Every finding on record at Windsor Hills Nursing Center

Based on observation, record review, and interview, the facility failed to ensure a resident was not touched sexually by another resident for 1 (#3) of 3 sampled residents reviewed for abuse. The facility's failure to prevent this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm.The administrator identified 54 residents resided in the facility. On 09/08/25 at 10:43 a.m., Resident #3 was observed lying in bed, with the bed in the low position, with fall mat in place. Their room was clutter free and the trash can was empty. Resident #3's room was next to the nurse's station on hall 300. Resident #3 was unable to appropriately respond to surveyor.On 09/09/25 at 1:08 p.m., Resident #27 was in attendance during resident council.On 09/09/25 at 2:00 p.m., Resident #27 was observed playing bingo in the dining room.On 09/10/25 at 10:25 a.m., LPN #2 and CNA #3 were observed coming out of Resident #3's room. Resident #3 was observed in bed repeating well, well, well, okay, okay, okay. The fall mat was observed in place next to bed. The bed was in low position, and the call light was in their hand.An Oklahoma State Department of Health final report, for an incident dated 09/02/25, showed LPN #2 went to Resident #3's room and found Resident #27 with their hand underneath Resident #3's gown near their groin with a fondling motion. Resident #27 asked Resident #3 if they liked it. LPN#2 asked Resident #27 what they were doing and Resident #27 stated they were trying to help Resident #3 into bed. Resident #3 was unaware of their circumstances or surroundings currently. Resident #27 was instructed not to go into other residents' rooms and Resident #27 stated they did not know what LPN #2 was talking about and then left the room. Resident #27 was immediately placed on 1:1 monitoring. Resident #3 had a head-to-toe assessment completed with no abnormalities noted. The physician, administrator, DON, local police and APS were notified. Resident #27 remained on 1:1 observation for 72 hours with no attempts to go into any other resident's room or exhibit any behaviors. The facility sent medical paperwork into numerous behavioral hospitals, and the resident had been accepted for in-patient evaluation once a bed became open. Resident #27's care plan would be updated for any new medication changes upon return from the hospital. If any future incidents occurred after return, the facility would look at alternative placement.A policy Abuse, Neglect and Exploitation, revised 01/18/25, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident.Resident #3's Significant Change assessment, dated 07/03/25, showed Resident #3 had a BIMS score of 2 indicating severe problems with thinking and memory. The assessment showed Resident #3 had a diagnosis of metabolic encephalopathy [a brain dysfunction with symptoms that include confusion, memory loss, and altered consciousness]. The assessment showed Resident #3 was dependent upon staff for personal hygiene, dressing, bathing, transfers, toileting, and mobilization.A Nurse Progress Note, dated 09/02/25 at 1:59 p.m., showed Resident #3 was lying in their bed with the door open, and Resident #27 was found fondling underneath Resident #3's gown and asking if they liked it. Resident #3 was unable to respond appropriately to actions or questions from Resident #27. LPN #2 interrupted Resident #27's actions and asked what they were doing. Resident #27 stated they were trying to help Resident #3 get into bed. Resident #27 was instructed not to enter anyone's room without permission or staff presence.A Nurse Progress Note, dated 09/02/25 at 2:42 p.m., showed the evening shift nurse performed a head-to-toe assessment with no physical injuries or bruises noted. Resident #3 refused any pain medication but was anxious. Anxiety medication was last administered at 2:00 p.m.A Quarterly assessment for Resident #27, dated 08/09/25, showed a BIMS score of 6 which indicated severe problems with thinking and memory. The assessment showed Resident #27 had a diagnosis of dementia. The assessment showed Resident #27 required cues from staff for dressing, partial assistance with bathing, and substantial assistance with toileting.On 09/08/25 at 1:30 p.m., Resident #3's emergency contact #1 stated they lived in a different state and did not see Resident #3 often. They stated they were not aware of any abuse, but the facility did inform them of hospitalizations, Resident #3's refusal to eat and their rapid decline a few weeks ago. They stated Resident #3 gets taken care of as far as they know.On 09/09/25 at 9:30 a.m., LPN #2 stated the housekeeper noticed Resident #27 in Resident #3's room and alerted CNA #3, who then proceeded to alert them. LPN #1 stated they heard Resident #27 saying you like that, while they were touching Resident #3 under their gown around the groin area. LPN #2 stated Resident #27 had gotten more confused within the last two weeks. LPN #2 stated they asked Resident #27 about it the next day, but Resident #27 did not remember. LPN #2 stated they had never witnessed Resident #27 ever trying to enter Resident #3's room before. LPN #2 stated Resident #27 had entered another resident's room to go to the bathroom before. LPN #2 stated Resident #27 was easy to redirect.On 09/09/25 at 11:48 a.m., CNA #3 stated when they walked past Resident #3's room, Resident #27 was lifting the cover off of Resident #3, so they went to get the nurse. CNA #3 stated they had not seen Resident #27 do anything like that before.On 09/09/25 at 11:52 a.m., the administrator stated Resident #27 was put on 1:1 observation for 72 hours. The administrator stated Resident #27 did not go into any other resident's rooms or have any behaviors during that time. The administrator stated Resident #27 did not even remember the incident happened. The administrator stated they sent out referrals to three different behavioral health facilities to get Resident #27 evaluated. The administrator stated ultimately by the time a bed was available Resident #27 no longer qualified due to having no behaviors within the last 72 hours. The administrator stated their psychiatric doctor came to the facility once a month, but the facility was trying to get psychiatric to come weekly. The administrator stated Resident #3 and Resident #27 were their own responsible parties. The administrator stated there had been no other concerns since the incident. They stated they did not do Safe Surveys or any additional in-service training because the incident had been witnessed and stopped by staff. The administrator stated the facility had dementia training with a speaker in March of 2025. The administrator stated Resident #3 had not shown any signs of distress or acted any differently than previous to the incident.On 09/09/25 at 2:03 p.m., MDS coordinator #1 stated interventions were discussed in the morning stand up meeting. They stated Resident #27 was in the dining room with other residents 90% of the time. MDS Coordinator #1 stated the staff were made aware of the interventions through digital communication, and face to face shift report. They stated after the initial 72 hours of 1:1 observation, the staff were monitoring Resident #27's whereabouts.On 09/09/25 at 2:11 p.m., CMA #1 stated they were aware of the inappropriate touching, and that staff were instructed to keep an eye on Resident #27. CMA #1 stated Resident #27 was confused but was usually seen in the dining room playing games with other residents they lived with prior to being in the facility. CMA #1 stated they had never heard of Resident #27 doing anything like that before.On 09/09/25 at 2:13 p.m., LPN #3 stated they were aware of the incident and Resident #27 had been put on 1:1 monitoring but was unsure if that was still in effect. LPN #3 stated their responsibility when made aware of allegations of abuse was to make sure all the residents were safe, separate the residents, and try to educate the residents were able to comprehend. LPN #3 stated Resident #27 had never done anything like that before, and Resident #27 was usually in the dining room with their spouse, that is also a resident.On 09/09/25 at 2:17 p.m., CNA #1 stated they had provided 1:1 observation on a morning shift after the incident. CNA #1 stated Resident #27 stayed in the dining room most of the day, ate popcorn, and went out to the patio. CNA #1 stated they did not see any inappropriate behavior, and they were not aware of any other incidents involving Resident #27.

Based on record review and interview, the facility failed to have a designated and trained infection preventionist to oversee the infection control program. The administrator identified 55 residents resided in the facility. Findings: The facility policy title Infection Preventionist, last reviewed 01/18/25, read in part, The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention control program.An undated Windsor Hills Nursing Center key staff list, provided by at the time of entrance conference, did not identify any staff members as an infection preventionist. On 09/08/25 at 10:25 a.m., during the entrance conference the DON and business office manager were asked to identify who the facility infection preventionist was. The DON stated they had been without an infection preventionist since the previous DON resigned. The DON stated they oversee the wounds in the facility and was not trained and certified to be an infection preventionist. On 09/09/25 at 10:12 a.m., the administrator was asked who the designated infection preventionist was and when they had left. The administrator stated the previous DON was the infection preventionist and they left on 08/15/25.

Based on observation, record review, and interview, the facility failed to ensure call lights were within reach for 2 (#10 and #19) of 23 sampled residents reviewed for call light accessibility.The administrator identified 55 residents resided in the facility.Findings:A Call Lights: Accessibility and Timely Response policy, copyright date 2024, read in part, Staff will ensure the call light is within reach of each resident and secured, as needed. 1. On 09/08/25 at 10:24 a.m., Resident #19s call light button was observed on the floor. An annual assessment, dated 08/05/25, showed Resident #19 had a BIMS of 15, indicating no cognitive impairment. The assessment showed Resident #19 was dependent on staff for dressing, toileting, bathing, transferring, and bed mobility. On 09/08/25 at 10:28 a.m., LPN #2 stated I don't know how the call light got in the floor (for Resident #19), it should not be, it is supposed to be in the resident's reach at all times. 2.On 09/08/25 at 10:48 a.m., Resident #10's call light was observed at the foot of the bed, out of reach of resident. A quarterly assessment, dated 09/04/25, showed Resident #10 had a BIMS of 11, indicating moderate impairment of cognition. The assessment showed Resident #10 required maximum assistance with dressing, toileting, bathing, and transferring. On 09/08/25 at 10:49 a.m., CMA #2 stated the call light was at the foot of the bed, where Resident #10 could not reach it

Based on observation, record review, and interview, the facility failed to implement infection control practices a. for the care of oxygen tubing for 2 (#9 and #36) of 2 sampled residents reviewed for respiratory care, and b. for utilizing EBP during the provision of wound care for 2 (#8 and #12) of 2 sampled residents reviewed for wound care.The administrator identified 14 residents who had orders for oxygen and 18 residents that required the use of EBP. Findings: An undated facility policy Enhanced Barrier Precautions, read in part, It is the policy of this facility to implement enhanced barrier precautions of transmission of multi-drug-resistant organisms.An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds. 1. On 09/08/25 at 2:28 p.m., Resident #12's room was observed. A sign located on the door showed Resident #12 was on EBP. On 09/10/25 at 10:02 a.m., LPN #1 was observed performing Resident #12's wound treatment. LPN #1 gathered supplies, set up a barrier on the bedside table, washed their hands and donned a pair of gloves. LPN #1 did not put a gown on. LPN #1 applied a treatment and doffed her gloves. LPN #1 was observed without washing their hands and donning a new pair of gloves applying a sterile boarded gauze. LPN #1, after applying the gauze, went to the sink, washed their hands and donned a new pair of gloves. After applying the treatment to the second wound to Resident #12, LPN #1 took of their gloves and with their bare hands applied a band-aide dressing. LPN #1 did not wear a gown and did not perform proper handwashing and gloves changes. An undated face sheet for Resident #12 showed they had diagnoses which included the absence above the knee right and left leg, non-pressure chronic ulcer of buttock limited to break down of skin, stage III pressure ulcer. A physician order for Resident #12, dated 02/18/25, read in part, Enhanced Barrier Precautions (EBP) per CMS/OSDH guidelines. every shift for enhanced barrier precautions. A care plan for Resident #12, last revised 09/09/25, showed they had breakdown related to impaired mobility and disease process. The interventions read in part, Enhanced Barrier Precautions (EBP) per CMS/OSDH guidelines On 09/08/25 at 2:31 p.m., Resident #12 stated they had wounds that were being treated, and staff completed the treatments as ordered. Resident #12 stated staff did not always wear gloves and gowns when performing wound care. On 09/10/25 at 10:45 a.m., after the wound care was finished, LPN #1 was asked what the EBP sign on Resident #12's room meant. LPN #1 stated full PPE was not to be worn unless the resident had an infection. On 09/10/25 at 2:18 p.m., the DON stated EBPs were to be used when residents had wounds, a colostomy, or any port or open area on their body. The DON stated staff were to wear gloves and gowns when providing direct care. The DON stated they did not monitor to ensure the staff were utilizing EBP when providing care and wound treatments. 2. On 9/10/25 at 1:48 p.m., LPN #2 was observed providing wound care to Resident #8. LPN #2 washed their hands and donned a pair of gloves. LPN #2 did not put a gown on. LPN #2 removed dressing and cleaned the wound. The wound to buttocks was actively bleeding after the light cleaning with gauze. LPN #2 doffed gloves and donned new gloves. LPN #2 did not sanitize their hands. LPN #2 applied a collagen treatment and a foam pad, secured with a border dressing, and doffed their gloves. LPN #2 donned a new pair of gloves. LPN #2 did not put a gown on. LPN #2 removed dressing and cleaned the wound to right heel. LPN #2 doffed gloves and donned new gloves. LPN #2 did not sanitize their hands. LPN #2 donned new gloves and then applied a treatment and doffed their gloves. After completing the dressing LPN #2 went to the sink and washed their hands. An undated face sheet for Resident #8's showed they had a diagnosis of stage III pressure ulcer to the right heel. A physician order for Resident #8's, dated 02/19/25, read in part, Enhanced Barrier Precautions (EBP) per CMS/OSDH guidelines. every shift for enhanced barrier precautions. A care plan for Resident #8, last revised 08/27/25, showed they had impairment to skin integrity related to a deep tissue injury on the right heel. The care plan showed Resident #8 had maceration and shearing to the left buttocks. On 09/08/25 at 10:58 a.m., Resident #8 stated they had wounds, but staff did not wear gowns when they provided wound care or ADL care. On 09/10/25 at 2:08 p.m., LPN #2 was asked what EBPs were. LPN #2 stated they did not know and then guessed it was when they lay the barrier on the bedside table to place the wound supplies on. LPN #2 was asked if there was an EBP sign on the door to alert staff they should be using EBP. LPN #2 stated no. 3. On 09/09/25, at 10:14 a.m., Resident #9 was observed to have a nasal canula on. The tubing was not labeled when it was last changed. An undated facility policy Oxygen Administration, read in part, Change oxygen tubing and mask/canula weekly and as needed. An undated face sheet for Resident #9, showed they had diagnoses which included anxiety, chronic obstructive pulmonary disease, epilepsy, and unspecified systolic congestive heart failure. A physician's order, dated 06/03/24, showed Resident #9 was to receive 2 liters of oxygen via nasal canula. A physician's order, dated 08/31/25, documented to change the oxygen tubing every Sunday on the 10:00 p.m. - 6:00 a.m. shift. On 09/09/25 at 10:16 a.m., Resident #9 stated the last time the tubing was changed was last week 4. On 09/09/25 at 11:05 a.m. Resident #36 was observed in bed with a nasal canula on. There was no date on the tubing. An undated face sheet for Resident #36 showed they had diagnoses which included anemia, chronic kidney disease, depression, and hypertension. A physician's order, dated 08/31/25, showed Resident #36 was to receive 2 liters of oxygen via nasal canula. There was no order for changing the tubing. On 09/10/25 at 11:24 a.m., LPN #3 was asked about the procedure when changing oxygen tubing. LPN #3 stated they put their name, date, and time of the tubing change on the mask. LPN #3 was asked about the last time the tubing was changed for Resident #36. LPN #3 stated they did not know because the night shift nurse was supposed to complete the task. LPN #3 stated there was not an order for changing the oxygen tubing for Resident #36. On 09/10/25, at 11:37 a.m., the DON was asked about Resident #36's order for oxygen. The DON stated the order was not complete. The DON was asked about the policy regarding the tubing needing to be changed. The DON stated their policy was tubing needed to be changed weekly on Sundays with the initials, date, and time.

Based on observation, record review, and interview the facility failed to develop a care plan for the provision range of motion services for 1 (#6) of 1 sampled resident reviewed for range of motion.The administrator identified eight residents with range of motion deficits. Findings: On 09/08/25 at 12:45 p.m., Resident #6 was observed in their room with his right hand slightly contracted and unable to move his right side. An undated facility policy titled Prevention of Decline in Range of Motion, read in part, Appropriate care planning . Based on the Comprehensive assessment, the facility will provide interventions, exercise and/or therapy to maintain or improve range of motion. An undated admission Record for Resident #6 showed they had diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. An annual assessment for Resident #6, dated 06/19/25, showed they were severely cognitively impaired with a BIMS score of five. The assessment showed Resident #6 had upper and lower range of motion deficits. A care plan for Resident #6, last reviewed 06/02/25, read in part, I have a problem expressing myself to others because I had a stroke and it affecting my speech. The care plan was not developed to address Resident #6's ROM deficit to their right side. On 09/10/25 at 1:23 p.m., CNA #2 stated Resident #6 had stiffness to their right arm and had the limited use to the right side since they had been working here for two years. On 09/09/25 at 1:30 p.m., CNA #1 stated they had worked here for six months, and Resident #6 was weak on the right side due to a stroke. On 09/10/25 at 1:49 p.m., MDS coordinator #1, stated Resident #6 had right sided weakness and range of motion deficits. They stated the care plan did not address the range of motion and right-side weakness and it should have been developed and addressed.

Based on record review and interview, the facility failed to ensure residents accounts within $200 of the $2,000 resource received notices of the balances for 4 (#3, 12, 34, and #23) of 5 sampled residents reviewed for balances in the and trust accounts. This had the potential for Residents (#3, 12, 34, and #23 to lose their Medicaid eligibility. The facility identified 23 residents with Medicaid as a payor source and had the facility manage their funds. Findings: An undated facility policy Resident Personal Funds, read in part, Notices of Certain Balances. The facility must notify each resident that receives Benefits: when the amount in the resident's account reaches $200 less than the SSI resource limit for one person.and if the amount in the account in addition to the value of the resident's nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid and SSI. 1. An undated face sheet for Resident #3 showed they had a payor source of Medicaid. A trust account ledger balance for Resident #3, dated 09/09/25, showed they had a current balance of $4666.92. 2. An undated face sheet for Resident #12 showed they had a payor source of Medicaid. A trust account ledger balance for Resident #12, dated 09/09/25, showed they had a current balance of $2479.44. 3. An undated face sheet for Resident #34 showed they had a payor source of Medicaid. A trust account ledger balance for Resident #34, dated 09/09/25, showed they had a current balance of $4699.50. 4. An undated face sheet for Resident #23 showed they had a payor source of Medicaid. A trust account ledger balance for Resident #23, dated 09/09/25, showed they had a current balance of $2,620.23 On 09/11/25 at 8:57 a.m., the business office manager stated the resource limit for residents on the trust account with a Medicaid payor source was $2,000. They stated the new system will generate a letter when the residents were within $200 of the resource limit but the old system did not have that. The business office manager stated they did not have documentation that showed notices had been provided but would look and see if they could find anything. No further documentation was provided to show the notices had been provided.

Based on record review and interview the facility failed to ensure care plans were updated to reflect the current status of medications for 1 (#53) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 35 residents received psychoactive medications. Findings: An undated admission record for Resident #53 showed they had diagnoses which included respiratory disorders in disease classified elsewhere, chronic pain, constipation, sleep apnea, ventricular fibrillation, atrial fibrillation, insomnia, anxiety, adjustment disorder with mixed anxiety, and depression. Resident #53's orders for Buspirone (an anti-anxiety medication) showed the medication was discontinued on 07/13/25. Resident #53's orders for trazadone (an antidepressant) showed the medication was discontinued on 07/13/25. A care plan for Resident #53, last updated 07/23/25, showed the resident was currently taking Trazadone and Buspirone. On 09/09/25 at 2:28 p.m., MDS coordinator #1, stated they were responsible for updating care plans for the residents. They stated Resident #53's Trazadone and Buspirone was discontinued on 07/13/25. MDS Coordinator #1 was asked if the care plan reflected the current status of medication use. They stated the medications were not taken off the care plan and they should have been.

