Every finding on record at Ambassador Manor Nursing Center

Based on record review and interview, the facility failed to accurately transcribe admission orders and ensure medications were administered for one (#1) of three sampled residents reviewed for medication administration.The administrator identified 124 residents who resided in the facility. Findings:A medical diagnoses record showed Resident #1 had diagnoses which included encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, diabetes mellitus due to underlying condition with diabetic amyotrophy, acute kidney failure, unspecified, chronic obstructive pulmonary disease, unspecified, and hyperkalemia. Clinical discharge instructions for Resident #1, dated 03/09/25 at 1:12 p.m., showed to administer insulin Glargine (a diabetes medication), 30 units subcutaneous every 24 hours.An Order Summary Report showed an active physician order to start on 03/10/26 for Insulin Glargine Subcutaneous 100 unit/mL, (a diabetes medication), Inject 30 units subcutaneously one time a day for DMII.A review of the Medication Administration Record showed a start date of 03/10/26 for Insulin Glargine Subcutaneous solution 100 units/mL, (a diabetes medication), inject 30 units subcutaneous one time a day for DMII.Entries made on the MAR for 03/10/26, 03/11/26, 03/12/26 and 03/13/26 showed a code 9 with initials. Per the code legend on the MAR, Code 9 is a chart code indicating charting in nurses notes.On 03/10/26 at 08:05 a.m., progress notes showed CMA #2 Documented Note Text: Insulin Glargine subcutaneous Solution 100Units/mL Inject 30 units subcutaneously one time a day for DMII, Notified Nurse.On 03/11/26 at 07:35 a.m., progress notes showed CMA #2 Documented Note Text: Insulin Glargine subcutaneous Solution 100Units/mL Inject 30 units subcutaneously one time a day for DMII, Notified Nurse. 03/12/26 at 07:40 a.m., progress notes showed CMA #2 Documented Note Text: Insulin Glargine subcutaneous Solution 100Units/mL Inject 30 units subcutaneously one time a day for DMII, Notified Nurse. On 03/13/26 at 07:45 a.m., progress notes showed CMA #2 Documented Note Text: Insulin Glargine subcutaneous Solution 100Units/mL Inject 30 units subcutaneously one time a day for DMII, Notified Nurse.A Medication Orders policy, dated January 2022, read in part, the nurse who transcribes the orders to the physician order sheet/electronic medical record and MAR documents on the admission form the date, the time and by whom the orders were noted.On 03/18/26 at 3:14 p.m., CMA #2 stated when a medication was on the MAR, such as inhalers and insulins, they informed the nurse in charge for the day and documented it on the MAR and in the progress notes. CMA #2 stated they did not give any insulins, only nurses do, so they inform them when it was on the MAR and not the TAR. CMA #2 stated Resident #1 did have insulin on their MAR for several days and they told the nurse. CMA #1 stated they did not tell anyone else and does not think Resident#1 received the medication.On 03/18/26 at 3:25 p.m., LPN #2 stated they administered medications that were on the TAR and the CMA's administered the medications on the MAR. They stated they understood how the medication got missed as they did not look at the MAR when administering medications, only the TAR, and the Glargine insulin was listed on the MAR when it should have been listed on the TAR. LPN #2 stated the resident did not receive the doses of insulin that were not on the TAR.On 03/18/26 3:35 p.m., the ADON stated they realized there was a medication error when the hospital called for a list of medications the resident had received. They stated when reviewing orders the Glargine insulin was listed on the MAR and not the TAR and had been missed. A facility Quality report showed the problem was identified on 03/13/26. The facility Quality report showed an audit of all insulin orders was completed to ensure the correct tab was selected and staff training was completed on 03/17/26.

Based on record review and interview, the facility failed to assess, monitor and intervene for 2 (#1 and #3) of 5 sampled residents reviewed for administration of medication and following physician orders. The administrator identified 124 residents who resided in the facility.Findings:Resident #1 had a physician order dated 03/09/26 for Insulin Aspart injection solution 100 units/mL (Insulin Aspart) (a medication for diabetes), which read in part, .FSBS 351- 400 =10 units Recheck in 2 hours. If still 400, Notify MD. FSBS 401 - 450 = 12 units Recheck in 2 hours, if till greater than 400 notify MD. Resident #1 had the following readings:On 03/09/26 at 9:00 p.m. FSBS 383, 03/10/26 at 4:00 p.m. FSBS 401, 03/10/26 at 9:00 p.m. FSBS 399, 03/11/26 at 07:30 a.m. FSBS 390, 03/11/26 at 11:00 a.m. FSBS 360, 03/11/26 at 4:00 p.m. 384, 03/12/26 at 07:30 a.m. 370, 03/12/26 at 11:00 a.m. FSBS 366, and 03/12/26 at 4:00 p.m. FSBS 383. No documentation of repeat FSBS or physician notification was provided.Resident #11 had a physician order dated 12/08/25 for Insulin Aspart injection solution 100 units/mL (Insulin Aspart) (a medication for diabetes), which read in part, .FSBS 401 - 450 = 12 units Recheck in 2 hours, if till greater than 400 notify MD, FSBS 451-500 = 15 units Recheck in 2 hours and if still greater than 400 notify MD. Resident #11 had the following readings: 03/01/26 at 4:00 p.m. FSBS 411, 03/02/26 at 11:00 FSBS 460, 03/02/26 at 4:00 p.m. FSBS 481, 03/08/26 st 4:00 p.m. FSBS 411, 03/11/26 at 4:00 p.m. FSBS 429. 03/11/26 at 9:00 p.m. FSBS 461, 03/17/26 at 9:00 p.m. FSBS 455. No documentation of repeat FSBS or physician notification was provided.On 03/19/26 at 11:06 a.m. LPN #1 stated that sliding scale between 351-400 that stated to recheck in 2 hours should have a recheck in 2 hours - if over 400 would call the physician and document repeat FSBS and physician contact in progress notes and under vital signs.On 03/19/26 at 2:25 p.m. RN#1 stated the TAR for Resident #1 showed if a blood sugar was 351-400 to administer 10 units of insulin and re-check FSBS in 2 hours. RN #1 stated they document in the nurses notes under progress notes when the FSBS is rechecked but does not see where it was done for Resident #1.On 3/19/26 at 2:35 p.m. the DON stated they did not find documentation that there were repeat FSBS performed when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.

Based on record review and interview, the facility failed to notify law enforcement and Oklahoma State Department of Health of suspected criminal activity for 1 (#7) of 9 sampled residents reviewed for notifying law enforcement and Oklahoma State Department of Health of suspected criminal activity.The administrator identified 124 residents who resided in the facility.Findings:A facility policy titled Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, read in part, Crime; Section 1150B(b)(1) of the Social Security Act (42 U.S.C &1320b-25) provides that a crime is defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township, or village, or any local unit of Government created by or pursuant to State law. Crime is defined by Oklahoma state law as an act or omission forbidden by law. 21 O.S. &3.The facility will also file reports with agencies in accordance with state regulations. If there is a suspicion of a crime against a resident has occurred, the facility shall report the incident to the Department and law enforcement. Title 63 of the (name of state withheld) Statute S 2-405, (2025), read in part, No person shall deliver, sell, possess or manufacture drug paraphernalia knowing, or under circumstances where one reasonably should know, that it will be used to plant, propagate, cultivate, grow, harvest, manufacture, compound, convert, produce, process, prepare, test, analyze, pack, repack, store, contain, conceal, inject, ingest, inhale or otherwise introduce into the human body a controlled dangerous substance in violation of the Uniform Controlled Dangerous Substances Act. An admission assessment, dated 03/21/25, showed Resident #7 was admitted on [DATE] with diagnoses which included alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse.A quarterly assessment, dated 02/17/26, showed a BIMS score of 15 which indicated Resident #7 was cognitively intact.A nurse's note for Resident #7 dated 02/17/26, read in part, Care plan team and administrator met with resident. Resident in-serviced regarding his revocation of self sign out privileges due to [their] non-compliance in the matter of smoking devices and paraphernalia. Resident signed that [they] are understanding of this.A nurses' note for Resident #7, dated 02/24/26, showed on 02/17/26, Resident #7 received in-service education over revocation of self-sign out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia violating the facility rules. The note showed Resident #7 continued to use illicit substances in and was reported to provide substances to other residents despite prior education. There was no documentation a report of suspected illegal activity was made to the police or Oklahoma State Department of Health of the illicit paraphernalia found in Resident #7's possession on 02/17/26.On 03/18/26 at 11:35 a.m., Resident #7 stated the facility found a methamphetamine pipe in their room in February. They stated the facility confiscated the pipe and threw it in the trash. Resident #7 stated they used illegal drugs including methamphetamine, cocaine, and marijuana. On 03/20/26 at 8:58 a.m., the HK supervisor stated on 02/17/26, housekeeping saw Resident #7 put a small glass pipe with residue in a box. They stated the administrator was notified and they went with the administrator to discuss with Resident #7 the concern. They stated Resident #7 gave the suspected drug paraphernalia to the administrator and they disposed of it in the trash. On 03/20/26 at 11:07 a.m., the DON was asked about the suspected drug paraphernalia found in Resident #7's possession on 02/17/26. The DON stated they followed the abuse policy and was not aware the suspected drug paraphernalia was a crime, so it was not reported to the police. They stated the incident on 02/17/26 should have been reported to the Oklahoma State Department of Health and it was not reported. On 03/20/26 at 11:21 a.m., the administrator the police and Oklahoma State Department of Health were not notified of the incident.

Based on record review and interview, the facility failed to notify the physician of suspected illegal drug paraphernalia found in a resident's possession for 1 (#7) of 9 sampled residents reviewed for notification of the physician.The administrator identified 124 residents who resided in the facility.Findings:A facility policy titled Notification of Change, dated 06/2025, read in part, The facility will notify the resident, the resident's physician, and the resident's representative (if applicable) promptly when there is: .An accident involving the resident that results in injury or has the potential for requiring physician intervention.All notifications should be documented in the medical record.An admission assessment, dated 03/21/25, showed Resident #7 was admitted on [DATE] with diagnoses which included alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse.A quarterly assessment, dated 02/17/26, showed a BIMS score of 15 which indicated Resident #7 was cognitively intact.A nurse's note for Resident #7, dated 02/17/26, read in part, Care plan team and administrator met with resident. Resident in-serviced regarding his revocation of self sign out privileges due to [their] non-compliance in the matter of smoking devices and paraphernalia. Resident signed that [they] are understanding of this.A nurses' note for Resident #7, dated 02/24/26, showed on 02/17/26, Resident #7 received in-service education over revocation of self-sign out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia violating the facility rules. The note showed Resident #7 continued to use illicit substances in and was reported to provide substances to other residents despite prior education. There was no documentation the physician was notified of the illicit paraphernalia found in Resident #7's possession on 02/17/26.On 03/18/26 at 11:35 a.m., Resident #7 stated the facility found a methamphetamine pipe in their room in February. They stated the facility confiscated the pipe and threw it in the trash. Resident #7 stated they used illegal drugs including methamphetamine, cocaine, and marijuana. On 03/19/26 at 9:41 a.m., the medical director stated they were not notified of the suspected drug paraphernalia found in Resident #7's possession on 02/17/26. The medical director stated it was important to notify them of suspected drug abuse by residents because the illicit drugs may interact with prescribed medications. On 03/20/26 at 8:58 a.m., the HK supervisor stated on 02/17/26, housekeeping saw Resident #7 put a small glass pipe with residue in a box. They stated the administrator was notified and they went with the administrator to discuss with Resident #7 the concern. They stated Resident #7 gave the suspected drug paraphernalia to the administrator and they disposed of it in the trash. On 03/20/26 at 11:07 a.m., the DON stated it was not documented the physician was notified of the incident.On 03/20/26 at 11:21 a.m., the administrator stated the physician was not notified.

On 07/08/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure residents were monitored for the safe use of electronic vaping devices.Resident #1, 6, and Resident #11 were observed to use supplemental oxygen. The latest cognition assessments showed all three residents were intact in their cognition. Their care plans showed the three residents smoked, vaped, or both. The care plan showed the residents were not to use smoking or vaping materials while in the possession of or near any type of oxygen.On 07/08/25 at 3:43 p.m., Resident #11 was observed sitting in their motorized wheelchair in their room, vaping. The two O2 concentrators present in their room were running for the resident and their roommate. Resident #11's oxygen concentrator was approximately six inches from Resident #11 as they vaped.On 07/08/25 at 3:50 p.m., Resident #1 was observed lying in bed and vaping. The resident was observed to wear oxygen at 2 liters per nasal cannula.On 07/08/25 at 4:35 p.m., Resident #6 was observed vaping in their room while lying in bed with oxygen on per nasal cannula.On 07/08/25 at 4:52 p.m., Resident #6 was observed sitting in their motorized scooter in the dining room, at the dining table, vaping with Resident #12 at the head of the table. Resident #12 was observed to wear oxygen at 2 liters per minute via nasal cannula. The residents were observed to be less than five feet apart from each other.Interviews with direct care staff showed they were unaware or uncertain of the use of oxygen while vaping.On 07/08/25 at 6:25 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 07/08/25 at 6:57 p.m., the administrator, DON, and regional administrator were notified of the IJ situation and was provided a copy of the template.On 07/09/25 at 9:20 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Ambassador Skilled Nursing and Therapy Plan of Removal 7/8/25 1. Inservice on facility smoking procedures/designated locations. What to do if someone is smoking outside of those areas or in the presence of oxygen. 2. Re-assess all residents who vape for safety and understanding of the agreement and policy. 3. Re-issue the smoking agreement to these residents. 4. Any of the residents who have been reported to smoke freely around o2, be it theirs or their roommates, must have privileges revoked and put on supervised vaping. 5. Initiate a supervised smoking schedule and ensure each resident who is supervised has this information. 6. All of this to be completed by midnight 7/8/25.The IJ was lifted, effective 07/08/25 at 10:46 p.m., when all components of the plan of removal had been verified as completed. Direct care staff from all three shifts were interviewed about inservice/education and showed the staff were knowledgeable of the facility's policy regarding vaping and the risks involved if residents vaped while utilizing supplemental oxygen. Review of clinical records showed residents who vaped had been assessed for safety related to vaping and had signed a smoking/vaping agreement. The supervised smoking schedule showed what type of supervision residents required for vaping. The deficient practice remained at a pattern level with the potential for more than minimal harm.Based on observation, record review, and interview, the facility failed to ensure residents were monitored for the safe use of electronic vaping devices for 6 (#1, 2, 6, 11, 12, and #13) of 6 sampled residents who were reviewed for the use of electronic vaping devices.The alphabetical room roster identified 131 residents resided in the facility.Findings:1. On 07/08/25 at 3:33 p.m., Resident #1 was observed in their motorized wheelchair wheeling down the 100 hall with an electronic vape in their lap.On 07/08/25 at 3:48 p.m., Resident #1 was observed laying in bed, vaping, and had oxygen on at 2.5L via nasal canula. Resident #1 and Resident #11 were observed to be roommates. A physician order, dated 12/03/24, showed Resident #1 was ordered oxygen at two to five liters per minute via nasal cannula as needed.A policy titled Smoking/Vaping, dated 02/24/20, read in part, Oxygen equipment is not permitted in smoking areas. Smoking is not permitted while in possession of or in the presence of oxygen equipment .To offer the resident the ability to smoke/vape free of danger to self or others. The term smoking/vaping referenced herein includes the use of any type of cigarette, pipe, electronic device, battery powered device or any other object/device that produces smoke/vape.A policy titled Smoking, signed by Resident #1 on 01/18/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others.An annual assessment, dated 04/28/25, showed Resident #1 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making and had a diagnosis of multiple sclerosis.A care plan, updated 05/22/25, showed Resident #1 was independent with vaping.A Smoking/Vaping Supervision Checklist, dated 06/10/25, showed Resident #1 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.On 07/08/25 at 3:50 p.m., Resident #1 stated they had quit smoking cigarettes and now utilized electronic vapes. Resident #1 stated they did not go outside, the staff allowed them to vape in their room and could vape with their oxygen on. Resident #1 stated they utilized oxygen most of the time.2. On 07/08/25 at 11:10 a.m., Resident #2 was observed vaping while sitting in their wheelchair in the dining room.On 07/08/25 at 3:32 p.m., Resident #2 was observed in their wheelchair on the 100 hall with an electronic vape in their lap. The resident seemed confused and was asking where their room was located. A Smoking and Behavior Agreement, signed by Resident #2 on 04/04/25, read in part, I [Resident #2] acknowledge the importance of the facility smoking policy to my own safety of others [sic] residents and agree to comply with the terms and conditions of that policy.A significant change assessment, dated 05/30/25, showed Resident #2 had a BIMS score of 05, which indicated the resident was severely impaired in cognition for daily decision making, and the resident utilized tobacco.A Smoking/Vaping Supervision Checklist, dated 05/30/25, showed Resident #2 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.A care plan, updated 07/03/25, showed Resident #2 was independent with smoking and mainly vaped. The care plan showed Resident #2 agreed to smoke/vape in designated smoking areas only and the residents would be monitored to ensure they were not vaping while in the vicinity of oxygen equipment.3. On 07/08/25 at 3:30 p.m., Resident #6 was observed in the therapy room vaping around other residents.On 07/08/25 at 4:02 p.m., Resident #6 was observed vaping in the back common area vaping.On 07/08/25 at 4:35 p.m., Resident #6 was observed vaping in their room while lying in bed with oxygen on per nasal cannula. A policy titled Smoking, signed by Resident #6 on 01/18/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others.A physician order, dated 10/10/24, showed Resident #6 was ordered oxygen at 2-4L per minute via nasal cannula every shift.An annual assessment, dated 06/02/25, showed Resident #6 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, utilized tobacco, and utilized supplemental oxygen.A Smoking/Vaping Supervision Checklist, dated 06/02/25, showed Resident #2 utilized tobacco and vaping products, received oxygen, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.A care plan, updated 07/03/25, showed Resident #6 smoked. The care plan did not show the resident utilized an electronic vape.4. On 07/08/25 at 3:38 p.m., Resident #11 was observed in their motorized wheelchair in their room, approximately 6 inches from their oxygen concentrator, vaping. The oxygen concentrator was observed to be on at 2L, water in the canister was observed to bubble, and the nasal canula was observed to lay over the top of the concentrator. On 07/08/25 at 3:43 p.m., Resident #11 was observed to have cigarettes and a lighter on the bedside table and two electronic vapes on their dresser.A Smoking/Vaping and Behavior Agreement, signed by Resident #11 on 11/29/22, read in part, Resident agrees to not smoke tobacco products or use vaping products, lighters or matches while in possession of oxygen equipment or while in the presence or vicinity of such equipment.A significant change assessment, dated 12/09/24, showed Resident #11 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision making, and utilized tobacco.A care plan, updated 01/27/25, showed Resident #11 was at risk for smoking related injuries, agreed to smoke/vape in smoking designated areas only, had signed and will abide by the smoking/vaping and behavior agreement, and the resident would be monitored to ensure they were not vaping in the vicinity of oxygen equipment.A physician order, dated 06/23/25, showed Resident #11 was ordered oxygen at 2-4L per minute via nasal cannula as needed.A Smoking/Vaping Supervision Checklist, dated 07/02/25, showed Resident #11 utilized vaping products, received oxygen, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.On 07/08/25 at 3:43 p.m., Resident #11 stated they were allowed to vape in their room.5. A policy titled Smoking, signed by Resident #12 on 04/03/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others. A significant change assessment, dated 01/27/25, showed Resident #12 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, utilized tobacco, and utilized supplemental oxygen.A care plan, updated 02/04/25, showed Resident #12 vaped, to remind them of designated smoking areas, and that they kept their vaping material in their room.A physician order, dated 02/25/25, showed Resident #12 was ordered oxygen at 2-4L per minute via nasal cannula every shift.A Smoking/Vaping Supervision Checklist, dated 06/04/25, showed Resident #12 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.6. On 07/08/25 at 3:57 p.m., CNA #1 was observed to make Resident #13's bed while the resident was observed to sit in their wheelchair beside the bed and vape. Resident #13's roommate, Resident #6, was not observed in the room but their oxygen concentrator was observed to be on. A policy titled Smoking, signed by Resident #13 on 08/08/24, read in part, The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2, and in non-public areas to prevent offending others.A care plan, updated 05/24/25, showed on 11/12/24 the administrator and the social services director met with the resident and discussed the resident smoked in their room earlier in the day, and they would now purchase them a vape.An annual assessment, dated 05/07/25, showed Resident #13 had a BIMS score of 02, which indicated the resident was severely impaired in cognition for daily decision making, and that the resident utilized tobacco.A Smoking/Vaping Supervision Checklist, dated 06/04/25, showed Resident #13 utilized vaping products, was able to demonstrate safe charging capabilities of vaping products such as not charging in bed or next to oxygen, and the resident was independent in their ability to utilize vape products.On 07/08/25 at 4:59 p.m., CNA #1 stated residents were allowed to vape in the facility. CNA #1 stated the residents could vape while oxygen was in use because there was not a flame.On 07/08/25 at 5:01 p.m., RN #1 stated a lot of residents used electronic vapes in their rooms. RN #1 stated if a resident utilized supplemental oxygen, they encouraged them to remove the oxygen while they vaped. RN #1 stated Resident #6 vaped everywhere in the facility, including the common areas, and utilized supplemental oxygen. RN #1 stated they just found out Resident #13 (Resident #11's roommate) vaped. RN #1 stated they had informed Resident #11 they should remove their oxygen if they were going to vape.On 07/08/25 at 5:08 p.m., CMA #1 stated residents were not allowed to vape inside the facility.On 07/08/25 at 5:13 p.m., CMA #2 stated residents were allowed to vape in the facility. CMA #2 stated they thought residents could vape in the common areas as well because residents did and no one had told them they could not vape there. CMA #2 stated residents could use electronic vapes and utilize supplemental oxygen because there was not a risk if residents vaped and utilized oxygen, only if they smoked cigarettes and utilized oxygen.On 07/08/25 at 5:15 p.m., CMA #3 stated residents were allowed to vape in the facility and they were not aware of any places they could not use electronic vapes. CMA #3 stated they do ask residents to be mindful and not vape while they were at the dining room tables. CMA #3 stated they did not think the use of supplemental oxygen while using an electronic vape had any potential negative effects, but they did not know for sure.On 07/08/25 at 5:23 p.m., CNA #2 stated they were not sure if residents were allowed to use electronic vapes while wearing supplemental oxygen or what the negative impact could be. On 07/08/25 at 5:25 p.m., LPN #1 stated residents were not allowed to vape inside the facility.On 07/08/25 at 5:55 p.m., CNA #1 stated they had observed Resident #6 use an electronic vape while wearing oxygen.On 07/08/25 at 5:57 p.m., CNA #3 stated Resident #1 and Resident #11 utilized oxygen regularly and knew both residents vaped. CNA #3 stated they had not observed either resident to wear supplemental oxygen and use an electronic vape.On 07/08/25 at 6:02 p.m., CMA #1 stated they had observed Resident #1 and Resident #11 both use electronic vapes while wearing supplemental oxygen.On 07/08/25 at 6:14 p.m., the DON stated they completed smoking/vaping assessments on residents on admission, quarterly, and as needed. The DON stated residents were allowed to vape in the facility, except in the dining room. The DON stated residents were not to wear supplemental oxygen or be in the vicinity of oxygen equipment while utilizing electronic vapes. The DON defined vicinity as approximately six feet. The DON stated themselves and the ADON monitored to ensure residents who utilized electronic vapes were safe by completing the smoking assessments, interviewing the residents who vaped, and speaking with staff. The DON stated utilizing an electronic vape while wearing supplemental oxygen could be risk to the residents because it could be flammable and the residents could get burned or injured. The DON stated they were aware Resident #1, 6, and Resident #11 utilized oxygen at times and vaped at times. The DON stated they had not observed the residents use their electronic vapes while wearing oxygen. The DON stated staff were made aware of the smoking/vaping policy through inservice. The DON stated the last inservice was conducted on 07/08/25 because staff had come to them with questions about residents who vaped and utilized supplemental oxygen after they had been interviewed by the survey team. They stated prior to 07/08/25 they had not been made aware residents vaped while utilizing supplemental oxygen.

Based on record review and interview, the facility failed to maintain complete and accurate clinical records fortwo (#1 and #2) of three residents whose clinical records were reviewed for wound care documentation, andone (#6) of one resident whose clinical records were reviewed for medication administration. The alphabetical room roster showed there were 131 residents who resided in the facility.Findings: 1. The comprehensive assessment, dated 05/30/25, showed Resident #2 was severely impaired in daily decision making (BIMS = 5), had pressure ulcers and venous stasis ulcers, received pressure ulcer care, applications of ointments/medications, and the application of nonsurgical dressings. On 07/08/25 at 10:20 a.m., Resident #2 was observed in their room with long socks pulled to just below the knees bilaterally. A physician's order, dated 04/29/25, showed Resident #2 was to receive a daily dressing to right lateral calf and right posterior calf. A physician's order, dated 05/30/25, showed Resident #2 was to receive a daily dressing to the left heel. A treatment sheet, dated June 2025, did not show the daily dressings were performed on 06/07/25, 06/08/25, 06/21/25, 06/28/25, 06/29/25, or 06/30/25. A treatment sheet, dated July 2025, did not show the daily dressings were performed on 07/04/25, 07/06/25, or 07/07/25. On 07/08/25 at 10:20 a.m., Resident #2 stated the staff dressed their wounds but was not sure of the frequency of the wound care or the progression of the wounds. On 07/10/25 at 3:10 p.m., the DON stated the dressing changes to the left heel, the right posterior calf, and the right lateral calf were discontinued on 07/07/25 and would not be documented as performed for that date. The DON stated they were unable to find documentation the dressing changes were performed on any of the dates in June of 2025 or for July 4 and July 6, 2025. The DON stated they knew if the dressings were not documented they were not considered done. 2. On 07/08/25 at 10:31 a.m., LPN #2 was observed to provide wound care to Resident #1. The annual assessment, dated 04/28/25, showed Resident #1 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, had an ostomy, and had pressure ulcers. A physician order, dated 06/16/25, showed the resident was to have wound care to the sacrum every day shift on Monday, Tuesday, Wednesday, and Friday. A physician order, dated 06/17/25, showed the resident was to have wound care to the right posterior thigh every day shift. A physician order, dated 06/17/25, showed the resident was to have wound care to the right buttock every day shift. A physician order, dated 06/17/25, showed the resident was to receive wound care to their urostomy site every day shift. A physician order, dated 06/17/25, showed the resident was to have wound care to the left buttock every day shift. The treatment administration record, dated 07/01/25-07/31/25, showed the wound care to the left buttock, sacrum, right posterior thigh, right buttock, and the urostomy site for Resident #1 had not been documented for 07/04/25. On 07/08/25 at 10:53 a.m., Resident #1 stated staff performed wound care as ordered every day. On 07/10/25 at 3:40 p.m., the DON stated staff must have forgotten to document the wound care for Resident #1 on 07/04/25. They stated if the treatments were not documented they could not verify they had been completed. On 07/11/25 at 1:07 p.m., LPN #3 stated the wound care nurses had not worked on 07/04/25. LPN #1 stated they had performed wound care for Resident #1. They stated they should have documented the wound care on the treatment administration record but they had not documented for 07/04/25. 3. A physician order, dated 10/08/24, showed Resident #6 was to receive Insulin Glargine 28 units subcutaneously twice daily from 7:00 a.m. to 11:00 a.m. and 6:00 p.m.to 10:00 p.m. An annual assessment, dated 06/02/25, showed Resident #6 had a diagnosis of diabetes, had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had received insulin for seven out of seven days during the look back period. The treatment administration record, dated 07/01/25-07/31/25, showed the insulin administration for Resident #6 had not been documented for the 6:00 p.m. to 10:00 p.m. dose on 07/04/25, 07/17/25, or 07/18/25. On 07/08/25 at 2:15 p.m., Resident #6 stated they received their insulin as ordered by the physician. On 07/10/25 at 5:42 p.m., the DON stated they did not have documentation insulin had been provided to Resident #6 on 07/40/25, 07/17/25, or 07/18/25 for the 6:00 p.m. to 10:00 p.m. dose.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program for the abatement of flies for 1 (center) of 4 halls observed for pests. A facility policy dated 10/24/08 and titled, Pest Control Policy, showed that an abundance of flies was often associated with an unhealthy environment. The policy showed that mechanical control measures such as window screens, screen doors that opened outwardly, the use of electric fans, and black light style traps were important interventions in the abatement of flies. On 07/08/25 at 11:35 a.m., during an observation of wound care, multiple flies were observed in the room of Resident #2. On 07/08/25 at 11:38 a.m., LPN #2 waved their gloved hand in front of their face and stated the flies were terrible due to the warm weather. On 07/08/25 at 11:39 a.m., LPN #2 asked Resident #2 how they were. The resident replied they had fought with flies all day long. On 07/08/25 at 11:42 a.m., Resident #2 continued to wave their hand about their face and asked LPN #2 if the room they were in was in fact the resident's own room. LPN #2 responded yes and commented the flies were particularly bad in this room. Resident #2 stated there were flies everywhere and asked to be removed from the fly room. The comprehensive assessment, dated 05/30/25, showed that Resident #2 was severely impaired in daily decision making (BIMS = 5), had unhealed pressure ulcers, and received hospice services. The exterminator's service report, dated 06/13/25, showed that light was visible around exterior doors which provided an entry point for pest. The report recommended to replace seals/door sweeps to prevent pest access to structure. On 07/11/25 at 8:50 a.m., the maintenance supervisor stated the facility pest control program for flies included lighted insect traps at main entrances and wind curtains above frequently used exterior doors. The maintenance supervisor stated they observed the exterior doors were held open for extended periods of time, allowing for flying insects to land on or follow residents as they re-entered the facility from outside. The maintenance supervisor stated they observed flies in the facility but did not witness a concentration of flies nor had a concentration of flies in any particular resident's room been reported to them. The maintenance supervisor stated they would ask housekeeping staff to inspect and clean the resident's room to determine what may be attracting the flies.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of residents' property for 1 (#19) of 4 sampled residents reviewed for abuse. The administrator reported the facility census was 139. Findings: A facility policy titled Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, read in part, Upon receiving an allegation of resident abuse, neglect or misappropriation of resident property or a report of a facility incident as defined in this policy, the facility will begin an investigation of the incident. A care plan, initiated 05/26/25, showed Res #19 had diagnoses which included anxiety disorder and major depressive disorder. An admission assessment, dated 05/29/25, showed Res #19 had a BIMS score (a test for cognition) of 11, which was indicative of moderate impairment for daily decision making. A physician order, dated 06/05/25, showed Res #19 was to receive alprazolam 0.5mg (an antianxiety medication) by mouth every eight hours as needed for anxiety for five days. An undated hand-written facility document, provided by the DON, showed on 06/11/25 CMA #1 reported a medication card with approximately six of Res #19's alprazolam were missing off the medication cart along with the corresponding narcotic sheet. On 06/23/25 at 12:05 p.m., CMA #1 stated on 06/11/25, they noted a card containing approximately six of Res #19's alprazolam and the narcotic sheet for that medication were not on the medication cart. CMA #1 stated they looked for the narcotic sheet at the nurse's desk and were unable to locate it, so they reported the missing medication to the DON. On 06/23/25 at 2:45 p.m., the DON stated they were notified Res #19's medications were missing. The DON stated they had investigated the missing medication, but they did not get any written statements from staff members, and they did not have any notes related to interviewing staff members. The DON also stated they did not determine what happened to the missing medications.

Based on observation and interview, the facility failed to ensure medications were secured for 1 of 2 medication carts on the South hall. The administrator identified 139 residents resided in the facility. Findings: On 06/18/25 at 3:05 p.m., the South hall medication cart located outside the DON's office was observed to be unlocked and unattended. On 06/18/25 at 3:20 p.m., CMA #1 walked up to the cart to lock it. On 06/18/25 at 3:21 p.m., CMA #1 stated the medication cart should have been locked. The CMA stated it was the facility's policy to keep medication carts locked when they were unattended.

Based on record review and interview, the facility failed to report an allegation of misappropriation of property to local law enforcement and the OSDH for 1 (#19) of 4 sampled residents reviewed for abuse. The administrator reported the facility census was 139. Findings: A facility policy titled Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, read in part, Upon receiving an allegation of resident abuse, neglect or misappropriation of resident property or a report of a facility incident as defined in this policy, the facility will begin an investigation of the incident. The facility will also file reports with agencies in accordance with state regulations. If there is a reasonable suspicion that a crime against a resident has occurred, the facility shall report the incident to the Department and law enforcement. A care plan, initiated 05/26/25, showed Res #19 had diagnoses which included anxiety disorder and major depressive disorder. An admission assessment, dated 05/29/25, showed Res #19 had a BIMS score (a test for cognition) of 11, which was indicative of moderate impairment for daily decision making. A physician order, dated 06/05/25, showed Res #19 was to receive alprazolam 0.5mg (an antianxiety medication) by mouth every eight hours as needed for anxiety for five days. An undated hand-written facility document provided by the DON, showed on 06/11/25, CMA #1 reported a medication card with approximately six of Res #19's alprazolam were missing off the medication cart along with the corresponding narcotic sheet. On 06/23/25 at 12:05 p.m., CMA #1 stated on 06/11/25 they noted a card containing approximately six of Res #19's alprazolam and the narcotic sheet for that medication were not on the medication cart. CMA #1 stated they looked for the narcotic sheet at the nurse's desk and were unable to locate it, so they reported the missing medications to the DON. On 06/23/25 at 2:45 p.m., the DON stated they were notified Res #19's medications were missing. The DON stated they did not report the missing narcotics to the OSDH or local law enforcement.

