Every finding on record at Barnsdall Nursing Home

Based on observation and interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for two ( #102 and #104) of three sampled residents reviewed for homelike environment. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 28 residents resided in the facility. Findings: 1. On 08/15/23 at 2:55 p.m., Resident #102 was observed in their room. They stated, It's too cold. I am freezing in this room. Resident #102 stated they had to get under covers to nap. They were observed wearing a jacket. The thermostat across the hall from the residents room read 74 degrees. On 08/16/23 at 8:44 a.m., Resident #102 was observed in their room. They were observed wearing a jacket and stated it was freezing in the room. The ambient air temperature was measured at 67 degrees. On 08/16/23 at 8:54 a.m., the maintenance supervisor was asked what the policy was for maintaining comfortable air temperature. They stated they checked air temperatures daily and tried to keep them between 70 and 80 degrees. The maintenance supervisor was taken to Resident #102's room and informed the ambient air temperature was 67 degrees. They stated the thermostat read 74 degrees. The maintenance supervisor was asked if 67 degrees would be considered a comfortable air temperature for residents. They stated, No. 2. On 08/16/23 at 10:11 a.m., Resident #104's room was observed. There was an accumulation of dust and debris observed on the floor behind the door, under the bed, and on the baseboard. On 08/16/23 at 10:16 a.m., the housekeeper was asked what the policy was for ensuring a clean, comfortable, homelike environment. They stated they had schedules for cleaning rooms. The housekeeper stated they swept and mopped residents' rooms daily. The housekeeper was shown the dust and debris in Resident #104's room behind the door and behind the bed. They stated, Yes, we are working on deep cleaning rooms. The housekeeper was asked how often they pulled the beds out away from the wall to clean. They stated they cleaned under the beds daily. The housekeeper stated, As far as getting behind the bed, we do the best we can.

Based on record review and interview, the facility failed to ensure care plan interventions were put in place after falls for one ( #21) of 14 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 28 residents resided in the facility. Findings: A Falls policy, dated 05/26/21, read in part, .All falls are to be care planned .within 72 hours . Resident #21 had diagnoses which included chronic diastolic (congestive) heart failure, HTN, COPD, and anxiety. An annual assessment, dated 06/03/23, documented Resident #21 required extensive assistance of one for bed mobility and transfers. The assessment documented Resident #21 had one fall with injury. BIMS 08 A Care Plan, last revised 07/08/23, documented Resident #21 had seven falls from 01/22/23 through 07/08/23. The resident sustained injuries with three of the falls. There were no new interventions implemented after each fall. On 08/18/23 at 10:28 a.m., the DON was asked if Resident #21 was at risk for falls. They stated, Yes. The DON was asked what interventions had been put in place to prevent falls. They stated the resident was using a wheelchair and had a fall mat in their room. The DON was shown Resident #21's care plan and was asked what new interventions had been put in place after each of the seven falls. They stated, I don't see any. The DON was asked what the policy was for updating the care plan after falls. They stated after the incidents were reviewed, the MDS coordinator would update the care plan and put interventions in place.

