Every finding on record at Accel At Crystal Park

Based on observation, record review, and interview, the facility failed to ensure: a. blood pressure parameters were followed to prevent a significant medication error for 1 (#43) of 33 medication observations; and b. an IV antibiotic was administered per physician's orders for 1 (#89) of five sampled residents reviewed for IV antibiotics. The administrator identified 60 residents resided in the facility. The MDS coordinator identified 42 residents received blood pressure medications in the facility. Findings: 1.On 08/27/26 at 8:52 a.m., CMA #1 was observed to administer one tablet of Midodrine HCL (a vasopressor/antihypotensive) 2.5mg to Resident #43 without taking a blood pressure prior. On 08/27/26 at 8:56 a.m., CMA #1 was observed taking the blood pressure after giving Resident #43 one tablet of Midodrine HCL 2.5mg. The reading showed 140/57. A physician's order for Resident #43, dated 10/14/25, showed Midodrine HCL 2.5mg tablet daily was to be held if systolic blood pressure was 120 or greater. The MAR for Resident #43, dated 08/2026, showed no documentation on 08/27/26 to indicate a blood pressure was taken for Resident #43 prior to receiving the Midodrine HCL. On 08/27/26 at 8:54 a.m., CMA #1 stated they had not taken Resident #43's blood pressure, but LPN #1 had taken the blood pressure and not given it to them yet. CMA #1 stated Resident #43's blood pressure was always below 120. On 08/27/26 at 8:55 a.m., LPN #1 stated they had not taken Resident #43's blood pressure and the medication aides took their own blood pressures. On 08/27/26 at 8:56 a.m., CMA #1 acknowledged the blood pressure for Resident #43 was 140/57 and stated they should have held the medication. On 08/27/26 at 2:04 p.m., the DON stated CMA #1 should have taken a blood pressure before giving Resident #43 their blood pressure medication. They stated staff were to follow physician's orders. 2. A baseline care plan for Resident #89, dated 08/21/26, showed the resident had diagnoses of disruption or dehiscence of closure of other specified internal operation (surgical) wound, and presence of aortocoronary bypass graft. A hospital discharge summary for Resident #89, dated 08/21/26, showed the resident was to receive daptomycin (an antibiotic) 500 mg IV one time with the first dose starting on 08/20/26. A nursing admission progress note for Resident #89, dated 08/21/26, showed the resident was admitted to the facility on [DATE]. A MAR for Resident #89, dated 08/2026, showed the resident was to receive daptomycin 500 mg IV one time a day on 08/22/26, 08/23/26, and 08/24/26. There was no explanation for the missed doses in the medical record. An Active Orders Report for Resident #89, dated 08/2026, showed and order on 08/24/26 for daptomycin sodium chloride (daptomycin/sodium chloride 500 mg/50mg-0.9% Solution) 500 mg IV one time daily. An admission assessment for Resident #89, dated 08/25/26, showed the resident had a BIMS score of 12, which indicated the resident's cognition was moderately impaired. An incident log report for medication related, dated 8/28/26, showed Resident #89 had an error report completed on 08/24/26. An incident care report, dated 08/24/26, showed Resident #89 reported a medication related error. On 08/25/26 at 7:13 p.m., Resident #89 stated they had an order for daily IV antibiotics when they left the hospital. Resident #89 stated they did not start the medication until Tuesday. 08/27/26 at 12:15 p.m., the infection control nurse stated they had concerns that the resident did not receive antibiotics. They were notified Monday Resident #89 did not have the antibiotic. They stated they would consider this to be a significant medication error because the wound site could have gotten worse. The infection prevention nurse stated would have notified the infection disease doctor and would expect their staff to have done that. They stated they notified the infection control doctor after discovery on Monday. 08/27/26 at 4:05 p.m., the DON stated the surgeon was notified about the delay in medication. They consider the delay in administering the medication IV antibiotics a significant medication error.

Based on observation, record review, and interview, the facility failed to ensure medication administration pass was completed in a manner to prevent cross contamination for 1 (#43) of 33 medication observations. The administrator identified 60 residents resided in the facility.Findings:, On 08/27/26 at 8:42 a.m., CMA #1 was observed pouring 4 capsules of Imbruvica (an antineoplastic) 140 mg for Resident #43 in their hands which were not gloved. A physician order for Resident #43, dated 09/10/24, showed Imbruvica 140 mg capsule, 4 capsules by mouth daily for diagnosis of malignant neoplasm of brain An annual assessment for Resident #43, dated 08/16/26, showed the resident had active diagnoses which included cancer, chronic diastolic congestive heart failure, and type 2 diabetes mellitus. On 08/27/26 at 8:42 a.m., CMA #1 stated they should not have put Imbruvica in their ungloved hand but poured the medication into the cap. CMA #1 stated they did not follow policy. On 08/27/26 at 2:04 p.m., the DON stated medications should not have been placed in CMA #1s ungloved hand. They stated the medications should have been placed in the cup.

Based on observation, record review, and interview, the facility failed to perform hand hygiene and wear a gown during wound care per enhanced barrier precautions for 1 (#1) of 3 sampled residents reviewed for wound care and infection control. The DON identified 19 residents with wounds and 21 residents with enhanced barrier precautions.Findings: On 05/26/26 at 11:40 a.m., LPN #1 was observed to complete wound care to the right calf of Resident #1. LPN #1 gathered supplies, entered the room of Resident #1, and donned a pair of gloves. LPN #1 was not observed to don a gown. LPN #1 positioned the legs of Resident #1 and removed a dressing from their right calf. LPN #1 was observed to change their gloves but was not observed to perform hand hygiene prior to donning another pair of gloves. LPN #1 cleaned the wound to the right calf with gauze moistened with wound cleanser, applied topical gentamicin (an antibiotic medication) with a tongue depressor, applied Santyl ointment (a medicated wound ointment), and calcium alginate (a wound care dressing) to the wound bed. LPN #1 was observed to change their gloves but was not observed to wash their hands or perform hand hygiene before they donned another pair of gloves. LPN #1 placed a dressing to right calf of Resident #1 and removed their gloves. LPN #1 was not observed to perform hand hygiene before they exited the room.A facility policy titled Hand Hygiene for Staff and Residents, dated 07/2018, read in part, Hand hygiene is the most important component for preventing the spread of infection.Hand hygiene is done: .Before: A. resident contact,.G. taking part in a medical or surgical procedure. After: A. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. resident contact. C. contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds.H. removal of medical/surgical or utility gloves.A facility policy titled ENHANCED BARRIER PRECAUTIONS, dated 04/01/24, read in part, EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High Contact Resident Care Activities:.h. Wound Care any skin opening requiring a dressing. Indicate the residents who are on EBP by subtle means, such as alternate color of the resident's name badge on door.An undated record of admission form showed Resident #1 had diagnoses which included paroxysmal atrial fibrillation, an unstageable pressure ulcer of the sacral region, problems related to social environment, pain, and aphasia following cerebral infarction. A physician order, dated 03/05/26, showed to apply Santyl (a medicated wound ointment) 250 units/1 gram ointment topically on day shift. A physician order, dated 03/25/26, showed to apply gentamicin sulfate (an antibiotic cream) 0.1% cream topically to the right calf daily. A physician order, dated 04/03/26, showed Resident #1 was to have enhanced barrier precautions. On 05/26/26 at 11:55 a.m., LPN #1 stated they had heard of enhanced barrier precautions but did not know which residents required enhanced barrier precaution. LPN #1 stated they had not had any training/education about enhanced barrier precautions. LPN #1 stated they would wash their hands when visibly soiled and at the end of wound care. On 05/27/26 at 11:42 a.m., the DON stated residents with enhanced barrier precautions were identified by the colored name badge on their door. The DON stated staff were to wear a gown and gloves during contact care for residents with wounds, a peg tube, or a catheter. The DON stated staff should have worn a gown during wound care for Resident #1. The DON stated hand washing/ hand hygiene was to be completed before donning gloves and with each glove change.

Based on record review and interview, the facility failed to ensure medications were available for administration per physician orders for 2 (#5 and #11) of 6 sampled residents reviewed for medication administration.The administrator identified 53 residents resided in the facility.Findings1. A physician order for Resident #11, dated 04/02/26, showed Xalatan 0.005% solution (a medicated eye drop for glaucoma) one drop into both eyes nightly at bedtime, with a start date of 04/02/26.A physician order for Resident #11, dated 04/02/26, showed Modafinil (a medication to promote wakefulness) 200 mg one time a day, with a start date of 04/03/26.A medication administration record for Resident #11, dated 04/02/26 through 04/12/26, showed the following:Modafinil 200 mg tablet was held or missed from 04/03/26 through 04/11/26. Documentation showed the medication was not available.Xalatan 0.005% eye drops were held or missed from 04/04/26 through 04/10/26. Documentation showed the medication was not available.A Record of Admission form, dated 05/28/26, showed Resident #11 admitted to the facility on [DATE] with diagnoses which included unspecified fracture of left femur, muscle weakness, chronic pain, and hypersomnia. 2. A physician order for Resident #7, dated 05/17/26, showed Cefdinir (an antibiotic used to treat infections) 300mg one capsule by mouth every 12 hours for three days with a start date of 05/18 26 and end date of 05/21/26.A physician order for Resident #7, dated 05/17/26, showed ipratropium bromide-albuterol (a medication used to increase air flow in the lungs) one inhalation every eight hours.A medication administration record for Resident #7, dated 05/01/26 through 05/26/26, showed Cefdinir 300 mg capsule was documented as held on 05/21/26 for the 9:00 a.m. dose. Documentation showed the medication was not available. A treatment administration record for Resident #7, dated 05/01/26 through 05/26/26, showed ipratropium bromide-albuterol was documented as held on 05/18/26 at 5:00 p.m., 05/19/26 at 5:00 p.m., 05/21/26 at 1:00 a.m., and 05/21/26 at 9:00 a.m. Documentation showed the medication was on order.A Record of Admission form, dated 05/28/26, showed Resident #7 admitted to the facility on [DATE] with diagnoses which included hypertension, saddle embolus of pulmonary artery and mild intermittent asthma.A policy titled Medication Ordering and Receiving from Pharmacy Provider, dated 01/2023, read in part, timely delivery of new orders is required so that medication administration is not delayed.On 05/28/26 at 10:20 a.m., the DON stated the medications were ordered for Resident #7 and Resident #11 and were not documented as given per the medical record. The DON stated the medications should have been available and administered to the residents.