Based on record review and interview, the facility failed to ensure residents' property was not misappropriated for 1 (#19) of 4 sampled residents reviewed for abuse. The administrator reported the facility census was 139. Findings: A facility policy titled Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, read in part, The facility will not tolerate mistreatment, neglect, or abuse of residents, including verbal, mental, sexual, or physical abuse, misappropriation of property, corporal punishment or involuntary seclusion. A care plan, initiated 05/26/25, showed Res #19 had diagnoses which included anxiety disorder and major depressive disorder. An admission assessment, dated 05/29/25, showed Res #19 had a BIMS score (a test for cognition) of 11, which was indicative of moderate impairment for daily decision making. A physician order, dated 06/05/25, showed Res #19 was to receive alprazolam 0.5mg (an antianxiety medication) by mouth every eight hours as needed for anxiety for five days. An undated hand-written facility document provided by the DON showed on 06/11/25 CMA #1 reported a medication card with approximately 6 for Res #19's alprazolam were missing off the medication cart along with the corresponding narcotic sheet. On 06/23/25 at 12:05 p.m., CMA #1 stated on 06/11/25, they noted that a card containing approximately six of Res #19's alprazolam and the narcotic sheet for that medication were not on the medication cart. CMA #1 stated they looked for the narcotic sheet at the nurse's desk and were unable to locate it, so they reported the missing medication to the DON. On 06/23/25 at 2:45 p.m., the DON stated they were notified that Res #19's medications were missing. The DON also stated they were unable to determine what had happened to the medications.

Based on observation and interview, the facility failed to ensure dishes were air dried. The dietary manager identified 32 residents ate meals in their rooms. Findings: On 10/21/24 at 11:48 a.m., CNA #1 was observed making room trays. The plate covers had liquid on running down to the edges on the underside of the cover. The CNA stated the plate covers were not dry. On 10/21/24 at 12:24 p.m., the dishwasher stated when the dishes came out of the dishwasher they immediately stacked them on the rack. On 10/21/24 at 12:26 p.m., the dietary manager stated dishes and plate covers should not be immediately stacked after coming out of the dishwasher, but should be allowed to air dry

Based on observation, record review, and interview, the facility failed to ensure an enteral tube feeding bag was properly labeled for one (#37) of one sampled resident reviewed for tube feeding management. RN#1 identified two residents who received enteral tube feeding via continuous pump. A facility tube feeding policy, dated 06/24/10, read in part, change and label (name of resident, date and time) feeding set ( tubing and appropriate syringe) every 24 hours. Findings: Resident #37 had diagnoses which included a gastrostomy. A physician order, dated 04/30/24, documented every shift Isosource 1.5 at 45mL/hr continuous. On 10/23/24 at 10:44 a.m., the tube feeding for Resident #37 was observed running at 45 ml/hr. The bag containing the formula was dated 10/21/24. The bag was not labeled with any other information. On 10/24/24 02:18 p.m., RN #2 stated when a new bag was hung it should be labeled with the date, time, and the type of formula. They stated sometimes the bag was refilled instead of changed. On 10/24/24 at 2:07 p.m., the enteral feeding bag for Resident #37 was labeled 10/24/24 at 00:00. On 10/24/24 at 2:25 p.m., the DON stated the tube feeding bag should be changed every 24 hours. They stated a new bag should be hung and labeled with the residents name, formula type, rate, date, and time it was changed.

Based on record review and interview, the facility failed to prevent abuse for one (#5) of three residents who were sampled for abuse. The administrator identified 125 resident resided in the facility. Findings: A facility policy titled Resident Abuse, Neglect and Misappropriation of Property, read in part . the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion . Resident #5 had diagnoses which included dementia with behaviors and a history of traumatic brain injury. An Incident Report Form, dated 08/10/24, documented Resident #5 had hit RN #1 and RN #1 had then slapped the resident. RN #1 was terminated by the administrator immediately. A police report, an incident report, and a report to the licensure board was made. All staff present were inserviced on the abuse policy. On 08/14/24 at 12:20 p.m., the administrator stated the incident was investigated immediately, RN #1 was fired on the spot and walked them out of the building. The resident was assessed and stated they were not hurt and did not want to go to the hospital. The police and all other agency notifications were made. Our corporate Q.M. and R.M. were notified and came onsite. We began the Q.A. by immediately in-servicing all the staff present. We continued with educating the staff on abuse until all employees were re-educated. The last inservice was held on 08/12/24. A review of the punch detail for the facility from 08/10/24 through 08/13/24 documented a clock out time for RN #1 on 08/10/24 of 10:20 a.m. A current employee list provided by the facility on 08/12/24 did not list RN #1 as an employee.

Based on observation, record review and interview, the facility failed to ensure resident records were accurate for one (#1) of thirteen residents whose records were reviewed. The administrator reported the census was 117. Findings: Resident #1 had diagnoses including acquired absence of other parts of the urinary tract and anxiety. A physician order, dated 01/03/24, documented the area around the left and right nephrostomy sites were to be cleaned with normal saline, patted dry, and covered with a dry drainage sponge every day and as needed. The TAR, dated February 2024, documented the nephrostomy care was performed on 02/03/24 and 02/04/24. On 02/05/25 at 11:48 a.m., LPN #1 was observed providing nephrostomy care for resident #1. The dressing LPN #1 removed from the left and the right nephrostomy site were dated 02/02/24. On 02/05/24 at 11:55 a.m., LPN #1 stated they recognized the dressings they removed as the ones they applied on 02/02/24 when they provided nephrostomy care for Resident #1. They also stated that if the dressings from 02/02/24 were still in place on 02/05/24 then nephrostomy care had not been provided on 02/03/24 and 02/04/24.

Based on observation, record review and interview, the facility failed to ensure nephrostomy care was provided as ordered for 1 (#1) of one resident reviewed for nephrostomy care. The administrator reported the census was 117. Findings: Resident #1 had diagnoses including acquired absence of other parts of the urinary tract and anxiety. A physician order, dated 01/03/24, documented the area around the left and right nephrostomy sites were to be cleaned with normal saline, patted dry, and covered with a dry drainage sponge every day and as needed. On 02/05/25 at 11:48 a.m., LPN #1 was observed providing nephrostomy care for resident #1. The dressing LPN #1 removed from the left and the right nephrostomy site were dated 02/02/24. On 02/05/24 at 11:55 a.m., LPN #1 stated they recognized the dressings they had removed as the ones they had applied on 02/02/24 when they provided nephrostomy care for Resident #1. They also stated that if the dressings from 02/02/24 were still in place on 02/05/24 then nephrostomy care had not been provided on 02/03/24 and 02/04/24. On 02/06/24 at 2:35 p.m., the DON stated the nephrostomy care should be provided daily according to the physician order.

Based on record review and interview, the facility failed to ensure a prescribed medication was available for administration for one (#2) of three residents reviewed for medication administration. The administrator reported the census was 117. Findings: A Medication Ordering and Receiving from Pharmacy policy, dated January 2022, read in part, .Medications and related products are received from the dispensing pharmacy on a timely basis . Resident #2 had diagnoses including sepsis and hypertension. A physician order, dated 01/12/24, documented the resident was to receive bisacodyl (a laxative) 10 MG suppository daily. The TAR, dated January 2024, does not document if the bisacodyl was given or held on 1/13/24 and that the medication was held on 1/14/24. The medication was administered on 01/15/24. On 02/05/24 at 1:05 p.m., the DON stated pharmacy delivers medication twice a day and that it should not take over 24 hours to receive medication from the pharmacy.

Based on observation, record review, and interview, the facility failed to cover food carts while being transported from the kitchen across the facility to prevent foreign contamination. The DON identified 112 residents received nutrition from the kitchen. Findings: On 09/21/23 at 8:40 a.m., breakfast trays were observed uncovered on a meal tray cart on the South Hall. The bottom half of the meal tray cart was uncovered with eight meal trays and fluids exposed as it was moved down the hall by staff. Residents and staff were observed to pass by the cart in near proximity of the uncovered meal cart. The plastic bag on the meal tray cart was observed bunched up at the top and a CNA repositioned it to cover only the top half of the cart and continued to push the meal tray cart down the hall with eight trays uncovered at the bottom of the cart. A non-cognitive resident in a wheel chair came from their room and tried to touch the uncovered trays on the meal cart. A CNA redirected the resident. Resident #20 had diagnoses which included type 2 diabetes, chronic kidney disease, and heart disease. On 09/20/23 at 9:57 a.m., Resident #20 was asked about the food. They stated the food was cold and uncovered when it was served in their room. On 09/21/23 at 7:40 a.m., the CDM was asked if the plate domes that were stored in the kitchen were being utilized. The CDM stated that carts going to the hall are covered in plastic bags and they were not using the domes, due to the domes were too tall to fit on the meal tray cart.

Based on record review and interview, the facility failed to ensure a Medicaid recipient was notified in writing when the resident's trust account was within $200 of the resouce limit for one (#28) of five sampled residents reviewed for notifications. The BOM identified 59 resident's trust were managed by the facility. Findings: A Medicaid Recipient Trust Policies and Procedure document, revised 02/19/21, read in parts, .The facility must notify each resident that receives Medicaid benefits of the following .When the amount reaches $200 less than the Social Security Income (SSI) resource limit for one person (i.e., $2000-$200=$1800) . Resident #28 had diagnoses of osteoporosis, Vitamin D deficiency, and unspecified dementia. A Quarterly Assessment, dated 08/14/23, documented Resident #28's cognition was mildly impaired. Resident #28's Trust Statements were reviewed from 05/02/23 through 08/31/23. The statements documented the Trust balances on the following dates: a. on 05/02/23 it was $3881.26, b. on 6/12/23 it was $3952.92, c. on 07/03/23 it was $4102.99, and d. on 08/01/23 it was $4253.06. The residents Trust account was over the SSI resource amount from 5/02/23 through 08/17/23. Resident #28's clinical record did not contain documentation the resident was notified that they were over the SSI resource amount for Medicaid. On 09/19/23 at 3:08 p.m., Resident #28 was asked if there was any concerns with their trust account managed by the facility. Resident #28 stated that they were notified verbally by Social Services and did not receive a letter or statement in August of '23 that they needed to spend down the resident's trust account. On 09/21/23 at 8:57 a.m., HR was asked what the policy was for monitoring residents who were in Medicaid trust accounts and the amounts. HR stated the resident cannot have more than $2000 dollars and they try to keep the amounts below $1800. HR was asked how residents were notified when their trust account reached $1800. They stated Social Services discussed it with the resident and they did not provide a written notification. On 09/21/23 at 10:12 a.m., Social Services was asked to discuss the trust account for Resident #28's spend down. Social Services stated Resident #28 had $2500 over the Medicaid amount. They stated sometime in August 2023, HR and Social Services informed Resident #28 verbally and did not provide a statement or notification in writing.

Based on observation, record review, and interview, the facility failed to maintain complete and accurate documentation of the meal percentage ingested for two (#2 and #4) of four residents whose clinical records were reviewed. The ADON identified 112 residents who ate meals prepared in the kitchen and 54 residents who received supplements. Findings: 1. Resident #2 had diagnoses which included metabolic encephalopathy; Alzheimer's dementia; senile degeneration of the brain; and psychosis. The physician's order summary documented the resident was to receive a regular diet with a high protein frozen supplement twice a day with their lunch and dinner tray. On 06/02/23 at 6:10 p.m., CNA #3 stated resident #2 had trouble using a fork and a hard time eating noodles. The CNA stated the resident ate poorly but did eat a roll and a piece of cake for dinner. The CNA was asked who documented meal percentages. The CNA stated they did. They were asked how they kept up with how much each resident ate. The CNA stated they already knew who would eat and who would not eat their meals. The CNA pointed to a room and stated the resident would not eat then pointed to another room and states the resident does not like pasta. On 06/05/23 at 12:00 p.m., the breakfast tray for resident #2 was observed uneaten. On 06/05/23 at 1:40 p.m., CNA #2 was asked how well resident #2 had ate. The CNA stated the resident ate 50% for breakfast and 25% for lunch. On 06/14/23 at 1:10 p.m., the resident's noon day meal tray was observed uneaten. There was no frozen protein supplement present. On 06/14/23 at 5:50 p.m., the resident's evening meal tray was observed uneaten and the desert cake appeared to have one bite removed. There was no frozen protein supplement present. On 06/14/23 the documented intake for the noon meal for resident #2 was 51-75%. On 06/16/23 the clinical record was reviewed. There was no documentation for meal percentages or supplements for the evening meals dated 06/01/23, 06/02/23, 06/05/23, 06/07/23, 06/12/23, 06/14/23, 06/15/23 and there were no meal percentages or supplements documented for the dates 06/03/23, 06/04/23, 06/10/23, and 06/11/23. 2. Resident #4 had diagnoses which included metabolic encephalopathy; dementia; and dysphagia. A physician's order, dated 10/08/22, documented the resident was to receive a high protein frozen supplement once a day with their lunch tray. On 06/15/23 at 1:20 p.m., the lunch tray for resident #4 was observed on the return cart. The resident ate 25% of the meal and none of the high protein frozen treat. On 06/15/23, the clinical record documented the resident ate 75-100% of the noon day meal and 100% of the high protein frozen treat. The clinical record for resident #4 was reviewed. There was no documentation of meal percentages or supplement for breakfast or the noon day meal on 06/03/23, 06/04/23, 06/10/23, and 06/11/23. On 06/16/23 at 12:00 p.m., CNA #1 stated they had not picked up the noon day meal trays but entered the resident's meal percentages and supplements intakes for the noon day meal for 06/16/23. CNA #1 was asked how they knew how much each resident ate for lunch. The CNA stated they knew how much each resident usually ate from experience and entered the meal percentages and supplement intake based on their experience of what the resident would eat. CNA #1 was asked if the meal percentages were written down for them. The CNA stated no. On 06/16/23 at 11:30 a.m., the DON stated the facility had identified there was a problem with incomplete and inaccurate documentation of the residents' meal percentages and supplement intake and were working to educate the staff.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to honor a resident's advanced directive for a do not resuscitate (DNR) and failure to follow their policy for advanced directives. Resident #168 had signed an Oklahoma Do-Not-Resuscitate (DNR) consent form on [DATE] and was admitted to the facility on [DATE]. On [DATE], the nursing staff found the resident unresponsive, not breathing and started CPR. The nursing staff stopped CPR when emergency medical services arrived. The emergency medical services personnel did not start CPR due to the DNR form signed by the resident. The Oklahoma State Department of Health was notified and verified the IJ situation. At 1:53 p.m., the administrator and the director of nursing were informed of the IJ regarding failure to honor the do not resuscitate advanced directive for one resident who was unresponsive and not breathing and was identified as a DNR code status and failure to follow their policy for advanced directives. They were informed this placed the facility in an extended survey. At 3:28 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented, Plan of removal Ambassador Manor [DATE] All licensed nursing staff, licensed therapy staff and Administrator will be in-serviced by nurse managers and acknowledge understanding. In-services will start at 3:30 and be completed by 12:00pm (sic) [DATE]. In-service scope: DNR/advance directive policy and procedure. Honoring a DNR and what is an appropriate representative that would have authority to withdraw an active DNR. All nurse managers will be in service (sic) by (Name deleted) RN Nurse consultant. An addendum to the plan of removal, dated [DATE], documented, (Name deleted), LPN is on medical leave. She will be in serviced prior to returning to work. On [DATE] staff were interviewed regarding the inservice education of the DNR and the DNR policy. The IJ was removed on [DATE] at 10:59 p.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interview and record review, it was determined the facility failed to honor a resident's advanced directive for a do not resuscitate (DNR) directive and failed to follow their policy for advanced directives for one (#168) of four sampled residents who were identified as having a DNR code status. This had the potential to effect all 114 residents who resided in the facility. Resident #168 had signed an Oklahoma Do-Not-Resuscitate (DNR) consent form on [DATE] and was admitted to the facility on [DATE]. On [DATE], the nursing staff found the resident unresponsive, not breathing and started CPR. The nursing staff stopped CPR when the emergency medical services arrived. The emergency medical services personnel did not start CPR due to the DNR form signed by the resident. Findings: Oklahoma Statutes Citationized, Title 63. Public Health and Safety, Chapter 61A - Oklahoma Do-Not-Resuscitate Act, Section 3131.3 - Definitions documents: As used in the Oklahoma Do-Not-Resuscitate Act: .10. 'Representative' means an attorney-in-fact for health care decisions acting pursuant to the Uniform Durable Power of Attorney Act, a health care proxy acting pursuant to the Oklahoma Rights of the Terminally Ill or Persistently Unconcious Act, or a guardian of the person appointed under the Oklahoma Guardianship and Conservatorship Act . A facility policy and procedure, titled DNR, Advance Directives and End of Life Decisions, documented, It is the policy of this Facility to comply with a Resident's Advanced Directive and Do Not Resuscitate Consent (DNR Consent) which has been provided to the Facility. Advanced Directives A valid Directive is binding even if family members disagree with the Directive unless there is a reason to believe that the Directive does not comply with the law. An Oklahoma Do-Not-Resuscitate (DNR) consent form, signed by resident #168 on [DATE], documented, I, (Name deleted, resident #168), request limited health care as described in this document. If my heart stops beating or if I stop breathing, no medical procedure to restore breathing or heart function will be instituted by any health care provider including, but not limited to, emergency medical services (EMS) personnel. I give my permission for this information to be given to EMS personnel, doctors, nurses, and other health care providers. I hereby state that I am making an informed decision and agree to a do-not-resuscitate order. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED].DNR . A care plan, dated [DATE], documented, Code Status: DNR (Do not resuscitate)-NO CPR .Goal .Residents wishes to not be resuscitated will be honored in the absence of respirations and/or heartbeat x90 days .Interventions .DNR-NO CPR If (name deleted) has no respirations or heartbeat, DO NOT START CPR Make residents wishes known to staff RED NAME TAG TO DOOR A nurse's note, dated [DATE], documented, CMA went to the resident's room to administer his night medication, she found resident unresponsive, not breathing, this resident is a DNR, call wife (name deleted) and she requested this nurse to call 911 and start CPR, (emergency medical services) was called and staff started CPR per wife request, (emergency medical services) arrived and the CPR form was giving (sic) to them, nursing staff stopped CPR, the (emergency medical services) personnel did not restart CPR due to the DNR form in hand, (emergency medical services) supervisor call (sic) the resident's wife over the phone and explain (sic) to her that because the DNR was signed and in place they couldn't do CPR and had to pronounce the resident expired at 2110 wife verbalized understanding and (emergency medical services) left . There were no vital signs documented in the nurse's note and the nurse's note was signed by LPN #1. On [DATE] at 11:22 a.m., the DON was asked if the resident had a power of attorney. The DON stated, He was his own responsible party. The DON was asked why CPR had been initiated when the resident's advanced directive was a DNR. The DON stated, I will have to find out. The DON was asked if he was aware of this incident when CPR was initiated on a resident who had a signed DNR. The DON stated, I just knew he expired. I didn't know they started CPR. At 12:18 p.m., RNC #1 provided a document titled, Oklahoma Statutes Citationized Section 3131.7 - Revocation of Consent - Form - Cancellation of Order. RNC #1 stated, We went by section A. The document titled, Oklahoma Statutes Citationized Section 3131.7 - Revocation of Consent - Form - Cancellation of Order, section A. documented, At any time, a person under the care of a health care agency may revoke such person's do-not-resuscitate consent by making an oral, written, or other act of communication to a physician or other health care provider of a health care agency. There was no revocation of consent form documented or provided. The administrator was asked about the incident that had occurred when the LPN initiated CPR on the resident when he had a signed DNR. The administrator stated, (Name deleted-LPN #1) called (Name deleted-ADON #2) after the conversation with the wife to start CPR. Then (Name deleted-ADON #2) called me. I said to start CPR and call (emergency medical services). The administrator stated, It is my understanding that family has the right to rescind it (DNR). The wife was overwrought. We did it for her comfort. The administrator was asked if the resident's wife was his power of attorney. She stated, No. She was asked to provide any other forms or documentation regarding the directive. On [DATE] at 4:08 p.m., LPN #1 was asked if she was the charge nurse on duty the night the resident had expired. She stated, Yes. The LPN was asked why she had initiated CPR on the resident when he had a DNR advanced directive. She stated, The CMA said (Name deleted-resident #168) is not breathing. I checked his pulse and there was no pulse and then I checked his O2 and it wasn't reading, so after that I checked his chart and he was a DNR. I told the manager on duty that he was unresponsive and not breathing. She asked me to call his family. When I called his wife, I told her he was not breathing and was unresponsive. She (wife) told me to start CPR and call 911, she was on her way. I hung up and called the ADON. I told him what the wife said. We sent him the DNR copy. He said to go ahead to start CPR. I called 911 and started the CPR on him. When (emergency medical services) got here I stopped and gave them the copy (DNR) and they didn't start the CPR. The (emergency medical services) supervisor called the wife and stated they could not start CPR cause he was a DNR. Then (emergency medical services) left. The LPN was informed there were no vital signs documented in the nurse's note. She was asked if she had taken the resident's vital signs. She stated, Yes. She was asked why they were not documented in the nurse's note. She stated she had documented them on a piece of paper. There was no documentation provided to show the vital signs had been taken. The LPN was asked if a resident had a signed DNR did she know not to start CPR. She stated, Yes.