Based on record review and interview, the facility failed to ensure medications were available and administered as orderered for three (#6, 12, and #22) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 28 residents resided in the facility. Findings: 1. Resident #6 had diagnoses which included pain and anxiety. A Resident Assessment, dated 05/18/23, documented Resident #6 had pain and facial grimacing. A Physician's Order, dated 03/08/22, documented hydrocodone/acetaminophen 7.5/325 mg one tablet daily at bedtime for pain. A Physician's Order, dated 04/11/23, documented Lorazepam intensol 2 mg/ml, give 0.5 ml daily at 3:00 p.m. for anxiety. A Physician's Order, dated 06/22/23, documented Lorazepam intensol 2 mg/ml, give 0.5 ml every two hours as needed for anxiety. A June MAR, documented the following: a. Hydrocodone/acetaminophen 7/5/325 mg had been circled on 06/20 and 06/21/23., and b. Lorazepam intensol 2 mg/ml had been circled twice on 06/19, twice on 06/20, twice on 06/21, and once on 06/22/23. The MAR documented the medications were unavailable and awaiting pharmacy. On 08/18/23 at 9:25 a.m., the DON was asked what the policy was for ensuring medications were available and administered as ordered. They stated staff checked the five rights, looked at the MAR to pull medications, did not pop a medication without clicking it in the MAR. and compared the MAR to the medication card incase there may be two different orders. The DON was made aware of Resident #6's Hydrocodone/Acetaminophen and Lorazepam intensol unavailable. They stated they had been aware of a problem with the company changing pharmacies. The DON stated, It was a mess. 2. Resident #12 had diagnoses which included atrial fibrillation, hyperlipidemia, insomnia, delusional disorder, htpertensiondry eyes, and pain. Physician's Orders, documented the following: a. Eliquis 2.5 mg tablet twice daily, 03/04/22, b. Atorvastatin 40 mg tablet once daily, 03/09/22, c. Melatonin 10 mg tablet daily, 04/05/22, d. Refresh eye drops one drop to each eye twice daily, 10/05/22, and e. Hydrocodone/Acetaminophen 7.5/325 mg one tablet three times daily, 12/01/22. A June MAR, documented the following: a. Eliquis was circled on 06/12, 06/18, and on 06/19/23 for the 9:00 p.m. dose, b. Atorvastatin was circled on 06/18/23, c. Melatonin was circled on 06/18/23, d. Refresh was circled on 06/18/23 for the 9:00 p.m. dose, and e. Hydrocodone/Acetaminophen was circled on 06/18/23 for the 9:00 p.m. dose. The MAR documented the medications were unavailable, waiting on pharmacy, or held by the nurse. On 08/17/23 at 10:29 a.m., LPN #2 was asked what the policy was for administering medications. They stated per physician orders. LPN #2 was asked how staff ensured residents received their medications as ordered by the physician. They stated staff would triple check names, medications, and dosage. On 08/17/23 at 10:35 a.m., CMA #1 was asked what the policy was for ordering and re-ordering medications. They stated most of the medications had a re-order sticker on them, they would put the sticker on the re-order sheet, and fax it to the pharmacy. CMA #1 was shown the June MAR and was asked if the medications had been administered as ordered. CMA #1 stated the hospice had switched pharmacies and that was likely what happened. 