Based on observation, record review, and interview, the facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for 1 (#1) of 1 sampled resident reviewed for PEG tube medication administration. The DON identified two residents with PEG tubes. Findings: On 05/27/26 at 9:25 a.m., a PEG tube medication administration was observed for Resident #1. LPN #2 prepared the mediation to be administered per Resident #1's peg tube. LPN #2 donned a gown and a pair of gloves and entered the resident's room. LPN #2 stopped the tube feeding and checked for placement and residual. LPN #2 poured water into a 30 ml cup with the crushed medication. LPN #2 held the PEG tube and attempted to pour the diluted medication directly into the tube without the use of a syringe. The diluted medication spilled out over and around the tube. LPN #2 obtained another 30 ml cup with diluted crushed medication. LPN #2 obtained a syringe but did not know how to connect the syringe to the peg tube. LPN #2 hesitated, activated the call light, and stated they would call for assistance. On 05/27/26 at 9:48 a.m., the DON was observed to enter Resident #1's room. The DON provided instructional assistance to LPN #2 regarding the process of administering medication through a PEG tube.A facility policy titled Medication Administration Enteral Tubes, dated 05/2023, read in part, The nursing care center assures the safe and effective administration of enteral formulas and medications.In-service training on safety, administration, and monitoring of enteral solutions and medications via the enteral tube is provided by the nursing care center to nursing personnel.An undated record of admission form showed Resident #1 had diagnoses which included an unstageable pressure ulcer of the sacral region, pain, and aphasia following cerebral infarction.A physician order, dated 10/14/25, showed to flush Resident #1's PEG tube with 30 ml of water before and after medications. The order showed to use 15 ml of water to flush between each medication administration.On 05/27/26 at 10:20 a.m., LPN #2 stated they were unsure how much medication Resident #1 received when the diluted medication spilled during administration. On 05/27/26 at 10:47 a.m., the DON stated licensed nurses completed a skills competency check list when they were hired and yearly during a skills fair. The DON stated LPN #2 did not correctly administer medication via the PEG tube for Resident #1. The DON stated the medication was spilled and the resident did not receive the full dose of the medication. The DON stated LPN #2 should have notified the physician.On 05/28/26 at 11:58 a.m., the DON stated the facility did not have a staff competency policy, but a skills competency list was completed upon hire. The DON stated LPN #2 did not have a skills competency check list completed upon hire. The DON stated the facility had 90 days to complete the skills competency check list upon hire. The DON stated LPN #2 was past the 90 days to complete the skills check list. The DON stated a process was needed to ensure completion of skills competencies.

