**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/22/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from significant medication errors.On 07/22/25 at 2:11 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation.On 07/22/25 at 2:29 p.m., the administrator, DON, and the corporate nurse consultant were notified of the IJ situation. An IJ template was provided to the administrator.On 07/23/25 at 1:03 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal read in part, Regional Nurse Consultant will educate the Director of Nursing on identification of significant medication errors and administration of medication per physician orders. DON/Designee will educate all licensed nurses and certified medication aides by 2359 [11:59 p.m.] on 7/23/2025 regarding administering medication according to physician orders and identification of significant medication errors. Medication aides and Licensed nurses will document medication administration in the eMAR. Any licensed nurse or certified medication aide not educated by 2359 [11:59 p.m.] on 7/23/2025 will not be allowed to work until they have received education.An audit of current residents missing significant medications for the last 7 days was conducted and completed by 2359 [11:59 p.m.] on 7/23/2025 by nursing management to assure that significant medications are given as ordered by physician.Any significant medication errors found during the audit will be reviewed by the DON. The medical director will be notified of the findings for any further recommendations.The IJ was lifted, effective 07/23/25 at 11:59 p.m., when all components of the plan of removal had been completed. Staff interviews regarding significant medication errors and administering medications as ordered by the physician was completed and all components of the plan of removal was reviewed.Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (#3) of 7 sampled residents reviewed for significant medication errors.The DON reported 94 residents resided in the facility.Findings:An undated medical diagnosis sheet showed Resident #3 admitted to the facility on [DATE] with diagnoses which included seizures, chronic kidney disease, dependence on dialysis, hypothyroidism, cardiomegaly, and atherosclerotic heart disease.A physician order, dated 04/16/25, showed Levetiracetam (an anticonvulsant) 500 mg tablet, one tablet every 12 hours for seizures.A medication administration record, dated 04/16/25 to 05/12/25, showed 9 out of 26 missing morning doses of Levetiracetam (an anticonvulsant) 500mg on 04/18/25, 04/23/25, 04/25/25, 04/28/25, 04/30/25. An emergency department physician note, dated 04/30/25 at 10:50 p.m., showed Resident #3 was presented for seizures and was given Keppra due to the missed doses. The physician noted Resident #3 could discharge and reiterated the importance of twice daily dosing of her Levetiracetam.An interdisciplinary progress note, dated 05/01/25 at 8:02 a.m., showed the Resident returned from the hospital around 3:00 a.m. via EMS. Family reported resident had received IV Levetiracetam for seizure activity. Writer reported to family that her meds will be given prior to Dialysis from now on.On 07/23/25 at 1:05 p.m., the DON stated they were not aware of why the resident went to the emergency room or the significant medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/31/23 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Res #43's right to be free from emotional distress due to neglect. Res #43 had multiple pressure ulcers upon admission. Physician orders were to change dressings daily in the morning. On 10/31/23 at 3:26 p.m., all wound dressings were dated for 10/29/23. Upon exposure of the resident's back a pungent putrid odor was evident. The dressings on the resident's back were observed to be saturated with drainage. The resident was observed with dried and fresh blood and other brown stains on the absorbent pad under their back. Further brown stains were observed on the sheet between the resident's legs and toward the bottom of the bed. The resident was observed with dried feces on the bottom of their hospital gown. The resident was observed with an ostomy bag on the left side of their abdomen that was full of feces and bloated with gas. The resident's nails were observed to be long, curling, and had brown and black substance under the nails. The resident was observed with a urine collection bag with approximately 700 ml clear yellow urine with sediment accumulation in drainage tube. The resident expressed their current condition made them want to cry and they had given up hope of getting better. They stated they were tired of trying to get care for their wounds and they had given up trying. On 10/31/23 at 5:53 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 10/31/23 at 6:02 p.m., the administrator was notified of the IJ situation. On 11/01/23 at 1:58 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan of Removal 1) DON/Designee will educate all licensed nurses on changing wound dressings per physician order and notification of DON/Administrator if wound care is not completed. Education completed on 10/31/2023 in person and by phone. Nurses who could not be reached by phone will be in- serviced prior to working next schedule shift. 2) All staff will be educated on prevention of neglect and ADL care. All education be completed by in person or by phone by 11:59 pm 10/31/23. If unable to reach for education, staff education will be in-serviced prior to working next scheduled shift. 