Every finding on record at Willow Park Health Care Center

On 01/14/26, an IJ situation was determined to exist related to the facility's failure to ensure Resident #9 had adequate supervision to prevent elopements on 07/11/25, 07/27/25, 09/04/25, and 09/30/25.Resident #9's cognition was severely impaired with a diagnosis of dementia. Resident #9 had three elopement assessments that placed them at high risk for elopement. Resident #9 had two episodes of exit seeking where staff redirected them and brought them back into the facility, and four additional elopements where staff were not aware the resident was gone from the facility. The facility failed to ensure adequate supervision to protect Resident #9 from elopement. Direct Care staff were not aware the resident was at risk for elopement, and stated there was a lack of communication and training. On 01/14/26 at 5:52 p.m., the OSDH was notified and verified the existence of an IJ situation.On 01/14/26 at 6:12 p.m., the administrator, DON, and AIT were notified of the IJ situation and provided the IJ template.On 01/15/26 at 2:30 p.m., an acceptable POR was approved by the OSDH. The POR, read in part, Resident #9 directly involved in this deficient practice is no longer in the facility at this time.Elopement Risk Assessments were completed on 100% of residents.Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.An At-Risk Elopement Book with care plan was created and posted at the nurse's station, accessible only to staff, in accordance with HIPAA [Health Insurance Portability and Accountability Act] requirements.All nursing staff on all shifts received immediate education on wandering, elopement, and resident safety from the DON or designee(s).Elopement and wandering residents' policy was reviewed.Facility has implemented appropriate monitoring sheet for our elopement risks residents.An Elopement Response Drill schedule was implemented, with drills occurring quarterly on all shifts.The DON or designee will perform a daily audit of clinical data to ensure adequate supervision is in place and assigned when the attempt to exit seek of active wandering and triggered elopement residents occur.The IJ was lifted, effective 01/15/26, when all components of the POR were verified as corrected:a. Resident #9's discharge MDS, dated [DATE], showed they were discharged to another facility with a memory care unit,b. the facility's documentation showed all residents were reassessed for elopement risk. The assessments identified three residents were at risk for elopement, c. three residents' care plans were reviewed. The care plans showed the residents had a focus and interventions to address the elopement risk,d. the elopement book was reviewed at the nurse's station. The elopement book contained pictures of the three identified resident at risk for elopement, their care plans, and a post elopement check list,e. the care plan monitoring tool document was reviewed. The document showed the time, location, and staff initials to monitor the care plans, f. in-service training documentation, dated 01/15/26, showed forty-three staff members from multiple departments were in-serviced by the DON over elopements and elopement drills, andg. fifteen staff members from multiple departments and shifts were interviewed. All fifteen staff members interviewed were able to communicate how to identify residents at risk for elopement, how to identify interventions for residents at risk, and what to do in the event of an elopement. This deficient practice remained at an isolated level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 (#9) of 3 sampled residents reviewed for adequate supervision to prevent elopements. The administrator identified 82 residents resided in the facility and three residents who were identified at risk for elopements. Findings: A facility policy titled Elopement and Wandering resident, dated 04/14/24, read in part, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to decrease the risk of accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering/elopement risk.An Elopement Risk Assessment for Resident #9, dated 04/14/25, showed the resident was a high risk for elopement with a score of 10.An admission assessment for Resident #9, dated 04/20/25, showed the resident's cognition was severely impaired with a BIMS score of 2. The assessment showed they were admitted with diagnoses which included dementia and anxiety. The assessment showed Resident #9 had wandering behaviors for one to three days during the seven day look back period. The assessment showed Resident #9 ambulated and transferred independently. An Elopement Risk Assessment for Resident #9, dated 07/11/25, showed the resident was a high risk for elopement with a score of 10.A facility incident report, dated 07/11/25, showed Resident #9 exited the facility with visitors. The report showed Resident #9 was located outside the front door and was redirected by staff to re-enter the facility. The report showed the care plan of Resident #9 was updated to reflect the elopement. A nurse's note for Resident #9, dated 07/11/25, showed Resident #9 walked out of the front door with visitors. The note showed residents sitting near the door notified staff and Resident #9 was redirected inside. A facility document titled Resident One on One, dated 07/12/25, showed Resident #9 was on one-on-one supervision on 07/11/25 from 7:30 p.m. to 10:00 p.m. The document was not filled out with time intervals showing Resident #9 received the one-on-one supervision. The one-on-one supervisions were not added to the care plan to show increased supervision.A nurse's note for Resident #9, dated 07/12/25, showed the resident was on focused charting and was observed wandering through the facility aimlessly displaying exit seeking behaviors.A nurse's note for Resident #9, dated 07/24/25, showed the resident attempted to exit the facility after following a delivery driver out the door. The note showed family was notified about social services helping to find a locked unit for the resident.A facility incident report, dated 07/24/25, showed Resident #9 was reported to have attempted to exit the facility when a visitor held the door for the resident. The report showed Resident #9 was redirected back inside and the resident's care plan was updated to reflect the resident's current status.A facility document titled Resident One on One, dated 07/24/25, showed Resident #9 was on-one-on supervision on 07/24/25 from 1:30 p.m. to 10:00 p.m. The document was not filled out with time intervals showing Resident #9 received the one-on-one supervision. The one-on-one supervisions were not added to the care plan to show increased supervision.A nurse's note for Resident #9, dated 07/27/25, showed the resident was observed by staff walking toward the storage facility next door outside the facility and redirected to the facility. The note showed the resident was agitated, difficult to redirect, and continued to exit seek. A facility incident report, dated 07/28/25, showed on 07/27/25 Resident #9 was observed by staff walking in the parking lot by staff near a busy street and storage facility next door. The report showed the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. An Elopement Risk Assessment for Resident #9, dated 08/18/25, showed the resident was a high risk for elopement with a score of 10.A nurse's note for Resident #9, dated 08/21/25, showed the resident was wandering in and outside the room throughout the shift. A facility incident report, dated 08/23/25, showed Resident #9 was observed by staff walking out the front door after someone entered into the facility. The report showed the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status.A nurse's note for Resident #9's, dated 08/23/25, showed the resident walked out of the facility following another resident. The note showed staff witnessed the resident leaving and redirected them back into the facility. A facility document titled Resident One on One, dated 08/23/25, showed Resident #9 was on one-on-one supervision on 07/24/25 from 12:00 p.m. to 10:00 p.m. The document was not filled out with time intervals showing Resident #9 received the one-on-one supervision. The one-on-one supervision intervention was not added to the care plan to show increased supervision.A facility incident report, dated 09/04/25, showed Resident #9 was observed by staff walking out the front door with a visitor. The report showed the staff were notified and the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. The report showed alarms were placed on the doors to alert staff and signs were placed to alert visitors of wandering residents.A nurse's note for Resident #9, dated 09/04/25, showed another resident's family was leaving the facility when Resident #9 was observed outside. The note showed the exiting visitor notified the staff Resident #9 was by the curb outside the facility and returned to the facility by a staff members car. A facility document titled Resident One on One, dated 09/04/25, showed Resident #9 was on one-on-one supervision on 09/04/25 from 10:00 a.m. to 9:00 p.m. The document was not filled out with time intervals showing Resident #9 received the one-on one supervision. The one-on-one supervision intervention was not added to the care plan to show increased supervision.A nurse's note for Resident #9, dated 09/05/25, showed the resident was wandering the facility and walking up to the front doors. The note showed Resident #9 was redirected. A facility incident report, dated 09/30/25, showed Resident #9 was observed by a visitor walking out the front door after they entered into the facility. The report showed the staff was notified and the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. The report showed an alarm was placed on the doors to alert staff and signs were placed to alert visitors of wandering residents. A nurse's note for Resident #9, dated 09/30/25, showed the resident exited the doors behind a visitor. The note showed Resident #9 was redirected back inside the facility. A facility document titled Resident One on One, dated 09/30/25, showed Resident #9 was on one-on-one supervision on 09/30/25 from 4:00 p.m. to 10:00 p.m. The document was not filled out with intervals showing Resident #9 received the one-on one supervision. The one-on-one supervision intervention was not added to the care plan.A care plan for Resident #9, revised 10/14/25, showed a focus related to elopement. The care plan showed Resident #9 was observed to pull on locked doors on 08/21/25. The care plan showed on 08/30/25 Resident #9 walked out of the facility following visitors. The care plan showed the following interventions:a. distract from wandering by offering pleasant diversions, activities, food, and conversations dated 08/19/25,b. observe for fatigue and weight loss dated 08/19/25,c. observe location in the community dated 08/19/25, andd. provide directional cues to reduce distractions dated 08/22/25.The care plan did not show interventions were updated to increase supervision after Resident #9's exit seeking and wandering on 07/24/25 and 08/23/25. The care plan did not show interventions for increased supervision after elopements on 07/11/25, 07/27/25, 09/04/25, and 09/30/25.On 01/14/26 at 1:30 p.m., CNA #2 stated interventions for a resident who was an elopement risk would be found in the care plan. CNA #2 stated they were unsure what to do when a resident had multiple elopement attempts and would report to the RN.On 01/14/26 at 1:36 p.m., LPN #2 stated Resident #9 eloped from the facility when a visitor let the resident out of the facility. LPN #2 stated Resident #9 would shake the exit doors and try to open them. On 01/14/26 at 1:47 p.m., CNA #3 stated they could identify residents at risk for elopement by word of mouth or the care plan. CNA #3 stated there was an elopement book on the [NAME] hall, but they were not sure who checked or looked at the book. CNA #3 stated unless there was a person standing by the exit door twenty-four hours a day, they could not keep track of who was exiting the facility. CNA #3 stated there was a busy road outside the facility and there was a potential for harm if a resident eloped from the facility. On 01/14/26 at 1:47 p.m., ADON #1 stated a resident with an elopement risk score on 10 or higher would be considered a high risk for elopement. On 01/14/26 at 2:17 p.m., the DON stated Resident #9 eloped from the facility on 07/27/25. The DON stated Resident #9 was found in the parking lot near a very busy street. The DON stated there was a potential for harm to Resident #9. The DON stated Resident #9 was placed on focused charting and on one-on-one supervision on 07/11/25 after an exit seeking attempt. The DON stated the system failure was related to one-on-one forms were not completed by staff to reflect the Resident #9's location in time intervals and there was no documentation the one-on-ones were added to Resident #9s care plan to ensure adequate supervision after elopements and exit seeking attempts on 07/11/25, 07/24/25, 07/27/25, 08/23/25, 09/04/25, and 09/30/25. The DON stated Resident #9 should have been on one-on-one supervision after the first exit seeking attempt on 07/11/25 to ensure adequate supervision.On 01/14/26 at 4:33 p.m., resident representative #1 stated they were never informed Resident #9 was placed on one-on-one supervision. They stated Resident #9 was moved to a different facility with a memory care because Resident #9 was not safe at the facility due to exit seeking attempts and elopements.