Based on observation, record review, and interview the facility failed to provide range of motion services for 1 (#6) of 1 sampled resident reviewed for range of motion services. The administrator identified eight residents with range of motion deficits. Findings: On 09/08/25 at 12:45 p.m., Resident #6 was observed in their room with his right hand slightly contracted and unable to move his right side. An undated facility policy titled Prevention of Decline in Range of Motion, read in part, Appropriate care planning . Based on the Comprehensive assessment, the facility will provide interventions, exercise and/or therapy to maintain or improve range of motion. An undated admission Record for Resident #6 showed they had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. An annual assessment for Resident #6, dated 06/19/25, showed they were severely cognitively impaired with a BIMS score of five. The assessment showed Resident #6 had upper and lower range of motion deficits. A care plan for Resident #6, last reviewed 06/02/25, read in part, I have a problem expressing myself to others because I had a stroke and it affecting my speech. The care plan was not developed to address Resident #6's ROM deficit to their right side. On 09/10/25 at 1:23 p.m., CNA #2 stated Resident #6 had stiffness to their right arm and had the limited use to the right side since they had been working there for two years. On 09/09/25 at 1:30 p.m., CNA #1 stated they had worked there for six months, and Resident #6 was weak on the right side due to a stroke. On 09/10/25 at 1:35 p.m., LPN #1 stated Resident #6 had limited use to their right side due to a stroke. LPN #1 stated Resident #6's right hand was tight and they needed to make sure their nails were kept trim. LPN #1 stated they did not know of Resident #6 having restorative services. On 09/10/25 at 1:40 p.m., RA #1 stated they had been doing restorative services for six months and they had 19 residents on services. RA #1 stated Resident #6 was not receiving any services and they had ROM deficits due to a stroke. RA #1 stated MDS coordinator #1 was the one who assisted with determining residents that would benefit from the services. On 09/10/25 at 1:49 p.m., MDS Coordinator #1, stated Resident #6 had right sided weakness and range of motion deficits. They stated Resident #6 is not on a restorative program and no ROM services were being provided. MDS Coordinator #1 stated they were not sure when Resident #6 had been screened and would look for documentation to show when they were screened. No additional documentation was provided.

On 05/09/25 at 10:15 a.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure residents were monitored for safe smoking and the use of electronic vaping devices. Resident #1 was a known vape device user, in their room with continuous oxygen use. Resident #1 did not have a care plan that addressed the vape device, and the use of the device in their room. Staff confirmed the knowledge of the use of the vaping devices in the room and they charged them. On 05/02/25, Resident #1 while in their room with oxygen on lit a cigarette causing flash burns to his face. Based on observation, record review, and interview, the facility failed to have a system in place to ensure residents were supervised and monitored for safe smoking and the use of electronic vaping devices for 1 (#1) of 4 sampled residents reviewed for smoking and electronic vaping use. Resident #1 lit a cigarette in their room, while oxygen was in use, causing a flash burn to their nostrils and left cheek. The DON identified one resident who vaped, three unsupervised smokers and nine supervised smokers reside in the facility. Findings: On 05/06/25 at 10:20 a.m., Resident #1's room was observed with a cup filled with brown liquid substance from chewing tobacco on the sink counter. Next to the bed was a plastic container on the over bed table that contained a can of chewing tobacco and four various colored vaping devices. An oxygen concentrator was observed against the wall. 05/07/25 at 2:05 p.m., Resident #1 was observed in his hospital bed with their left cheek red, with a large blister on the lower left cheek. Resident #1's nose was observed with peeling skin, brownish in color. A facility policy Resident Smoking, revised 01/08/25, read in part, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking.Smoking is prohibited in all areas except the designated smoking areas.Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include but are not limited to: .Use of E cigarettes in designated smoking areas.A safe smoking assessment will be completed on all residents using e-cigarettes.Don't use the device around flammable gases or liquids, such as oxygen, propane, or gasoline. An undated smoking list, provided by the DON on 05/06/25 at 1:30 p.m., did not list Resident #1 as a smoker or a vape user. Resident #1's care plan, revised on 06/27/23, read in part, I am a independent tobacco user. I use tobacco products or smoke.Goal I wish to continue to maintain my independence in the usage of tobacco products.Interventions I am a tobacco user and have been educated on the health risk of dipping or chewing tobacco but I choose to use. I have been informed about nurses will perform periodic evaluations on me about my safety to continue to use tobacco independently I have been educated on smoke times, tobacco products use, and dangers of smoking (cigarette burns or health). I still choose to use tobacco products. The care plan did not address Resident #1's use of vape's. Resident #1's care plan, revised on 02/20/25, read in part, OXYGEN: I require oxygen at by nasal cannula to maintain adequate oxygen and to breathe easier r/t my COPD/SOB Diagnosis. I refuse breathing treatments at times.Intervention Provide oxygen via nasal cannula at L/min as ordered by my doctor. Resident #1's Smoking Assessment, dated 03/19/24, showed they did not smoke. Resident #1's annual Minimum Data Set assessment, with an assessment reference date of 08/16/24, showed they were a current tobacco user and had a brief interview for mental status score of 15, which showed no cognitive impairments for daily decision making. Resident #1's order summary, dated 05/06/25, read in part, keep oxygen saturations above 90% by adjusting oxygen every shift for SOB related to SHORTNESS OF BREATH. The order was first written 08/17/24. Resident #1's quarterly Minimum Data Set assessment, with an assessment reference date of 02/14/25, showed they had no cognitive impairments with a brief interview for mental status score of 15. Resident #1 was dependent on staff for all activities of daily living skills. Resident #1's Smoking Assessment, dated 04/17/25, showed they used a vape. Resident #1's Incident Report, dated 05/02/25, read in part, Nursing Description: Resident called out for help from his bed. Nurse aide went into Resident room and notified nurse and upon entering Residents room, Nurse observe cheeks, nose, around nose, facial hair charred some parts blistered. Upper part of Oxygen tubing burnt.Resident Description: Resident verbalized My face got caught on fire I can't explain how. Resident reports facial burn and discomfort.Description: Head to toe assessment done. Focus assessment on face. Vitals are BP 127/68. HR 88 02 93 on room air. Temp 97.8. Resident sent to ER for evaluation. DON ADON and Administrator notified. Resident is his own responsible party. Resident #1's hospital record, dated 05/02/25, read in part, Mechanism of injury: flame.Circumstances of injury: Patient was on oxygen and try [SIC] to smoke and sustained flash burn.Date of injury: May 2, 2025.Skin: Partial thickness burn to lower face including both nostrils.Assessment and Plan: [age and gender deleted] with history of asthma, COPD, 3 L oxygen, stroke with hemiparesis of the left side, anxiety disorder, depression who sustained flash burn to the nose and lower part of face.Partial thickness burn to face wash with water and soap daily, apply glucan Pro 3000 daily.Inhalation injury inhalation protocol including Heparin, Mucous, albuterol started. Resident #1's care plan, revised on 05/06/25, read in part, 5/2/25 Burns to face from smoking incident.Interventions 5/2/25 Send to ER for assessment of burns to face. On 05/05/25, the facility initiated their quality assurance with all committee members to develop a performance improvement plan related to residents attempting to smoke in the room while having oxygen on. The plan included vaping devices. On 05/05/25, the facility implemented new smoking assessments, smoking agreements, and a questionaire to monitor and track smokers understanding of the policy. Resident #1 would have their agreement completed once back from the hospital. On 05/05/25 all residents were reviewed for their smoking status and a new assessment was completed for all the smokers. Care plans were reviewed and updated as indicated by the assessments. On 05/05/25 in-services were completed with all staff regarding smoking, supervised smoking and the policy which included vaping devices. On 05/07/25 at 8:00 am., the facility completed all-staff training through a message regarding the same information as the face-to-face in-service on 05/05/25. All facility employees were verified as receiving the messaged in-service. A third in-service was scheduled for 05/09/25 for all staff over the same information. On 05/07/25 at 11:04 a.m., the housekeeping supervisor stated Resident #1 vaped and never smoked. They stated Resident #1 never came out of their room to smoke, and vaped in their room. The housekeeper stated Resident #1 used oxygen daily. On 05/07/25 at 11:20 a.m., CMA #2 stated Resident #1 vaped and did not get up and go out of their room. CMA #2 stated Resident #1 can dip tobacco and use a vape on their own and was very independent. CMA #2 stated Resident #1 used oxygen all the time. On 05/07/25 at 11:33 a.m., CNA #1 stated the facility smoking policy was residents needed to be outside. CNA #1 stated Resident #1 vaped and three or four vape's were kept in their room. CNA #1 stated Resident #1 never used materials that had to be lit by staff. CNA #1 stated staff charged the vapes' everyday for Resident #1. CNA #1 stated on Friday, Resident #1 called out their name. CNA #1 stated when they went in to check on Resident #1, they had burned their face. CNA #1 stated Resident #1's face was really red from lighting a cigarette with oxygen on. CNA #1 stated Resident #1 always vaped and they were not sure where the cigarette and lighter came from. CNA #1 stated Resident #1 was bed bound and only vaped prior to the incident. CNA #1 stated they have never found Resident #1 with oxygen on while vaping because they knew to take it off. CNA #1 stated everyone knew Resident #1 vaped in their room. On 05/07/25 at 12:41 p.m., LPN #1 stated Resident #1 was independent except for getting up and dressed. LPN #1 stated Resident #1 smoked using a vape, chewed tobacco and stayed in their room. LPN #1 stated Resident #1 used oxygen and always vaped in their room. LPN #1 stated Resident #1 always knew to take of their oxygen when vaping. On 05/07/25 at 1:00 p.m., CMA #1 stated Resident #1 smoked by using a vape. CMA #1 stated Resident #1 vaped in their room, used oxygen, but never kept it on when vaping. CMA #1 stated Resident #1 yelled out their names, and they smelled an odor of something that had been burnt. CMA #1 stated Resident #1 stayed in their room, vaped and they did not know where the cigarette and lighter came from. CMA #1 stated they charged the vapes' for Resident #1 and everyone knew he vaped in the room. On 05/07/25 at 2:10 p.m., Resident #1 stated they had not smoked in a very long time and they had a craving. Resident #1 stated they vaped and chewed tobacco. Resident #1 stated it was stupid of them to have a craving and smoke in the room and they regret they ever did. Resident #1 stated they had never done this before and never will again. Resident #1 stated he put the flames out with their hands and a blanket. Resident #1 stated they knew to remove the oxygen when they vaped in the room. On 05/08/25 at 1:01 p.m., the DON stated residents who vape must vape in the designated smoke area. The DON stated they were not aware of Resident #1 ever smoking cigarettes. The DON stated they were not aware of the vaping in the room. The DON stated they would not allow vaping in the building because the device could explode. The DON stated they were not sure where the cigarette and lighter came from, and prior to the incident there had been no smoking materials found in the room. On 05/08/25 at 1:55 p.m., the administrator stated they did not know any residents vaped in the facility. The administrator stated Resident #1 only dipped tobacco and stopped smoking long before admission the facility. The administrator stated vaping was not to be done in the room and Resident #1 stated their family provided the cigarette and lighter.

Based on observation, record review, and interview the facility failed to ensure care plans were developed and revised for smoking and the use of electronic vaping devices for 1 (#1) of 4 sampled residents reviewed for smoking and electronic vaping use. The DON identified one resident who vaped, three unsupervised smokers and nine supervised smokers. Findings: On 05/06/25 at 10:20 a.m., Resident #1's room was observed with a cup filled with brown liquid substance from chewing tobacco on the sink counter. Next to the bed was a plastic container on the over bed table that contained four various colored vaping devices. An oxygen concentrator was observed against the wall. A policy, Resident Smoking, revised 01/08/25, read in part, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking.Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include but are not limited to: .Use of E cigarettes in designated smoking areas.A safe smoking assessment will be completed on all residents using e-cigarettes.Don't use the device around flammable gases or liquids, such as oxygen, propane, or gasoline.All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible residents while smoking. Supervision will be provided as indicated on each resident's care plan. Resident #1's care plan, revised on 06/27/23, read in part, I am a independent tobacco user. I use tobacco products or smoke.Goal I wish to continue to maintain my independence in the usage of tobacco products.Interventions I am a tobacco user and have been educated on the health risk of dipping or chewing tobacco but I choose to use. I have been informed about nurses will perform periodic evaluations on me about my safety to continue to use tobacco independently I have been educated on smoke times, tobacco products use, and dangers of smoking (cigarette burns or health). I still choose to use tobacco products. The care plan did not address Resident #1's use of vape's. Resident #1's care plan, revised on 02/20/25, read in part, OXYGEN: I require oxygen at by nasal cannula to maintain adequate oxygen and to breathe easier r/t my COPD/SOB Diagnosis. I refuse breathing treatments at times.Intervention Provide oxygen via nasal cannula at L/min as ordered by my doctor. The care plan was not updated to address Resident #1's use of a vape while in their room. Resident #1's Smoking Assessment, dated 03/19/24, showed they did not smoke. Resident #1's annual Minimum Data Set assessment, with an assessment reference date of 08/16/24, showed they were a current tobacco user and had a brief interview for mental status score of 15, which showed no cognitive impairments for daily decision making. Resident #1's quarterly Minimum Data Set assessment with and assessment reference date of 02/14/25, showed they had no cognitive impairments with a brief interview for mental status score of 15. Resident #1 was dependent on staff for all activities of daily living skills. Resident #1's Smoking Assessment, dated 04/17/25, showed they used a vape. On 05/07/25 at 11:04 a.m., the housekeeping supervisor stated Resident #1 vaped and never smoked. They stated Resident #1 never gets up to come out of their room and vaped in their room. On 05/07/25 at 11:20 a.m., CMA #2 stated Resident #1 vaped and did not get up and go out. On 05/07/25 at 11:33 a.m., CNA #1 stated staff charged the vape's everyday for Resident #1. CNA #1 stated everyone knew Resident #1 vaped in their room. On 05/07/25 at 12:41 p.m., LPN #1 stated Resident #1 was independent except for getting up and dressed. LPN #1 stated Resident #1 smoked using a vape, chewed tobacco and stayed in their room. LPN #1 stated Resident #1 always knew to take off their oxygen when vaping. On 05/07/25 at 1:00 p.m., CMA #1 stated Resident #1 smoked by using a vape. CMA #1 stated Resident #1 would vape in their room, used oxygen, but never kept it on when vaping. On 05/07/25 at 2:10 p.m., Resident #1 stated they vaped and chewed tobacco. Resident #1 stated they knew to remove the oxygen when they vaped in the room. On 05/08/25 at 1:01 p.m., the DON was asked to show how the care plan addressed Resident #1's vape use. The DON reviewed the care plan and stated the care plan did not address Resident #1's vape use.

Based on record review and interview, the facility failed to ensure a physician's order for monthly catheter changes was followed and failed to ensure a resident with a indwelling urinary catheter received services to help prevent urinary tract infections for one (#35) of two sampled residents reviewed for catheters. The deficient practice resulted in a bladder stone. The MDS Resident Matrix, dated 09/23/24, identified four residents with catheters. Findings: A Clinical Supplies in Case of Emergency policy, reviewed 09/17/24, read in part, It is the policy of this facility to establish procedures to ensure that needed clinical supplies are available to maintain continuity of care in the case of emergency. It also read, Par levels of various supplies will be set, base on use, and procedures for reordering will be followed accordingly to ensure availability of supplies on an ongoing basis. Res #35 had diagnoses which included acute kidney failure and retention of urine. The admission assessment, dated 04/29/24, documented the Brief Interview for Mental Status score of 15 indicating this resident was cognitively intact. A physician order, dated 04/22/24, documented to change indwelling catheter on the 15th of every month on the 10-6 shift starting on the 15th and ending on the 18th every month. The care plan did not mention their refusal to allow nurses to change catheter, or their request for urologist to provide this care. A progress note, dated 05/16/24 at 9:58 a.m., documented the catheter size was not currently in the building. A progress note, dated 05/17/24 at 6:14 a.m., documented the catheter size was on order. A progress note, dated 05/18/24 at 2:25 a.m., documented the catheter size not available that it was on order. There was no documentation that the physician or DON was notified that the catheter had not been replaced. After three days the order was removed from the medication administration notifying the staff that it needed to be done until it appeared again on the following month administration record for the 15th through the 18th. A progress note, dated 06/14/24 at 9:40 p.m., documented the catheter was draining cloudy yellow urine with foul odor and cream sediment observed in the drainage tube. It was documented the physician was notified and Macrobid (antibiotic medication) 100mg twice daily initiated. A progress note, dated 06/15/24 at 10:18 p.m., documented the catheter continues to drain cloudy yellow urine with foul odor and cream color sediment in tube. The catheter was not changed. A progress note, dated 06/16/24 at 9:38 p.m., documented the catheter was draining cloudy yellow urine with foul odor. It was documented the resident was on an antibiotic for UTI. A progress note, dated 06/17/24 at 6:05 a.m., documented the resident refused to have their catheter changed and was witnessed by two nurses. It was documented the resident continued on antibiotics and would continue to monitor. There was no notification of the refusal to the physician or DON. A progress note, dated 06/18/24 at 7:29 a.m., documented resident refused to allow any nurse to change their catheter, as they insisted on the urologist to change catheter. It was documented the physician was notified and gave an order to send to the ER for catheter change. It was documented the resident refused to go to ER. There was no documentation the physician or DON was made aware of their refusal to go to ER or that their catheter had remained unchanged since prior to the 04/22/24 admitted . A progress note, dated 07/16/24 at 6:09 a.m., documented the resident refused catheter change. It was documented they verbalized they would wait unit Wednesday to talk to their new primary care physician to refer them to a urologist instead. It was documented the ADON was notified. A progress note, dated 07/26/24 at 11:12 a.m., documented that resident's catheter was leaking. It was documented two nurses went to room to reinforce the resident's catheter. A progress note, dated 08/02/24 at 6:33 a.m., documented the resident reported not having any urine flow via catheter at 4:45 a.m. It was documented a nurse assessed and found 60cc urine in bag with no leak and abdomen distended. It was documented the resident complained of lower abdominal pain and felt like they were peeing. It was documented the physician was notified and an order was received to change the catheter. It was documented the resident refused stating they wanted a urologist to put in the catheter and wanted to go to ER. It was documented the DON was notified and the resident was transferred to hospital. A hospital update, faxed to the facility on [DATE], documented the resident had a new diagnosis of a bladder stone received on 08/02/24. A progress note, dated 08/08/24 at 4:48 p.m., documented the resident returned from the hospital on 08/08/24 at 3:40 p.m. It was documented a new order for finasteride (5-alpha reductase inhibitor) 5mg was sent with resident. A progress note, dated 08/18/24 at 1:44 a.m., documented the resident refused catheter change stating it was changed in the hospital. A progress note, dated 08/24/24 at 9:18 a.m., documented the resident told the nurse their catheter was leaking and had been disconnected at the hub and they had been reconnecting it. A progress note, dated 08/24/24 at 9:37 a.m., documented the DON and ADON were notified. It was documented the ADON instructed the nurse to send the resident to the hospital to have the catheter changed out. It was documented the resident refused stating they had an appointment with the urologist coming up. A progress note, dated 08/24/24 at 2:56 p.m., documented nurse was allowed by resident to change out the drainage containment part to see if that would help with the leaking. A progress note, dated 09/16/24 at 4:51 a.m., documented the resident refused to have their catheter changed. On 09/26/24 at 2:42 p.m., the ADON was asked the reason the resident was allowed to go so long without having their catheter changed. They stated, Hindsight is 20/20, coulda, shoulda, woulda. I don't know. On 09/27/24 at 9:43 a.m., the administrator and corporate nurse #2 stated the protocol was to notify the DON or administrator if supplies were not in the facility so the administrator could place an order. Corporate Nurse #2 stated the resident should have been educated on the consequences of not changing catheter or allowing staff to provide care. They stated going forward they will just make sure Resident #35 had a urologist appointment monthly to allow the urologist to change their catheter.