3. Resident #22 had diagnoses which included neuromuscular disfunction of the bladder, UTI, Cerebral Palsy, and anxiety disorder. Physician's Orders, documented the following: a. Xanax 0.5 mg tablet one at bedtime, 02/08/23, b. Baclofen 10 mg one tablet four times daily, 02/15/23, c. Pyridium 100 mg one table three times daily for seven days, 08/12/23, and d. Ciprofloxacin 500 mg one tablet every 12 hours for 10 days, 08/13/23. An August MAR, documented the following: a. Xanax was circled on 08/15/23, b. Baclofen was circled on 08/01, 08/02, 08/03, and 08/04/23 at the 11:00 p.m. dose, 08/10 and 08/14 at the 6:00 p.m. dose, c. Pyridium was circled three times on 08/01, once on 08/02, and twice on 08/14/23, and d. Ciprofloxacin was circled on 08/14/23 at 9:00 p.m. The MAR documented the medications were awaiting delivery from pharmacy, resident sleeping, and unknown if evening medication was given. On 08/17/23 at 10:35 a.m., CMA #1 was shown the August 2023 MARs. They stated they were waiting for hard script from the doctor for Xanax for the missed dose. CMA #1 stated, with the Baclofen, the CMA on the evening shift was new. They were asked if Resident #22 had a physician's order to hold medications if they were sleeping. CMA #1 stated, No. On 08/17/23 at 10:59 a.m., the DON was made aware of the above medications not administered or not available. 46216 Resident #22 FTag Initiation 08/16/23 12:47 PM DX: cerebral palsy, anxiety, recurrent depressive disorders, supraventricular tachycardia, palpitations, generalized osteoarthritis , obstructive sleep apnea, vit d deficiency, seasonal allergic rhinitis, GERD physicians orders: singulair tab 10 mg claritin cap 10 mg protonix tab 40mg vit d3 1000 unit carvedilol tab 12.5 mg naproxen tab 500 mg alprazolam tab 1 mg xananx tab 0.5 mg cephalexin 250mg give 1 cap daily for prophylaxis quarterly assessment BIMS 04 no behaviors bed mobility 4/2 transfers 4/2 walking 8/8 locomotion 1/1 dressing 4/4 eating 1/1 toilet use 4/2 personal hygiene bathing 4/2 always incontinent of bowel and bladder no antibiotic use significant change assessment 8/16/22 bed mobility 3/3 transfers 3/3 walking 8/8 transfers 3/2 dressing 3/2 eating 1/1 toilet use 3/3 personal hygiene 3/2 bathing 8/1 always incontinent of bowel and bladder no antibiotics June 2023 antibiotic orders: cephalexin 500 mg give 1 tablet po bidx7 days for UTI - 6/5/23 - 6/13/23 dc'd 6/8/23 cipro 500 mg q 12 hours po x 10 days 6/9/23 -6/18/23 for uti dc'd 6/9/23 ciprofloxacin hydrochloride 500mg give 1 tablet q 12 hours routinely for 10 days 6/9/23 - 6/19/23 for uti dc'd 6/19/23 amoxicillian/clavulanate potassium tab 875-125 mg administer one tab po q 12 hours times 5 days for pneumonia 6/19/23 - 6/23/23 dc date 6/25/23 azithromycin tab 250 mg administer one tab po q daily for 4 days dx upper respiratory infection levofloxacin 500 mg give 1 tab po daily for uti 6/24/23 - 6/30/23 dc'd 7/2/23 July and July 2023 antibiotic orders: cephalexin cap 250 mg give one cap daily for prophylaxis of UTI 7/1/23 no stop date

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer treatment was provided per physician orders for one ( #12) of one sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 08/15/23, documented one resident had a pressure ulcer. Findings: Resident #12 had diagnoses which included pressure ulcer to the right outer foot. A Physician's Order, dated 08/02/23, documented to apply medihoney to the right outer foot pressure ulcer. On 08/16/23 at 9:22 a.m., LPN #1 was observed to provide wound care to Resident #12's right outer foot pressure ulcer. LPN #1 applied hydrogel to the wound bed. On 08/17/23 at 10:29 p.m., LPN #2 was asked what the policy was for providing wound care. They stated, According to the orders. LPN #2 was asked how they ensured staff followed physician orders for wound care. They stated they read the orders every time before providing the treatment. LPN #2 was asked what Resident #12's order was for wound care to the right outer foot pressure ulcer. They stated it was for wound honey. LPN #2 was informed of the above wound care observation.