Based on record review and interview, the facility failed to ensure a discharge plan was completed, reviewed with resident, and a copy was provided to the resident and/or family for 2 (#5 and #11) of 3 sampled residents reviewed for discharges.The DON identified 188 residents had been discharged in the past 90 days.Findings:A facility policy titled Discharge Plan, dated 04/26/24, read in part, as a minimum, the post discharge plan will include,.social services will review the plan with the resident and family before the discharge is to take place,.a copy of the post discharge plan will be provided to the resident and a copy will be filed in the resident's medical records.1. A record of admission document, dated 03/11/26, showed Resident #5 admitted with diagnoses which included acute systolic and diastolic heart failure, type 2 diabetes mellitus, acute kidney failure, end stage renal disease, and dependence on renal dialysis. The medical record showed Resident #5 was discharged on 04/14/26.A discharge planning document for Resident #5, dated 03/18/26, showed incomplete documentation for goals, members participating, and discharge planning. 2. A record of admission document, dated 04/02/26, showed Resident #11 was with diagnoses which included fracture of left femur, atherosclerotic heart disease, peripheral vascular disease, and hypersomnia. The medical record showed Resident #11 was discharged on 04/12/26. There was no documentation to show Resident #11 was provided discharge planning prior to discharge from the facility. On 05/27/26 at 2:45 p.m., Resident #11 stated they received instructions regarding medications to continue, but they were not clear on the discharge day or time until they were told they were ready to go home and needed to have someone pick them up.On 05/28/26 at 9:20 a.m., the social services director stated there was not a care plan meeting or discharge planning meeting held for Resident #11 due to the length of time the resident resided in the facility. They stated they kept notes regarding planning and conversations, but the notes were not in the medical record and copies of the notes were not provided to the resident or family. On 05/28/26 at 11:05 a.m., the DON stated the discharge planning form should have been completed by all members of the disciplinary team and should have been in the medical record. They stated they did not know if a copy had been given to the Resident #5 and Resident #11 or their family as there was no documentation in the electronic medical record.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure physicians orders were followed for medication administration and colostomy care in order to receive timely intervention to prevent a new stoma from becoming necrotic.On [DATE] at 1:59 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On [DATE] at 3:04 p.m., the administrator and corporate nurse consultant were notified of the IJ situation and the IJ template was provided.On [DATE] at 8:37 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY.Summary of Details which lead to outcomesFailed to ensure timely intervention for a necrotic stoma for Resident #7.The notification of the alleged immediate jeopardy states as follows:The facility failed to ensure a resident received timely intervention for an odorous necrotic stoma.How other residents with the potential to be affected by the same deficient practice will be identified. Residents requiring colostomy care are at risk.What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur.a. Resident #7 was discharged to hospitalb. Audit of current residents inhouse was performed to ensure stoma is patent and healthy appearing.c. Stoma site will be evaluated daily with care on the treatment record.d. DON/designee will provide education to all clinical staff on completion of colostomy care, evaluation, and documentation on the treatment record by 11:59 pm on [DATE].Involvement of Medical DirectorThe Medical Director has been notified of IJ status on [DATE] at 4:23 pm.Involvement of QA [quality assurance]An Ad Hoc [for this purpose] QAPI [quality assurance and performance improvement] meeting was held on [DATE] with the Medical Director, Facility Administrator, and Director of nursing to review the plan of removal.Who is responsible for the implementation of the process?The Administrator/designee will be responsible for the implementation of the New Process. The New Process/system will be started on [DATE] and no licensed staff will be able to return to work until they complete the above stated education. To be completed by 11:59pm on 10-14-25.The IJ was lifted, effective [DATE], when all components of the plan of removal had been verified as completed. Multiple staff on different shifts were interviewed regarding the in-service they received and able to verbalize understanding. Audit of residents with a colostomy including orders for colostomy care, assessment, and documentation in treatment records were reviewed. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to ensure:a. medications were administered per physicians' orders,b. daily assessment for colostomy care was performed in order to receive timely intervention to prevent a new stoma from becoming necrotic for 1 (#7) of 3 sampled residents reviewed for assessment, monitoring, and intervention; andc. daily assessment was completed for 1 (#3) of 9 sampled residents whose daily assessments were reviewed.The DON identified 52 residents resided in the facility and one resident had a colostomy.Findings:A policy titled POUCHING A COLOSTOMY OR AN ILLEOSTOMY, revised [DATE], read in part, Observe stoma for type, location, color, swelling, sutures, trauma, or irritation .Record the procedure in the record.A policy titled CHANGE OF CONDITION, revised [DATE], read in part, The practitioner needs a detailed description of the patient's condition to determine whether a symptom is problematic or simply a normal or expected variant.A policy titled DOCUMENTATION, revised [DATE], read in part, The Daily Skilled Note will trigger if the patient's payor is Medicare A or insurance and for the first 7 days from admit for other payors.1.A hospital Discharge summary, dated [DATE], showed Resident #7's gastrointestinal was soft, non-distended, nontender, ostomy was pink, patent, and protruding. The summary showed Resident #7 had physician orders for:a. Colace (a laxative medication) 100 mg, give one capsule in the evening,b. polyethylene glycol (a laxative medication) 17 gm/scoop powder to give one capful in the morning,c. diltiazem (a heart medication) HCl 240 mg capsule, extended release 24 hours. Take 240 mg by mouth in the morning, andd. metoprolol succinate (a blood pressure medication) 200 mg tablet, extended release 24 hours. Take 200 mg by mouth in the morning.Resident #7's physician orders, dated [DATE], showed:a. comprehensive metabolic panel one time only related to volvulus. The order was set to start on [DATE],b. complete blood count with auto differential one time only related to volvulus. The order was set to start on [DATE],c. acetaminophen (a pain medication) 500 mg tablet, give two tablets by mouth every six hours for 10 days related to unspecified pain,d. output check every two shift related to volvulus,e. colostomy care day shift one day related to volvulus, andf. pain scale check every two shift related to volvulus.Resident #7's physician orders, dated [DATE], showed:a. ondansetron (anti-nausea medication) HCl 4 mg tablet. Give one tablet by mouth every six hours as needed nausea/vomiting related to nausea, andb. tramadol (opioid pain medication) 50 mg tablet. Give one tablet by mouth every six hours as needed related to unspecified pain.A 5-day scheduled assessment, dated [DATE], showed Resident #7 was admitted to the facility on [DATE]. The assessment showed the resident had an ostomy, surgical wound, and pain. The assessment showed the resident's memory was ok and had diagnoses which included volvulus, heart failure, and chronic kidney disease. A [DATE] MAR showed Resident #7:a. received acetaminophen for pain every six hours from [DATE] for 9:00 p.m. dose to [DATE] for 3:00 p.m. dose,b. had generalized pain with a rating of 4 out of 10 and a rating of 6 out of 10 using the pain assessment in advanced dementia rating on [DATE], and 5 out of 10 on [DATE],c. received tramadol twice on [DATE] and once on [DATE], d. received ondansetron twice on [DATE] and twice on [DATE],e. did not receive the Colace that was part of the discharge orders from the hospital, andf. started taking the polyethylene glycol, diltiazem, and metoprolol on [DATE].A Daily Skilled Note, dated [DATE] at 10:51 p.m., showed Resident #7 had an ostomy under gastrointestinal and nutrition assessment. The note showed the resident had a rash and redness and their skin color was normal.A review of the Resident #7's health record did not have documentation the resident's colostomy site, stoma, and bowel sounds were assessed, and colostomy care was completed on [DATE].A nurse's note, dated [DATE] at 10:06 a.m., read in part, [Physician #1] was here rounding in facility this morning and seen [Resident #7] and wrote new orders for torsemide [a diuretic medication] 40mg QD [every day] and a KUB x-ray. resident is aware of new orders.A Radiology Interpretation report for abdominal x-ray, dated [DATE], showed Resident #7's abdomen had mixed air and stool with some interspersed areas of distended colon. The report showed there was more fecal material than normal involving the distal colon. The report showed significant stool was present.A nurse's note, dated [DATE] at 12:20 p.m., read in part, KUB results sent to [Physician #3], New order for 1L [litters] IV NS [normal saline] (one liter intravenous normal saline fluids), Bisacodyl supp [supplement] [treats constipation] to stoma x [times] 1. Family at bedside and aware of new orders. No new concerns at this time.There was no documentation the one liter intravenous normal saline fluids was administered on [DATE].A nurse's note, dated [DATE] at 7:53 p.m., read in part, Suppository to be placed into stoma, when colostomy bag remove, stoma noted to be black and necrotic with an odor. [Physician #3] updated with report and a picture. New order for CBC [complete blood count], CMP [comprehensive metabolic panel], and KUB. All these studies have already been taken, labs were done this morning and KUB was already sent to [Physician #3]. Direction received to watch for bleeding from stoma. Resident continued to decline, Speech became weak and blood note to bleed into colostomy bag, New order to send resident out to ED [emergency department] for further Evaluation. Family at bedside and involved in care. EMSA arrived and took pt [patient] to [hospital name withheld] at 1602 [4:02 p.m.] this afternoon.A Change of Condition form, dated [DATE] at 9:31 p.m., read in part, For new symptoms, signs and other changes in condition: Evaluate the resident and complete the COC [change of condition] form below, Check vital signs and finger stick blood sugar if indicated, Review medical record for pertinent history. The report had Resident #7's vital signs completed on [DATE] at 10:19 a.m. and pain rating score of 5 out of 10 completed on [DATE] at 10:47 a.m.There was no documentation the facility completed a focus assessment of Resident #7's vital signs, assessed bowel sounds, and pain when the resident's stoma was observed to be black and necrotic with an odor.An EMSA report, dated [DATE], showed emergency service was called at 3:37 p.m. The report showed they arrived Resident #7's side at 3:54 p.m. and left the facility at 4:15 p.m. The report showed the facility nursing staff on scene reported abdominal distention at the site of colostomy that was no longer functioning. The report showed the site was bleeding and bruising was noted around the site. The report showed Resident #7 was alert and oriented and breathing rapidly without distress. The report showed Resident #7's skin was cold, clammy, pale, jaundiced, and their speech was slurring. The report showed Resident #7 reported low to mild pain in their abdomen. The report showed respiratory rate at 3:56 p.m. was 48.A hospital report, dated [DATE], showed Resident #7 had diagnoses of acute kidney injury, generalized abdominal pain, bowel ischemia, and hemoperitoneum. The report showed Resident #7 had abdominal distention, nausea, and blood was in the ostomy bag with minimal stool present. The report showed Resident #7 reported intermittent fever and chills. The report showed Resident #7 expired at 8:48 p.m.A computed tomography scan, dated [DATE], showed Resident #7 had mildly dilated and thickened loops of small bowel with scattered areas of pneumatosis.A death certificate for Resident #7 showed the immediate cause of death was bowel ischemia on [DATE].On [DATE] at 11:46 a.m., a review of text messages between LPN #2 and physician #3 showed the physician was notified of the observation of the stoma on [DATE] at 12:40 p.m. The text message showed at 12:44 p.m. the physician informed the nurse to watch for bleeding from the colostomy after the nurse informed them that the labs and x-ray they just ordered had been completed that morning. The text message showed at 3:29 p.m. the nurse informed physician #3, Resident #7 was now slurring, their colostomy was bleeding, and the resident's family wanted the resident to go back to acute care. Physician #3 responded to send Resident #7 out.On [DATE] at 10:21 a.m., resident rep #1 stated Resident #7 was sent to the hospital on [DATE] only because Resident #7 was slowing their speech and had blood in their colostomy bag. They stated the facility did not have any sense of urgency.On [DATE] at 10:23 a.m., resident rep #1 stated they visited Resident #7 in the morning of [DATE] and the resident was clammy and was unable to do physical therapy because their blood pressure was high.On [DATE] at 10:25 a.m., resident rep #1 stated Resident #7 had nausea and a little bit of vomiting on [DATE]. They stated the resident continued to have nausea on [DATE] and [DATE]. They stated the resident had pain from the surgery. Resident Rep #1 stated a nurse provider saw the resident on [DATE] and thought the resident had a urinary tract infection and ordered a urinalysis. They stated the urine sample was collected the evening of [DATE].On [DATE] at 10:28 a.m., resident rep #1 stated the resident did not receive their bowel medication they ordered at the hospital.On [DATE] at 10:30 a.m., resident rep #1 stated a doctor listened to Resident #7 in the morning of [DATE] and ordered an abdominal x-ray. They stated the nurse saw how dark the colostomy area looked because they had to remove the bag on [DATE].On [DATE] at 10:36 a.m., resident rep #1 stated it took the facility about two hours to send Resident #7 to the hospital from the time the nurse observed how the resident's colostomy looked like.On [DATE] at 11:22 a.m., the surveyor was unable to reach Physician #3 via phone call. Physician #3 was identified as the main physician for Resident #7. On [DATE] at 11:24 a.m., physician #1 stated Resident #7 was not their resident. They stated they were rounding on [DATE] and the facility had asked for some blood work and abdominal x-ray because Physician #3 was not there. Physician #1 stated if a resident had a necrotic stoma with odor that was not present before, they would send them to the emergency room. They stated it was an immediate intervention.On [DATE] at 11:28 a.m., physician #2 stated if a resident had a necrotic stoma with odor, that was not bleeding, and the resident did not have pain and nausea, the nurse needed to call the provider and if the provider wanted to assess the resident themselves. Physician #2 stated the stoma could get discolored and if the middle was pink and the patient was asymptomatic, they needed to monitor the resident closely because things like that could happen. They stated they would order KUB and blood work. Physician #2 stated if the resident got worse like having a fever, bloody stool coming from the stoma, tenderness to abdomen, those were symptoms they were getting infected or ischemic and needed to be sent to the emergency room.On [DATE] at 1:05 p.m., the DON stated the admission assessment, dated [DATE], showed Resident #7's stoma was normal and protruding and bowel sounds active.On [DATE] at 1:13 p.m., the DON stated colostomy care meant cleaning the bag and switching out the bags. They stated the nurses signed off on the care.On [DATE] at 1:24 p.m., the DON stated the Colace was not ordered and should have been.On [DATE] at 1:25 p.m., the DON stated it appeared the normal saline was not administered at 1:00 p.m. They stated the reason documented was the resident was not available. The DON stated the resident was still in the facility at that time.On [DATE] at 1:31 p.m., the DON stated not receiving the ordered Colace and polyethylene glycol could contribute to the results seen on the abdominal x-ray.On [DATE] at 1:34 p.m., the DON stated Resident #7 received ondansetron twice on [DATE] and twice on [DATE].On [DATE] at 1:36 p.m., the DON stated Resident #7 received as needed tramadol twice on [DATE] and once on [DATE].On [DATE] at 4:08 p.m., the DON stated the only assessment the nurse completed on [DATE] after observing the stoma to be black, necrotic with an odor was the information on the nurse's notes. The DON stated they would have expected to see an assessment of Resident #7's vital signs, pain, bowel sounds, and document what the stool looked like in the bag. 2. Resident #3's 5-day PPS scheduled assessment for a Medicare Part A Stay, dated [DATE], showed the resident was admitted on [DATE].A Daily Skilled Note, dated [DATE], showed Resident #3 had diagnoses which included malignant neoplasm of the mandible, malignant neoplasm of mouth, malignant neoplasm of anus, and pressure ulcer of the sacral region stage 3.There was no documentation daily skilled notes/assessments were completed from [DATE] through [DATE].On [DATE] at 10:25 a.m., the traveling DON stated they could not locate the daily nursing assessments for the dates above.On [DATE] at 1:58 p.m., RN #1 stated assessments were completed daily and involved observing and communicating with the resident. They stated the assessments had pre-generated questions to ask the resident in areas like pain, skin issues, assistance needed, and oxygen use.On [DATE] at 2:02 p.m., RN #1 stated the last daily assessment completed on Resident #3 was on [DATE]. They stated the assessment was supposed to be completed by night shift.On [DATE] at 1:02 p.m., the DON stated they expected the daily assessments to be completed.