Based on record review and interview, the facility failed to ensure a resident who received an antipsychotic medication had an appropriate diagnosis for the use of medication for one (#36) of five sampled residents for psychotropic medication. The Administrator identified 58 residents resided in the facility. Findings: The DON stated 58 residents resided in the facility. The Medication Orders Policy dated, 01/08/24, read in part, This facility shall use uniform guidelines for the ordering of medication. J. Diagnosis or indication of use. Resident #36 had a diagnosis of which included Congestive Heart Failure. On 09/26/24 at 8:32a.m., Resident #36 had a September physician order which documented, Buspirone HCL of 15 MG, start date of 06/29/24 at 6:00 a.m., twice daily, with no diagnosis or reason for administering medication. On 09/26/24 at 8:35a.m., the updated diagnosis record, care plan, gradual dose reduction and nursing level of care assessment plan, had no documentation of anxiety diagnosis found for Resident #36. On 09/26/24 at 8:39a.m., the ADON reported the updated diagnosis sheet, care plan, gradual dose reduction and nursing level of care assessment plan, had no documentation of a diagnosis of anxiety. On 09/26/24 at 8:40a.m., the Regional Director of Clinical Systems reported Resident #36 should have had a diagnosis for the administration anti-anxiety medication.

Based on observation, record review, and interview, the facility failed to ensure food was maintained at an appropriate temperature for two of two kitchen observations and maintain a sanitary tray line for one of two kitchen observations. The administrator identified 58 residents resided in the facility. Findings: A Record of Food Temperatures policy, reviewed 01/08/24, read in part, Hot foods will be held at 135 degrees Fahrenheit or greater. A Maintaining a Sanitary Tray Line policy, reviewed 01/08/24, read in part, Change gloves when activities are changed, or when the type of food being handles is changed, or when leaving the workstation. It also read, Periodically monitor food temperatures throughout the meal service to ensure proper hot (at or above 135 degrees) or cold holding temperatures (at or below 41 degrees) are maintained. On 09/23/24 at 7:35 a.m., the food to be served was observed sitting on the grill of the stove. The temperature of the pureed sausage was noted to be at 113.2 degrees Fahrenheit. [NAME] #1 stated the facility had not had a steam table in years. On 09/23/24 at 7:42 a.m., cook #1 is observed wearing gloves to prepare plates. [NAME] #1 is observed spreading out the menu cards onto the prep table to be read, then proceeding to dish out food including touching toast with gloved hands that were just touching menu cards and prep table. [NAME] was noted to only change gloves once during entire service. On 09/23/24 at 8:10 a.m., [NAME] #1 stated the policy was to try not to touch foods with same gloves. They stated the prep table should have been cleaned today, but they did not clean it. On 09/24/24 at 8:15 a.m., the test tray was handed to surveyor directly from the serving line that was on the grill, with temperatures recorded to be eggs 110 degrees, sausage patty 98 degrees, hash brown 94 degrees. On 09/27/24 at 9:35 a.m., the administrator stated staff are supposed to temperature check food before providing to the residents to prevent food borne illness. The administrator stated staff are supposed to wash hands and change gloves between touching different surface areas.

Based on observation, record review, and interview, the facility failed to have effective communication using picture exchange communication for one (#53) of one resident who required pictures and/or words for their activities of daily living. The Administrator identified 58 residents resided in the facility. Findings: Resident #53 had a diagnosis which included atrial fibrillation, high blood pressure and chronic pain. Resident #53's care plan, dated 08/27/24, read in part, I can express my wants/needs by pointing to pictures to let staff know what I am wanting. Resident #53s progress notes, dated 08/02/24, read in part, 1950 [7:50 p.m.] Resident c/o right hand pain rated 6/10 and this nurse gave him Tylenol 650mg. On 09/23/24 at 10:40a.m., it was observed with the ADON and Administrator that Resident #53 could not effectively communicate the location of pain or the level of pain. The pictures of communication were not able to be found or used as requested in Resident #53 care plan, dated 08/27/24. On 09/23/24 at 6:47a.m., the ADON reported that Resident #53 doesn't use the iPAD with me they just point. On 09/23/24 at 8:16a.m., the Administrator reported they needed to find a way that every staff person can communicate for provision of care and activities of daily living with Resident #53.

Based on record review and interview, the facility failed to ensure an accurate comprehensive care plan was developed and implemented for three (#7, #23, and #53) of 24 sampled residents who were reviewed for accurate comprehensive care plans. The Administrator identified 58 residents resided in the facility. Findings: Resident #7 admitted to the facility 04/11/23. They had a diagnosis of vascular dementia with behavioral disturbances, but there was no care plan to address their needs. Resident #23 admitted to the facility 05/06/23. They had an illeostomy, but there was no care plan to address their needs. Resident #53 admitted to the facility 05/10/24. The resident was dependent on staff to provide incontinent care, but the care plan documented, .daily care .toileting .I need staff assistance to use the bathroom .including help transferring on/off toilet . On 09/27/24 at 1:45 p.m., CNA #6 stated they do not toilet (resident #53) on the commode, they can not put on or take off their shoes or pants, and has not changed since they were hired. On 09/27/24 at 1:55 p.m., RN #2 stated care plans should be reviewed and updated.

Based on record review and interview, the facility failed to ensure the advance directive acknowledgement forms were completed for two (#7 and #23) of three sampled residents reviewed for advance directives. The Administrator identified 58 residents resided in the facility. Findings: Resident #7 admitted to the facility 04/11/23. There was no advance directive form found in their electronic health record or their admission packet designating the decision by the resident or the resident's representative. Resident #23 admitted to the facility 05/06/23. There was no advance directive form found in their electronic health record or their admission packet designating the decision by the resident or the resident's representative. On 09/24/24 at 12:56 p.m., social services stated there was no advanced directive found in the admission packet or electronic health record with the decision of the resident or resident representative about advance directives for resident #7 and resident #23.

Based on observation, record review, and interview, the facility failed to ensure accurate menus were posted and followed for three of three meal services observed. Findings: The Administrator identified 58 residents resided in the facility. The facility's policy Menus and Adequate Nutrition dated 08/01/24, read in part Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance. Menus will be followed as posted. Notification of any deviation from the menu shall be made as soon as practicable. On 09/23/24 at 7:35 a.m., observation of breakfast to be served was oatmeal, scrambled eggs, sausage patties, bacon and toast. The menu guide report documented ham egg cheese skillet was to be served for this meal. On 09/23/24 at 8:10 a.m., cook #1 stated the food was already being cooked when they arrived. They stated they normally follow the menu. Only the daily menu was posted. The alternatives were not posted and the weekly menu was not posted. On 09/24/24 at 12:23 p.m., residents were observed eating roasted turkey breast, mashed potatoes and gravy, mixed vegetables, and buttered corn muffins. The alternatives were not posted and the weekly menu was not posted. The menu guide report documented roasted turkey breast, wild rice greens of choice, and buttered corn muffin were to be served for this meal. The dietary manager stated they changed the rice to mashed potatoes because the residents just had rice for lunch yesterday. On 09/25/24 at 8:10 a.m., residents were observed eating oatmeal, scrambled eggs, sausage, bacon, and biscuit with gravy. The menu guide report documented blueberry pancakes were to be served for this meal. On 09/25/24 at 2:18 p.m., cook #1 stated they did not get the supplies to make blueberry pancakes, so they made the decision on what to serve instead. The alternatives were not posted and the weekly menu was not posted. On 09/25/24 at 3:12 p.m. the dietary manager was on the phone with the corporate executive. The dietary manager stated their supply company only forgot the blueberries, but they did have pancake mix. The dietary manager stated their supply company was often out of the things that were on the menu making it difficult to follow the menu. The corporate executive stated we are not supposed to make substitutions all the time, only for extenuating circumstances or for resident preferences. The corporate executive stated they would work on getting the menu updated to reflect resident preferences and items the supply company would be able to supply. They stated an accurate menu was supposed to be posted for residents to access, but they did not want to post alternatives in case they didn't always have them available. On 09/26/24 at 1:25 p.m., CNA #1 stated staff does not ask what residents want for breakfast they get what the kitchen provides. [NAME] #1 stated residents get whatever they previously stated they wanted and then if they don't want that, the aides will let the kitchen know to make the residents something else. On 09/27/24 at 9:30 a.m., the administrator stated residents should be able to know what is on the menu at least a week ahead of time.

Based on observation, record review and interview, the facility failed to ensure Resident Assessments were accurately coded for one (#17) of 15 residents reviewed for assessments. The Administrator identified 58 residents resided in the facility. Findings: A Conducting an Accurate Resident Assessment policy, undated, read in part, qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. Resident #17 had diagnoses which included generalized anxiety, psychotic disorder with delusions, and sclerosis of central nervous system. A care plan initiated on 06/28/19, documented that Resident #17 had a behavior problem related to dementia and other psychological causes that included continuously screaming out and repeating the same thing. A quarterly Resident Assessment and Care Screening dated 08/23/24, documented that resident #17 had no behaviors during the previous 7 days. On 08/17/24 at 11:13 a.m., a progress note documents, Was a behavior observed? YES On 08/20/24 at 9:15 a.m., a progress note documents, Was a behavior observed? YES On 08/22/24 at 9:15 a.m., a progress note documents, Was a behavior observed? YES On 09/23/24 at 9:36 a.m., LPN #1 stated resident #17 yells out to get staffs attention. On 09/23/24 at 9:36 a.m., Resident #17 was heard yelling help me. LPN #1 acknowledged them. On 09/25/24 from 9:00 to 9:07, CMA #2 tried to get resident to take medications, then LPN #1 tried to get resident #17 to take medications. Resident #17 refused and stated they were upsetting them. On 09/25/24 at 10:20 a.m., CMA #2 and LPN #1 both attempted to convince resident #17 to take their medications. Resident #17 refused. Resident #17 was heard throughout survey yelling help me multiple times per day, even when staff were observed to have just left their room. On 09/26/24 at 9:25 a.m., corporate nurse #1 stated the MDS dated [DATE] was inaccurate in regard to behaviors. On 09/27/24 at 9:40 a.m., the administrator and corporate nurse #2 were interviewed and corporate nurse #2 stated the policy was to code the MDS accurately.

Based on observation and interview, the facility failed to ensure the medication room was secured when not in use. The Administrator identified 58 residents resided in the facility. Findings: A Medication Storage policy, dated 01/08/24, read in part, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. On 09/23/24 at 10:45 a.m., the medication room door was observed propped wide open with the trash can holding the door open. There were no staff inside or in sight. The medication room was located right across from the dining room where multiple mobile residents were located. One resident was observed within four feet of the wide-open door. They were in a wheelchair they could propel themselves. On 09/23/24 at 10:48 a.m., LPN #1 stated the policy is to keep the door closed and locked. They stated the other staff just loaded their cart and must have forgot to close the door. On 09/27/24 at 9:38 a.m., the administrator and corporate nurse #2 were interviewed and corporate nurse #2 stated the policy was to keep medications locked and secured.

Based on interview and record review, the facility failed to provide dietary interventions as ordered by the physician for one (#5) of one resident whose clinical records were reviewed for nutrition. The Administrator identified 58 residents resided in the facility. Findings: A Medication Orders policy, dated 01/08/24, documented Handwritten Order Signed by the Physician- The charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic order format . Resident #5 had diagnoses which included severe intellectual disabilities, cerebral palsy, and dysphagia. The Weight Summary documented a weight of 176.8 lbs. on 04/01/24, followed by a weight of 164.0 lbs. on 05/01/24, indicating a 5% decrease in one month. On 05/27/24, the dietician recommended health shakes twice a day to aid in weight loss prevention. On 06/03/24, the physician agreed and ordered weekly weights times four. On 07/01/24, Resident #5's weight was documented as 159 lbs. On 07/23/24, the dietician recommended updating diet orders. On 07/24/24, the physician ordered please get twice daily health shakes on resident #5's orders. On 08/01/24, Resident #5's weight was documented as 156.2 lbs. On 08/01/24, an order for house health shakes three times a day for supplement was placed in the electronic health record. There was no documentation to indicate that weights were done weekly in June as ordered. Health shakes were not provided to the resident as ordered until 08/07/24, two months after initially ordered by physician. On 09/25/24 at 11:58 a.m., the ADON stated once we receive the order the nurse on the floor is responsible to put the physician order in to the computer. On 09/25/24 at 12:12 p.m., the dietician returned call and stated that the physician ordered the health shake on 06/03/24, but it was not started until 08/01/24. On 09/27/24 at 9:41 a.m., the administrator and corporate nurse #2 were interviewed and corporate nurse #2 stated that orders should be transcribed to the medication administration record in a timely manner.