Based on interview and record review, it was determined the facility failed to ensure a comprehensive care plan had been developed for six (#6, #7, #10, #12, #17, #21) of 11 sampled residents whose care plans were reviewed. This had the potential to affect all 25 residents who resided in the facility. Findings: An undated facility policy titled, Care Plan Guidelines, documented: .In long ter [Sic] care facilities, the care plan is the basis of the work routine. When properly utilized, it provides a guideline for daily care which can be implemented by nursing, dietary, activity, social staffs .Approaches .Approaches are actions taken by the staff to achieve the foal [Sic] and resolve the problem. Approaches should be worded so that the staff knows the exact action to take . An undated facility policy titled, Implementation of Care Plan Policy, documented: .The interdisciplinary team shall assist in developing quantifiable objectives for the highest level of functioning that the resident may be expected to attain based on the comprehensive assessment . 1. Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/02/21, documented the resident was moderately impaired in cognition, rejected care one to three days during the seven day look back period, and required a walker for mobility. The assessment documented the resident was independent in most ADL but required extensive assistance with one person physical assist for personal hygiene and bathing. The assessment documented the resident had been administered an antipsychotic for seven days during the seven day look back period. The facility care plan, dated 03/23/21, documented, .Problem .taking [MEDICATION(S)] 0.25 mg po bid for mood. He is at risk for adverse side effects of this medication . Goal .I wish for my [CONDITION(S)] medications to work properly without any side effects to their respective diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Approach .Monitor me for adverse side effects using the monthly behavior monitoring flowsheet . A physician order, dated May 2021, documented, [MEDICATION(S)] Tab 0.25 mg Give one tab by mouth twice a day .Delusional disorders . The care plan had not included what side effects staff should be aware of when care was provided. 2. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive assessment, dated 03/25/21, documented the resident's cognition was intact, utilized a wheelchair for mobility, and required supervision for ADLs. A physician order, dated 03/25/21, documented, [MEDICATION(S)] 2 mg/ml give 0.25 ml sublingual (SL) every 2 hours as needed (PRN) for dyspnea and severe anxiety (review in 90 days). A care plan, dated 04/11/21, had not documented the resident's [MEDICATION(S)] medication or list any side effects or interventions. 3. Resident #10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 05/02/21, documented the resident was moderately impaired in cognition, had no behaviors, required limited assistance with ADLs (activities of daily living), and required a walker for mobility. A physician order, dated May 2021, documented, .[MEDICATION(S)] Tab(s) 5 MG Give 1 tablet PO BID .Anxiety disorder . A review of the MAR (Medication Administration Record), dated May 2021, revealed documentation of [MEDICATION(S)] 5mg administered twice daily. The undated care plan for psychoactive medication, documented, .Problem .started on [MEDICATION(S)] 5mg BID r/t anxiety. [MEDICATION(S)] has potential for adverse effects . Goal .Resident will not have side effects r/t taking [MEDICATION(S)] . Interventions .Resident will be monitored for side effects via the behavior book charting . The care plan had not included what side effects staff should be aware of when providing care to the resident. 4. Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 02/05/21, documented the resident was cognitively intact, ambulatory, and independent in all ADLs. The assessment documented the resident had been administered an antidepressant seven days of the seven day look back period. The facility care plan, dated 03/09/21, documented, .Problem .taking [MEDICATION(S)] 100 mg daily .He is at risk of adverse side effects .Goal .I wish for my [CONDITION(S)] medications to work properly without any side effects The possible adverse side effects staff should observe for had not been provided in the care plan. Physician orders, dated May 2021, documented the following: ~Sertraline HCL Tabs 50 mg administer one tab by mouth every day for anxiety disorder. On 05/10/21 at 3:00 p.m., the ADON was asked why the possible adverse side effects were not listed so staff would know what to observe for. She stated, Would you have to list them all. 5. Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 02/18/21, documented the resident was cognitively intact, independent with ADLs, utilized a walker for mobility, had no behaviors, and received an antidepressant medication seven days of the seven day look back period. The facility care plan, dated 03/09/21, documented, .Problem .currently taking .[MEDICATION(S)] 60mg .[MEDICATION(S)] 20mg .He is at risk for adverse side effects from these medications . Goal .I wish for my [CONDITION(S)] medications to work properly without any side effects to their respective diagnosis . Approach .Monitor me for adverse side effects using the monthly behavior monitoring flowsheet . A physician order, dated May 2021, documented, .[MEDICATION(S)] [MEDICATION(S)] Cap(s) 10 MG Administer one tablet po once daily .Major depressive disorder . [MEDICATION(S)] [MEDICATION(S)] Cap(s) 60 MG Administer one cap po BID .Major depressive disorder . The care plan had not included what side effects staff should be aware of when providing care to the resident. 6. Resident #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive assessment, dated 03/16/21, documented the resident's cognition was intact, utilized a walker for mobility, and required one person assist with ADLs. A physician order, dated 03/16/21, documented [MEDICATION(S)] 10 mg, administer one tablet every eight hours as needed for agitation and anxiousness. A care plan, dated 03/30/21, had not documented the resident's [MEDICATION(S)] medication or list any side effects or interventions. On 05/10/21 at 3:48 p.m., the ADON was asked who was responsible for updating care plans. She stated she was. She was asked how often care plans were updated. She stated, Quarterly. She was asked what the process for updating care plans was if an event occurred before the quarterly update. She stated she wanted to train the LPNs to update the care plans as needed but had not had the opportunity to implement that training.