On 01/14/26, an IJ situation was determined to exist related to the facility's failure to ensure a comprehensive care plan was developed for Resident #9 to prevent an elopement on 07/27/25. Resident #9's cognition was severely impaired with a BIMS score of 2. Resident #9 had four elopement assessments which identified Resident #9 as a high risk for elopement. Resident #9 had several exit seeking attempts and elopements during a three-month period. After each elopement or attempted elopement, the resident was placed on one-on-one supervision. Resident #9's care plan was not updated with one-on-one supervision, and there was no documentation of one-on-one supervision was ongoing to prevent elopement. CNA #2 stated they did not know what was supposed to happen when a resident had multiple elopement events.On 01/14/26 at 5:52 p.m., the OSDH was notified and verified the existence of an IJ situation.On 01/14/26 at 6:12 p.m., the administrator, DON, and AIT were notified of the IJ situation and the IJ template was provided. On 01/15/26 at 2:30 p.m., an acceptable POR was approved by the OSDH. The POR, read in part, Resident #9 directly involved in this deficient practice is no longer in the facility at this time.Elopement Risk Assessments were completed on 100% of residents.Facility completed 100% audit of residents who were identified at risk for elopement.Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.IDT received immediate education on reviewing, revising, developing and implementing care plans from the VP of Reimbursement or designee(s).IDT team has implemented appropriate monitoring sheet for our elopement risks residents.The IJ was lifted. effective 01/15/26, when all components of the POR were verified as corrected:a. Resident #9's discharge MDS, dated [DATE], showed they were discharged to another facility with a memory care unit,b. the facility's documentation showed all residents were reassessed for elopement risk. The assessments identified three residents were at risk for elopement, c. three residents care plans were reviewed. The care plans showed the residents had a focus and interventions to address the elopement risk,d. the elopement book was reviewed at the nurse's station. The elopement book contained pictures of the three identified resident at risk for elopement, their care plans, and a post elopement check list. The post elopement check list showed eight questions to ensure the resident was located, assessed, the proper individuals were notified, and the proper documentation was completed,e. the care plan monitoring tool document was reviewed. The document showed the time, location, and staff initials to monitor the care plans, f. in-service training documentation, dated 01/15/26, showed team members of the IDT were in-serviced by the VP of reimbursement over ensuring comprehensive care plans were revised after incidents, andg. members of the IDT team were interviewed. The IDT team members were able to communicate they understood the care plan should be updated to reflect interventions in place to prevent elopements after each incident or assessment.This deficient practice remained at an isolated with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure a resident's comprehensive care plan was implemented after exit seeking behaviors and elopements to ensure adequate supervision for 1 (#9) of 3 sampled residents reviewed for comprehensive care plans.The administrator identified 82 residents resided in the facility. Findings:A facility policy titled, Comprehensive Care Plans, dated 08/01/24, read in part, The comprehensive care plan will include measurable objectives, and time frames to meet the resident's need as identified in the resident comprehensive assessment. The objective will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. An Elopement Risk Assessment for Resident #9, dated 04/14/25, showed the resident was a high risk for elopement with a score of 10.An admission assessment for Resident #9, dated 04/20/25, showed the resident's cognition was severely impaired with a BIMS score of 2. The assessment showed they were admitted with diagnoses which included dementia and anxiety. The assessment showed Resident #9 had wandering behaviors for one to three days during the seven days look back period. The assessment showed Resident #9 ambulated and transferred independently. A care plan for Resident #9, date initiated 05/08/25, showed a focus for elopement. The care plan showed Resident #9 eloped from the facility on 07/11/25 and on 07/27/25. The care plan showed the following interventions to prevent elopement:a. distract the resident from wandering by offering diversions like food and activities initiated on 05/08/25 and cancelled on 08/06/25,b. identify a pattern of wandering and intervene as appropriate initiated on 07/28/25 and cancelled on 08/06/25, andc. provide structured activities like signs, memory boxes, and walking inside and outside initiated on 05/08/25 and cancelled on 08/06/25.The care plan initiated on 05/08/25 did not show interventions were added to the care plan after the elopement on 07/11/25.An Elopement Risk Assessment for Resident #9, dated 07/11/25, showed the resident was a high risk for elopement with a score of 10.A facility incident report, dated 07/11/25, showed Resident #9 was reported to exit the facility with visitors and was notified by visitors Resident #9 was outside the front door. The report showed Resident #9 was redirected back inside and the resident's care plan was updated to reflect the resident's current status.A facility document titled Resident One on One, dated 07/11/25, showed Resident #9 was on one-on-one supervision on 07/11/25 from 7:30 p.m. to 10:00 p.m. The one-on-one supervision intervention was not added to the care plan.A facility incident report, dated 07/24/25, showed Resident #9 was reported to have attempted to exit the facility when a visitor held the door for the resident. The report showed Resident #9 was redirected back inside and the resident's care plan was updated to reflect the resident's current status.A facility document titled Resident One on One, dated 07/24/25, showed Resident #9 was on one-on-one supervision on 07/24/25 from 1:30 p.m. to 10:00 p.m. The one-on-one supervision intervention was not added to the care plan.A nurse's note for Resident #9, dated 07/27/25, showed the resident was observed by staff walking in the parking lot near the next door storage facility. The note showed Resident #9 was agitated and hard to redirect. The note showed the resident continued to have exit seeking behaviors. A facility incident report, dated 07/28/25, showed Resident #9 was observed by staff on 07/27/25 walking in the parking lot by staff near a busy street and storage facility next door. The report showed the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. An Elopement Risk Assessment for Resident #9, dated 08/18/25, showed the resident was a high risk for elopement with a score of 10.A facility incident report, dated 08/23/25, showed Resident #9 was observed by staff walking out the front door after someone entered into the facility. The report showed the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. A facility document titled Resident One on One, dated 08/23/25, showed Resident #9 was one-on-one supervision on 08/23/25 from 12:00 p.m. to 10:00 p.m. The one-on-one supervision intervention was not added to the care plan.A facility incident report, dated 09/04/25, showed Resident #9 was observed by staff walking out the front door by a family member. The report showed the staff was notified and the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. The report showed alarms were placed on the doors to alert staff and signs were placed to alert visitors of wandering residents.A facility document titled Resident One on One, dated 09/04/25, showed Resident #9 was on one-on-one supervision on 09/04/25 from 10:00 a.m. to 9:00 p.m. The one-on-one supervision intervention was not added to the care plan.A facility incident report, dated 09/30/25, showed Resident #9 was observed by a visitor walking out the front door after they entered into the facility. The report showed the staff was notified and the resident was redirected inside, assessed, and the care plan updated to reflect the resident's current status. The report showed an alarm was placed on the doors to alert staff and signs were placed to alert visitors of wandering residents. A facility document titled Resident One on One, dated 09/30/25, showed Resident #9 was on one-on-one supervision on 09/30/25 from 4:00 p.m. to 10:00 p.m. The one-on-one supervision intervention was not added to the care plan.A care plan for Resident #9, revised 10/14/25, showed a focus related to elopement. The care plan showed Resident #9 was observed to pull on locked doors on 08/21/25. The care plan showed on 08/30/25, Resident #9 walked out of the facility following visitors. The care plan showed the following interventions:a. distract from wandering by offering pleasant diversions, activities, food, and conversations dated 08/19/25,b. observe for fatigue and weight loss dated 08/19/25,c. observe location in the community dated 08/19/25, andd. provide directional cues to reduce distractions dated 08/22/25.A care plan for Resident #9, revised 10/14/25, did not show previous elopements and interventions from Resident #9's care plan initiated on 05/08/25 and cancelled on 08/09/25. The care plan did not show the interventions were revised to include one-on-one supervisions after Resident #9's exit seeking behaviors and elopements on the following dates:a. on 07/11/25, Resident #9 eloped from the facility,b. on 07/24/25, Resident #9 had exit seeking behaviors,c. on 07/27/25, Resident #9 eloped from the facility,d. on 08/23/25, Resident #9 was had exit seeking behaviors,e. on 09/04/25, Resident #9 eloped from the facility, and f. on 09/30/25, Resident #9 eloped from the facility.On 01/14/26 at 1:30 p.m., CNA #2 stated interventions for a resident who was an elopement risk would be found in the care plan. CNA #2 stated they were unsure what to do when a resident had multiple elopement attempts and would report to the RN. They stated if a resident was confused, had dementia, or was always trying to go home, a resident would be at risk for elopement.On 01/14/26 at 1:36 p.m., LPN #2 stated interventions for residents at risk for elopement should be in the resident's care plan. LPN #2 stated Resident #9 eloped from the facility when a visitor let the resident out of the facility. They stated Resident #9 was found in the parking lot near the busy road. LPN #2 stated Resident #9 would shake the exit doors and try to open them. On 01/14/26 at 1:47 p.m., CNA #3 stated they could identify residents at risk for elopement by word of mouth or the care plan. CNA #3 stated there was an elopement book on the [NAME] hall, but they were not sure who checked or looked at the book. CNA #3 stated unless there was a person standing by the exit door twenty-four hours a day, they could not keep track of who was exiting the facility. CNA #3 stated there was a busy road outside the facility and there was a potential for harm if a resident eloped from the facility. On 01/14/26 at 1:47 p.m., ADON #1 stated residents with an elopement risk score on 10 or higher would be considered a high risk for elopement. The ADON stated Resident #9's care plan was revised on 7/15/25 after Resident #9 attempted to exit the facility with visitors on 7/11/25. The ADON stated Resident #9 attempted to exit the facility on 07/24/25 when a delivery driver was leaving. The ADON stated they identified residents at risk for elopement through in-service training, the elopement book with a green sheet, and reporting from nurses.On 01/14/26 at 2:17 p.m., the DON stated Resident #9 eloped from the facility on 07/27/25. The DON stated Resident #9 was found in the parking lot near a very busy street. The DON stated there was a potential for harm to Resident #9. The DON stated Resident #9 was placed on focused charting and on one-on-one supervision after an exit seeking attempt on 07/11/25. The DON stated the system failure was related to one-on-one forms to reflect the location of Resident #9, and the facility's lack of documentation in the care plan for the exit seeking and elopements of Resident #9. On 01/14/26 at 4:33 p.m., resident representative #1 stated they were never informed Resident #9 was placed on one-on-one supervision. They stated Resident #9 was moved to a different facility with a memory care because Resident #9 was not safe at the facility due to the residents exit seeking behaviors.

Based on observation, record review, and interview, the facility failed to provide adequate assistance to prevent a lift accident for 1 (#3) of 3 residents reviewed for accidents. The administrator reported 78 residents resided at the facility. Findings: On 05/28/25 at 11:07 a.m., Resident #3 was observed in their room sitting in their wheelchair. A policy Lifting Machine, Using a Portable, dated December 2013, showed the purpose of the procedure was to help lift residents using a manual lifting device. The policy showed two nursing assistants were required to perform the procedure. A quarterly assessment, dated 02/13/25, showed Resident #3 was moderately impaired with cognition. The assessment showed the resident was dependent on staff for assistance with activities of daily living. The assessment showed the resident had diagnoses which included multiple sclerosis, paralytic syndrome, lack of coordination, and tremors. A progress note, dated 04/17/25 at 5:07 p.m., showed ADON #1 responded to an incident with Resident #3. The note showed the resident was assessed while still on the floor after the lift tilted while staff was transferring the resident. The note showed Resident #3 did not feel the staff member was at fault but needed additional education on transferring with the lift. The note showed a family member had viewed camera footage and reported the resident did not fall hard and could see the staff member lower the resident to the floor. On 05/28/25 at 11:10 a.m., Resident #3 reported there had been one incident when the lift tipped over and fell on them. The resident reported they were not injured and were not afraid of the lift. On 05/28/25 at 1:17 p.m., CNA #1 reported it was standard procedure and facility policy to have two people use the lift when transferring residents. On 05/28/25 at 1:25 p.m., LPN #1 reported it was standard practice to have two people when using the lift while providing care to residents. On 05/28/25 at 1:40 p.m., RN #1 reported the facility had a few residents who required the lift and it was always a two-person assist. On 05/29/25 at 7:07 a.m., CNA #2 reported they couldn't remember the name of the aide who used the lift without a second person assist, but CNA #2 was called in to replace the aide when they were suspended after the incident with Resident #3. CNA #2 reported lifts were always used with two people. On 05/29/25 at 8:15 a.m., ADON #1 reported CNA #3 came and got them to let them know Resident #3 was on the floor after the lift tilted. The ADON reported CNA #3 was able to lower the resident to the floor without injury. The ADON was asked if CNA #3 reported why they did not have a second person assisting. The ADON reported they thought the resident was in a hurry to get up so the aide did not wait for assist. The ADON reported there was plenty of staff available the day of the incident and there was no reason the aide could not get assistance with transferring the resident. On 05/29/25 at 9:44 a.m., CNA #3 was interviewed by phone. CNA #3 reported on the day of the incident, Resident #3 wanted to get up for a smoke break and was in a hurry. CNA #3 reported they knew they should have gotten a second person to assist with the lift but did not take the time to get someone to help.