Based on observation, record review, and interview, the facility failed to ensure residents were provided supervision to prevent falls and implement interventions to prevent falls for two (#1 and #2) of three sampled residents reviewed for falls. Resident #1 had seven falls without having any interventions in place and sustained a fracture to the face on 05/09/23. Resident #2 had 22 falls in a six month period without changes in fall interventions and sustained hematoma, bruising, and lacerations that required stitches. The DON identified 43 residents who were moderate to high risk for falls. Findings: The facility's Fall Policy, implemented 01/01/23, read in part, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .the nurse will indicate .the resident's fall risk and initiate interventions on the baseline care plan in accordance with the resident's level of risk each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .interventions will be monitored for effectiveness .the plan of care will be revised as needed .when any resident experiences a fall, the facility will .review the resident's care plan and update as indicated . 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, chronic kidney disease, anxiety, chronic pain insomnia, convulsions, fracture of the lower end of left radius and fracture of shaft of humerus left arm. A fall risk assessment, dated 01/28/23, documented the resident was a moderate risk for falls. A base line car plan, dated 01/28/23, did not address the resident was at risk for falls on admission. An admission assessment, dated 02/08/23, documented Resident #1's cognition was severely impaired, and totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The assessment documented the resident was incontinent of bowel and bladder, and no history of falls prior to admission. A fall risk assessment, dated 02/10/23, documented the resident was at moderate risk for falls. Resident #1 admission comprehensive care plan, dated 02/12/23, did not address the resident was a moderate risk for falls. An incident report, dated 03/04/23, at 2:00 p.m., documented Resident #1 was found sitting on the floor in front of their wheel chair and stated they had fell . An incident report, dated 03/04/23, at 11:28 p.m., documented Resident #1 fell from her wheelchair with no injures. A fall risk assessment, dated 03/06/23, documented Resident #1 was at high risk for falls. An incident report, dated 03/17/23, documented staff heard Resident #1 screaming and found them on the floor, floor mat in place, and bed was in the lowest position. A fall risk assessment, dated 03/19/23, documented Resident #1 was a moderate risk for falls. An incident report, dated 03/23/23 at 4:31 a.m., documented staff saw Resident #1 sitting on the floor mat upright on their buttocks. Resident #1 had stated they were trying to go to the bathroom. A fall risk assessment, dated 03/23/23, documented the resident was a high risk for falls. There was no documentation the facility assessed Resident #1's four falls in March and implemented interventions to aide in the prevention of further falls. An incident report, dated 04/14/23 at 10:10 p.m., documented the nurse heard a loud noise and observed Resident #1's upper extremity on the floor mat with the bed in the lowest position. A fall risk assessment, dated 04/15/23 and 04/16/23, documented the resident was a moderate risk for falls. A fall risk assessment, dated 04/19/23 and 04/25/23, documented the resident was a high risk for falls. An incident report, dated 04/30/23 at 8:00 a.m., documented Resident #1 was observed sitting on the floor mat. Resident #1 stated they fell and the report documented the intervention was to educate the resident on the use of call light. Another incident report, dated 04/30/2 at 10:15 a.m., documented a CMA screamed that Resident #1 was on the floor. A fall risk assessment, dated 05/01/23, documented Resident #1 was a high risk for falls. There was no documentation the facility assessed Resident #1's three falls in April to determine the root cause and develop interventions to aide in the prevention of further falls. Resident #1's care plan, dated 05/05/23, read in part, .I have risk for falls because I am unsteady in my walking and balance (and from my fall score assessment). I had an actual fall in the last 30 days - I fell on [DATE] twice; 04/14/23, 03/23/23, 03/17/23 .I have frequent falls because I am forgetful with impaired cognition and unaware of my safety needs .Interventions .Attempt to anticipate and meet my needs .Avoid repositioning furniture in my room .Be sure my call light is within reach and encourage me to use it for assistance as needed. Answer my call light in timely manner .Beveled edge fall mat to floor at bedside .Continue to encourage me to work with physical therapy (PT) to work on my .Keep Call-light within reach and answer in a timely manner .Place my bed in a low position when I am not receiving care .Place non skid pad in my chair .Please review if I need or need a change in adaptive equipment or devices as needed .Review information if I have a fall and attempt to determine cause of fall. Record possible root cause. Alter and remove any potential cause if possible. Educate me, my family/caregivers as to the cause .Staff will continue to anticipate and meet my needs everyday . Resident #1 had seven falls since admission and the care plan, dated 05/05/23, this was the first care plan that addressed the residents falls and risk for falls. A quarterly assessment, dated 05/09/23, documented Resident #1 had two or more falls without injury and one fall with a minor injury. Two fall risks assessments, dated 05/09/23, documented Resident #1 was a high risk for falls. An incident report, dated 05/09/23 at 1:11 a.m., read in part, . resident had an unwitnessed fall in her room .hit the right side of her face, swelling/redness noted to right side of face .resident transferred via stretcher .to ER for eval and treat for facial/head injury . An incident report, dated 05/09/23 at 11:25 a.m., documented Resident #1 had fallen out of their wheelchair onto their buttocks. A nurse's note dated 05/09/23 at 1:54 p.m., read in part, .CNA called this nurse to resident's room that she fell on floor. This nurse immediately entered resident's room and observed her lying on her right side on floor mat .Head to toe assessment done by this nurse. Swollen noted to her upper right cheek .New order to transfer to ER for evaluate and treat as indicated d/t fall with head injury .injury location face . A nurse's note dated 05/09/23 at 6:22 p.m., read in part, .Received report from .Hospital .that resident has fracture of right cheek bone . A nurse's note dated 05/09/23 at 8:28 p.m., read in part, .1955 [7:55 p.m.] returned to facility from .Hospital Discharge instructions received to schedule appointment with .DDS as soon as possible for a visit .Bruise observed to right eye . There was no documentation the facility assessed Resident #1's two fall on 05/09/23 to determine the root cause and develop interventions to aide in the prevention of further falls. An incident report, dated 05/19/23 at 1:55 p.m., documented Resident #1 had an unwitnessed fall due to throwing themselves onto the floor onto the right side. A corresponding nurse's note dated 05/19/23 at 8:49 p.m., read in part, .1355 [1:55 p.m.] Resident was sitting her bed, threw self onto the floor on her right side .Resident stated that she is a vegin, that she is not afraid . A nurse's note dated 05/31/23 at 7:07 p.m., read in part, .Resident f/u charting r/t fall no injuries noted . There was no additional documentation in the clinical record or an incident report regarding Resident #1's fall referenced in the nurse's note. An incident report dated 06/03/23 at 1:25 a.m. documented Resident #1 had a fall in her room, was on all fours and confused. A nurse's note dated 06/03/23 at 1:31 a.m., read in part, .focused charting r/t resident out of bed on the side on all fours resident is confused .this nurse asked why resident is on the ground resident do not know why .resident on using call light . A nurse's note dated 06/08/23 at 8:21 p.m., read in part, .1940 [7:40 p.m.] This nurse observed resident crawling on the floor picking things sister-in-law sitting in the chair in resident's room stated that resident was sitting in her w/c trying to put on her shoes, the w/c went away from her . There was no further documentation of Resident #1's fall from the wheelchair while putting on her shoes. An incident report dated 06/10/23 at 11:45 p.m., documented Resident #1 was on the ground and didn't know what happened. The incident report further documented Resident #1 was sent to ER due to their catheter being pulled out. There was no additional documentation in the clinical record regarding the resident's fall. An incident report dated 06/26/23 at 11:45 p.m., documented Resident #1 had a fall in their room while attempting to go to the bathroom unassisted. A nurse's note dated 06/26/23 at 1:23 p.m., read in part, .CNA called this nurse to resident's room that she fell and on floor .resident lying on floor on her left side in bathroom .therapists said that resident went to bathroom unassisted and unable to get back on w/c by herself .Staff to continue to monitor resident frequently . A nurses note dated 07/04/23 at 11:57 p.m., read in part, .Focused charting r/t fall unwitnessed @ 2357 [11:57 p.m.] this nurse walked by resident room and noticed resident was on the ground on fall mat on left side, bed was at lowest position, this nurse asked resident what happen Res is alert but confused, unable to give description of incident. Head to toe assessment was preformed .there is a c/o pain to left arm 2/10 pain medication was given, this nurse order x ray to left arm order number #2757 . A nurse's note dated 07/05/23 at 12:09 p.m., read in part, .Resident had a x-ray of left forearm done today, results shows forearm demonstrates normal bony ossification . Resident #1 had four falls in the month of June and one on 07/04/23. There was no documentation the facility assessed Resident #1 falls for root cause analysis and reviewed and revised any interventions to aide in the prevention of further falls. On 07/21/23 at 1:58 p.m., Resident #1 was observed up in the wheelchair propelling themselves around their room and out into the hall. There was a mat in the room and the bed was in the lowest position. The resident was asked about their falls and they respond by saying they had to go to the airport. On 07/24/23 at 1:40 p.m., MDS coordinator #1 stated Resident #1 was a moderate risk for falls on admission and there should have been a comprehensive care plan to address the fall risk. The MDS coordinator was asked if the base line care plan should address a newly admit resident with a moderate risk for falls. They stated it should not be addressed on the base line care plan, but the comprehensive care plan should address the fall risk. On 07/25/23 at 8:23 a.m., CNA #1 stated Resident #1 was a fall risk due to attempting to stand and transfer on their own. CNA #1 further stated the resident had fallen one time and had a wound by her eye. The CNA further stated Resident #1 now had a low bed, mat, and a special pillow for their bed to prevent falls. When asked, the CNA was not sure how long the interventions had been in place. On 07/25/23 at 8:40 a.m., LPN #1 stated Resident #1 had a low bed, fall mat, and was at risk of falls. LPN #1 further stated they did not know how long the resident had been at risk for falls and had only been employed for two weeks. On 07/25/23 at 8:52 a.m., CMA #1 stated Resident #1 will have anxiety and get very impulsive and compulsive. CMA #1 stated they did not know if Resident #1 had falls but knew they were at risk because of the low bed a floor mat. CMA #1 further stated they were not aware of any further interventions in place for Resident #1. On 07/25/23 at 10:05 a.m., MDS Coordinator #1 stated Resident #1 was a moderate risk for falls on admission and had her first two falls on 03/04/23. The MDS Coordinator stated the resident had 14 falls since admission and sustained a fracture to the face on one of the falls. The MDS Coordinator was asked when fall interventions were first implemented. The MDS Coordinator stated on 05/05/23 and the care plan should have been developed on admission. On 07/25/23 at 10:57 a.m., the ADON stated they and the DON were responsible for investigating falls and determining the root cause. The ADON further stated the care plan should be reviewed for falls after a fall or when a MDS was completed. The ADON stated Resident #1 was a high risk for falls and had a lot of falls. The ADON further stated the resident had injuries from the falls but not after every fall. The ADON reviewed the care plan and stated Resident #1 should have had a care plan for falls on admission and it should not have taken several months to develop a care plan. On 07/25/23 at 11:34 a.m., the DON stated newly admitted residents that were moderate and high risk for falls should have a care plan developed for falls on admission and with the base line care plan. The DON further stated the post fall assessment would determine the root cause and interventions should be reviewed and implemented as needed. When asked about the root cause analysis for Resident #1 they stated they had not been completed due to not having an employee doing them and now they were not being completed consistently. The DON was made aware of the lack of care plan until May 2023 and they stated Resident #1's care plan was not developed and revised timely. 2. Resident #2 had diagnosis of disorder with seizures, chronic pain, insomnia, asthma, anxiety, dementia with behavioral disturbance, COPD, muscle weakness, and down syndrome, and recurrent depression. A fall risk assessment, dated 12/29/22, documented the resident was a moderate risk for falls. An incident report, dated 01/16/23 at 1:50 p.m., documented Resident #2 had fallen in the dining room and was lying in between the walker with the right side of the walker under his back. Resident #2 sustained a contusion to the back of their head and was sent to the hospital. A hospital emergency report, dated 01/16/23, read in part, .chief complaint .unwitnessed fall is on eliquis .radiology hematoma to posterior scalp .final diagnosis .closed head injury . A fall risk assessment, dated 01/17/23, documented the resident was a high risk for falls. An incident report, dated 01/17/23 at 9:55 a.m., and a nurse's note, at 10:35 a.m., read in part, .This nurse was notified by the housekeeper that the resident was on the floor. Upon arrival this nurse noticed that the resident was laying on his stomach and he was awake and alert to self which is the resident baseline. Head-to-toe assessment done. Resident had a red bruise with abrasion on the middle of his for head and his left nostril was bleeding .Resident does still having bruising to the back middle of his head d/t fall on 1/16/23 . EMSA arrived around 1015 and left around 1030 . An incident report, dated 02/07/23 at 6:00 a.m., documented Resident #2 was in the dining room and was observed trying to get out of the chair and fell . A fall risk assessment, dated 02/07/23, documented Resident #2 was a moderate risk for falls. There was no documentation the facility had assessed the two falls in January and one fall in February for the root cause and reviewed and revised the care plan interventions. A quarterly assessment, dated 02/27/23, documented Resident #2 had a severe cognitive impairment, required extensive assistance from staff for bed mobility, transfers, and toilet use. The assessment documented the resident was always incontinent of bowel and bladder and had two or more falls without injury and one fall with an injury. Resident #2's care plan, reviewed on 02/28/23, documented they were at risk for falls due to socks hanging on their feet causing them to trip and for not using a walker. It also documented the resident refused to wear a helmet. The care plan documented the interventions included the following: Assure I have shoes or non-slip socks on; Attempt to anticipate and meet my needs; Be sure my call light is within reach and encourage me to use it for assistance as needed. Answer my call light in timely manner; Give me verbal reminders to call for assistance when needing to transfer; Give verbal reminders to use my walker; I need a safe environment with keeping my assistive device within reach at all times; I use a walker with tennis balls on back legs; Floors free from spills and/or clutter; Adequate, glare-free light and personal items within reach; Review information if I have a fall and attempt to determine cause of fall and record possible root cause; Alter and remove any potential cause if possible; and Educate me, my family/caregivers as to the cause. All care plan interventions for Resident #2 had been implemented between 2019 and 2021. An incident report, dated 03/25/23 at 5:55 a.m., and a nurse's note, at 6:12 a.m., read in part, .Nurse was sitting at nursing station when resident was heard screaming. Upon going to patients room patient was found sitting on floor with legs crossed beside the bedside table/ nightstand. A wound to side of the head was observed (laceration/deep cut) wound area was assessed and cleaned and bleeding controlled .Order to send to ER for eval and treat . A hospital emergency report, dated 03/25/23, read in part, .assessment .closed head injury .facial laceration laceration repair .location scalp length (cm)3 .repair method .sutures .final diagnosis laceration without foreign body .long term (current) use of anticoagulants .external cause .fall . An incident report, dated 03/29/23 at 12:17 p.m., and a nurse's note, at 12:16 p.m., documented the resident had a witnessed fall with no injuries. Documented intervention was to make sure the resident had on non-skid socks. A fall risk assessment, dated 03/25/23 and 03/29/23, documented Resident #2 was a moderate risk for falls. There was no documentation the facility had assessed the two falls in March for the root cause and reviewed and revised the care plan interventions. An incident report, dated 04/06/23 at 8:00 a.m., and a nurse's note, at 8:08 a.m., read in part, .Res lost his balance in the lounge area while ambulating with walker Res was assisted from floor, non-skid sock put on . A fall risk assessment dated [DATE], documented Resident #2 was a moderate risk for falls. An incident report, dated 04/09/23 at 11:10 a.m., and a nurse's note, at 11:29 a.m., read in part, .walked into PT room to see co Nurse, cleaning up Pt face, fall mat folded in half on floor in front of Pt bed as well as walker lying over on its side .Pt had a cut in middle of forehead and one under right nostril .PT is on blood thinner, could not get bleeding to stop .called 911 and Pt was taken to ER . A hospital emergency report, dated 04/09/23, read in part, .impression .fall .closed head injury .accidental fall .epistaxis [nose bleed] .chief complaint .fall at nursing home .on Eliquis .final diagnosis .injury of head initial encounter .epistaxis .external cause fall . A fall risk assessment, dated 04/09/23, documented Resident #2 was a high risk for falls. An incident report, dated 04/12/23 at 8:20 p.m., documented Resident #2 had an unwitnessed fall in their room and non skid socks had to be placed on their feet. A nurse's note, dated 04/12/23 at 10:29 p.m., read in part, .1930 [7:30 p.m.] CMA found resident sitting on the floor next to bed .Resident was then assisted by this nurse and the CMA to bed. Non-skid sock put on .continues to take off his socks ambulate self with a walker to the dinning room and back to his bed . An incident report, dated 04/14/23 at 7:55 a.m., read in part, .This nurse was notified that res had a fall in the lounge area face down and was bleeding .res unable to articulate .active bleeding stopped .pain 7 [scale of 1:10] . A corresponding nurse's note, dated 04/14/23 at 8:01 a.m., read in part, .This nurse was notified that res was on the floor, face down in the lounge area. Res was assisted to sitting position, active bleeding stopped .Res refused to wear helmet this morning .Res transported via ambulance to .Hospital . A nurse's note, dated 04/14/23 at 8:30 a.m., read in part, .resident's sister and his Responsible party called back asking what happened and what hospital her brother sent to .This nurse told her that resident fell and probably broke his nose because blood coming out of his nose from hitting his head on the floor. That resident is on Eliquis which is a blood thinner with tendency to bleed more. Resident transported to .Medical Center for evaluate and treat as indicated d/t fall with head injury . A hospital emergency report, dated 04/14/23, read in part, .medical decision making problems addressed .closed head injury .epistaxis .has multiple abrasions to his face and I can tell he is had some epistaxis from right nares final diagnosis injuries of head .abrasions of other part of head .epistaxis .cause if injury .fall . An incident report, dated 04/15/23 at 1:22 p.m., documented Resident #2 was sent to the hospital due to a head injury after a fall in their room. A nurse's note, dated 04/15/23 at 1:45 p.m., read in part, .Resident sent out [hospital name withheld] .due to fall with injury to head . A hospital emergency room report, dated 04/15/23, read in part, patient had an unwitnessed fall .patient has approximately 2 inch laceration of left lateral eyebrow patient has existing sutures to above right eyebrow .upon arrival to the ED patient has previous stitches over right eyebrow from another recent fall. Nursing home staff reports to EMS that the patient has frequent falls. He arrives with a bleeding laceration superior to his left eye. The patient takes Eliquis [a blood thinner] .laceration repair .3 cm on the frontal region of head superior to left eyebrow .6 4-0 sutures placed .admission diagnosis .laceration without forgiven body of left eyelid and periocular area external cause of injury .fall . A fall risk assessment, dated 04/15/23, documented Resident #2 was a high risk for falls. A nurse's note, dated 04/18/23 at 9:59 p.m., read in part, .Res refused putting on the helmet during this shift .Res refused to wear non-skid socks . There was no documentation the facility had assessed the five falls, three with injuries in April for the root cause and reviewed and revised the care plan interventions. An incident report, dated 05/12/23 at 8:30 a.m., documented the resident had a non-injury fall in the dining room. A nurse's note, dated 05/12/23 at 9:35 a.m., read in part, .Focused charting r/t fall this nurse was told by staff that resident had a fall in the dining room. This nurse quickly went to dining area and resident was sitting upright in his wheel chair .This nurse told resident next time he needs help just call . An incident report, dated 05/22/23 at 6:30 a.m., documented Resident #2 had an unwitnessed fall in their room and sustained a laceration to the forehead and was transported to the hospital for treatment and evaluation. A nurse's note, dated 05/22/23 at 7:50 a.m., read in part, .CNA reported to this nurse that resident fell in his room. This nurse and another nurse immediately entered resident's room and observed him sitting on floor next to his floor mat. Resident stated that I fell .Head to toe assessment done and a small laceration noted to his forehead .New order to transfer to ER for evaluate and treat as indicated d/t fall with head injury . A hospital emergency report, dated 05/22/23, read in part, .admission diagnosis .injury of head .final diagnosis .abrasion of scalp .cause of injury .fall from bed . A fall risk assessment, dated 05/12/23 and 05/22/23, documented Resident #2 was a moderate risk for falls. There was no documentation the facility had assessed the two falls, one with an injury in May for the root cause and reviewed and revised the care plan interventions. An annual assessment, dated 06/01/23, documented Resident #2 required extensive assistance from staff for bed mobility, transfers,walking and eating. Resident #2 was totally dependent on staff for dressing, toilet use and personal hygiene. An incident report, dated 06/02/23 at 10:18 p.m., documented Resident #2 fell out of the bed and sustained a red mark above the left eyebrow. The documented intervention was to educate resident on using the call light. A nurse note, dated 06/02/23 at 10:22 p.m., read in part, .focused charting r/t fall out of bed this nurse was walking by resident room when this nurse noticed that resident was on the ground this nurse asked resident what happen resident cant not communicate well resident bed was at lowest position fall mat was down this nurse eval resident there were no bruise just red mark above left eyebrow .this nurse educated resident on how to use call light . A fall risk assessment, dated 06/05/23, documented Resident #2 was a high risk for falls. An incident report, dated 06/06/23 at 8:31 a.m., documented Resident #2 had an unwitnessed fall in their room and sustained a hematoma to the left forehead. Resident was transferred to the hospital for evaluation and treatment. A nurse's note, dated 06/06/23 at 9:35 a.m., read in part, .Nurse was called at 8:20 am that resident has fallen, this nurse found resident face down on the floor in resident room. Upon assessment, nurse found hematoma on resident left forehead .Resident could not tell this nurse if he has any pain .EMSA called and resident was transfer .for Evaluation and treatment. An incident report, dated 06/06/23 at 10:13 p.m., documented Resident #2 was found on the floor mat by his bed with no injuries. There were no documented interventions on the incident report or in the clinical record. A hospital emergency report, dated 06/06/23, read in part, .final diagnosis injury of head .cause of injury fall from bed . An incident report, dated 06/14/23 at 12:02 p.m., documented the resident had an unwitnessed fall in their room and the nurse found the resident yelled out in his room. Resident #2 was found lying supine with both legs straight on the floor mat. There were no documented interventions on the incident report or in the clinical record. An incident report, dated 06/19/23 at 2:44 a.m., and a nurse's note, at 3:12 a.m., read in part, .focused charting r/t fall in room this nurse saw resident on the fall mat on right side in front of bed. The bed was at the lowest position .resident has some red marks on face .this nurse educated resident on not getting out of bed and using call light . An incident report, dated 06/21/23 at 11:07 a.m., and a nurse's note, at 11:47 a.m., read in part, .This nurse called to the dinning room that resident has fallen. Nurse found resident lying on his right side with both legs straight . There were no documented interventions on the incident report or in the clinical record. There was no documentation the facility had assessed the five falls, one with an injury in June for the root cause and reviewed and revised the care plan interventions. An incident report, dated 06/26/23 at 12:15 a.m., documented Resident #2 was found on the ground by his dresser and was not able to communicate what had happened. The report documented the resident was sent to the hospital for evaluation and treatment. A hospital emergency report, dated 06/26/23, read in part, .reason for visit contusion of eyeball and orbital tissue left eye final diagnosis .contusion of eyeball and orbital tissue left eye .causes of injury .fall . A fall risk assessment, dated 06/07/23, 06/16/23, 06/19/23, 06/21/23, 06/22/23, and 06/27/23, documented Resident #2 was a moderate risk for falls. Resident #2's care plan, up-dated on 06/28/23, documented the following interventions were implemented: Beveled edge fall mat placed to floor at bedside; Be in view of staff when I am out of bed; Provide encouragement and monitoring helmet is on to decrease risk for head injuries; Keep my bed in a low position; Medication review; Physical therapy to evaluate and treat me as ordered; Restorative and ambulation with walker; Staff to do frequent checks while in bed; Staff to monitor for no-skid footwear; Staff to anticipate and meet needs; and standard fall mat at bedside. The interventions were the first documented since the last review of the care plan on 02/28/23. An incident report, dated 07/15/23 at 11:07 a.m., documented Resident #2 had an unwitnessed fall in the dining room and was bleeding above the left eye. A nurse's note, dated 07/15/23 at 11:07 a.m., read in part, .Resident was sent out this morning, due to a fall in the dining room with injury .was sent out with EMSA .wound above eye was no longer bleeding when he left . There were no documented interventions on the incident report or in the clinical record the facility assessed the fall for the root cause and reviewed and revised interventions. Resident #2 had 22 falls from 01/16/23 through 07/15/23 and the only care plan intervention changes was on 06/28/23. On 07/21/23 at 4:15 p.m., Resident #2 was observed in his bed with a floor mat on the floor and the bed in the lowest position and observed with bruising to their right temple. The resident was asked general questions and would not respond to them. LPN #5 entered the room and stated the resident had a fall in the dining room and was sent to the hospital because he was not responding a few days earlier. The nurse further stated Resident #2 could not ask for help or understand to use the call light. On 07/24/2023 at 3:56 p.m., Resident #2's power of attorney stated the resident had a lot of falls. The power of attorney stated the facility has a fall mat and a helmet but Resident #2 does not like wearing it. The power of attorney stated from what they had been told there was nothing more the facility could do about the falls. The power of attorney stated Resident #2 did not understand to ask for help and why they would need to wear the helmet or use the call light. On 07/25/23 at 8:31 a.m., CNA #1 stated the resident was a fall risk and they did not understand to use the call light and ask for help. CNA #1 stated they had a floor mat next to his bed and a helmet to wear. They stated they did not know of anything else the resident had for fall interventions. On 07/25/23 at 9:13 a.m., CNA #2 stated Resident #2 can not use the call and did not know to call for assistance. CNA #2 stated Resident #2 had fallen at least four times and had stitches or bruises. The CNA stated they needed to make sure the bed was in the low position and have the floor mat next to the bed. The aide further stated Resident #2 had a lot of falls with injuries to his head and stated they did not know of any other interventions the facility was doing to prevent falls. < [TRUNCATED]