Based on observation, record review, and interview, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#16) of two sampled residents who had experienced falls. Resident #16 experienced 12 falls in six months (March through (MONTH) (YEAR)) and sustained four major injuries which included a left hand fracture, a right facial fracture which required surgery, a laceration to his forehead which required seven stitches, and two lacerations to the forehead that were closed with surgical glue. The facility identified 62 residents who were high risk for falls. Findings: A fall awareness program policy, documented, .The Fall Awareness Program is designed to identify those residents who may be at risk for falls and injury .The fall risk assessment will be completed on all admissions, readmission, falls, and significant changes. Falls and significant changes are reported to the Director of Nursing and the Quality Manager for review .Evaluate fall risk factors .Review any health problems or conditions that can cause fall .Review medications .Review and investigate previous falls if able .fall occurs .Assess resident for injuries .complete incident report .complete additional fall risk assessment tool .Consider factors regarding the fall. Develop care plan using appropriate interventions .Re-evaluate toileting rounds to reduce unassisted trips to the bathroom .Review and/or revise plan of care as needed in Q2 meeting .Review the fall at the next safety committee meeting and gain input for interdisciplinary team members for other possible interventions to prevent falls . Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated on 03/31/17, documented, Focus: .has a history of falls and is at risk for future falls. He often is non-compliant with asking for assistance, using call light, or tries to walk with pants down to ankles. He has impaired balance, ROM, gait, mobility, potential for side effects of antidepressant, antianxiety, antipsychotic, incontinence. He has a dx of hx of [MEDICAL CONDITION], muscle weakness, difficulty walking, lack of coordination, reduced mobility, disorder of muscle .Goal: .will not sustain serious injury through the review date .Interventions: Falling star interventions .call light within reach .frequently used items within reach .pathways clear, dry, clutter free and well lit .Lock WC brakes before transfers .appropriate non-skid footwear .Additional interventions R/T previous falls .Encourage .to use the call light with any needed assistance .concave mattress .restorative program .ambulatory aid within reach .High-back WC for mobility . A physician's orders [REDACTED]. An incident report dated 03/13/18, documented, Called to room by CNA who said she was standing by her cart by the residents room and heard resident holler, as she entered room resident was seen falling to the floor by CNA. Resident stated, I was just trying to get that chair out of my room and slid out of my chair .Immediate action taken: .assisted resident to standing position then into wheelchair. Neuro checks WNL, witnessed fall, resident denies hitting his head .Intervention is that resident was educated not to put pads or sheets in his wheelchair on top of his cushion . The care plan, updated 03/13/18, documented, .Non-injury fall .Intervention: Resident educated not to put pads or sheets in his w/c on to (sic) of his cushion . An incident report, dated 03/29/18, documented, This nurse heard loud sound from residents room, upon arrival resident was on the floor on his left side facing his bed awake, alert and oriented x2, with his head resting on the bottom bar of his bedside table, resident was fully dressed with slip resistant socks, visible trauma to residents head, on his left and right side of forehead, minimal amount of blood noted, bruising to left hand, residents wheelchair next to bed, call light in reach, call light was not used by resident. Resident stated he was trying to go to the restroom and lost his balance due to his socks, he reports he has pain located to his buttocks 6/10 and pain to his left side of head 7/10 .Immediate action taken: Resident was assisted back to bed x3, his skin was assessed, skin tear cleansed with wound cleaner, pressure applied to stop bleeding, neurological status monitoring started .this nurse verbalized to resident to use his call light when needing assistance to go to the restroom to prevent further incidents. CNA stayed with resident while (emergency medical services) was called . The care plan, updated 03/29/18, documented, fall with laceration x 2 to left outer lower eyebrow, bruising left hand, pain to buttock and left side of head .Intervention nurse verbalized to resident to use his call light when needing assistance to go to the restroom to prevent further incidents, ER . The care plan did not address new fall interventions to prevent further falls when the resident fell attempting to go to the restroom. A nurse's note, dated 3/30/18, documented, Resident readmitted to facility from (hospital). Transported via (ambulance). Resident has two small lacerations on left corner of eye that has been closed using skin glue. Resident c/o left arm hurting, where they stuck me with needles, and my bottom hurting when I fell . Resident medicated with [MEDICATION NAME] 325mg 2 tablets PO. Resident assisted to restroom then into bed X2 .Resident educated on the importance of using the call light before getting up and waiting for assistance to get up. Resident verbalized understanding. Call light within reach. Neuro checks reinitiated . An incident report, dated 04/08/18, documented, Dietary staff called this nurse to the dining room because he witnessed this resident reach for the pepper on his table as his wheel chair slid out from under him and he slid to the floor on his buttocks. Resident stated that he was reaching for his pepper shaker that was across the table from him, the next this (sic) he knew his wheel chair was going backwards and he landed on his butt .Immediate action taken: Range of motion to all extremities good, no apparent injuries, resident denies pain at this time, no wounds or marks noted from fall .gripper strips to be placed in the seat of resident's wheel chair to prevent sliding out of chair . The care plan, dated 04/08/18, documented, .Non-injury fall (reaching forward and wheelchair slid out from under him) Intervention: Gripper strips place in seat of resident's wheelchair to prevent sliding out of chair changed to dycem .Non-injury witnessed fall, RCA: w/c brakes not locked. Intervention: Resident will be educated on locking w/c brakes for safety . A quarterly assessment, dated 04/17/18, documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with bed mobility, transferring, walking, and toileting, was frequently incontinent, had two or more falls with no injury, and one fall with injury since the previous assessment. A state reportable incident report, dated 05/05/18, documented, On 5-2-18 resident was heard yelling for help from his room, when nurse arrived he was on the floor and stated he had fallen asleep and rolled off his bed onto the floor. There was a contusion with blood noted on his right cheek bone. Dr. (name deleted) notified order given to obtain x-ray. on 5-2-18 Left hand swollen, x-ray obtained, no broken bones noted .Resident cont to c/o of pain and swelling, on 5-5-18 x-ray was obtained of wrist and there was a focal disruption of the articular cortex of the distal radius that was not on 5-3-18 x-ray. Dr. (name deleted) notified and gave order to send resident to the hospital for eval and tx. Resident returned from hospital on 5-6-18 with no new orders .Facility initiated investigation .Resident stated when asked what happened that he fell asleep watching a television show and rolled off his bed, landing on his hand and bumping his head. Hospital orders stated to follow up with Dr. (name deleted) in 48 hours .gave order for OT to eval residents hand, a cockup splint was then placed on residents hand, to be removed q shift to check for skin integrity and during showers .Resident educated on correct body alignment in the middle of the bed so as not to be on the edge of the bed possible rolling out again . The care plan, documented, Interventions: 5/2/18 fall with contusion, pain left wrist fx {focal disruption of the articular cortex of the distal radius} (fell asleep then OOB) Intervention: Educate resident on proper positioning while in bed to prevent falls . An incident report, dated 06/01/18, documented, Resident was observed on floor. Resident stated he was trying to transfer himself from bed to w/c .Immediate action taken: resident assessed and vitals taken and assisted into bed no first aide needed . There were no fall interventions addressed to be implemented to prevent further falls. The care plan, documented, .6/1/18 lab, medication review .Non-injury fall (trying to transfer himself without assistance from bed to wheelchair) . A nurse's note, dated 06/04/18, documented, Due to residents frequent falls, pharmacy evaluation of medications .gave order to decrease [MEDICATION NAME] to 5mg TID . An incident report, dated 06/15/18, documented, CNA was in room assisting resident out of bed. Resident trying to ambulate without assistance, lost balance and fell backwards into wall, landing on bottom .Immediate Action Taken: Head to toe assessment performed. Resident has bruising to the left temple and left elbow from hitting the bed. these were cleansed with wound cleanser and left open to air. Resident was assisted x 2 to a standing position and placed into WC and assisted to bathroom. Resident assisted back to bed and neuro checks were initiated . The care plan, dated 06/15/18, documented, 6/15/18 fall with bruising to left temple and elbow (trying to ambulate without assist) .Medication review . A nurse's note, dated 06/17/18, documented, resident put his c/l on, this nurse was at med cart, went to assist resident immediately but before I could reach resident he fell against the wall then slid to the floor landing on his splint. Laceration to l. forehead above eyebrow .order to send to (hospital) for eval/tx .resident c/o's of l hand hurting that has splint in place. A state reportable incident report, dated 06/17/18, documented, Nurse was standing at the med cart by residents room when his call light came on, nurse went to assist resident immediately, before she could get there, resident stood up, fell against the wall, slid down, landing on his splinted hand. Laceration to the left forehead, above the eyebrow, pressure was applied, Dr. (name deleted) was notified, orders given to send resident to ER for eval and Tx .(ambulance) arrived and resident transported to ER .The facility completed an initial investigation by interviewing the resident and staff, and by completing a focused assessment on the resident, an evaluation of his medication, foot ware, incident hx, environment, chart and record review .Upon completion of the investigation, the facility determined that the resident turned on his call light, got up by himself as nurse was entering the room, and fell . A focused assessment was completed, laceration to the left side of his eyebrow was cleaned and pressure was applied. Order was received to send resident to ER for eval and Tx. ROM WNL for the resident, neuro checks started and WNL for resident. Resident was educated wait until assistance arrives before getting up to go to the bathroom . The care plan, dated 06/17/18, documented, .6/17/18 ER for sutures, PT to eval and treat .Fall with laceration to forehead (got up on own) . There was no documentation PT (physical therapy) had evaluated or treated the resident regarding falls. There were no new interventions to prevent further falls other than the physical therapy that was not provided. On 06/18/18, the pharmacist documented that all medications continued as before and the [MEDICATION NAME] had been reduced in effort to reduce falls in a previous medication review. An annual assessment, dated 06/28/18, documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with bed mobility, locomotion on and off unit, and toilet use, had experienced a fall in the last month, last two to six months, had a fracture related to a fall in the six months prior to admission/reentry and had two or more falls with injury since admission or prior assessment. A state reportable incident report, dated 07/15/18, documented, .staff reported to this nurse resident put c/l on and as she went to assist him he began running to the bathroom, slipped hitting right side of face on toilet. laceration to r. side of face. resident began getting himself up. assisted to w/c after he would not remain in floor until (ambulance) transport arrives, stating he is ok .Update plan of care upon return. ER called and reported facial fracture and resident would be returning .The facility completed an initial investigation by interviewing the resident and staff, and by completing a focused assessment on the resident, an evaluation of his medication, foot ware, incident hx, environment, chart and record review .Upon completion of the investigation, the facility determined that the resident got up by himself to go to the bathroom and as the aide was entering began to run, tripped and fell , hitting his face on the toilet .gave orders to send to ER for eval and tx. Resident returned from the hospital with referral to plastic surgeon. Resident was offered a bed side commode, which he refused to use, he was educated to use the call light and wait for assistance when going to the restroom or transferring. The facility has updated the plan of care to include the appropriate safety/fall risk, transfer status and falling star updated. The care plan, dated 07/15/18, documented, .7/15/18 ER, BSC refuses to use, new order for PT eval and treat .fall with laceration to right side of face, facial fracture (running, unassisted, non-compliance with asking and waiting for assistance, tripped over his own feet) . A physical therapy service log, dated (MONTH) (YEAR), documented the resident had received Physical therapy from 07/20/18 through 07/31/18 for a total of six days. An incident report, dated 08/16/18, documented, .LPN informed this nurse that resident was on the floor. Upon entering the room resident was noted laying on the floor next to his closet. When asked what had happened resident started talking loudly saying that man pulled me out of my chair. I want him to stay out of my room, I am going to (administrator). this nurse tried to talk to resident ask him if he is hurt continuing to talk with a loud voice he said he was fine and he did not hurt him self .Immediate action taken: Resident was assisted off the floor with extensive assist of 2 staff members .resident refused to allow nurse to look for any injuries said he was fine . The care plan, dated 08/16/18, documented, Interventions: 8/16/18 educate resident to use call light when peer in room to have them assisted out .Non-injury fall (pushing peer out of his room, peer began wheeling self and he fell ) . The care plan did not address new fall interventions to prevent further falls when the resident fell attempting to remove another resident from his room. A physical therapy service log, dated (MONTH) (YEAR), documented the resident had received physical therapy once on 08/20/18 and had refused seven other days. A physician's orders [REDACTED]. Pt has declined restorative services @ this time. There were no new fall interventions implemented to prevent further falls. An incident report, dated 08/31/18, documented, Heard loud thud from the nurses station upon entering residents room resident was noted on the floor between the bed and the night stand sitting on the trash can. Resident was looked over for injuries and assisted off the floor with the assist of two staff members.Upon inspection of resident bruising was noted to the right side of the back from the shoulder to the waist area. Resident denied any complaints of pain or discomfort at the time. Resident was encouraged to ask for assistance when transferring and family notified of the residents need for better fitting shoes .I stood up and pushed my call light and fell . The care plan, dated 08/31/18, documented, .8/31/18 Fall with bruise to right right (sic) side of his back from the shoulder to the waist area (I stood up and pushed my call light and fell ) .Put sign on closet door directly in line of sight to rimind (sic) resident when getting up 'Remember to Lock your wheels' .Family called and to replace/get new shoes . On 09/18/18 at 3:21 p.m., the resident was asked if he had any falls recently. He stated, I had to have surgery on my face when I fell and hit the toilet. That was the last major fall I had. During the interview, it was observed the resident was wearing a pair of worn, black house shoes with velcro straps. The resident stated, I need new shoes. These don't fit right. An incident report, dated 09/24/18 at 11:30 a.m., documented, Resident was noted on the floor in the bathroom, feet towards toilet and head under the sink. resident was looked over for injuries no apparent injuries noted and denies any complaint of pain or discomfort. Resident was assisted off the floor with max assist of two staff members and was placed on the toilet .I was leaning over to pick up my glasses off the floor when I slid out of my chair .Immediate action taken: Looked over for injuries, asked about pain and assisted off the floor with assistance of two staff members . There were no new fall interventions addressed to prevent further falls when the resident fell attempting to go to the restroom on his own. On 09/24/18 at 3:54 p.m., the administrator, the DON, and ADON #1 were asked what fall interventions were in place to prevent further falls. The ADON stated, Signs up to remember to call for help. fast food of choice if he doesn't fall in a week. Padding on window, dycem in wheelchair. Remind to lock wheelchair. Tell him to wait for assist with transfer. She was asked if the resident used his call light. She stated, He turns it on but gets up and takes off. He is very impatient. The ADON was asked what labs were drawn related to the fall on 06/01/18. She sated, We did a CBC and BMP. She was asked what the labs showed. She stated, We were looking for infection to cause him to be off balance, like a UTI. They were asked if the labs ruled out an infection and what other new interventions were implemented to prevent falls. No answer was provided. She was asked if the resident had received physical therapy as care planned for the fall on 06/17/18. She stated, I believe he refused. The administrator, the DON and the ADON were asked what other new interventions were implemented when he refused physical therapy. No answer was provided. The administrator and ADON #1 were asked if the resident had received new shoes as an intervention for the fall on 08/31/18. They stated his brother was supposed to be sending money down to buy new shoes but had not done so yet. They were asked what interventions were put in place to prevent other residents from entering his room. The ADON stated, We told him to use the call light for us to come remove the residents. She was asked if there were any other interventions to keep residents out of his room. She stated, Other than that, I don't believe so. The administrator and the ADON were asked if they had toileting interventions in place for the resident. The ADON stated, He is to ask for assistance and staff do frequent checks for toileting. We keep him in a room next to the nurses' station for staff to get to him faster. The administrator stated, He also has a private bathroom so he doesn't have to wait. A nurse's note, dated 9/24/18 at 7:25 p.m., documented, Focused charting r/t nurse called to resident's room by med aide nurse observed resident laying on floor in middle of room face down. Resident assessed for injuries to bumps to forehead noted resident only knew who he was was unable to tell me where he was and date or day of the week. When asked what happened resident stated He got up to walk to the door to talk to med aide and fell . Resident assisted up by staff into w/c Dr. (name deleted) notified .and new order received to send resident to the hospital for eval and tx . On 09/25/18 at 10:39 a.m., LPN #2 was asked if the shoes had caused the resident to fall on 8/31/18. She stated, That's what he said. She was asked when the falling star program was started. She stated, I can't give an exact date. She removed the star from the wall and stated, 03/04/17 is the earliest date I see. She stated, He had two falls yesterday, so he is one on one right now. At 10:55 a.m., the resident was observed sitting in his wheelchair in his room with a staff member. The wheelchair had a cotton bed pad in the seat of his wheelchair. At 11:47 a.m., the administrator, the DON, and ADON #1 were informed of the observation of the resident sitting in the wheelchair with the cotton bed pad in the seat of the wheelchair. They asked if they did a fall investigation after each fall to determine the cause of the fall and interventions to implement. The DON stated, Yes. There's a fall risk and post fall in the chart. The DON provided fall risk assessments but no fall investigations were provided.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure the care plan was implemented to initiate and maintain CPR until emergency personnel arrived for one resident who was identified by the facility as a full code status. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. The Oklahoma State Department of Health was notified and verified the IJ situation. At 1:42 p.m., the administrator, the director of nursing, the assistant director of nursing, and the corporate consultant were informed of the IJ regarding failure to initiate and maintain CPR for one resident who had experienced [MEDICAL CONDITION] and was identified as a full code status by the facility. They were informed this placed the facility in an extended survey. At 1:52 p.m., an acceptable plan of removal was received from the administrator, the DON, and the corporate consultant. The plan of removal documented, Plan of Removal Immediate Jeopardy Ambassador Manor [DATE] All staff will be in-service (sic) by nurse managers/department heads and acknowledge understanding. In-services will start at 2:00 and be completed by 12:00 [DATE]. In-service scope: Pt. found unresponsive call nurse to assess. Nurse if full code and resident is in need of CPR start CPR call code. Code status can be found outside of door (red name tag is DNR and Green name tag is FULL CODE). If unsure call for help and start code, initiate CPR have someone check code status and call 911, get assistance from other nurses in building as needed. If no signed DNR is in front of chart cont CPR. CPR continues until EMS arrive and take over. Notify family and physician and supervisors/administration. All staff will be in-serviced on the facility abuse, neglect and misappropriation of resident property. They will also be in-serviced on the CPR and DNR. In-services will start at 2:00 and be completed by 12:00 [DATE]. Resident charts will be audited to ensure DNR status matches room door plates per policy. Audits will start at 2:00 and be completed by 12:00 [DATE]. RN and LPN employee files will be audited for updated CPR cards. Nurses needing CPR training will be conducted at 4:00 [DATE] Facility investigation will be reviewed and action taken per policy. An Addendum to the Plan of Removal Immediate Jeopardy, dated [DATE] at 3:20 p.m., documented, PRN STAFF THAT HAVE NOT BEEN INSERVICED: (Name deleted), RN (Name deleted), CNA (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN (Name deleted), CNA (Name deleted), CNA Staff on FMLA (Name deleted), Housekeeping (Name deleted), LPN Termed Employees that are still in Payroll System (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN Employee With No Phone- She will be back to work Thursday. (Name deleted), CNA Missing Employee (Name deleted), CNA Suspended (Name deleted), RN (Name deleted), RN On [DATE] staff were interviewed regarding education of the CPR policy, code status identification, observations were made regarding the red and green identification system, and the red folders were observed in residents' clinical records regarding code status. The IJ was removed on [DATE] at 3:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on interview and record review, it was determined the facility failed to follow the care plan for one (#3) of nine sampled residents whose care plans were reviewed for advanced directives. The facility identified 132 residents who resided in the facility. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. Findings: A cardiopulmonary resuscitation (CPR) policy, revised [DATE], documented, BASIC RESPONSIBILITY: Licensed Nurses and Others which have currently been instructed in CPR PURPOSE: To ventilate and establish circulation on an elder with absence of respirations and pulse . EQUIPMENT: [MEDICAL CONDITION] board or hard surface .Airway .Oxygen .Suction machine .Disposable CPR mask . CPR QUICK REFERENCE GUIDE- ADULTS 1. Call for help, if elder is unresponsive delegate someone to call 911 emergency services. 2. If the elder is not breathing begin rescue breathing: Give two full breaths. 3. If the elder does not breath or show signs of circulation in reponse to rescue breaths, locate the compression landmark: Trace the ribs into the sternal notch; place two fingers on the sternum, place your hand above this position. 4. Do chest compressions with: Two hands stacked; heel of one hand on sternum. Rate of chest compressions per minute: ,[DATE] Compression depth: one inch or 1 ,[DATE] inches Ratio of compressions to breaths: ,[DATE] Continue uninterrupted until you are relieved by another person knowledgeable about CPR, emergency lift support arrives, a physician pronounces the elder expired or you are unable to continue . Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].admit to .skilled level of care .CPR/Full Code . A skilled daily nurse's note, dated [DATE], documented the resident was awake, alert, and oriented to person, place, time, and situation. A care plan, dated [DATE], documented, Focus: .Resident is a Full Code status .Goal: Residents (sic) wishes to be resuscitated will be honored and will recieve (sic) all emergency services and aggressive treatment X 90 days .Interventions: If found in cardiac or respiratory arrest, start CPR immediately .If found in cardiac or respiratory arrest, activate emergency services (911) immediately .Make wishes known to staff . A nurse's note, dated [DATE] at 7:07 a.m., documented, Nurse called to room by on coming CNA resident unresponsive with mottling noted to BLE CPR .911 called. An ambulance report, dated [DATE], documented, [MEDICAL CONDITION]. Pt is a 65 yom who is a resident at a nursing home. EMS was called for the pt in [MEDICAL CONDITION] .FD (fire department) reports that when they arrived on the scene they were directed to the pts room. When they arrived the door was shut and that pt was laying supine on the floor with his shirt pulled up on his chest .FD reports that there was no nursing staff at side and that there was no CPR upon their arrival .fire department was given a basic report from the nurse who showed them the room that they found the pt in arrest and that they did CPR for about 10mins while another staff member was calling 911. After 911 was called they report that CPR was stopped and they went back to doing other things until .FD arrived .FD reports they were given a face sheet with the pts basic demos and no HPI. They report that after they arrived at pt side the staff member left and went back to the desk .FD reports that when they arrived on side (sic) the pt was noted to be apenic with no pulse. They started CPR and placed pads on the pt. Pts was noted to be asystole. At that time EMS arrived on scene. During the arrest one of the EMS crew members went and asked the staff for more information and all he was given was that the pt had been there for a couple of days and that he has a hx of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Staff reports that the nurse who found him had already left and that they had no further information on the pt .PT is noted to be unresponsive with no respiratory effort or pulse .CPR was continued during transport .transported to (hospital, name deleted) per protocol. Pt was placed on ER bed with CPR continued for several mins. Pt was called by Staff several minutes after EMS arrival. Report was given to ER staff . The following times were documented on the ambulance report: Recv'd: 07:04:25 [DATE] Dispatch: 07:07:33 [DATE] En Route: 07:07:39 [DATE] At Scene: 07:13:31 [DATE] At Patient: 07:14:28 [DATE] Transport: 07:41:39 [DATE] At Dest: 07:48:59 [DATE] . A hospital emergency department provider note, dated [DATE], documented, .65 y.o. male who presents in [MEDICAL CONDITION] by ambulance. The patient lives in a nursing home. They apparently found him in [MEDICAL CONDITION]. Per EMS report, they began doing CPR but stopped CPR when they called 911. Fire Department arrived to the patient not having compressions performed. Patient had been in asystole the entire time. He was given ten rounds of [MEDICATION NAME] prior to arrival .Unable to obtain review of systems due to the patient in [MEDICAL CONDITION] .Patient remained in [MEDICAL CONDITION]. He stayed in asystole. At this point the patient has not had any recovery or return of spontaneous circulation. The code was stopped. Time of death was 7:53 AM .Clinical Impression: [MEDICAL CONDITION] . A hospital death report, documented, .date of death : [DATE] Time of death: 0753 (7:53 a.m.) . An initial state reportable incident, reported by facsimile on [DATE] at 8:59 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation . On [DATE] at 10:25 a.m., CNA #3 was asked about the incident regarding resident #3 and if CPR was provided to the resident. She stated she observed the resident. She stated no staff or anyone else was in the room with the resident and CPR was not being done. She stated the resident was on the floor and there was not an emergency cart in the room and no oxygen was on the resident. CNA #3 stated three staff from the fire department came in and she saw LPN #7 point them toward the resident's room. She stated she (CNA #3) showed them to the resident's room and one of the fireman yelled, Why are they not doing CPR. She stated she told them she would get the nurse. CNA #3 stated she went to LPN #7 and she sent her to RN #1. She stated RN #1 gave her the paperwork to send with the resident to the hospital and she took it to the fire department staff. She stated she observed the emergency/fire department staff leaving with the resident and heard the fireman ask facility staff at the desk why CPR was not done. She stated, I heard LPN #7 kind of get smart with the fireman and he said I'll just write this up. She stated she then heard LPN #7 tell him to do what he had to do regarding CPR not being done. CNA #3 was asked if anyone at the facility took a statement from her regarding what had occurred. She stated, (ADON/LPN #5) took statement from me and told me to write it out and turn in to her on [DATE]. She was asked if she had any training on [DATE] regarding what had occurred. She stated no. She stated, No one said anything to me after I turned in my statement. At 11:20 a.m., ADON/LPN #5 was asked about what had occurred regarding the resident on the morning of [DATE]. She stated she came in around 11:15 a.m., and had spoken with LPN #7 and took statements from other staff. She was asked if she had completed a state reportable incident report on what had occurred. She stated no and stated ADON/LPN #1 had done that the next day. She was asked why it was not done and why education/training was not started on [DATE]. She stated ADON/LPN #1 had done an inservice the next day on the evening/night shift. At 11:35 a.m., CNA #4 was asked what had occurred regarding the resident on the morning of [DATE]. She stated she was the on coming CNA for the hall the resident was on and came in about 6:50 a.m. She stated the CNA she was to relieve was not in sight so she started making rounds on the hall and checking on the residents. She stated she found the resident lying across his bed with his hand across his chest. She stated she asked the resident if he was going to get up and he did not respond. She stated she tapped him, he was unresponsive, and she immediately reported it to the nurses. CNA #4 stated RN #1 and RN #2 came into the room first. She stated she assisted them to move the resident to the floor. She stated LPN #7 came in and asked what code status the resident was. She stated the resident's name was in green paper on the door and that meant he was a full code and CPR should be started. She was asked if anyone started CPR at that time. She stated, No mam. She stated RN #2 went back to the other hall and RN #1 asked LPN #7 if she had called 911. LPN #7 stated no and then RN #1 left the room and went to the office. She stated, Nobody performed CPR. She stated, To my knowledge he only got CPR when firefighters came in. She stated no one stayed with the resident. She stated another CNA came in and asked if she could help her clean up the resident and LPN #7 told them no and to leave the resident on the floor. She was asked where the nurses were at that time. She stated, (RN #2) was on her end (of the hall), (RN #1) was in office making phone calls, and (LPN #7) was standing at the desk. She stated (CNA #3) gave the fire fighters and EMS the resident's paperwork. CNA #4 stated she heard the fire fighters ask LPN #7 why CPR was not done on the resident. She was asked if anyone interviewed her about what had occurred. She stated, After it all calmed down (ADON/LPN #5) came on and had everyone write a statement. She stated, I went off on my own and wrote it and gave it to her before I left. She was asked if she had received any education/training regarding what had occurred. She stated, ADON/LPN #1 came in and talked to her privately regarding an unresponsive resident and what to do on [DATE] or [DATE]. At 12:10 p.m., ADON/LPN #1 was asked what had occurred regarding the resident on [DATE]. He stated he had received a call from one of the therapy staff regarding the fire fighters were going to report CPR had not been done on the resident before they arrived. He stated he called ADON/LPN #5 who was the manager on duty and she was going to look into what had occurred. He stated he came in the next day and asked about it. He stated he did a reportable incident and asked staff about what had occurred. He stated he was told all three nurses (RN #1, RN #2, and LPN #7) were in the room. He stated they moved the resident to the floor and RN #1 left the room to check records, RN #2 went to check on a resident who was yelling, and LPN #7 left to go call 911. He stated a CNA was left in the room and she did two chest compressions on the resident and then stopped and left the room. He stated LPN #7 was suspended. He was asked if anyone else was suspended at that time. He stated no. He was asked who was responsible to complete the state reportable incident and address interventions to prevent reoccurrence. He stated any of the managers, the DON, and the administrator. He stated the manager on duty when the incident occurred should have reported it. He stated he did the report the next day and started inservices/training when he noticed it had not been done on the evening of [DATE]. He stated he also notified the DON and administrator. He stated, Our plan was to get everyone education and we were going to do others as they came in. He was asked if they should have immediately addressed what had occurred. He stated, Yes. At 12:43 p.m., the DON was asked about the incident. He stated it had been determined CPR had not be initiated and maintained by the facility staff present at the time the resident was found unresponsive. On [DATE] at 9:52 a.m., paramedic #1 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were called out for a [MEDICAL CONDITION]. He stated when we arrived there were a couple of staff at the desk and one or two more around a medication cart in the hall. He stated there were two CNAs in the hall and one of them told him where the resident was. He stated the fire department/paramedics were already in the resident's room performing CPR. He stated they reported to us they had came in the room and the resident was alone lying on the floor and had not received CPR until they arrived. They stated they had asked why no one was providing CPR to the resident and they were told they just stopped and were waiting for them to arrive. At 10:00 a.m., paramedic #2 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were dispatched to the facility regarding a resident in [MEDICAL CONDITION]. He stated upon entrance they had difficulty locating the resident and received no information about the resident. He stated a nurse pointed them down a hall and they passed the room where the resident was. He stated one staff member then showed them the room. He stated the door was closed and the resident was alone in the room lying on the floor. He stated no one was performing CPR on the resident. He stated there was no oxygen on the resident and no emergency cart in the room. He stated, They just weren't doing anything. He stated they started CPR and he asked facility staff why they were not performing CPR and someone stated we knew you were coming so we stopped. He stated, The resident was in asystole the whole time. He stated the whole attitude at the facility was very uncaring. He stated one nurse even stated the word, whatever, as he tried to address the situation. He stated they received no history on the resident and at one point someone just said here is your face sheet. He stated no staff helped in the room or stayed in the hall to answer questions. He stated, It's typically this way at this facility. It seems no one cares or is willing to provide info like they should. You have to hunt them down to get any information. He stated one staff member asked me if the resident was going to make it and I told them probably not because he had been in asystole, no vital signs, the whole time. On [DATE] at 11:00 a.m., the DON and administrator were asked if the documentation in the nurses' notes on [DATE] were accurate and complete regarding what had occurred. The DON stated it was false and not accurate documentation. The DON was asked if the care plan had been followed regarding the interventions to implement during the situation when the resident was unresponsive and had experienced a [MEDICAL CONDITION]. He stated no. He stated the care plan should have been followed but was not.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure there abuse policy and procedures were implemented to ensure a resident was not neglected and received adequate, timely, and appropriate nursing care in regards to the facility's failure to initiate and maintain CPR until emergency personnel arrived for one resident who was identified by the facility as a full code status. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. The Oklahoma State Department of Health was notified and verified the IJ situation. At 1:42 p.m., the administrator, the director of nursing, the assistant director of nursing, and the corporate consultant were informed of the IJ regarding failure to initiate and maintain CPR for one resident who had experienced [MEDICAL CONDITION] and was identified as a full code status by the facility. They were informed this placed the facility in an extended survey. At 1:52 p.m., an acceptable plan of removal was received from the administrator, the DON, and the corporate consultant. The plan of removal documented, Plan of Removal Immediate Jeopardy Ambassador Manor [DATE] All staff will be in-service (sic) by nurse managers/department heads and acknowledge understanding. In-services will start at 2:00 and be completed by 12:00 [DATE]. In-service scope: Pt. found unresponsive call nurse to assess. Nurse if full code and resident is in need of CPR start CPR call code. Code status can be found outside of door (red name tag is DNR and Green name tag is FULL CODE). If unsure call for help and start code, initiate CPR have someone check code status and call 911, get assistance from other nurses in building as needed. If no signed DNR is in front of chart cont CPR. CPR continues until EMS arrive and take over. Notify family and physician and supervisors/administration. All staff will be in-serviced on the facility abuse, neglect and misappropriation of resident property. They will also be in-serviced on the CPR and DNR. In-services will start at 2:00 and be completed by 12:00 [DATE]. Resident charts will be audited to ensure DNR status matches room door plates per policy. Audits will start at 2:00 and be completed by 12:00 [DATE]. RN and LPN employee files will be audited for updated CPR cards. Nurses needing CPR training will be conducted at 4:00 [DATE] Facility investigation will be reviewed and action taken per policy. An Addendum to the Plan of Removal Immediate Jeopardy, dated [DATE] at 3:20 p.m., documented, PRN STAFF THAT HAVE NOT BEEN INSERVICED: (Name deleted), RN (Name deleted), CNA (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN (Name deleted), CNA (Name deleted), CNA Staff on FMLA (Name deleted), Housekeeping (Name deleted), LPN Termed Employees that are still in Payroll System (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN Employee With No Phone- She will be back to work Thursday. (Name deleted), CNA Missing Employee (Name deleted), CNA Suspended (Name deleted), RN (Name deleted), RN On [DATE] staff were interviewed regarding education of the CPR policy, code status identification, observations were made regarding the red and green identification system, and the red folders were observed in residents' clinical records regarding code status. The IJ was removed on [DATE] at 3:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on record review and interviews, it was determined the facility failed to ensure their abuse/neglect policy and procedure was implemented to ensure: ~ a resident was not neglected and received adequate, timely, and appropriate nursing care regarding the facility's failure to initiate and maintain CPR until emergency personnel arrived; ~ a thorough investigation of an allegation of neglect was conducted; ~ an allegation of neglect was reported to all appropriate agencies; and ~ an allegation of neglect was reported within the required timeframe to the OSDH for one (#3) of one sampled resident involved in an allegation of neglect. The facility identified 132 residents resided in the facility. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. Findings: A resident abuse, neglect, and misappropriation of property policy, revised [DATE], documented, .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas . Protection: Any employee found to be guilty of any type of abuse as defined above is subject to immediate termination .If an employee is alleged to have abused a resident, the administrator shall then suspend the accused employee until allegations are thoroughly investigated . Identification/Reporting: All employees of a nursing facility are mandated reporters of resident abuse, to appropriate personnel, neglect or misappropriation of property and must report any and all incidents. All employees shall report any reasonable suspicion of a crime against any individual who is a resident of the facility . Investigation: A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 .All allegations and incidents of abuse, neglect or misappropriation of resident's property, must be reported .If the incident is reportable the administrative staff should document information obtained during the investigation .The preliminary report (within 24 hours) .preliminary findings of the investigation. The 5 day and final report .shall include preliminary and follow-up information and: a summary of investigative actions; investigative findings and conclusions based on findings; and corrective measures to prevent future occurrences. If items are omitted, why the items are omitted and when they will be provided . A cardiopulmonary resuscitation (CPR) policy, revised [DATE], documented, BASIC RESPONSIBILITY: Licensed Nurses and Others which have currently been instructed in CPR PURPOSE: To ventilate and establish circulation on an elder with absence of respirations and pulse . EQUIPMENT: [MEDICAL CONDITION] board or hard surface .Airway .Oxygen .Suction machine .Disposable CPR mask . CPR QUICK REFERENCE GUIDE- ADULTS 1. Call for help, if elder is unresponsive delegate someone to call 911 emergency services. 2. If the elder is not breathing begin rescue breathing: Give two full breaths. 3. If the elder does not breath or show signs of circulation in reponse to rescue breaths, locate the compression landmark: Trace the ribs into the sternal notch; place two fingers on the sternum, place your hand above this position. 4. Do chest compressions with: Two hands stacked; heel of one hand on sternum. Rate of chest compressions per minute: ,[DATE] Compression depth: one inch or 1 ,[DATE] inches Ratio of compressions to breaths: ,[DATE] Continue uninterrupted until you are relieved by another person knowledgeable about CPR, emergency lift support arrives, a physician pronounces the elder expired or you are unable to continue . Resident #3 had [DIAGNOSES REDACTED]. An entry assessment, dated [DATE], documented the resident was admitted to the facility on [DATE]. A nurse's note, dated [DATE], documented, Pt arrived from (hospital name, deleted) via ambulance transport with attendants. On continuous O2 . A physician's orders [REDACTED].admit to .skilled level of care .CPR/Full Code . A skilled daily nurse's note, dated [DATE], documented the resident was awake, alert, and oriented to person, place, time, and situation. A care plan, dated [DATE], documented, Focus: .Resident is a Full Code status .Goal: Residents (sic) wishes to be resuscitated will be honored and will recieve (sic) all emergency services and aggressive treatment X 90 days .Interventions: If found in cardiac or respiratory arrest, start CPR immediately .If found in cardiac or respiratory arrest, activate emergency services (911) immediately .Make wishes known to staff . A nurse's note, dated [DATE] at 7:07 a.m., documented, Nurse called to room by on coming CNA resident unresponsive with mottling noted to BLE CPR .911 called. A nurse's note, dated [DATE] at 7:17 a.m., documented, (ambulance services) at facility .Paramedics took over CPR. Resident is own responsible party. Nurse attempted to call next emergency contact s any answer CNA where (sic) left in room to cont to assist. on call was attempted to be called number s any answer. A nurse's note, dated [DATE] at 7:43 a.m., documented, Resident was taken by (ambulance services) to (hospital, name deleted) c vital signs present per paramedic. An ambulance report, dated [DATE], documented, [MEDICAL CONDITION]. Pt is a 65 yom who is a resident at a nursing home. EMS was called for the pt in [MEDICAL CONDITION] .FD (fire department) reports that when they arrived on the scene they were directed to the pts room. When they arrived the door was shut and that pt was laying supine on the floor with his shirt pulled up on his chest .FD reports that there was no nursing staff at side and that there was no CPR upon their arrival .fire department was given a basic report from the nurse who showed them the room that they found the pt in arrest and that they did CPR for about 10mins while another staff member was calling 911. After 911 was called they report that CPR was stopped and they went back to doing other things until .FD arrived .FD reports they were given a face sheet with the pts basic demos and no HPI. They report that after they arrived at pt side the staff member left and went back to the desk .FD reports that when they arrived on side (sic) the pt was noted to be apenic with no pulse. They started CPR and placed pads on the pt. Pts was noted to be asystole. At that time EMS arrived on scene. During the arrest one of the EMS crew members went and asked the staff for more information and all he was given was that the pt had been there for a couple of days and that he has a hx of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Staff reports that the nurse who found him had already left and that they had no further information on the pt .PT is noted to be unresponsive with no respiratory effort or pulse .CPR was continued during transport .transported to (hospital, name deleted) per protocol. Pt was placed on ER bed with CPR continued for several mins. Pt was called by Staff several minutes after EMS arrival. Report was given to ER staff . The following times were documented on the ambulance report: Recv'd: 07:04:25 [DATE] Dispatch: 07:07:33 [DATE] En Route: 07:07:39 [DATE] At Scene: 07:13:31 [DATE] At Patient: 07:14:28 [DATE] Transport: 07:41:39 [DATE] At Dest: 07:48:59 [DATE] . A hospital emergency department provider note, dated [DATE], documented, .65 y.o. male who presents in [MEDICAL CONDITION] by ambulance. The patient lives in a nursing home. They apparently found him in [MEDICAL CONDITION]. Per EMS report, they began doing CPR but stopped CPR when they called 911. Fire Department arrived to the patient not having compressions performed. Patient had been in asystole the entire time. He was given ten rounds of [MEDICATION NAME] prior to arrival .Unable to obtain review of systems due to the patient in [MEDICAL CONDITION] .Patient remained in [MEDICAL CONDITION]. He stayed in asystole. At this point the patient has not had any recovery or return of spontaneous circulation. The code was stopped. Time of death was 7:53 AM .Clinical Impression: [MEDICAL CONDITION] . A hospital death report, documented, .date of death : [DATE] Time of death: 0753 (7:53 a.m.) . An initial state reportable incident, reported by facsimile on [DATE] at 8:59 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation . On [DATE] at 10:25 a.m., CNA #3 was asked about the incident regarding resident #3 and if CPR was provided to the resident. She stated she had come on duty for day shift shortly before 7:00 a.m., and spoke with CNA #4 regarding the resident and asked if she could assist her to clean up the resident and do end of life care. She stated CNA #4 had told her no and told her LPN #7 had said the resident was a full code and to leave him on the floor and the fire department was coming. She stated she observed the resident. She stated no staff or anyone else was in the room with the resident and CPR was not being done. She stated the resident was on the floor and there was not an emergency cart in the room and no oxygen was on the resident. CNA #3 stated three staff from the fire department came in and she saw LPN #7 point them toward the resident's room. She stated she (CNA #3) showed them to the resident's room and one of the fireman yelled, Why are they not doing CPR. She stated she told them she would get the nurse. CNA #3 stated she went to LPN #7 and she sent her to RN #1. She stated RN #1 gave her the paperwork to send with the resident to the hospital and she took it to the fire department staff. She stated she observed the emergency/fire department staff leaving with the resident and heard the fireman ask facility staff at the desk why CPR was not done. She stated, I heard LPN #7 kind of get smart with the fireman and he said I'll just write this up. She stated she then heard LPN #7 tell him to do what he had to do regarding CPR not being done. CNA #3 was asked if anyone at the facility took a statement from her regarding what had occurred. She stated, (ADON/LPN #5) took statement from me and told me to write it out and turn in to her on [DATE]. She was asked if she had any training on [DATE] regarding what had occurred. She stated no. She stated, No one said anything to me after I turned in my statement. At 11:20 a.m., ADON/LPN #5 was asked about what had occurred regarding the resident on the morning of [DATE]. She stated she came in around 11:15 a.m., and had spoken with LPN #7 and took statements from other staff. She was asked if she had completed a state reportable incident report on what had occurred. She stated no and stated ADON/LPN #1 had done that the next day. She was asked why it was not done and why education/training was not started on [DATE]. She stated ADON/LPN #1 had done an inservice the next day on the evening/night shift. No further comment was made as to why the incident was not reported and further investigated on [DATE]. At 11:35 a.m., CNA #4 was asked what had occurred regarding the resident on the morning of [DATE]. She stated she was the on coming CNA for the hall the resident was on and came in about 6:50 a.m. She stated the CNA she was to relieve was not in sight so she started making rounds on the hall and checking on the residents. She stated she found the resident lying across his bed with his hand across his chest. She stated she asked the resident if he was going to get up and he did not respond. She stated she tapped him, he was unresponsive, and she immediately reported it to the nurses. CNA #4 stated RN #1 and RN #2 came into the room first. She stated she assisted them to move the resident to the floor. She stated LPN #7 came in and asked what code status the resident was. She stated the resident's name was in green paper on the door and that meant he was a full code and CPR should be started. She was asked if anyone started CPR at that time. She stated, No mam. She stated RN #2 went back to the other hall and RN #1 asked LPN #7 if she had called 911. LPN #7 stated no and then RN #1 left the room and went to the office. She stated, Nobody performed CPR. She stated, To my knowledge he only got CPR when firefighters came in. She stated no one stayed with the resident. She stated another CNA came in and asked if she could help her clean up the resident and LPN #7 told them no and to leave the resident on the floor. She was asked where the nurses were at that time. She stated, (RN #2) was on her end (of the hall), (RN #1) was in office making phone calls, and (LPN #7) was standing at the desk. She stated (CNA #3) gave the fire fighters and EMS the resident's paperwork. CNA #4 stated she heard the fire fighters ask LPN #7 why CPR was not done on the resident. She was asked if anyone interviewed her about what had occurred. She stated, After it all calmed down (ADON/LPN #5) came on and had everyone write a statement. She stated, I went off on my own and wrote it and gave it to her before I left. She was asked if she had received any education/training regarding what had occurred. She stated, ADON/LPN #1 came in and talked to her privately regarding an unresponsive resident and what to do on [DATE] or [DATE]. At 12:10 p.m., ADON/LPN #1 was asked what had occurred regarding the resident on [DATE]. He stated he had received a call from one of the therapy staff regarding the fire fighters were going to report CPR had not been done on the resident before they arrived. He stated he called ADON/LPN #5 who was the manager on duty and she was going to look into what had occurred. He stated he came in the next day and asked about it. He stated he did a reportable incident and asked staff about what had occurred. He stated he was told all three nurses (RN #1, RN #2, and LPN #7) were in the room. He stated they moved the resident to the floor and RN #1 left the room to check records, RN #2 went to check on a resident who was yelling, and LPN #7 left to go call 911. He stated a CNA was left in the room and she did two chest compressions on the resident and then stopped and left the room. He stated LPN #7 was suspended. He was asked if anyone else was suspended at that time. He stated no. He was asked who was responsible to complete the state reportable incident and address interventions to prevent reoccurrence. He stated any of the managers, the DON, and the administrator. He stated the manager on duty when the incident occurred should have reported it. He stated he did the report the next day and started inservices/training when he noticed it had not been done on the evening of [DATE]. He stated he also notified the DON and administrator. He stated, Our plan was to get everyone education and we were going to do others as they came in. He was asked if they should have immediately addressed what had occurred. He stated, Yes. At 12:43 p.m., the DON was asked about the incident. He stated he was notified by the manager on duty (ADON/LPN #5) on the morning of [DATE] regarding a resident who had coded and was sent out. He stated, She was going to do an investigation, I wasn't told of any wrong doing at that time. He stated the following morning another ADON (ADON/LPN #1)was on duty called and he was told of the results of the investigation. He stated, I told him to suspend the nurse (LPN #7) and do initial report to the state and continue the investigation. He stated that night ([DATE]) inservices were started. He was asked why it took over one and a half days to do an initial investigation, report it to the state, and educate staff. He stated, I can't answer that. He was asked if he should have been notified of the findings of the initial investigation after it was determined there was a problem with staff's response to an emergency situation regarding a resident that was unresponsive. He stated yes if the allegations were substantiated. He was asked if staff had identified issues to be addressed regarding what had occurred. He stated, Yes. He was asked what the issues identified were. He stated based off interviews with staff, CPR was not started and continued through the time emergency personnel arrived at the facility. He was asked if it had been determined why CPR was not performed. He stated, I can't say why she didn't, but I would say nursing judgement should have determined she did. The DON was asked why all three of the nurses left the unresponsive resident. He stated one nurse left to go get paperwork and one nurse left to check another resident who was yelling. He was asked if that was an appropriate response for the nurses during a code situation when a resident was unresponsive. He stated, I can't gage that, not knowing what the other resident was needing. He was asked if the other two nurses were suspended. He stated no. He was asked why they left the room and did not assist to ensure the resident received CPR. He stated he assumed why they left to be in the normal course of nursing duty. The DON was asked what the priority shoud have been during the emergency situation, leaving the room to gather paperwork, leaving the room to check on another resident who was yelling, or performing CPR on an unresponsive resident. He stated starting and maintaining CPR on the resident. The DON was asked why they had not immediately educated staff after what had occurred. He stated, I honestly did not understand the scope and severity of what had happened. A final state reportable incident, reported by facsimile on [DATE] at 6:47 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation .Relevant resident history .cognitive status .Alert, oriented x 3, [MEDICAL CONDITIONS], Chronic resp failure . SUMMARY OF WITNESSES: On [DATE] (CNA #4) came on shift and stated she noticed (Resident #3) lying across his bed CNA entered room to check on him, he was unresponsive she notified charge nurse (LPN #7) Nurse x 2 went in to room to assess resident. (RN #1) heard someone say he is unresponsive and went into hall and saw (RN #2 and LPN #7) go into room (# deleted) she followed them into room and left to check code status. (RN #2) stated she went to check on her resident that was calling for help down the hall and left (LPN #7) in room with CNA's. (RN #1) yelled out to them he (Resident #3) is a full code and began gathering health information and demographics for (ambulance) when they arrive. Staff placed resident on the floor. Nurse (LPN #7) called 911. Another CNA (CNA #6) was walking by and went into room to help and stated she did chest compressions x 2 then followed (LPN #7) to the desk. (CNA #6) said she asked if they should be doing something and (LPN #7) was on the phone and said he (Resident #3) was gone and did not go back into the room. During this time (CNA #3) came on duty and went by room and heard of event and went and looked in on resident where he was lying on floor, no one was with him. She asked (LPN #7) is (sic) she should help clean him up and she was told no he is a full code leave him on the floor. No one was performing CPR at that time. She stated she heard the sirens of (ambulance). When .F Dept arrived (LPN #7) pointed them to room and then went down hallway on opposite end to her cart .FD asked (CNA #3) if he (Resident #3) was a DNR and she told them no full code, he yelled why is no one doing CPR. (CNA #3) stated she had to get paper work from (RN #1) and give to (ambulance). (CNA #3) said Fire dept asked her who the nurse was and she said the one in black coming up the hall. (CNA #3) said that Fire dept told her they were reporting this and (LPN #7) stated do what you have to do. Resident transported to (hospital, name deleted) ER for eval and treat by (ambulance). Nurse (LPN #7) has been suspended pending investigation of events. FINDINGS: Interview with all persons involved only (CNA #6) had performed any CPR and only for 2 compressions then stopped. (LPN #7) who was in charge of hall failed to perform CPR not ensure CPR was performed on resident under her care. Allegation of neglect substantiated. (LPN #7) has been terminated. All other (sic) involved have been re-educated and disciplinary action taken. Additional information at this time we have decided to further investigation (sic) and have suspended (RN #2 and RN #1) effective [DATE] pending findings . On [DATE] at 10:30 a.m., the social services director was asked about the resident's code status. She stated she confirmed with the resident and he stated he was full code status. At 11:04 a.m., the admission's coordinator was asked what the resident's code status was. She stated the paperwork showed he was a full code. On [DATE] at 9:52 a.m., paramedic #1 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were called out for a [MEDICAL CONDITION]. He stated when we arrived there were a couple of staff at the desk and one or two more around a medication cart in the hall. He stated there were two CNAs in the hall and one of them told him where the resident was. He stated the fire department/paramedics were already in the resident's room performing CPR. He stated they reported to us they had came in the room and the resident was alone lying on the floor and had not received CPR until they arrived. They stated they had asked why no one was providing CPR to the resident and they were told they just stopped and were waiting for them to arrive. At 10:00 a.m., paramedic #2 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were dispatched to the facility regarding a resident in [MEDICAL CONDITION]. He stated upon entrance they had difficulty locating the resident and received no information about the resident. He stated a nurse pointed them down a hall and they passed the room where the resident was. He stated one staff member then showed them the room. He stated the door was closed and the resident was alone in the room lying on the floor. He stated no one was performing CPR on the resident. He stated there was no oxygen on the resident and no emergency cart in the room. He stated, They just weren't doing anything. He stated they started CPR and he asked facility staff why they were not performing CPR and someone stated we knew you were coming so we stopped. He stated, The resident was in asystole the whole time. He stated the whole attitude at the facility was very uncaring. He stated one nurse even stated the word, whatever, as he tried to address the situation. He stated they received no history on the resident and at one point someone just said here is your face sheet. He stated no staff helped in the room or stayed in the hall to answer questions. He stated, It's typically this way at this facility. It seems no one cares or is willing to provide info like they should. You have to hunt them down to get any information. He stated one staff member asked me if the resident was going to make it and I told them probably not because he had been in asystole, no vital signs, the whole time. At 11:00 a.m., the DON and administrator were asked if the documentation in the nurses' notes on [DATE] were accurate and complete regarding what had occurred. The DON stated it was false and not accurate documentation. They were asked if during the investigation had they determined why the staff had not reported the incident timely and completed a thorough investigation regarding staff involved and what had occurred. The administrator stated they had not found that out yet but would be addressing that and were still investigating the incident. The DON was asked if the care plan had been followed regarding the interventions to implement during the situation when the resident was unresponsive and had experienced a [MEDICAL CONDITION]. He stated no. He stated the care plan should have been followed but was not. A second final state reportable incident, reported by facsimile on [DATE] at 12:42 p.m., documented, .Incident date: [DATE] .Additional info: on [DATE] Spoke with (name deleted), chief of emergency medical service from .FD. He confirmed what witnesses had said that resident was in room on floor and no one was present with him when they arrived, his shirt had been pulled up but no one was performing CPR. Nurse just pointed to room and did not go with responders to situation. Stated pt was warm when they arrived. FINDINGS: (LPN #7) who was in charge of hall failed to perform CPR, not ensure CPR was performed on resident under her care. In addition Nurse had falsified documentation that EMS had took over CPR when in fact no CPR was being performed at that time. Allegation of neglect substantiated. (LPN #7) has been terminated. (RN #2) was present at the beginning of the code left to care for another resident and failed to return to ensure process carried out. (RN #1) was also present at beginning of code left room to gather demographics and failed to follow up with ensuring that CPR was being carried until EMS arrived. (RN #2 and RN #1) have also been suspended, and additional education performed and disciplinary action will be performed before they may return to work. All parties reported to (appropriate licensing board). There was no documentation in the report where the two other nurses involved in the incident had been reported to the licensing board. At 1:27 p.m., the DON was asked if they had sent a report to the board of nursing on the two RNs involved. He stated, No.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to ensure a resident was not neglected and received adequate, timely, and appropriate nursing care in regards to the facility's failure to initiate and maintain CPR until emergency personnel arrived for one resident who was identified by the facility as a full code status. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. The Oklahoma State Department of Health was notified and verified the IJ situation. At 1:42 p.m., the administrator, the director of nursing, the assistant director of nursing, and the corporate consultant were informed of the IJ regarding failure to initiate and maintain CPR for one resident who had experienced [MEDICAL CONDITION] and was identified as a full code status by the facility. They were informed this placed the facility in an extended survey. At 1:52 p.m., an acceptable plan of removal was received from the administrator, the DON, and the corporate consultant. The plan of removal documented, Plan of Removal Immediate Jeopardy Ambassador Manor [DATE] All staff will be in-service (sic) by nurse managers/department heads and acknowledge understanding. In-services will start at 2:00 and be completed by 12:00 [DATE]. In-service scope: Pt. found unresponsive call nurse to assess. Nurse if full code and resident is in need of CPR start CPR call code. Code status can be found outside of door (red name tag is DNR and Green name tag is FULL CODE). If unsure call for help and start code, initiate CPR have someone check code status and call 911, get assistance from other nurses in building as needed. If no signed DNR is in front of chart cont CPR. CPR continues until EMS arrive and take over. Notify family and physician and supervisors/administration. All staff will be in-serviced on the facility abuse, neglect and misappropriation of resident property. They will also be in-serviced on the CPR and DNR. In-services will start at 2:00 and be completed by 12:00 [DATE]. Resident charts will be audited to ensure DNR status matches room door plates per policy. Audits will start at 2:00 and be completed by 12:00 [DATE]. RN and LPN employee files will be audited for updated CPR cards. Nurses needing CPR training will be conducted at 4:00 [DATE] Facility investigation will be reviewed and action taken per policy. An Addendum to the Plan of Removal Immediate Jeopardy, dated [DATE] at 3:20 p.m., documented, PRN STAFF THAT HAVE NOT BEEN INSERVICED: (Name deleted), RN (Name deleted), CNA (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN (Name deleted), CNA (Name deleted), CNA Staff on FMLA (Name deleted), Housekeeping (Name deleted), LPN Termed Employees that are still in Payroll System (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN Employee With No Phone- She will be back to work Thursday. (Name deleted), CNA Missing Employee (Name deleted), CNA Suspended (Name deleted), RN (Name deleted), RN On [DATE] staff were interviewed regarding education of the CPR policy, code status identification, observations were made regarding the red and green identification system, and the red folders were observed in residents' clinical records regarding code status. The IJ was removed on [DATE] at 3:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on interview and record review, it was determined the facility failed to ensure a resident was not neglected and received adequate, timely, and appropriate nursing care regarding the facility's failure to initiate and maintain CPR until emergency personnel arrived for one (#3) of three sampled residents who were identified as having a full code status. The facility identified 86 residents who were a full code status. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. Findings: A resident abuse, neglect, and misappropriation of property policy, revised [DATE], documented, .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas . Protection: Any employee found to be guilty of any type of abuse as defined above is subject to immediate termination .If an employee is alleged to have abused a resident, the administrator shall then suspend the accused employee until allegations are thoroughly investigated . Identification/Reporting: All employees of a nursing facility are mandated reporters of resident abuse, to appropriate personnel, neglect or misappropriation of property and must report any and all incidents. All employees shall report any reasonable suspicion of a crime against any individual who is a resident of the facility . Investigation: A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 .All allegations and incidents of abuse, neglect or misappropriation of resident's property, must be reported .If the incident is reportable the administrative staff should document information obtained during the investigation .The preliminary report (within 24 hours) .preliminary findings of the investigation. The 5 day and final report .shall include preliminary and follow-up information and: a summary of investigative actions; investigative findings and conclusions based on findings; and corrective measures to prevent future occurrences. If items are omitted, why the items are omitted and when they will be provided . A cardiopulmonary resuscitation (CPR) policy, revised [DATE], documented, BASIC RESPONSIBILITY: Licensed Nurses and Others which have currently been instructed in CPR PURPOSE: To ventilate and establish circulation on an elder with absence of respirations and pulse . EQUIPMENT: [MEDICAL CONDITION] board or hard surface .Airway .Oxygen .Suction machine .Disposable CPR mask . CPR QUICK REFERENCE GUIDE- ADULTS 1. Call for help, if elder is unresponsive delegate someone to call 911 emergency services. 2. If the elder is not breathing begin rescue breathing: Give two full breaths. 3. If the elder does not breath or show signs of circulation in reponse to rescue breaths, locate the compression landmark: Trace the ribs into the sternal notch; place two fingers on the sternum, place your hand above this position. 4. Do chest compressions with: Two hands stacked; heel of one hand on sternum. Rate of chest compressions per minute: ,[DATE] Compression depth: one inch or 1 ,[DATE] inches Ratio of compressions to breaths: ,[DATE] Continue uninterrupted until you are relieved by another person knowledgeable about CPR, emergency lift support arrives, a physician pronounces the elder expired or you are unable to continue . Resident #3 had [DIAGNOSES REDACTED]. An entry assessment, dated [DATE], documented the resident was admitted to the facility on [DATE]. A nurse's note, dated [DATE], documented, Pt arrived from (hospital name, deleted) via ambulance transport with attendants. On continuous O2 . A physician's orders [REDACTED].admit to .skilled level of care .CPR/Full Code . A skilled daily nurse's note, dated [DATE], documented the resident was awake, alert, and oriented to person, place, time, and situation. A care plan, dated [DATE], documented, Focus: .Resident is a Full Code status .Goal: Residents (sic) wishes to be resuscitated will be honored and will recieve (sic) all emergency services and aggressive treatment X 90 days .Interventions: If found in cardiac or respiratory arrest, start CPR immediately .If found in cardiac or respiratory arrest, activate emergency services (911) immediately .Make wishes known to staff . A nurse's note, dated [DATE] at 5:30 a.m., documented, Resident awake .sitting up on side of bed states to CNA he wants to go smoke. Resident is supervised smoker .resident reminded of that verbalized understanding. Resident was asked if he wanted to have a snake (sic) or lay down he stated NO as he was noted to have dyspnea c O2 in place. VSS denies any c/o pain . A nurse's note, dated [DATE] at 7:07 a.m., documented, Nurse called to room by on coming CNA resident unresponsive with mottling noted to BLE CPR .911 called. A nurse's note, dated [DATE] at 7:17 a.m., documented, (ambulance services) at facility .Paramedics took over CPR. Resident is own responsible party. Nurse attempted to call next emergency contact s any answer CNA where (sic) left in room to cont to assist. on call was attempted to be called number s any answer. A nurse's note, dated [DATE] at 7:43 a.m., documented, Resident was taken by (ambulance services) to (hospital, name deleted) c vital signs present per paramedic. An ambulance report, dated [DATE], documented, [MEDICAL CONDITION]. Pt is a 65 yom who is a resident at a nursing home. EMS was called for the pt in [MEDICAL CONDITION] .FD (fire department) reports that when they arrived on the scene they were directed to the pts room. When they arrived the door was shut and that pt was laying supine on the floor with his shirt pulled up on his chest .FD reports that there was no nursing staff at side and that there was no CPR upon their arrival .fire department was given a basic report from the nurse who showed them the room that they found the pt in arrest and that they did CPR for about 10mins while another staff member was calling 911. After 911 was called they report that CPR was stopped and they went back to doing other things until .FD arrived .FD reports they were given a face sheet with the pts basic demos and no HPI. They report that after they arrived at pt side the staff member left and went back to the desk .FD reports that when they arrived on side (sic) the pt was noted to be apenic with no pulse. They started CPR and placed pads on the pt. Pts was noted to be asystole. At that time EMS arrived on scene. During the arrest one of the EMS crew members went and asked the staff for more information and all he was given was that the pt had been there for a couple of days and that he has a hx of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Staff reports that the nurse who found him had already left and that they had no further information on the pt .PT is noted to be unresponsive with no respiratory effort or pulse .CPR was continued during transport .transported to (hospital, name deleted) per protocol. Pt was placed on ER bed with CPR continued for several mins. Pt was called by Staff several minutes after EMS arrival. Report was given to ER staff . The following times were documented on the ambulance report: Recv'd: 07:04:25 [DATE] Dispatch: 07:07:33 [DATE] En Route: 07:07:39 [DATE] At Scene: 07:13:31 [DATE] At Patient: 07:14:28 [DATE] Transport: 07:41:39 [DATE] At Dest: 07:48:59 [DATE] . A hospital emergency department provider note, dated [DATE], documented, .65 y.o. male who presents in [MEDICAL CONDITION] by ambulance. The patient lives in a nursing home. They apparently found him in [MEDICAL CONDITION]. Per EMS report, they began doing CPR but stopped CPR when they called 911. Fire Department arrived to the patient not having compressions performed. Patient had been in asystole the entire time. He was given ten rounds of [MEDICATION NAME] prior to arrival .Unable to obtain review of systems due to the patient in [MEDICAL CONDITION] .Patient remained in [MEDICAL CONDITION]. He stayed in asystole. At this point the patient has not had any recovery or return of spontaneous circulation. The code was stopped. Time of death was 7:53 AM .Clinical Impression: [MEDICAL CONDITION] . A hospital death report, documented, .date of death : [DATE] Time of death: 0753 (7:53 a.m.) . An initial state reportable incident, reported by facsimile on [DATE] at 8:59 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation . On [DATE] at 10:25 a.m., CNA #3 was asked about the incident regarding resident #3 and if CPR was provided to the resident. She stated she had come on duty for day shift shortly before 7:00 a.m., and spoke with CNA #4 regarding the resident and asked if she could assist her to clean up the resident and do end of life care. She stated CNA #4 had told her no and told her LPN #7 had said the resident was a full code and to leave him on the floor and the fire department was coming. She stated she observed the resident. She stated no staff or anyone else was in the room with the resident and CPR was not being done. She stated the resident was on the floor and there was not an emergency cart in the room and no oxygen was on the resident. CNA #3 stated three staff from the fire department came in and she saw LPN #7 point them toward the resident's room. She stated she (CNA #3) showed them to the resident's room and one of the fireman yelled, Why are they not doing CPR. She stated she told them she would get the nurse. CNA #3 stated she went to LPN #7 and she sent her to RN #1. She stated RN #1 gave her the paperwork to send with the resident to the hospital and she took it to the fire department staff. She stated she observed the emergency/fire department staff leaving with the resident and heard the fireman ask facility staff at the desk why CPR was not done. She stated, I heard LPN #7 kind of get smart with the fireman and he said I'll just write this up. She stated she then heard LPN #7 tell him to do what he had to do regarding CPR not being done. CNA #3 was asked if anyone at the facility took a statement from her regarding what had occurred. She stated, (ADON/LPN #5) took statement from me and told me to write it out and turn in to her on [DATE]. She was asked if she had any training on [DATE] regarding what had occurred. She stated no. She stated, No one said anything to me after I turned in my statement. At 11:20 a.m., ADON/LPN #5 was asked about what had occurred regarding the resident on the morning of [DATE]. She stated she came in around 11:15 a.m., and had spoken with LPN #7 and took statements from other staff. She was asked if she had completed a state reportable incident report on what had occurred. She stated no and stated ADON/LPN #1 had done that the next day. She was asked why it was not done and why education/training was not started on [DATE]. She stated ADON/LPN #1 had done an inservice the next day on the evening/night shift. No further comment was made as to why the incident was not reported and further investigated on [DATE]. At 11:35 a.m., CNA #4 was asked what had occurred regarding the resident on the morning of [DATE]. She stated she was the on coming CNA for the hall the resident was on and came in about 6:50 a.m. She stated the CNA she was to relieve was not in sight so she started making rounds on the hall and checking on the residents. She stated she found the resident lying across his bed with his hand across his chest. She stated she asked the resident if he was going to get up and he did not respond. She stated she tapped him, he was unresponsive, and she immediately reported it to the nurses. CNA #4 stated RN #1 and RN #2 came into the room first. She stated she assisted them to move the resident to the floor. She stated LPN #7 came in and asked what code status the resident was. She stated the resident's name was in green paper on the door and that meant he was a full code and CPR should be started. She was asked if anyone started CPR at that time. She stated, No mam. She stated RN #2 went back to the other hall and RN #1 asked LPN #7 if she had called 911. LPN #7 stated no and then RN #1 left the room and went to the office. She stated, Nobody performed CPR. She stated, To my knowledge he only got CPR when firefighters came in. She stated no one stayed with the resident. She stated another CNA came in and asked if she could help her clean up the resident and LPN #7 told them no and to leave the resident on the floor. She was asked where the nurses were at that time. She stated, (RN #2) was on her end (of the hall), (RN #1) was in office making phone calls, and (LPN #7) was standing at the desk. She stated (CNA #3) gave the fire fighters and EMS the resident's paperwork. CNA #4 stated she heard the fire fighters ask LPN #7 why CPR was not done on the resident. She was asked if anyone interviewed her about what had occurred. She stated, After it all calmed down (ADON/LPN #5) came on and had everyone write a statement. She stated, I went off on my own and wrote it and gave it to her before I left. She was asked if she had received any education/training regarding what had occurred. She stated, ADON/LPN #1 came in and talked to her privately regarding an unresponsive resident and what to do on [DATE] or [DATE]. At 12:10 p.m., ADON/LPN #1 was asked what had occurred regarding the resident on [DATE]. He stated he had received a call from one of the therapy staff regarding the fire fighters were going to report CPR had not been done on the resident before they arrived. He stated he called ADON/LPN #5 who was the manager on duty and she was going to look into what had occurred. He stated he came in the next day and asked about it. He stated he did a reportable incident and asked staff about what had occurred. He stated he was told all three nurses (RN #1, RN #2, and LPN #7) were in the room. He stated they moved the resident to the floor and RN #1 left the room to check records, RN #2 went to check on a resident who was yelling, and LPN #7 left to go call 911. He stated a CNA was left in the room and she did two chest compressions on the resident and then stopped and left the room. He stated LPN #7 was suspended. He was asked if anyone else was suspended at that time. He stated no. He was asked who was responsible to complete the state reportable incident and address interventions to prevent reoccurrence. He stated any of the managers, the DON, and the administrator. He stated the manager on duty when the incident occurred should have reported it. He stated he did the report the next day and started inservices/training when he noticed it had not been done on the evening of [DATE]. He stated he also notified the DON and administrator. He stated, Our plan was to get everyone education and we were going to do others as they came in. He was asked if they should have immediately addressed what had occurred. He stated, Yes. At 12:43 p.m., the DON was asked about the incident. He stated he was notified by the manager on duty (ADON/LPN #5) on the morning of [DATE] regarding a resident who had coded and was sent out. He stated, She was going to do an investigation, I wasn't told of any wrong doing at that time. He stated the following morning another ADON (ADON/LPN #1) was on duty called and he was told of the results of the investigation. He stated, I told him to suspend the nurse (LPN #7) and do initial report to the state and continue the investigation. He stated that night ([DATE]) inservices were started. He was asked why it took over one and a half days to do an initial investigation, report it to the state, and educate staff. He stated, I can't answer that. He was asked if he should have been notified of the findings of the initial investigation after it was determined there was a problem with staff's response to an emergency situation regarding a resident that was unresponsive. He stated yes if the allegations were substantiated. He was asked if staff had identified issues to be addressed regarding what had occurred. He stated, Yes. He was asked what the issues identified were. He stated based off interviews with staff, CPR was not started and continued through the time emergency personnel arrived at the facility. He was asked if it had been determined why CPR was not performed. He stated, I can't say why she didn't, but I would say nursing judgement should have determined she did. The DON was asked why all three of the nurses left the unresponsive resident. He stated one nurse left to go get paperwork and one nurse left to check another resident who was yelling. He was asked if that was an appropriate response for the nurses during a code situation when a resident was unresponsive. He stated, I can't gage that, not knowing what the other resident was needing. He was asked if the other two nurses were suspended. He stated no. He was asked why they left the room and did not assist to ensure the resident received CPR. He stated he assumed why they left to be in the normal course of nursing duty. The DON was asked what the priority shoud have been during the emergency situation, leaving the room to gather paperwork, leaving the room to check on another resident who was yelling, or performing CPR on an unresponsive resident. He stated starting and maintaining CPR on the resident. The DON was asked why they had not immediately educated staff after what had occurred. He stated, I honestly did not understand the scope and severity of what had happened. A final state reportable incident, reported by facsimile on [DATE] at 6:47 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation .Relevant resident history .cognitive status .Alert, oriented x 3, [MEDICAL CONDITIONS], Chronic resp failure . SUMMARY OF WITNESSES: On [DATE] (CNA #4) came on shift and stated she noticed (Resident #3) lying across his bed CNA entered room to check on him, he was unresponsive she notified charge nurse (LPN #7) Nurse x 2 went in to room to assess resident. (RN #1) heard someone say he is unresponsive and went into hall and saw (RN #2 and LPN #7) go into room (# deleted) she followed them into room and left to check code status. (RN #2) stated she went to check on her resident that was calling for help down the hall and left (LPN #7) in room with CNA's. (RN #1) yelled out to them he (Resident #3) is a full code and began gathering health information and demographics for (ambulance) when they arrive. Staff placed resident on the floor. Nurse (LPN #7) called 911. Another CNA (CNA #6) was walking by and went into room to help and stated she did chest compressions x 2 then followed (LPN #7) to the desk. (CNA #6) said she asked if they should be doing something and (LPN #7) was on the phone and said he (Resident #3) was gone and did not go back into the room. During this time (CNA #3) came on duty and went by room and heard of event and went and looked in on resident where he was lying on floor, no one was with him. She asked (LPN #7) is (sic) she should help clean him up and she was told no he is a full code leave him on the floor. No one was performing CPR at that time. She stated she heard the sirens of (ambulance). When .F Dept arrived (LPN #7) pointed them to room and then went down hallway on opposite end to her cart .FD asked (CNA #3) if he (Resident #3) was a DNR and she told them no full code, he yelled why is no one doing CPR. (CNA #3) stated she had to get paper work from (RN #1) and give to (ambulance). (CNA #3) said Fire dept asked her who the nurse was and she said the one in black coming up the hall. (CNA #3) said that Fire dept told her they were reporting this and (LPN #7) stated do what you have to do. Resident transported to (hospital, name deleted) ER for eval and treat by (ambulance). Nurse (LPN #7) has been suspended pending investigation of events. FINDINGS: Interview with all persons involved only (CNA #6) had performed any CPR and only for 2 compressions then stopped. (LPN #7) who was in charge of hall failed to perform CPR not ensure CPR was performed on resident under her care. Allegation of neglect substantiated. (LPN #7) has been terminated. All other (sic) involved have been re-educated and disciplinary action taken. Additional information at this time we have decided to further investigation (sic) and have suspended (RN #2 and RN #1) effective [DATE] pending findings . On [DATE] at 10:30 a.m., the social services director was asked about the resident's code status. She stated she confirmed with the resident and he stated he was full code status. At 11:04 a.m., the admission's coordinator was asked what the resident's code status was. She stated the paperwork showed he was a full code. On [DATE] at 9:52 a.m., paramedic #1 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were called out for a [MEDICAL CONDITION]. He stated when we arrived there were a couple of staff at the desk and one or two more around a medication cart in the hall. He stated there were two CNAs in the hall and one of them told him where the resident was. He stated the fire department/paramedics were already in the resident's room performing CPR. He stated they reported to us they had came in the room and the resident was alone lying on the floor and had not received CPR until they arrived. They stated they had asked why no one was providing CPR to the resident and they were told they just stopped and were waiting for them to arrive. At 10:00 a.m., paramedic #2 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were dispatched to the facility regarding a resident in [MEDICAL CONDITION]. He stated upon entrance they had difficulty locating the resident and received no information about the resident. He stated a nurse pointed them down a hall and they passed the room where the resident was. He stated one staff member then showed them the room. He stated the door was closed and the resident was alone in the room lying on the floor. He stated no one was performing CPR on the resident. He stated there was no oxygen on the resident and no emergency cart in the room. He stated, They just weren't doing anything. He stated they started CPR and he asked facility staff why they were not performing CPR and someone stated we knew you were coming so we stopped. He stated, The resident was in asystole the whole time. He stated the whole attitude at the facility was very uncaring. He stated one nurse even stated the word, whatever, as he tried to address the situation. He stated they received no history on the resident and at one point someone just said here is your face sheet. He stated no staff helped in the room or stayed in the hall to answer questions. He stated, It's typically this way at this facility. It seems no one cares or is willing to provide info like they should. You have to hunt them down to get any information. He stated one staff member asked me if the resident was going to make it and I told them probably not because he had been in asystole, no vital signs, the whole time. At 11:00 a.m., the DON and administrator were asked if the documentation in the nurses' notes on [DATE] were accurate and complete regarding what had occurred. The DON stated it was false and not accurate documentation. They were asked if during the investigation had they determined why the staff had not reported the incident timely and completed a thorough investigation regarding staff involved and what had occurred. The administrator stated they had not found that out yet but would be addressing that and were still investigating the incident. The DON was asked if the care plan had been followed regarding the interventions to implement during the situation when the resident was unresponsive and had experienced a [MEDICAL CONDITION]. He stated no. He stated the care plan should have been followed but was not. A second final state reportable incident, reported by facsimile on [DATE] at 12:42 p.m., documented, .Incident date: [DATE] .Additional info: on [DATE] Spoke with (name deleted), chief of emergency medical service from .FD. He confirmed what witnesses had said that resident was in room on floor and no one was present with him when they arrived, his shirt had been pulled up but no one was performing CPR. Nurse just pointed to room and did not go with responders to situation. Stated pt was warm when they arrived. FINDINGS: (LPN #7) who was in charge of hall failed to perform CPR, not ensure CPR was performed on resident under her care. In addition Nurse had falsified documentation that EMS had took over CPR when in fact no CPR was being performed at that time. Allegation of neglect substantiated. (LPN #7) has been terminated. (RN #2) was present at the beginning of the code left to care for another resident and failed to return to ensure process carried out. (RN #1) was also present at beginning of code left room to gather demographics and failed to follow up with ensuring that CPR was being carried until EMS arrived. (RN #2 and RN #1) have also been suspended, and additional education performed and disciplinary action will be performed before they may return to work. All parties reported to (appropriate licensing board). There was no documentation in the report where the two other nurses involved in the incident had been reported to the licensing board. At 1:27 p.m., the DON was asked if they had sent a report to the board of nursing on the two RNs involved. He stated, No.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility to initiate and maintain CPR until emergency personnel arrived for one resident who was identified by the facility as a full code status. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. The Oklahoma State Department of Health was notified and verified the IJ situation. At 1:42 p.m., the administrator, the director of nursing, the assistant director of nursing, and the corporate consultant were informed of the IJ regarding failure to initiate and maintain CPR for one resident who had experienced [MEDICAL CONDITION] and was identified as a full code status by the facility. They were informed this placed the facility in an extended survey. At 1:52 p.m., an acceptable plan of removal was received from the administrator, the DON, and the corporate consultant. The plan of removal documented, Plan of Removal Immediate Jeopardy Ambassador Manor [DATE] All staff will be in-service (sic) by nurse managers/department heads and acknowledge understanding. In-services will start at 2:00 and be completed by 12:00 [DATE]. In-service scope: Pt. found unresponsive call nurse to assess. Nurse if full code and resident is in need of CPR start CPR call code. Code status can be found outside of door (red name tag is DNR and Green name tag is FULL CODE). If unsure call for help and start code, initiate CPR have someone check code status and call 911, get assistance from other nurses in building as needed. If no signed DNR is in front of chart cont CPR. CPR continues until EMS arrive and take over. Notify family and physician and supervisors/administration. All staff will be in-serviced on the facility abuse, neglect and misappropriation of resident property. They will also be in-serviced on the CPR and DNR. In-services will start at 2:00 and be completed by 12:00 [DATE]. Resident charts will be audited to ensure DNR status matches room door plates per policy. Audits will start at 2:00 and be completed by 12:00 [DATE]. RN and LPN employee files will be audited for updated CPR cards. Nurses needing CPR training will be conducted at 4:00 [DATE] Facility investigation will be reviewed and action taken per policy. An Addendum to the Plan of Removal Immediate Jeopardy, dated [DATE] at 3:20 p.m., documented, PRN STAFF THAT HAVE NOT BEEN INSERVICED: (Name deleted), RN (Name deleted), CNA (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN (Name deleted), CNA (Name deleted), CNA Staff on FMLA (Name deleted), Housekeeping (Name deleted), LPN Termed Employees that are still in Payroll System (Name deleted), CNA (Name deleted), LPN (Name deleted), LPN Employee With No Phone- She will be back to work Thursday. (Name deleted), CNA Missing Employee (Name deleted), CNA Suspended (Name deleted), RN (Name deleted), RN On [DATE] staff were interviewed regarding education of the CPR policy, code status identification, observations were made regarding the red and green identification system, and the red folders were observed in residents' clinical records regarding code status. The IJ was removed on [DATE] at 3:15 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on interview and record review, it was determined the facility failed to initiate and maintain CPR until emergency personnel arrived for one (#3) of three sampled residents who were identified as having a full code status. The facility identified 86 residents who were a full code status. Resident #3, who had a full code status, was not provided CPR after he was found nonresponive without pulse or respirations, until emergency responders arrived. The resident was provided CPR by emergency responders and then hospital staff in the emergency room . The resident did not have any recovery or return of spontaneous circulation and the code was stopped. The time of death was 7:53 a.m. Findings: A cardiopulmonary resuscitation (CPR) policy, revised [DATE], documented, BASIC RESPONSIBILITY: Licensed Nurses and Others which have currently been instructed in CPR PURPOSE: To ventilate and establish circulation on an elder with absence of respirations and pulse . EQUIPMENT: [MEDICAL CONDITION] board or hard surface .Airway .Oxygen .Suction machine .Disposable CPR mask . CPR QUICK REFERENCE GUIDE- ADULTS 1. Call for help, if elder is unresponsive delegate someone to call 911 emergency services. 2. If the elder is not breathing begin rescue breathing: Give two full breaths. 3. If the elder does not breath or show signs of circulation in reponse to rescue breaths, locate the compression landmark: Trace the ribs into the sternal notch; place two fingers on the sternum, place your hand above this position. 4. Do chest compressions with: Two hands stacked; heel of one hand on sternum. Rate of chest compressions per minute: ,[DATE] Compression depth: one inch or 1 ,[DATE] inches Ratio of compressions to breaths: ,[DATE] Continue uninterrupted until you are relieved by another person knowledgeable about CPR, emergency lift support arrives, a physician pronounces the elder expired or you are unable to continue . Resident #3 had [DIAGNOSES REDACTED]. An entry assessment, dated [DATE], documented the resident was admitted to the facility on [DATE]. A nurse's note, dated [DATE], documented, Pt arrived from (hospital name, deleted) via ambulance transport with attendants. On continuous O2 . A physician's orders [REDACTED].admit to .skilled level of care .CPR/Full Code . A skilled daily nurse's note, dated [DATE], documented the resident was awake, alert, and oriented to person, place, time, and situation. A care plan, dated [DATE], documented, Focus: .Resident is a Full Code status .Goal: Residents (sic) wishes to be resuscitated will be honored and will recieve (sic) all emergency services and aggressive treatment X 90 days .Interventions: If found in cardiac or respiratory arrest, start CPR immediately .If found in cardiac or respiratory arrest, activate emergency services (911) immediately .Make wishes known to staff . A nurse's note, dated [DATE] at 5:30 a.m., documented, Resident awake .sitting up on side of bed states to CNA he wants to go smoke. Resident is supervised smoker .resident reminded of that verbalized understanding. Resident was asked if he wanted to have a snake (sic) or lay down he stated NO as he was noted to have dyspnea c O2 in place. VSS denies any c/o pain . A nurse's note, dated [DATE] at 7:07 a.m., documented, Nurse called to room by on coming CNA resident unresponsive with mottling noted to BLE CPR .911 called. A nurse's note, dated [DATE] at 7:17 a.m., documented, (ambulance services) at facility .Paramedics took over CPR. Resident is own responsible party. Nurse attempted to call next emergency contact s any answer CNA where (sic) left in room to cont to assist. on call was attempted to be called number s any answer. A nurse's note, dated [DATE] at 7:43 a.m., documented, Resident was taken by (ambulance services) to (hospital, name deleted) c vital signs present per paramedic. An ambulance report, dated [DATE], documented, [MEDICAL CONDITION]. Pt is a 65 yom who is a resident at a nursing home. EMS was called for the pt in [MEDICAL CONDITION] .FD (fire department) reports that when they arrived on the scene they were directed to the pts room. When they arrived the door was shut and that pt was laying supine on the floor with his shirt pulled up on his chest .FD reports that there was no nursing staff at side and that there was no CPR upon their arrival .fire department was given a basic report from the nurse who showed them the room that they found the pt in arrest and that they did CPR for about 10mins while another staff member was calling 911. After 911 was called they report that CPR was stopped and they went back to doing other things until .FD arrived .FD reports they were given a face sheet with the pts basic demos and no HPI. They report that after they arrived at pt side the staff member left and went back to the desk .FD reports that when they arrived on side (sic) the pt was noted to be apenic with no pulse. They started CPR and placed pads on the pt. Pts was noted to be asystole. At that time EMS arrived on scene. During the arrest one of the EMS crew members went and asked the staff for more information and all he was given was that the pt had been there for a couple of days and that he has a hx of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Staff reports that the nurse who found him had already left and that they had no further information on the pt .PT is noted to be unresponsive with no respiratory effort or pulse .CPR was continued during transport .transported to (hospital, name deleted) per protocol. Pt was placed on ER bed with CPR continued for several mins. Pt was called by Staff several minutes after EMS arrival. Report was given to ER staff . The following times were documented on the ambulance report: Recv'd: 07:04:25 [DATE] Dispatch: 07:07:33 [DATE] En Route: 07:07:39 [DATE] At Scene: 07:13:31 [DATE] At Patient: 07:14:28 [DATE] Transport: 07:41:39 [DATE] At Dest: 07:48:59 [DATE] . A hospital emergency department provider note, dated [DATE], documented, .65 y.o. male who presents in [MEDICAL CONDITION] by ambulance. The patient lives in a nursing home. They apparently found him in [MEDICAL CONDITION]. Per EMS report, they began doing CPR but stopped CPR when they called 911. Fire Department arrived to the patient not having compressions performed. Patient had been in asystole the entire time. He was given ten rounds of [MEDICATION NAME] prior to arrival .Unable to obtain review of systems due to the patient in [MEDICAL CONDITION] .Patient remained in [MEDICAL CONDITION]. He stayed in asystole. At this point the patient has not had any recovery or return of spontaneous circulation. The code was stopped. Time of death was 7:53 AM .Clinical Impression: [MEDICAL CONDITION] . A hospital death report, documented, .date of death : [DATE] Time of death: 0753 (7:53 a.m.) . An initial state reportable incident, reported by facsimile on [DATE] at 8:59 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation . On [DATE] at 10:25 a.m., CNA #3 was asked about the incident regarding resident #3 and if CPR was provided to the resident. She stated she had come on duty for day shift shortly before 7:00 a.m., and spoke with CNA #4 regarding the resident and asked if she could assist her to clean up the resident and do end of life care. She stated CNA #4 had told her no and told her LPN #7 had said the resident was a full code and to leave him on the floor and the fire department was coming. She stated she observed the resident. She stated no staff or anyone else was in the room with the resident and CPR was not being done. She stated the resident was on the floor and there was not an emergency cart in the room and no oxygen was on the resident. CNA #3 stated three staff from the fire department came in and she saw LPN #7 point them toward the resident's room. She stated she (CNA #3) showed them to the resident's room and one of the fireman yelled, Why are they not doing CPR. She stated she told them she would get the nurse. CNA #3 stated she went to LPN #7 and she sent her to RN #1. She stated RN #1 gave her the paperwork to send with the resident to the hospital and she took it to the fire department staff. She stated she observed the emergency/fire department staff leaving with the resident and heard the fireman ask facility staff at the desk why CPR was not done. She stated, I heard LPN #7 kind of get smart with the fireman and he said I'll just write this up. She stated she then heard LPN #7 tell him to do what he had to do regarding CPR not being done. CNA #3 was asked if anyone at the facility took a statement from her regarding what had occurred. She stated, (ADON/LPN #5) took statement from me and told me to write it out and turn in to her on [DATE]. She was asked if she had any training on [DATE] regarding what had occurred. She stated no. She stated, No one said anything to me after I turned in my statement. At 11:20 a.m., ADON/LPN #5 was asked about what had occurred regarding the resident on the morning of [DATE]. She stated she came in around 11:15 a.m., and had spoken with LPN #7 and took statements from other staff. She was asked if she had completed a state reportable incident report on what had occurred. She stated no and stated ADON/LPN #1 had done that the next day. She was asked why it was not done and why education/training was not started on [DATE]. She stated ADON/LPN #1 had done an inservice the next day on the evening/night shift. No further comment was made as to why the incident was not reported and further investigated on [DATE]. At 11:35 a.m., CNA #4 was asked what had occurred regarding the resident on the morning of [DATE]. She stated she was the on coming CNA for the hall the resident was on and came in about 6:50 a.m. She stated the CNA she was to relieve was not in sight so she started making rounds on the hall and checking on the residents. She stated she found the resident lying across his bed with his hand across his chest. She stated she asked the resident if he was going to get up and he did not respond. She stated she tapped him, he was unresponsive, and she immediately reported it to the nurses. CNA #4 stated RN #1 and RN #2 came into the room first. She stated she assisted them to move the resident to the floor. She stated LPN #7 came in and asked what code status the resident was. She stated the resident's name was in green paper on the door and that meant he was a full code and CPR should be started. She was asked if anyone started CPR at that time. She stated, No mam. She stated RN #2 went back to the other hall and RN #1 asked LPN #7 if she had called 911. LPN #7 stated no and then RN #1 left the room and went to the office. She stated, Nobody performed CPR. She stated, To my knowledge he only got CPR when firefighters came in. She stated no one stayed with the resident. She stated another CNA came in and asked if she could help her clean up the resident and LPN #7 told them no and to leave the resident on the floor. She was asked where the nurses were at that time. She stated, (RN #2) was on her end (of the hall), (RN #1) was in office making phone calls, and (LPN #7) was standing at the desk. She stated (CNA #3) gave the fire fighters and EMS the resident's paperwork. CNA #4 stated she heard the fire fighters ask LPN #7 why CPR was not done on the resident. She was asked if anyone interviewed her about what had occurred. She stated, After it all calmed down (ADON/LPN #5) came on and had everyone write a statement. She stated, I went off on my own and wrote it and gave it to her before I left. She was asked if she had received any education/training regarding what had occurred. She stated, ADON/LPN #1 came in and talked to her privately regarding an unresponsive resident and what to do on [DATE] or [DATE]. At 12:10 p.m., ADON/LPN #1 was asked what had occurred regarding the resident on [DATE]. He stated he had received a call from one of the therapy staff regarding the fire fighters were going to report CPR had not been done on the resident before they arrived. He stated he called ADON/LPN #5 who was the manager on duty and she was going to look into what had occurred. He stated he came in the next day and asked about it. He stated he did a reportable incident and asked staff about what had occurred. He stated he was told all three nurses (RN #1, RN #2, and LPN #7) were in the room. He stated they moved the resident to the floor and RN #1 left the room to check records, RN #2 went to check on a resident who was yelling, and LPN #7 left to go call 911. He stated a CNA was left in the room and she did two chest compressions on the resident and then stopped and left the room. He stated LPN #7 was suspended. He was asked if anyone else was suspended at that time. He stated no. He was asked who was responsible to complete the state reportable incident and address interventions to prevent reoccurrence. He stated any of the managers, the DON, and the administrator. He stated the manager on duty when the incident occurred should have reported it. He stated he did the report the next day and started inservices/training when he noticed it had not been done on the evening of [DATE]. He stated he also notified the DON and administrator. He stated, Our plan was to get everyone education and we were going to do others as they came in. He was asked if they should have immediately addressed what had occurred. He stated, Yes. At 12:43 p.m., the DON was asked about the incident. He stated he was notified by the manager on duty (ADON/LPN #5) on the morning of [DATE] regarding a resident who had coded and was sent out. He stated, She was going to do an investigation, I wasn't told of any wrong doing at that time. He stated the following morning another ADON (ADON/LPN #1) was on duty called and he was told of the results of the investigation. He stated, I told him to suspend the nurse (LPN #7) and do initial report to the state and continue the investigation. He stated that night ([DATE]) inservices were started. He was asked why it took over one and a half days to do an initial investigation, report it to the state, and educate staff. He stated, I can't answer that. He was asked if he should have been notified of the findings of the initial investigation after it was determined there was a problem with staff's response to an emergency situation regarding a resident that was unresponsive. He stated yes if the allegations were substantiated. He was asked if staff had identified issues to be addressed regarding what had occurred. He stated, Yes. He was asked what the issues identified were. He stated based off interviews with staff, CPR was not started and continued through the time emergency personnel arrived at the facility. He was asked if it had been determined why CPR was not performed. He stated, I can't say why she didn't, but I would say nursing judgement should have determined she did. The DON was asked why all three of the nurses left the unresponsive resident. He stated one nurse left to go get paperwork and one nurse left to check another resident who was yelling. He was asked if that was an appropriate response for the nurses during a code situation when a resident was unresponsive. He stated, I can't gage that, not knowing what the other resident was needing. He was asked if the other two nurses were suspended. He stated no. He was asked why they left the room and did not assist to ensure the resident received CPR. He stated he assumed why they left to be in the normal course of nursing duty. The DON was asked what the priority shoud have been during the emergency situation, leaving the room to gather paperwork, leaving the room to check on another resident who was yelling, or performing CPR on an unresponsive resident. He stated starting and maintaining CPR on the resident. The DON was asked why they had not immediately educated staff after what had occurred. He stated, I honestly did not understand the scope and severity of what had happened. A final state reportable incident, reported by facsimile on [DATE] at 6:47 p.m., documented, .Incident date: [DATE] .Incident Type: Allegations of Neglect Description of Incident: .Allegation of neglect on (LPN #7) failure to care for resident upon finding unresponsive on morning of [DATE]. Resident transferred to (hospital, name deleted) for eval and treat. Suspended nurse (LPN #7) pending investigation .Relevant resident history .cognitive status .Alert, oriented x 3, [MEDICAL CONDITIONS], Chronic resp failure . SUMMARY OF WITNESSES: On [DATE] (CNA #4) came on shift and stated she noticed (Resident #3) lying across his bed CNA entered room to check on him, he was unresponsive she notified charge nurse (LPN #7) Nurse x 2 went in to room to assess resident. (RN #1) heard someone say he is unresponsive and went into hall and saw (RN #2 and LPN #7) go into room (# deleted) she followed them into room and left to check code status. (RN #2) stated she went to check on her resident that was calling for help down the hall and left (LPN #7) in room with CNA's. (RN #1) yelled out to them he (Resident #3) is a full code and began gathering health information and demographics for (ambulance) when they arrive. Staff placed resident on the floor. Nurse (LPN #7) called 911. Another CNA (CNA #6) was walking by and went into room to help and stated she did chest compressions x 2 then followed (LPN #7) to the desk. (CNA #6) said she asked if they should be doing something and (LPN #7) was on the phone and said he (Resident #3) was gone and did not go back into the room. During this time (CNA #3) came on duty and went by room and heard of event and went and looked in on resident where he was lying on floor, no one was with him. She asked (LPN #7) is (sic) she should help clean him up and she was told no he is a full code leave him on the floor. No one was performing CPR at that time. She stated she heard the sirens of (ambulance). When .F Dept arrived (LPN #7) pointed them to room and then went down hallway on opposite end to her cart .FD asked (CNA #3) if he (Resident #3) was a DNR and she told them no full code, he yelled why is no one doing CPR. (CNA #3) stated she had to get paper work from (RN #1) and give to (ambulance). (CNA #3) said Fire dept asked her who the nurse was and she said the one in black coming up the hall. (CNA #3) said that Fire dept told her they were reporting this and (LPN #7) stated do what you have to do. Resident transported to (hospital, name deleted) ER for eval and treat by (ambulance). Nurse (LPN #7) has been suspended pending investigation of events. FINDINGS: Interview with all persons involved only (CNA #6) had performed any CPR and only for 2 compressions then stopped. (LPN #7) who was in charge of hall failed to perform CPR not ensure CPR was performed on resident under her care. Allegation of neglect substantiated. (LPN #7) has been terminated. All other (sic) involved have been re-educated and disciplinary action taken. Additional information at this time we have decided to further investigation (sic) and have suspended (RN #2 and RN #1) effective [DATE] pending findings . On [DATE] at 10:30 a.m., the social services director was asked about the resident's code status. She stated she confirmed with the resident and he stated he was full code status. At 11:04 a.m., the admission's coordinator was asked what the resident's code status was. She stated the paperwork showed he was a full code. On [DATE] at 9:52 a.m., paramedic #1 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were called out for a [MEDICAL CONDITION]. He stated when we arrived there were a couple of staff at the desk and one or two more around a medication cart in the hall. He stated there were two CNAs in the hall and one of them told him where the resident was. He stated the fire department/paramedics were already in the resident's room performing CPR. He stated they reported to us they had came in the room and the resident was alone lying on the floor and had not received CPR until they arrived. They stated they had asked why no one was providing CPR to the resident and they were told they just stopped and were waiting for them to arrive. At 10:00 a.m., paramedic #2 was asked what occurred when he was called to the facility on the morning of [DATE]. He stated we were dispatched to the facility regarding a resident in [MEDICAL CONDITION]. He stated upon entrance they had difficulty locating the resident and received no information about the resident. He stated a nurse pointed them down a hall and they passed the room where the resident was. He stated one staff member then showed them the room. He stated the door was closed and the resident was alone in the room lying on the floor. He stated no one was performing CPR on the resident. He stated there was no oxygen on the resident and no emergency cart in the room. He stated, They just weren't doing anything. He stated they started CPR and he asked facility staff why they were not performing CPR and someone stated we knew you were coming so we stopped. He stated, The resident was in asystole the whole time. He stated the whole attitude at the facility was very uncaring. He stated one nurse even stated the word, whatever, as he tried to address the situation. He stated they received no history on the resident and at one point someone just said here is your face sheet. He stated no staff helped in the room or stayed in the hall to answer questions. He stated, It's typically this way at this facility. It seems no one cares or is willing to provide info like they should. You have to hunt them down to get any information. He stated one staff member asked me if the resident was going to make it and I told them probably not because he had been in asystole, no vital signs, the whole time. At 11:00 a.m., the DON and administrator were asked if the documentation in the nurses' notes on [DATE] were accurate and complete regarding what had occurred. The DON stated it was false and not accurate documentation. They were asked if during the investigation had they determined why the staff had not reported the incident timely and completed a thorough investigation regarding staff involved and what had occurred. The administrator stated they had not found that out yet but would be addressing that and were still investigating the incident. The DON was asked if the care plan had been followed regarding the interventions to implement during the situation when the resident was unresponsive and had experienced a [MEDICAL CONDITION]. He stated no. He stated the care plan should have been followed but was not. A second final state reportable incident, reported by facsimile on [DATE] at 12:42 p.m., documented, .Incident date: [DATE] .Additional info: on [DATE] Spoke with (name deleted), chief of emergency medical service from .FD. He confirmed what witnesses had said that resident was in room on floor and no one was present with him when they arrived, his shirt had been pulled up but no one was performing CPR. Nurse just pointed to room and did not go with responders to situation. Stated pt was warm when they arrived. FINDINGS: (LPN #7) who was in charge of hall failed to perform CPR, not ensure CPR was performed on resident under her care. In addition Nurse had falsified documentation that EMS had took over CPR when in fact no CPR was being performed at that time. Allegation of neglect substantiated. (LPN #7) has been terminated. (RN #2) was present at the beginning of the code left to care for another resident and failed to return to ensure process carried out. (RN #1) was also present at beginning of code left room to gather demographics and failed to follow up with ensuring that CPR was being carried until EMS arrived. (RN #2 and RN #1) have also been suspended, and additional education performed and disciplinary action will be performed before they may return to work. All parties reported to (appropriate licensing board). There was no documentation in the report where the two other nurses involved in the incident had been reported to the licensing board. At 1:27 p.m., the DON was asked if they had sent a report to the board of nursing on the two RNs involved. He stated, No.

