolitis is not excluded . On 03/28/18 at 9:33 a.m., LPN #1 was asked who was responsible for completing skin assessments when a resident was admitted to the facility. She stated the admitting nurse completed the initial skin assessment and then documented the assessment in the electronic record on the wound manager screen. She was asked when that was done. She stated it was completed on admission. LPN #1 was asked how the assessment was completed. She stated when the resident came to the facility, a head to toe assessment was done. She stated if there were any wounds, it was documented and put into the initial nursing note. She stated the very first nursing note should have the skin condition documented. LPN #1 was asked what was done if a resident was admitted with a pressure ulcer, but there were no orders for a treatment for [REDACTED]. She was asked who was responsible for transcribing the order received. She stated the nurse that completed the admission should do the transcription. She stated there was supposed to be some one who went through the chart to verify orders were transcribed. She stated that was where some breakdown in the system was happening. LPN #1 was asked what the process was for ensuring physician orders were added to medication and treatment sheets, as indicated. She stated that was done in the computer system. She stated that once the orders were entered into the computer, they automatically appeared on the medication or treatment sheets. LPN #1 was asked how often pressure ulcer assessments were completed. She stated, Once a week. She was asked who completed those assessments. She stated various nurses, depending on what shift they were working. She stated the assessments were assigned out over the different shifts. LPN #1 was asked where the pressure ulcer assessments were documented. She stated they were documented on the skin assessment sheets and were kept in the report book all month. She stated they were then taken out and placed in the resident's charts. She was asked to provide the skin assessments for resident #4. She obtained the report book, looked through the book, and looked through the resident's clinical record. No skin assessments were located. LPN #1 was asked who completed pressure ulcer treatments. She stated the charge nurses did. She was asked what training she had in pressure ulcer care. She stated the only training she had was being a nurse for [AGE] years. She stated she had no specialized training. She was asked if the facility had provided any inservice education related to pressure ulcers. She stated, No as far as I can remember. She was asked how long she had been employed by the facility. She stated a time frame over one year. LPN #1 was asked if resident #4 had a pressure ulcer upon admission to the facility. She stated, Yes. She was asked how that was addressed on the resident's baseline care plan. She reviewed the care plan and stated the only thing that was documented was to turn and reposition the resident. She stated it did not reflect the current pressure ulcer, any treatments, or the fact the resident had a specialty mattress. LPN #1 was asked what treatment orders were in place for the resident's pressure ulcer. She stated she believed Santyl was initially ordered but then in was changed to Venelex or vice versa. She stated, I'm not sure why. She stated, It was closed, eschared over. She stated the resident was very combative and would not let the nurses do anything. She stated, I don't know if that is charted. LPN #1 was asked when the order for the Santyl treatment was obtained. She stated 03/13/18. She was asked if the ulcer was treated with the Santyl, as ordered by the physician. She reviewed the treatment sheets and stated, It's not there. She reviewed the nursing medication administration sheets and stated, I don't see it on there. She was asked if she had treated the pressure ulcer with Santyl as ordered. She stated, I never did. She was asked why she did not. She stated, It did not show up and wasn't on my report. LPN #1 was asked to describe the resident's pressure ulcer. She stated it was pretty good size. She stated it was almost perfectly round and was complete eschar. She was asked if the facility had a wound care doctor. She stated, Yes. She stated the wound care doctor had been at the facility on 03/20/18 but did not see the resident. She was asked why the resident was not seen by the wound care doctor. She stated if there had been no treatment orders and the ulcer had not been reported on, the wound care doctor would not know to see the resident. LPN #1 was asked if she had knowledge these orders were not carried out prior to the survey. She stated, Yes. She was asked if she had taken that information to anyone. She stated, Yes. She was asked if anything had been done after that. She stated, No. LPN #1 was asked why the pressure ulcer treatment had been changed to Venelex on 03/15/18. She stated, I have no idea. She stated a reason had not been documented. She was asked if there was Santyl in the facility. She stated, Yes. She stated she did not understand why it would not have been documented on the treatment sheets. She was asked if the resident received the Venelex treatment as ordered. She stated, Yes. She stated she did that treatment herself on the days she was at work. LPN #1 was asked why the Santyl was re-ordered on [DATE]. She stated it was her belief the MDS coordinator had asked about it and had wanted to look at the pressure ulcer. She stated that was when they, she and the MDS coordinator, had taken the concern to the DON. She stated she believed that was when it was changed. She was asked if the resident had received that treatment, as ordered by the physician. She stated, I don't know. She was asked if it was documented. She reviewed the treatment sheets. LPN #1 was asked again if the resident received the Santyl treatment as ordered. She stated, No, I don't think so. LPN #1 was asked why the resident did not receive the pressure ulcer treatments as ordered by the physician. She stated, The only thing I can tell you is there is a huge communication problem. She stated no one was verifying orders were put into the computer or verifying orders showed up on the treatment sheets. LPN #1 was asked to describe the pressure ulcer at the time the resident went back to the hospital on [DATE]. She stated it had not changed at all on the day she had observed it last, which would have been 03/22/18. She was asked what interventions had been implemented to care for the pressure ulcer. She stated, Having him stay off it. She stated the resident could turn side to side. She stated, That's all I know of, except for a specialty mattress. She was asked what kind of specialty mattress the resident