On 10/03/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #38, who had been assessed to require supervision and a smoking apron when smoking, was provided adequate supervision. A care plan intervention, updated 01/31/24, documented Resident #38 required staff supervision with smoking and the use of a smoking apron. A smoking assessment, dated 02/15/24, documented Resident #38 was safe for smoking with supervision and use of a smoking apron. An incident report, dated 04/19/24, documented an unwitnessed incident. The report documented Resident #38 reported, I was lighting my cigarette and my beard caught on fire. The incident report documented two small burns to the left side of the resident's face and under their left ear. A smoking assessment, dated 09/08/24, read in part, Safe for smoking with one-on-one assist and a smoking apron. On 10/03/24 at 12:41 p.m., Resident #38 was observed smoking without supervision and without a smoking apron. Cigarette ashes were observed on the resident's right thigh. On 10/03/24 at 12:55 p.m., the AIT was observed to bring Resident #38 two cigarettes and provided assistance with lighting one of the cigarettes. On 10/03/24 at 12:57 p.m., Resident #38 was observed smoking without a smoking apron. The AIT was observed providing water to other residents in the smoking area. On 10/03/24 at 1:00 p.m., the AIT reported not being aware if Resident #38 required a smoking apron and would have to check. On 10/04/24 at 1:25 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 10/04/24 at 1:35 p.m., the administrator was notified of the IJ situation. On 10/07/24 at 3:29 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented: The facility asserts that the likelihood of serious harm no longer exists as of 10/04/24, at 4:30 p.m. Issue Cited: Resident #38 had smoking assessments, dated 01/31/24 and 02/15/24, and was found to be unsafe to smoke unsupervised and required smoking interventions. Care plan interventions, dated 01/31/24 and last reviewed 07/23/24, documented resident #38 required staff supervision and the use of a smoking apron. An incident report, dated 04/19/24, documented an unwitnessed smoking incident for resident #38 where he caught his beard on fire lighting his cigarette. The incident resulted in two small burns to left side of face and under left ear. A smoking assessment, dated 09/08/24, found resident to be unsafe for smoking without one-on-one assist, supervision and a smoking apron. Staff interview reported knowledge of resident needing to be supervised with smoking but not aware if a smoking apron was required. On 10/03/24 at 12:41 p.m., resident #38 was observed smoking in the designated smoking area unsupervised and without a smoking apron in place. Identification of Residents Affected or Likely to be Affected: ( Completion Date 10/03/24.) a. Resident #38 reside in the building at time of the survey b. Resident #4 [name withheld] c. Resident #33 [name withheld] d. Resident #54 [name withheld] e. Resident #30 [name withheld] Actions to Prevent Occurrence Recurrence: 1. MDS conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status. 10/04/24. 2. Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status. 10/04/24. 3. Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status. 10/04/24. 4. The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision. 10/03/24. 5. The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers. 10/03/24. 6. The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status. 10/03/24. 7. The Administrator attended a resident meeting to review the smoking policy with the residents. 10/04/24. 8. The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials. 10/03/24. 9. The DON and Administrator conducted a smoking in-service for all employees, which was completed on 10/04/24. Ongoing education will be provided to new staff and as needed. Conduct telephonic in-service with staff who are currently out with follow up ongoing education prior to working their assigned shift. 10. The Administrator conducted QAPI to discuss the smoking policy and procedure, completed on 10/03/24. 11. Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers. 10/03/24. 12. The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions. 10/04/24. 13. Admissions and Social Service will review the smoking times and policy with each new admission. 10/04/24. The IJ was lifted, effective 10/07/24 at 4:39 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained at an isolated with a potential harm. Based on observation, record review, and interview, the facility failed to ensure adequate supervison was provided and a smoking apron was in place while smoking for one (#38) of three sampled residents reviewed for smoking safety. The administrator identified 78 residents resided in the facility. Findings: An undated resident smoking policy, read in part, All safe smoking measures will be documented on each resident's care plan .Supervision will be provided as indicated on each resident's care plan .Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff or designee . Resident #38 had diagnoses which included hemiplegia, seizure disorder and cerebral infraction. A smoking assessment, dated 01/31/24, read in part, Residents need for adaptive equipment: smoking apron and supervision. A smoking assessment, dated 02/15/24, read in part, Resident reassessed for smoking .Found to be safe to smoke with supervision and smoking vest .Charge nurse and staff made aware that the resident would need to be monitored while smoking and that the smoker's apron would need to be utilized. A facility incident report, dated 04/19/24, documented an unwitnessed smoking injury. The incident report documented Resident #38 reported, I was lighting my cigarette and my beard caught on fire. The incident report documented two small burns to the left side of the resident's face and under their left ear. The incident report, read in part, Area to left side of face cleansed with wound cleaner, pat dry, silvasorb applied, physician notified, resident agreed to allow staff to shave today, and two small one mm areas noted below left ear. A smoking assessment, dated 04/24/24, read in part, Resident needs supervision when smoking and beard needs to be kept short .Resident unable to light cigarette safely and supervision required to ensure lit cigarette does not make contact with beard, hair, skin, and clothing. A comprehensive assessment, dated 07/18/24, documented Resident #38 was dependent on staff for most activities of daily living and dependent on staff to ambulate with a wheelchair. The comprehensive assessment documented the resident was unable to complete the brief interview for mental status. A care plan, last reviewed 07/23/24, read in part, I require staff supervision/adaptations when using tobacco products, revised 01/31/24. *Staff will complete a smoking assessment to ensure my safety quarterly, revised 01/31/24. *I require assistance with lighting tobacco products only, initiated 10/29/21. *I require the community to keep all tobacco and fire starting materials for, initiated 10/29/21. *I require the use of an Adaptive Device: Smokers Apron, initiated 01/31/24. *My smoking supplies are stored at the nurse's station, initiated 10/29/21. A smoking assessment, dated 09/08/24, read in part, Safe to smoke with supervision, beard must be kept short, needs one-on-one assist and a smoking apron. On 10/03/24 at 11:30 a.m., CNA #5 reported not being aware which residents required supervision with smoking. The CNA reported if a resident was required to be supervised, and an employee was available, they went out with the resident to smoke. On 10/03/24 at 12:36 p.m., Resident #38 was observed sitting in their wheelchair by the smoking area door in the common area with an unlit cigarette in their mouth waiting to go outside. On 10/03/24 at 12:41 p.m., Resident #38 was observed outside in the smoking area smoking. They were observed leaned over to the right in their wheelchair. There was no staff present in the smoking area and the resident did not have a smoking apron on. The resident was observed to have cigarette ashes on their right thigh and the cigarette was very short. The resident was observed dozing off to sleep while smoking. On 10/03/24 at 12:50 p.m., Resident #38 was observed in the smoking area and no longer smoking. The resident's head was down and sleeping. The resident reported they were okay. On 10/03/24 at 12:55 p.m., the AIT was observed to bring Resident #38 two cigarettes and provided assistance with lighting one of the cigarettes. On 10/03/24 at 12:57 p.m., Resident #38 was observed smoking without a smoking apron. The AIT was observed providing water to other residents in the smoking area. On 10/03/24 at 1:00 p.m., the AIT reported not being aware if Resident #38 required a smoking apron and would have to check. On 10/03/24 2:22 p.m., CMA #2 reported cigarettes were kept on the medication cart. The CMA reported supervised smokers got a cigarette if they had someone to go out and smoke with them. The CMA reported they were not aware if Resident #38 required a smoking apron and was not aware where the smoking aprons were kept. On 10/03/24 2:22 p.m., CMA #3 reported they went out with supervised smokers when they were working the floor. They reported they were not sure which smokers needed an apron. The CMA stated they thought Resident #38 required an apron due to just visualizing the resident outside smoking with a smoking apron on. On 10/03/24 at 2:28 p.m., CNA #2 reported no smoking aprons had been used for smokers and was unaware where the smoking aprons were stored. On 10/03/24 at 2:36 p.m., CNA #3 reported working on both sides of the facility. They reported Resident #38 required supervision with smoking due to leaning over to the side in their wheelchair, but not a smoking apron. On 10/03/24 at 3:40 p.m. the administrator and AIT reported all staff should be aware who required smoking supervision and a smoking apron. The AIT reported three residents required supervision with smoking and a smoking apron. The administrator reported a new smoking policy was initiated, on 09/01/24 from corporate, and all staff had been in-serviced on the new policy. The AIT reported Resident #38 required a smoking apron and required supervision for smoking.

Based on observation, record review, and interview, the facility failed to ensure: a. enhanced barrier precautions were implemented for two (#69 and #78) of three sampled residents observed during wound care; b. enhanced barrier precautions were implemented for one (#69) of one sampled resident observed during Foley catheter care; and c. contact precautions were implemented for one (#49) of one sampled resident observed for transmission-based precautions. The ADON #2 identified one resident required TBP. The regional consultant identified 19 residents required enhanced barrier precautions. The administrator identified 78 residents resided in the facility. Findings: An Enhanced Barrier Precautions policy, dated 04/01/24, read in part, *It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms. *An order for enhanced barrier precautions will be obtained for wounds and/or indwelling medical devices. *Make gowns and gloves available near or outside the resident's room. *Face protection may also be needed if performing activity with risk of splash or spray. *PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. An undated isolation policy titled Contact Precautions, read in part, *Implement contact precautions for residents known or suspected to be infection with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment *Wear gloves when entering the room. *Wear a disposable gown upon entering the contract precautions room. *The facility will implement a system to alert staff to the type of precautions resident requires. *The facility will also ensure that the resident's care plan and care specialist communication system indicates the type of precautions implemented for the resident. 1. Resident #78 had diagnoses which included diabetes mellitus, lung cancer, and dementia. A comprehensive assessment, dated 9/13/24, documented Resident #78's cognition was severely impaired and required extensive assistance with activities of daily living. A physician's order, dated 09/18/24, read in part, Cleanse right heel with wound cleanser, pat dry, apply leptospermum honey daily x 23 days .Float/off load heels as ordered .Left side of neck cleanse with wound cleanser, apply leptospermum honey, apply alginate calcium, cover with border gauze daily x 23 days . A physician's order, dated 09/20/24, read in part, Cleanse sacrum wound with wound cleanser, pat dry, apply alginate calcium, apply island gauze cover with boarder dressing daily x 30 days. On 09/30/24 at 11:25 a.m., the wound care nurse and wound physician removed the resident's wound dressing to coccyx, right heel, and left side of their neck. They were observed to wear gloves. There was no gowns donned for enhanced barrier precautions. The resident's room was observed to have no enhanced barrier precaution signage in place or PPE supplies outside of the room. A care plan, dated 10/01/24, read in part, I have actual impairment to skin integrity of the neck related to infection of abscessed area to neck due to my cancer. A care plan, dated 10/04/24, read in part, I am on enhanced barrier precautions related to skin openings, abscesses due to my cancer .Apply appropriate PPE during all high-contact resident care activities .Notify all staff of enhanced barrier precautions. 2. Resident #69 had diagnoses which included malignant neoplasm of connective and soft tissue and local infection of the skin and subcutaneous tissue. A comprehensive assessment, dated 06/21/24, documented Resident #69's cognition was moderately impaired and dependent on staff for most activities of daily living. A physician's order, dated 06/19/24, read in part, Foley catheter care every shift and as needed. A physician's order, dated 09/24/24, read in part, Cleanse right anterior chest with wound cleanser, apply alginate rope with silver, apply collagen powder, cover with gauze island with boarder dressing daily x 30 days. On 10/02/24 at 9:45 a.m., Resident #69's room had no enhanced barrier precautions signage or PPE supply available outside of the room. On 10/02/24 at 9:49 a.m, ADON #1 provided wound care to the right side of Resident #69's chest. The ADON wore gloves to perform wound care, but no other PPE was donned related to enhanced barrier precautions. On 10/02/24 at 2:09 p.m., CNA #3 donned a gown and gloves to empty Resident #69's Foley catheter bag. The CNA reported they did not like them to wear gowns to empty the Foley catheter bags, but they had started using them because it is messy. The resident's room was observed to have an enhanced barrier precautions signage on the door at this time. A care plan, dated 10/04/24, read in part, I am on enhanced barrier precautions related to nonhealing surgical incision and indwelling catheter. 3. Resident #49 had diagnoses which included diabetes mellitus. A comprehensive assessment, dated 09/01/24, documented Resident #49's cognition was moderately impaired and required substantial/maximal assistance with activities of daily living. A physician's order, dated 09/30/24, read in part, Initiate contact isolation precautions for MRSA in the would of the toe .Gentamicin sulfate external ointment 0.1% apply to left great toe topically one time a day for wound infection x 10 days. A care plan, dated 10/01/24, read in part, I have a diabetic ulcer of the left great toe related to diabetes .I do have MRSA to my toe, new orders and antibiotics obtained following results of wound culture .Contact isolation initiated. On 10/02/24 at 12:34 p.m., Resident #49 was observed setting up in the recliner in their room with their feet elevated. The resident's wound to the left great toe was observed with no dressing in place. The resident reported the dressing was removed before their shower. The wound care nurse provided wound care to left great toe wearing gloves, no other PPE was used. The wound care nurse reported the resident's wound culture came back as a staph infection and they were treating with gentamycin ointment (antibiotic) for 10 days. The wound care nurse disposed of used wound care supplies in a clear plastic bag, then removed from the clear plastic bag from the room and placed the bag in the side trash can of the treatment cart. On 10/02/24 at 2:34 p.m., ADON#2 reported not being aware of any resident having MRSA in a wound or on contact precautions. They reported signage for isolation, biohazard bags in the room, and PPE outside side the residents door should be in place for a resident on transmission based/contact . The ADON reported the wound care nurse/infection preventionist and charge nurse were responsible to ensure staff were aware of residents on isolation and putting out the PPE supplies and isolation signage. The ADON reported enhanced barrier precaution signage should not be used if a resident was on isolation precautions. They reported contact precautions for Resident #49 should have been put into place when the order was received. On 10/02/24 at 3:00 p.m., ADON #2 reported Resident #49 should have had contact precautions in place, but staff had failed to do so. They reported residents with a Foley catheter and open wounds should have enhanced barrier precautions used by staff for catheter care and wound care. The ADON was not aware the reason staff were not following enhanced barrier precautions or the reason signage was not in place.

Based on record review and interview, the facility failed to refer residents with newly diagnosed mental illnesses to the OHCA for a Level II PASARR evaluation for three (#9, 38, and #60) of three sampled residents reviewed for PASARRs. The administrator identified 78 residents resided in the facility. Findings: An undated Resident Assessment - Coordination with PASARR Program policy, read in part, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review . 1. Resident #9 was admitted to the facility on [DATE]. The Level I PASARR screen, dated 09/06/07, documented no mental illness. On 11/20/14, the resident was diagnosed with bipolar disorder. On 12/18/29, the resident was diagnosed with major depressive disorder and schizophrenia. 2. Resident #38 was admitted to the facility on [DATE]. The Level I PASARR screen, dated 07/24/19, documented no mental illness. On 06/06/20, the resident was diagnosed with major depressive disorder. On 09/06/20, the resident was diagnosed with mood disorder. 3. Resident #60 was admitted to the facility on [DATE]. The Level I PASARR screen, dated 10/19/22, documented no mental illness. On 11/21/22, the resident was diagnosed with schizoaffective disorder. On 11/22/22, the resident was diagnosed with mood disorder. On 10/02/24 at 3:19 p.m., the MDS coordinator reported not being aware if a residents new diagnosis of mental illness, not documented on the Level I PASARR screening at admission, had to be reported to the OHCA to evaluate the need for Level II services. They reported no PASARR policy had been received to follow for completing PASARR screenings. They reported they had only reported new mental illness if a resident had an inpatient mental hospital stay. On 10/03/24 at 11:28 a.m., the MDS coordinator agreed, after reading over the facility's PASARR policy Resident #9, #38, and #60's new diagnoses of mental illness should have been reported to the OHCA when they were newly evident.