A past noncompliance with harm was determined to exist effective 01/12/23 related to the facility's failure to provide correctly administered pain medication. The facility failed to follow their medication administration policy which resulted in a resident being sent to the ER for treatment of Narcan. The resident was sent from the facility 01/12/23 at 8:08 a.m., to the ER and was returned to the facility 01/13/23 at 5:11 p.m. On 01/18/23 at 10:45 a.m., the Oklahoma State Department of Health verified the existence of the past noncompliance with harm related to the improper administration of pain medications to a resident. Based on record review and interview, the facility failed to administer pain medication correctly to one (#1) of three sampled residents who were on a pain management program. The facility reported a resident census of 59. The facility reported 42 residents on a pain management program. Findings: Medication errors policy, read in part, .It is the policy of this facility to provide protections for the health, welfare, and right of each resident by ensuring resident receive care and services safely in an environment free of significant medication errors . Medication administration policy, read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . LPN #3 was hired 05/24/21 and worked nights. Resident #1 admitted to the facility 08/07/21 with diagnoses to include chronic pain syndrome, acute respiratory failure with hypoxia and hypercapnia, shortness of breath, hemiplegia and hemiparesis/cerebrovascular disease affecting left non-dominant side, anxiety, depression, and COPD. A physician order, dated 06/27/22, to monitor O2 sats every shift. The January 2023 MAR documented O2 sats in the 90's with 4 L NC. A care plan, dated, 07/26/22, read in part, .I am resistive to care related to having anxiety and COPD which makes me have air hunger .I will request prn nebulizer 4-6 times per day, then will have manipulative behaviors saying I didn't get the treatments and call EMSA .I refuse my O2 at times and will have manipulative behaviors saying staff did not make O2 available to me .explain to me and/or my representative of the possible outcome or consequences that can occur if I do not comply with care or treatment . A nurses note, dated 01/09/23, read in part, .nurse noticed that the resident had his nasal cannula off each time. This nurse replaced the nasal cannula into the resident nose and educated the resident on the importance of wearing it . A nurses note, dated 01/10/23, read in part, .resident has been seen several times with his nasal cannula out of his nose. This nurse along with the CNA's placed it back on him and educated him on the importance of wearing it . A nurses note, dated 01/12/23 at 8:10 a.m., read in part, .when this nurse went into the resident room this nurse noticed that the resident did not have his nasal cannula on. The resident nasal cannula was on the floor. This nurse replace the nasal cannula. Resident oxygen level was 35%. B/P 87/56, pulse 76. This nurse administered the resident routine inhaler and prn breathing treatment. Resident oxygen level went up to 89-90% (B/P 92/65, pulse 86) with the breathing treatment but a few minutes afterward the resident oxygen level dropped down to 77-78%. Dr (name-deleted) notified and this nurse received an order to send the resident to the ER. EMSA notified. The resident representative (name-deleted) notified and verbalized understanding. EMSA and the fire department arrived and the resident stated that he did not want to go but the EMSA personnel explained to the resident of the importance of him going due to his low oxygen level. Resident left the building at 0808 [8:08 a.m.] . A nurses note, dated 01/12/23 at 11:54 a.m., read in part, .The ER nurse stated that the resident keeps taking off his oxygen and he refuses to get intubated . An incident report, dated 01/12/23, read in part, .notifications made to physician, family, adult protective services and the appropriate licensing board . Fax receipts were included of the notifications to APS and OBN. A medication error report form, dated 01/12/23, read in part, .incident details .occurred at 0438 .Discovered 1300 .by the hospital .Norco .description of error: nurse gave midnight and 0400 dose at the same time .wrong dose, wrong time . Notification of Incident .01/12/23 1330 Dr. (name-deleted) Notified .01/12/23 1340 (name-deleted) pharmacist notified .Results of investigation: nurse (LPN) administered 2 doses (Norco 7.5) at same time . Resident evaluation .resident unresponsive .sent to ER .intervention: Narcan and Narcan drip . Interventions/Corrections implemented: suspension of staff member, med cart audited, chart and record review. LPN (#3) educated on med administration procedures including PIG method, med audits on LPN (#3) x 7 shifts then every other shift x 7 shifts then 2/wk x 60 days . The individual narcotic count sheet, dated 01/12/23, documented a midnight dose and a 0400 dose of Norco 7.5 mg signed out by LPN (#3). The medication administration record, dated 01/12/23, documented the midnight dose and 0400 dose of Norco 7.5 mg being given at the same time through the RN's investigation and medication administration audit report. A written statement by the LPN (#3), dated 01/12/23, read in part, .01/12/23 at midnight dose of Lortab was held due to resident sleeping. Around 4-5 a.m. Lortab was popped out also and took to the resident room. Only 4 a.m. dose was given and 1 wasted the 12 midnight dose in the trash . There was no documentation of a waste. Employee disciplinary counseling action, dated 01/12/23, signed 01/13/23, read in part, .On 01/12/23 employee administered the 0000 and 0400 dose of Norco 7.5 at the same time 0438 to resident (#1). Resident was then found by day shift nurse as having a O2 sat of 35% resulting in resident being transferred via EMSA to the hospital. Hospital stated resident presented with hypercarbic respiratory failure (the level of carbon dioxide is too high usually because something prevents the person from breathing normally) and was given Narcan. Patient currently in ICU on Narcan drip and need for continuous monitoring . Resident #1 returned to the facility the following day, 01/13/23 at 1711. Physician ordered change of Norco from 7.5 mg to 5 mg. A nurses note, dated 01/13/23, read in part, .resident return form (name-deleted) hospital by stretcher van at about 5 p.m. Resident cont to be alert and oriented to time, place and self. No s/s of acute distress .B/P 121/68, HR 66, O2 93% 4 L NC. New order for BMP and to stop Xanax . A printed slide show presentation, controlled substances in long-term care facilities was included in the LPN (#3) training. Controlled substances in Long-term care facilities (quiz) was dated as completed 01/13/23. Medication regimen review, dated 01/13/23 through 01/17/23, as individual entries of RN audits of LPN (#3). Medication administration competencies, dated 01/13/23 through 01/17/23, as individual medication administration evaluations of LPN (#3) by an RN. A fax, dated 01/16/23, read in part, .Oklahoma board of nursing .ODH form 283 .Oklahoma board of nursing verification report . A nurse note, dated 01/16/23 at 0920, read in part, .when this nurse went to give the resident his morning medication this nurse noticed that he resident did not have his nasal cannula on and this placed the nasal cannula back on and educated the resident on the importance of wearing it . A nurses note, dated 01/17/23 at 0831, read in part, .The CNA informed this nurse on rounds that the resident did not have his nasal cannula on and she replaced it back in his nose. When this nurse went to give morning medication to the resident, the resident had his nasal cannula on his forehead. This nurse tried to replace the nasal cannula back in the resident nose. The resident told this nurse no that it is giving him a headache . On 01/17/23 at 3:33 p.m., Resident #2 had no concerns or complaints about receiving medications correctly. At 3:53 p.m., the DON stated (LPN #3) did not waste (narcotic) with anybody. There was no proof (documentation) it was wasted by reviewing the individual narcotic record. The DON stated it looked like both (Norco 7.5 mg midnight dose and 0400 dose) were given at the same time. On 01/18/23 at 12:10 p.m., Resident #1 was observed with head of bed elevated, awake, alert, not wearing O2. LPN #1 attempted to place O2, but resident refused. Resident #1 had no concerns or complaints about receiving medications correctly. At 12:25 p.m., Resident #3 had no concerns or complaints about receiving medications correctly. At 1:25 p.m., records were reviewed with the DON. Completed documentation was provided as evidence past non-compliance had been corrected and LPN (#3) would continue to be monitored.

Based on interview and record review, it was determined the facility failed to ensure pharmacy procedures were in place to provide pain medication in a timely manner for one (#176) of two sampled residents who were reviewed for pain management. Resident #176 was in the facility for more than 16 hours in severe pain before she received the ordered pain medication. The facility failed to utilize an emergency pharmacy service upon admission when the resident rated her pain a seven on a scale from zero to ten. The facility identified 67 residents who received pain medication. Findings: A Pain Assessment and Management policy, revised 10/2010, documented, .Purpose .to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . General Guidelines .based on a facility-wide commitment to resident comfort . Steps in the Procedure .Implement the medication regimen as ordered . A Provider Pharmacy Requirements policy, dated 11/2018, documented, .Procedures .Providing .emergency pharmacy service 24 hours per day, seven days per week .Emergency or stat medications are available for administration no more than 4 hour(s) after the order is received by the pharmacy .(pharmacy name deleted) .hours .24/7 . Resident #176 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Evaluation, dated 03/12/19 at 6:00 p.m., documented, .Arrival time: 1800 (6:00 p.m.) .Sleep Pattern .Do you have any difficulty sleeping? no .Pain .Numeric Rating Scale (00-10) 7 .Verbal Descriptor Scale .Severe .Location left hip .When did the pain begin? Resident stated that she is in pain all the time .Describe the pain: aching .What alleviates the pain? Pain medication help .Pain Management .Prior to admission, was resident on a scheduled pain medication regimen? .Yes .Prior to admission, was resident receiving prn pain medications? .Yes . A physician's orders [REDACTED]. The resident's baseline care plan, dated 03/13/19, documented, .Focus .I broke my leg and had surgery .Goal .return home in the next 30 days .Interventions .Give me my medications as per orders-see MAR for my frequency and dosage . Review of the clinical record from 03/12/19 at 6:00 p.m. through 03/13/19 at 10:34 a.m., did not include documentation the resident had received pain medication. There was no documentation related to the resident's pain description after the admission assessment on 03/12/19 at 6:00 p.m. A pharmacy packing slip, dated 03/13/19, documented the facility had received [MEDICATION NAME] 10/325 mg 18 tablets. A Controlled Drug Record, dated 03/13/19 at 10:35 a.m., documented the resident had received the first dose of [MEDICATION NAME] 10/325 mg. On 03/25/19 at 11:44 a.m., the resident was asked if her pain was managed. She stated she had been admitted on [DATE] at 6:00 p.m. She stated she had not received her [MEDICATION NAME] until the next day at 10:00 a.m. She was asked how it made her feel to wait that long for her pain medication. She stated, Neglected, like they weren't prepared for me, lonely. She stated her pain in her left hip was rated a 10 upon admission and it remained a 10 until she received her first dose of [MEDICATION NAME]. The resident was asked what she had done when her pain was severe. She stated, I moaned and groaned and got up in my wheelchair, anything to distract me. She stated she placed a washcloth on her face and neck constantly. She stated, It was terrible, the worst day of my entire life. The resident was asked if the staff had administered any kind of pain medication before the first dose of [MEDICATION NAME] on 03/13/19. She stated she thought they had administered [MEDICATION NAME]. She stated, It didn't begin to knock it off, the pain was over the top and I got anxious and tensed up. She stated she had cried and screamed and got on (social media site name deleted) and complained. The resident was asked what the staff had done for her pain. She stated, They kept reassuring me it (pain medication) would be here in an hour. I felt like I was lied to. She stated one of the nurses finally explained to her that they had a new pharmacy and they only delivered medication once a day. She stated she had not slept at all that night. On 03/28/19 at 8:54 a.m., LPN #1 was asked when they became aware of new admissions who were referred by the hospital. She stated sometimes they knew right before the resident arrived and sometimes they knew days in advance. She was asked how they prepared for a resident who required pain medication. She stated they made sure they received the hard script for the pain medication upon admission and that the resident received a dose of the pain medication just before they left the hospital because they did not have an in-house pharmacy. She stated they called their pharmacy upon admission and asked them to get the pain medication to the facility stat. LPN #1 was asked when the resident was admitted to the facility. She stated on (MONTH) 12th. She was asked what her pain rating was when she was admitted . She stated it was documented the resident had rated her pain a seven on 03/12/19 at 6:00 p.m. and pain medication helped her pain. She was asked what the nurse had done in response to a pain rating of seven. She stated, It doesn't say in the nurse's notes or admission assessment what we did. LPN #1 was asked when the resident had received the first dose of pain medication. She stated the facility had received the [MEDICATION NAME] from the pharmacy on 03/13/19. She stated the first dose of [MEDICATION NAME] documented on the narcotic count sheet was on 03/13/19 at 10:35 a.m. At 9:17 a.m., the DON was asked when the resident had received the first dose of pain medication. She stated on 03/13/19 at 10:35 a.m. She was asked why the resident had not received pain mediation when she rated her pain a seven upon admission on 03/12/19 at 6:00 p.m. She stated the pharmacy had not delivered the medication that evening, so the resident did not have her pain medication. The DON stated the staff had called the DON on 03/13/19 at 2:00 a.m. to alert her to the situation. She stated she had arrived to the facility at 7:15 a.m. and they called the pharmacy. She stated, I talked to the pharmacy myself and they said they were sending it out stat. She stated the pharmacy was located way up by Tulsa. She stated the medications had arrived at the facility at 10:15 a.m. The DON was asked what the resident's condition was during the night related to pain. She stated the resident was hurting through the night and they did not have her pain medication in. She stated, They gave her [MEDICATION NAME]. The DON was asked if they were made aware of a resident's need for pain medication before they were admitted from the hospital. She stated, I tell the staff to make sure the resident is medicated before they come because this pharmacy takes at least one and a half hours to get here. She stated their pharmacy only made one run a day at about 10:30 p.m. She stated the staff had faxed the orders to the pharmacy upon admission, but they had not called the pharmacy to make sure they delivered the medications that night. The DON was asked what they did in an emergency situation if a resident needed a medication. She stated, We have no solution, the pharmacy had already made a run and (pharmacy name deleted) was already closed. She stated all they could have done was prevent it from happening. The DON was asked what their policy was for receiving stat medications. She stated they were supposed to receive stat medications within two hours. She stated, This stat order was not done until the next morning (03/13/19). She was asked why a local pharmacy had not been utilized. She stated, I have no clue. She stated when the medication was not here at 10:30 p.m., the nurse should have called the pharmacy. She stated the staff had called her all through the night. The DON was asked if the staff was responsible to get the pain medication for the resident in a timely manner to ensure optimal pain management. She stated, Yes, it was a delay in treatment. She suffered throughout the night. At 10:11 a.m., the administrator was asked for their contract or letter of agreement related to emergency pharmacy services. A contract or letter of agreement related to emergency pharmacy services was not provided.

Based on interview and record review, it was determined the facility failed to ensure pain management was provided in a timely manner for one (#176) of two sampled residents who were reviewed for pain management. Resident #176 was in the facility for more than 16 hours in severe pain before she received the ordered pain medication. The facility failed to utilize an emergency pharmacy service upon admission when the resident rated her pain a seven on a scale from zero to ten. The facility identified 67 residents who received pain medication. Findings: A Pain Assessment and Management policy, revised 10/2010, documented, .Purpose .to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . General Guidelines .based on a facility-wide commitment to resident comfort . Steps in the Procedure .Implement the medication regimen as ordered . A Provider Pharmacy Requirements policy, dated 11/2018, documented, .Procedures .Providing .emergency pharmacy service 24 hours per day, seven days per week .Emergency or stat medications are available for administration no more than 4 hour(s) after the order is received by the pharmacy .(pharmacy name deleted) .hours .24/7 . Resident #176 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Evaluation, dated 03/12/19 at 6:00 p.m., documented, .Arrival time: 1800 (6:00 p.m.) .Sleep Pattern .Do you have any difficulty sleeping? no .Pain .Numeric Rating Scale (00-10) 7 .Verbal Descriptor Scale .Severe .Location left hip .When did the pain begin? Resident stated that she is in pain all the time .Describe the pain: aching .What alleviates the pain? Pain medication help .Pain Management .Prior to admission, was resident on a scheduled pain medication regimen? .Yes .Prior to admission, was resident receiving prn pain medications? .Yes . A physician's orders [REDACTED]. The resident's baseline care plan, dated 03/13/19, documented, .Focus .I broke my leg and had surgery .Goal .return home in the next 30 days .Interventions .Give me my medications as per orders-see MAR for my frequency and dosage . Review of the clinical record from 03/12/19 at 6:00 p.m. through 03/13/19 at 10:34 a.m., did not include documentation the resident had received pain medication. There was no documentation related to the resident's pain description after the admission assessment on 03/12/19 at 6:00 p.m. A pharmacy packing slip, dated 03/13/19, documented the facility had received [MEDICATION NAME] 10/325 mg 18 tablets. A Controlled Drug Record, dated 03/13/19 at 10:35 a.m., documented the resident had received the first dose of [MEDICATION NAME] 10/325 mg. On 03/25/19 at 11:44 a.m., the resident was asked if her pain was managed. She stated she had been admitted on [DATE] at 6:00 p.m. She stated she had not received her [MEDICATION NAME] until the next day at 10:00 a.m. She was asked how it made her feel to wait that long for her pain medication. She stated, Neglected, like they weren't prepared for me, lonely. She stated her pain in her left hip was rated a 10 upon admission and it remained a 10 until she received her first dose of [MEDICATION NAME]. The resident was asked what she had done when her pain was severe. She stated, I moaned and groaned and got up in my wheelchair, anything to distract me. She stated she placed a washcloth on her face and neck constantly. She stated, It was terrible, the worst day of my entire life. The resident was asked if the staff had administered any kind of pain medication before the first dose of [MEDICATION NAME] on 03/13/19. She stated she thought they had administered [MEDICATION NAME]. She stated, It didn't begin to knock it off, the pain was over the top and I got anxious and tensed up. She stated she had cried and screamed and got on (social media site name deleted) and complained. The resident was asked what the staff had done for her pain. She stated, They kept reassuring me it (pain medication) would be here in an hour. I felt like I was lied to. She stated one of the nurses finally explained to her that they had a new pharmacy and they only delivered medication once a day. She stated she had not slept at all that night. On 03/28/19 at 8:54 a.m., LPN #1 was asked when they became aware of new admissions who were referred by the hospital. She stated sometimes they knew right before the resident arrived and sometimes they knew days in advance. She was asked how they prepared for a resident who required pain medication. She stated they made sure they received the hard script for the pain medication upon admission and that the resident received a dose of the pain medication just before they left the hospital because they did not have an in-house pharmacy. She stated they called their pharmacy upon admission and asked them to get the pain medication to the facility stat. LPN #1 was asked when the resident was admitted to the facility. She stated on (MONTH) 12th. She was asked what her pain rating was when she was admitted . She stated it was documented the resident had rated her pain a seven on 03/12/19 at 6:00 p.m. and pain medication helped her pain. She was asked what the nurse had done in response to a pain rating of seven. She stated, It doesn't say in the nurse's notes or admission assessment what we did. LPN #1 was asked when the resident had received the first dose of pain medication. She stated the facility had received the [MEDICATION NAME] from the pharmacy on 03/13/19. She stated the first dose of [MEDICATION NAME] documented on the narcotic count sheet was on 03/13/19 at 10:35 a.m. At 9:17 a.m., the DON was asked when the resident had received the first dose of pain medication. She stated on 03/13/19 at 10:35 a.m. She was asked why the resident had not received pain mediation when she rated her pain a seven upon admission on 03/12/19 at 6:00 p.m. She stated the pharmacy had not delivered the medication that evening, so the resident did not have her pain medication. The DON stated the staff had called the DON on 03/13/19 at 2:00 a.m. to alert her to the situation. She stated she had arrived to the facility at 7:15 a.m. and they called the pharmacy. She stated, I talked to the pharmacy myself and they said they were sending it out stat. She stated the pharmacy was located way up by Tulsa. She stated the medications had arrived at the facility at 10:15 a.m. The DON was asked what the resident's condition was during the night related to pain. She stated the resident was hurting through the night and they did not have her pain medication in. She stated, They gave her [MEDICATION NAME]. The DON was asked if they were made aware of a resident's need for pain medication before they were admitted from the hospital. She stated, I tell the staff to make sure the resident is medicated before they come because this pharmacy takes at least one and a half hours to get here. She stated their pharmacy only made one run a day at about 10:30 p.m. She stated the staff had faxed the orders to the pharmacy upon admission, but they had not called the pharmacy to make sure they delivered the medications that night. The DON was asked what they did in an emergency situation if a resident needed a medication. She stated, We have no solution, the pharmacy had already made a run and (pharmacy name deleted) was already closed. She stated all they could have done was prevent it from happening. The DON was asked what their policy was for receiving stat medications. She stated they were supposed to receive stat medications within two hours. She stated, This stat order was not done until the next morning (03/13/19). She was asked why a local pharmacy had not been utilized. She stated, I have no clue. She stated when the medication was not here at 10:30 p.m., the nurse should have called the pharmacy. She stated the staff had called her all through the night. The DON was asked if the staff was responsible to get the pain medication for the resident in a timely manner to ensure optimal pain management. She stated, Yes, it was a delay in treatment. She suffered throughout the night. At 10:11 a.m., the administrator was asked for their contract or letter of agreement related to emergency pharmacy services. A contract or letter of agreement related to emergency pharmacy services was not provided.