Based on record review and interview, the facility failed to:a. ensure a hospital's discharge orders were transcribed and administer as ordered for 1 (#7); andb. administer medications as ordered for 1 (#4) of 5 sampled residents reviewed for medications as ordered.The DON identified 52 residents resided in the facility. Findings:A policy titled Non-Controlled Medication Orders, dated 01/2023, read in part, Implement a transfer order without further validation if is signed and dated by the resident's current physician, unless the order is unclear or incomplete.A policy titled Medication Administration, dated 01/2024, read in part, Medications are administered as prescribed.1. Resident #7's hospital Discharge summary, dated [DATE], showed a physician's order for:a. Colace (a laxative medication) 100 mg, give one capsule in the evening,b. polyethylene glycol (a laxative medication) 17 gm/scoop powder to give one capful in the morning,c. diltiazem (a heart medication) HCl 240 mg capsule, extended release 24 hours. Take 240 mg by mouth in the morning,d. metoprolol succinate (a blood pressure medication) 200 mg tablet, extended release 24 hours. Take 200 mg by mouth in the morning,e. aspirin (a non-steroidal anti-inflammatory drug medication) 81 mg chewable tablet. Chew 81mg in the morning,f. calcium carbonate (an antacid medication) 600 mg chewable tablet. Chew 600 mg in the morning,g. cholecalciferol (vitamin D3) 50 micrograms (2,000 unit), take one capsule in the morning,h. Lasix (a diuretic medication) 20 mg tablet. Take 20mg in the evening,i. potassium chloride (a supplement) 10 milliequivalent extended-release tablet. Take one tablet by mouth in the morning, andj. oxycodone (an opioid pain medication) 5 mg immediate release, take one tablet by mouth every six hours if needed for severe pain (pain scale 7-10) for up to five days.A review of Resident #7's December 2024 physician orders showed oxycodone, aspirin, calcium carbonate, cholecalciferol, diltiazem, metoprolol, polyethylene glycol, and potassium were ordered by the facility on 12/25/24. The physician orders showed the facility did not order Lasix and Colace.Resident #7's 5 -day scheduled assessment, dated 12/26/24, showed the resident was admitted to the facility on [DATE]. The assessment showed the resident had diagnoses which included volvulus, heart failure, and chronic kidney disease. On 10/14/25 at 1:14 p.m., the DON stated their preference for transcribing hospital discharge orders was to have the individual putting the orders in and to initial and have the DON or assistant DON check and initial off on the orders.On 10/14/25 at 1:16 p.m., the DON stated an acceptable timeframe for new admits to receive their prescribed medications would be three hours.On 10/14/25 at 1:21 p.m., the DON reviewed Resident #7's discharge medication orders. They stated oxycodone, aspirin, calcium carbonate, cholecalciferol, diltiazem, metoprolol, polyethylene glycol, and potassium were ordered by the facility on 12/25/24.On 10/14/25 at 1:22 p.m., the DON stated the facility did not order the Lasix and Colace. They stated both medications should have been ordered on admit.2. Resident #4's 5-day PPS scheduled assessment, dated 04/19/25, showed the resident had diagnoses which included diabetes, hypertension, and abnormalities of gait and mobility. The assessment showed the resident had occasional pain and received pain medication. A physician's order, dated 05/22/25, showed Lortab (an opioid pain medication) 7.5/325 mg. Give one tablet by mouth every six hours for pain.Resident #4's May 2025 MAR showed letter H on the following administration times:a. on 05/23/25 at 7:00 a.m., 1:00 p.m., and 7:00 p.m. The pain rating for these administration times was 8 out of 10., andb. on 05/24/25 at 7:00 a.m., and 7:00 p.m. There was no pain rating at the 7:00 a.m. dose and the pain rating was 8 out of 10 on the 7:00 p.m. dose.On 10/15/25 at 8:58 a.m., the travelling DON stated CMAs administered routine pain medications.On 10/15/25 at 1:32 p.m., CMA #1 stated if they held medications due to parameters or if the resident was not available, they were to let the nurse know.On 10/15/25 at 1:38 p.m., CMA #1 stated H on the resident's MAR meant the medication was held.On 10/15/25 at 1:39 p.m., CMA #1 stated if a medication was not available, they were to let the nurse know and call the pharmacy. They stated if the pharmacy did not have the medication, they were to let the physician know about it.On 10/15/25 at 1:46 p.m., CMA #1 stated they could not see why the medication was held on 05/23/25 at 7:00 a.m. and 1:00 p.m.On 10/15/25 at 1:48 p.m., CMA #1 stated the dose for 05/23/25 at 7:00 p.m. was held because the medication was not available. They stated they could not locate any notes showing staff communicated with pharmacy or the facility staff.On 10/15/25 at 1:53 p.m., CMA #1 stated the dose for 05/24/25 at 7:00 a.m. was held because the medication was on the nurse's cart. They stated there was no documentation why the dose on 05/24/25 at 7:00 p.m. was held.On 10/15/25 at 1:58 p.m., CMA #1 stated it was important for residents to receive their pain medications because they could be in pain and may have been on their pain medications for years.On 10/15/25 at 3:26 p.m., the DON stated medications were held for reasons not on the orders, they should notify the physician.

Based on record review and interview, the facility failed to ensure baseline care plans were completed for 2 (#4 and #5) of 9 sampled residents whose baseline care plans were reviewed.The DON identified 52 residents resided in the facility. Findings:1. Resident #5's 5-day PPS scheduled assessment, dated 08/31/25, showed the resident was re-admitted on [DATE]. The assessment showed the resident had a diagnosis of other major orthopedic surgery.There was no documentation a baseline care plan was completed upon re-admission to the facility on [DATE].On 10/13/25 at 2:00 p.m., the traveling DON stated they could not locate a baseline care plan for Resident #5. 2. Resident #4's 5-day PPS scheduled assessment, dated 04/19/25, showed the resident was admitted on [DATE]. The assessment showed the resident had diagnoses which included diabetes, hypertension, and abnormalities of gait and mobility.There was no documentation a baseline care plan was completed upon admission to the facility on [DATE].On 10/15/25 at 8:25 a.m., the traveling DON stated Resident #4 did not have a baseline care plan. They stated nurses were responsible for completing baseline care plans on admit.

Based on observation, record review, and interview, the facility failed to handle intravenous tubing to prevent cross contamination and follow EBP protocol during IV medication infusion for 1 (#5) of 2 sampled residents reviewed for IV therapy.The travelling DON identified 21 residents on EBP in the facility. Findings:On 10/07/25 at 8:01 a.m., IV tubing was observed without an end cap and hanging about 2 to 3 inches above the floor in Resident #5's room. The tubing was connected to a new bag of meropenem 1 gram /50 milliliters (an antibiotic medication). The tubing had no date. Two empty bags of meropenem and a white syringe cap were observed in the trashcan. There was a small amount of clear liquid in the trashcan.On 10/07/25 at 8:23 a.m., Resident #5 was observed with a PICC line in their right arm. LPN #1 was observed to pick up the IV tubing and pole and bring it closer to resident. With gloves on, LPN #1 wiped the end tubing with an alcohol prep wipe. LPN #1 wiped the PICC hub with an alcohol prep wipe and connected the tubing to the PICC line.On 10/07/25 at 8:28 a.m., LPN #1 was observed to start Resident #5's infusion.LPN #1 did not have a gown on while administering the IV medication.A policy titled ADMINISTRATION SET CHANGE, revised 10/2024, read in part, For intermittent administration sets that are used more than once in 24-hour period, attached a new single use sterile cap on the end of the set after each intermittent use .Label the administration set with the date, and time hung, date set is due to be replaced, and initials .Change intermittent primary and secondary sets every 24 hours.A policy titled ENHANCED BARRIER PRECAUTIONS, revised 03/2025, read in part, This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC [Centers for Disease Control and Prevention]-targeted and epidemiologically important MDROs [multidrug-resistant bacteria] when Contact Precautions do not apply .Device care or use: Central line.Resident #5's 5-day PPS scheduled assessment, dated 08/31/25, showed the resident had central IV access. The assessment showed the resident had diagnosis of other major orthopedic surgery.Resident #5's physician's order, dated 09/20/25, showed meropenem 1gm powder for solution one IV every eight hours related to atherosclerosis of native arteries of right leg with ulceration.On 10/07/25 at 8:00 a.m., LPN #1 stated they just set up Resident #5's antibiotic for when they returned to their room for infusion.On 10/07/25 at 8:58 a.m., LPN #1 stated they were not sure of the frequency of IV tubing change in the facility. They stated it was their fifth day of work. They stated IV tubing was usually changed every 24 hours. LPN #1 stated they did not change Resident #5's IV tubing and it had no date.On 10/07/25 at 9:00 a.m., LPN #1 stated they were not sure if the resident was supposed to be on EBP and did not know what it meant.On 10/07/25 at 9:01 a.m., LPN #1 stated the IV tubing was supposed to have an end cap for infection control. They stated Resident #5's tubing did not have an end cap. They stated the tubing initially had a normal saline syringe white cap on it, so they discarded it. On 10/07/25 at 12:37 p.m., the DON stated the IV tubing should be discarded after use if used once in 24 hours. They stated if the tubing was used for multiple administrations in the day, the tubing should have an end cap and discarded after 24 hours. The DON stated the tubing should have the date and time it was hung, and date and time it should be changed with staff initials.On 10/07/25 at 1:14 p.m., the DON stated a gown and gloves were needed for EBP.

Based on observation, record review, and interview, the facility failed to ensure a resident had a care plan for the use of a PICC line for 1 (#5) of 9 sampled residents whose care plans were reviewed.The DON identified 52 residents resided in the facility. Findings:On 10/07/25 at 8:23 a.m., Resident #5 was observed with a PICC line in their right arm.Resident #5's 5-day PPS scheduled assessment, dated 08/31/25, showed the resident had central IV access. The assessment showed the resident had diagnosis of other major orthopedic surgery.Resident #5's care plan, revised 09/08/25, did not document the use of a PICC line.On 10/13/25 at 1:57 p.m., RN #1 stated the resident had a PICC line since admit to the facility.On 10/13/25 at 2:27 p.m., the MDS coordinator stated all PICC lines should be included in the resident's care plan.On 10/13/25 at 2:29 p.m., the MDS coordinator stated Resident #5's care plan did not include the use of a PICC line.