Based on record review and interview, the facility failed to ensure advance directive acknowledgement forms were completed for two (#10 and #24) of 18 sampled residents reviewed for advance directives. Findings: The administrator identified 78 residents resided in the facility. The Advance Directives policy, dated December 2016, read in part, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive. 1. Resident #10 was admitted to the facility on [DATE] with a re-entry date of 09/15/24. A physician order, dated 06/15/23, documented full code. Full code was marked in the electronic record. No acknowledgement form for an advance directive was in the clinical record or electronic record. 2. Resident #24 was admitted to the facility on [DATE]. A physician order, dated 05/29/24, documented full code. Full code was marked in the electronic record. No acknowledgement form for an advance directive was in the clinical record or electronic record. On 10/01/24 at 3:15 p.m., the administrator was asked the reason the advance directive acknowledgements were completed for Residents #10 and Resident #24 during the current survey. They reported the acknowledgement forms were part of the admission packet, but at this time the forms were not being completed.

Based on record review and interview, the facility failed to ensure an allegation of neglect was reported to the State Agency (OSDH) for one (#38) of one sampled resident reviewed for abuse. The administrator identified 78 residents resided in the facility. Findings: Resident #38 had diagnoses which included hemiplegia. A comprehensive assessment, dated 07/18/24, documented Resident #38's cognition was impaired and was dependent on staff to complete activities of daily living. An incident report form ODH Form 283, dated 09/03/24, documented an allegation of neglect involving Resident #38. The incident report documented notifications made to the following: physician, family, local law enforcement, and nurse aide registry. The incident report documented no proof of the fax transmission. On 10/03/24 at 9:37 a.m., the OSDH complaint department confirmed no incident reports had been received from the facility since 06/18/24. On 10/03/24 at 10:00 a.m., the administrator provided an email confirmation submitted to the OSDH on 09/09/24 at 12:57 p.m. The administrator reported the email confirmation documented no proof the fax transmission was received by OSDH.

Based on record review and interview, the facility failed to provide supervision to prevent elopement for one (#5) of one resident reviewed for elopement. The DON reported three residents who exhibited exit-seeking behaviors and no incidents of elopement. Findings: An Elopements policy, dated December 2017, documented in part, .Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .Examine the resident for injuries .Document the event in the resident's medical record . Resident #5 was admitted with diagnoses which included hemiplegia/hemiparesis, hypertension, aphasia, dysphagia, muscle weakness, and a history of transient ischemic attack. An MDS assessment for resident #5, dated 07/03/24, documented the resident was cognitively impaired and had memory problems. The assessment documented the resident ambulated independently. A care plan for resident #5, dated 07/15/24, documented the resident was an elopement risk due to wandering behaviors. Interventions included assessment, distraction, and identification of patterns related to wandering. On 09/06/24 at 5:10 p.m., the ADON reported they were not aware of any residents who had eloped. The ADON reported the facility had a couple of residents who were allowed to check themselves out of the facility and go into the community on their own. On 09/10/24 at 10:50 a.m., CMA #1 and #2, and CNA #1, reported they were not aware of any resident elopements. The staff reported there were certain residents who were allowed to check themselves out of the facility and go into the community. On 09/10/24 at 3:45 p.m., a resident who requested to remain anonymous reported they had heard about a resident getting out of the facility and going near the street. The resident gave a first name of the resident in question but did not know a last name. The resident stated they did not witness the incident and did not know the outcome. On 09/10/24 at 4:10 p.m., the surveyor reviewed the resident roster and there was not a resident listed with the first name provided by the anonymous resident. On 09/11/24 at 10:05 a.m., LPN #1 was interviewed regarding any incidents of resident elopement. The LPN reported there was a previous resident, resident #5, who had wandering behaviors but had never eloped on day shift. The LPN reported the resident had been discharged to another long term care facility. On 09/11/24 at 10:15 a.m., the closed medical record for resident #5 was reviewed and documented the resident was discharged on [DATE] to another long term care facility. The nurse notes contained no documentation related to an elopement incident. Nurse notes documented the resident was being monitored for wandering behaviors. On 09/11/24 at 10:26 a.m., the corporate RN reported there was not an incident report for resident #5 related to an elopement incident. On 09/11/24 at 12:15 p.m., CNA #1 reported they had heard about resident #5 getting out of the facility but stated they did not witness it and they were not working at the time of the incident. On 09/11/24 at 1:35 p.m., LPN #2 reported they worked at the facility the evening of 09/02/24 when they received a phone call at the nurse's station by an anonymous caller. The caller reported they thought one of the facility's residents was out of the building near the street. The LPN #2 stated by the time they got to the door, an unidentified staff member was walking in with resident #5 and the resident was unharmed. The LPN stated she thought the nurse she was training under was going to report the incident to the DON. On 09/11/24 at 2:20 p.m., CNA #2 reported they were working the evening of 09/02/24 but had gone on break and wasn't aware of the incident with resident #5 until they got back from break. The CNA stated resident #5 was known to wander around the facility independently but they were not aware of the resident ever trying to leave the facility. The CNA #2 stated they talked with the resident that evening, the resident was unharmed, and staff continued to monitor the resident for wandering behaviors. On 09/11/24 at 2:35 p.m., the DON reported they had been notified of resident #5 going out of the door toward the laundry room but stated the resident was never out of sight. The DON stated since the resident was never out of sight, they did not complete an incident report. The DON stated the door leading to the laundry room would not give the resident access to the street, and they were never informed of an incident when the resident got near the street. The DON reported the facility had been looking for more appropriate placement for resident #5 due to the resident's wandering behaviors, and the resident had been discharged on [DATE].

Based on record review and interview, the facility failed to complete a discharge summary, to include a recapitulation of the resident's stay, for two (#4 and #5) of two residents reviewed for discharge. The administrator reported a census of 78 residents. Findings: A Discharging the Resident policy, dated December 2016, documented in part, .The resident should be consulted about the discharge .ensure that resident and/or responsible party receive teaching and discharge instructions .ensure that a transfer summary is completed .assess and document resident's condition at discharge . 1. Resident #4 was admitted to the facility on [DATE] and discharged on [DATE]. A physician order for resident #4, dated 05/03/24, documented to discharge the resident home on 05/04/24 with medications and discharge instructions. An MDS discharge assessment for resident #4, dated 05/04/24, documented the resident was cognitively intact. The assessment documented the discharge was planned. A discharge summary was not completed for resident #4. 2. Resident #5 was admitted to the facility on [DATE] and discharged on [DATE]. An MDS assessment, dated 07/03/24, documented resident #5 was cognitively impaired with memory problems. Progress notes for resident #5, dated 09/08/24, documented the resident was discharged to another long term care facility. The progress notes documented the resident was being monitored for wandering behaviors. A discharge summary was not completed for resident #5. On 09/11/24 at 2:35 p.m., the DON reported discharge summaries could not be located but should have been completed for resident #4 and #5.

Based on record review and interview, the facility failed to complete performance reviews for CNAs as required annually. The DON reported 15 CNAs had been employed and worked in the facility for over one year. Findings: A review of facility records was conducted and did not document an annual skills review had been completed for CNAs who had worked in the facility for at least one year. On 08/08/23 at 4:51 p.m., RN #1 reported performance reviews had not been completed and there was no documentation related to a review of CNA competencies.

Based on record review and interview, the facility failed to notify the physician, per physician orders, for systolic blood pressure readings out of parameters for one (#13) of five residents reviewed for physician orders. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility. Findings: A facility policy and procedure, Change in a Resident's Condition or Status, read in part, .specific instruction to notify the Physician of changes in the resident's condition . Resident #13 was admitted with diagnoses which included hypertension. A physician order, dated 12/08/22, documented to administer Norvasc 5 mg [a blood pressure medication], one tablet by mouth daily, and to call the physician if the systolic blood pressure was above 180. Medication administration records for resident #13 documented the following blood pressure readings: 05/15/23 - B/P 190/90 05/23/23 - B/P 193/86 06/16/23 - B/P 197/96 06/27/23 - B/P 191/88 07/07/23 - B/P 188/82 07/16/23 - B/P 193/65 Resident #13's clinical record did not document the physician was notified of the systolic blood pressure readings. On 08/07/23 at 3:29 p.m., RN #1 reviewed the clinical record and reported they were unable to find any documentation to indicate the physician had been notified of the above findings. The RN reported the physician should have been notified, per physician orders, each time the B/P readings were out of range.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program so that the facility remained free of flies. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility. Findings: A facility Pest Control policy, dated May 2008, documented in part, This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents .Maintenance services assist, when appropriate and necessary, in providing pest control services . On 08/01/23 at 11:30 a.m., a tour of the facility was conducted. Numerous flies were observed throughout the building. Flies were observed in all hallways, at nurse stations, in resident rooms, in common areas, and in the dining room. On 08/01/23 at 12:05 p.m., a tour of the facility kitchen was conducted and one fly was observed in the kitchen. Approximately six flies were observed in the main dining room. On 08/02/23 at 9:31 a.m., Resident #34 was observed to be sitting at the nurse's station. Four flies were observed flying around the resident's face and head, landing on the resident's shoulders and hair. An unidentified nurse reported the flies had been especially bad lately and she thought they were worse at the nurse's station because of the door nearby leading out to the courtyard where residents smoked. On 08/02/23 at 9:35 a.m., CNA #1 was asked if anything had been done about the flies and she stated someone had come out last week and sprayed, but nothing seemed to help. The CNA reported several residents who smoked went in and out of the doors to the courtyard throughout the day, and she felt this contributed to the fly problem. On 08/02/23 at 11:02 a.m., multiple flies were observed around the medication cart, landing on residents and staff. LPN #2 was asked if she was aware of anything the facility was doing to help with the flies. The LPN reported she usually worked weekends but she had not observed any interventions. The LPN stated something needed to be done because the flies had been awful. On 08/04/23 at 10:29 a.m., Resident #31 was observed lying in bed with the blanket pulled up over their face and four flies were observed to be hovering around the resident's head. The resident was asked if the flies were bothering them and they stated, yeah. Two staff members were observed in the hallway outside of the resident's room. The staff were asked to check on the resident and see if they could do anything to make the resident more comfortable. On 08/07/23 at 3:03 p.m., Resident #31 was observed during care of their tube feeding site. The resident was observed to have a fly strip hanging from the ceiling and had a fan blowing toward their bed. There were no flies observed at that time. Staff was uncertain of when the fly strip and fan were placed in the resident's room. On 08/08/23 at 10:04 a.m., LPN #3 was asked about the fly strip and fan in Resident #31's room, and asked if maintenance had done this to help with the flies. The LPN reported the resident's family had done this over the weekend. CNA #1 reported the resident's daughter had visited over the weekend, stated the flies were awful, so the daughter put the fly strip up herself and placed the fan in the resident's room to try and help with the fly situation. On 08/08/23 at 10:47 a.m., pest control receipts were reviewed and documented monthly routine pest control. A detailed Products Summary, dated 07/13/23, documented the pest control company targeted crickets and flies. An invoice, dated 07/26/23, documented hallways were treated with Alpine Fly Bait.

Based on record review and interview, the facility failed to have a process in place, to ensure medications were administered as ordered, for one (#85) of six sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility. Findings: A facility Subcutaneous Injections policy, dated March 2011, documented in part, Verify that there is a physician's medication order for this procedure .Review the resident's care plan to assess for any special needs of the resident .Follow documentation guidelines in the procedure entitled Documentation of Medication Administration .Report other information in accordance with facility policy and professional standards of practice . Resident #85 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, embolism, and thrombosis. Resident #85's care plan, dated 06/21/23, documented the resident received anticoagulant therapy related to atrial fibrillation, CVA, DVT, and valve replacement. The care plan documented to administer medications as ordered, at the same time on the days ordered. The resident's MDS admission assessment, dated 06/23/23, documented the resident received anticoagulant medication seven of seven days previous. The June 2023 TAR, documented an order for Enoxaparin Sodium Solution, 80 mg/0.8 ml, inject 80 mg subcutaneously every 12 hours for prevention of blood clotting. The order had a start date of 06/17/23. The TAR documented the medication was not administered on 06/17/23, 06/18/23, or 06/19/23. The TAR documented the first dose was administered at 8:00 a.m. on 06/20/23, and the resident was discharged on [DATE] after receiving one dose that day. The TAR documented the resident received a total of seven doses. On 08/02/23 at 3:51 p.m., LPN #1 was interviewed regarding the TAR for resident #85. The TAR documented the first five doses of Enoxaparin were not administered on 6/17/23, 6/18/23, or 6/19/23. The TAR documented OT where the medication was not given. The LPN reported OT was for other and the system would prompt the nurse or CMA to enter a progress note to explain why the medication was not given. The LPN reviewed the progress notes and determined the medication was initially entered on the MAR instead of the TAR. Because the medication was entered on the MAR, and CMAs did not administer injections, the CMAs had entered on the progress notes, nurse will give. LPN #1 stated if she had a resident on Lovenox [Enoxaparin], she would know to look in the treatment cart for the medication and if she didn't find it there, she would check the medication room or ask other staff. The LPN stated the progress notes were confusing because the CMAs were documenting nurse will give but there was no follow-up to indicate a nurse had seen the note or responded in any way. On 08/02/23 at 3:58 p.m., the DON reported she had recognized there needed to be an improvement in shift report and communication between the CMAs and nurses in regard to any questions about medications. On 08/03/23 at 9:04 a.m., RN #1 reported she had checked to see exactly how many doses of Enoxaparin were delivered to the facility, how many doses were administered, and how many were left when the resident discharged on [DATE]. The RN reported 10 doses were delivered and three doses remained in the facility, which indicated the resident had received a total of seven doses. On 08/03/23 at 10:04 a.m., RN #1 reported the previous ADON had entered the order for the Enoxaparin injections on the MAR instead of the TAR. CMA #1 recognized the medication had been entered on the MAR instead of the TAR and notified the ADON. CMA #2 was also involved in entering progress notes related to the Enoxaparin but all of these staff members were no longer employed at the facility. RN #1 reported the medication was in-house and stated it was delivered on 06/16/23. The RN provided an invoice which documented 10 doses of Enoxaparin were delivered. On 08/03/23 at 4:04 p.m., the resident's physician was interviewed regarding Resident #85 missing five doses of the anticoagulant, Enoxaparin. The physician reported the resident was on another anticoagulant at the same time and was being monitored. The physician reported the missed doses of Enoxaparin did not cause a negative outcome to the resident.