had. She stated, Maybe just a mattress with bevels. She stated she did not know what kind. On 03/28/18 at 10:21 a.m., the MDS coordinator was asked if she had spoke with LPN #1 regarding the resident's pressure ulcer. She stated she had asked for clarification. She stated she had needed to see the wound sheet and see the actual dressing. She was asked what she had determined the treatment to be. She stated she would have to look at the note. She stated she was getting some clarification and went and looked at the wound. She was asked if she had talked with the DON. She stated, Yes. She was asked what the conversation with the DON was about. She stated she needed clarification on the pressure ulcer. She was asked what clarification she needed. She stated what type of treatment was actually getting done to the wound. She was asked what date it was she spoke with the DON. She stated it would have been the date of the assessment. On 03/28/18 at 10:25 a.m., the DON was asked how she monitored the facility's pressure ulcer system. She stated weekly skin sheets were completed and a weekly report was done for any pressure ulcer above a stage II. She stated, I knew he was coming in, so I measured myself and put it into the system. She stated pressure ulcers were talked about every morning during a meeting. The DON was asked how she monitored to ensure treatments were completed as ordered by the physician. She stated that in the computer system, a treatment would show up red if they were not done. She stated they communicated well with the nurses. She stated they tried to set treatments for the morning shift. She stated the computer software would not allow you to close it (finalize) if there was no documentation. She was asked how she monitored to ensure physician orders were put into the computer system. She stated they went through orders every morning. The DON was asked why resident #4 did not receive the pressure ulcer treatments as ordered by the physician. She stated, My understanding is they didn't want it to open. She stated the resident was really hospice appropriate. She was asked where that information was documented. She stated, It probably isn't documented. She stated there was no order for Santyl. The surveyor provided the order for the DON's review. The DON was asked why the wound assessment, dated 03/12/18 and signed electronically by herself, documented measurements, a treatment of [REDACTED]. She stated she did not do the wound assessment. She stated, I did a nurses' note on him. She was asked where that was documented. She reviewed the clinical record and stated she could not find the note. The DON was asked what the admitting nurse's documentation noted about the resident's skin. She stated, Coccyx is red, oh dear. She was asked if the resident received the Santyl treatment, as ordered on [DATE]. She reviewed the treatment sheets and stated, No, he didn't. It's not on there at all. She was asked why the Venelex was ordered on [DATE]. She stated, I don't know. She stated she would have to ask the nurse why. The DON was asked why the treatment was changed back to Santyl on 03/20/18. She stated, I don't know. She was asked if the resident received that treatment. She stated, That order wasn't processed either. The DON was asked who completed the wound assessment on 03/12/18 if she did not. She stated, I must have had it (the computer screen) open or something. She stated the admitting nurse must have done it. She stated she looked at the resident the following day (03/13/18). She was asked where that documentation was. She stated, I remember on him I wrote a note. The DON was asked if she had any knowledge the resident had not received his pressure ulcer treatments, as ordered by the physician, prior to this day. She stated, No, I did not. The DON was asked when she had observed the resident's pressure ulcer. She stated the day after his admission. She stated, It was my understanding we were leaving it alone. If we opened it, it would be a mess. She stated, I was not aware of (the order for) Santyl at all. The DON was asked if she had observed the pressure ulcer again. She stated she did not know if she had or not. She was asked if the wound doctor had seen the resident. She stated she did not think so. She then stated she thought she had looked at it to measure it on 03/20/18 with the nurse because she was concerned about the ulcer. She was asked why she did not check the orders and treatments if she was concerned about the ulcer. She stated she wanted to make sure the ulcer was not infected. She stated if it opened up, there would be a mess. The DON was asked at what time was it not appropriate to treat a pressure ulcer. She stated when a person was as sick as resident #4 was. She stated the resident needed hospice services. She was asked if the resident was receiving hospice services. She stated, No. She was asked how the physician was involved in making a decision not to treat the resident's pressure ulcer. She stated she had talked with the doctor's office but did not know who it was she had talked with. She was asked if the family had been involved in making that decision. She stated the facility had not talked with the family. The DON was asked if there was a physician's order for hospice services. She stated, No. 2. A hospital wound care evaluation report, dated 01/15/18, documented resident #1 had the following pressure ulcers: ~ a suspected deep tissue injury to the left trochanter that measured 10 cm x 4 cm by 0.1 cm. It was documented, .pink-red open ulcer black slough-eschar purple .4 cm x 1.5 cm area in center that is dark tissue, 2nd area just posterior to trochanter Stage 1 or possible DTPI that in deep red that is intact and 8 cm x 4 cm .; ~ a stage II pressure ulcer to the left upper arm that measured 14 cm x 4 cm x 0.1 cm; and ~ an abrasion to the top of the left shoulder that was scabbed. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 01/24/18 at 7:35 p.m., documented, .Admit .Pt has wounds to left hipt (sic), left upper FA, back of neck, coccyx reddened .To right ankle red/purple scar noted. To pts. right heel bandage noted . A skilled nurse's note, dated 01/25/18 at 2:46 a.m., documented, .wounds .wound care .Resident has drsg intact to left heel . A skilled nurse's note, dated 01/25/18 at 6:18 p.m., documented, .pts. wounds covered to left upper FA, left hip, neck . Review of the resident's clinical record, from 01/24/18 through 01/30/18, revealed no documentation the resident received any treatments to the pressure ulcers. There were no physician orders for treatments, and there was no documentation the pressure ulcers had been assessed when the resident was admitted to the facility. An admission assessment, dated 01/31/18, documented the resident was cognitively intact, required extensive assistance with bed mobility and transfers, and had one stage I pressure ulcer and one unstageable pressure ulcer. The resident's care plan, dated 01/31/18, documented a problem related to impaired skin integrity. It was documented the resident was admitted with a left lateral thigh wound and left heel blister. The goal was the areas would show signs of healing and be free of infection within 30 days. Approaches included to complete skin assessments quarterly and as needed; nurse documentation weekly and as needed on any aspects of wound healing; and a wound care consultation. A wound assessment report, dated 01/31/18, documented the resident had a blister on the left heel. It was documented the blister measured 4.0 cm x 4.5 cm and was present on admission. It was documented there was no drainage or infection. Another wound assessment report, dated 01/31/18, documented the resident had an open wound to the left, rear thigh. It was documented the wound measured 2.2 cm x 7.0 cm x 0.0 cm, had no drainage, and no signs of infection. It was documented the wound had slough and was present upon admission. Physician's orders, dated 01/31/18 and untimed, documented, .Vit C 500 mg caplet. Take one P.O. BID .Zinc 50 mg capsule. Take 2 capsules by mouth twice a day .Wound Care Consult .Santyl Ointment. Cleanse wound to (left) hip c N.S. Pat dry. Apply Santyl to the wound bed .Silverdene .Apply a thin layer of silverdene peri-wound bed and cover with [MEDICATION NAME]. Skin Prep to (right) heel q shift .Cleanse (left) shoulder c N.S. Pat dry. Apply [MEDICATION NAME] and cover (with) a band aid once daily . Review of treatment sheets, dated 01/31/18, revealed no documentation the resident received the treatments, except the application of skin pr (TRUNCATED)

On 01/29/14, an Immediate Jeopardy was determined to exist in regard to the facility's failure to provide supervision to prevent elopement. On 01/29/14 at 5:05 p.m., the Oklahoma State Department of Health confirmed the existence of the Immediate Jeopardy. On 01/29/14 at 5:10 p.m., the Administrator and the Director of Nursing were informed of the existence of the Immediate Jeopardy. On 01/29/14 at 5:55 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as follows: "Plan of Correction to Remove Immediate Jeopardy for Supervision to Prevent Elopement 1. Director of Nursing will use device to check Wanderguard unit on each resident that is currently in-house that is at risk for elopement ensuring the unit functions properly by 6:30 p.m. on January 29, 2014. 2. She will record this test on a Daily Transmitter Log Form. This log includes the Transmitter Expiration Date for each resident with a Wanderguard. 3. Staff will be in-serviced on the Facility Elopement Policy and the Daily Transmitter Log Documentation Form by 6:30 p.m. on January 29, 2014. 4. Day Shift Charge Nurse for each hall will check each resident with a Wanderguard unit for proper functionality. This check will be documented on the Daily Transmitter Log Documentation Form. Follow up will take place immediately, as warranted on any Wanderguard unit that may not be functioning properly. 5. The Daily Transmitter Documentation Form will be turned into the Director of Nursing or designee at the end of the shift to ensure compliance." On 01/30/14 at 2:27 p.m., after interviews with staff, review of inservices, and observations of wanderguard functioning, the administrator was informed the immediacy had been lifted on 01/30/14 at 2:27 p.m. The deficient practice remained at no actual harm with potential for more than minimal harm at a pattern. Based on record review, observation, and interviews, it was determined the facility failed to provide adequate supervision to prevent elopement for one (#1) of ten (#1 and #3 through #10) sampled residents who were at risk for elopement. The facility failed to: ~ Check placement of the wandergard every shift, ~ Check function and expiration date of the wandergard everyday, ~ Take the resident to the door every week to ensure function of the wandwegard bracelet, ~ Reassess for the need of further intervention to prevent elopement, ~ Obtain physician's orders for the wandergard placement when assessed for the need of a wandergard, and ~ Perform quarterly assessments on residents with wandergard placement. This had the potential to affect ten residents who were identified by the facility as being at risk for elopement. Findings: A facility policy documented, "...Resident Elopement Policy, OBJECTIVE: To identify residents who are at risk for elopement and interventions are put into place to prevent elopement. Admissions: All residents will be assessed on admission by the admitting nurse for risk factors that would place the resident at risk for elopement. This will be completed using the AHT assessment form (this form identified by the facility as their Elopement Risk Assessment). If the resident triggers for elopement risk, the admitting nurse will determine appropriate interventions which may include placement of a wanDergard on the patient. Orders for a code alert will be written as follows: Wandergard placement Check placement of wandergard every shift Check function and expiration date of wandergard every day. Staff to take resident to door every week to ensure function. All new admissions who are identified at risk for elopement and have a code alert placed will have their picture taken and be placed in the elopement book. ASSESSMENTS: All residents will be reassessed quarterly by the social services director for potential for elopement. This will be done using the AHT elopement risk assessment. A resident who is identified as potential risk will be assessed for need of wandergard placement. Any residents with elopement attempts will be reassessed immediately for need of further intervention to prevent elopement. Elopement Book: The center will keep an elopement book at a nurse station. The book should contain information of the residents who are identified at being at risk for elopement. Each resident's page should include resident's name, current picture, height, weight, hair color, eye color, any scars or identifying marks, and nicknames. This should be validated monthly by the social services director to be updated and accurate. A copy of this audit should be turned into the administrator by the 15th of the month. DRILLS: All facility staff shall demonstrate an understanding and competency in the implementation of the elopement policies and procedures. Resident elopement drills will be held once a quarter. The facility will document the implementation of the drills." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An elopement risk assessment, dated 01/11/14, documented, "...Interventions: Date Initiated 01/10/14 Frequent monitoring..." A social service's admission evaluation, dated 01/13/14, documented, "... Family Information: ... Resident moved to ALF for dementia after wandering street while living alone..." A Physician's Telephone Order, dated 01/13/14 at 1:30 p.m., documented, "...Wander gard to leg at all times. Elopement risk..." A care plan, dated 01/21/14, documented, "...Problem/Need: Exhibits alteration in mood/behavior AEB: She has dx of Alzheimer with behaviors/psychosis. Refuses to allow staff to assist her, touch her and wanders about facility at times. Goal & Target Date: She will not exhibit any behaviors that are harmful to herself or others through NRD as evidenced by decreased reports of evidence by staff... Approaches: ...*Wanderguard as appropriate; verify placement and function per protocol *Monitor whereabouts when wandering and redirect as needed...Wanderguard to ankle @ all x's..." A 30-day assessment with an assessment reference date of 01/24/14 documented the resident was severely impaired in her cognitive skills for daily decision making. The assessment documented the resident did not have any wandering behaviors. An incident/accident report, dated 01/27/14 at 9:50 p.m., documented, "...Resident found outside the building, resident was brought back into the building by staff members. No apparent injurys noted. Resident continues to try get outside the building..." A nurse's note, dated 01/27/14 at 10:00 p.m., documented, "... Resident last seen in the building 945 pm, o (no) s/s of distress..." There was no documentation in the clinical record of the resident's elopement date on 01/27/14. An attachment to the incident/accident report, dated 01/27/14 at 10:00 p.m., documented, "Interdisciplinary Progress Notes: Community citizens alerted staff that a resident was possibly missing. Immediately bed cant (sic) of facility performed at this time. One resident (name deleted) was missing at this time 2 CNA's followed citizens to home. DON notified at this time. As facility protocol. CNA's identified person to be (name deleted) and returned resident to facility via personal vehicle ((name deleted) - CNA) stated (name deleted) police was present when resident was picked up. Upon return full head-to-toe assessment performed. No apparent injurys noted... No s/s of distress. D.O.N. notified, Admin notified, Dr. notified, (family member name deleted) notified @ 9:55 p.m. ...New Wanderguard in place and verified to be in working order, 1 on 1 staff placed c resident. 10 -6 charge nurse notified. Resident has a history of elopement from facility..." A typed document attached to the incident/accident report, dated 01/27/14, documented, "Community member came into facility to notify staff that a resident may be missing. Staff did an immediate head count and identified (name deleted) was indeed out of the facility. Staff accompanied community member to address that the resident had given to them as her home. Staff identified that she was (resident name deleted)... Resident was assessed as high risk for elopement on admission and had an ankle wonderguard band on at time of elopement with no noted malfunction of equipment..." This typed document was signed by the Director Of Nurses. There was no documentation of a reassessment for elopement risk completed as documented by the facility policy. There was no documentation of the wandergard being checked for function and expiration everyday as documented by the facility policy. There was no documentation of the staff taking the resident to the door each week to ensure function of the wandergard as documented by the facility policy. On 01/29/14 at 11:30 a.m., the Director of Nursing informed this surveyor that resident #1 had eloped from the facility on the evening of 01/27/14. She stated the resident left the building through the front door and the resident had a wanderguard on at the time of the elopement. She stated the resident walked up to the door, pressed on the door for a period of time, and even though the door had a lock for the wanderguards the door would open automatically. She stated the resident left the building at 9:12 p.m. according to the security cameras. She stated the staff informed her that the resident was found at the house of the people who found her. The DON was asked how they monitor residents who are at risk for elopement. She stated they did an elopement risk assessment upon admission. If the resident was at risk for elopement, they put a wanderguard on the resident. She stated they did not document the monitoring of the resident's wandergard. She stated the staff knew the wanderers and just looked out for them. On 01/29/14 at 11:50 a.m., a family member was interviewed regarding resident #1's elopement on the evening of 01/27/14. The family member was asked about the resident's elopement. The family member stated she/he received a call from someone at the facility on the night of the 27th that the resident had been missing from the facility for 5 to 10 minutes. The family member stated the nurse did not tell her/him where they found the resident or anything about the police being involved. At 12:15 p.m., LPN #1 was interviewed regarding resident #1's elopement on the evening of 01/27/14. LPN #1 stated the resident left the building a little before 10:00 p.m. She stated she had just seen her in her room on hall four. She stated the staff realized the resident was missing at 9:55 p.m. She stated a young couple came into the facility and said they thought they saw a resident approaching MacArthur Blvd. LPN #1 stated the couple took the resident to a house where the resident said she lived. She stated the people who lived at the house called the police. LPN #1 stated they checked the facility and found that resident #1 was missing from the facility. At that time two of the staff members followed the couple to the house where they had left the resident. She stated the police were at the house when the two CNAs got there. The two CNAs, CNA#1 and CNA#2, put the resident in CNA #1's car and brought the resident back to the facility. She stated the resident was missing 15-20 minutes. She stated when the resident returned, CNA #1 placed a new wanderguard on the resident and Nurse #1 took the resident's vital signs and did a head to toe assessment. At 2:30 p.m., CNA #1 was interviewed regarding resident #1's elopement on the evening of 01/27/14. CNA #1 stated a lady came into the facility at 9:00 p.m., and stated she saw a lady walking north. CNA #1 and CNA #2 got in CNA #1's car, drove down MacArthur to the neighborhood, and looked for resident #1. She stated they did not see the resident so they went back to the facility. She stated LPN #1 told them the