Based on interview and record review, it was determined the facility failed to ensure residents were treated with dignity and respect for two (#23 and #176) of three sampled residents who were reviewed for dignity and respect. Resident #176 was in the facility for more than 16 hours in severe pain before she received the ordered pain medication. The facility failed to utilize an emergency pharmacy service upon admission when the resident rated her pain a seven on a scale from zero to ten. The resident stated she felt neglected, like they weren't prepared for me, lonely. The facility identified 78 residents who resided in the facility. Findings: 1. Resident #176 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Evaluation, dated 03/12/19 at 6:00 p.m., documented, .Arrival time: 1800 (6:00 p.m.) .Sleep Pattern .Do you have any difficulty sleeping? no .Pain .Numeric Rating Scale (00-10) 7 .Verbal Descriptor Scale .Severe .Location left hip .When did the pain begin? Resident stated that she is in pain all the time .Describe the pain: aching .What alleviates the pain? Pain medication help .Pain Management .Prior to admission, was resident on a scheduled pain medication regimen? .Yes .Prior to admission, was resident receiving prn pain medications? .Yes . A physician's orders [REDACTED]. The resident's baseline care plan, dated 03/13/19, documented, .Focus .I broke my leg and had surgery .Goal .return home in the next 30 days .Interventions .Give me my medications as per orders-see MAR for my frequency and dosage . Review of the clinical record from 03/12/19 at 6:00 p.m. through 03/13/19 at 10:34 a.m., did not include documentation the resident had received pain medication. There was no documentation related to the resident's pain description after the admission assessment on 03/12/19 at 6:00 p.m. A pharmacy packing slip, dated 03/13/19, documented the facility had received [MEDICATION NAME] 10/325 mg 18 tablets. A Controlled Drug Record, dated 03/13/19 at 10:35 a.m., documented the resident had received the first dose of [MEDICATION NAME] 10/325 mg. On 03/25/19 at 11:44 a.m., the resident was asked if her pain was managed. She stated she had been admitted on [DATE] at 6:00 p.m. She stated she had not received her [MEDICATION NAME] until the next day at 10:00 a.m. She was asked how it made her feel to wait that long for her pain medication. She stated, Neglected, like they weren't prepared for me, lonely. She stated her pain in her left hip was rated a 10 upon admission and it remained a 10 until she received her first dose of [MEDICATION NAME]. The resident was asked what she had done when her pain was severe. She stated, I moaned and groaned and got up in my wheelchair, anything to distract me. She stated she placed a washcloth on her face and neck constantly. She stated, It was terrible, the worst day of my entire life. The resident was asked if the staff had administered any kind of pain medication before the first dose of [MEDICATION NAME] on 03/13/19. She stated she thought they had administered [MEDICATION NAME]. She stated, It didn't begin to knock it off, the pain was over the top and I got anxious and tensed up. She stated she had cried and screamed and got on (social media site name deleted) and complained. The resident was asked what the staff had done for her pain. She stated, They kept reassuring me it (pain medication) would be here in an hour. I felt like I was lied to. She stated one of the nurses finally explained to her that they had a new pharmacy and they only delivered medication once a day. She stated she had not slept at all that night. On 03/28/19 at 8:54 a.m., LPN #1 was asked when they became aware of new admissions who were referred by the hospital. She stated sometimes they knew right before the resident arrived and sometimes they knew days in advance. She was asked how they prepared for a resident who required pain medication. She stated they made sure they received the hard script for the pain medication upon admission and that the resident received a dose of the pain medication just before they left the hospital because they did not have an in-house pharmacy. She stated they called their pharmacy upon admission and asked them to get the pain medication to the facility stat. LPN #1 was asked when the resident was admitted to the facility. She stated on (MONTH) 12th. She was asked what her pain rating was when she was admitted . She stated it was documented the resident had rated her pain a seven on 03/12/19 at 6:00 p.m. and pain medication helped her pain. She was asked what the nurse had done in response to a pain rating of seven. She stated, It doesn't say in the nurse's notes or admission assessment what we did. LPN #1 was asked when the resident had received the first dose of pain medication. She stated the facility had received the [MEDICATION NAME] from the pharmacy on 03/13/19. She stated the first dose of [MEDICATION NAME] documented on the narcotic count sheet was on 03/13/19 at 10:35 a.m. At 9:17 a.m., the DON was asked when the resident had received the first dose of pain medication. She stated on 03/13/19 at 10:35 a.m. She was asked why the resident had not received pain mediation when she rated her pain a seven upon admission on 03/12/19 at 6:00 p.m. She stated the pharmacy had not delivered the medication that evening, so the resident did not have her pain medication. The DON stated the staff had called the DON on 03/13/19 at 2:00 a.m. to alert her to the situation. She stated she had arrived to the facility at 7:15 a.m. and they called the pharmacy. She stated, I talked to the pharmacy myself and they said they were sending it out stat. She stated the pharmacy was located way up by Tulsa. She stated the medications had arrived at the facility at 10:15 a.m. The DON was asked what the resident's condition was during the night related to pain. She stated the resident was hurting through the night and they did not have her pain medication in. She stated, They gave her [MEDICATION NAME]. The DON was asked if they were made aware of a resident's need for pain medication before they were admitted from the hospital. She stated, I tell the staff to make sure the resident is medicated before they come because this pharmacy takes at least one and a half hours to get here. She stated their pharmacy only made one run a day at about 10:30 p.m. She stated the staff had faxed the orders to the pharmacy upon admission, but they had not called the pharmacy to make sure they delivered the medications that night. The DON was asked what they did in an emergency situation if a resident needed a medication. She stated, We have no solution, the pharmacy had already made a run and (pharmacy name deleted) was already closed. She stated all they could have done was prevent it from happening. The DON was asked what their policy was for receiving stat medications. She stated they were supposed to receive stat medications within two hours. She stated, This stat order was not done until the next morning (03/13/19). She was asked why a local pharmacy had not been utilized. She stated, I have no clue. She stated when the medication was not here at 10:30 p.m., the nurse should have called the pharmacy. She stated the staff had called her all through the night. The DON was asked if the staff was responsible to get the pain medication for the resident in a timely manner to ensure optimal pain management. She stated, Yes, it was a delay in treatment. She suffered throughout the night. At 10:24 a.m., the DON was asked if the staff had treated the resident with dignity and respect related to pain management. She stated, No. 2. Resident #23 had [DIAGNOSES REDACTED]. An annual assessment, dated 01/01/19, documented the resident was independent in cognitive skills for daily decision making. He required extensive assistance of one person for toileting and hygiene. He was always incontinent of bowel and bladder. On 03/25/19 at 4:50 a.m., a strong smell of urine was detected upon entrance to the facility. At 5:01 a.m., the resident's bed linen was observed to be soaked with urine. The area was approximately 3' x 4', extending from one side to the other and from the mid-back area down to the knee level area. The outer edges of the area was dried approximately 1 around the circumference. A strong smell of urine was detected in the room and outside the room in the hallway. The resident was not observed in the room. CNA #1 was asked why the bed was wet. She stated she had just seen the resident outside his room. She was asked if the urine was dried around the edges. She stated, Yes. She was asked if the resident required assistance with incontinent care. She stated, Yes. CNA #1 removed the wet linen. She did not wipe down the mattress. At 5:40 a.m., CNA #1 was observed in the hallway talking to the resident outside his room. She stated, We need to change you. At 5:42 a.m., CNA #1 was observed in the resident's room with gloves on. The room had a strong smell of urine. The CNA removed the resident's shirt and put on a clean shirt. She did not wash the resident's back. She laid a pair of clean pants, a clean brief, and clean wipes on the mattress (it had not been wiped down since the wet linen had been removed at 5:01 a.m.). She removed the resident's brief. The resident's brief was observed to be saturated with dark colored urine. She put a clean brief and pants on the resident. She did not wipe the mattress down. She then put a clean sheet and disposable pad on the bed. CNA #1 did not change her gloves between cleaning the resident of urine and applying the clean brief and pad. She did not wipe the mattress down after it was observed to be saturated with urine. At 6:22 a.m., CNA #1 was asked how often they provided incontinent care. She stated every two hours and as needed. CNA #1 was asked why the resident's bed and brief was saturated at 5:01 a.m. She stated the resident had been asleep when she arrived at 10:00 p.m. She stated he had went to the vending machine at 1:00 a.m. and he told her she could change him later. He went back to bed and when she checked on him at 2 a.m. he was not like that. She stated she checked him and he was not saturated, so she let him go back to sleep. She stated, Right before you came he was going back to vending and he said I could do it when he came back. CNA #1 was asked what the condition of his brief and clothing were at 5:01 a.m. She stated his brief was saturated and his pants were wet. She was asked if his bed was saturated. She stated, Yes. She was asked why the brief was dark-colored. She stated, His urine is dark because he would rather drink coca-cola than water. CNA #1 was asked if she had cleaned the mattress after it was observed to be saturated. She stated, No. She was asked if she should have cleaned the mattress. She stated, Yes. She was asked if she was aware she had placed the clean items on the dirty mattress. She stated, Yes, it was my nerves. At 8:02 a.m., a strong smell of urine was detected in the hallway outside the resident's room. At 12:22 p.m., a strong smell of urine was detected in the resident's room. The resident was asked what the strong odor was from. He stated, I don't know. It always smells in here. He was asked if the odor bothered him. He stated, Yes. He was asked if the staff assisted him to change his brief and clothes. He stated, Every once in a while. He was asked how it made him feel to be sitting in a saturated brief. He stated, It makes me want to go home, I can do a better job. He was asked how often his brief was as wet as it was early that morning. He stated one to two times per day. On 03/28/19 at 11:01 a.m., the DON was asked if the resident required assistance with incontinent care. She stated, Yes. She was asked what the staff should do when a resident's mattress is soaked with urine. She stated they should sanitize the mattress and not let the resident back in bed. She stated they could have housekeeping clean the bed and if it was not cleanable, they should change out the mattress.

Based on interview and record review, it was determined the facility failed to provide supervision to prevent falls and implement new interventions to prevent further falls for two (#1 and #2) of three sampled residents who were reviewed for falls. Resident #1 had two falls in two days and sustained a fractured arm, a laceration to her nose that required seven sutures to close, and two closed head injuries. The facility identified 26 residents as being at risk for falls. Findings: 1. An incident report, dated 09/04/18, documented resident #1 had a fall on a previous admission to the facility. Resident #1 was re-admitted to the facility on [DATE] for respite care, with [DIAGNOSES REDACTED]. A baseline care plan, dated 10/24/18, documented the resident had a history of [REDACTED].no major injuries R/t fall x 5 days . No interventions were documented. A nurse's note, dated 10/25/18 at 5:41 p.m., documented the resident fell out of her wheel chair onto the floor in the facility's lobby at 3:15 p.m. that day. The note documented the resident was bleeding from an abrasion on her right forehead. The note documented the resident had been sent to the emergency room for evaluation at 3:30 p.m. An Emergency Department Provider Note, dated 10/25/18 at 5:42 p.m., documented: .Assessment 1. Closed head injury without concussion 2. Neck sprain 3. Proximal humeral fracture . Patient presents with Fall Witnessed fall from w/c, hit head and right arm on floor . She states her head hurts. She is complaining of some mild neck pain . A contusion is noted to the right shoulder .She has a contusion to her right scalp .A right shoulder x-ray was also obtained .She will receive a shoulder imobilizer placed by the nurse to the right arm. We will give closed head injury precautions to the nursing home . Exam: XR Shoulder .Findings:Three views of the right shoulder are provided .There is a nondisplaced [MEDICAL CONDITION] humerus . Exam: Ct Head .A right frontal scalp hematoma is prestent . A nurse's note, dated 10/25/18 at 11:46 p.m., documented the resident returned to the facility at 8:15 p.m., with [DIAGNOSES REDACTED]. No documentation was found that fall prevention interventions had been implemented. A nurse's note, dated 10/25/18 at 11:46 p.m., documented at 9:00 p.m. .Hospice nurse here, assessed resident. Will continue to monitor . No documentation was found that fall prevention interventions had been implemented. A physician's orders [REDACTED]. An OSDH Protective Health Services Initial Incident Report, faxed to OSDH on 10/26/18 at 1:08 p.m., documented, on 10/25/2018 at approximately 1750 (5:50 p.m.), resident was observed on the floor .bleeding noted on the right side of residents forehead related to abrasion, .Resident sent to ER for further evaluation .Upon return from hospital, resident had sling to right arm related to fracture to right humerous from fall . There was no documentation of fall interventions. A Resident Incident Report, faxed to OSDH on 10/26/18 at 11:31 a.m., documented, pt was on the floor and had blood on her nose from a cut. Pt also had a large hematoma on her forehead. I had received report this morning and nurse stated pt had went to hospital last night 10/25/2018 for a fall and hurt her right shoulder and had a bump on her forehead .hematoma on center of forehead. Notes stated forhead (sic) injury last night but after speaking with (name deleted) he stated that the one from last nigth (sic) was on the right side. This was on the center. Large tennis ball size bruised . The note documented the resident had been sent to the ER for evaluation. An Emergency Department Provider Note, dated 10/26/18 at 11:35 a.m., documented: .Assessment 1. Closed head injury 2. Laceration of nose 3. Contusion of nose . 4. Skin tear of right upper arm without complication . 5. Frequent falls . Patient presents with Fall from bed at NH, pt has lac to nose . Patient is an [AGE] year-old female who presents to the emergency department via EMS after a fall. Patient was seen here yesterday for a seperate fall. Patient again hit her head during the fall .Patient had anterior forehead bruising from yesterday however EMS reports the contusion of the bridge of the nose is noted today . Review of Systems . Skin: Hematoma of anterior forehead, new contusion with laceration of the bridge of the nose, right shoulder skin tear . Physical Exam .large hematoma of the forehead, contusion and small laceration of the bridge of the nose . Procedures Laceration Repair .location: bridge of nose. Length (cm): 3 Depth (mm): 2 .Number of sutures: 7 . An OSDH Protective Health Services Incident Report initial report, faxed to OSDH on 10/26/18 at 1:10 p.m., for the fall on 10/26/18,documented, .on 10/26/18 at approximately 1145 (11:45 a.m.), the CNA was in the room about to transfer resident out of her wheelchair, the CNA turned his back and resident fell out of chair. Focus assessment completed and bleeding noted to right ear related to abrasion, first aide (sic) performed, hematoma noted to forehead related to previous fall . ROM WNL,neuro checks initiated .Resident sent to ER for further evaluation per physician order [REDACTED]. An OSDH Protective Health Services Incident Report final report, faxed to OSDH on 11/05/18, for the fall on 10/25/18, documented, .the facility completed an initial investigation, by interviewing staff members, completing a focus assessment, footwear, incident history from previous admissions, and environmental chart and record review .Upon completion of investigation the facility determine (sic) the resident leaned forward and slid out chair on to the floor resulting in an abrasion to the right side of the resident's forehead. Resident sent to ER for further evaluation per physician order. Resident returned to facility at (YEAR) (8:15 p.m.) with sling to right arm related right humerus fracture. Family and physician notified of fracture and a closed head injury, no new orders from hospital related to fracture or closed head injury .The facility added a non slid pad for wheelchair to residents plan of care, closed head injury precautions, fracture precautions to residents plan of care. Resident discharge from facility on 10/26/18 . A non slid pad for the wheelchair, closed head injury precautions, and fracture precautions had not been added to the resident's care plan. On 11/13/18 at 12:40 p.m., the DON provided a copy of the final OSDH Protective Health Services Incident Report form, for the 10/26/18 incident, which she stated she had faxed that day. An OSDH Protective Health Services Incident Report final report, faxed to OSDH on 11/13/18, for the fall on 10/26/18, documented, .Amend: on 10/26/2018 at approximately 1145, the CNA was in the room about to transfer resident our of her bed, the CNA turned his back and resident slid off of bed .The facility completed an initial investigation by interviewing staff involved .and by completed (sic) a focused assessment on the resident, footwear and incident history. Focus assessment abrasion to ear and nose, first aide performed. Hematoma noted to forehead related to previous falls. ROM WNL except right humerus related to fracture with sling in place from previous fall on 10/25/2018 .Resident sent to ER .Upon completion of investigation the facility determined the CNA was transferring the resident from the bed to the chair, when the CNA turned to get the chair the resident slid out of bed .Resident did not return to facility . No fall interventions were identified. At 3:12 p.m., the DON was asked for documentation of an investigation of resident #1's fall on 10/25/18. She stated the only documentation was on the state report and the nurse's note. The DON was asked if any interventions had been documented on the resident's care plan following the fall on 10/25/18. She stated No, only on the state reportable form. On 11/15/18 at 9:56 a.m. the DON was asked who was responsible for investigating falls. She stated she did not have a designated person for that. She stated she tried to follow up on falls. She stated they discussed falls in the clinical meeting. The DON was asked if the resident had a history of [REDACTED]. She was asked if the resident had fallen during a previous admission. She stated, Yes. The DON was asked if interventions for fall prevention were documented on the resident's baseline care plan. She stated, No. She was asked if after the resident's first fall on 10/25/18, any interventions were documented in the care plan. She stated, No. The DON was asked if there was documentation of an investigation of the falls on 10/25/18 and/or 10/26/18 regarding root causes. She stated, No. The DON was asked if standards of care had been followed. She stated, No. 2. Resident #2 was admitted with [DIAGNOSES REDACTED]. The care plan, dated 09/05/17, documented the resident required assistance for safe completion of all ADLs including toileting. A Grievance Decision Report form, dated 10/17/18, documented, .Res stated CNA .told her when he finish (sic) rounding on her roommate and the room next door he would come back and take her to the restroom and he did not return and she tried to take herself and fell . There was no documentation in the resident's record regarding the incident and there was no incident report documented. A handwritten document by CNA #5, dated 10/17/18, documented, .On Saturday night, I helped (resident #2) to the bathroom two times that night and around 5:45 am when I was doing my rounds, she asked me to take her to the bathroom again and I told her I will come take her once I finished changing her roommate and the last two people. When I trashed the garbage from the hall I forgot going back into her room . On 11/13/18 at 2:35 p.m., resident #2 was asked if she had had a fall recently. She stated, yes on the 22nd of last month. She stated she had pushed her call light but no one came so she got up and was going to go by herself to the bathroom and she slid off the bed. She stated I yelled help and four people came. She stated she didn't know how long it was after she pressed the call light, but it was a long time. She stated that's why she tried to get up herself. On 11/15/18 at 10:10 a.m., the DON was was asked to review the nurse's notes for 10/17/18. She was asked if there was documentation resident #2 had fallen that day. She stated, No. The DON was shown the Grievance Decision Report form, dated 10/17/18, and was asked if the form documented a fall. She stated, Yes. She was asked if an incident report had been completed regarding the fall. She stated, No. The DON was asked if on the day of the fall any staff had responded to a fall for the resident. She stated yes, two CNAs and two nurses. She was asked if any of the staff reported the fall to her. She stated, No. The DON was asked if any of the staff that had responded to the fall had documented the fall in a nurse's note or on an incident report. She stated, No. She stated she did not know if the staff had considered it a fall since she slid to the ground, however, they still should have reported and made a nurse's note about it. The DON was asked when resident #2 had reported the fall to her. She stated on 10/18/18 after the grievance report was completed. She stated the grievance report was made on 10/17/18 but the report had not been completed until 10/18/18. The DON stated the Social Worker had spoken to resident #2 on 10/18/18 and found out about the fall and reported it to the DON. She stated she had re-interviewed the resident and discovered the information about the fall. The DON was asked if she had completed an incident report. She stated, No, sir. The DON was asked if the standard of care had been met for the resident. She stated, No. At 10:42 a.m., the DON was asked what kind of training and monitoring of facility staff was done in regard to falls and fall prevention. She stated, I've done an inservice a while back on falls and documentation and reporting. The DON was asked if the inservice included training on fall prevention and supervision to decrease the risk of falls. She stated, No. She was asked if the facility did training on falls for new employees. She stated, No, nothing formal.