Based on record review and interview, the facility failed to ensure required staff in-service training was provided to address dementia management, pain recognition, first aid procedures, CPR, and the Heimlich maneuver. The Resident Census and Conditions of Residents form, dated [DATE], documented 92 residents resided in the facility. Findings: On [DATE] at 4:15 p.m., facility in-service and education records were reviewed. The records contained no documentation of staff training for required dementia management, pain recognition, first aid procedures, CPR, or Heimlich training. On [DATE] at 4:51 p.m., RN #1 reported they were unable to locate any documentation related to the required in-services being provided.

Based on record review and interview, the facility failed to transmit a resident assessment as required for one (#76) of 22 resident assessments reviewed for timely transmission. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility. Findings: Resident #76 was admitted on [DATE] and an MDS admission assessment was completed on 03/14/23. A progress note, dated 04/18/23, documented the resident was discharged on this date. An MDS discharge assessment, returned not anticipated, was not completed for the discharged resident. On 08/08/23 at 1:47 p.m., the former DON reviewed the assessments and reported a corporate staff member was completing resident assessments remotely. They reported a discharge assessment had not been completed as required and was greater than 120 days past due.

Based on record review and interview, the facility failed to develop a person-centered care plan for a resident who required respiratory treatments for one (#31) and failed to complete smoking safety assessments quarterly for one (#42) of 19 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 08/02/23, documented 92 residents resided in the facility and the DON identified 22 residents who required smoking safety assessments. Findings: 1. A Care Planning - Interdisciplinary Team policy, dated September 2013, read in part, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team . Resident #31 was admitted with diagnoses which included dysphagia, hypertension, and a history of pneumonia and sepsis. Resident #31's care plan, dated 01/11/23, contained no documentation related to the resident's respiratory status. An admission MDS assessment, dated 01/12/23, documented the resident was cognitively impaired. The assessment documented the resident had a major infection with pneumonia and sepsis. The assessment did not document the resident received respiratory therapy. A progress note, dated 01/20/23 at 5:04 p.m., documented the resident received an Albuterol nebulizer treatment, ordered to be given every six hours as needed for shortness of breath or wheezing. A progress note, dated 02/14/23 at 8:16 p.m., documented the resident was found to have audible rhonchi, a breathing treatment was administered, and a chest x-ray was ordered. A nurse note, dated 02/16/23 at 9:24 a.m., documented administration of Albuterol Sulfate nebulizer treatment, ordered as needed every six hours for shortness of breath. The note documented the resident had audible wheezing and shortness of breath. A nurse note, dated 03/28/23 at 2:48 p.m., documented the resident was wheezing. The note documented the physician was notified and orders received for a chest x-ray and routine breathing treatments. A nurse note, dated 03/30/23 at 3:24 p.m., read in part, .X-ray findings-right perihilar infiltrate .notified new order for Levaquin 750 mg Q Day x 7 days . An MDS quarterly assessment, dated 04/14/23, did not document the resident received respiratory therapy. Resident #31's care plan, updated 08/04/23, was provided by RN #1. The care plan documented the resident had a self-care deficit related to activity intolerance. The care plan documented the resident received tube feedings related to dysphagia. The care plan did not include any documentation related to the resident's respiratory status. On 08/08/23 at 8:55 a.m., RN #1 was interviewed regarding the resident's history of pneumonia and sepsis. The RN reviewed the MDS assessment and noted the assessment documented major infection with pneumonia and sepsis, but did not document the resident received respiratory therapy. The RN reviewed the resident's care plan and reported the care plan should have included the resident's respiratory status and the need for respiratory treatments. 2. A facility Smoking Policy, undated, read in part, .all residents that smoke will have a smoking evaluation completed and updated as needed . A Smoking Safety Evaluation for Resident #42, dated 07/16/21, documented the resident was independent with smoking. Resident #42's clinical record did not contain any other smoking evaluations. A care plan for resident #42, dated 07/26/23, read in part, I am resistive to care (refusing to give smoking materials to staff) .Staff will complete a smoking assessment to ensure my safety quarterly . On 08/07/23 at 2:53 p.m., Resident #42 was observed smoking outside in the courtyard with other residents. On 08/08/23 at 3:09 p.m., the DON reviewed the clinical records and reported smoking safety assessments had not been completed and/or updated as required.

Based on record review, observation, and interview, the facility failed to ensure the physician or facility staff acted upon pharmacist recommendations of findings identified during monthly medication regimen reviews for four (#9, 24, 44, and #45) of five residents reviewed for unnecessary medications. The Resident Census and Census of Conditions, dated 11/15/22, documented 78 residents resided in the facility. Findings: The facility's Medication Regimen Review policy, dated 01/01/18, read in parts, .The consultant pharmacist reviews the medication regimen of each resident at least monthly .The consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards .The consultant pharmacist identifies irregularities through a variety of sources of the resident .The consultant pharmacists documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for the prescriber and/or nursing review .Recommendations are acted upon and documented by the facility staff and/or the prescriber within 30 days . 1. Resident #9 had diagnoses which included anxiety disorder, depression, [CONDITION(S)] and hypertension. The resident's Medication Regimen Review, dated 04/10/22, documented recommendation to discontinue the PRN order for [MEDICATION(S)] powder due to non-use. The MRR documented no action taken from the physician. The resident's Medication Regimen Review, dated 05/17/22, documented the resident was taking [MEDICATION(S)] and lorsartan which are duplication of therapy, consider to discontinue one of these orders. The MRR documented no action taken by the physician. The resident's Medication Regimen Review, dated 05/17/22, documented a pharmacist recommendation to add an order to monitor behaviors and adverse effects of [CONDITION(S)] medications. The MRR documented no action taken by the physician or facility staff. The resident's Medication Regimen Review, dated 06/05/22, documented to consider a gradual dose reduction of antidepressant therapy, buproprion xl 150 mg daily to [MEDICATION(S)] xl 75 mg daily. The MRR documented no action taken by the physician. The resident's Medication Regimen Review, dated 07/23/22, documented to consider a trial dosage reduction of [MEDICATION(S)] dr 250 mg every morning and 500 mg at night to [MEDICATION(S)] dr 250 mg twice a day per CMS regulation. The MRR documented no action taken by the physician. The resident's Medication Regimen Review, dated 07/23/33, documented [MEDICATION(S)] requires antipsychotic behavior and side effect monitoring, and [MEDICATION(S)] and [MEDICATION(S)] requires antidepressant side effect monitoring. The MRR documented no action taken by the physician or facility staff. The resident's Care Plan, dated 08/27/22, read in parts, .At risk for side effects related to [CONDITION(S)] medication therapy .Resident uses antidepressant medication related to depression .The resident uses [CONDITION(S)] medications related to [CONDITION(S)] .The resident has depression .The resident has hypertension . The Quarterly MDS Assessment, dated 09/23/22, documented the resident's cognition intact and no behaviors exhibited. The assessment documented the resident received antipsychotic and antidepressant medication for seven of the seven previous days. The resident's Physician Orders, dated 11/01/22 documented the following: [MEDICATION(S)] 25 mg three at bedtime, [MEDICATION(S)] extended release150 mg one every day, [MEDICATION(S)] 20 mg one every day, [MEDICATION(S)] delayed release 250 mg one every day, and [MEDICATION(S)] 250 mg delayed release two at bedtime, [MEDICATION(S)] 10 mg two every day, [MEDICATION(S)] extended release 25 mg one every day, [MEDICATION(S)] 25 mg one very six hours as need for systolic blood pressure greater than 170, [MEDICATION(S)] powder applied to groin as needed, and no order was in place to monitor behaviors or side effects of [CONDITION(S)] medication. On 11/17/22 at 2:00 p.m., the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed ensure the recommendations were acted upon for the time period of April 2022 to October 2022. 2. Resident #24 had diagnoses which included major depressive disorder, and anxiety disorder. The resident's Medication Regimen Review, dated 05/17/22, documented recommendation to add an order to monitor behaviors and adverse side effects of [CONDITION(S)] medications. The MRR documented no action taken by the physician or facility staff. The resident's Care Plan, dated 09/08/22, read in parts, .Use of anti-anxiety medications related to anxiety disorder .Use of [CONDITION(S)] medications related to behavior management .Diagnoses of major depressive disorder . The resident's MDS Assessment, dated 10/17/22, documented moderately impaired cognition with no behaviors exhibited. The assessment documented antipsychotic and anti-anxiety medications had been administered for seven of the previous seven days. The resident's Physician Orders, dated 11/01/22, documented [MEDICATION(S)] 0.5 mg one at night, [MEDICATION(S)] 0.5 mg one twice a day and no order to monitor behaviors and adverse effects of [CONDITION(S)] medications. On 11/17/22 at 2:00 p.m., the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed ensure the recommendations were acted upon for the time period of April 2022 to October 2022. On 11/18/22 at 10:00 a.m., the ADON reported the task of ensuring MRRs are acted upon has been assigned to the DON. 3. Resident #44 had diagnoses which included mood disorder. The resident's Quarterly MDS Assessment, dated 09/05/22, documented cognition moderately impaired and received an antipsychotic medication. The resident's Care Plan, dated 11/19/21, read in parts, The resident uses antidepressant medication (olanzipine) .olanzipine doseage reduced on 11/19/21. The resident's Medication Regimen Review, dated 09/16/22, documented a recommended trial dose reduction of [MEDICATION(S)] 5 mg given one time a day. The MRR documented no action was taken by physician. The resident's Physician Orders, dated 11/01/22 documented [MEDICATION(S)] 5 mg one daily. On 11/17/22 the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed to ensure the recommendations were acted upon for the time period of April 2022 to October 2022. 4. Resident #45 had diagnoses which included anxiety disorder, mood disorder, and pseudobulbar affect. The resident's Medication Regimen Review, dated 05/17/22, documented the recommendation to add an order to monitor behaviors and adverse effects of antidepressant medications. The MRR documented no action taken by the physician or facility staff. The resident's Quarterly MDS Assessment, dated 08/23/22, documented severely impaired cognition with verbal behaviors. The assessment documented the resident received anti-anxiety and antidepressant medication for seven of the previous seven days. The resident's Care Plan, dated 08/27/22, read in parts, .Resident uses antianxiety medications related to anxiety disorder .Administer anti-anxiety medications as ordered by physician .Monitor for side effects and effectiveness every shift .Resident uses antidepressant medication related to pseudobulbar affect and mood disorder .Administer antidepressant medications as ordered by physician .Monitor/document side effects and effectiveness every shift . The resident's Physician Orders, dated 11/01/22, documented the following [CONDITION(S)] medications: [MEDICATION(S)] 20-10 mg one twice a day, [MEDICATION(S)] 0.5 mg one at night, [MEDICATION(S)] 7.5 mg one at night, and no order to monitor behaviors and adverse effects of antidepressant medications. On 11/17/22 at 2:00 p.m., the RN Consultant reported the facility's consulting pharmacist had conducted monthly medication regimen reviews but due to staff turnover the facility failed ensure the recommendations were acted upon for the time period of April 2022 to October 2022.