3) A visual audit was conducted and completed on 10/31/2023 by nursing management to assure that all wound dressings were changed per physician order. 4) DON/designee will do rounds daily to ensure dressings are changed and as ordered by physician. Random visual ADL care audits will be conducted during angel rounds on residents to ensure ADL care is provided. 5) QA Committee meeting held on 10/31/23 with facility staff. Resident #43: On 10/31/2023 wound care completed on all wounds, ADL care provided including nail care, linen and gown changed, foley bag emptied and colostomy bag changed. Charge nurses evaluated resident's psychosocial status throughout shifts. Pysch plus will follow up with resident related to psychosocial needs on 11/1/2023. The IJ was lifted, effective 11/01/23 at 12:58 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the residents. Based on observation, record review, and interview, the facility failed to protect Res #43's right to be free from emotional distress due to neglect. The MDS coordinator identified 98 residents resided in the facility. Findings: A facility abuse policy, effective 06/23/17, documented in part .each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion .Neglect: Failure of the facility, its employees or service providers to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Res #43 admitted to the facility on [DATE] with diagnoses which included pressure ulcers, paraplegia, low BMI, depression, and contractures. A physician order, dated 08/10/23, documented to apply bacitracin topical ointment Monday and Wednesday to pressure ulcer of other site, stage IV. A TAR for August 2023, documented the bacitracin was not administered on two of 9 opportunities. A physician order, dated 08/10/23, documented to cleanse wound to left posterior inferior knee, pat dry, apply bacitracin, apply Xeroform, cover with ABD pad, and wrap with Kerlix and secure with medical tape every Monday, Wednesday, and Friday day shift for pressure ulcer of other site, stage IV. A TAR for August 2023, documented the treatment was not completed two of eight opportunities. A physician order, dated 08/10/23, documented to cleanse wound to right buttock, apply bacitracin, apply Xeroform, and cover with silicone foam adhesive border gauze every Monday, Wednesday, and Friday day shift for pressure ulcer of right buttock, stage III. A TAR for August 2023, documented the treatment was not completed for two of eight opportunities. A physician order, dated 08/10/23, documented to cleanse wound to right medial knee, pat dry, apply bacitracin, apply Xeroform, cover with ABD pad, wrap with Kerlix and secure with medical tape every Monday, Wednesday, and Friday day shift for pressure ulcer of other site, stage III. A TAR for August 2023 documented the treatment was not completed for two of eight opportunities. A physician order, dated 08/10/23, documented to cleanse wound to sacrum, pat dry, apply Xeroform, apply bacitracin, and cover with sacral adhesive silicone border dressing, every Monday, Wednesday, and Friday day shift for pressure ulcer of sacral region, stage IV. A TAR for August 2023 documented the treatment was not completed two of eight opportunities. A physician order, dated 08/10/23, documented to perform colostomy care one time per day for one day. A TAR for August 2023, documented the treatment was completed on 08/11/23. There was no order for ostomy care from 08/11/23 through 08/22/23. An annual MDS, dated [DATE], documented the resident was cognitively intact, required extensive to total assistance with ADLs, had not rejected care, and had three stage III pressure ulcers and one stage IV pressure ulcer. A physician order, dated 08/22/23, documented to complete ostomy care one time per day. A TAR for August 2023, documented the ostomy care was not completed six of nine opportunities. A physician order, dated 08/22/23, documented to complete catheter care every shift. A TAR for August 2023, documented the catheter care was not completed 21 of 30 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to left posterior inferior knee, pat dry, apply gentamicin ointment, apply calcium alginate with silver, cover with ABD pad, wrap with Kerlix and secure with medical tape every day shift for pressure ulcer of other site, stage IV. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to right buttock, apply Santyl nickel thick, apply calcium alginate, and cover with silicone foam adhesive border gauze every day shift for pressure ulcer of right buttock, stage III. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to right medial thigh, pay dry, apply hydrofiber with silver every day shift for pressure ulcer of other site, stage III. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A physician order, dated 08/30/23, documented to cleanse wound to sacrum, pat dry, apply gentamicin, apply calcium alginate with silver, and cover with sacral adhesive silicone border dressing every day shift for pressure ulcer of sacral region, stage IV. A TAR for September 2023 documented the treatment was not completed two of 27 opportunities. A TAR for September 2023, documented ostomy care was not completed daily three of 28 opportunities. A TAR for September 2023, documented foley catheter care was not completed every shift three of 81 opportunities. The resident was hospitalized from [DATE] through 10/02/23. An undated LTC bath schedule, documented Res #43 was to be bathed on Wednesdays and Saturdays. Upon record review of ADLs in the EHR from 10/02/23 through 11/02/23, bathing had not been documented for the resident in the EHR's ADL tracking. A physician order, dated 10/04/23, documented to cleanse wound to back with hibicleanse, pat dry, apply gentamicin, apply calcium alginate, and cover with large border gauze every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of 14 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to left posterior inferior knee with hibicleanse, pat dry, apply gentamicin ointment, apply calcium alginate with silver, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed four of 27 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to right buttock with hibicleanse, pat dry, apply Santyl ointment nickel thick, apply gentamicin, apply calcium alginate, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 18 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to right medial thigh with hibicleanse, pat dry, and apply hydrofiber with silver every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 26 opportunities. A physician order, dated 10/04/23, documented to cleanse wound to sacrum with hibicleanse, pat dry, apply gentamicin ointment, apply calcium alginate with silver, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of 14 opportunities. A physician order, dated 10/04/23, documented to apply santyl ointment topically to right buttock every day shift for pressure ulcer of other site, stage IV. A MAR for 10/01/23 through 10/31/23 documented the ointment was not administered seven of 27 opportunities. A physician order, dated 10/15/23, documented to cleanse wound to right medial calf with hibicleanse, pat dry, apply gentamicin, apply calcium alginate with silver, cover with ABD pad, wrap with Kerlix and secure with medical tape every day shift for pressure ulcer of other site, stage III. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 16 opportunities. A physician order, dated 10/17/23, documented to cleanse wound to sacrum with hibicleanse, pat dry, apply bacitracin ointment, apply Xeroform gauze, and cover with bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 14 opportunities. A physician order, dated 10/17/23, documented to cleanse wound to back with hibicleanse, pat dry, apply bacitracin ointment, apply Xeroform gauze, and cover with large border gauze every day shift for pressure ulcer of other site, stage IV. The TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 14 opportunities. A physician order, dated 10/23/23, documented to cleanse wound to right medial knee with hibilcleanse, pat dry, apply gentamicin, apply calcium alginate with silver, cover with ABD pad, wrap with Kerlix, and secure with medical tape every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of eight opportunities. A physician order, dated 10/23/23, documented to cleanse wound to right buttock with hibicleanse, pat dry, apply Santyl ointment nickel thick, apply gentamicin, apply calcium alginate, cover with superabsorbent dressing and bordered dressing every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed two of eight opportunities. A physician order, dated 10/25/23, documented to cleanse left calf with hibicleanse, pat dry, apply gentamicin, apply calcium alginate with silver, cover with ABD pad, and wrap with Kerlix every day shift for pressure ulcer of other site, stage IV. A TAR for 10/01/23 through 10/31/23 documented the treatment was not completed three of 16 opportunities. On 10/31/23 at 3:09 p.m., Res #43 was observed in their room in their bed. The resident was in a hospital gown with a single sheet over their lower torso. The resident was observed to be severely contracted on their lower extremities and some contractions to the wrist and hands were noted. The feet were exposed and were observed to be dry, cracking, and with long, curling, and discolored toenails. The resident stated they were not receiving wound care. They stated it was supposed to be done daily but it had not been completed since Sunday (10/29/23). They stated they felt their wounds were healing well before admission to this facility and now they were afraid they were worsening. They stated months of work have been undone because they haven't done it. The resident stated they had notified staff today their wound care had not been completed, but it had still not been done. They stated they were told by a nurse [she] can't be doing everyone's job because she had too much to do and then the care was pawned off on another nurse who did not do it. The resident stated they had not received a bath in over a week, and were supposed to get one on Wednesdays. The resident stated the staff never offered to trim their nails. Upon observation, the resident's fingernails were long, curling over the end of their finger, and were discolored with brown and black substances underneath the nails. The resident stated I'm covered in wounds, it just makes me want to cry. The resident became tearful and apologized for getting emotional. They stated I just gave up trying because they always have some excuse as to why they can't do my care. I'm just tired of it. I can't even sleep because i'm so worried about my wounds being wet or becoming septic from them. On 10/31/23 at 3:26 p.m., CNA #10 assisted the resident to reposition for visualization