young couple that was in the facility had picked resident #1 up and had taken her to a house. She stated LPN #1 told the CNAs to follow the couple in their car to the house. She stated when they arrived at the house, CNA #1 saw resident #1 sitting on the couch with a blanket over her. CNA #1 stated resident #1 was wearing pants, a blouse, and socks but no shoes. She stated she was not wearing a coat or a jacket. CNA #1 stated the police were at the house and CNA#1 had to convince resident #1 to leave with them. CNA #1 stated resident #1 kept saying, "I'm cold, I'm cold." She stated they made it back to the facility around 9:20 p.m. to 9:30 p.m. CNA #1 stated when they returned to the facility, resident #1's wanderguard did not set the front door alarm off. She stated the CNAs were told to put the resident to bed. She stated the last time she saw the resident was around 7:00 p.m. to 8:00 p.m. At 5:30 p.m., CNA #2 was interviewed regarding resident #1's elopement on the evening of 01/27/14. CNA #2 stated she had come back from taking out the trash when a lady came in the facility and said there was a lady outside walking. She stated that was around 9:30 p.m., a bed check was done and they realized the resident was not in the building. She stated she along with CNA#1 went to look for the resident and while they were out looking they got a call from LPN #1 telling them to come back to the facility because they knew where resident #1 was. She stated the resident was at a house. CNA #2 stated she and CNA #1 went back to the facility and followed some people to a house where resident #1 was sitting on the couch with a blanket on her because she was cold. She stated they brought the resident back to the facility in CNA #2's car. She stated the police were at the house. CNA #2 was asked if she heard the door alarm sound when the resident eloped from the facility. She stated the door alarm did not sound or go off, a lady came in and told them that she saw a lady outside walking, and that is how they discovered the resident was missing. At 5:45 p.m., CNA #3 was interviewed regarding resident #1's elopement on the evening of 01/27/14. CNA #3 stated she and another CNA were doing bed check around 9:30 p.m. and she saw resident #1 entering another resident's room. She stated she re-directed resident #1 and the resident went to LPN #1 who was the nurse on the hall. She stated when she saw that the resident was with LPN #1 she continued with her bed check. CNA #3 stated it wasn't until after she came back from taking the linen barrel to the laundry room that a lady came in the facility and said she saw a lady walking along the street who might be one of their residents. CNA #3 stated she went to LPN #1 and told her about it. The nurse and the CNAs did a resident count on each hall. CNA #3 stated she checked resident #1's room and noticed the resident was not in the facility. She stated two of the CNAs and two of the nurses left in their cars to look for resident #1. She stated a couple (a lady and a man) came into the facility and said someone took a lady to a house close by. She stated the couple said they followed the people who took resident #1 to the house and they came to the facility to tell them. She stated LPN #1 called the CNAs and told them to come back. When the CNAs returned, they followed the couple to the house, got the resident, and brought her back to the facility. She stated they never heard the door alarm sound. She stated the police did not come to the facility while she was on duty. She stated CNA #1 and CNA #2 brought resident #1 back to the facility. At 6:00 p.m., CNA #4 was interviewed regarding resident #1's elopement on the evening of 01/27/14. CNA #4 stated she took out the trash and came back in the facility. The other CNAs told her resident #1 was gone out of the facility and they said they found her. She stated two of the nurse aides went to pick the resident up and brought her back to the facility. She stated the police did not come to the facility while she was on duty. She stated she did not hear the door alarm sounding when the resident left the facility. On 01/30/14 at 11:40 a.m., CNA #5 was interviewed regarding resident #1's elopement on the evening of 01/27/14. CNA #5 stated she was working on hall 300 doing bed checks around 8:30 p.m. when LPN #2 came down and told her to check to see if any residents were missing on her hall. She went to check on another resident since none of her residents were missing and when she came out of that residents room, resident #1 was back in the facility. She stated the staff told her CNA #1 and CNA #2 brought resident #1 back to the facility. She stated she did not see the police in the facility during her shift. At 11:50 a.m., LPN #2 was interviewed regarding resident #1's elopement on the evening of 01/27/14. She stated she was working on hall 300 and a CNA said resident #1 was missing. She stated she then initiated a code green meaning everyone was to look for each resident on each hall. She stated resident #1 was verified as missing. She stated someone came to the facility and said they saw a lady walking down MacArthur. She stated LPN #2 and another nurse got into LPN #2's car and went down MacArthur to look for resident #1. She stated they made a loop, did not see anyone, and came back to the facility. She stated that was when she found out the resident was at someone's house without permission. She stated a CNA brought the resident back. She stated she never saw the police in the facility, but the CNAs said the police were at the house where the resident was. She stated CNA #1 brought resident #1 back to the facility. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, updated 10/31/13, documented, "...Problem/Need: Problem Onset: Exhibits alteration in mood/behavior AEB: yelling at staff with additional risk r/t dx depression, anxiety, and memory issues, and hx of refusing care, wandering...potential for exit seeking related to cognition and behaviors...Goals & Target Date: Behaviors will be easily altered with staff interventions...Approaches: Monitor whereabouts when wandering and redirect as needed...Wanderguard placement check per policy..." The elopement policy documented under Admissions was not followed. There was no physician order for [REDACTED]. The elopement policy documented, "...If the resident triggers for elopement risk, the admitting nurse will determine appropriate interventions which may include placement of a wanDergard on the patient. Orders for a code alert will be written as follows: Wandergard placement Check placement of wandergard everyshift Check function and expiration date of wandergard everyday. Staff to take resident to door everyweek to ensure function..." After placement of the wanderguard on 10/31/13, there was no documentation the wandergard was checked every shift. There was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A quarterly assessment, dated 01/16/14, documented the resident's skills for daily decision making were moderately impaired. The assessment documented the resident did not have any wandering behaviors. A physician's telephone order, dated 01/29/14, documented, "...Wanderguard to ankle, monitor placement q shift..." There was no quarterly assessment for potential elopement. The facility policy documented, "....All residents will be assessed quarterly by the social services director for potential for elopement..." 