Based on interview and record review, it was determined the facility failed to update/revise a care plan to reflect their current status related to pressure ulcers for one (#13) of one sampled resident whose care plans were reviewed. The facility census and condition identified two residents with pressure ulcers who resided in the facility. Findings: Resident #13 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 11/11/20, documented, the resident's cognition was severely impaired and required extensive assistance with bed mobility, transfers, personal hygiene and bathing. The assessment documented the resident was high risk for developing a pressure ulcer, utilized a wheelchair for mobility, and was incontinent of bowel and bladder. The care plan, dated 03/09/21, documented the resident required extensive assistance for activities of daily living, and was low risk for pressure wounds. Interventions included to turn and reposition every two hours and as needed, inspect skin during baths for any sign of breakdown and report immediately to the nurse. Physician orders, dated April 2021, documented, .Right second digit, soak daily, spray with wound cleanser, pat dry, apply [MEDICATION(S)] ointment, change daily . On 05/02/21 the wound measured 0.5 cm in length, 0.5 cm in width, and 0.25 cm in depth. No documentation was found to indicate the resident had acquired a pressure wound to the right second toe. On 05/10/21 at 3:45 p.m., the ADON was asked who was responsible for updating care plans. She stated she was. She was asked how often care plans were updated. She stated, Quarterly. She was asked what the process was for updating care plans if something occurred before the quarterly update was due. She stated she was planning to teach the licensed practical nurses to update the care plans. She stated when an event occurred that should be included on the care plans.

Based on interview and record review, it was determined the facility failed to provide sufficient nurse staffing related to no full time DON and/or RN at least eight consecutive hours a day, seven days a week. The facility identified 25 residents who resided in the facility. Findings: On 05/03/21 at 10:10 a.m., during entrance conference the administrator was asked if the facility had a full time DON. He stated, No, not full time. He stated they have been without a full time RN since before March 2021. He was asked if the facility had an RN at least eight consecutive hours a day, seven days a week. He stated, Not everyday. He was asked if the facility had any nursing waivers. He stated no. Staffing was reviewed for March, April, and May 2021. The review revealed the facility had been without an RN on the following days: ~Sunday, 03/14/21; ~Friday and Saturday, 04/02/21 and 04/03/21; ~Sunday and Monday, 04/04/21 and 04/05/21; ~Friday and Saturday, 04/09/21 and 04/10/21; ~Monday, 04/12/21; ~Wednesday, 04/14/21; ~Monday, 04/19/21; ~Friday and Saturday, 04/30/21 and 05/01/21; ~Sunday, 05/02/21; and ~Friday and Saturday, 05/07/21 and 05/08/21. On 05/10/21 at 3:00 p.m., the ADON was asked if the facility had a full time DON. She stated no. She was asked if the facility had an RN eight consecutive hours a day, seven days a week. She stated no not everyday. She stated they were trying to hire an RN.