Based on observation, interview, and record review, it was determined the facility failed to provide services and/or treatments to prevent a decrease in range of motion for one (#3) of three sampled residents who were reviewed for contractures. From 09/05/16 to 02/21/17, the resident experienced a decline in her abilities to turn herself in bed, transfer, ambulate, propel her wheelchair, dress, eat, and perform personal hygiene. The facility did not implement any services or treatments to maintain or improve the resident's functional abilities or range of motion when the decline was first identified. The facility identified 27 residents as having contractures. Findings: The facility's policy on restorative nursing, revised 07/06/09, documented, .It is the policy .to provide restorative nursing services to promote the resident's ability to adapt and adjust to living as independently and safely as is possible. This concept actively focuses on maintaining optimal physical, mental, and psychosocial functioning. Skill practice in such activities as walking and mobility, dressing and grooming, eating and swallowing, transferring .can maintain function in physical abilities and ADLs and prevent further impairment . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, revised on 06/23/16, documented a problem related to impaired balance, range of motion, and cognition. It was documented the resident was having a slow steady decline. The goal was the resident would be assisted as needed with all activities of daily living through the next review date. It was documented the resident needed extensive assistance with showers and toileting; supervision and set up to extensive assistance with dressing; no assistance with bed mobility and transfers; limited assistance with personal hygiene; and supervision with eating. A quarterly assessment, dated 09/05/16, documented the resident was moderately impaired in cognitive skills for daily decision making. It was documented the resident required extensive assistance of one person for bed mobility; transfers; walking in the corridor and room; locomotion on and off the unit; toilet use; and personal hygiene. It was documented the resident required supervision for eating and was totally dependent on one staff for bathing. The assessment documented the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position; walking; turning around and facing opposite direction while walking; moving on and off the toilet; and surface to surface transfers. It was documented the resident had functional limitations in range of motion bilaterally on the upper and lower extremities. It was documented the resident used a wheelchair for mobility. A progress note, dated 10/01/16 at 4:32 p.m., documented, .up in wheelchair with assist, self propels .feeds self . A progress note, dated 11/13/16 at 1:23 p.m., documented, .was in dining room, at the table, feeding self . A quarterly assessment, dated 11/23/16, documented the resident was moderately impaired in cognitive skills for daily decision making. It was documented the resident required extensive assistance of one person for bed mobility; locomotion on and off the unit; dressing; toilet use; and personal hygiene. It was documented the resident required extensive assistance of two people for transfers. It was documented walking did not occur. It was documented the resident required supervision for eating and was totally dependent on staff for bathing. The assessment documented the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position and moving on and off the toilet. It was documented walking; turning around and facing the opposite direction while walking; and surface to surface transfers did not occur. It was documented the resident had functional limitations in range of motion bilaterally on the upper and lower extremities. It was documented the resident used a wheelchair for mobility. It was documented the resident had not received any services related to restorative nursing services, including active or passive range of motion, or any training or skills practices related to eating, bed mobility, transfers, or walking. Comparison of the assessments, dated 09/05/16 and 11/23/16, revealed documentation the resident had declines in transfers, walking and the ability to turn around and face the opposite direction while walking. A progress note, dated 12/05/16 at 2:03 p.m., documented, .resident transfers with assist ambulates via wc propelling self with feet . A progress note, dated 12/21/16 at 5:55 p.m., documented, .Nurse explained to POA that resident fed herself some nights and other nights she needed to be fed . A range of motion assessment, dated 12/30/16, documented the resident was not steady and only able to stabilize with staff assistance when moving from a seated to standing position; walking, turning, and moving on and off the toilet did not occur; and the resident was not steady and only able to stabilize with staff during surface to surface transfers. It was documented direct care staff did not believe the resident was capable of increased independence in at least some activities of daily living. A progress note, dated 12/31/16 at 11:49 a.m., documented, .up in wheelchair with assist, to dining room for meals, feeds self with some assistance from staff . A progress note, dated 01/01/17 at 5:14 p.m., documented, .up in wheel chair with assist, to dining room for meals, spoon fed by staff . A progress note, dated 01/11/17 at 4:00 p.m., documented, .was assisted into WC and taken to dining room for dinner . A range of motion assessment, dated 01/17/17, documented the resident was not steady and only able to stabilize with staff assistance when moving from a seated to standing position; walking, turning, and moving on and off the toilet did not occur; and the resident was not steady and only able to stabilize with staff during surface to surface transfers. It was documented direct care staff did not believe the resident was capable of increased independence in at least some activities of daily living. A care plan update, dated 02/07/17, documented, .NOTE: .Has contractures to bilateral arms, left wrist, left pinky, bilateral knees, bilateral ankles, toes . A significant change assessment, dated 02/21/17, documented the resident was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, personal hygiene, and bathing. It was documented walking did not occur, and the resident required extensive assistance of one person for eating. It was documented the resident had not received any services related to restorative nursing services, including active or passive range of motion, or any training or skills practices related to eating, bed mobility, transfers, or walking. Comparison of the assessments, dated 11/23/16 and 02/21/17, revealed documentation the resident had declines in her ability to transfer, ambulate, move on and off the unit, dress, eat, perform personal hygiene, and participate in bathing. Review of the clinical record revealed no documentation the facility had implemented any services or treatments to maintain or improve the resident's functional abilities or range of motion. The resident's care plan, updated 02/26/17, documented a problem related to impaired balance, range of motion, and cognition. It was documented the resident had been having a slow steady decline. The goal was the resident would be assisted as needed with all activities of daily living through the next review date. It was documented the resident required total assistance with bathing, bed mobility, dressing, personal hygiene, toileting, and transfers. It was documented the resident required extensive to total assistance with eating. Facility documentation of passive range of motion services provided to the resident, dated 02/26/17 through 04/18/17, documented the resident received passive range of motion services for 15 minutes or more during a 24 hour period on 13 of 52 days. A physician's orders [REDACTED].Restorative: PROM to Upper and Lower Extremities for contractures . Facility documentation of passive range of motion services provided to the resident, dated 4/19/17 through 04/24/17, documented the resident received passive range of motion services totally 15 minutes or more during a 24 hour period on two of six days. On 04/24/17 at 9:50 a.m., resident #3 was observed in the dining room. She was seated in a Broda chair (a cushioned, positioning chair), and her feet were hanging down without support. She was being fed by staff. On 04/24/17 at 12:15 p.m., CNA #1 was observed providing incontinent care and transferring the resident from her bed to her Broda chair. Her legs were bent at the knees, with her feet on the bed. The right foot was observed to be turned, resting on its' lateral side, with foot drop noted. The resident's fingers were rigid on both hands. It appeared there was no movement of the fourth and fifth digits on each hand, and they appeared to curl inward. The first through third digits on each hand appeared straight but with little movement. The resident did not straighten her arms fully. CNA #1 rolled the resident from side to side during the incontinent care. The resident did not participate in the movement. Upon request, the resident was able to lift her hips off the bed slightly so CNA #1 could remove and replace her brief. CNA #1 was asked if the resident could straighten her legs. She stated, Oh no. She stated she could move them out some and proceeded to move the lower legs slightly. She moved the lower legs out less than two inches. The legs could not be straightened. After care was provided, CNA #1 transferred the resident to her Broda chair. The resident did not participate in the transfer. CNA #1 did not raise the foot platform on the Broda chair, and the resident's feet hung down without support. CNA #1 asked the resident if she would like some Pepsi. The resident stated yes. CNA #1 placed a child-sized plastic cup with handles on both sides and a straw in the resident's hands and stated, Look what she can do. The resident held the cup with the first, second and third digits on each hand for a moment. She then brought the cup to her chest and rested it there and drank from the straw. She could not grip the handles on the cup. CNA #1 was asked if the resident could grip the cup and drink by herself. She stated, No. A restorative weekly note, dated 04/24/17 at 1:39 p.m., documented, .RA attempted to preform (sic) restorative therapy for resident and resident started holler out 'NO NO NO THAT HURTS I DONT WANT TO STOP; RA explained the importance of doing her restorative therapy and resident stated she didn't want to because it hurt . An edit task sheet, with a creation date of 04/25/17, documented, .Edit task .created by: System Generated .Created Dated: 4/25/2017 .Status: (marked active) .Date Initiated 1/17/2017 .Description: Nursing Rehab: Passive ROM: To all extremities .Kardex Category: None Flowsheet Type: Restorative .Certified Nursing Aide .Frequency: As Necessary . On 04/25/17 at 9:18 a.m., the resident was observed sitting in her Broda chair. The foot platform was not up, and the resident's feet were hanging down without support. She was being fed breakfast by staff. On 04/25/17 at 9:40 a.m., staff was observed pushing the resident's Broda chair down the hall to her room. Her feet were hanging down without support. On 04/25/17 at 3:19 p.m., LPN #1 was asked if the resident had contractures upon admission. She stated when she had started working at the facility in September of 2016, the resident was able to stretch out some and could propel herself a little in her wheelchair. She stated, Her fingers have gotten worse. LPN #1 was asked when the decline began. She stated, Around November. LPN #1 was asked what services were provided to prevent further decline for the resident. She stated, Restorative was or is working with her. She was asked when restorative started working with the resident. She stated she did not know. On 04/25/17 at 4:09 p.m., UM #1 was asked if the resident had contractures upon admission. She stated when she started to work at the facility in September of 2016, the resident did not really stand up. She stated she could propel her wheelchair some and could hold her cup. She stated the resident opened and closed her hands and fingers more then. She was asked when the decline began. She stated around November or December of 2016. UM #1 was asked what services were provided to prevent further decline for the resident. She stated range of motion was provided when the resident was transferred from the bed to the chair and while putting on her clothes. UM #1 was asked why restorative or therapy had not been involved when the decline was first noted. She stated, Maybe we thought she wouldn't participate. She was asked if she knew that for a fact. She stated, No. UM #1 stated restorative was working with the resident now. She was asked when that started. She stated restorative started working with the resident's hands in February she believed and then the upper and lower extremities last month. She was asked where that was documented. She stated it was documented on the aide's flowsheets. On 04/26/17 at 9:41 a.m., the DON, UM #2, and the resident's physician were interviewed. The DON stated staff documented the range of motion services they provided to the resident on each shift under the activities of daily living task on the computer charting system. She stated the facility started this documentation on 01/17/17 so they could see how long staff was working providing range of motion services to the resident. She stated the facility had added the recommendation that restorative see the resident, but the resident was refusing. The DON was asked to provide the documentation of the range of motion services and the documentation for restorative services. The DON was asked why restorative services were not provided to the resident when it was first noted she was having a decline in November or December. She stated, I don't remember them telling us then. UM #2 stated the resident may have received restorative services prior to the time when staff began documenting in the computer system. The DON and UM #2 stated they would look for additional information related to restorative services for the resident. At 9:46 a.m., the DON provided a copy of the documentation of range of motion services that had been provided to the resident. The form was dated from 02/26/17 at 6:42 a.m. through 04/25/17 at 4:19 a.m. The DON was asked if this was what staff was doing for all residents. She stated, Yes, those with contractures. The DON was asked to provide the documentation from 01/17/17 when, according to the previous interview, staff was supposed to start documenting the passive range of motion services. On 04/26/17 at 12:01 p.m., UM #2 was asked if the staff had been able to find any further documentation on the resident's contractures and any restorative documentation. He stated he had not been able to find anything else in the resident's charting. He stated he did not know if they were still looking. On 04/26/16 at 3:00 p.m., the administrator was asked if the facility had found any other documentation related to the resident's contractures and any services that had been provided. She stated there was nothing other than the documentation of passive range of motion services provided earlier, and those services fell under the umbrella of restorative services. On 04/27/16 at 9:54 a.m., CNA #1 was asked to describe what she did for the resident during those minutes when it was documented she was providing passive range of motion. She stated that was her me time with the resident. She stated she would ask the resident to straighten her legs out, and she would work with the resident's hands and legs. She stated she usually spent about five minutes per day working with the resident. On 04/27/16 at 10:01 a.m., the restorative aide was asked when she started working with the resident. She stated, About a week ago. She stated she thought she had two sessions with the resident. She was asked what was done for the resident. She stated she only allowed a little passive range of motion. She stated the resident did not allow a lot with her shoulders. The restorative aide was asked why the resident did not allow many services. She stated, Doesn't say. I just continue to encourage. The restorative aide was asked if the resident had complained of pain with the services. She stated, No, it's more I don't want to do it.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure residents were not neglected and received adequate, timely, and appropriate nursing care in regards to the facility's failure to: ~ notify the physician of changes in condition and/or a need to alter treatment; ~ assess, monitor, and intervene in a timely manner; and ~ provide interventions to aid in the prevention and/or worsening of pressure ulcers and to promote healing of pressure ulcers. Resident #4 experienced unrelieved continued back pain after a fall on [DATE], with increasing difficulty rising from a sitting position, requiring assistance of one to two staff members to stand. The resident experienced a second fall on [DATE], and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 4:30 p.m., the administrator, the DON, and two corporate RN consultants were informed of the IJ regarding neglect and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 6:20 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Removal of IJ for Pressure Ulcers Ambassador Manor [DATE] Pressure Ulcers: Nurses on duty will be immediately in-serviced by the Administrator and/or designee, related to assessing pressure ulcers and notifying the MD of changes. They will be in-serviced related to skin assessments upon admission and documentation of any abnormalities of assessment and MD notification of findings. Nursing staff will also be in-serviced on facility wound and skin care guidelines. These in-services will be completed by 2359 on [DATE]. New nursing staff members will be in-serviced prior to beginning their work on the floor. Skin assessments will be completed by an RN on [DATE], on all residents currently residing in the facility, and the physician(s) will be notified of current pressure ulcers and current tx orders. Failure to Assess: All staff will be in-serviced by 2359 (11:59 p.m.) on [DATE], by the Administrator and/or designee on recognizing pain and notification of the charge nurse and/or Physician for the appropriate treatment of [REDACTED]. This in-service will be completed by 2359 on [DATE]. New nursing staff members will be in-serviced prior to beginning their work on the floor. Pain assessments on current residents will be reviewed by an RN. Any resident noted to be having pain will have their pain assessment redone and the physician notified for appropriate treatment for [REDACTED]. Failure to Notify: Nursing staff will be in-serviced by 11:59 p.m., on [DATE], by the Administrator and/or designee related to notification to physician of changes in condition, worsening of pressure ulcers and increased pain. This in-service will be completed by 11:59 p.m. on [DATE]. New nursing staff members will be in-serviced prior to beginning their work on the floor. Skin assessments will be completed by an RN on [DATE], on all residents currently residing in the facility, and the physician(s) will be notified of current pressure ulcers and current tx orders. Pain assessments on current residents will be reviewed by an RN by 11:59 p.m. on [DATE]. Any resident noted to be having pain will have their pain assessment redone and the physician notified for appropriate treatment for [REDACTED].>Neglect: All staff will be in-serviced by 2359 (11:59 p.m.) on [DATE], by the Administrator and /or designee related to the definition of neglect. In-service will include any signs of neglect to be reported immediately to the administrator for appropriate intervention and follow-up per facility policy. These in-services will be completed by 2359 (11:59 p.m.) on [DATE]. New nursing staff members will be in-serviced prior to beginning their work on the floor. Staff were interviewed on [DATE] regarding the components of the plan of removal. Not all components to the plan of removal had been completed. Staff were informed an addendum was required. On [DATE] at 9:00 a.m., the administrator provided an addendum to the plan of removal. The addendum documented: Ambassador Manor Addendum to the Plan of Removal [DATE] The following residents who had skin assessments completed on [DATE] will have an addendum added on [DATE] by an RN, to include description and measurement of current wounds and treatments, documentation of improvement or decline of condition of wounds and physician notification of wounds status .Pain assessments that were completed on [DATE] with pain intensity greater than 5 will be re-done by an RN on [DATE]. The doctor will be notified and any new orders noted. Staff were interviewed on [DATE] regarding the components of the plan of removal, and the assessments were reviewed. All components to the plan of removal had been completed. The IJ was removed effective [DATE] at 11:55 p.m., when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from neglect and received adequate, timely, and appropriate nursing care, provided by qualified staff. Resident #4 experienced unrelieved continued back pain after a fall on [DATE], with increasing difficulty rising from a sitting position, requiring assistance of one to two staff members to stand. The resident experienced a second fall on [DATE], and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. This had the likelihood to affect all 131 residents who resided in the facility. A facility policy titled, 'Resident Abuse, Neglect and Misappropriation of Property', documented, .Grace Living Centers will not tolerate mistreatment, neglect, or abuse of residents .neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas .All employees will be in-serviced on abuse/reporting abuse during the orientation process following employment. On-going abuse training will be provided to all employees throughout the year which include .what constitutes abuse, neglect, and misappropriation of resident property .all employees of a nursing facility are mandated reporters of resident abuse, neglect or misappropriation of property, as well as reasonable suspicion of a crime against a resident and must report any and all incidents . Findings: 1. The facility failed to ensure the physician had been notified: ~ of new or worsening pressure ulcers; of the use of a [MEDICATION NAME] brace and the need to obtain orders for the care of the resident with the brace; of a change in condition and unrelieved pain after a fall; of swelling in the resident's arm; and of the presence of a surgical wound and the need to obtain orders for the care of the surgical wound for one (#4) of nine sampled residents with a change in condition and four sampled residents who had experienced pain and had pressure ulcers. ~ of frequent refusal of wound care and unrelieved pain for one (#3) of four sampled residents who had experienced pain and had pressure ulcers. Resident #4 experienced unrelieved continuing back pain after a fall on [DATE], with increasing difficulty rising from a sitting position, requiring assistance of one to two staff members to stand. The resident experienced a second fall on [DATE], and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. Please refer to F157. 2. The facility failed to: ~ assess, monitor, and intervene in a timely manner for one (#4) of nine sampled residents who had a change in condition; ~ assess and monitor a surgical wound for one (#4) of one sampled resident with a surgical wound; and ~ provide pain management for two (#3 and #4) of four residents who had experienced pain. Resident #4 experienced a change in condition after a fall. The resident had unrelieved back pain after the fall on [DATE], that continued, with increasing difficulty rising from a sitting position, requiring the assistance of one to two staff members to stand. The resident experienced a second fall on [DATE], and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. The facility identified 120 residents who were on a pain management program. Please refer to F309. 3. The facility failed to: ~ perform initial and ongoing thorough skin and wound assessments; ~ notify the physician of the use of a [MEDICATION NAME] brace and obtain orders for the care of the resident related to the brace; ~ notify the physician consistently of new wounds or the worsening of existing wounds; ~ obtain wound consultations; ~ obtain physician orders [REDACTED]. ~ obtain xrays as recommended by wound specialists; and/or ~ update the care plans to address pressure ulcers, changes in pressure ulcers or pressure ulcer care and the use of braces for two (#4 and #7) of six sampled residents who had pressure ulcers. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. The facility identified 15 residents who had pressure ulcers. Please refer to F314. On [DATE] at 10:16 a.m., the administrator and DON were asked if they had a system in place to prevent neglect. The administrator stated, If any neglect is observed or heard about we take immediate action. They were asked if neglect had been addressed in the last QA meeting. The DON stated, I don't remember. No further information was provided.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to notify the physician of new or worsening pressure ulcers; of a [MEDICATION NAME] brace and the need to obtain orders for the care of the resident with the brace; of a change in condition after a fall and unrelieved pain; and of swelling in the resident's arm. Resident #4 experienced unrelieved continued back pain after a fall on [DATE], with increasing difficulty rising from a sitting position, requiring assistance of one to two staff members to stand. The resident experienced a second fall on [DATE], and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 4:30 p.m., the administrator, the DON, and two corporate RN consultants were informed of the IJ regarding the failure to notify the physician of a resident's change of condition and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 6:20 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Removal of IJ . Ambassador Manor [DATE] . Failure to Notify: Nursing staff will be in-serviced by 11:59 p.m., on [DATE], by the Administrator and/or designee related to notification to physician of changes in condition, worsening of pressure ulcers and increased pain. This in-service will be completed by 11:59 p.m. on [DATE]. New nursing staff members will be in-serviced prior to beginning their work on the floor. Skin assessments will be completed by an RN on [DATE], on all residents currently residing in the facility, and the physician(s) will be notified of current pressure ulcers and current tx orders. Pain assessments on current residents will be reviewed by an RN by 11:59 p.m. on [DATE]. Any resident noted to be having pain will have their pain assessment redone and the physician notified for appropriate treatment for [REDACTED]. Staff were interviewed on [DATE] and assessments were reviewed. Not all components to the plan of removal had been completed. Staff were informed an addendum was required. On [DATE] at 9:00 a.m., the administrator provided an addendum to the plan of removal. The addendum documented: Ambassador Manor Addendum to the Plan of Removal [DATE] The following residents who had skin assessments completed on [DATE] will have an addendum added on [DATE] by an RN, to include description and measurement of current wounds and treatments, documentation of improvement or decline of condition of wounds and physician notification of wounds status .Pain assessments that were completed on [DATE] with pain intensity greater than 5 will be re-done by an RN on [DATE]. The doctor will be notified and any new orders noted. Staff were interviewed on [DATE] and assessments were reviewed. All components to the plan of removal had been completed. The IJ was removed effective [DATE] at 11:55 p.m., when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to ensure the physician had been notified: ~ of new or worsening pressure ulcers; of the use of a [MEDICATION NAME] brace and the need to obtain orders for the care of the resident with the brace; of a change in condition and unrelieved pain after a fall; of swelling in the resident's arm; and of the presence of a surgical wound and the need to obtain orders for the care of the surgical wound for one (#4) of nine sampled residents with a change in condition and four sampled residents who had experienced pain and had pressure ulcers. ~ of frequent refusal of wound care and unrelieved pain for one (#3) of four sampled residents who had experienced pain and had pressure ulcers. Resident #4 experienced unrelieved continuing back pain after a fall on [DATE], with increasing difficulty rising from a sitting position, requiring assistance of one to two staff members to stand. The resident experienced a second fall on [DATE], and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. The facility identified 15 residents who had pressure ulcers and 120 residents who were on a pain management program. Findings: Findings: A policy titled, Resident's Family or physician notification of change guideline, documented, Purpose - this is a guideline to know when it may be necessary to notify the resident's family or physician .The facility will inform the resident; consult with the resident's physician .of the following events: .an accident involving the resident, that results in injury and has the potential for requiring physician intervention .A significant change in the resident's physical, mental, or psychosocial status .A need to alter treatment significantly . 1. Wound assessments for Resident #4 from a specialty hospital, dated [DATE] and [DATE], documented the resident had a surgical wound to her midline back, 18 cm in length, with staples present. Resident #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's progress note, dated [DATE], documented, .Admission Summary . upon arrival head to toe assessment done .overall skin intact .with chest braise (sic) to protect back . No documentation was found regarding the stage II pressure ulcers to the right and left heel, or the condition of the skin under the resident's [MEDICATION NAME] brace. A physician's orders [REDACTED]. A physician's orders [REDACTED].Apply to buttocks topically every 8 hours as needed for wound care. A physician's orders [REDACTED]. A physician's orders [REDACTED].Apply to buttocks topically one time a day for wound care. There were no admission orders [REDACTED]. There was no documentation the resident's primary physician or surgeon had been notified of the [MEDICATION NAME] brace, clarification of how often the brace was to be worn, and when skin assessments were to be completed. A skin/wound note, dated [DATE], documented, .readmit to facility. Head to toe skin assessment done. admitted with Stage II pressure ulcer on right heel measuring 3 cm L x 4.5 cm W x 0 cm. Wound bed is covered by intact blood blister. Surrounding skin is clear. Has stage II pressure ulcer on left heel measuring 3 cm L x 4 cm W x 0 cm. Wound bed is covered by intact blister. Surrounding skin is clear. Has excoriation to buttocks and posterior thighs. Has order for [MEDICATION NAME] iodine to heels Q Mon Wed Fri. Has order for [MEDICATION NAME] paste to buttocks and posterior thighs Q 8 hours/prn. Notified resient's (sic) gaurdia (sic) .of residnet's (sic) wounds and treatments. Dr .notified. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. There was no documentation the physician had been notified for orders for the use of the [MEDICATION NAME] brace. A physician's orders [REDACTED]. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance of two staff persons for bed mobility, transfers, hygiene, and toileting, and the resident required total assistance with two staff persons for dressing and bathing, the resident had two stage II pressure ulcers that had been present on admission, and a surgical wound. The care plan did not address the surgical wound or the care related to the use of the resident's [MEDICATION NAME] brace. A skin/wound note, dated [DATE], documented, .stage II pressure ulcer on right heel measures 3 cm x 4.5 cm x 0 cm. Wound bed is covered by blood blister. Surrounding skin is clear .stage II pressure ulcer on left heel measures 2 cm x 4 cm x 0 cm. Wound bed is covered by deflatd (sic) blister. Surrounding skin is clear .Dr .notified . There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. Monthly physician's orders [REDACTED].To wear heel protectors at all times .Wound consultant to screen, evaluate as (sic) treat as needed .[MEDICATION NAME] skin protectant paste .apply to buttocks topically every 8 hours as needed for wound care .[MEDICATION NAME] skin protectant paste .apply to buttocks topically one time a day for wound care .[MEDICATION NAME]-Iodine Ointment 10% Apply to left and right heel topically one time a day every Mon, Wed, Fri for prevention . The monthly physician's orders [REDACTED]. A telephone order, dated [DATE] at 2:48 p.m., documented, .Ally (sic) [MEDICATION NAME] to right heel Q day. Leave open to air. Every day shift for Stage II pressure ulcer . A telephone order, dated [DATE] at 2:49 p.m., documented, .clean wound on left heel with wound cleaner. Apply Hydrogel to wound bed. Apply Allevyn hell (sic) cup. Wrap with gauze roll and secure with tape. Change Qday/prn. Every 8 hours as needed for Stage II pressure ulcer and every day shift . A skin/wound note, dated [DATE], documented, .stage II pressure ulcer on right heel measures 3.5 cm x 5.5 cm x 0 cm. Wound bed is covered by eschar. Surrounding skin is clear .stage II pressure ulcer on left heel measures 3 cm x 1.5 cm x <0.2 cm. Wound bed is pink/red with minimal serous drainage. Surrounding skin is clear Dr .notified . Between [DATE] and [DATE], documentation revealed the stage II pressure ulcer to the resident's right heel had worsened. There was no documentation the physician had been notified that the wound had worsened, or if new treatment orders had been received. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. A nurse's progress note, dated [DATE], documented, .CNA notified this nurse re .open area @ R buttock 2 cm x 1.5 cm with a 2 cm x 3 cm purple area next to it. Areas @ L buttock 4 x 6 cm and open area @ coccyx 1.5 x 1.5 cm. Cleansed with NS, applied hydrogel and covered all open areas with bordered foam dressing .Notified MD . There was no documentation the physician had provided any specific orders for treatments for the newly developed pressure ulcers. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. A telephone order, dated [DATE] at 8:21 a.m., documented, .clean wound on coccyx with wound cleaner. Apply Hydrogel and cover with foam dressing with border. Change Qday/prn. Every 8 hours as needed for Stage II pressure ulcer and every day shift . A telephone order, dated [DATE] at 8:23 a.m., documented, .clean wound on right buttock with wound cleaner. Apply Hydrogel and cover with foam dressing with border. Change Qday/prn. Every 8 hours as needed for unstageable pressure ulcer and every day shift . A telephone order, dated [DATE] at 8:25 a.m., documented, .clean wound on left gluteal fold with wound cleaner. Apply Hydrogel and cover with foam dreeing (sic) with border. Change Qday/prn. Every 8 hours as needed for unstageable pressure ulcer and every day shift . A 30 day assessment, dated [DATE], documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance of two staff persons for bed mobility, transfers, and toileting, required extensive assistance with one staff person for hygiene, and dressing, the resident had one stage II pressure ulcer that had not been present on admission or reentry, and two unstageable pressure ulcers that had not been present on admission, reentry, or prior assessment. A care plan, dated [DATE], documented, Focus: .has a 4 cm x 6 cm open wound to her left gluteal fold . .has a Stage II pressure ulcer on right heel measures 3.5 cm x 5.5 cm x 0 cm. Wound bed is covered by eschar. Surrounding skin is clear . .has a Stage II pressure ulcer on left heel measure 3 cm L x 1.5 cm W x <0.2 cm. Wound bed is pink/red with minimal serous drainage. Surrounding skin is clear . .has a 1.5 cm x 1.5 cm open area to her coccyx . .has a 2 cm x 1.5 cm open area with a 2 cm x 3 cm purple area next to it . .Goal: .will resolve without complications x 90 days . .Interventions: .assist to turn and reposition frequently .carafoam mattress .diet as ordered .encourage fluids .float heels with pillows while in bed .heel protectors to bilateral feet when out of bed .measure and assess wound weekly .monitor pain with dressing changes .refer to dietician as needed for recommendations to aid in wound healing .refer to physician as needed, update physician weekly of wound status .refer to wound consultant as needed .update family weekly of current wound status . The care plan did not address the use of a [MEDICATION NAME] brace, or the care of a resident with a surgical incision. Skilled daily nurses' notes were reviewed from [DATE] through [DATE]. The skin condition and anatomical diagram for documenting the site of the resident's pressure ulcers had not been completed consistently. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. A skin/wound note, dated [DATE], documented, .stage II pressure ulcer on right heel measures 3 cm L x 5 cm W x 0 cm. Wound bed is covered by scab. Surrounding skin is clear .stage II pressure ulcer on left heel measures 1.7 cm L x 3.5 cm W x <0.2 cm. Wound bed is 50% slough and 50% pink with minimal serous drainage. Surrounding skin with 0.5 cm [DIAGNOSES REDACTED] .unstageable pressure ulcer on right buttock measures 3 cm L x 3.5 cm W x <0.2 cm. Wound bed is covered by slough and has minimal serous drainage. Surrounding skin is clear . Stage II pressure ulcer on coccyx measures 3 cm L x 1 cm W x 0.2 cm. Wound bed is pink with minimal serous drainage. Surrounding skin is clear .unstageable pressure ulcer on left gluteal fold measures 4 cm L x 11 cm W x <0.2 cm. Wound bed 75% slough and 25% pink with minimal serous drainage. Surrounding skin is clear. Dr .notified. Documentation revealed the pressure ulcers to the left heel, the coccyx, the right buttock, and the left gluteal fold had worsened between [DATE] and [DATE]. There was no documentation the physician had been notified regarding the worsening pressure ulcers or if new treatment orders for the worsening pressure ulcers had been received. A skilled daily nurse's note, dated [DATE] at 8:25 p.m., documented, .pressure ulcer management .pain management .resident declined to get out of bed today, wound care provided per orders .yellowish slough noted to left gluteal fold wound and right buttock wound . There was no documentation the physician had been notified of the yellowish slough that had been noted to the left gluteal fold wound or the right buttock wound. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. A skin/wound note, dated [DATE], documented, .focused charting r/t pressure ulcers areas noted on left and right heel, right buttock and coccyx area . The note did not document the unstageable pressure ulcer to the left gluteal fold. No dimensions, or current stages were documented for each pressure ulcer. There was no documentation the physician had been notified, or if he had given new orders for the treatment of [REDACTED]. A nurse's progress note, dated [DATE], documented the resident had been transferred to the hospital .per the physician's orders [REDACTED]. Emergency department notes, dated [DATE] at 3:35 p.m., documented, .musculoskeletal: intact distal pulses, [MEDICAL CONDITION] diffusely, back brace in place .Integument: warm, dry, deep necrotic [MEDICAL CONDITION] covered in stool .We have covered the patient for pneumonia and other sources of infection including her [MEDICAL CONDITION] . At 3:45 p.m., the emergency department note documented, .she shows evidence of septic shock .skin color is mottles (sic), pale .she has severe decubitus wounds .The patient has symptoms [MEDICAL CONDITION] that are being treated with IV fluid resuscitation and antibiotics, however the patient appears to be worsening .admitted to the ICU in severely critical condition . At 4:28 p.m., an emergency department note, documented, .upon log rolling pt with spinal precautions, multiple pressure wounds noted to sacral, gluteal area. Caved, tunneling, blackened, green, malodorous wounds; unstageable. Heart shaped [MEDICATION NAME] to coccyx area. [MEDICATION NAME] placed to bilateral heels. Blackened wound to R heel. Heeling (sic) white/red wound to L heel .upon removing TLSO brace, a ,[DATE] dollar size and a dime size, opening to L axillary area. Irregular shaped. Green/yellow center, hardened upon palpation. Reddened edges. No obvious drainage . At 4:53 p.m., a culture of the decubitus ulcer to the buttock was collected. The culture result included, .many gram negative rods .few staphylococcus aureus .many [MEDICATION NAME] species .many beta Streptococcus group A .many Bacteroides species (not fragilis) .Many Bacteroides thetaiotaomicron .few diphtheroids . At 5:45 p.m., a hospital wound care note, documented the resident had a pressure injury to the left and right buttock that was unstageable. The visible tissue was documented as sloughing, with odor and brown, cloudy green purulent bleeding drainage. The assessment documented the pressure injury had 10 cm of tunneling. The hospital wound care note documented an unstageable pressure injury in the left armpit related to the back brace. The pressure injury was documented as a large, black irregular shaped wound, that was present on arrival. The state of healing was documented as non-healing/chronic. The site assessment was documented as black, fragile, red, sloughing. The peri-wound area was documented as boggy, purple. A hospital history and physical note, dated [DATE] at 5:52 p.m., documented, .Skin: warm/dry, unstageable wounds to buttocks/sacrum/perineal area .severe tunneling wounds in her perineal area with purulence leaking .Decub wounds .these appear to be infected . At 7:24 p.m., a hospital physician consult note, documented, .patient in septic shock with necrotizing wounds to perineal area .grossly infected perineal and buttock pressure wound .she began, according to her daughter, to have some change in her mental status last Thursday that got worse over the weekend .On exam the wound was discovered and we were consulted. No one known (sic) how long the wound has been there .she is currently .non responsive, and critically ill .Physical Exam .Skin: deep tracking wounds perineum, surrounding buttock and upper thighs with [DIAGNOSES REDACTED] .Assessment/Plan: .septic shock - due to wound .infection of perineal wounds - this wound does need urgent surgical debridement . At 8:14 p.m., a hospital RN progress note, documented, .extensive, tunneling unstageable wounds noted on pt's buttocks/gluteal folds, with large amounts of malodorous drainage. Unstageable wounds also noted on pt's bilat heels, L great toe amputation site, and L armpit, all present upon arrival from .nursing home. Wounds assessed by multiple RNs and physicians. At 9:30 p.m., the resident was pronounced dead after absence of vital signs assessed by the night supervisor. At 10:01 p.m., a death summary, documented, .Admit [DIAGNOSES REDACTED].decubitus wounds POA .severe tunneling wound in her perineal area with purulence leaking . On [DATE] at 5:00 p.m., the wound nurse was asked where he documented the physician's response after he had been notified of a change in the resident's wounds. He stated, I talk to him in person or on the phone. I don't document his response. If he gives me an order over the phone I put it in the computer. If I talk to him in person and get an order, I put it in the computer. I don't document the physician's response in a nurse's note. He was asked why he didn't document the physician's response. He stated, I'm so overwhelmed with residents who need wound treatments to be done. I don't have time to do all the documentation that is required. I just try to save time by not going into detail on the notes. On [DATE] at 9:46 a.m., LPN #6 was asked if he had been the nurse who admitted the resident back to the facility on [DATE]. He stated, Yes. He was asked if he called the surgeon's office to get clarification on the back brace and post surgical care. He stated, No. He was asked how he knew how to take care of the brace and the surgical incision. He stated, I got report from the nurse from the transferring hospital. She mentioned the brace and when to wear it and when to take it off, and that it was to be worn over her clothing. He stated the surgical incision had staples with an island dressing over it. He stated they didn't give instructions on how to take care of the incision. He stated he called the surgeon's office to see about removing the staples because there were no instructions for cleaning, bathing, etc. He stated they said to take the dressing off and at the follow-up visit with the surgeon, they would take out the staples. He was asked about the swelling in her arm. He stated she did not have swelling when she was on this floor. He stated he knew she started having swelling when she went to the North Hall. He was asked where he had documented calling the surgeon's office. He looked in the computer and stated, I don't think I did. At 10:43 a.m., the resident's physician was interviewed per phone. The physician was asked if she had been notified when the resident's wounds had worsened. She stated, I don't remember specifically. Typically the wound nurse does notify me if there is a change in the wrong direction and I would tell him what to do as far as care. She was asked if she had been made aware of the worsening of the resident's pressure wounds. She stated, I don't remember being notified without being able to look at the resident's chart. The physician was asked if she had been aware of the resident wearing a back brace when she was readmitted to the facility. She stated, These would be specialized orders depending on the surgery. The admission order should have included an order for [REDACTED]. The physician was asked if this would have been something the admitting nurse should have gotten clarification on from the surgeon. She stated, Yes. At 3:15 p.m., when asked about the resident's arm, LPN #4 stated he had noticed swelling in the resident's right arm because she dangled it a lot. He stated he was in the process of ordering a cushion to rest her arm on. He stated he hadn't gotten it yet. He stated she did have [MEDICAL CONDITION] on Fri ([DATE]) with good pulses and no discoloration. He stated he assessed her arm when she came back from the Dr's office and he couldn't find any pulses. He stated there was some light discoloration, a sort of ashy color and 3+ [MEDICAL CONDITION]. He was asked if he had noticed any change in the resident's condition on the morning of [DATE] before she went to her doctor's appointment. He stated, Yes, she had a foul odor about her when we got her up. I used to be a wound nurse and that type of foul odor made me think there was infection somewhere. He was asked if he had notified the physician of the foul odor that he had noticed. He stated, I was going to have the wound nurse look at her when she got back from the doctor's office, but the resident was transferred to the hospital instead. On [DATE] at 3:31 p.m., the DON was asked why LPN #4 had not documented in the resident's record or notified the physician when he had noticed a foul odor when he had gotten the resident up. She stated, He should have documented the findings. He should have notified the physician and me or the unit manager. She was asked why no orders had been obtained for the care of the resident's [MEDICATION NAME] brace. She stated, The physician should have been notified and orders should have been obtained for the use of the [MEDICATION NAME] brace. She was asked if the nurses should be notifying the physician when a resident has a change in condition and documenting his response in the nurses' notes. She stated, Yes. 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, Focus: .has potential for pain .Goal: .will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date .Interventions: .is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain .monitor/report to nurse any s/sx of non-verbal pain: changes in breathing .vocalizations .mood/behavior changes .eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) .pain screen q shift as ordered . A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident was independent with transfers, ambulated independently in corridor, required supervision for toilet use and dressing, and did not receive scheduled or as needed pain medication in the last five days. An incident report, dated [DATE], documented the resident had fallen while attempting to go to the bathroom. No injuries were documented. A nurse's note, dated [DATE] at 10:35 a.m., documented, .continue to complain of flank pain .travel by rolling walker. BRP ad lib & sometimes need help getting up from stool . There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A nurse's note, dated [DATE] at 1:01 p.m., documented, IDT met to discuss incident on [DATE]. Resident is alert, oriented with cognitive deficits. Resident ambulates with walker independently and needs assist with ADL care .No injuries noted at time of assessment . A nurse's note, dated [DATE] at 2:38 p.m., documented, focus charting r/t rsd cont on ATB therapy for tx of UTI rsd c/o back pain and request assist getting up to standing position times 2 assist then rsd able to amb with walker assist .will cont to monitor for changes . There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A Medication Administration Record, [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for pain. A nurse's note, dated [DATE] at 10:02 p.m., documented, Focused charting related to antibiotic treatment with [MEDICATION NAME] for UTI. Resident continues to complain of back pain and is having diffic(TRUNCATED)