Based on observation, record review, and interview, the facility failed to administer IV medication as ordered for 1 (#5) of 2 sampled residents reviewed for IV therapy.The travelling DON identified seven residents received IV therapy in the facility. Findings: On 10/07/25 at 8:28 a.m., LPN #1 was observed to start Resident #5's infusion. The rate was set at 125ml/hr on the dial of the IV tubing.A policy titled INTRAVENOUS FLUID AND DRUG ADMINISTRATION GENERAL POLICIES, dated 10/2024, read in part, The nurse should assess the rate of the solution/medication ordered .The nurse will verify that the container's label coincides with the prescriber's order. Verify contents, dose, prescribed rate, and expiration date of the solution.A physician's order, dated 09/20/25, showed meropenem (an antibiotic) 1gm powder for solution one intravenous every eight hours related to atherosclerosis of native arteries of right leg with ulceration. There was no rate of infusion Resident #5's antibiotic order in the physician's order and medication administration record.On 10/07/25 at 8:28 a.m., LPN #1 stated there was no specific ordered rate by the physician for the meropenem. They stated they would infuse the antibiotic at a rate of 125ml/hr because that was what they do. On 10/07/25 at 8:30 a.m., Resident's #5's meropenem bag was observed infusing. The bag showed to infuse at a rate of 100ml/hr every eight hours. On 10/07/25 at 8:47 a.m., LPN #1 stated they were to double check orders for the right medication, right route, allergies, and date of birth prior to administration.On 10/07/25 at 8:48 a.m., LPN #1 stated if an IV medication did not have a rate, they would contact the physician. They stated they had not contacted the physician. LPN #1 stated the physician should be contacted prior to infusing the medication. On 10/07/25 at 8:49 a.m., LPN #1 stated they had reviewed the medication bag prior to infusing and it had the resident's name, date of birth , and dose.On 10/07/25 at 8:51 a.m., LPN #1 stated they did see the rate on the bag and did not infuse the medication at the rate of 100ml/hr. They stated they would change the rate.On 10/07/25 at 12:49 p.m., the DON stated nurses were to verify orders against the bag for IV medication administration. They stated they were to follow the five rights of medication administration.On 10/07/25 at 12:50 p.m., the DON stated an IV infusion needed to have the rate to be administered.On 10/07/25 at 12:51 p.m., the DON stated Resident #5's antibiotic order did not have the rate for infusion, but they mostly infused them over 30 minutes. They stated their policy showed the label should have the rate to be infused.On 10/07/25 at 12:54 p.m., the DON stated the importance of having rates on the resident's order was for interactions and side effects.

Based on observation, record review and interview, the facility failed to ensure a topical pain medication was administered as ordered for one (#85) of five sampled residents reviewed for unnecessary medications. The administrator identified 56 residents resided in the facility. Findings: The Medication Administration policy, dated 01/2024, read in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Resident #9 had diagnoses which included pain. A physician's order, dated 01/08/25, documented Voltaren arthritis pain 1% topical gel. Apply by topical every 12 hours right knee for pain. The January 2025 MAR documented x for Resident #85's Voltaren arthritis pain 1% topical gel for the 9:00 a.m. administration on the 9th, 11th, 12th, 13th and the 9:00 p.m. administration on the 11th. It documented due to special parameters on the above dates. There was no documentation to explain what due to special parameters was for the above dates. On 01/15/25 at 8:42 a.m., Resident #85 stated they did not receive any topical medication for their knee. They stated they would not mind having a topical pain medication. Resident #85's family member was at their bedside. They stated they had never seen staff apply any pain cream to the resident's knee. On 01/15/25 at 9:14 a.m., LPN stated the nurses administered topical pain medications. On 01/15/25 at 9:18 a.m., LPN #1 reviewed Resident #85's MAR. They stated they were not sure what the x, or due to special parameters meant on the resident's January 2024 MAR. On 01/15/25 at 9:19 a.m., LPN #1 stated they had cared for the Resident #85 during their current stay. They stated they had not administered any topical pain gel for the resident. On 01/15/25 at 9:28 a.m., the DON reviewed Resident #85's January 2025 MAR. They stated the x meant the medication was not administered. They stated the medication was added to the med aide MAR and they would change it to the nurses discipline. The DON stated due to parameters could be related to vital signs.

Based on record review and interview, the facility failed to ensure the abuse policy was implemented and abusive behavior was reported to the abuse coordinator in a timely manner within 2 hours of occurrence to prevent further risk to other residents for one (#21) of one resident sampled for abuse. The administrator identified 56 residents resided in the facility. Findings: An Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, reviewed 02/2020, read in part, All staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator. The policy also read, Upon learning of a suspected incident of resident abuse, neglect, exploitation, and/or misappropriation of resident property, the Charge Nurse or her Department Manager or Supervisor must immediately notify the Abuse Coordinator the DON of the incident. The policy also read, Upon receiving and allegation abuse .the abuse coordinator will notify .a. not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #21 had diagnoses which included end stage renal disease and legally blind. A Nurses Note, dated 01/12/25 at 11:07 p.m., read in part, At about [8:30 a.m.] Pt asked for PRN pain med, that [they] was in pain. This nurse asked the med aide if [they] had given pt. [their] night meds. The med aide said no but [they] was on [their] way down there. This nurse added Pt's pain medicine with [their] night meds. The med aid returned with the message that this Pt. also wanted [their] PRN Flexeril [muscle relaxer]. this nurse was in the middle of another pt's wound care. This nurse said the Flexeril will be taken to this Pt when current wound care is done. After wound care was done, the Flexeril was taken to this pt. This Pt's told this nurse that the CNA was lying about the time that [they] told me about Pt's request for pain med. CNA came in the room and said [they] was not, I asked CNA to leave the room and calmed this patient down telling that it might have been a misunderstanding or miscommunication, I asked this patient if [they] needed anything else and this pt said [they] was fine. At approximately [10:00 p.m.] this patient's [family member] called the facility yelling and saying that this nurse and the CNA was intimidating [their] [Resident #21] and [they] was going to get our licenses revoked. This nursed politely asked Pt's [family member] to calm down and tell this nurse what the problem was, Pt's [family member] refused and kept yelling on the phone, saying that this nurse called the DON and told [them] that this Pt. had lied. This nurse denied calling the DON about this issue and that this nurse has no idea what [they] was this pt's [family member] was talking about. This Pt's [family member] said this was condescending and said [they] would come to facility in the am and hung up. The CNA time detail report for 01/12/25 documented CNA #3 start time was 2:55 p.m. on 01/12/25, and the end time was 12:15 a.m. on 01/13/25. An OSDH Incident Report Form, dated 01/13/24 (date year error), documented Resident involved was Resident #21. Part B read in part, Administrator informed that patient had an incident last night. When discussing with the patient [they] stated that the PRN [person] [they] call [name withheld] was very nice at the beginning of the shift. Later in the shift when [they] had asked for [their] pain medication [the PRN person] became rude and was making fun of [their] eyes and talking about [their] family. Patient felt this is abusive behavior. CNA [name withheld] suspended pending investigation. Investigation ongoing. An undated OSDH Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form, documented CNA #3 was suspended on 01/13/24. (Dates are incorrect and do not correlate with the nurse note). On 01/13/25 at 10:41 a.m., Resident #21's family member was present with resident and stated there had been an incident the night before stating Resident #21 had stated they were scared after an incident with the evening CNA and nurse. They stated Resident #21 called them stating CNA #3 brought the meal in and they were asked to get pain medication. They stated they kept pushing the button because it had taken them too long to come. Then CNA #3 became frustrated and stated, You were not the only one here. They stated they asked that the CNA stay out of their room and they kept coming back arguing and cursing and saying Resident #21's concerns were not as much as other people there. The family member stated they reported the verbal abuse concerns to the charge nurse LPN #4 who told them to have the resident look past the CNA as they were young. Resident #21 stated they were made to feel so bad. On 01/13/25 at 11:24 a.m., the administrator stated they were made aware of an allegation of abuse regarding Resident #21 on the morning of 01/13/25 and that it was regarding the way a staff member had spoke to them by making fun of them and were being inappropriate. They stated the resident stated it was abuse the way they were talking to them. On 01/14/25 at 9:10 a.m., LPN #4 stated the details of the nurses note, they did not feel was abuse, but that was a misunderstanding. They stated there was some back and forth between Resident #21 and CNA #3 about the details of when the resident requested the pain medication. LPN #4 stated they had to ask the CNA to leave the room because things began to escalate and then calmed the resident down. LPN #4 stated they reported the incident to the DON the next morning. LPN #4 stated the resident had been upset by the incident. LPN #4 stated the meaning of abuse was anything verbally or physically harming the patient. They stated the abuse process for something like that incident was to have the CNA leave the room, talk to the patient, and see what's going on. LPN #4 stated CNA #3 took care of the other patients for the remainder of the shift and told them not to go into Resident #21's room. On 01/14/25 at 10:28 a.m., the administrator stated in the presence of the corporate nurse, they were the abuse coordinator. They stated they were notified of the allegation of abuse by reading the clinical notes and were not informed by the staff in the facility. The administrator stated they would have expected to have been notified by their staff at the time of the incident. On 01/14/25 at 10:35 a.m., the administrator stated they had also suspended the nurse that worked that evening as well since they did not notify the administrator.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered and a resident was supervised during the administration of a nebulizer treatment for one (#243) of one sampled resident reviewed for respiratory care. The DON identified 20 residents who received continuous oxygen therapy in the facility. Findings: The Medication Administration, Nebulizers Updraft policy, revised 01/2023, read in part, Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. Resident #243 had diagnoses which included acute respiratory failure, unspecified whether with hypoxia or hypercapnia. A physician's order, dated 01/08/25, documented oxygen 2 liters per minute inhalation every two shifts via nasal cannula, oxygen saturation check related to acute respiratory failure, unspecified whether with hypoxia or hypercapnia. A physician's order, dated 01/09/25, documented albuterol sulfate 2.5mg/3 ml (0.083%) solution for nebulization, one vial inhalation three times per day. Minute check 15. On 01/12/25 at 1:35 p.m., Resident #243 was observed receiving a nebulizer breathing treatment in their room via a mask. There was no staff in the room or outside of the resident's room. The oxygen concentrator was set at 3.5 liters per minute. On 01/12/25 at 1:36 p.m., Resident #243 asked the surveyor if they could turn off the nebulizer. They were informed to call for assistance using their call light. The resident stated staff administered the breathing treatment, but they were unsure what time. On 01/12/25 at 1:40 p.m., Resident #243 turned off the nebulizer treatment. The medicine chamber was empty. Resident #243 had a moist cough. On 01/12/25 at 1:42 p.m., Resident #243 stated they were on 3.5 liters per minute oxygen. On 01/12/25 at 1:47 p.m., CNA #2 entered Resident #243's room. They stated to the Resident, Oh you turned off the treatment. CNA #2 put the nebulizer mask in a bag. The resident informed CNA #2 they would like another breathing treatment. On 01/12/25 at 1:50 p.m., LPN #2 came and assessed the resident's oxygen saturation. They stated it was 93%. On 01/12/25 at 1:54 p.m., LPN #2 stated the process for administering nebulizer treatment was to administer and check on the resident in about two to three minutes. They stated they had about three to four nebulizer treatments on different residents at the same time and could not stay in the resident's room during the treatment. On 01/12/25 at 2:03 p.m., LPN #2 observed the resident's oxygen concentrator. They stated the concentrator was set at 3.5 liters per minute. On 01/12/25 at 2:08 p.m., LPN #2 stated the nurses were responsible for stopping the nebulizer treatments. They stated they stopped Resident #243's treatment, but could not recall or verify on the resident's TAR what time. They stated the resident may had given themselves a breathing treatment. On 01/12/25 at 2:10 p.m., LPN #2 stated Resident #243's order was for 2 liters per minute oxygen. They stated they had notified the resident's provider on 01/08/25 the Resident was on 3.5 liters per minute oxygen at home and had the order to keep the resident on 3.5 liters per minute. They stated they could not locate documentation to support the communication they had with the provider. On 01/12/25 at 2:19 p.m., Resident #243 stated they did not self-administer the nebulizer treatment. On 01/13/25 at 11:29 a.m., the DON stated staff was to follow physician orders. They stated all orders were to be updated in the electronic health record. On 01/13/25 at 11:31 a.m., the DON stated staff were to stay with the residents during nebulizer treatments. On 01/13/25 at 12:37 p.m., the DON stated Resident #243 was not assessed to self-administer nebulizer treatment.