3. Resident #4 was admitted with [DIAGNOSES REDACTED]. An care plan documented, "...Problem/Need: Problem Onset: (undated) Exhibits alteration in mood/behavior AEB: crawling around on the floor, throwing his matress (sic) over and attempting to "fix it", yelling at staff. He is at continued risk d/t his dx of dementia and use of psychotropic medications. Potential exit seeking behaviors r/t cognition & mood...Goals & Target Date: Behaviors will be easily altered with staff interventions more that 75% of the time x 90 days... Approaches: Wanderguard as appropriate; verify placement and function per protocol, monitor whereabouts when wandering and redirect as needed... " A physician's telephone order, dated 12/28/13, documented, "...Wanderguard to ankle- monitor placement q shift Ind: Safety..." The elopement policy documented under Admissions was not followed. There was no physician order for [REDACTED]. After placement of the wanderguard on 10/15/13, there was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A quarterly assessment, dated 01/10/14, documented the resident skills for daily decision making were severely impaired. The assessment also documented the resident did not have any wandering behaviors. There was no quarterly assessment for potential elopement. The facility policy documented, "...All residents will be assessed quarterly by the social services director for potential for elopement..." The elopement book did not contain any information on resident #4 as documented by the facility policy. 4. Resident #5 was admitted with [DIAGNOSES REDACTED]. The resident's cognition was not documented on the Interdisciplinary Care Plan dated 01/23/14. The resident was admitted to the faciltiy on 01/23/14. An undated elopement risk assessment documented no elopement risk. An Interdisciplinary Care Plan, dated 01/23/14, documented, "...Activities: Potential for exit seeking wanderguard placement monitor per protocol Behavior: Aggressive c staff, combative, spreading feces everywhere..." The elopement policy documented under Admissions was not followed. There was no physician order for [REDACTED]. After placement of the wanderguard on 01/23/14, there was no documentation the wandergard was checked every shift. There was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A nurse's note, dated 01/24/14, documented, "Resident is putting hands in brief and spreading feces everywhere. Combative c staff. Attempted to re-orient resident and unable to do so..." A physician's telephone order, dated 01/29/14, documented, "...Wanderguard placement to ankle monitor placement every shift..." A nurse's note, dated 01/29/14 at 10:00 p.m., documented, "...Wanderguard placement to ankle, monitor placement every shift..." The elopement book did not contain any information on resident #5 as documented by the facility policy. Resident #5 did not have a MDS assessment due until 02/06/14. 5. Resident #6 was admitted with [DIAGNOSES REDACTED]. An elopement risk assessment, dated 04/08/13, documented, "...Interventions: Exit and stairwell alarms..." A quarterly assessment, dated 01/10/14, documented the resident was cognitively intact with skills for daily decision making. The assessment also documented the resident did not have any wandering behaviors. On 01/29/14 after the Immediate Jeopardy was determined, resident #6's wanderguard was documented on the facilities "Daily Transmitter Testing Log" to pass with a transmitter expiration date of 03/2015. The elopement policy documented under Assessments was not followed. There were no quarterly elopement risk assessments completed for resident #6 from the dates of 04/08/14 to 01/28/14. The elopement policy documented under Admissions was not followed. There was no physician's order for wanderguard placement. This resident was admitted on [DATE]. There was no documentation the wandergard was checked every shift. There was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A care plan documented, "...Problem/Need: Problem Onset: 01/30/14 potential for alteration in mood/behavior AEB: Episodes of wandering/refusing to leave room...Goals & Target Date: (name deleted) will maintain a stable mood as evidenced by expressing feelings, interacting with others, and keeping involved in activity programs of interest or choice through NRD>... Approaches: Wanderguard as appropriate; verify placement and function per protocol, Monitor whereabouts when wandering and redirect as needed... " The elopement book did not contain any information on resident #6 as documented by the facility policy. 6. Resident #7 was admitted with [DIAGNOSES REDACTED]. An elopement risk assessment, dated 10/18/11, did not document any interventions for elopement. There was no quarterly elopement risk assessment documented in the resident's clinical record from. A Wander Data Collection Tool documented, "... Interventions: 19. Wanderguard Bracelet..." A Wander Data Collection Tool, dated 09/15/12, documented, "...Summary Of Findings: Res wandered out front door of facility witnessed by staff. Res stated he was going to talk to someone in the parking lot. Res reoriented. N/O for wanderguard...Interventions number(s) utilized: 19..." A Wander Data Collection Tool, dated 01/26/13, documented, "...Intervention number(s) utilized:19..." A care plan, dated 11/12/13, documented, "...Problem/Need: Problem Onset: ... Potential exit seeking behavior r/t cognition. He likes to go outside and does not always ask for assistance and cannot always get back inside...Goals & Target Date: Needs will be anticipated and met by staff daily x 90 days...Approaches: Wanderguard placement-Nsg. Check per policy... " The elopement policy documented under Admissions was not followed. There was no physician's order for wanderguard placement for resident #7 for the dates of 09/15/12 to 01/30/14. After placement of wanderguard on 09/15/12, there was no documentation the wandergard was checked every shift. There was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A quarterly assessment, dated 01/27/14, documented the resident's skills for daily decision making were moderately impaired. The assessment documented the resident did not have any wandering behaviors. The elopement book did not contain any information on resident #7 as documented by the facility policy. 