On 04/04/17 at 10:50 a.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma Stated Department of Health (OSDH) regarding the facilities failure to provide the necessary treatments and services to promote the healing of pressure ulcers. The facility failed to provide timely and adequate assessment and monitoring of a resident's pressure ulcers. The facility failed to provide the physician's orders [REDACTED]. At 1:10 p.m., the administrator and the DON were informed of the IJ situation related to the facility's failure to provide timely and adequate assessment and monitoring of a resident's pressure ulcers, and the facility's failure to provide the physician's orders [REDACTED]. At 5:45 p.m., the administrator provided the surveyor with an acceptable plan of removal (POR). The plan of removal documented the following: Windsor Hills Nursing and Rehabilitation Plan of Removal of IMMEDIATE JEOPARDY On 04/04/17 an Immediate Jeopardy was called by the surveyor due to concerns in the areas of pressure ulcer assessment and treatment and Pharmacy Services related to verifying and clarifying medication orders. Based on the concerns identified, the following plan of action was implemented. 1. On 04/04/17 skin assessments were started on 100% of the residents and will be completed by 5pm on 4/5/17. Complete head to toe assessments will be completed by the Director of Nurses (DON) and MDS Coordinators. In accordance to facility policy and procedure the physician and responsible party will be notified of all new skin problems identified to include pressure ulcers and stasis ulcers. Reeducation was started on 4/4/17 by the DON for Licensed Nurses. Training will include assessment and proper staging of pressure areas, measurement management of pressure and non-pressure areas, and communication with attending physician and wound care physician changes in wound condition. Facility will provide wound vac training to ?DON, MDS and Licensed Nurses by RQM on 4/5/17 by 5pm. 2. DON, ADON, MDS nurse and Administrator will review Treatment Administration Record at the Daily Start up meeting to ensure that documentation is accurate as of 4/5/17. 3. As of 4/4/17 all licensed nursing staff and CNAs will be reeducated by DON and Regional Nurse in accordance to the facility policy and procedures regarding identification, training of staging, measuring and identifying unstageable pressure ulcers and reporting and treatment of [REDACTED]. In-service training will include review of Braden Scale to ensure residents are assessed for proper risk factors. The CNAs will be reeducated on the utilization of the Stop and Watch tool for reporting of newly identified skin conditions on 4/5/17 by 5pm. 4. An audit of all Physician orders [REDACTED]. Clarification orders will be obtained if discrepancy is identified. 5. Don/ADON will reeducate Licensed Nurses on the policy and procedure for reconciliation of medications and verification of orders on admission starting 4/4/17 and completed by 4/5/17 at 5pm. Reeducation training will include notification of physician for verification of orders. On 04/06/17 at 1:20 p.m., staff interviews were conducted related to the content of the inservices they had attended on 04/05/17. Three staff members stated they had not been inserviced and one staff member stated they had been inserviced by the night nurse when she arrived to the facility that morning. At 1:45 p.m., the administrator was informed the immediacy would not be lifted as all staff had not received the inservices for the removal. At 1:55 p.m., the administrator presented a revised POR with the completion date and time changed to 04/06/17 at 2:00 p.m. The revised POR was accepted at at this time. All staff from both shifts present at 1:50 p.m., were inserved on the POR, a message was sent out to all staff phones via a secure message system and all other staff had received a phone inservice before 2:00 p.m. The facility had been unable to get ahold of two staff members and they were removed from the schedule until they could be inserviced. The immediate jeopardy was a removed on 04/06/17 at 2:00 p.m., after all components of the POR were carried out. The deficient practice remained isolated at a level of actual harm. Based on observation, record review and interviews, it was determined the facility failed to ensure to provide the necessary treatments and services to promote the healing of pressure ulcers for two (#1 and #5) of three sampled residents who were reviewed for pressure ulcers. The DON identified 11 residents with pressure ulcers and three resident were receiving wound vac treatments. Findings: A Skin System Policy and Procedure Policy documented, .the facility must ensure that .A resident having a pressure sore receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing . The intent of this policy is to .Promote healing or pressure ulcers that are present . A skin assessment will be completed on admission .and weekly thereafter .Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing using the NPUAP current guidelines . 1. Resident #1 had [DIAGNOSES REDACTED]. The resident had been in a long term acute care (LTAC) unit for wound care prior to his admission to the facility. He had surgical debridement on the sacral wound and sharps debridement on the right ischial wound. He had a stage IV pressure ulcer to the sacral/coccyx area, a stage III pressure ulcer to the right ischial tuberosity, a stage II pressure ulcer to the left ischial tuberosity and a skin tear to the left lateral lower leg. The LTAC records of 01/18/17 and 01/19/17, documented the wound descriptions as follows: A. Sacral/coccyx: 16.00 x 14.00 x 5.00 (Length x Width x Depth in centimeters) with a wound base of 80% granulation tissue and 20% yellow slough. B. Right ischial tuberosity: 3.00 x 4.00 x 7.00 with a wound bed of 100% granulation tissue. C. Left ischial tuberosity: 0.3 x 0.50 x 0.10 with a wound bed of 100% granulation tissue. D. Left lateral lower leg: 6.00 x 4.00 x 0.10 with a wound bed of 100% granulation tissue. On 01/20/17, the resident was admitted to the facility for continued wound care. The admission physician's orders [REDACTED].Apply Santyl to wound bed of sacrum and right ischium. Apply NPTW (sic - negative pressure wound therapy) continuious (sic) medium intensity 150 mm/hg (milligrams of mercury) with vac dressing change . The left ischial and the left lower leg were to have Puracol plus applied three times a week. A Visual Body Map, undated, Documented the resident had a pressure ulcer on sacral/coccyx area and a pressure on the back of the upper left thigh. No other wounds were documented. A nurse's note, dated 01/20/17, documented, .Resident also has a wound vac connected to right and left sacrum and ischeim (sic) . A Wound Assessment Report, dated 01/21/17, documented the sacral pressure ulcer measured 15.00 x 9.00 x 4.00 with a wound bed of 90% [MEDICATION NAME] tissue. No other wounds were documented on this report. A Wound Healing Progress Report, dated 01/21/17, documented a pressure ulcer on the left thigh measured 4.00 x 3.00 x (unstageable due to suspected deep tissue injury). A pressure ulcer on the sacrum measured 15.0 x 9.00 x 4.00. There was no documentation of a comprehensive assessment of the wounds including a description of the wound bed, the peri wound or any exudate. No other wounds were located on the form. A nurse's note, dated 01/21/17 at 4:52 p.m., documented, . Report given to oncoming nurse to F/U (follow up) with wound vac orders d/t orders state 150mmHg and machine only runs up to 125 mmHg. Wound care clinic closed at this time unable to get in new machine for wound vac . A nurse's note, dated 01/21/17 at 8:00 p.m., documented, Unable to get wound vac on profeciently (sic). No wound vac supplies left . A nurse's note, dated 01/21/17 at 8:55 p.m., documented, Resident transported to (hospital name deleted) due to not being able to get wound vac back running again .report was given to EMSA, DON and family member for wound to be evaluated with slow bloody drainage . A nurse's note, dated 01/22/17 at 4:40 p.m., documented, Resident returned to the facility during the night shift. Has new orders for wet-to-dry dressing change TID .Wound care nurse to follow up with the resident tomorrow A nurse's note, dated 01/23/17 at 2:00 p.m., documented, .Wound care performed on wound to sacrum. Wound vac effeciently (sic) on Res. wound. No foul odor. No discharge from wound . A nurse's note, dated 01/23/17 at 9:46 p.m., documented, Wound care done, wound vac with good seal . An Interdisciplinary Progress Note, dated 01/26/17, documented, Skin sweep of building performed - noted resident has surgical incision/debridement of sacral/lower back area is 16cm x 9.5cm x 5.5 cm with visible sign/symptoms of bleeding noted .wound vac placed bridged to R ischial wound 9 1/2cm x 4cm x 3 cm .L ischial wound was 2.5cm x 2cm x 0.2cm .also noted L lateral leg brown scabbed area 1cm x 1cm . both heels soft and mushy . No comprehensive assessments of the wounds were documented. A Medicare nurse's note, dated 01/27/17 at 4:07 a.m., documented, .Wound vac dressing non functioning. Wet to dry dressing applied at 12am . The admission assessment, dated 01/27/17, documented the resident was independent with cognitive skills for daily decision making. He required the extensive assistance of two person physical assist for bed mobility, transfers, personal hygiene and bathing. He was at risk for developing pressure ulcers and had one stage II ulcer, two stage IV ulcers and an unstageable ulcer. A Medicare nurse's note, dated 01/29/17 at 6:53 p.m., documented, .wound vac function well. red drainage in container . A nurse's note, dated 01/31/17 at 3:49 p.m., documented, Resident wound vac remains intact and suctioning .This note observed resident tank filled with blood, less than 24 hours of wound vac being changed .physician notified and gave no N.O. (new orders) except to refer concerns to wound care specialist . A care plan, dated 01/31/17, documented, Problem .Impaired skin integrity AEB (as evidenced by) surgical wound to back, stage IV pressure ulcer right ischail (sic), stage II to left ischial, DTI (deep tissue injury) left lateral foot, and skin tear to left lower leg-with additional risks R/T related to wound vac . Approaches: .Report SX (symptoms) infection (odor, increase drainage, pain or redness) . Notify MD, family, responsible party of changes as needed . Treatment as ordered . Weekly wound monitoring . Pressure redistributing Mattress and/or chair cushion On 02/01/17, the resident was admitted to the hospital following an office visit with his wound care physician. The hospital records, dated 02/01/17, documented the following wounds: A. Sacrum: 15.8 x 10 x 8.5 with 8cm of undermining. There was approximately 250 cc of red drainage in the vac container. There was a slight odor, moist eschar and exposed bone. There was evidence of necrosis and granulation tissue. B. Right ischial: 5.5 x 4.3 x 5.5 with 4.4cm of undermining and all necrotic tissue. There was no evidence of granulation tissue. This wound had deteriorated from 01/20/17. C. Left posterior thigh: 0.6 x 1 x 0.2. This wound had deteriorated from 01/20/17. D. Medial left leg: 3.1 x 1.6 x 0.2 and weeping. This was a new wound. E. Left lateral leg: 4.9 x 3 x 0.2. This wound had deteriorated from the assessment dated [DATE]. F. Left lateral foot: Deep tissue injury with no open area. This was a new area of concern. On 04/03/17 at 12:30 p.m., the administrator was asked if the facility had any wound nurses. She stated, No. She was asked who took care of the wounds. She stated the floor nurses took care of the wounds on their halls. She was asked if the nurses had any special training in wound care. She stated, No. She was asked if there was any other documentation of wound assessments other than what was in the computer program. She stated there was one report but had been unable to print it off. She stated she would try again. At 1:30 p.m., LPN #1 was asked if she could remember resident #1. She stated she did. She was asked if she could remember where the wound vac had been placed. She stated she knew it had been a big wound and was placed into two wounds. She thought it might have been a hip but she had never changed the wound vac, but had only changed out the canister. She was asked if she had very much experience using a wound vac. She stated she had never used one until she came to work here. She was asked if she had any training on the use of the wound vac. She stated the DON at the time had given her some instruction and she had a small inservice on it with a former job. She stated she did not work with [DEVICE] very often even now. At 3:00 p.m., the MDS nurse was asked about the resident. She was asked where the wound vac was placed on the resident. She stated it had been bridged between the sacrum and the right ischial. She was asked about the settings on the vac. She stated the one they usually use is preset at 125 mm/hg. They had to obtain one for the 150 mm/hg order. She stated it had been preset also and the facility could not change the settings. She was asked if skin assessments were performed. She stated they should be done on admission and then weekly. She was asked where they would be documented. She stated on the TARS and/or the wound/skin sheets. She was shown the January 2017 TARs and asked if skin assessments had been done. She stated they were not on the TARs. She would look for the skin sheets. She was shown the undated Body Map and was asked if it was correct. She stated, No, he had a surgical wound on the lower back, right and left ischial wounds, a wound on the left lower leg and scabbed areas on the lower leg. She was asked if the facility had trouble with the wound vac during the resident's care. She stated they had been unable get the vac sealed on 01/21/17. Several nurses had attempted to get the seal but they ran out of supplies and had to send the resident to the emergency room . They did wet to dry dressings until it could he could be seen by the physician on 01/23/17. The administrator had entered the room and stated they had two inservices on the wound vac about the time the resident was in the facility. She was asked to locate the documentation of the inservices. No documentation was presented prior to exit. She was asked if she could locate any comprehensive wound assessments for all four of the resident's wounds. She stated the facility had done a complete wound sweep of the facility and showed me the interdisciplinary note, dated 01/26/17, where she had assessed the wounds. She was asked if they were comprehensive assessments. She stated, No. She was asked if all four wounds should have been assessed and monitored. She stated, Yes. She was asked if all four wounds were assessed and monitored. She stated, No, but she would keep looking. At 3:40 p.m., the MDS nurse was asked if she was wound care certified. She stated she had three years of experience with wound care but had not been certified. She was asked if she was familiar with the [DEVICE]. She stated she had lots of experience with [DEVICE]. She was asked if the facility had called her to come in and assist with the wound vac when they were having difficulty with it on 01/21/17. She stated they did not call her because it was a weekend. At 4:20 p.m., the MDS nurse was asked if I&Os (intake and output) were kept on the wound vac canisters. She stated, No. She was asked how they knew how much was draining. She stated they usually changed the canisters about every 24 hours. She was asked if there was a policy. She stated she would look. At 4:25 p.m., the MDS nurse presented the wound vac manual and showed where it documented the canister would probably be changed out about every day. She was asked how they knew how much was draining. She stated they would document if the canister got full. On 04/04/17 at 12:20 p.m., the administrator was asked to see if they could determine who actually placed the wound vac on 01/23/17 or 01/24/17. At 1:00 p.m., the MDS nurse reported she had placed the wound vac on the resident on 01/23/17. She was asked if the wound vac had been difficult to replace. She stated, No. She stated the resident's wound physician had been called about the wound vac. The physician stated the resident's followup was scheduled for 02/01/17 and to put him back on the vac. She placed the vac but she heard it keep beeping. When she checked it, it said the seal was no good and they had to order another vac which she then placed on 01/24/17. She was asked if the floor nurses were aware the vac was beeping because of a bad seal on 01/23/17. She stated, No. She stated they also had trouble with it when the canister was too full on 01/31/17. She was asked if the floor nurses were aware it was not working properly because the canister was too full. She state, No, I had to tell them. She was asked if there was documentation of the call to the wound physician on 01/23/17. She stated the previous DON had made the call and had not documented it. On 04/05/17 at 4:20 p.m., LPN #1 was observed performing wound care which involved a wound vac. She was placing the wound vac on an ankle wound. She had a little difficulty placing the film for the wound vac. The dressing took 25 minutes. At 4:20 p.m., RN #1 was observed performing wound care which involved a wound vac. She was placing the wound vac on an ankle wound. The resident had to coach her several times on what to do. Several times throughout the procedure she stated, I don't know the wound vac very well, I'm just learning. The wound care took one and a half hours to complete. At 6:10 p.m., the DON was informed about the difficulties RN #1 had with the wound care using the wound vac. She stated, We will be working with them. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had a tube feeding and went to [MEDICAL TREATMENT] three times a week. An admission nurse's note, dated 03/02/17 at 9:24 p.m., documented, .Scrotum swollen, skintear at the bottom part of scrotum, bandaid in place. Red area of what appear to be a sacral wound healed, no open wounds noted. Dry flaky feet, no wounds or open areas noted . A care plan, dated 03/06/17, documented, .at risk for impaired skin integrity r/t impaired mobility, incontinence, [MEDICAL TREATMENT] .Approaches .skin eval by licensed nurse routinely and prn .Document findings/eval . The admission assessment, dated 03/09/17, documented the resident was independent in cognitive skills for daily decision making. He required extensive assistance of two person physical assist for bed mobility and was dependent on two person physical assist for transfers. He required the extensive assistance of one person for hygiene and bathing. He was always incontinent of of bowel and bladder. He was considered at risk for developing pressure ulcers and had no pressure ulcers on that date. A nurse's note, dated 03/26/17, documented, .pt continues to roll over back to left side, causing reddened areas to left hip, side of left foot, and open sore to left lateral malleolus Family member notified staff of presence of open are of skin . A care plan, dated 03/26/17, documented, .Pressure ulcer to left lateral ankle, and lateral foot .Approaches .Report changes in skin integrity promptly .Weekly wound monitoring and referral to wound care consulting physician .Prompt resident to shift weight at least q 2hrs while awake .treatment as ordered . Wound assessment reports, dated 04/05/17, documented the following wounds: 1. Left pad of foot; left lateral foot: 2.0 x 1.5 x 0 with 100% eschar. 2. Left buttock; left and right buttock have DTI. 4.0 x 1.50 x 0. pink with slight [MEDICAL CONDITION]. 3. Left pad of foot;left great toe: 2.0 x 0.50 x 0 with 100% eschar. 4. Left heel slightly red. 2.0 x 2.0 x 0. On 04/10/17 at 1:40 p.m., LPN #1 was observed performing the resident's wound care. The DON was in the room during the wound care. She was asked how long the resident had the wounds. She stated she wasn't sure about the ankle but she had only identified the other wounds when they did the skin sweep on 04/05/16. She was asked if the wounds should have been identified sooner. She stated she hadn't found any documentation until she found them.