Based on observation, record review and interview, the facility failed to ensure a medication error of less than five percent for one (#142) of four residents observed during medication administration. The medication error rate was 7.14% The administrator identified 56 residents resided in the facility. Findings: A Medication Administration policy, dated 01/2024, read in part, Medications are administered as prescribed in accordance with the manufacturers' specifications, good nursing principle and practices. The policy also read, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. The policy also read, Medications are administered in accordance with written orders of the prescriber. The policy also read, Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. The policy also read, Verify medication is correct three (3) times before administering the medication. The policy also read, Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing center. Resident #142 had diagnoses which included hypothyroidism. A physician's order, modified date of 01/13/25, documented levothyroxine 200 mcg tablet (hormone) 1 tablet by mouth at 5:00 a.m. The patient to take with 25mcg dose to equal 225mcg. The date of administration for 01/14/25 was documented 9:10 a.m. A physician's order, dated 01/13/25 documented levothyroxine 25mcg tablet 1 tablet by mouth at 5:00 a.m. The patient to take with 200mcg dose to equal 225mcg. The date of administration for 01/14/25 was documented 9:10 a.m. On 01/14/24 at 9:01 a.m., CMA #1 was observed to prepare medication for Resident #142. They were observed to prepare and administer levothyroxine 200mcg 1 tab and levothyroxine 25mcg 1 tab by mouth to the resident. On 01/14/25 at 2:36 p.m., LPN #2 was asked about the medication since the CMA had gone home for the day. LPN #2 stated both the levothyroxine dose orders were to be administered every morning at 5:00 a.m. They stated they were administered at 9:10 a.m. LPN #2 stated they were aware the medication was given after 5:00 a.m. They stated the outgoing agency nurse told the CMA that morning they had given all the meds due, but during observation of the meds the CMA had noticed the levothyroxine had not been given, therefore, LPN #2 stated they told the CMA to ask the resident if they received the medication and if they had not then to administer the medication. On 01/14/25 at 2:28 p.m., LPN #2 stated both doses of the levothyroxine were not administered according to physician orders. On 01/15/25 at 8:42 a.m., the DON stated they had called and notified the resident's physician and nurse practitioner of the levothyroxine being given and no new orders were received.

Based on observation, record review, and interview, the facility failed to ensure a discharge hospital order for a fluid restriction was followed upon admission for one (#241) of three sampled residents reviewed for fluid restrictions. The administrator identified three residents on fluid restrictions resided in the facility. Findings: The FLUID RESTRICTION policy, revised 04/14/23, read in part, The Dining Services Department will coordinate with nursing services to verify that the resident's order for fluid restriction is implemented. Resident #241 had diagnoses which included chronic kidney disease and pulmonary edema. A hospital After Visit Summary, dated 12/26/24, documented fluid restriction, no more than 2000 milliliters in a 24 hour period. Resident #241 had no fluid restriction orders. On 01/13/25 at 12:28 p.m., Resident #241 stated staff were not sure if they were on fluid restriction. There was a water pitcher observed on the bedside table with 700 ml clear fluids. On 01/14/25 at 10:39 a.m., CNA #2 stated the nurses would inform them if a resident was on a fluid restriction. On 01/14/25 at 10:40 a.m., CNA #2 stated the ADON informed them Resident #241 was not on fluid restriction due to confusion on the resident's fluid restriction status when they admitted . On 01/14/25 at 12:12 p.m., LPN #3 stated if a resident was on fluid restriction it would be on their orders. On 01/14/25 at 12:15 p.m., LPN #3 reviewed Resident #241's orders. They stated they did not have an order for a fluid restriction. On 01/14/25 at 12:16 p.m., the ADON stated the DON and ADONs put in the hospital orders when a resident admitted to the facility. On 01/14/25 at 12:21 p.m., the ADON reviewed Resident #241's discharge orders. They stated the resident should have been on a fluid restriction of no more than 2000 ml in 24 hours. They stated they would correct and inform the provider.

Based on record review and interview, the facility failed to ensure the admission weight and weekly weights were obtained for a resident on dialysis for one (#21) of one sampled resident reviewed for dialysis. The DON identified three dialysis residents resided in the facility. Findings: A Weight monitoring policy, reviewed 05/2023, read in part, Newly admitted and readmitted residents are weighed upon admission and weekly x 4 and then monthly thereafter, unless otherwise indicated by physician's order. The policy also read, Weekly weights and reweighs results are to be recorded in the EHR. Resident #21 was admitted on [DATE] with diagnosis which included end stage renal disease and dependence on dialysis. A physician order, dated 12/28/24, read in part, Weekly weights every Wednesday on day shift 28 days on admission then x 4 weeks then monthly if stable. The Resident weight record, had only one weight for 01/01/25 at 2:24 p.m. On 01/12/25 at 11:36 a.m., Resident #21 stated they did not get weighed weekly. On 01/14/25 at 11:34 a.m., CNA #1 stated they do monthly weights on the first and third of the month. They stated the weekly weights, the nurse gave them a list and we got them. They stated the nurse documents the weights. They stated they only document the physical function things they assist the residents with. On 01/14/25 at 11:39 a.m., LPN #3 stated the weights were documented in the EHR and they popped up on the system to do. They stated they make a list to delegate to the aides to do and if not done then they did themselves. They stated Resident #21 had one weight in the EHR for 01/01/25 of 132 pounds. LPN #3 stated the physician order documented weights weekly every Wednesday on day shift. They stated the weights for Resident #21 had not been done as ordered.

Based on record review and interview, the facility failed to ensure dialysis communication forms were consistently filled out for one (#21) of one sampled resident reviewed for dialysis. The administrator identified three residents in the facility received dialysis services. Findings: A Dialysis-Hemodialysis policy, reviewed 04/2023, read in part, c. Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C. Resident #21 had diagnoses which included end stage renal disease. A physician's order, dated 12/28/24, documented Resident #21 was to receive dialysis every Tuesday, Thursday, and Saturday. A Dialysis Pre/Post Communication Report, dated 01/09/25, did not have any documentation for the This section to be completed by the nursing home staff upon return part of the form. The section was to included the vital signs and assessment of the resident. A Dialysis Pre/Post Communication Report, dated 01/11/25, did not have any documentation for the This section to be completed by the nursing home staff upon return part of the form. The section was to included the vital signs and assessment of the resident. On 01/12/25 11:36 a.m., Resident #21 stated the staff did not take their vital signs or assess them prior to or after returning from dialysis. On 01/14/25 at 11:55 a.m., LPN #2 was asked to review the dialysis communication forms for Resident #21 for 01/09/25 and through 01/11/25. They stated there was no documentation for the post dialysis section. LPN #2 stated the post dialysis section should have been completed. On 01/14/25 at 01:19 p.m., the DON stated they verified they did not have the post dialysis forms for 01/09/25 and 01/11/25 and they had spoke to the resident who stated they did not do it.