7. Resident #8 was admitted with [DIAGNOSES REDACTED]. An admission assessment, dated 12/04/13, documented the residents skills for daily decision making were moderately impaired. The assessment documented the resident did not have any wandering behaviors. A care plan, dated 12/31/13, documented, "...Problem/Need: Problem Onset: ... Potential for exit seeking d/t cognition behavior...Goals & Target Date: Resident will respond to question or statement with appropriate response or with assistance through NRD...Approaches: Wanderguard to L ankle. Monitor placement Q shift..." An undated Elopement Risk Assessment documented the resident was not at risk for elopement. There were no other Elopement Risk Assessments documented in the clinical record. The elopement policy documented under Admissions was not followed. There was no physician's order for wanderguard placement for resident #8. After placement of the wanderguard on 12/31/13, there was no documentation the wandergard was checked every shift. There was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. The information in the elopement book was incomplete for resident #8. 8. Resident #9 was admitted with [DIAGNOSES REDACTED]. An Elopement Risk Assessment, dated 12/17/12, documented no elopement risk interventions. There were no quarterly elopement risk assessments documented in the resident's clinical record. The elopement policy documented under Admissions was not followed. There was no physician's order for wanderguard placement order for resident #9 for the dates of 03/13/13 to 01/30/14. After placement of wanderguard, there was no documentation the wandergard was checked every shift. There was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A Wander Data Collection Tool, dated 03/13/13, documented, "...Summary of Findings... Is a wander/elopement risk...Intervention number(s) utilized: resident currently has wanderguard to r leg..." An annual assessment, dated 12/06/13, documented the resident's skills for daily decision making were severely impaired. The assessment documented the resident had wandering behaviors that occurred 4 to six days, but less than daily. An undated care plan, documented, "...Problem/Need: Problem Onset: ... Potential exit seeking behaviors R/T mood & cognition...Goals & Target Date: *Behaviors will be easily altered with staff interventions more than 90% of the time x 90 * Mood/Behaviors will not interfere with daily routine and quality of life more than __ % of the time x 90 days...Approaches: *Wanderguard as appropriate; verify placement and function per protocol *Monitor whereabouts when wandering and redirect as needed..." The elopement book did not contain any information for resident #9 as documented by the facility policy. 9. Resident #10 was admitted with [DIAGNOSES REDACTED]. An Elopement Risk Assessment, dated 11/30/11, documented no elopement risk interventions. There were no quarterly elopement risk assessments documented in the resident's clinical record. The elopement policy documented under admissions was not followed. There was no physician's order for wanderguard placement for resident #10. After placement of wanderguard, there was no documentation the function and expiration date of the wandergard were checked every day. There was no documentation the staff took the resident to the door every week to ensure function of the wandergard. A Wander Data Collection Tool, dated 03/22/13, documented, "...Summary of Findings... Not a wander/elopement risk..." A care plan, updated 11/04/13, documented, "...Problem: ... Potential exit seeking behaviors r/t cognition...Goal: I will respond to q

On 07/09/13, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to maintain safe hot water temperatures on four of four halls. Seven resident rooms and one shower room had hot water temperatures that exceeded 126 degrees Fahrenheit (F.) and were up to 142.5 degrees. At 9:52 a.m., The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 9:55 a.m., the administrator and DON were informed of the IJ situation related to hot water temperatures and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 4:05 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented, ">Survey team informed Administrator and DON of high water temperatures in Rooms 205 (142.5), 201 (141.4), 200 (138.1), 206 (137.1), 208 (134), Shower room on Hall 400 (128.3), 307 (127.4), 106 (106.2) (126.2), and past documented temperatures in Hall 400 shower. 10am >The Administrator met with the DON and Maintenance Director. 10:05 am >The Maintenance Director and Administrator made calls and had the plumber on site assist us with the mechanical temperature gauge issue. 10:15 am >Plumber begins adjusting temperatures. 10:20 am >Plumber and Maintenance Director begin tour to check all specified rooms. 10:20 am >The DON formulated an Inservice plan and met with affected Hall staff on the 100, 200, 300 and 400 halls. 10:30 am - 11:00 pm (a.m.) >The inservice described for staff how to redirect affected residents to other water locations until their immediate room water was at a safe temperature. (10:30 - 11:00 a.m.) 1. The hot water in the following rooms must not be used until staff have been advised or redirected that the water is at the safe temperature. 1a. Room -205 1b. Room 201 1c. Room 200 1d. Room 206 1e. Room 208 1f. Hall 400 -Shower room 1g. Room 307 1h. Room 106 2. Additional precaution for the safety of the residents and staff - staff must FIRST FEEL each water location for COMFORT AND SAFETY prior to use (hand-wash, bath, etc.). 3. If water (hot-water) temperature feels hot, uncomfortable, or unsafe, STOP; and do not use the water from the room or site, or shower-room; notify MAINTENANCE immediately. 4. For the safety of the residents and staff as well, it is important that staff be aware of the danger of burning from hot water. >Maintenance Director is making (rounds) every 15 minutes, 1 room per hall monitor of water temperature. He will then move and do one room on another hall. The room checked will be both those listed by the survey team and others. 