On 03/17/17 an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to assess, monitor, and intervene in a timely manner for a resident who experienced a change in condition after a fall. The resident had unrelieved back pain after the fall on 12/26/17, that continued, with increasing difficulty rising from a sitting position, requiring the assistance of one to two staff members to stand. The resident experienced a second fall on 01/02/07, and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 4:30 p.m., the administrator, the DON, and two corporate RN consultants were informed of the IJ regarding the failure to assess, monitor, and intervene in a timely manner for the resident with a change in condition and unrelieved pain and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 6:20 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Removal of IJ . Ambassador Manor 3/17/17 . Failure to Assess: All staff will be in-serviced by 2359 (11:59 p.m.) on 3/17/17, by the Administrator and/or designee on recognizing pain and notification of the charge nurse and/or Physician for the appropriate treatment of [REDACTED]. This in-service will be completed by 2359 on 03/17/17. New nursing staff members will be in-serviced prior to beginning their work on the floor. Pain assessments on current residents will be reviewed by an RN. Any resident noted to be having pain will have their pain assessment redone and the physician notified for appropriate treatment for [REDACTED]. Staff were interviewed on 03/21/17 and assessments were reviewed. Not all components to the plan of removal had been completed. Staff were informed an addendum was required. On 03/22/17 at 9:00 a.m., the administrator provided an addendum to the plan of removal. The addendum documented: Ambassador Manor Addendum to the Plan of Removal 3/22/17 The following residents who had skin assessments completed on 3/17/17 will have an addendum added on 3/22/17 by an RN, to include description and measurement of current wounds and treatments, documentation of improvement or decline of condition of wounds and physician notification of wounds status .Pain assessments that were completed on 3/17/17 with pain intensity greater than 5 will be re-done by an RN on 3/22/17. The doctor will be notified and any new orders noted. Staff were interviewed on 03/22/17 and assessments were reviewed. All components to the plan of removal had been completed. The IJ was removed effective 03/22/17 at 11:55 p.m., when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ assess, monitor, and intervene in a timely manner for one (#4) of nine sampled residents who had a change in condition; ~ assess and monitor a surgical wound for one (#4) of one sampled resident with a surgical wound; and ~ provide pain management for two (#3 and #4) of four residents who had experienced pain. Resident #4 experienced a change in condition after a fall. The resident had unrelieved back pain after the fall on 12/26/17, that continued, with increasing difficulty rising from a sitting position, requiring the assistance of one to two staff members to stand. The resident experienced a second fall on 01/02/07, and developed bilateral lower extremity weakness and then was unable to bear weight with decreased feeling in her legs. The resident was transferred to the hospital and found to have a T12 fracture with spinal cord compression with [MEDICAL CONDITION] secondary to the T12 fracture with cord contusion and impingement. The resident required laminectomy surgery. The facility identified 120 residents who were on a pain management program. Findings: A policy, titled Pain Assessment, documented, An individualized pain assessment is a vital first step in pain management. Failure to properly assess pain can lead to its under-treatment. Pain complaints may be screened by a licensed practical nurse and a registered nurse shall conduct an individualized assessment .Pain should be assessed in all residents .Pain will also be measured as warranted by the residents condition with the results recorded in the clinical record .Evaluate physical function, including effect on range of motion and activities of daily living . A policy, titled Pain Orientation, documented, Things to know about pain: Many residents experience pain that can impair mobility, disturb sleep, cause depression, or diminish quality of life Staff should therefore be aware of the potential signs that a resident is experiencing pain and notify appropriate personnel so that it my be addressed .Pay attention to the following signs that a resident could be in pain .If a resident frowns, grimaces, or appears uncomfortable .If a resident has decreased activity, decreased appetite, decreased energy, or decreased sleep . 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 06/15/16, documented, Focus: .has potential for pain .Goal: .will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date .Interventions: .is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain .monitor/report to nurse any s/sx of non-verbal pain: changes in breathing .vocalizations .mood/behavior changes .eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) .pain screen q shift as ordered . A quarterly assessment, dated 11/15/16, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact for daily decision making. The assessment documented the resident was independent with transfers, walking in room and in corridor, required supervision for toilet use and dressing, and did not receive scheduled or PRN pain medication in the previous five days. An incident report, dated 12/26/16, documented the resident had a fall while attempting to go to the bathroom. No injuries were documented. A nurse's note, dated 12/27/16 at 10:35 a.m., documented, .continue to complain of flank pain .travel by rolling walker. BRP adlib & sometimes need help getting up from stool . There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A nurse's note, dated 12/27/16 at 1:01 p.m., documented, IDT met to discuss incident on 12/26/16. Resident is alert, oriented with cognitive deficits. Resident ambulates with walker independently and needs assist with ADL care .No injuries noted at time of assessment . A nurse's note, dated 12/28/16 at 2:38 p.m., documented, focus charting r/t rsd cont on ATB therapy for tx of UTI rsd c/o back pain and request assist getting up to standing position times 2 assist then rsd able to amb with walker assist .will cont to monitor for changes . There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A Medication Administration Record, [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for pain. A nurse's note, dated 12/28/16 at 10:02 p.m., documented, Focused charting related to antibiotic treatment with [MEDICATION NAME] for UTI. Resident continues to complain of back pain and is having difficulty getting up out of chair and is requiring two people to help her up. The Medication Administration Record [REDACTED]. There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A nurse's note, dated 12/29/16 at 2:15 p.m., documented, focus charting r/t rsd cont to c/o lower back pain midline rated at 6 rsd cont to have difficulty getting to standing position requires 1-2 max assist notified Dr. (name deleted) new order to Xray lower back . A nurse's note, dated 12/29/16 at 8:37 p.m., documented, .Resident continues to complain of back pain and has difficulty getting up from sitting position . The Medication Administration Record, [REDACTED]. A nurse's note, dated 12/30/16 at 1:55 p.m., documented, focus charting r/t f/u Xray results of lumbar spine impression: multilevel [MEDICAL CONDITION] spondylosis (sic) rsd cont to c/o pain lower back rated 4-5 requesting assist to get to standing position then able to amb with walker assist rsd given prn Tylenol notified Dr. (name deleted) of xray results and rsd cont c/o pain awaiting response The Medication Administration Record, [REDACTED] There was no documentation the physician had responded regarding the resident's continued complaints of pain. The Medication Administration Record [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for pain. A nurse's note, dated 12/30/16 at 9:29 p.m., documented, focused charting related to back pain. Resident continues to have pain and stiffness after sitting for any period of time. Resident requires assistance to stand. Tylenol given prn for pain. The Medication Administration Record [REDACTED]. There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A nurse's note, dated 12/31/16 at 6:55 a.m., documented, focused charting r/t fall .no apparent injury from fall noted . A nurse's note, dated 01/01/17 at 1:17 a.m., documented, focus charting r/t fall .still needs help with getting up from commode, walks with a walker .no delayed injuries noted. denies pain @ this time. There was no documentation the physician was notified of the change in condition regarding the resident required assistance standing from a seated position. A nurse's note, dated 01/02/17 at 12:15 p.m., documented, Called to memory unit dining room where resident was sitting on floor in front of nurses station with her legs pointed towards dining room and he (sic) back resting on the nurses station. Resident was witnessed falling by CNA .who stated that she just hit her bottom hard but did not hit head. Resident denies pain and discomfort at this time. ROM WNL. BLE weak. Dr.(name deleted) with new orders for PT eval and tx and to extend [MEDICATION NAME] 500mg daily x 5 days . A nurse's note, dated 01/02/17 at 12:43 p.m., documented, .Resident BLE weak with unsteady gait . A nurse's note, dated 01/02/17 at 9:20 p.m., documented, .Resident continues to complain of back pain and did not get up for supper . There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain, had BLE weakness and refused to get up for dinner. A nurse's note, dated 01/02/17 at 9:24 p.m., documented, Focused charting related to incident. Resident continues to have back discomfort and refused to come up to dinner this evening. Resident is taking Tylenol with some relief. Staff continues to assist Resident when getting up from a sitting position. The Medication Administration Record, [REDACTED]. There was no documentation the physician was notified of the change in condition regarding the resident continued to have pain and required assistance standing from a seated position. A quality manager progress note, dated 01/03/17 at 9:16 a.m., documented, Resident lying in bed eyes open breathing labored R 24 lung sounds diminished .Skin c/d no injuries noted .Resident moves all extremities resident has no objective or subjective s/s of pain resident states 'I feel fine' resident strength in legs is decreased, resident shaky once sitting on bed side. Charge nurse at bedside assisting transfer of resident into wc .Report to this nurse resident is being transferred to ER . A nurse's note, dated 01/03/17 at 9:35 a.m., documented, focus charting r/t rsd noted this am non wt bearing in bilat lower extremities rsd with noted decrease feeling and reaction to touch of BLE at times denied feeling in LLE notified Dr. (name deleted) received order to transfer to ER for eval and tx . A nurse's note, dated 01/05/17, documented, Received call that resident has a fracture to T-12. After incident on 12/26/16 resident was complaining of back pain . The Medication Administration Record, [REDACTED]. A progress note, dated 01/31/17, documented the resident was diagnosed with [REDACTED]. The note documented [MEDICAL CONDITION] (secondary to) T fx & cord contusion with cord impingement S/P T12 laminectomy 1/10/17. weakness BLE with [MEDICAL CONDITION] bowel & bladder . On 03/17/17 at 11:00 a.m., CNA #4 was asked if the resident had complained of pain after her falls. She stated, She was in a lot of pain. She couldn't lift her leg or nothing. She was screaming in pain the day she left. At 2:20 p.m., LPN #4 was asked if the resident required extensive assistance with standing prior to her falls. He stated, Not before the fall but did require it after the fall. He was asked why he did not notify the physician when the resident had a change in condition. He stated, She didn't complain of pain so I didn't call the doctor. On 03/17/17 at 2:20 p.m., the DON was asked if the resident had a change in condition. She stated, I don't remember, and if there was a change they should notify doctor. She was informed of the continued back pain and no pain medications being given. She was asked why on 12/30/16 the resident complained of pain at 2:00 p.m., but was not given pain medication until after 5:00 p.m. according to the medication administration record. She stated, They may have given out of house stock and not documented until later. I can't remember, they tell me numerous things. She was asked when the resident started requiring more assistance why no new interventions were put in place. She stated, I can't explain that. I will look. No further information was provided. At 2:21 p.m., CNA #4 was asked if the resident required extensive assistance with standing prior to her falls. She stated, No. She could stand and transfer by herself. She was asked if the resident required extensive assistance after the falls. She stated, Yes. She needed help getting out of bed. She was asked if the nurse was aware the resident had required extensive assistance with standing. She stated, Yes, she would be down in the room helping us with her. At 2:26 p.m., CNA #14 was asked if the resident needed extensive assistance with standing prior to her falls. He stated, No, she was walking and standing on her own before the fall. He was asked if she needed extensive assistance standing after the falls. He stated, Yes, we had to help her stand. She complained of pain in her back after the falls. He was asked if the nurse had been aware of the resident's complaints of pain. He stated, Yes. He was asked if the nurse was aware the resident had required extensive assistance with standing. He stated, Yes. 2. Resident #3 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/21/16, documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident was independent with activities of daily living, had [DIAGNOSES REDACTED]. A care plan, updated 12/21/16, documented, .Focus: .frequent pain at a 7 .Goal: relief of pain or ability to cope with incompletely relieved pain .Interventions: Adminster (sic) [MEDICATION NAME], [MEDICATION NAME] as ordered .Notify my physician if interventions are unsuccessful or if current complaint is a significant change from my past experiences of pain .Pain screen as ordered . A nurse's note, dated 01/31/17, documented, .refused wound care doctor appointment because he doesn't feel well, med support and doctor's office notified. Refused leg care per order, because he doesn't feel like getting them treated. Monthly physician's orders [REDACTED].[MEDICATION NAME] ER Tablet Extended Release 15 MG Give 1 tablet by mouth every 8 hours as needed for breakthrough pain . [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed for acute leg . [MEDICATION NAME] HCI Tablet 20 MG Give 1 tablet by mouth every 4 hours for severe pain . [MEDICATION NAME] Tablet 500 MG ([MEDICATION NAME]) Give 1 tablet by mouth every 6 hours for muscle spasms . [MEDICATION NAME] Cream 1% (Silver [MEDICATION NAME]) Apply to BLE topically one time a day for BLE wounds cleanse BLE with wound cleanser pat dry, apply [MEDICATION NAME], place ABD pads over open areas, wrap with krillex (sic) and apply [MEDICATION NAME] . A nurse's note, dated 02/17/17, documented, Resident chooses not to take a bath or shower today says 'it hurts when I stand.' refused leg and heel treatments. There was no documentation the physician had been notified the resident experienced unrelieved pain and refused the skin treatments. The Medication Administration Record [REDACTED]. A care plan, updated 02/22/17, documented, .Focus: .has an unstageable wound to right heel .Goal: .will resolve without complications .Interventions: .monitor pain with dressing changes .refer to physician as needed . A nurse's note dated 02/27/17, documented, .Resident refused (treatment to right heel), stated 'my foot hurts too much.' Nurse explained treatment to be done twice a day, resident still refused. A nurse's note, dated 02/28/17 at 2:19 a.m., documented, .offered to do wound care he said 'No, it was done earlier that's too many times and it hurts and I don't feel well.' A progress note by the wound care nurse, dated 02/28/17 at 11:52 a.m., documented, .Refused treatment x 3 attempts. There was no documentation the physician had been notified the resident experienced unrelieved pain and refused skin treatments. The Medication Administration Record [REDACTED]. A treatment administration record, dated February 2017, documented the resident did not receive the Microcyn spray, Iodosorb gel, calcium alginate, and bandage to his right heel 11 times during the month and did not receive the [MEDICATION NAME] cream and bandages to his bilateral lower extremities ten times for the month. A Medication Administration Record, [REDACTED]. The record documented the resident had received one dose of the as needed pain medication, [MEDICATION NAME], and seven doses of the as needed pain medication, [MEDICATION NAME], for the month. Monthly physician's orders [REDACTED].Clean right heel with Microcyn Spray and gauze. Apply Iodosorb gel. Cover with Calcium Alginate and ABD pad. Wrap with gauze roll and secure with tape BID .every morning and at bedtime .PRN every 8 hours as needed for unstageable pressure ulcer . [MEDICATION NAME] ER Tablet Extended Release 15 MG Give 1 tablet by mouth every 8 hours as needed for breakthrough pain . [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed for acute leg . [MEDICATION NAME] HCI Tablet 20 MG Give 1 tablet by mouth every 4 hours for severe pain . [MEDICATION NAME] Tablet 500 MG ([MEDICATION NAME]) Give 1 tablet by mouth every 6 hours for muscle spasms . [MEDICATION NAME] Cream 1% (Silver [MEDICATION NAME]) Apply to BLE topically one time a day for BLE wounds cleanse BLE with wound cleanser pat dry, apply [MEDICATION NAME], place ABD pads over open areas, wrap with krillex (sic) and apply [MEDICATION NAME] . A nurse's note, dated 03/12/17 at 6:56 p.m., documented, Resident refused to have his dressing changed resident stated 'it hurts to bad, I can't do it tonight.' There was no documentation the physician had been notified the resident experienced unrelieved pain and refused skin treatments. The Medication Administration Record [REDACTED]. A treatment administration record, dated 03/01/17 - 03/21/17, documented the resident did not receive the Microcyn spray, Iodosorb gel, calcium alginate, and bandage to his right heel 16 times and did not receive the [MEDICATION NAME] cream and bandages to his bilateral lower extremities four times. A Medication Administration Record, [REDACTED]. The record documented the resident had received one dose of the as needed pain medication, [MEDICATION NAME], and seven doses of the as needed pain medication, [MEDICATION NAME]. On 03/23/17 at 10:30 a.m., the resident was asked about his pain. He stated, I get pain meds every four hours. He was asked how often he required the as needed pain medication for pain unrelieved by his routine pain medication. He stated, No extra, I didn't know I could get them. He was asked if he was aware if staff notified his physician when he had pain that was not relieved by his routine medication. He stated, They don't tell me that, I just know I get pain medication every four hours. At 10:45 a.m., LPN #3, the charge nurse, was asked about the resident's refusal of skin and wound treatments. She stated he usually did not want to do the treatments and would refuse often. She was asked if he refused due to pain. She stated he did at times and when they offered him the as needed pain medication, he usually did not want to take it. She was asked if the physician should be notified when a resident continued to refuse skin treatments and wound care. She stated yes. She stated the physician should be notified if the resident had a change in their mental or physical condition and for continued refusals of care. At 11:00 a.m., the wound care nurse was asked if he did the skin assessments/skin treatments/wound care. He stated he performed the skin assessments/skin treatments/wound care on Monday through Friday in the day and the charge nurses performed them on evenings and weekends. He was asked about the resident's refusals of skin assessments, treatments, and wound care. The wound nurse stated if the resident refused due to pain he should premedicate before the treatment. He was asked if he had premedicated the resident when he refused his treatments due to pain. He stated he was not sure but should have. He was informed the Medication Administration Record [REDACTED]. No comment was made. At 11:30 a.m., the DON was informed of the resident's pain, refusals of skin assessments, treatments, and wound care. She was asked when staff should notify the physician. She stated the physician should be notified each time or at least a weekly update should be done if the resident continued to refuse after the physician had been notified several times of the refusals. She stated the resident should have been premedicated for pain as needed and encouraged to allow the skin assessments/treatments/wound care to be completed by staff.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to perform initial and ongoing thorough skin and wound assessments; notify the physician of the use of a [MEDICATION NAME] brace, new wounds or the worsening of existing wounds; and obtain wound consultations. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10 cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with a green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident expired in the hospital on [DATE]. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 4:30 p.m., the administrator, the DON, and two corporate RN consultants were informed of the IJ regarding pressure ulcers and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 6:20 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Removal of IJ for Pressure Ulcers Ambassador Manor [DATE] Pressure Ulcers: Nurses on duty will be immediately in-serviced by the Administrator and/or designees, related to assessing pressure ulcers and notifying the MD of changes. They will be in-serviced related to skin assessments upon admission and documentation of any abnormalities of assessment and MD notification of findings. Nursing staff will also be in-serviced on facility wound and skin care guidelines. These in-services will be completed by 11:59 p.m. on [DATE]. New nursing staff members will be in-serviced prior to beginning their work on the floor. Skin assessments will be completed by an RN on [DATE], on all residents currently residing in the facility, and the physician(s) will be notified of current pressure ulcers and current tx orders. Staff were interviewed on [DATE] and assessments were reviewed. Not all components to the plan of removal had been completed. Staff were informed an addendum was required. On [DATE] at 9:00 a.m., the administrator provided an addendum to the plan of removal. The addendum documented: Ambassador Manor Addendum to the Plan of Removal [DATE] The following residents who had skin assessments completed on [DATE] will have an addendum added on [DATE] by an RN, to include description and measurement of current wounds and treatments, documentation of improvement or decline of condition of wounds and physician notification of wounds status .Pain assessments that were completed on [DATE] with pain intensity greater than 5 will be re-done by an RN on [DATE]. The doctor will be notified and any new orders noted. Staff were interviewed on [DATE] and assessments were reviewed. All components to the plan of removal had been completed. The IJ was removed effective [DATE] at 11:55 p.m., when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ perform initial and ongoing thorough skin and wound assessments; ~ notify the physician of the use of a [MEDICATION NAME] brace and obtain orders for the care of the resident related to the brace; ~ notify the physician consistently of new wounds or the worsening of existing wounds; ~ obtain wound consultations; ~ obtain physician orders [REDACTED]. ~ obtain xrays as recommended by wound specialists; and/or ~ update the care plans to address pressure ulcers, changes in pressure ulcers or pressure ulcer care and the use of braces for two (#4 and #7) of six sampled residents who had pressure ulcers. Resident #4 was readmitted to the facility on [DATE] with Stage II pressure ulcers to her right and left heels (Intact Blisters) and excoriation to her buttocks and posterior thighs. The resident was sent to the hospital on [DATE], after seeing her surgeon for a follow-up appointment, with signs [MEDICAL CONDITION] and suspicion of a blood clot in her right arm, and was found to have multiple pressure ulcers, many unstageable, to her buttocks, sacrum, perineal area, bilateral heels and left armpit. Hospital records documented the resident had multiple pressure wounds to her sacral and gluteal areas that were caved, tunneling, blackened, green, malodorous and unstageable. The wounds to the left and right buttock were unstageable with visible tissue that was sloughing, with odor and brown, cloudy, green purulent bleeding drainage, with 10cm tunneling. She had a blackened wound to her right heel. Upon removing her back brace, she had a half dollar size and a dime size opening to her left axillary area, with green/yellow center which was hardened upon palpation, with reddened edges. These were described as unstageable pressure injuries. She was found to have severe tunneling unstageable wounds in her perineal area with purulent leaking that appeared to be infected. A physician's consult documented the resident was in septic shock with necrotizing wounds to the perineal area with grossly infected perineal and buttock pressure wounds. The resident was in septic shock and expired in the hospital on [DATE]. The facility identified 15 residents who had pressure ulcers. Findings: A facility policy, titled 'Skin and Wound Care Guidelines', documented, .Purpose .to provide a systematic approach and monitoring process for skin integrity/pressure ulcer care. To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and developing interventions. To promote healing of pressure ulcers .Objective .To maintain an optimal level of skin integrity and to promote optimum healing of pressure ulcers using an individualized plan of care .within eight (8) hours of initial admission or, following hospital stay the resident will be assessed for the existence of pressure ulcers by the charge nurse or staff nurse. The attending physician will be notified to approve prevention and/or treatment interventions. The facility's wound care nurse(s) should be notified of the ulcers that have been identified per facility preference as well as the unit charge nurse .If resident develops skin breakdown, complete the wound care status report, weekly. The nurse who identified areas of skin breakdown should .document his/her finding in the nurses notes .document those health care providers who have been notified .obtain a treatment and initiate .notify treatment nurse and/or DON .residents identified with pressure ulcers will be reassessed on a daily basis for additional areas of concern and assessment documented .any areas found will be reported to the charge nurse and the wound care nurse of the facility. A treatment will be obtained from the physician or there (sic) designee and implemented . 1. Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].Apply to buttocks topically every 8 hours as needed for wound care. A physician's orders [REDACTED]. A nurse's progress note, dated [DATE], documented, .Admission Summary .upon arrival head to toe assessment done .overall skin intact .with chest braise (sic) to protect back . There were no physician's admission orders [REDACTED]. There was no documentation the resident's primary physician had been notified of the [MEDICATION NAME] brace, clarification of when the brace was to be worn, or if skin assessments were to be conducted under the brace. A physician's orders [REDACTED].Apply to buttocks topically one time a day for wound care. There were no admission orders [REDACTED]. There was no documentation the resident's primary physician or surgeon had been notified of the [MEDICATION NAME] brace, clarification of how often the brace was to be worn, and when skin assessments were to be completed. A skin/wound note, by the wound nurse, dated [DATE], documented, .readmit to facility. Head to toe skin assessment done. admitted with Stage II pressure ulcer on right heel measuring 3 cm L x 4.5 cm W x 0 cm. Wound bed is covered by intact blood blister. Surrounding skin is clear. Has stage II pressure ulcer on left heel measuring 3 cm L x 4 cm W x 0 cm. Wound bed is covered by intact blister. Surrounding skin is clear. Has excoriation to buttocks and posterior thighs. Has order for [MEDICATION NAME] iodine to heels Q Mon Wed Fri. Has order for [MEDICATION NAME] paste to buttocks and posterior thighs Q 8 hours/prn. Notified resient's (sic) gaurdian (sic) .of residnet's (sic) wounds and treatments. Dr .notified. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. There was no documentation the physician had been notified for orders for the use of the [MEDICATION NAME] brace. There was no documentation the wound consultant had observed the resident's pressure ulcers or made recommendations regarding treatment. A physician's orders [REDACTED]. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance of two staff persons for bed mobility, transfers, hygiene, toileting, dressing, and bathing, had two stage II pressure ulcers that had been present on admission, and had a surgical wound. Monthly physician's orders [REDACTED].To wear heel protectors at all times .Wound consultant to screen, evaluate as (sic) treat as needed .[MEDICATION NAME] skin protectant paste .apply to buttocks topically every 8 hours as needed for wound care .[MEDICATION NAME] skin protectant paste .apply to buttocks topically one time a day for wound care .[MEDICATION NAME]-Iodine Ointment 10% Apply to left and right heel topically one time a day every Mon, Wed, Fri for prevention . The monthly physician orders, for February 2017, did not contain any orders for the [MEDICATION NAME] brace the resident had been wearing on admission. A telephone order, dated [DATE] at 2:48 p.m., documented, .Ally (sic) [MEDICATION NAME] to right heel Qday. Leave open to air. Every day shift for Stage II pressure ulcer . clean wound on left heel with wound cleaner. Apply Hydrogel to wound bed. Apply Allevyn hell (sic) cup. Wrap with gauze roll and secure with tape. Change Qday/prn. Every 8 hours as needed for Stage II pressure ulcer and every day shift . A skin/wound note, by the wound nurse, dated [DATE], documented, .stage II pressure ulcer on right heel measures 3.5 cm x 5.5 cm x 0 cm. Wound bed is covered by eschar. Surrounding skin is clear .stage II pressure ulcer on left heel measures 3 cm x 1.5 cm x <0.2 cm. Wound bed is pink/red with minimal serous drainage. Surrounding skin is clear .Dr .notified . The stage II pressure ulcer to the resident's right heel had worsened from 3 cm x 4.5 cm x 0 cm ([DATE]) to 3.5 cm x 5.5 cm x 0 cm ([DATE]). There was no documentation the wound consultant had been notified of the worsening pressure ulcer to the resident's right heel, or made recommendations regarding changes in treatment. There was no documentation regarding the condition of the skin under the resident's [MEDICATION NAME] brace. A nurse's progress note, dated [DATE], documented, .CNA notified this nurse re .open area @ R buttock 2 cm x 1.5 cm with a 2 cm x 3 cm purple area next to it. Areas @ L buttock 4 x 6 cm and open area @ coccyx 1.5 x 1.5 cm. Cleansed with NS, applied hydrogel and covered all open areas with bordered foam dressing .Notified MD . There was no documentation the physician had provided orders for specific treatments for the newly developed pressure ulcers. A skin assessment weekly summary, by the wound nurse, dated [DATE], documented, .Buttocks (Right) .Onset Dt: [DATE] .In-house .L 3 cm .W 4 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 7 Unstageable - slough and/or eschar &/or DTI .Drainage .light serous .Wound bed appearance .granulation tissue (Pink/Red) .Wound bed is 70% suspected deep tissue injurury(sic) purple and 30% pink. Surrounding skin with 0.5 cm [DIAGNOSES REDACTED] . Coccyx .Onset Dt: [DATE] .In-house .L 2.5 cm .W 1.5 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 2 Drainage .light serous .Wound bed appearance .granulation tissue (Pink/Red) .Surrounding skin is clear . Left gluteal fold .Onset Dt: [DATE] .In-house .L 4 cm .W 11 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 7 Unstageable - slough and/or eschar &/or DTI .Drainage .light serosanguinous .Wound bed appearance .Granulation tissue (pink/Red) .Surrounding skin is clear . Heel (Right) .On admission .L 3 cm .W 5 cm .D .0 cm .Diagnosis: [REDACTED].Stage 2 .Wound bed appearance .Scab .surrounding skin is clear. Wears heel protectors . Heel (Left) .On admission .L 1.5 cm .W 2 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 2 .Drainage .light .serous .Wound bed appearance: Granulation tissue (Pink/Red) .Surrounding skin is clear. Wears heel protectors . A telephone order, dated [DATE] at 8:21 a.m., documented, .clean wound on coccyx with wound cleaner. Apply Hydrogel and cover with foam dressing with border. Change Qday/prn. Every 8 hours as needed for Stage II pressure ulcer and every day shift .clean wound on right buttock with wound cleaner. Apply Hydrogel and cover with foam dressing with border. Change Qday/prn. Every 8 hours as needed for Unstageable pressure ulcer and every day shift .clean wound on left gluteal fold with wound cleaner. Apply Hydrogel and cover with foam dreeing (sic) with border. Change Qday/prn. Every 8 hours as needed for Unstageable pressure ulcer and every day shift . There was no documentation the wound consultant had been notified of the newly developed pressure ulcers to the right and left buttocks and coccyx, or recommendations made regarding treatment. A 30 day assessment, dated [DATE], documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance of two staff persons for bed mobility, transfers, and toileting, required extensive assistance with one staff person for hygiene, and dressing, the resident had one stage II pressure ulcer that had not been present on admission or reentry, and two unstageable pressure ulcers that had not been present on admission, reentry, or prior assessment. A care plan, dated [DATE], documented, Focus: .has a 4 x 6 cm open wound to her left gluteal fold . has a Stage II pressure ulcer on right heel measures 3.5 cm x 5.5 cm x 0 cm. Wound bed is covered by eschar. Surrounding skin is clear . has a Stage II pressure ulcer on left heel measure 3 cm L x 1.5 cm W x <0.2 cm. Wound bed is pink/red with minimal serous drainage. Surrounding skin is clear . has a 1.5 x 1.5 cm open area to her coccyx . has a 2 x 1.5 cm open area with a 2 x 3 cm purple area next to it . Goal: .will resolve without complications x 90 days . Interventions: .assist to turn and reposition frequently .carafoam mattress .diet as ordered .encourage fluids .float heels with pillows while in bed .heel protectors to bilateral feet when out of bed .measure and assess wound weekly .monitor pain with dressing changes .refer to dietician as needed for recommendations to aid in wound healing .refer to physician as needed, update physician weekly of wound status .refer to wound consultant as needed .update family weekly of current wound status . The care plan did not address the right heel pressure ulcer had worsened, new pressure ulcers had developed, and no new interventions had been addressed to prevent further pressure ulcers. There was no care plan to address the use of a [MEDICATION NAME] brace and to assess the resident's skin. A skin assessment weekly summary, by the wound nurse, dated [DATE], documented, .Heel (Right) .On admission .L 3 cm .W 5 cm .D .0 cm .Diagnosis: [REDACTED].Stage 2 .Wound bed appearance .Scab .surrounding skin is clear. Wears heel protectors . Heel (Left) .On admission .L 1.7 cm .W 3.5 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 2 .Drainage .light .serous .Wound bed appearance .Granulation tissue (Pink/Red) .Surrounding skin is clear. Wears heel protectors . Buttocks (Right) .Onset Dt: [DATE] .In-house .L 3 cm .W 3.5 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 7 Unstageable - slough and/or eschar &/or DTI .Drainage .light serous .Wound bed appearance .slough .Surrounding skin with 0.5 cm [DIAGNOSES REDACTED] . Coccyx .Onset Dt: [DATE] .In-house .L 3 cm .W 1 cm .D 0.2 cm .Diagnosis: [REDACTED].Stage 2 Drainage .light serous .Wound bed appearance .granulation tissue (Pink/Red) .Surrounding skin is clear . Left gluteal fold .Onset Dt: [DATE] .In-house .L 4 cm .W 6 cm .D <0.2 cm .Diagnosis: [REDACTED].Stage 7 Unstageable - slough and/or eschar &/or DTI .Drainage .light serosanguinous .Wound bed appearance .slough .Surrounding skin is clear . A telephone order, dated [DATE] at 10:04 a.m., documented, .resident to only be out of bed for one hour for meals then put back to bed due to multiple pressure ulcers on buttocks. Every day and evening shift for pressure ulcers . A skin/wound note, by the wound nurse, dated [DATE], documented, .stage II pressure on right heel measures 3 cm L x 5 cm W x 0 cm. Wound bed is covered by scab. Surrounding skin is clear .stage II pressure ulcer on left heel measures 1.7 cm L x 3.5 cm W x <0.2 cm. Wound bed is 50% slough and 50% pink with minimal serous drainage. Surrounding skin with 0.5 cm [DIAGNOSES REDACTED] .Unstageable pressure ulcer on right buttock measures 3 cm L x 3.5 cm W x < 0.2 cm. Wound bed is covered by slough and has minimal serous drainage. Surrounding skin is clear .stage II pressure ulcer on coccyx measures 3 cm L x 1 cm W x 0.2 cm. Wound bed is pink with minimal serous drainage. Surrounding skin is clear .Unstageable pressure ulcer on left gluteal fold measures 4 cm L x 11 cm W x <0.2 cm. Wound bed 75% slough and 25% pink with minimal serous drainage. Surrounding skin is clear .Dr .notified. Documentation revealed the pressure ulcers to the left heel, the coccyx, the right buttock, and the left gluteal fold had worsened between [DATE] and [DATE]. There was no documentation the physician had been notified regarding the worsening pressure ulcers or if new treatment orders for the worsening pressure ulcers had been received. A nurse's report sheet, dated [DATE] - [DATE], documented, .SNF .wound care .wound to L buttock increased slough noted .back brace . There was no documentation the physician had been notified of the worsening pressure ulcer. A skilled daily nurse's note, dated [DATE] at 8:25 p.m., documented, .Skin Conditions .(anatomical diagram blank) .resident declined to get out of bed today, wound care provided per orders .yellowish slough noted to left gluteal fold wound and right buttocks wound . There was no documentation the physician had been notified of the yellowish slough that had been noted to the left gluteal fold wound or the right buttock wound. There was no documentation the condition of the resident's skin under the [MEDICATION NAME] brace had been assessed. A skin/wound note, by the wound nurse, dated [DATE], documented, .focused charting r/t pressure ulcers areas noted on left and right heel, right buttock and coccyx area . The note did not address the unstageable pressure wound to the left gluteal fold, the yellowish slough to the left gluteal fold and the yellowish slough to right buttock. No dimensions, or current stages were documented for each pressure ulcer. A nurse's progress note, dated [DATE] at 11:44 a.m., documented, Resident was being seen at (Physician specialist office) for f/u from fx to spine. Dr. (name deleted) notified me that resident is being sent to (name deleted) hospital due to s/s [MEDICAL CONDITION] and stated that he was afraid she had a blood clot in her right arm area. A nurse's progress note, dated [DATE] at 2:15 p.m., documented, (Name deleted) transport brought resident back here instead of to (name deleted) hospital as was discussed with (Physician specialist office). (Name deleted transport) driver stated that they don't transport people to the E.R. Upon assessment of resident, right arm +3 [MEDICAL CONDITION] and is cold with no palpable pulse. Respirations of 34 and shallow with no congestion noted. Resident had a scared look on her face. Notified Dr. (name deleted) with new orders to send to E.R. of (name deleted) hospital where residents daughter is expecting her. Called 911. O2 stats (sic) down to 78 as (ambulance) arrived and they hooked up O2 via nasal cannula which only brought it up to 83% on 4 liters of O2. (Ambulance company) then put on non rebreather mask and it came up to 88%. Transported to (hospital) E.R. at this time. A hospital emergency department note, dated [DATE] at 3:35 p.m., documented, .musculoskeletal: intact distal pulses, [MEDICAL CONDITION] diffusely, back brace in place .Integument: warm, dry, deep necrotic [MEDICAL CONDITION] covered in stool .We have covered the patient for pneumonia and other sources of infection including her [MEDICAL CONDITION] . At 3:45 p.m., an emergency department note documented, .she shows evidence of septic shock .skin color is mottles (sic), pale .she has severe decubitus wounds .The patient has symptoms [MEDICAL CONDITION] that are being treated with IV fluid resuscitation and antibiotics, however the patient appears to be worsening .admitted to the ICU in severely critical condition . At 4:28 p.m., an emergency department note, documented, .upon log rolling pt with spinal precautions, multiple pressure wounds noted to sacral, gluteal area. Caved, tunneling, blackened, green, malodorous wounds; unstageable. Heart shaped [MEDICATION NAME] to coccyx area. [MEDICATION NAME] placed to bilateral heels. Blackened wound to R heel. Heeling (sic) white/red wound to L heel .upon removing TLSO brace, a half dollar size and a dime size, opening to L axillary area. Irregular shaped. Green/yellow center, hardened upon palpation. Reddened edges. No obvious drainage . At 4:53 p.m., a culture of the decubitus ulcer to the buttock was collected. The culture result included, .many gram negative rods .few staphylococcus aureus .many [MEDICATION NAME] species .many beta Streptococcus group A .many Bacteroides species (not fragilis) .Many Bacteroides thetaiotaomicron .few diphtheroids . At 5:45 p.m., a hospital wound care note, documented the resident had a pressure injury to the left and right buttock that was unstageable. The visible tissue was documented as sloughing, with odor and brown. cloudy green purulent bleeding drainage. The wound care note documented the pressure injury had 10 cm of tunneling. The hospital wound care note also documented an unstageable pressure injury in the left armpit related to the back brace. The pressure injury was documented as a large, black irregular shaped wound, that was present on arrival. The state of healing was documented as non-healing/chronic. The site assessment was documented as black, fragile, red, sloughing. The peri-wound area was documented as boggy, purple. A history and physical note from the physician, dated [DATE] at 5:52 p.m., documented, .Skin: warm/dry, unstageable wounds to buttocks/sacrum/perineal area .severe tunneling wounds in her perineal area with purulence leaking .Decub wounds .these appear to be infected . A physician consult note, dated [DATE] at 7:24 p.m., documented, .patient in septic shock with necrotizing wounds to perineal area .grossly infected perineal and buttock pressure wound .she began, according to her daughter, to have some change in her mental status last Thursday that got worse over the weekend .On exam the wound was discovered and we were consulted. No one known (sic) how long the wound has been there .she is currently .non responsive, and critically ill .Physical Exam .Skin: deep tracking wounds perineum, surrounding buttock and upper thighs with [DIAGNOSES REDACTED] .Assessment/Plan: .septic shock - due to wound .infection of perineal wounds - this wound does need urgent surgical debridement . An RN progress note, dated [DATE] at 8:14 p.m., documented, .extensive, tunneling unstageable wounds noted on pt's buttocks/gluteal folds, with large amounts of malodorous drainage. Unstageable wounds also noted on pt's bilat heels, L great toe amputation site, and L armpit, all present upon arrival from .nursing home. Wounds assessed by multiple RNs and physicians. On [DATE] at 9:30 p.m., the resident was pronounced dead after absence of vital signs assessed by night supervisor. A hospital death summary, dated [DATE] at 10:01 p.m., documented, .Admit [DIAGNOSES REDACTED].decubitus wounds POA .severe tunneling wound in her perineal area with purulence leaking . On [DATE] at 3:55 p.m., corporate RN #1 was asked who performed wound care. She stated the wound nurse worked Monday through Friday, and the charge nurses did the wound care on the weekend shifts. At 4:20 p.m., corporate RN #1 was asked if there had been an order for [REDACTED]. She stated, That's all I could find. The document contained no orders or instructions regarding the brace. On [DATE] at 5:00 p.m., the wound nurse was asked where he documented the physician's response after he had been notified of a change in the resident's wounds. He stated, I talk to him in person or on the phone. I don't document his response. If he gives me an order over the phone I put it in the computer. I don't document the physician's response in a nurse's note. The wound nurse was asked why he didn't document the physician's response. He stated, I'm so overwhelmed with residents who need wound treatments to be done. I don't have time to do all the documentation that is required. I just try to save time by not going into detail on the notes. At 5:05 p.m., the DON was asked if a head to toe skin assessment should have been done on the resident before she had been transferred to the hospital. She stated, It's not our policy to do a head to toe assessment before transferring to the hospital. She was asked if the skin under the resident's brace should have been assessed. She stated yes. She was asked how often the skin should have been assessed. She stated the skin should have been assessed each time before the brace was put on the resident. She was asked when the resident's pressure wounds were increasing in size and showing signs of infection, should the physician have been notified and his response documented in the resident's chart. She stated, Yes. On [DATE] at 9:46 a.m., LPN #6 was asked if he had been the nurse who admitted the resident back to the facility on [DATE]. He stated, Yes. He was asked if he called the surgeon's office to get clarification on the back brace and post surgical care. He stated, No. He was asked how he knew how to take care of the brace and the surgical incision. He stated, I got report from the nurse from the transferring hospital. She mentioned the brace and when to wear it and when to take it off, and that it was to be worn over her clothing. The LPN was asked why there were no orders in the resident's clinical record regarding the [MEDICATION NAME] brace. He stated, She came from the hospital with it on. He was asked if he had notified the physician. He reviewed the resident's records and stated he couldn't find an order for [REDACTED]. He was asked how staff would know how to take care of the brace when there were no orders for its use. He stated, I instructed the CNAs on how to take care of it. He stated he had taken care of residents with braces before. He was asked if he should have notified the physician and obtained orders for the [MEDICATION NAME] brace. He stated, Yes. He was shown his documentation from the admission summary. He was asked why he had documented the resident's overall skin condition was intact when the resident had two stage II pressure ulcers on her heels. He stated, I didn't document her pressure ulcers, I just called the wound nurse so he could assess the resident's wounds so there would be no conflict of how the wound was assessed. The wound nurse was asked what training he had received regarding wound care. He stated, A lady came in for a week and went through a textbook and showed me how to do the wound treatments. He was asked how long ago he had received the training. He stated it had been approximately six years ago. He was asked if he had received any training since that time. He stated, No. At 10:43 a.m., the resident's physician was interviewed per phone. The physician was asked if she had been notified when the resident's wounds had worsened. She stated, I don't remember specifically. Typically the wound nurse does notify me if there is a change in the wrong direction and I would tell him what to do as far as care. She was asked if she had been made aware of the worsening of the resident's pressure wounds. She stated, I don't remember being notified without being able to look at the resident's chart. <(TRUNCATED)