Based on observation, record review, and interview, the facility failed to ensure toileting was provided in a timely manner for one (#142) of three sampled residents reviewed for timely ADLs. The DON identified 46 residents who needed assistance with ADLs resided in the facility. Findings: Resident #142 had diagnoses which included shortness of breath. Resident #142's care plan for elimination, dated 01/10/25, documented the resident would have a decrease in the number of incontinent episodes by implementation of a scheduled toileting program over the next 90 days. On 01/14/25 at 9:10 a.m., during medication administration, Resident #142 informed CMA #1 they needed to urinate. CMA #1 turned on the resident's call light and exited the room. On 01/14/25 at 9:14 a.m., Resident #142's call light remained on and was beeping. On 01/14/25 at 9:19 a.m., CMA #1 and LPN #2 were observed on the resident's hall. LPN #2's cart was positioned opposite the resident's room. Resident #142's call light remained on and was beeping. On 01/14/25 at 9:28 a.m., the wellness director went past the resident's room. The call light was still on and beeping. On 01/14/25 at 9:30 a.m., the DON went into the resident's room. They came out immediately and the call light was off. They proceeded to go to room [ROOM NUMBER], then left the hall. On 01/14/25 at 9:37 a.m., Resident #142 was in bed. They stated they were still waiting to use the urinal. The resident stated they did not see anyone come into their room or turn off the call light. They stated their eyes must have been closed. On 01/14/25 at 9:55 a.m., the DON stated Resident #142 was asleep when they went into the resident's room to turn off the call light. They stated the process for answering a call light was to find out what the resident needed. They stated they did not ask the resident what they needed or why the call light was on. On 01/14/25 at 9:56 a.m., the DON stated they should have asked Resident #142 what they needed. On 01/14/25 at 9:57 a.m., the DON went to Resident #142's room. The resident informed the DON they needed to urinate and they used a urinal because it was easier. The DON informed the resident they would assist. They walked out of the room and had CNA #4 to assist the resident. CNA #4 told the DON they were not aware the resident need to urinate. On 01/14/25 at 10:00 a.m., the DON stated the resident's needs were not met in a timely manner.

Based on interview, and record review the facility failed to ensure appropriate placement was found to meet the health and safety needs for one (#1) of three sampled residents reviewed for involuntary discharges. The administrator identified five residents who had received involuntary discharges in the past 12 months. Findings: A Policy and Procedure titled, Notice of Resident Transfer or Discharge .Effective: February 12,2020, read in part, .Standard of Practice: The facility will provide the resident and/or responsible party with a notice of impending transfer or discharge in accordance with the residency agreement and state/CMS guidelines . Res #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #1's care plan, read in part, .Discharge plan[09/20/2021:Onset] .Resident and/or representative will be assisted in planning for discharge to safest environment over the next 90 days .IDT to assist with setting up follow-up care Home Health, DME, appointments with primary care physician (PCP), and specialist. Provide contact information and appointment times.[01/27/22:Onset] .Assess residents overall expectations concerning discharge [09/20/21:Onset] . Res #1's quarterly assessment, dated 12/20/21, documented residents cognitive status was moderately impaired, needed extensive assistance with transfers, dressing, and bathing. Resident did not ambulate. A Long Term Care Facility Involuntary Transfer And Discharge Notice, read in part, .Date of notice to resident 12/20/2021 .Reason for discharge or transfer: You have failed, after reasonable notice, to pay for a stay at the facility (or to have paid under Medicaid or Medicare) .Notice received by: Pt refused to sign . A Progress Note, dated 12/27/21, read in part, Plan .Restorative nursing to attempt exercises with patient as indicated . The clinical record did not contain any documentation restorative services were started. A progress note titled, Social Note, dated 01/14/22 at 4:04 p.m., documented, [Family member] returned call today and stated [family member] wasn't coming to get him and we needed to send him to a Nursing Home or Just keep him. [Family member] also informed BOM she wasn't able to do anything about the facility bill. A progress note titled, Social Note, dated 01/17/22 at 3:08 p.m., read in part, .Admin and FC went with me today to speak with patient at bedside regarding the bill and discharge options. Admin hand delivered the bill to the patient and explained each charge line by line to patient and he expressed understanding. Patient was aware that his [family members] and other family members have been unable to help with his DC planning due to various reasons .Patient is willing to join a men's group home or shelter that will assist him with job placement and other resources . A Nurses Note dated 01/18/22, read in part, .Patient retested for covid last night d/t fever, he tested positive. NP notified . A progress note titled, Social Note, dated 01/18/22 at 2:54 p.m., read in part, Spoke with patient at bedside regarding placement. Patient agreed to a screening through the [shelter] for shelter placement . A Progress Note, dated 01/25/22, read in part, Plan .Continue LTC management .continue covid isolation . A progress note titled, Social Note, dated 01/25/22 at 4:16 p.m., read in part, Spoke with [employee] at [shelter] and she informed me that the [town] location has open beds every day this week due to weather conditions and to have the member transported by 3PM on the day of his DC. Resident made aware of DC location and he has verbalized understanding . Res #1's discharge assessment, dated 01/27/22, documented residents cognitive status was intact. Functional status was still in progress. Covid-19 Monitoring Data form, dated 01/27/22 at 2:14 a.m., read in part .Positive test results for COVID-19 .Temperature 99.2 .Treatment plan-Isolation . The clinical record did not contain any documentation Res #1 was reassessed after 2:14 a.m. on 01/27/22 until his discharge/transport to the shelter at approximately 3:15 to 3:30 p.m. on 01/27/22. Res #1's Discharge Instructions For Care, dated 01/27/22 at 2:21 p.m., read in part, .Cognitive Status alert and orient x 3 .Mobility: Independent Bed-to-chair, Walking, Wheelchair, Bathes Self, Dresses Self, Feeds Self, Brushes Teeth, Shaves Self and Toilet Use . The discharge instructions for care did not document setting up follow-up care Home Health, DME, appointments with primary care physician (PCP), and specialist, or provide contact information and appointment times. The resident was not accurately assessed prior to discharge to meet his health and safety needs. A progress note titled, Social Note, dated 01/27/22 at 2:21 p.m., read in part, Wheelchair and Clothes purchased for the patient today by the facility for his discharge today. Patient will DC to [shelter] in [town] due to a confirmed bed for him today @ 4pm .Explained to the family that this was the only available option at this time unless he could go home with them or have access to his money, but [family member] declined to speak about the money or assisting him at [family members] home . A hospital Provider Note, dated 01/27/22 at 7:25 p.m., read in part, .Patient presents with chest pain .male with a history of hypertension but no reported [CONDITION(S)] presents the ED by EMS for evaluation of chest pain that started after eating approximately 2 hours prior to arrival . A hospital Provider Note, dated 01/27/22 at 9:03 p.m., read in part, .The patient is here for evaluation of chest pain .The patient is [CONDITION(S)] but other wise his vitals within acceptable limits .I suspect that his pain is primarily related to his recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital Progress note, dated 01/27/22 at 10:48 p.m., read in part, .I was contacted by ED staff concerning disposition of [Res #1] due to social circumstances .[Res#1] reports he was then sent to [facility name] for rehab .Since his hospital stay in [Month] he had been non-ambulatory/wheelchair-bound and incontinent of bowel/bladder .He said he is not independent with personal care .He was transported in a van to [shelter] in [town], left on the sidewalk, and told good luck.[Shelter] said he cannot return there as they do not have the means to care for him . A hospital After Visit Summary dated 01/27/22, read in part, .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/31/22 the admissions coordinator was asked who transported Res #1 to the [shelter]. He replied, our driver. He was asked what the resident was wearing. He stated, Went shopping for him at [NAME], he had a red hoodie, military jacket, joggers and .house shoes. On 2/1/22 at 9:44 a.m., an interview was conducted with the social services director at the [shelter]. She was asked what the process was for getting a bed. She stated, one side it's a first come first serve until beds are full. There is a shelter that has twelve male and six female beds. These clients are in every night, and have to follow program guidelines. The clients must be able to manage their medications individually and must be fully independent with self-care. No type of assistance is offered. At 10:55 a.m., the transport driver was asked if he remembered what Res #1 was wearing the day he transported him. He stated, Pants, shirt, and jacket, he was asked if Res #1 had shoes on. He replied, he had grip socks on. The driver was asked what took place when you arrived to the shelter. He stated, [employee] went with me, unloaded him, and rang the doorbell. Said they didn't open til 4. He was asked what time did they arrived at the shelter. He replied, 3:15 to 3:30. He was asked what happened then. He stated, We left. The driver was asked where was Res #1 when you left? He stated, At the door. The transport driver was asked who told you to leave him. He stated, I had a conversation with [admissions coordinator] and [Administrator] that he was being discharged . I knew a couple days in advance. http://www localconditiond.com/weather-[town]-oklahoma/[zip code]/past.php, [Town] Ok Past Weather documented .high temperature as 46.4 at 3:35 p.m . At 11:59 a.m., the administrator was asked if restorative had started with Res #1 as ordered on 12/27/21. He was not sure. At 12:37 p.m., RN #1 was asked if the assessment completed on the discharge instructions was accurate. Was Res #1 able to ambulate independently? She stated, I didn't see him walking. RN #1 said the discharge instructions were completed by a nurse that she was training. RN #1 was asked if he needed assistance with any other ADL's listed on the discharge instructions. She stated, he would need assistance with bathing/showers. RN #1 was asked if Res #1 should have been released to self-care. She stated, To me he may need assistance sometimes. At 12:25 p.m., the administrator stated, he talked to physical therapy and the resident did not receive restorative services. The program had just recently been started. At 1:58 p.m., the administrator stated, there was no documentation of an assessment or vital signs taken prior to Res #1 discharging out of the facility. At 2:20 p.m., Res #1's [family member] was asked when he went to the emergency room ? She replied, on Thursday after he got to the [shelter]. At 2:40 p.m., the admissions coordinator was asked when he spoke with the [shelter] did you believe it was an appropriate placement for Res #1? He stated, He was on day ten of covid. He had full function of arms and had spoken with nurses how care was. I talked to [shelter] what they can and can't take, that he was a male with w/c, couldn't use his legs but he had use of his arms. The [shelter] said they could accommodate him. At 3:09 p.m., Res #1 was asked what his understanding was when he was being discharged to the [shelter]. He stated, My understanding was to get rehab and physical therapy. He was asked what happened when he was discharged . He stated, They loaded me up put me in the van with the W/C and started out to [town], get there, pulled upside put stuff on curb. Res #1 was asked what was he wearing. He stated, a jacket that was too small, sweatpants, and a hat. He was asked if he had shoes, he replied no. Res #1 was asked how he ended up in the ER. He stated, he was eating and started having chest pains. 911 was called and he was transferred to ER at [town] around 7:30 or 8:00 p.m. His heart had started racing. He was in the ER until the next night. Res #1 was asked if this had happened before. He stated, No. Res #1 was asked if he was able to walk when he was discharged . He stated, I could shuffle short distances. He was asked if he needed assistance with bathing, he replied yes. At 3:33 p.m., Res #1 was asked if he had any anxiety when he was dropped off at the [shelter]. He stated, Oh yes, bunches. I thought I would just give em my name go from there. Res #1 was asked if he was under the impression he would be staying at the shelter. He replied, I thought they had facilities to take care of me. On arrival to the shelter he was told, No we can't facilitate you, not in good enough shape. At 3:40 p.m., the admissions coordinator was asked what services Res #1 would be receiving at the homeless shelter, how does it work? He stated, we would get him in a guaranteed bed and make sure they could accommodate him with his wheelchair. He would have to go do the same thing every day, leave and come back at 4 p.m. The admissions coordinator was asked if he ever gave a guarantee to Res #1 he would be housed on the other side (program side). He replied, no.