Based on record review, observation and interview, the facility failed to implement comprehensive care plan interventions for three (#9, #24, and #45) of five residents reviewed for the use of unnecessary meds. The Resident Census and Conditions of Residents, form documented 78 residents resided in the facility. Findings: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, dated 08/27/22, read in parts, .The resident uses antidepressant medication related to depression .Administer antidepressant medications as ordered by physician Monitor/document side effects and effectiveness every shift .The resident uses [CONDITION(S)] medications related to [CONDITION(S)] .Administer [CONDITION(S)] medications as ordered by physician .Monitor for side effects and effectiveness every shift .The resident has depression .Administer medications as ordered .Monitor/document for side effects and effectiveness . The Quarterly MDS Assessment, dated 09/23/22, documented the resident's cognition was intact and no behaviors were exhibited. The assessment documented the resident received antipsychotic and antidepressant medication for seven of the seven previous look back days. The resident's Treatment Administration Record, dated 11/01/22, documented the following [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR documented no monitoring of the resident's side effects of taking [CONDITION(S)] medication or the effectiveness of the medication had been conducted every shift. 2. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, dated 09/08/22, read in parts, .Use of anti-anxiety medications related to anxiety disorder .Administer anti-anxiety medications as ordered by physician .Monitor/document side effects and effectiveness every shift .Use of [CONDITION(S)] medications related to behavior management .Administer [CONDITION(S)] medications as ordered by physician .Monitor for side effects and effectiveness every shift .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS Assessment, dated 10/17/22, documented moderately impaired cognition with no behaviors exhibited. The assessment documented antipsychotic and anti-anxiety medications had been administered for seven of the previous seven days. The resident's Physician Orders, dated 11/01/22, documented [CONDITION(S)] medication as follows: [MEDICATION(S)] 0.5 mg one at night and [MEDICATION(S)] 0.5 mg one twice a day. The resident's TAR, dated 11/01/22, documented no monitoring every shift for the effectiveness and side effects of [CONDITION(S)] medication. 3. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Quarterly MDS Assessment, dated 08/23/22, documented severely impaired cognition with verbal behaviors. The assessment documented the resident received anti-anxiety and antidepressant medication for seven of the previous seven days. The resident's Care Plan, dated 08/27/22, read in parts, .Resident uses anti-anxiety medications related to anxiety disorder .Administer anti-anxiety medications as ordered by physician .Monitor for side effects and effectiveness every shift .Resident uses antidepressant medication related to pseudobulbar affect and mood disorder .Administer antidepressant medications as ordered by physician .Monitor/document side effects and effectiveness every shift . The resident's Physician Orders, dated 11/01/22, documented the following [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Treatment Administration Record, dated 11/01/22, documented no monitoring had been conducted every shift related to the side effects and effectiveness of [CONDITION(S)] medication. On 11/17/22 at 2:17 p.m., the ADON reported the resident's side effects and effectiveness to [CONDITION(S)] medications should be documented on the resident's treatment administration record. The ADON agreed the care plan had not been followed for resident #9, 24, and #45 related to monitoring the side effects and effectiveness of [CONDITION(S)] medications every shift and documented on the resident's TAR.

Based on record review, observation, and interview, the facility failed to ensure care plans were updated for two (#9, and #44) of 14 residents whose care plans were reviewed. The Resident Census and Conditions of Residents, form documented 78 residents resided in the facility. Findings: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Smoking Safety Evaluation, dated 08/18/22, read in parts, .The resident cannot dispose of ash safely, without ash falling onto resident's clothes .Adaptive equipment needed includes smoking apron and supervision .Resident needs facility to store lighter and cigarettes .Plan of care is used to assure resident is safe while smoking .Safe to smoke with supervision per team decision .Rationale/Conditions: resident is unsafe to smoke alone, she must be supervised and wear a smoking apron. The resident's Care Plan, revised 08/27/22, read in parts, .For my safety, I need to wear a fireproof apron when smoking .My smoking supplies are to be stored by the nurse .I cannot smoke unless I am supervised .I am able to safely use and maintain smoking materials(01/25/21) . The resident's Quarterly MDS Assessment, dated 09/23/22, documented cognition intact and one staff physical assist with most activities of daily living. On 11/17/22 at 9:52 a.m., resident #9 was up in her wheelchair by the nurse's station, transport staff member handed a pack of cigarettes to the resident which she put in side a small bag she carried. Resident observed to be able to self-propel in manual wheelchair around the facility and to go outside to smoke. On 11/17/22 at 10:05 a.m., the resident was observed in the facility courtyard, smoking without supervision of staff, and not wearing a smoking apron. On 11/17/22 at 2:08 p.m., the resident reported no longer being required to wear a smoking apron or be supervised while smoking. The resident reported being allowed to store cigarettes and lighter on self. The resident reported having smoking restrictions after surgery when staff had to assist her in a Geri chair around the facility. The resident reported since the use of a Geri chair was no longer needed, she is safe to smoke unsupervised, without a smoking apron, and can store her smoking supplies. On 11/17/22 at 2:15 p.m., LPN #1 reported the resident was did not require supervison with smoking, since she no longer used the Geri chair. On 11/17/22 at 2:16 p.m., the transportation driver reported the resident was allowed to smoke unsupervised and allowed to store own smoking supplies. The transportation driver reported getting cigarettes out of the nurse cart for the resident earlier that day. On 11/17/22 02:17 p.m., the ADON reported resident #9 was no longer required to be supervised with smoking and no longer required a smoking apron. The ADON reported the resident was allowed to store her smoking supplies safely. The ADON reported the smoking precautions were put in place post-surgery when a Geri chair was used for the resident. The ADON reported the resident's care plan should have been revised to remove the smoking precautions. 2. Resident #44 quarterly assessment, dated 09/05/22, documented the resident had a mood disorder. It documented the resident was on an antipsychotic. The resident's care plan, dated 11/19/21, read in parts, The resident uses antidepressant medication (olanzipine) .Administer antidepressant medications as ordered by physician .Olanizipine dosage was reduced on 11/19/21. A physicians order, dated 11/19/21, read [MEDICATION(S)] tablet give 2.5 mg by mouth one time a day related to unspecified mood [affective] disorder. A physicians order, dated 07/21/22, read [MEDICATION(S)] tablet give 5 mg by mouth one time a day related to unspecified mood [affective] disorder. On 11/17/22 at 11:15 a.m., the corporate nurse reported olanzipine is not an antidepressant, it's an antipsychotic. On 11/18/22 at 10:10 a.m., the ADON reported the care plan should have been updated to show it's an antipsychotic and the olanzipine had been increased.

Based on record review, observation, and interview, the facility failed to ensure a resident received necessary treatment and services, for a pressure ulcer, for one (#1) of eight residents sampled for wound care. The facility failed to ensure: a. weekly skin assessments were completed, and; b. the resident was seen by the wound care physician for follow-up wound care. The Administrator reported seven residents with wounds who resided in the facility. Findings: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care (WC) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented the resident had two wounds, including a shear wound of the left buttock measuring 11 cm x 9 x 0.2. The physician documented the wound was unable to progress to a healing phase because of the presence of a biofilm. A surgical excisional debridement procedure was done which documented 19.8 cm of devitalized tissue, including slough, biofilm, and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.3 cm. Goal of treatment was, healing evidenced by a 50% decrease in necrotic tissue within the wound bed. The second wound was to the left lower back measuring 5.5 x 2.5 x 0.1 cm. Treatment plan for both wounds was to apply [MEDICATION(S)] three times a day for 30 days. A Weekly Skin Observation report, dated 01/26/22, read in parts .Does the resident have skin impairments - Yes (Document below and complete weekly wound progress) .Site 23) Coccyx, Type: Pressure. The clinical record was reviewed and contained no other weekly skin observation reports or wound progress notes for resident #1. A WC physician note, dated 01/27/22, documented the resident's visit had been rescheduled due to COVID-19. The clinical record was reviewed and documented no follow-up appointment with the wound care physician. An Annual Assessment, dated 03/21/22, documented the resident required total dependence for bed transfers, extensive assistance for bed mobility, had a catheter for urinary continence, and was always incontinent of bowel movements. The assessment documented the resident was cognitively intact. Treatment Administration Records for January, February, March, April, and May 2022 documented a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The April TAR documented the order ended on 04/10/22. The TAR documented a new order (by the attending physician), dated 04/11/22, for [MEDICATION(S)] cream 1%, apply to left buttock/lower back topically every shift; lower back 11.0 x 9.0 x 0.2 and 5.5 x 2.5 x 0.1 cm. The clinical record was reviewed and contained no documentation to indicate the wounds were ever re-assessed to check for improvement or worsening of the wounds. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Review of System documented, See skin assessment in patient record. A Nurse Note, dated 05/11/22 at 11:43 a.m., documented the resident had increased swelling and redness with pain on the left side of the groin. The note documented the old surgical incision had opened up and was draining thick, white, w/yellow drainage. The note documented the resident's mother was at the bedside and requested the resident be sent out, as she was seeing a change in condition from the previous day. The PA was notified and an order given for an ice pack and Motrin 800 mg by mouth every eight hours as needed. The resident was unable to tolerate being touched with the ice pack. The note documented due to the mother's request, the resident was being sent to the ER for evaluation. The Death Summary Note, documented in parts .Date of Admission: 05/11/22. date of death : 05/20/22 .Cause of Death: decompensated septic shock .[CONDITION(S)] due to Fournier's Gangrene. Hospital Course: .chronic sacral decubitus ulcer now presenting as a transfer with c/f Fournier's Gangrene.incision and debridement of the scrotum, perineum, and left abdominal wall on 05/11/22, 05/13/22, 05/15/22 and 05/18/22. Patient made very little progress despite multiple debridements, broad spectrum antibiotics and maximum ICU level care . Procedures; multiple wound washouts and debridements. Pt discharged to: morgue. On 06/09/22 at 3:45 p.m., the Administrator expressed concerned about the situation and reported, I thought the staff were doing what they were supposed to be doing. The Administrator was asked if she knew why the wound care physician had not consulted or followed up on this resident and she shook her head, no. On 06/09/22 at 4:10 p.m., RN #1 was interviewed and asked if she had completed weekly skin assessments for resident #1. She reported she was looking at the wound and, got used to how it looked. The RN stated the wound never healed and seemed to just stay the same. The RN stated, I considered it like we were doing palliative care. The RN reported she was doing the skin checks wrong and was not completing the skin assessment forms. On 06/14/22 at 1:44 p.m., the attending physician was interviewed and asked if he had consulted on resident #1 or assessed the resident's wound. He reported, I don't remember ever seeing it. The physician reported he wrote in his progress notes to, see skin assessment in patient record. On 06/14/22 at 2:00 p.m., LPN #1 was interviewed regarding documentation on the TARs and the same wound measurements repeated each month, with no assessments to show improvement or worsening. The LPN stated, I thought it was being taken care of. On 06/14/22 at 2:57 p.m., the WC physician was interviewed by phone. The physician was informed there was no documentation related to a follow-up to the 12/29/22 wound care. The physician reported she had an accident in January and was out of work until April. She reported another WC physician was filling in for her during that time period. On 06/14/22 at 4:48 p.m., the second WC physician was interviewed by phone. The physician reported he had taken over seeing patients at the facility on 02/11/22. He stated he didn't remember ever seeing resident #1. He reported he relied on the facility to make him aware of which residents needed to be seen but always asked the staff, while he was in the facility each week, if there were any other residents he needed to see. He reported, No one ever made me aware that this resident needed wound care.