Based on record review, observation, and interview, it was determined the facility failed to provide supervision to prevent falls and to identify and implement interventions to aid in the prevention of falls for two (#5 and #8) of five residents who were reviewed for falls. Resident #8 sustained a fracture of her upper arm when she was pushed by another resident and fell . The facility identified 92 residents who were at high risk for falls. Findings: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/13/16, documented the resident had a long/short term memory problem and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had exhibited physical, verbal, and other behaviors in the past one to three days, had rejected care daily, had wandered throughout the facility daily, required supervision with transfers, required limited assistance with ambulation, required limited assistance with toileting, had not experienced any falls, and had received an antianxiety medication within the past six days. A care plan, dated 12/19/16, documented, Focus .is at risk for falls r/t hx of falls, Gait/balance problems, Incontinence, poor communication/comprehension, Psychoactive drug use, Unaware of safety needs, Wandering .Goal: (No goal documented) .Interventions .Staff to monitor and keep her from other persons room .Anticipate and meet .needs .Be sure .call light is within reach and encourage her to use it for assistance .Check on her frequently as she may not remember to use call light .bed in low position at night .uses a walker for ambulation. Make sure she has it with her .Encourage .to participate in activities .Ensure .wearing appropriate footwear when ambulating . An incident report, dated 12/19/16 at 10:15 a.m., documented, .Resident was seen in another residents room sitting on the floor with her walker in front of her .When we asked other resident if she had pushed her she stated, She was in my closet and I felt like it. but wouldn't admit to actually pushing her down .denies pain and discomfort at this time .Someone pushed me .Immediate Action Taken .Assisted resident back to her feet and removed resident from room and situation .No injuries observed . The care plan did not address any new fall interventions to be implemented after the resident had fallen on 12/19/16 when the resident was found on the floor in another resident's room. An incident report, dated 12/19/16 at 8:00 p.m., .a resident called help upon entering room this nurse saw the resident laying on the floor with most of body in bathroom & head in room 11 near a recliner but not touching. her walker was overturned. floor & residents clothes was dry. no objects on floor room 11 overhead light was turned off. bathroom light on light off in room 9. resident had shoes on & was dressed. stated I got lost .Immediate Action Taken .new intervention close bathroom door when leaving .head to toe assessment done no bruises, swollen or broken skin seen .denies pain . The care plan, updated 12/21/16, documented, Focus .is at risk for falls .Interventions .Keep adjoining Close bathroom door at night . An incident report, dated 01/13/17, documented, .Resident was ambulating with walker up ramp into dining room and tripped. Resident hit back of head on railing causing immediate goose egg. Resident landed in sitting position. Nurse aid (sic) was present .Immediate Action Taken .Resident was assisted to sitting position .total assessment done .Resident assisted up on feet with walker .Resident to sit in chair .Level of Pain .3 .No injuries observed . The care plan, updated 01/13/17, documented, Focus .is at risk for falls .Interventions .Place tennis balls on walker . A significant change assessment, dated 02/14/17, documented the resident had a long/short term memory problem and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had exhibited other behaviors in the past one to three days, had wandered throughout the facility daily, required supervision with transfers, required limited assistance with ambulation, required limited assistance with toileting, had experienced two falls with no injury sustained and one fall with an injury sustained, and had received an antianxiety medication within the past six days. An incident report, dated 02/22/17 at 11:25 a.m., documented, .Called to room 30 where resident was lying on her back in the doorway to the hallway. Resident had on non skid socks and had walker above her trying to life (sic) herself up. Resident had just got done eating lunch and was confused on where her room was .Denies pain and discomfort at this time .Assisted resident back to her feet x 1 assist and showed where room was. No visible injuries observed at this time .Immediate Action Taken .Talked with unit manager about possibly room changing closer to dining room .Level of Pain .1 . The care plan did not address any new fall interventions to be implemented after the resident had fallen on 02/22/17 when the resident was found on the floor in another resident's room. An incident report, dated 02/22/17, .Resident was witnessed being pushed by another resident and falling to the floor. Resident landed on her bottom and braced the fall with her arms. Resident lying on floor with her arms bracing her up with walker next to her. The other resident who pushed her still denied pushing her and stated, She needed to get out of my room. She pushed me! She pushed me but was unable to tell me who .Immediate Action Taken .Seperated (sic) residents and informed the resident who pushed her that it was unacceptable to be pushing people .No injuries observed .Level of Pain .1 .Injuries Report Post Incident .Fracture .Right Upper Arm .Level of Pain .3 The care plan did not address any new fall interventions to be implemented after the resident had fallen on 02/22/17 when the resident was found on the floor in another resident's room after another resident had pushed her down. A state reported incident report, dated 02/22/17, documented, .Resident .was witnessed being pushed by another resident .falling to the floor .braced the fall with her arms .Doctor notified due to resident later not using her arm and x-ray showed fracture to humerus .order to keep arm wrapped with ace bandage .will re-evaluate safety/fall precautions .was moved off the unit to another unit . The care plan did not address any new fall interventions to be implemented after the resident had fallen on 02/22/17 when the resident was found on the floor in another resident's room after another resident had pushed her down and she had sustained a fracture to her right arm. An incident report, dated 03/01/17, documented, .(resident) is on floor upon entering room alarm had been reset off, the resident was laying on right side with right arm away from body, has an (sic) 1 in. abrasion on lower right side of head .I wanted up & slid off the bed said I hit my head on the dresser .denies pain .Immediate Action Taken .returned resident to center of bed .Add non skid strips to floor by bed . The care plan, updated 03/01/17, documented, Focus .is at risk for falls .Interventions .non skid strips to floor by bed . On 03/17/17, at 2:20 p.m., the DON was informed of the resident's falls and injuries. The DON was asked why no new fall interventions had been implemented after the resident had continued to fall. She stated, I believe my interventions were appropriate. The DON was asked if they had done a fall investigation to determine the root cause of these falls to develop the fall interventions. She stated, Yes, in the Q2 meetings. She was asked if they documented the fall investigation. She stated, We don't. On 03/22/17 at 4:27 p.m., LPN #2 was asked about the fall interventions that had been implemented for the resident to prevent her from falling. She stated they had placed a mat in her chair, grippers on the floor, and a bed alarm. On 03/23/17 at 9:30 a.m., the DON was asked if alarms prevented falls. She stated, It does not prevent falls. 2. Resident #5 had [DIAGNOSES REDACTED]. A care plan, updated 05/01/16, documented, Focus .is at risk for further falls and injury d/t hx of falls and fxs, impaired cognition, balance, ROM, bowel and bladder incontinence, potential side effects of psychotropic medications .has a behavior issue if you do not come when she hollors (sic) out as fast as she wants, she will sit herself in the floor, lean forward and fall out of chair .discussed with .and they decided they want a mattress on floor as well as bed .Goal .will have interventions in place to help reduce the risk for a serious injury related to falls . Interventions .Gripper socks to be worn .prop with pillow when in bed .Remind her to ask for help with transfers .perimeter defining mattress .Provide and make sure to place dycem in wheel chair seat .drop seat in Wheel chair .Frequent checks by staff. Fall mat in place .Toilet before and after meals .Provide Alarming floor mat to place on floor beside bed .Staff to increase frequency of observations of resident .clip alarm .when resident slides herself out of her chair it is a behavior and staff helps back into chair and nurse assesses her for injuries .Be sure call light is within reach and encourage her to use it for assistance as needed .Note: She does not (sic) and usually yells out for help, so check on her frequently .encourage her to participate in activities . A quarterly assessment, dated 11/23/16, documented the resident had a BIMS score of 10. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with transfers, required extensive assistance with locomotion on/off the unit, required extensive assistance with toilet use, required the use of a wheelchair, was always incontinent with bowel/bladder, had a [DIAGNOSES REDACTED]. seven days, and had received an antidepressant medication within the past seven days. An incident report, dated 01/23/17, documented, .CNA reported to this nurse that resident slid out of WC in dining room .CNA witnessed incident but was unable to reach resident before she slid out of the WC. Resident's chair alarm was in place and activated but did not disengage from monitor when resident slid out of chair .No injuries observed .Immediate Action Taken .Complied with resident's request and placed her back into bed . There were no new fall interventions documented, on the incident report, to be implemented to prevent further falls. The care plan did not address any new fall interventions to be implemented after the resident had fallen on 01/23/17. An incident report, dated 02/07/17, documented, .CNAs came and got this nurse saying .rolled out of bed. head-to-assessment (sic) complete. knot (sic) noted to right forehead, neuro checks implemented. S/T to right arm and right elbow noted .steri strips applied .CNA says that when he was standing in front of the bed with bed in lowest position, CNA pivoted slightly to the left to obtain w/C (sic) and resident rolled herself out of bed .Immediate Action Taken .when (sic) taken back to bed the next time, pillows propped up on left side to help prevent further rolling off the bed .when resident rolls herself out of bed it is a behavior . An incident report, dated 02/09/17, documented, .Nurse giving report to CNA's when a chair alarm was heard no sooner staff turned around to see who it was resident already in the floor in prone position head-to-toe assessment complete abrasion to left forehead noted and abrasion to bridge of nose noted .resident assisted back to chair .to w/c .chair alarm back in place, neuro checks implemented .Immediate Action Taken .Placed safety helmet on head . There were no new fall interventions documented, on the incident report, to be implemented to prevent further falls. The care plan documented the resident was to wear a helmet while up in the wheelchair, after the resident had fallen on 02/09/17 and received an abrasion to her left forehead and to the bridge of her nose. There were no new fall interventions addressed on the care plan to prevent the resident from further falls. An incident report, dated 02/19/17, documented, .this nurse and CMA were in the west hall lobby with this resident, this resident was leaning forward, resident was asked to lean back in her chair, this nurse turned around to speak to CMA, resident leaned forward and fell out of wheel chair onto floor, landing on her left side, range of motion to all extremities, good, small hematoma noted to outside corner of left eye, assisted to wheel chair .incontinent care provided, personal alarm in place, pink helmet on, non skid shoes on .Immediate Action Taken .neuro checks started .staff one on one with resident at this time . There were no new fall interventions documented, on the incident report, to be implemented to prevent further falls. The care plan documented a staff person was to provide one on one with the resident, after the resident had fallen on 02/19/17 and received a hematoma to the outside corner of her left eye. There was no documentation who was to provide the one on one, when the one on one would be provided, or how long the one on one would be provided. A significant change assessment, dated 02/21/17, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required total assistance with transfers, required total assistance with locomotion on/off the unit, required total assistance with toilet use, required the use of a wheelchair, was always incontinent with bowel/bladder, had a [DIAGNOSES REDACTED]. received an antianxiety medication within the past five days, and had received an antidepressant medication within the past six days. An incident report, dated 03/18/17, documented, DON entering dining room when resident was reaching for her sippy cup .and fell out of chair, assisted back into wheel chair .small skin tear noted to top to right hand . There were no new fall interventions documented, on the incident report, to be implemented to prevent further falls. The care plan documented staff were to ensure the resident was pushed up to the table. On 03/22/17 at 9:45 a.m., the resident was observed seated in her wheelchair at the west hall nurses' station. The resident had her helmet on her head. The resident was not engaged in any activity. She was facing forward at the nurses' counter and no staff were observed to be at the nurses' station or within view of the resident. At 4:45 p.m., CNA #9 was asked what fall interventions were in place to prevent the resident from falling. He stated she has a bed alarm, a mattress on the floor, and to keep her glasses and helmet in her chair. He stated she leans forward and a cushion was to be in her chair. He stated that sometimes pillows were used. At 4:47 p.m., the DON was asked what fall interventions were in place to prevent the resident from falling. She stated they used chair and bed alarms, they would place her at the nurses' station so she could be observed, and she was to wear a helmet. On 03/23/17 at random times the resident was observed at the nurses' station. She was seated in her wheelchair with her helmet on. She was not engaged in any activity. There were no staff observed at the nurses' station or within view of the resident. At 9:33 a.m., the administrator and the DON were informed of the resident's fall and the injuries sustained. They were asked if the resident was receiving the one on one with staff. The DON stated, No. They were asked if there were any new fall interventions implemented when the resident was falling out of her wheelchair and her bed. The DON stated, She has a behavior of pushing herself out of the chair when she wants attention. It's a behavior for her and care planned. We try to catch her and not let her do that. We try and keep her with someone at the nurses' station. At 12:30 p.m., care plan coordinator #2 was asked how the fall interventions were determined and updated to the care plans. She stated they have a team meeting in the mornings to discuss the residents and their falls. She stated a fall intervention would be determined and the intervention would be documented on the care plan. She was asked why the care plan had not been updated with new fall interventions. She stated, I do not have an answer for that. She was asked if the care plan should have been updated to include new fall interventions. She stated, Yes.