On [DATE] at 4:10 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility's failure to provide cardiopulmonary resuscitation (CPR) to a resident who had no pulse and no blood pressure and who was a full code. At 4:25 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility's failure to provide CPR for a resident. A plan of removal for the IJ situation was requested. At 5:37 p.m., the administrator provided the survey team with an acceptable written plan of removal. The facility's plan of removal, dated [DATE], documented the following: .Plan of Removal . -Inservice initiated with Licensed nurse [DATE] and completed [DATE]; over Change in Condition, CPR policy/procedure to include immediate initiation of CPR if Full Code, code status on hand, assessment of patient. This training included notification of change in condition to physician immediately upon identification of change. Nurses were educated in regard to identifying changes in condition. Facility expectation is based on the clinical situation of resident the nurse would notify the physician, director of nursing and call 911. -Mock Code Blue completed by DON on [DATE]. -Audit of crash cart completed [DATE] and will continue daily monitoring. - Audit of CPR certifications for licensed nurses completed [DATE] , and nurses scheduled for CPR certification training ,[DATE] and [DATE]. CPR and AED competencies to be completed with all current nurses by 5pm on [DATE]. - All new hired nurses will have CPR and AED training during orientation, with competencies completed and documentation of current CPR certification within 30 days of hire. -Social Services will ensure Advance Directive Acknowledgements are completed with new patients upon admission, order is obtained for code status and documentation is scanned into patient's record as indicated. - All new admits will be reviewed for code status and corresponding documents as indicated during daily clinical meeting and follow up completed as needed. -Any CODE conducted will be reviewed for any issues and corrective action taken as needed. -QAPI will review for any issues with CODE's or Code status at least monthly and make any revisions to the plan . A review of the facility's audit forms and training logs documented the facility had completed the audits and trainings by [DATE] at 2:45 p.m. On [DATE] at 5:45 p.m., the administrator was informed the IJ had been removed as of [DATE] at 2:45 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to provide CPR for one (#1) of two sampled residents who had no pulse and no blood pressure and was designated as a full code. This resulted in an IJ situation. Findings: A facility policy and procedure entitled Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/ Hands-Only CPR, dated [DATE], documented 1. The goal of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS) 2. If an individual is found unresponsive by an employee of the community the employee will initiate CPR unless: a. It is known that a Do Not Resuscitate order exists for the resident; . Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's medical record documented the resident had a full code status. A nurse's note, date [DATE] at 4:36 p.m., documented, Late Entry: [DATE]: Reported unresponsive after shaking shoulder by (name deleted), CNA. Pallor noted upon entry. Carotid & radial not palpable. Ext. cool to touch. No visible resp. No audible resp. No reading on pulse ox. Jaw slightly rigid & mouth open. Tongue cyanotic. 2nd assessment by (name deleted), RN w/ same findings. Mod amt dark tarry stool & straw colored urine. (Emergency medical services name deleted) called. 2 person CPR initiated w/ (name deleted), RN until (emergeency medical services name deleted) there to relieve. (Emergency medical services name deleted) performed CPR for 20 minutes and called @ 0820. Funeral home, wife and MD notified @ approx 0900 . An OSDH Incident Report Form Final, received [DATE], documented .At the change of shift LPN (name deleted), the 11:00 p.m. to 7:00 a.m. charge nurse was providing the change-of-shift report to the oncoming 7:00 a.m. to 3:00 p.m. charge nurse, (name deleted), RN and informed RN (name deleted) of a possible change in condition of Resident (name deleted). LPN (name deleted) was informed of the protocol in such change of condition scenarios. LPN (name deleted) assessed Resident (name deleted) and noted him to be without vital signs. CPR was initiated and (emergency medical services name deleted) was called, arrived and took over CPR efforts. (Emergency medical services name deleted) declared the resident deceased . The family and physician were notified. Upon becoming aware of the situation, the facility Director of Nursing, (name deleted), initiated an investigation and suspended LPN (name deleted) pending investigation DON (name deleted) initiated an investigation, which included interviewing the nursing personnel involved in the care of Resident (name deleted) on [DATE], including (name deleted), LPN, (name deleted), RN, (name deleted), RN and (name deleted), CNA. Such interviews indicated that at or about 5:00 a.m. on [DATE], CNA (name deleted) discovered that Resident (name deleted) was pale, nonresponsive and appeared, to not be breathing. CNA (name deleted) summoned LPN (name deleted) who assessed the resident and found him non-responsive. She was unable to obtain a reading using pulse oximeter or blood pressure. LPN (name deleted) summoned another charge nurse on duty, (name deleted), RN, who also evaluated the resident and found him to be non-responsive, cool to the touch, and having cyanosis. Based on the foregoing assessments, LPN (name deleted) apparently concluded that the resident was deceased . .As mentioned above, during the shift change she informed oncoming charge nurse (name deleted), RN of Resident (name deleted) change in condition. Based on RN (name deleted) response, LPN (name deleted) notified Dr. (physician's name deleted), the resident's attending physician, and then returned to the resident's room and initiated CPR with RN (name deleted). (Emergency medical service name deleted) was summoned at approximately 7:30 a.m. and upon arrival continued CPR until such time as (emergency medical service name deleted) declared the resident was deceased . LPN (name deleted) notified the family and the designated funeral home. The resident's body was removed from the facility at approximately 9:00 a.m . .After investigation it was noted that the patient's current code status was in the EHR as a full code. The facility determined that (name deleted), LPN an (name deleted), RN failed to follow the facility's policies regarding assessing a change in condition and responding appropriately per the resident's code status. Both nurses will be terminated from their positions and referred to the Oklahoma State Board of Nursing . .The facility has assessed each resident under LPN (name deleted) and RN (name deleted) care for changes in condition. The facility has implemented re-education for all nurses regarding CPR, Code Status, and change in condition policies and protocols. Crash carts have been checked for proper supplies and stocked accordingly. All nurses are being evaluated for current CPR certification and certification classes will be conducted as needed to ensure all nurses have current certifications. Mock CPR drills are to be completed per facility policy. The facility has completed an audit of all residents' code status in the EMR. The issues involved in this investigation will be monitored in QAPI monthly and as otherwise needed . On [DATE] at 2:45 p.m. the DON was asked what was done if a staff member noticed a change in a resident's condition. She stated if a CNA noticed a change, she would notify the nurse. She stated the nurse would do a head to toe assessment and notify the resident's physician and family. The DON was asked what would be done if a resident did not respond to stimuli or had no vital signs. She stated they would check the resident's code status. If there were no pulse or respirations and the resident was a full code, they would start CPR, have someone get the crash cart and call 911. The DON was asked how staff would know a resident's code status. She stated the resident's code status was entered into the residents electronic medical record. She stated at the beginning of each shift a print out of all residents code status was provided to the staff members. The DON was asked how staff knew what the facility's emergency protocols were. She stated staff went through orientation on hire and in-service training was provided every two weeks. She stated staff also had online in-service training they had to complete. The DON was asked if there had been recent training regarding emergency protocols and CPR. She stated, yes, a couple of weeks ago on CPR, change of condition and CPR and COVID. She stated CPR training was occurring that day ([DATE]) and the following day ([DATE]). The DON was asked to describe the incident with resident #1 on [DATE]. She stated CNA #1 found the resident unresponsive and reported to LPN #1. She stated LPN #1 came and did an assessment and checked for vital signs. She stated LPN #1 went and got RN#1 to assess the resident. She stated they felt like with their assessment, he had no vital signs and no respirations. The DON was asked what time this occurred. She stated between 5:30 a.m. and 6:00 a.m. The DON was asked what they did next. She stated at 7:00 a.m. LPN #1 gave the day shift nurse, RN #2, a report and stated that resident #1 had passed. The DON stated RN#2 asked what the resident's family had said. LPN #1 stated she had not contacted the family. The DON stated, RN #2 had told LPN #1 that resident #1 had been a full code and she should have begun CPR and notified emergency medical services. The DON stated RN #2 and another night nurse went and began CPR until emergency medical services arrived. She stated emergency medical services had called the code after 20 minutes. The DON was asked if appropriate protocol had been followed with resident #1. She stated, No. The DON was asked if there had been any explanation as to why CPR was not started. She stated she had started an investigation and LPN #1 stated she thought the resident was too far gone and had no pulse or respirations. The DON was asked if LPN #1 knew resident #1 was a full code. She stated LPN #1 said she did. The DON was asked if anything had been documented in the resident's record at the time. She stated, No. She stated LPN #1 had been upset and had been told she could go home and come back later and complete documentation. The DON was asked what had been done after she had completed her investigation. She stated there had been re-education on protocols and procedures and checks of staff CPR status. She stated LPN #1 and RN #1 had been terminated for not following proper protocol. At 3:30 p.m., the DON was asked if LPN #1 and RN #1 were certified in CPR at the time of the incident. She stated they were but the facility did not have copies of their CPR cards. She stated the facility had asked for copies of the cards but they had not been provided. The DON was asked if CPR should have been started when resident #1 had been assessed with [REDACTED].