On 04/04/17 at 10:50 a.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma Stated Department of Health (OSDH) regarding the facilities failure to have procedures in place for the clarifying of medication orders. The facility failed to clarify physician's orders [REDACTED]. At 1:10 p.m., the administrator and the DON were informed of the IJ situation related to the facility's failure to have procedures in place for the clarifying of medication orders. At 5:45 p.m., the administrator provided the surveyor with an acceptable plan of removal (POR). The plan of removal documented the following: Windsor Hills Nursing and Rehabilitation Plan of Removal of IMMEDIATE JEOPARDY On 04/04/17 an Immediate Jeopardy was called by the surveyor due to concerns in the areas of pressure ulcer assessment and treatment and Pharmacy Services related to verifying and clarifying medication orders. Based on the concerns identified, the following plan of action was implemented. 1. On 04/04/17 skin assessments were started on 100% of the residents and will be completed by 5pm on 4/5/17. Complete head to toe assessments will be completed by the Director of Nurses (DON) and MDS Coordinators. In accordance to facility policy and procedure the physician and responsible party will be notified of all new skin problems identified to include pressure ulcers and stasis ulcers. Reeducation was started on 4/4/17 by the DON for Licensed Nurses. Training will include assessment and proper staging of pressure areas, measurement management of pressure and non-pressure areas, and communication with attending physician and wound care physician changes in wound condition. Facility will provide wound vac training to ?DON, MDS and Licensed Nurses by RQM on 4/5/17 by 5pm. 2. DON, ADON, MDS nurse and Administrator will review Treatment Administration Record at the Daily Start up meeting to ensure that documentation is accurate as of 4/5/17. 3. As of 4/4/17 all licensed nursing staff and CNAs will be reeducated by DON and Regional Nurse in accordance to the facility policy and procedures regarding identification, training of staging, measuring and identifying unstageable pressure ulcers and reporting and treatment of [REDACTED]. In-service training will include review of Braden Scale to ensure residents are assessed for proper risk factors. The CNAs will be reeducated on the utilization of the Stop and Watch tool for reporting of newly identified skin conditions on 4/5/17 by 5pm. 4. An audit of all Physician orders [REDACTED]. Clarification orders will be obtained if discrepancy is identified. 5. Don/ADON will reeducate Licensed Nurses on the policy and procedure for reconciliation of medications and verification of orders on admission starting 4/4/17 and completed by 4/5/17 at 5pm. Reeducation training will include notification of physician for verification of orders. On 04/06/17 at 1:20 p.m., staff interviews were conducted related to the content of the inservices they had attended on 04/05/17. Three staff members stated they had not been inserviced and one staff member stated they had been inserviced by the night nurse when she arrived to the facility that morning. At 1:45 p.m., the administrator was informed the immediacy would not be lifted as all staff had not received the inservices for the removal. At 1:55 p.m., the administrator presented a revised POR with the completion date and time changed to 04/06/17 at 2:00 p.m. The revised POR was accepted at at this time. All staff from both shifts present at 1:50 p.m., were inserviced on the POR, a message was sent out to all staff phones via a secure message system and all other staff had received a phone inservice before 2:00 p.m. The facility had been unable to get ahold of two staff members and they were removed from the schedule until they could be inserviced. The immediate jeopardy was removed on 04/06/17 at 2:00 p.m., after all components of the POR were carried out. The deficient practice remained isolated at a level of no actual harm with potential fir more than minimal harm. Based on record review and interview, it was determined the facility failed to ensure to have procedures in place for the clarifying of medication orders. The facility failed to clarify physician's orders [REDACTED].#1) of five sampled residents whose medications were reviewed. The resident received two anticoagulant medications concurrently for 11 days. The DON identified 20 residents received anticoagulation medications. The Census and Conditions report, dated 03/31/17, documented 78 residents resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. The resident had been in a long term acute care (LTAC) unit for wound care prior to his admission to the facility. The LTAC clinical records documented in a physician's progress note, dated 01/19/17, to discontinue the Eliquis and start Xarelto 20 mg daily. Both medications are anticoagulants. On 01/20/17, the resident was admitted to the facility for continued wound care. On 01/21/17, the LTAC faxed the facility a Discharge Prescriptions report. The Eliquis had a check in the 'Stop' column and a check in the 'Continue at home' column. Vitamin C, Lipitor (used to treat high cholesterol), Zyrtec ( an antihistamine) and Collagenase (a wound treatment) also had checks in both the 'Stop' and the 'Continue at home' columns. The January 2017 physician's orders [REDACTED].Eliquis 5mg tablet 1 tablet PO (by mouth) BID (twice a day) .Xarelto 20mg tablet 1 tablet PO QD (every day) . The January 2017 MARs documented, Eliquis 5mg .BID The Eliquis was documented as having been administered for the evening dose on 01/20/17, both morning and evening doses from 01/21/17 through 01/30/17 and the morning dose on 01/31/17. The January 2017 MARs documented, Xarelto 20mg .QD . The Xarelto was documented as having been administered daily from 01/21/17 through 01/31/17. A nurse's note, dated 01/31/17, documented, .This nurse observed resident tank (wound vac canister) filled with blood, less than 24 hours of wound vac being changed. Resident physician notified, and gave no N.O. (new orders), except to refer concerns to wound care specialist. It is then observed by staff that residents (sic) orders from previous hospital, he is on Eliquis 5mg po BID and Xarelto 20mg po q day. Physician notified again with new observations of medications. New order given to DC (discontinue) Eliquis and continue Xarelto 20mg po Q day, and to obtain STAT (immediate) CBC (complete blood count) and CMP (complete metabolic profile). Residetn (sic) wife notified and has concerns of husband bleeding out . On 03/31/17 at 11:15 a.m., the DON was asked how medications were processed on admission. She stated the nurse would write the orders and fax them to the pharmacy. She was asked what the policy was if the orders were unclear. She stated the nurse should call the physician for clarification. She was asked why Eliquis and Xarelto were given. She stated they are blood thinners. She was asked if Eliquis and Xarelto are usually given together. She stated, Sometimes. She was asked if the nurses watched out for medications that could have negative interactions. She stated they should be. She was shown the Discharge Prescription report dated 01/20/17 from the LTAC. She was asked if she thought these orders were clear. After reviewing the report, she pointed to the five medications which were checked 'Stop' and 'Continue at home' and stated those medication orders were not clear. She was asked how they should be handled. She stated the physician should be called for clarification. She stated, Those are too unclear to not clarify them. She was asked if the resident should have been administered both medications. She stated she did not know because she was not sure if the orders had been clarified. She was asked if the orders should have been clarified. She stated they should have been clarified. At 11:50 a.m., the consulting pharmacy manager was asked how the facility had informed him of the resident's physician's orders [REDACTED]. He was asked if he had seen there was a check in the 'Stop' column and the 'Continue at home' column for five medications. He stated he had seen the checks but assumed that was where the facility had checked off the medication. He was asked why were there only the five checks when there were 34 medications on the list. He stated he didn't know why, he had not paid that much attention to them. He was asked if he had any concerns about the orders for two anticoagulants. He stated it looked like they were making a change of drugs. He stated sometimes they will continue two medications to allow the new drug to become affective. He stated when he entered the medications into the system the red flag warning did come up about the possible interactions but if they were both being given in the hospital he assumed he was to receive them both. He stated he thought if the facility had any questions about the orders they would have already clarified them. At 3:13 p.m., the resident's attending physician was asked if the facility had called him when the resident was admitted to clarify the orders for two anticoagulants. He stated, No. He stated even if they had called him, he would not have changed the orders because they were ordered by a specialist and he would not change their orders. He stated it is common to have a resident on two anticoagulants, especially if they have atrial fibrillation. He was asked if he was aware the Eliquis had been checked to 'Stop' and to 'Continue at home.' He stated, No. He was asked if he would have expected the facility to have clarified this. He stated, Yes. He was asked if he had remembered a nurse calling him on 01/31/17 to report the resident had been on two anticoagulants and that he had immediately discontinued the Eliquis and ordered lab work. He stated he did not really remember, but that's why the nurses document, to help him remember. He was asked if there was a reason he had decided to discontinue the Eliquis at that time. He stated he couldn't remember. He was asked if he read the admission orders [REDACTED]. He stated the referring physician was more familiar with the resident so he would not change any of the orders.

Based on record review and interviews, it was determined the facility failed to notify the physician of a severe weight loss for one (#1) of seven residents whose records were reviewed for weight loss. The resident experienced actual harm with a severe weight loss of 10.8 pounds (lbs)/7.2% within two weeks of admission and continued weight loss of 22.2 lbs/16.1% within eight weeks of admission to the facility. This had the potential to affect 20 residents identified by the facility who were at risk for weight loss. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], chronic [MEDICAL CONDITION] and history of cardiovascular accident. The admission assessment, dated 04/11/14, documented the resident scored 9 on the 'Brief Interview for Mental Status', indicating moderate cognitive impairment. The 'Resident Mood Interview' documented the resident experienced feeling tired/having little energy and poor appetite/overeating for several days during the last two weeks. The assessment documented the resident was independent with transfers, walking in room and toilet use and required oversight, encouragement or cueing with dressing, eating and personal hygiene. The assessment documented the resident required limited assistance with bathing and was continent of bowel and bladder. The assessment documented the resident had no weight loss or gain in the past six months. The care plan, dated 04/04/14, documented the resident was at risk for alteration in nutrition. Goals for the resident included to maintain current weight within three pounds and consume at least 75% of meals daily. Interventions included: ~ determining likes and dislikes, ~ providing diet as ordered, ~ encouraging at least 75% consumption of fluids and meals daily,~offering alternative or supplement with less than 50% meal consumption, ~ setup, cue and assisting as needed with meal consumption, ~ speech therapy/occupation therapy evaluation as needed and ~ notify physician, family, responsible party of changes as needed. The care plan had been updated on 05/21/14 to reflect continued risk for weight loss due to the resident giving her tray at meal times to a tablemate. Interventions included to monitor the resident during meals and encouraging her to eat her food if she attempted to give her tray to tablemates. A nursing note dated 04/04/14 at 4:44 p.m. documented the resident's admission weight was 160 lbs. Weekly weight records documented the following: week of 04/08/14 - 04/12/14: 152.4 lbs week of 04/15/14 - 04/21/14: 149.2 lbs week of 04/22/14 - 04/28/14: 145 lbs week of 05/01/14 - 05/09/14: 145 lbs week of 05/10/14 - 05/16/14: 142.4 lbs week of 05/17/14 - 05/23/14: 141.4 lbs week of 05/24/14 - 05/30/14: 137.8 lbs Within one week of admission, the week of 04/08/14 - 04/12/14, the resident had lost 7.6 lbs, a loss of 4.99%. No new interventions had been implemented to prevent further weight loss. Within two weeks of admission, the week of 04/15/14 - 04/21/14, the resident had lost 10.8 lbs, a severe loss of 7.2%. No new interventions had been implemented to prevent further weight loss. A progress note dated 04/23/14 at 4:05 p.m. by the registered dietician documented most recent weight was 149.2 lbs. The note documented the resident's current food/supplement intake met 26-75% of estimated needs, placing the resident at moderate risk for weight loss. The note documented the resident's daily estimated needs of 1431-1670 calories and 68-88 grams protein. The note documented the resident fed herself and received a regular diet. The note documented, "INTERVENTION: NO CHANGE..." Within eight weeks of admission, the week of 05/24/14 - 05/30/14, the resident had lost 22.2 lbs, a severe loss of 16.1%. No new interventions had been implemented to prevent further weight loss. On 06/17/14 at 11:00 a.m., the restorative aide, the staff member who was responsible for residents' weekly weight, was interviewed. She stated after weights were obtained they were given to the charge nurse, dietary manager, director of nursing and registered dietician. She stated weekly weights were obtained on all newly admitted residents for four weeks. She stated if a resident began loosing weight or continued to lose weight, the director of nursing or dietary manager then continued or initiated weekly weights. She stated when weight loss occurred, supplements were implemented with meals or between meals. On 06/17/14 at 2:15 p.m., the registered dietician was interviewed. She was asked about the resident's severe weight loss. She stated she had reviewed the resident's weight and wanted to wait another month before implementing further interventions. She stated the facility had been providing supplements when the resident did not eat well, and weight often varied after admission due to pre-admission conditions such as [MEDICAL CONDITION]. She was asked if she was aware of the resident's continued severe weight loss and she stated she was not. She stated if she had been aware she would have implemented other interventions for the prevention of further weight loss. On 06/17/14 at 3:15 p.m., the dietary manager was interviewed. She stated she was aware the resident did not eat much at times and offered alternative food items of her choice and supplements in order to try to get her to eat more. She was asked what she did when a resident had a significant or severe weight loss. She stated she notified the registered dietician. She was asked if the dietician had been notified of the resident's continued severe weight loss and she stated no, she thought the dietician had already been notified. On 06/18/14 at 9:00 a.m., the administrator stated weekly weight meetings were conducted with the medical director in attendance. She stated the medical director was aware of the resident's weight loss. On 06/18/14 at 2:40 p.m., the medical director was interviewed. He was asked if he was aware of the resident's severe weight loss. He stated he was aware and expected the staff to notify the resident's primary care physician. On 06/18/14 at 2:50 p.m., licensed practical nurse #2 was asked what she did when a resident had a significant or severe weight loss. She stated she notified the residents's physician. She was asked if she was aware of the resident's severe weight loss and she stated she was not. She was asked if the resident's physician had been notified of the resident's weight loss and she stated no.

Based on record review and interviews, it was determined the facility failed to implement interventions to prevent severe weight loss for one (#1) of seven residents whose records were reviewed for weight loss. The resident experienced actual harm with a severe unintended weight loss of 10.8 pounds (lbs)/7.2% within two weeks of admission and continued weight loss of 22.2 lbs/16.1% within eight weeks of admission to the facility. This had the potential to affect 20 residents identified by the facility who were at risk for weight loss. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], chronic [MEDICAL CONDITION] and history of cardiovascular accident. The admission assessment, dated 04/11/14, documented the resident scored 9 on the 'Brief Interview for Mental Status', indicating moderate cognitive impairment. The 'Resident Mood Interview' documented the resident experienced feeling tired/having little energy and poor appetite/overeating for several days during the last two weeks. The assessment documented the resident was independent with transfers, walking in room and toilet use and required oversight, encouragement or cueing with dressing, eating and personal hygiene. The assessment documented the resident required limited assistance with bathing and was continent of bowel and bladder. The assessment documented the resident had no weight loss or gain in the past six months. The care plan, dated 04/04/14, documented the resident was at risk for alteration in nutrition. Goals for the resident included to maintain current weight within three pounds and consume at least 75% of meals daily. Interventions included: ~ determining likes and dislikes, ~ providing diet as ordered, ~ encouraging at least 75% consumption of fluids and meals daily, ~ offering alternative or supplement with less than 50% meal consumption, ~ setup, cue and assisting as needed with meal consumption, ~ speech therapy/occupation therapy evaluation as needed and ~ notify physician, family, responsible party of changes as needed. The care plan had been updated on 05/21/14 to reflect continued risk for weight loss due to the resident giving her tray at meal times to a tablemate. Interventions included to monitor the resident during meals and encouraging her to eat her food if she attempted to give her tray to tablemates. A nursing note dated 04/04/14 at 4:44 p.m. documented the resident's admission weight was 160 lbs. Weekly weight records documented the following: week of 04/08/14 - 04/12/14: 152.4 lbs week of 04/15/14 - 04/21/14: 149.2 lbs week of 04/22/14 - 04/28/14: 145 lbs week of 05/01/14 - 05/09/14: 145 lbs week of 05/10/14 - 05/16/14: 142.4 lbs week of 05/17/14 - 05/23/14: 141.4 lbs week of 05/24/14 - 05/30/14: 137.8 lbs Within one week of admission, the week of 04/08/14 - 04/12/14, the resident had lost 7.6 lbs, a loss of 4.99%. No new interventions had been implemented to prevent further weight loss. Within two weeks of admission, the week of 04/15/14 - 04/21/14, the resident had lost 10.8 lbs, a severe loss of 7.2%. No new interventions had been implemented to prevent further weight loss. A progress note dated 04/23/14 at 4:05 p.m. by the registered dietician documented most recent weight was 149.2 lbs. The note documented the resident's current food/supplement intake met 26-75% of estimated needs, placing the resident at moderate risk for weight loss. The note documented the resident's daily estimated needs of 1431-1670 calories and 68-88 grams protein. The note documented the resident fed herself and received a regular diet. The note documented, "INTERVENTION: NO CHANGE..." Within eight weeks of admission, the week of 05/24/14 - 05/30/14, the resident had lost 22.2 lbs, a severe loss of 16.1%. No new interventions had been implemented to prevent further weight loss. On 06/17/14 at 11:00 a.m., the restorative aide, the staff member who was responsible for residents' weekly weight, was interviewed. She stated after weights were obtained they were given to the charge nurse, dietary manager, director of nursing and registered dietician. She stated weekly weights were obtained on all newly admitted residents for four weeks. She stated if a resident began loosing weight or continued to lose weight, the director of nursing or dietary manager then continued or initiated weekly weights. She stated when weight loss occurred, supplements were implemented with meals or between meals. On 06/17/14 at 2:15 p.m., the registered dietician was interviewed. She was asked about the resident's severe weight loss. She stated she had reviewed the resident's weight and wanted to wait another month before implementing further interventions. She stated the facility had been providing supplements when the resident did not eat well, and weight often varied after admission due to pre-admission conditions such as [MEDICAL CONDITION]. She was asked if she was aware of the resident's continued severe weight loss and she stated she was not. She stated if she had been aware she would have implemented other interventions for the prevention of further weight loss. On 06/17/14 at 3:15 p.m., the dietary manager was interviewed. She stated she was aware the resident did not eat much at times and offered alternative food items of her choice and supplements in order to try to get her to eat more. She was asked what she did when a resident had a significant or severe weight loss. She stated she notified the registered dietician. She was asked if the dietician had been notified of the resident's continued severe weight loss and she stated no, she thought the dietician had already been notified. On 06/18/14 at 9:00 a.m., the administrator stated weekly weight meetings were conducted with the medical director in attendance. She stated the medical director was aware of the resident's weight loss. On 06/18/14 at 2:40 p.m., the medical director was interviewed. He was asked if he was aware of the resident's severe weight loss. He stated he was aware and expected the staff to notify the resident's primary care physician. On 06/18/14 at 2:50 p.m., licensed practical nurse #2 was asked what she did when a resident had a significant or severe weight loss. She stated she notified the residents's physician. She was asked if she was aware of the resident's severe weight loss and she stated she was not. She was asked if the resident's physician had been notified of the resident's weight loss and she stated no.