Based on record review and interview, the facility failed to ensure a resident with a suprapubic catheter was assessed, monitored, and interventions implemented in a timely manner, to prevent a urinary tract infection, for one (#1) of one resident sampled for catheter care. The administrator reported they had no other residents with a suprapubic catheter. Findings: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 10/26/21, read in parts .Focus, The resident has Indwelling Suprapubic Catheter. Goal, The resident will show no s/sx of Urinary infection through review date 04/04/22. Interventions/Tasks, Monitor/record/report to MD for s/sx [CONDITION(S)]: .blood tinged urine, .deepening of urine color, .foul smelling urine. An Annual Assessment, dated 03/21/22, documented resident #1 had a catheter for urinary continence. A Nurse Note, dated 05/03/22, documented in parts .Resident declined his shower this AM . Shows little interest in out of bed activities. Prefers to stay in bed . Resident is total care .Urine is dark and odorous . There was no documentation the physician was notified of the dark and odorous urine. A Nurse Note, dated 05/07/22, documented the resident had a catheter change and was noted to have bloody urine return. There was no documentation the physician was notified of the bloody urine return. A Nurse Note, dated 05/09/22, documented in parts .Per urinary assessment, this nurse noted turbid brownish rustish colored putrid urine with odor equivalent to fish radiating through the air in room. Olfactory senses immediately smelled overwhelming odor upon entrance into room. PO fluids encouraged and accepted most of the time with no change to urine smell. A second Nurse Note, dated 05/09/22, documented in parts .Resident declines to get out of bed for meals, wound to buttocks, catheter draining amber urine via gravity. Urine is very odorous. Clear slimy substance appears to be coming from Rectum. Dr. [name deleted] contacted and new order for KUB . On 05/09/22, the KUB x-ray documented findings: There is a nonspecific bowel gas pattern. A hand-written note at the bottom of the report documented, Swelling to pubic area, redness, pain - N.O. for [MEDICATION(S)] x 10 days. No signature was on the hand-written note. A Blood Pressure Summary, report documented: Date 05/10/22 at 3:07 p.m., Value 74/52 mmHg. A Nurse Note, dated 5/10/22 at 4:11 p.m., documented, spoke with [name deleted] PA, IV fluids are to run at 50 cc/hr . A Blood Pressure Summary, report documented: Date 05/10/22 at 4:40 p.m., Value 84/54 mmHg. No other blood pressures were documented on the Blood Pressure Summary report to indicate if there was a follow-up blood pressure taken to see if the resident's blood pressure had returned to normal. A Nurse Note, dated 5/10/22 at 4:42 p.m., documented in parts .Resident C/O feeling weak, dizzie, Residents sister called voicing resident does not sound himself. Irregular labs from last week. [name deleted] PA notified . PA will come to the facility on ,d+[DATE] to assess resident. A Nurse Note, dated 5/10/22 at 5:06 p.m., documented in parts .Resident was observed with pain, swelling and redness to pubic area, left thigh and abdominal fold. Area tender to touch. Urine with dark color and with sediments and thick. Clear slimy substance appears to be coming from rectal area. Dr. [name deleted] was informed of the concerns and new order for [MEDICATION(S)] was given. Foley was changed. No immediate output upon insertion of new catheter . After a few seconds reddish thick return was observed . [name deleted] PA in facility this afternoon and spoke with resident and observed skin and wound and rectal concerns and encouraged him to drink more fluids and reposition as tolerated. A Nurse Note, dated 05/11/22 at 11:43 a.m., documented in parts .resident has increased swelling and redness with pain on left side of groin with increased pain the old surgical incision has opened up and is draining thick white w/yellow drainage mother at bedside requesting he be sent out as she sees a change in condition from yesterday. [name deleted] PA notified order for ice pac motrin 800 mg . resident unable to tol being touched with ice pac at this time due to residents mother request resident is being sent to [local hospital name deleted] ER for evaluation . ambulance called. Local hospital report, dated 05/11/22 at 1:06 p.m., documented in parts . Physical Exam: Significant swelling and [CONDITION(S)] to the entire mons pubis extending in the left inguinal crease .Sacral wound present . Laboratory evaluation obtained and shows a significant leukocytosis at 36,000 with lactic acidosis of 4.3 a urinary tract infection.Transfer to higher level of care hospital. Local hospital report, dated 5/11/22 at 1:04 p.m., documented CT scan findings and read in parts .Findings: Suprapubic catheter extends through the urinary bladder through the prostate gland with inflated balloon and tip within the penile urethra. Large amount of gas and fluid within the left perineum extending through the inguinal canal into the left groin. Impression: Abnormal placement of suprapubic catheter with balloon inflated within the penile urethra . Left perineal fluid collection and gas extending into the left groin, consistent with Fourier's gangrene . A hospital Blood Culture Report, dated 05/11/22 at 3:27 p.m., documented Final: Staphylococcus auricularis. A hospital Urine Culture Report, dated 5/11/22 at 4:00 p.m., documented Final: >100,000 CFU/ML Proteus mirabilis, (Final) Morganella morganii. Higher level of care hospital, CT Scan, dated 5/11/22 10:15 p.m., read in parts . Impression: Suprapubic catheter balloon is inflated in the perineum, where there appears to be contrast extravasation from the urinary bladder into the subcutaneous tissues of the perineum, inguinal region and left lateral abdominal wall. With punctate collections of gas, concerning for infection. A Nurse Note, dated 05/11/22 at 11:45 p.m., documented, Per [local hospital name deleted] pt transferred to [higher level of care hospital name deleted] and admitted for DX Fourier's gangrene, septic shock and [CONDITION(S)]. Higher level of care hospital, Operative report, dated 05/12/22, read in parts .Findings: 1. Urethra obliterated upon attempting to perform retrograde cystourethroscopy. 2. Antegrade systoscopy revealed large bulbar urethral injury secondary to prior suprapubic catheter balloon being inflated within the urethra. On 06/13/22 at 2:15 p.m., the Administrator reported [MEDICATION(S)] (an antibiotic) had been ordered because they thought the redness and swelling was cellulitus. The Administrator was asked why the resident was not sent to the hospital sooner, and she stated the physician was trying to treat the resident in-house. On 06/14/22 at 1:45 p.m., the attending physician was interviewed and questioned about obtaining a urine analysis (UA) for resident #1. The physician reported he had sent a text to LPN #1 to get a UA on 05/09/22 and showed the surveyor the text. He then stated his PA had seen the resident that day and it was decided they would take a different course of action. The physician stated they were trying to treat the resident in-house. On 06/14/22 at 2:05 p.m., LPN #1 was interviewed about the results of the hospital CT scans regarding the placement of the resident's catheter. The LPN stated, I don't know how I could have put it in the wrong place, I eventually had a urine return. I don't see how that's possible. She was asked why a UA was not obtained. She reported the resident had chronic UTIs and stated, we would have eventually gotten one. She was asked if she had seen the text from the physician to get a UA, she reported she never saw it.

Based on interview and record review, it was determined the facility failed to promptly notify the physician of a high critical PT/INR laboratory result {a blood test that measures how long it takes blood to clot and monitor the effects of [MEDICATION(S)]} for one (#1) of three sampled residents who were reviewed for laboratory monitoring. This resulted in actual harm and hospitalization of the resident. Findings: An undated Test Results policy, read in parts, .Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results .The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results . An undated, Verbal Orders policy, read in parts, .Text messaging is not an acceptable method of communicating an order . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] {a medication used to thin the blood} 2 mg, give one tablet by mouth in the evening related to congenital stenosis of aortic valve. A MAR, dated October 2021, documented [MEDICATION(S)] 2 mg was administered daily starting on 10/26/21. A Care Plan, dated 11/03/21, documented the resident was on an anticoagulant {[MEDICATION(S)]} and would show no signs or symptoms of adverse reaction to anticoagulant medication through the review period. Interventions included to administer medications per orders, monitor for effectiveness and signs and symptoms or adverse reaction, obtain labs as ordered by the physician, and monitor for bruising and signs of bleeding A Physician Order, dated 11/08/21, documented to obtain a PT/INR, CBC, CMP, HGBA1C, and Prealbumin on the next available lab day. A Progress Note, created by LPN #1 and dated 11/11/21, documented lab results were received. The note documented the physician was notified and new orders received to monitor and to have a new lab draw for a CBC in seven days. A laboratory test result, dated 11/11/21, documented a critical PT/INR result, with the INR of 15.6 and PT of 138.2. References ranges for the INR was 0.9 to 4.0. Reference ranges for the PT was 9.0 to 11.5. A MAR, dated November 2021, documented the resident continued to be administered [MEDICATION(S)] ([MEDICATION(S)]) from 11/11/21 through 11/15/21 after the critical lab result had been received. The above laboratory test results, dated 11/11/21, documented written orders from the physician to hold [MEDICATION(S)] {[MEDICATION(S)]} and monitor for bleeding and vital signs. The order documented if the resident was unstable, to send to the emergency department. The note documented the resident was currently anemic and not overtly bleeding. The note documented to check the PT/INR and CBC every three days. The order was noted to be electronically signed by the physician on 11/16/21. A Progress Note, dated 11/16/21, documented a nurse had talked with the physician regarding the resident's PT/INR lab results which documented PT 138.2 and INR 15.6. The note documented the physician gave new orders to stop [MEDICATION(S)] {[MEDICATION(S)]} and check the PT/INR every three days until levels were within normal range. The note documented the resident would be placed on fall precautions and monitored for bleeding every shift. A Medication Error Report, dated 11/16/21, documented date of medication error as 11/11/21. The report documented in parts, .allowed resident to continue to receive [MEDICATION(S)] {[MEDICATION(S)]} after knowing lab value .corrective action taken [MEDICATION(S)] stopped .labs ordered for every 3 days, bleeding and fall precautions put in place .failure to follow up with lab. A Progress Note, dated 11/16/21, documented staff had talked with the [CONDITION(S)] center to inform [CONDITION(S)] staff about the critical PT/INR results. The note documented [CONDITION(S)] staff reported they would hold [MEDICATION(S)] {a medication to thin the blood} for treatment the following day. A Progress Note, dated 11/17/21, documented at 4:00 p.m., bleeding was observed through the gauze covering the resident's left fistula {a connection used for [CONDITION(S)] made by joining a vein onto an artery}. The note documented the resident's blood pressure was checked and found to be 74/55. The note documented the physician was notified of the bleeding and low blood pressure, and an order was given to send the resident to the hospital for evaluation and treatment. A facility investigation, dated 11/18/21, documented LPN #1 was terminated for the following reasons: failure to assess resident #1 with a critical INR, to monitor the resident for bleeding, failure to put in orders received, to contact the DON, and failure to follow up with the physician. It was determined LPN #1 received the results and documented she had notified the physician and received new orders. The investigation found LPN #1 had contacted the physician via text message. The investigation confirmed the LPN's phone had received no response from the physician. It was verified the physician never responded and LPN #1 never actually received the initial orders as written in the 11/11/21 progress note. The investigation documented, as a result of the LPN's substandard work performance and actions, resident #1 had required hospitalization . A Hospital Demographic Sheet, dated 11/22/21, documented Res #1 was admitted to the hospital on 11/18/21. A Hospital Fax, dated 11/22/21, documented the resident was discharged from the hospital back to the facility. On 12/16/21 at 12:53 p.m., LPN #2 was asked when she became aware of Res #1's abnormal PT/INR. The LPN stated she came across the PT/INR results from 11/11/21 and notified the physician because the result was so high. She stated it was on 11/16/21 when she notified the physician with the PT/INR results and stated the physician didn't appear to be aware of the critical lab values. LPN #2 stated she received new orders to stop the [MEDICATION(S)] {[MEDICATION(S)]}. At 1:15 p.m., the Administrator was asked about the PT/INR result. She stated LPN #1 was terminated for not following up on the critical lab results. The Administrator stated LPN #1 sent a text message to the physician and did not follow up to make sure he had received it. At 3:38 p.m., the physician was interviewed via telephone. He was asked about the five doses of [MEDICATION(S)] Res #1 received after the critical PT/INR result. The physician stated if the facility knew about the result, the [MEDICATION(S)] should have been stopped. The physician discussed the target range for the INR, therapeutic ranges related to [MEDICATION(S)] therapy, and stated he did not know why the facility didn't get the results to him in a timely manner.

Based on record review and interview, it was determined the facility failed to provide sufficient fluid intake to maintain hydration for one (#114) of four sampled residents reviewed for hydration. This resulted in actual harm to the resident. He was diagnosed with [REDACTED]. The facility identified four residents with a feeding tube and being at risk for dehydration. Findings: Resident #114 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The November 2014 physician's orders [REDACTED]. A speech therapy evaluation and plan of treatment dated 11/04/14, documented the resident had a feeding tube and the physician had placed the resident on regular foods and liquids as well. The diet recommendations were "...Solids = Any/all oral intake...Liquids = All liquids...Swallow skills are WFL (within functional limits)." A nurse's note, dated 11/04/14 at 1:05 p.m., documented the resident's general diet as ordered by the physician had been confirmed by the physician on this date. "...I do not want to discontinue his general diet, I want him to eat as much as possible by mouth and then we can supplement with the feedings if his intake is not adequate..." A dehydration risk assessment, dated 11/05/14, documented the resident's daily fluid needs as his body weight in kilograms multiplied by 30 cubic centimeters (cc). The resident's documented weight on 11/07/14, was 173.40 pounds (lbs). This would calculate as 2,365 cc of water daily to meet his fluid requirements for his body weight. A discharge assessment dated [DATE], documented the resident was independent with daily decision making. He required extensive assistance with transfers, dressing, eating, personal hygiene and bathing. The resident was sent to a local hospital on [DATE], for nausea and vomiting and was admitted with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident's weight on 11/14/14, was documented as 166.40 lbs. His re-calculated fluid requirement at that time was 2,269 cc daily. The resident had received oral fluids in the facility from his admission date of [DATE] through 11/06/14, along with a regular diet. The resident was hospitalized with pneumonia from 11/06/14 - 11/12/14, when he was readmitted to the facility. On 11/23/14, the facility had sent the resident to a local emergency room for a generalized rash to his body. The Emergency Department Report documented the resident presented with generalized weakness over the last several days. " ...The patient appears very dehydrated. His lips are cracked and fissured. He has dry mucus membranes ...The patient has a PEG tube but he is allowed to take liquids by mouth. Wife states the nursing home has not been allowing the patient to hydrate himself by mouth ...The patient received 500 milliliters (ml) of normal saline in route and received 2 liters of normal saline in the emergency department ...We called the nursing home and told them to encourage fluids in this patient. He is profoundly dehydrated ... Diagnoses 1. Dehydration. 2. Urinary Tract Infection. " The resident had not been given a regular diet or liquids by mouth from 11/12/14 through 11/25/14. He had only received the Glucerna 1.2 with 120 ml flushes of water four times daily through his feeding tube. On 11/25/14, an investigation was conducted by Adult Protective Services prompted by the resident's documented dehydrated state in the emergency department. The physician was contacted this day by the facility and the diet order was clarified. The resident was to have been given a regular diet in addition to the Glucerna 1.2 and water flushes four times daily, per the APS report. An 8 ounce can of Glucerna 1.2 contains 237 ml of liquid. This totaled 948 cc of liquid when administered 4 times a day and water flushes of 120 cc 4 times a day totaled 480 cc. The total amount of fluids the resident received was 1428 cc daily. The resident's required daily fluid requirements were 2,269 cc/day. The amount he had been receiving (1428 ccs) from 11/12/14 until 11/25/14, was 841 cc less than what was required to maintain hydration. On 12/04/14 at 11:40 a.m., the resident stated he had not been fed or given water for a while. "...I did not get water for a while...and the amount of cans I got through this tube was not enough nutrition..." On 12/01/14 at 2:38 p.m., the director of nurses stated the facility had not been monitoring the amount of intake of fluids and output of urine for the resident. On 12/05/14 at 1:10 p.m., the physician was contacted via telephone and asked if he was aware the resident had not been receiving oral fluids or food from 11/12/14 through 11/25/14. He stated, "No."