Based on interview and record review, it was determined the facility failed to utilize a Registered Nurse at least eight consecutive hours a day, seven days a week. The facility identified 25 residents who resided in the facility. Findings: On 05/03/21 at 10:10 a.m., during entrance conference the administrator was asked if the facility had a full time DON. He stated, No, not full time. He stated they have been without a full time RN since before March 2021. He was asked if the facility had any nursing waivers. He stated no. Staffing was reviewed for March, April, and May 2021. The review revealed the facility had been without an RN on the following days: ~Sunday, 03/14/21; ~Friday and Saturday, 04/02/21 and 04/03/21; ~Sunday and Monday, 04/04/21 and 04/05/21; ~Friday and Saturday, 04/09/21 and 04/10/21; ~Monday, 04/12/21; ~Wednesday, 04/14/21; ~Monday, 04/19/21; ~Friday and Saturday, 04/30/21 and 05/01/21; ~Sunday, 05/02/21; and ~Friday and Saturday, 05/07/21 and 05/08/21. On 05/10/21 at 3:00 p.m., the ADON was asked if the facility had a full time DON. She stated no. She was asked if the facility had an RN eight consecutive hours a day, seven days a week. She stated no not everyday. She stated they were trying to hire an RN.

Based on interview and record review, it was determined the facility failed to ensure a medication regimen review had been completed at least monthly by the consulting pharmacist for one (#12) of five sampled residents whose records were reviewed for unnecessary medications. The facility census and condition identified 15 residents who were administered a psychoactive medication. Findings: Resident #12 was admitted to the facility with diagnoses which included diabetes mellitus, anxiety disorder, major depressive disorder, [CONDITION(S)], and [CONDITION(S)]. Monthly medication regimen review were as follows: ~05/2020 Not provided; ~06/2020 Not provided; ~07/13/20 Documented the resident was on [MEDICATION(S)] SR 150 mg by mouth twice daily. For moderate to severe hepatic function, a max of 100 mg SR or 150 mg SR QOD is recommended. Reminder that reordering a CMP could confirm if the elevations in liver enzymes were transient or persistent. The physician agreed and documented, Repeat Chem 14. No response from the physician regarding the medication dose change recommended; ~08/2020 Not provided; ~09/2020 Recommended [MEDICATION(S)] be decreased to 50 mg. The physician agreed; ~10/2020 Recommended to decrease [MEDICATION(S)] to SR 100 mg bid. The physician agreed; ~11/2020 Not provided; ~12/2020 Not provided; ~01/2021 No recommendations; ~02/2021 No recommendations; and ~03/2021 No recommendations. Medication regimen reviews for May, June, August, November, and December 2020 had not been provided by end of survey. An annual assessment, dated 02/05/21, documented the resident was cognitively intact, was ambulatory, and independent in all ADLs. The assessment documented the resident had been administered an antidepressant seven days of the seven day look back period. The physician orders, dated May 2021, documented the following: ~[MEDICATION(S)] HCL Tabs 50 mg administer one tab by mouth every day for anxiety disorder; and ~[MEDICATION(S)] [MEDICATION(S)] ER Tabs 150 mg give one tab by mouth twice daily for major depressive disorder. On 05/10/21 at 3:00 p.m., the ADON was asked to provide the missing medication regimen reviews. She returned and said she could not find any of the missing medication regimen reviews that had been requested for resident #12.