Based on interview and record review, it was determined the facility failed to acquire pain medications in a timely manner for three (#2, #3, and #6) of six sampled residents who were reviewed for pain. This resulted in actual harm for residents #2 and #6 when their pain medications were not acquired in a timely manner by the facility. The facility identified 111 residents as being on a pain management program. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3, #4, and #5 ribs. admission orders [REDACTED] ~ Tylenol 325 mg every four hours as needed for pain or fever; ~ Tylenol 500 mg every six hours as needed for pain; ~ Hydrocodone (a narcotic) 5/325 mg, every four hours as needed for moderate to severe pain; and ~ Assess for pain every shift. A fax confirmation for the admission orders [REDACTED] The Resident-Data Collection form, dated 10/09/13, documented the resident had constant, distressing pain all over; including low back, left leg, and right side. The form documented the pain was present on admission and was sharp with movement. The form documented, "See Pain Evaluation & Flow Sheet." The Pain Evaluation form, dated 10/09/13, documented the pain was caused from the fall with fractures occurring on 10/06/13. The pain was described as sore, sharp, stabbing, and increased with movement. The form documented the resident's low back pain on admission was at a four or five on a 1 to 10 scale. The worst the back pain would get was an eight. The best the pain was relieved to was rated at a one or two. The form documented the resident's left knee pain on admission was at a two or three on a one to ten scale. The worst the knee pain would get was a six. The best the pain was relieved to was pain free. The form documented the resident's right flank pain on admission was at an eight on a one to ten scale. The worst the flank pain would get was a ten. The best the pain was relieved to was at a four. The form documented the following changes in daily activities or habits: participation in activities, inability to perform ADLs, other sleep disturbances, incontinence, decreased ability to concentrate, withdrawal from activities or relationships, ability to focus/concentrate, decrease/increase in physical/social activity, and changes in mood/emotions (e.g., anger, crying, depressed, etc.). The form documented the following nonverbal signs of pain: grimacing/distorted face, frowning/scowling, moaning, gasping, screaming, cursing, strenuous or altered breathing, and/or striking out at others. The form documented the pain was relieved by medication, deep relaxation, diversional activity, and distraction. The form documented the resident's acceptable pain level was zero or no pain. The form documented the resident had Tylenol and hydrocodone available as needed for pain and was effective in relieving pain in one to two hours. The form documented, "Pain management intervention is necessary, refer to resident plan of care." The undated admission plan of care documented, "...Nursing/Diagnosis: [REDACTED]. The plan of care documented, "...Pain. Things you can do to help me: Make sure I get my routine and prn pain medication that my doctor prescribed. Monitor me for nonverbal signs of pain and discomfort such as favoring one extremity, guarding a certain body part, pulling my knees up, if I am rocking or rubbing a body part, wringing my hands or I have facial grimacing. Check back with me to make sure the pain medication worked. Assist me with repositioning for better comfort. Offer comfort measures such as warm blankets, warm towels, ROM etc. Notify my doctor if my pain worsens or is not relieved by pain medication. Monitor pain location, severity, duration, and level of relief provided by interventions. Goal: I will have reduced or relieved pain within 1 hour of the nurses interventions x30 days..." MARs, dated 10/09/13, contained no documentation the resident received either Tylenol or hydrocodone. The pharmacy delivery log, dated 10/10/13 at 1:10 a.m., documented the facility received a 31 tablet count of Tylenol 325mg and a 50 tablet count of hydrocodone 5/325mg for resident #2. The PT Evaluation & Plan of Treatment, dated 10/10/13, documented a personal history of falls, closed fracture of ribs, and a closed pelvic fracture with an onset date of 10/06/13. The evaluation documented the resident's pain at rest in his ribs and groin as intermittent, throbbing, sharp, quick, and rated at a five on a one to ten pain scale. The evaluation documented the resident's pain in his ribs and groin with movement as throbbing, sharp, quick, and rated at a six on a one to ten pain scale. The evaluation documented the pain limited the patient's functional activities, and the resident received pain medication as needed. MARs, dated 10/10/13, documented the resident received hydrocodone one time, with no time documented. The narcotic log for the hydrocodone documented the resident was first administered the medication on 10/10/13 at 9:00 p.m. Review of the clinical record revealed no documentation the resident received Tylenol. On 11/06/13 at 4:25 p.m., LPN #1 was interviewed. The LPN stated when she admitted the resident on 10/09/13, the resident had complained of a high level of pain all over. The LPN stated she informed the CMA #1 to medicate the resident for pain. The LPN was shown the MAR for October for resident #2. The MAR indicated [REDACTED]. The LPN was asked why the resident had not received any pain medication. The LPN stated she did not know but there was sometimes a delay in receiving medications from the pharmacy when a resident was admitted in the afternoon. The LPN was asked if she utilized any other pain management interventions. The LPN responded by shaking her head from side to side, "No." On 11/06/13 at 5:00 p.m., CMA #1 was interviewed. The CMA was asked if she remembered resident #2. The CMA stated, "Yes." The CMA was asked if she medicated resident #2 on 10/09/13 when he was admitted . The CMA stated, "No. We usually have to wait a long while before medications come from the pharmacy. When the resident is admitted in the afternoon, the meds usually do not come until late in the night or the next day. (Resident #2) did not have anything available the first night. I did not have anything to give him." The CMA was asked if she informed the nurse that the resident did not have anything available for pain. The CMA stated the nurse knew. On 11/07/13 at 10:25 a.m., COTA #1 was interviewed. The COTA was asked if she remembered resident #2. The COTA stated, "Yes." The COTA was asked if the resident was in pain during the evaluation on 10/10/13. The COTA stated, "Yes, he was in pain but we worked within the limits of his pain. He was very cooperative. He hurt more when standing but we would sit down when he needed. He never wanted to stop or quit therapy. He wanted afternoons to rest though." On 11/07/13 at 10:45 a.m., PTA #1 was interviewed. The PTA was asked if she recalled resident #2. The PTA stated, "Yes, a very pleasant man. Very cooperative." The PTA was asked if resident #2 complained of any pain during the evaluation on 10/10/13. The PTA stated, "(He) complained of back pain with functional things we worked on like transfers. He never wanted to quit though. If he complained of pain, we would see about changing what we were doing and go back to the task later." On 11/07/13 at 11:00 a.m., the DON was interviewed. The DON was asked when the facility had become aware of delays and/or difficulties with receiving medications from their contracted pharmacy. The DON stated, "I was not aware of any problems until now." The DON was asked if the facility had a policy to pre-medicate a resident prior to painful situations such as therapy, dressing changes, etc. The DON stated, "Nothing in writing but it is definitely a standard of practice for our nurses plus therapy works very closely with our nurses. I have never seen a therapy department communicate so well with nursing as I have here." On 11/07/13 at 2:20 p.m., the family member of resident #2 was interviewed. She stated the resident was in a lot of pain on admission to the nursing home and was told he would have to wait until the doctor had confirmed the medications before he would be able to receive any pain medication. The family member was asked if the resident received any pain medication the first day. The family member stated the resident did not receive pain medication the first night and had complained to her the next morning that he had not received pain medication, had been unable to sleep, and was still in pain. The family member was asked if the resident was given pain medication prior to therapy. The family member stated she did not recall the facility ever medicating the resident for pain prior to therapy. She stated the resident hurt during therapy but would not stop because he wanted to get stronger so he could go home. The family member stated, "You could tell any of them he was hurting and it did not matter." 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]. The Nurse's Notes, dated 10/30/13 at 7:35 p.m., documented, "Res arrived via transport van in w/c escorted by transport personnel. Res admitted to SNF for PT, OT, and ST therapy eval & tx and nursing rehab and wound care...Res states (no) c/o pain but grimacing & groaning c movement...Mult Dk purple bruises noted to BUE's. Wound/open area noted to R heel c dressing CDI. Wound/open area to L heel c dressing CDI. Sacral wound/open area noted c dressing CDI..." At 9:15 p.m. the Nurse's Note documented, "Assisted res c repositioning and distraction measures to assist c alleviation from c/o pain. (Doctor) aware of res condition and will review issues of pain tomorrow when here." The October MAR for resident #6 documented the resident did not receive Tylenol or oxycodone as ordered for pain on 10/30/13. The pharmacy delivery log, dated 10/31/13 at 12:15 a.m., documented the facility received a 30 tablet count of oxycodone 10/325mg for resident #6. The narcotic log for oxycodone 10/325mg for resident #6 documented the resident was first medicated on 11/01/13 at 12:00 p.m. and again at 5:00 p.m. The admission assessment, dated 11/01/13, documented the resident was severely cognitively impaired and experienced occasional moderate pain. On 11/07/13 at 6:10 p.m., LPN #1 was interviewed in the presence of the DON. The LPN was asked why she had not medicated resident #6 for pain on 10/30/13 when she had documented she had utilized distraction and repositioning for his complaint of pain. The LPN stated the order had been faxed to the pharmacy but had not been received. She stated she contacted the pharmacy to try to expedite the delivery. The LPN was asked if that was documented. The LPN stated, "Probably not." The LPN was asked if she contacted the DON or physician regarding the delay in the resident receiving pain medication. The LPN stated she contacted the physician regarding the admission and condition of the resident. On 11/07/13 at 6:15 p.m., the DON was interviewed. The DON was asked why a nurse would not give an ordered pain medication when the resident complained of pain. The DON stated, "I can not answer that." The DON was asked why the resident did not receive his pain medication when it arrived in the facility. The DON stated, "Our documentation does not say he is in pain on the 31st. There is no documentation." The DON was asked how long the pharmacy had to deliver medications. The DON stated, "A reasonable amount of time." The DON was asked to define what she meant by a reasonable amount of time. The DON stated, "(that is) a hard thing." When asked for further clarification, the DON did not respond. 3. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]. MARs, dated 10/2013, documented the resident received Neurontin 100mg at bedtime on 10/22/13 through 10/25/13 and 10/27/13 through 10/31/13. There was no documentation to show the resident received Neurontin on 10/26/13. MARs, dated 11/04/13, contained no documentation to show the resident received Neurontin. The entry for the Neurontin was circled. An entry on the back of the MAR, dated dated 11/04/13 at 9:00 p.m., documented, "...Neurontin 100mg med on order. Notified nurse..." On 11/07/13 at 11:03 a.m., the DON was interviewed. The DON was asked what it meant when the nurse or CMA circled an entry on the MAR. The DON stated, "If circled, it has not been given." The DON was shown copies of the MAR for resident #3 for October and November and asked if resident #3 had any Neurontin available on 10/26/13 or 11/04/13. The DON stated the medication was on order and was not available in the building. The DON was asked what the policy and procedure was for ordering medications for residents. The DON stated the CMA was to order medications on Mondays and Thursdays and as needed. The DON stated that if the medication was not in the building, the CMA was to notify the nurse manager, DON, and physician.