10:35 am - present. >Hot water from boiler drained and cooled by adding cold water. >Existing mixing valve being replaced today. >The maintenance director has replaced his water temperature monitor with a Taylor monitor and the old device has been disposed of. 2:00 - Present I would like to point out that the center was on emergency generator from 12:30 pm (a.m.) to 2:45 pm (a.m.) last night with power around the Center in the Warr acres community and Warr Acres itself, losing power. The generator worked fine. Coming back on full outside power may contribute to this excessive hot water. Regardless, the safety of our residents is uppermost. We will monitor these corrective steps daily..." The plan of removal was signed by the administrator. At 6:15 p.m., the administrator presented an addendum to the plan of removal. The addendum documented, "Commencing at 6:30 pm, on 7/9/13, a nursing staff trained by the Maintenance Director s (sic) will on the half-hour and hour, throughout the night, record water temperature in one room randomly on a hall, rotating through each hall, on the half-hour or hour. At shift change, the 2pm - 10pm staff will train their replacement on 10pm -6am shift. Our Maintenance Director will take over at 6am. The Maintenance Director will conduct water temperature checks every hour over the next 4 hours, to monitor consistency..." The addendum was signed by the administrator. On 07/10/13 at 7:50 a.m., the administrator provided documentation to show the plan of removal and addendum had been implemented as described. The administrator provided documentation ensuring all staff had been inserviced on hot water temperatures and reporting. At 3:15 p.m., the administrator provided additional documentation showing continuing monitoring of the hot water temperatures. Staff were interviewed on 07/10/13 in regards to their knowledge of the inservices, to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 07/09/13 at 6:30 p.m. when it was determined the hot water temperatures in the facility had fallen below 115 degrees Fahrenheit consistently and all components of the plan of removal and addendum had been completed. The deficient practice remained at the potential for more than minimal harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: A. Ensure water temperatures were maintained at safe levels and were not an accident hazard on four (halls 100, 200, 300, and 400) of four halls. Seven resident rooms and one shower room had hot water temperatures that exceeded 126 degrees F. and were up to 142.5 degrees F. This resulted in an Immediate Jeopardy situation. This had the likelihood to affect 86 of 87 residents who resided at the facility. One resident was bedfast most or all of the time; B. Ensure sharps containers on two (hall 100 and hall 200) of four halls were not overflowing with used syringes and finger stick blood sugar lancets and accessible to residents. The facility identified one resident who wandered about the facility but did not pilfer; and C. Ensure one flooring transition on one (Hall 200) of four halls did not create an accident hazard for residents. Findings: 1. Review of water temperature logs revealed the following temperatures (all temperatures in degrees Fahrenheit): 06/20/13 - room 104 - 122.4; hall 200 shower - 122.2 and sink - 124.9; room 209 - 123.4; hall 300 shower room sink - 121.5; room 303 - 121.3; hall 400 shower room sink - 126.1; room 407 - 124.8; 06/23/13 - hall 200 shower room sink - 122.1; hall 300 shower room sink - 127.6; 06/25/13 - hall 200 shower room sink - 123.1; hall 300 shower room sink - 124.9; 06/26/13 - hall 200 shower - 121.4 and sink - 122.2; room 205 - 121.9; hall 300 shower room sink - 128.3; room 301 - 125.5; and 07/05/13 - Room 105 - 121.4; hall 200 shower room sink - 120.4; hall 300 shower room sink - 120.3; hall 400 shower - 121.4 and sink - 122.6. On 07/09/13 at 9:00 a.m. the following temperatures were observed: Room 106 - 126.2, Room 200 - 138.1, Room 201 - 141.4, Room 205 - 142.5, Room 206 - 137.1, Room 208 - 134.0, Room 307 - 127.4, and Shower room Hall 400 - 128.3. At 9:05 a.m., resident #8, who resided in room 200, stated the water was hot. She stated cold water had to be used. At 9:19 a.m., resident #112, who resided in room 106 stated the water was "too hot to just have the hot water on." He stated it had to be adjusted. At 9:33 a.m., resident #34, who resided in room 208, stated the water was hot but could be adjusted. At 9:43 a.m., the maintenance supervisor was asked how often and when he monitored for hot water temperatures. He stated he monitored daily, mainly in the afternoon. He stated he monitored random rooms. The maintenance supervisor was asked what temperature range he attempted to maintain. He stated, "Between 112 and 115." He was asked if there had been episodes of the temperatures being higher. He stated yes, usually when no one had showered. The maintenance supervisor was asked if he adjusted the mixing valve when the higher temperatures were noted. He stated no. He stated he did not adjust the mixing valve because he had to keep boiler temperatures up because of the laundry. The maintenance man was asked how he obtained temperatures. He stated he used a laser thermometer and aimed it at the drain base in the sink. On 07/12/13 at 4:44 p.m., the administrator was asked if he had identified any concerns with hot water temperatures. He stated, "No." He stated he still had some questions as to whether a power outage and the use of the facility's generator had caused the water temperature spike. 2. On 07/08/13 at approximately 4:30 p.m., the 200 hall treatment cart sharps container was observed to be overflowing with used finger stick lancets. The lid could not be closed. At 4:35 p.m., the 100 hall treatment cart sharps container was observed to have one insulin syringe, with the safety cover in place, laying on the cover of the container. The lid of the sharps container could not be closed. At approximately 5:00 p.m., LPN #3, who was in charge of the 100 and 200 hall treatment carts, was asked when he changed sharps containers. He stated, "When they get full." He was asked if the sharps containers were full. He stated he could not remember how full the sharps containers had been. LPN #3 was asked when he was going to change the sharps containers. He stated he would change them when he had completed his finger stick blood sugar checks. 3. On 07/08/13 at 4:41 p.m. resident #80 was observed to be ambulating down hall 200 towards the dining room. The back left leg of the resident's walker was observed to get caught under the metal flooring transition between the carpeted and vinyl flooring areas. The transition was observed to be buckled up on both sides in multiple areas. The buckles were of varying sizes. Review of facility incident reports revealed no documentation of any accidents that occurred at the area. At 11:52 a.m., the maintenance supervisor was asked why the metal flooring transition on hall 200 was buckled. He stated when the plumbers came in to fix a water problem, they placed a pile of dirt on the floor that buckled the transition. The maintenance supervisor was asked when the incident had occurred. He stated, "November."