of their wounds. Upon exposure of the resident's back a pungent and putrid odor was evident. Two large bordered dressing were observed on the resident's back from their gluteal cleft extending up to their upper back. Both dressings on the resident's back were dated 10/29/23. The dressings were saturated with yellow, red, and brown drainage. The disposable absorbent pad beneath the resident's back was observed with dried and fresh blood scattered on the pad. The resident was observed with stretch gauze wrapping both lower legs from the knee to the ankle. Pillows were observed being used for positioning between and below the resident's legs. The pillow cases had scattered brown stains. The dressings below the stretch gauze on both legs were dated 10/29/23. The sheet below the resident's legs had scattered brown stains. The resident's ostomy was observed full of feces and bloated with gas. The resident stated the ostomy is not emptied very often and frequently leaked because it was full. The resident's hospital gown was observed with dried feces on the bottom hem. The resident's urinary catheter tubing was observed with sediment and urine in the drainage tubing. The foley catheter bag was observed with approximately 700 ml of clear yellow urine in the collection bag. The resident was unable to recall the last time their foley catheter was changed, but stated they believed it was when they were in the hospital around 10/02/23. The resident stated the staff tending to his needs in presence of surveyors was an act and they would not be helping him if [surveyors] were not here. A nurse progress note, dated 10/31/2023 at 5:41 p.m., the DON documented a medication error was completed related to the wound care missed on 10/31/23. The note documented the wound care was completed on 10/31/23 with no changes in wound characteristics. The note did not document the wounds had an odor. The note documented no new orders were received from the provider. On 11/01/23 at 8:44 a.m., CNA #4 stated Res #43 required a lot of care due to their diagnoses. They stated the resident didn't call for staff very often for assistance. They stated the resident's main care area was related to their wounds. They stated the resident was supposed to be bathed on Wednesday and Saturday. They stated they assisted with bathing prior to wound care, and the resident received a bed bath. They stated they were unsure the last time the resident was bathed. They stated Res #43 was not receiving wound care like they were supposed to. They stated there were times when care for residents was not completed because of lack of staff to ensure the care was done. They stated it was difficult to get the nurses to attend to resident needs because they were told the nurses were too busy. The CNA stated the ostomy was supposed to be emptied by a nurse, but they would do it if they noticed it was full because of the difficulty in getting a nurse to attend to the resident's needs in a timely manner. On 11/01/23 at 8:54 a.m., LPN #5 stated they did not provide care for the resident because they normally did not work the floor. They stated they were a supervisor and didn't typically care for residents and had only been in the facility for three weeks. They stated they would need to look at the orders to see what care the resident required. They stated the wound nurse was responsible for the resident's wound care. They consulted the resident's orders and stated the bag and wafer of the ostomy was ordered to be changed every three days. They stated the orders documented catheter care was supposed to be completed every shift. They stated the CNAs were able to empty the ostomy, but it was best for the nurse to do it so an assessment could be completed. On 11/01/23 at 9:02 a.m., the DON stated the nurses on the floor were responsible for ostomies. They stated the CNAs could empty the ostomies. The DON stated bathing was scheduled for all residents twice per week. They stated the CNAs were to perform ADLs and document every shift in the EHR. They stated linen changes were supposed to be completed daily if soiled, but at a minimum when the resident was bathed. The DON reviewed the EHR and stated they were unable to determine the last time Res #43 was bathed. The DON stated the wound care nurse completed all wound care for residents during the week and the floor nurses on the weekends. They stated all treatments should be documented on the TAR when they were completed. They stated an X on the TAR meant the treatment had not been completed. On 11/01/23 at 11:41 a.m., LPN #5 stated they completed the wound care for Res #43 on 10/31/23. They stated there was an odor present during wound care for the resident. They stated they did not notify the provider of the odor of the wounds. On 11/01/23 at 12:58 p.m., Res #43 was observed receiving wound care from the wound nurse. The two dressings on the resident's back, one to the left hip, and one on the sacrum were observed dated 10/31/23. The four dressings on the resident's legs were dated 10/29/23. The wound to the resident's hip was observed with a nickel sized area of slough in the center of the wound. The wounds on the back were observed with red beefy wound beds and with fresh bleeding upon cleansing. The resident's leg wounds were observed with red beefy wound beds and bleeding with cleansing. The sacral wound was observed with red beefy wound beds and bleeding upon cleansing.