Based on observation, record review and interview, it was determined the facility failed to provide services to prevent the development of pressure sores and failed to identify and provide treatment for [REDACTED]. This had the potential to affect the other four sampled residents who had pressure sores and two other residents who were identified by the facility's resident census and condition form as having pressure sores. Findings: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 03/07/11, documented the resident required extensive assistance from one staff for bed mobility, transfers, toileting, hygiene and bathing. She was occasionally incontinent of bowel and bladder. The resident's care plan, dated 06/15/09 and last reviewed dated 03/08/11, documented, "Problem: Potential for skin breakdown - related to 1. Dx (diagnosis) Peripheral [MEDICAL CONDITION]. 2. Impaired mobility. 3. Dx DMII (diabetes mellitus type II). 4. Hx (history of)[MEDICAL CONDITION]/Rt. paralysis. 5. Incontinence... Goal: (Resident #2) will show no further skin breakdown by next review date - 06/08/11. Interventions: Provide measures to decrease pressure/irritation to skin, as indicated & as needed. Keep skin clean and dry. Inspect skin while giving care. Report to nurse any redden areas or open areas... Provide foot care as ordered & prn... Weekly body audit and skin assessment to be done as indicated. Provide incontinent care with episode. Apply protective or barrier cream after incontinence, as needed... Monitor for circulatory problems, color and warmth of extremities..." The resident's Braden scale, dated 03/25/11, documented her score was 16. (High risk for developing pressure sores). A nurse's note, dated 04/08/11, documented, "16:54 (4:54 p.m.) - Resident was being transferred from bathroom back to wheelchair. She stated her leg hurt so aide lowered her to floor to get wt off the leg. Called for assistance from LPN. She was put back in her chair and had no complaints of pain at that (time). In about 15 mins later the med aide went in. She said her ankle hurt and increased swelling was noted. I called doctor and asked for x-ray. It showed (two) small fx with no displacement. Pain meds given and will make appt with (Orthopedic physician) next week. Brace was placed. She is to be non-weight bearing at this time." A handwritten update, dated 04/08/11, documented, "(Problem): 4-8-11 Lowered to floor. Weakness/pain R leg. (No goal documented). (Interventions): 4-8-11 X-ray - Pt. teaching on safety (staff/resident). Ice packs. Ankle stabilizer." A handwritten update, dated 04/09/11, documented, "(Goal) 4-9-11 - No falls X 1 month. 4-9-11 - Explain resident what you're going to do before transfer." A handwritten update, dated 04/11/11, documented, "(Comment) 4-11-11 - Schedule appt. c Ortho @ (Local hospital) for 4-12-11 (04/12/11). Fx (Fracture) R ankle. 4-30-11 (04/30/11) Tx to R ankle. 5-5-11 (05/05/11) Tx D/C'd (discontinued) - F/U appt c (Orthopedic physician) Tues 10th (05/10/11) R ankle." A nurse's note, dated 04/12/11, documented, "12:07 Resident returned from (Orthopedic physician)'s office... Keep cad cam walker (a hard, boot cast worn for an ankle injury/fracture) in place at all times. Do not remove for shower. Do not get it wet." A nurse's note, date 04/17/11, documented, "06:55 (6:55 a.m.) - ... Boot in place to right foot. Cap (capillary) refills brisk..." A nurse's note, dated 04/18/11, documented, "01:46 (1:46 a.m.) - ..Brace to right foot in place with no complaints voiced..." There were no nurses' notes documented from 04/18/11 at 1:46 a.m. through 04/20/11 at 10:55 a.m. The next nurse's note entry dated 04/20/11, "10:55 (a.m.) - Resident noted with 8 cm reddened bruise surrounding heel area. Notified (Orthopedic physician). Clarification Off loading boot on at all times. Take off each shift for 15 minutes. Intervention applied skin prep..." A nurse's note, dated 04/23/11, documented, "20:37 (8:37 p.m.) - Resident in bed with eyes open. Right lower extremity with immobilizer on. Removed this shift for 15 minutes then reapplied. Purple bruising noted to foot and ankle. Red/purple discoloration noted to the bottom of heel." A note by the dietary manager, dated 04/24/11, documented, "... Has no noted breakdown at this time." A nurse's note, dated 04/28/11, documented, "Report from day nurse (LPN #6), that right heel is broken down and skin prep in use. The right outer lateral foot area with blackened skin area 3.3 cm x 1 cm, skin prep used, and right heel with open peeling skin and blackened skin 4 cm x 5 cm, skin prep used. Right heel floated off the bed x 1 pillow." A nurse's note, dated 04/29/11, documented, "... Resident with brace to right foot. Removed X 15 mins. and floated on pillow... Right heel noted with eschar and slough. R lateral side noted with darkened area..." A nurse's note, dated 05/01/11, documented, "Right foot with blacken skin area 3.3 cm x 1 cm to the outer lateral area, see TMAR for trt plan, and right heel with trt plan for the wound 4 cm x 5 cm. Right heel floated off the bed x 1 pillow. Brace taken off at 1615 to 1630 per resident's request. Pedal pulse strong, positive. Soft boot in use due to fx to the right leg..." The skin breakdown care plan contained a handwritten update, dated 05/05/11, which documented, "(Problem): 5-5-11 (05/05/11) R heel/bottom. (No goal documented). (Interventions): 5-5-11 - Tx (treatment) as ordered." A nurse's note, dated 05/08/11, documented, "Right posterior lower leg with necrosis noted and posterior ankle, some pink tissue mixed in with necrosis (death of tissues due to injury and loss of blood supply), no drainage noted." A nurse's note, dated 05/10/11, documented, "... Right heel with black area noted..." A nurse's note, dated 05/10/11, documented, "... Off loading boot to R foot while up, heels floated while in bed..." A nurse's note, dated 05/16/11, documented, "... Areas to rt. foot observed to have 3 open areas. The center of each wound is dark purple in color with pinkish red skin surrounding... Measurements of the wounds to right foot are (1) 3 X 1.5 cm, (3) 4 X 2 cm, and (3) 2 X 1.5 cm..." A nurse's note, dated 05/17/11, documented, "...Wound to right heel x 3 noted dark in color...Top wound to right heel @ 1.0 cm x 2.0 cm x 0.3 cm. Wound to bottom heel @ 4 cm x 2 cm x 0.3 cm, and wound under right heel @ 4.0 cm x 2.0 x utd (unable to determine)..." A nurse's note, dated 05/19/11, documented, "Spoke with (Orthopedic physician). He stated for resident to wear soft foam boot when out of bed, then use walking boot when she is ready to bear wt on leg, when in bed just float heel off the bed. Cont. treatment that is in place." A nurse's note, dated 05/21/11, documented, "... Right heel noted with wounds X 3. Top heel wound dry and dark. Measures 2.0 cm x 1.0 cm. Under that wound to right heel is dry and dark, measures 4.0 cm x 2.0 cm. Under the right heel measures dark dry area of 4.0 x 2.0 cm..." A dietary consultant progress note, dated 05/24/11, documented, "Nutrition Assessment for Pressure Ulcers... Stage III (4/28) Upper right heel (no change) & 3 unstageable areas (no change) per 5/20 skin condition report... P (Plan): Suggest MVI (Multivitamin) with minerals to aid wound healing..." The dietary consultant's suggestion for wound healing was not put into place by the facility. A nurse's note, dated 05/26/11, documented, "... 8 cm reddened bruise noted to right heel. Tender to touch, heels floated..." A nurse's note, dated 05/29/11, documented, "... Right heel wound 1.5 cm l x 1 cm w. Above right heel wound 1.5 cm l x 1 cm w. right outer lateral foot wound 3 cm l x 1.5 cm w. all three wounds necrotic center dry, outer skin dry." A nurse's note, dated 06/05/11, documented, "Wound above right heel 1 cm l x 1 cm w. Right heel wound 2.5 cm l x 3.5 cm w. Right lateral foot 3 cm l x 1.7 cm w. All three wounds have black necrotic centers..." The resident's significant change assessment, dated 06/06/11, documented she required extensive assistance by two staff with bed mobility. She required total assistance by two staff with transfers, toileting and bathing. She was frequently incontinent of bowel and bladder and had one pressure sore on her right foot with eschar (a black, piece of dead tissue that is cast off from the surface of the skin, covering a pressure sore). A social services progress note, dated 06/09/11, documented, "Resident has shown some medical and cognitive decline. She has been in bed much of the time for several weeks and is just now getting up with minimal difficulty. She is passive, quiet and does not initiate conversation. She used to be out of her room and looking for me or nursing staff to discuss her current concerns. Now she sits quietly, she will smile if you approach her and she will respond with one or two word answers... She still spends much of her time in bed... She needs much assist with all cares and transfers. She has a medical condition with her foot and is being treated by nursing..." The resident's Braden scale, dated 06/12/11, documented her score was 13. (High risk for pressure sores). A physician's progress note, dated 06/20/11, documented, "She sustained a twisting injury during transfer early 4/2011 of her right LE with x-ray showing mildly displaced [MEDICAL CONDITION] right fibula and lateral malleoulus and non-displaced [MEDICAL CONDITION] malleolus...She wears a foam boot during the day...There has been interval development of pressure ulcers on the right heel. New problems: Pressure ulcer unstageable." On 06/30/11 at 10:00 a.m., the resident's skin was observed with LPN #2. The resident moaned and grimaced each time her right foot was touched. The back of the resident's right heel had a thick, necrotic area that covered the back of her heel. There was a dry, calloused area above the necrotic area with a hole in the center. The lateral side contained a thick, necrotic area. The LPN stated, "I know they look bad, but they are actually better than they were." The resident's left heel was laying on the bed and was not floated on a pillow. Her left heel was soft and boggy. The resident was assisted to turn onto her left side. She was wearing an incontinent brief and was incontinent of feces. Her call light was on the floor on the back side of her bed. An open area with depth was observed on her lower right buttock. The area was dark pink with a dark red center. The LPN stated, "This one is new. I am going to call the doctor for a treatment. I will get one of the girls (CNAs) to come clean her up." The resident's wheelchair was observed to ensure it contained a pressure relieving device. The resident's hard, black walking boot was in her wheelchair. The LPN stated, "I don't know why that is in here. She is suppose to be wearing the soft boot. This one is the one that caused the pressure sores to begin with." She reached into the resident's closet and retrieved a soft foam boot. The LPN was informed the resident had been wearing the hard black boot when she was up in her wheelchair on all days of the survey. She was informed she (LPN #2) was observed placing the boot on the resident on 06/27/11 at 10:00 a.m. She stated, "There has been a lot of confusion about which boot she is supposed to have on." Before the LPN left the room, CNA #4 opened the door and stated, "Again? I just cleaned her up a little while ago, but they said you need me to clean her up again." The LPN left the room. The CNA prepared the supplies for incontinent care, assisted the resident to turn onto her left side. She used a soapy wash cloth to clean the feces from between the resident's buttocks, used a wet cloth to rinse between her buttocks and a dry cloth to pat her dry. She assisted the resident to turn onto her back and asked the resident, "Do you want me to put a new brief on you?" The resident answered, "Yes, please." The CNA did not clean the rest of the resident's buttocks, her vagina or her groin areas. The CNA was asked to assist the surveyor to view the skin of the resident's vaginal and groin area. As she spread the resident's thighs, the resident cried out, "Oh! Oh!" A strong odor of stale urine was noted. A 2 cm x 1 cm open area was observed on the resident's left labia. The CNA was asked how long the area had been open. She stated, "I usually work restorative. I am just helping because they asked me too." She was asked if she had performed incontinent care for the resident earlier. She stated, "Yes, but I usually work restorative." At 10:30 a.m., the LPN was asked if she was aware of the open area on the resident's labia. She stated, "No, I wasn't. I will go check it out and tell the doctor about it when I call him for a treatment for [REDACTED]." At 11:50 a.m., the DON entered the surveyor's conference room and stated, "She had a pressure sore on her buttock in that same spot in March. It has just reopened." He was informed that it was not the same area, as that area was still healed with pink scar tissue." He stated, "I don't agree that is a pressure sore on her labia. There is no way it could be." He was informed of the observations, poor incontinent care and documentation regarding the resident's pressure sores. He stated, "We just can't win." At 2:30 p.m., the corporate RN stated, "We are getting her a new pressure relieving mattress. The one that is on her bed is the same one that is on all the other beds. It is a pressure reducing mattress, not a pressure relieving mattress. We are making a new care plan, too." He was informed the resident's prior care plan had not been updated with the pressure sores or interventions. He stated, "That is why we are making her a new care plan." At 2:45 p.m., the administrator was informed of the findings and was notified of an extended survey. She stated, "...We do not try to harm residents... I guess she fell through the cracks... They are working on getting a new care plan and interventions in place right now."