Based on interview and record review, it was determined the facility failed to provide pain medications as ordered by the physician for three (#2, #3, and #6) of six sampled residents who were reviewed for pain. This resulted in actual harm for residents #2 and #6 when they did not receive pain medications when they were showing signs and symptoms of pain. The facility identified 111 residents as being on a pain management program. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3, #4, and #5 ribs. admission orders [REDACTED] ~ Tylenol 325 mg every four hours as needed for pain or fever; ~ Tylenol 500 mg every six hours as needed for pain; ~ [MEDICATION NAME] (a narcotic) 5/325 mg, every four hours as needed for moderate to severe pain; and ~ Assess for pain every shift. A fax confirmation for the admission orders [REDACTED] The Resident-Data Collection form, dated 10/09/13, documented the resident had constant, distressing pain all over; including low back, left leg, and right side. The form documented the pain was present on admission and was sharp with movement. The form documented, "See Pain Evaluation & Flow Sheet." The Pain Evaluation form, dated 10/09/13, documented the pain was caused from the fall with fractures occurring on 10/06/13. The pain was described as sore, sharp, stabbing, and increased with movement. The form documented the resident's low back pain on admission was at a four or five on a one to ten scale. The worst the back pain would get was an eight. The best the pain was relieved to was rated at a one or two. The form documented the resident's left knee pain on admission was at a two or three on a one to ten scale. The worst the knee pain would get was a six. The best the pain was relieved to was pain free. The form documented the resident's right flank pain on admission was at an eight on a one to ten scale. The worst the flank pain would get was a ten. The best the pain was relieved to was at a four. The form documented the following changes in daily activities or habits: participation in activities, inability to perform ADLs, other sleep disturbances, incontinence, decreased ability to concentrate, withdrawal from activities or relationships, ability to focus/concentrate, decrease/increase in physical/social activity, and changes in mood/emotions (e.g., anger, crying, depressed, etc.). The form documented the following nonverbal signs of pain: grimacing/distorted face, frowning/scowling, moaning, gasping, screaming, cursing, strenuous or altered breathing, and/or striking out at others. The form documented the pain was relieved by medication, deep relaxation, diversional activity, and distraction. The form documented the resident's acceptable pain level was zero or no pain. The form documented the resident had Tylenol and [MEDICATION NAME] available as needed for pain and was effective in relieving pain in one to two hours. The form documented, "Pain management intervention is necessary, refer to resident plan of care." The undated admission plan of care documented, "...Nursing/Diagnosis: [REDACTED]. The plan of care documented, "...Pain. Things you can do to help me: Make sure I get my routine and prn pain medication that my doctor prescribed. Monitor me for nonverbal signs of pain and discomfort such as favoring one extremity, guarding a certain body part, pulling my knees up, if I am rocking or rubbing a body part, wringing my hands or I have facial grimacing. Check back with me to make sure the pain medication worked. Assist me with repositioning for better comfort. Offer comfort measures such as warm blankets, warm towels, ROM etc. Notify my doctor if my pain worsens or is not relieved by pain medication. Monitor pain location, severity, duration, and level of relief provided by interventions. Goal: I will have reduced or relieved pain within 1 hour of the nurses interventions x 30 days..." MARs, dated 10/09/13, contained no documentation the resident received either Tylenol or [MEDICATION NAME]. The pharmacy delivery log, dated 10/10/13 at 1:10 a.m., documented the facility received a 31 tablet count of Tylenol 325mg and a 50 tablet count of [MEDICATION NAME] 5/325mg for resident #2. The PT Evaluation & Plan of Treatment, dated 10/10/13, documented a personal history of falls, closed fracture of ribs, and a closed pelvic fracture with an onset date of 10/06/13. The evaluation documented the resident's pain at rest in his ribs and groin as intermittent, throbbing, sharp, quick, and rated at a five on a one to ten pain scale. The evaluation documented the resident's pain in his ribs and groin with movement as throbbing, sharp, quick, and rated at a six on a one to ten pain scale. The evaluation documented the pain limited the patient's functional activities, and the resident received pain medication as needed. MARs, dated 10/10/13, documented the resident received [MEDICATION NAME] one time, with no time documented. The narcotic log for the [MEDICATION NAME] documented the resident was first administered the medication on 10/10/13 at 9:00 p.m. Review of the clinical record revealed no documentation the resident received Tylenol. On 11/06/13 at 4:25 p.m., LPN #1 was interviewed. The LPN stated when she admitted the resident on 10/09/13, the resident had complained of a high level of pain all over. The LPN stated she informed the CMA #1 to medicate the resident for pain. The LPN was shown the MAR for October for resident #2. The MAR indicated [REDACTED]. The LPN was asked why the resident had not received any pain medication. The LPN stated she did not know but there was sometimes a delay in receiving medications from the pharmacy when a resident was admitted in the afternoon. The LPN was asked if she utilized any other pain management interventions. The LPN responded by shaking her head from side to side, "No." On 11/06/13 at 5:00 p.m., CMA #1 was interviewed. The CMA was asked if she remembered resident #2. The CMA stated, "Yes." The CMA was asked if she medicated resident #2 on 10/09/13 when he was admitted . The CMA stated, "No. We usually have to wait a long while before medications come from the pharmacy. When the resident is admitted in the afternoon, the meds usually do not come until late in the night or the next day. (Resident #2) did not have anything available the first night. I did not have anything to give him." The CMA was asked if she informed the nurse that the resident did not have anything available for pain. The CMA stated the nurse knew. On 11/07/13 at 10:25 a.m., COTA #1 was interviewed. The COTA was asked if she remembered resident #2. The COTA stated, "Yes." The COTA was asked if the resident was in pain during the evaluation on 10/10/13. The COTA stated, "Yes, he was in pain but we worked within the limits of his pain. He was very cooperative. He hurt more when standing but we would sit down when he needed. He never wanted to stop or quit therapy. He wanted afternoons to rest though." On 11/07/13 at 10:45 a.m., PTA #1 was interviewed. The PTA was asked if she recalled resident #2. The PTA stated, "Yes, a very pleasant man. Very cooperative." The PTA was asked if resident #2 complained of any pain during the evaluation on 10/10/13. The PTA stated, "(He) complained of back pain with functional things we worked on like transfers. He never wanted to quit though. If he complained of pain, we would see about changing what we were doing and go back to the task later." On 11/07/13 at 11:00 a.m., the DON was interviewed. The DON was asked when the facility had become aware of delays and/or difficulties with receiving medications from their contracted pharmacy. The DON stated, "I was not aware of any problems until now." The DON was asked if the facility had a policy to pre-medicate a resident prior to painful situations such as therapy, dressing changes, etc. The DON stated, "Nothing in writing but it is definitely a standard of practice for our nurses plus therapy works very closely with our nurses. I have never seen a therapy department communicate so well with nursing as I have here." On 11/07/13 at 2:20 p.m., the family member of resident #2 was interviewed. She stated the resident was in a lot of pain on admission to the nursing home and was told he would have to wait until the doctor had confirmed the medications before he would be able to receive any pain medication. The family member was asked if the resident received any pain medication the first day. The family member stated the resident did not receive pain medication the first night and had complained to her the next morning that he had not received pain medication, had been unable to sleep, and was still in pain. The family member was asked if the resident was given pain medication prior to therapy. The family member stated she did not recall the facility ever medicating the resident for pain prior to therapy. She stated the resident hurt during therapy but would not stop because he wanted to get stronger so he could go home. The family member stated, "You could tell any of them he was hurting and it did not matter." 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]. The Nurse's Notes, dated 10/30/13 at 7:35 p.m., documented, "Res arrived via transport van in w/c escorted by transport personnel. Res admitted to SNF for PT, OT, and ST therapy eval & tx and nursing rehab and wound care...Res states (no) c/o pain but grimacing & groaning c movement...Mult Dk purple bruises noted to BUE's. Wound/open area noted to R heel c dressing CDI. Wound/open area to L heel c dressing CDI. Sacral wound/open area noted c dressing CDI..." At 9:15 p.m. the Nurse's Note documented, "Assisted res c repositioning and distraction measures to assist c alleviation from c/o pain. (Doctor) aware of res condition and will review issues of pain tomorrow when here." The October MAR for resident #6 documented the resident did not receive Tylenol or [MEDICATION NAME] as ordered for pain on 10/30/13. The pharmacy delivery log, dated 10/31/13 at 12:15 a.m., documented the facility received a 30 tablet count of [MEDICATION NAME] 10/325mg for resident #6. The narcotic log for [MEDICATION NAME] 10/325mg for resident #6 documented the resident was first medicated on 11/01/13 at 12:00 p.m. and again at 5:00 p.m. The admission assessment, dated 11/01/13, documented the resident was severely cognitively impaired and experienced occasional moderate pain. On 11/07/13 at 6:10 p.m., LPN #1 was interviewed in the presence of the DON. The LPN was asked why she had not medicated resident #6 for pain on 10/30/13 when she had documented she had utilized distraction and repositioning for his complaint of pain. The LPN stated the order had been faxed to the pharmacy but had not been received. She stated she contacted the pharmacy to try to expedite the delivery. The LPN was asked if that was documented. The LPN stated, "Probably not." The LPN was asked if she contacted the DON or physician regarding the delay in the resident receiving pain medication. The LPN stated she contacted the physician regarding the admission and condition of the resident. On 11/07/13 at 6:15 p.m., the DON was interviewed. The DON was asked why a nurse would not give an ordered pain medication when the resident complained of pain. The DON stated, "I can not answer that." The DON was asked why the resident did not receive his pain medication when it arrived in the facility. The DON stated, "Our documentation does not say he is in pain on the 31st. There is no documentation." The DON was asked how long the pharmacy had to deliver medications. The DON stated, "A reasonable amount of time." The DON was asked to define what she meant by a reasonable amount of time. The DON stated, "(that is) a hard thing." When asked for further clarification, the DON did not respond. 3. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]. MARs, dated 10/2013, documented the resident received [MEDICATION NAME] 100mg at bedtime on 10/22/13 through 10/25/13 and 10/27/13 through 10/31/13. There was no documentation to show the resident received [MEDICATION NAME] on 10/26/13. MARs, dated 11/04/13, contained no documentation to show the resident received [MEDICATION NAME]. The entry for the [MEDICATION NAME] was circled. An entry on the back of the MAR, dated dated 11/04/13 at 9:00 p.m., documented, "[MEDICATION NAME] 100mg med on order. Notified nurse..." On 11/07/13 at 11:03 a.m., the DON was interviewed. The DON was asked what it meant when the nurse or CMA circled an entry on the MAR. The DON stated, "If circled, it has not been given." The DON was shown copies of the MAR for resident #3 for October and November and asked if resident #3 had any [MEDICATION NAME] available on 10/26/13 or 11/04/13. The DON stated the medication was on order and was not available in the building. The DON was asked what the policy and procedure was for ordering medications for residents. The DON stated the CMA was to order medications on Mondays and Thursdays and as needed. The DON stated that if the medication was not in the building, the CMA was to notify the nurse manager, DON, and physician.