Based on interview and record review, it was determined the facility failed to: ~Ensure as needed anti-anxiety medications were not ordered for more than 14 days without documentation of a clinical rationale for two (#7 and #21) of five sampled residents whose records were reviewed for unnecessary medications; and ~Implement a dose reduction of a [CONDITION(S)] medication as ordered by the physician for one (#17) of five sampled residents who were reviewed for unnecessary medications. The facility identified 15 residents who received [CONDITION(S)] medication and four residents who had [CONDITION(S)] medication ordered to be administered as needed. Findings: An undated facility policy titled, Anxiolytic/Sedative Drugs documented: .The reason for the medication is documented in the resident's medical record and included in the resident's care plan .The continued need for the anxiolytic/sedative medication shall be documented in the resident's medical record . A facility policy titled, Documentation and Communication of Consultant Pharmacist Recommendations, dated April 2018, documented: .The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion .Recommendations are acted upon and documented by the facility staff and/or the prescriber . 1. Resident #7 was admitted with diagnoses which included [CONDITION(S)], major depressive disorder, recurrent, anxiety disorder and chronic pain. A physician order, dated 03/16/21, documented, [MEDICATION(S)] 10 milligram (mg) oral tablet give 1 tablet by mouth (po) every 8 hours as needed (PRN) agitation and anxiety A physician order, dated May 2021, documented, [MEDICATION(S)] tab(s) 10 mg give 1 tab po every (Q) 8 hours PRN agitation and anxiousness. Start (ST: 03/16/21). 2. Resident #21 was admitted with diagnoses which included [CONDITION(S)], unspecified [CONDITION(S)], anxiety disorder, [CONDITION(S)] and stage 4 kidney disease. A physician's order, dated 03/29/21, documented, [MEDICATION(S)] 2 mg/milliliter (ml) give 0.25 ml sublingual (SL) Q 2 hours PRN dyspnea/restlessness/anxiety. A physician's order, dated May 2021, documented, [MEDICATION(S)] 2 mg/ml give 0.25 ml SL Q 2 hours PRN for dyspnea/restlessness/anxiety (review in 90 days) ST: 03/25/21. On 05/10/21 at 3:48 p.m., the assistant director of nursing (ADON) was asked who was responsible for ensuring PRN medications were not ordered longer than 14 days. She stated herself and the pharmacist. She was asked how often [CONDITION(S)] medications were reviewed. She stated, Monthly. She was asked the facility policy regarding PRN [CONDITION(S)] medications. She stated, PRN [CONDITION(S)] medications are not used for longer than 14 days without an order from the physician specifying why it would be longer than 14 days. The ADON was asked what she did if she had a PRN [CONDITION(S)] medication that was ordered for longer than 14 days. She stated, I contact the physician and ask if he wants to discontinue it or add an additional time period. I will then add the time frame and put in a specific end date. There was no documented stop time for this medication in the physician's orders. 3. Resident #17 had diagnoses which included depression. A review of the MRR (Medication Regimen Review), dated 06/08/20, documented a recommendation had been made by the consulting pharmacist to decrease the [CONDITION(S)] medication [MEDICATION(S)] 20mg by mouth daily to 10mg daily. The physician agreed, dated 07/14/20. The physician order was noted 07/18/20. A review of the MAR (Medication Administration Record), dated July 2020, documented [MEDICATION(S)] 10mg daily had been entered on the MAR but not documented as administered. [MEDICATION(S)] 20mg had been administered daily through July 2020. A quarterly assessment, dated 2/18/21, documented the resident was cognitively intact, independent with ADLs, utilized a walker for mobility, had no behaviors, and received an antidepressant medication seven days of the seven day look back period. On 05/06/21 at 11:20 a.m., the ADON (assistant director of nursing) was asked what the procedure was for recommendations made by the pharmacist during the medication regimen review. She stated the pharmacist usually conducted the medication reviews by the fifth of each month. She stated the DON (director of nursing) or ADON would review them and mail them to the physician. She stated the DON or ADON would receive them from the physician and note any new orders. She stated the new orders would be faxed to the pharmacy, entered into the electronic record which updated the MAR, and filed in the resident's medical record. She was asked why the resident's dose of [MEDICATION(S)] had not been reduced to 10mg based on the order noted 07/18/20. She stated it appeared the order for 20mg had been reentered in the MAR. She was asked if there was a physician order to support the 20mg reentered in the MAR. She stated no. She was asked what dose of [MEDICATION(S)] the resident should have received starting 07/18/20. She stated, based on the order, 10mg daily. She was asked who was responsible for reviewing resident's medication. She stated the ADON would be responsible.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication labels were written to reflect a current physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility identified 25 residents who received medications. Findings: A facility policy titled, Medication Management, dated April 2018, documented, .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use . 1. Resident #13 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated May 2021, documented, .HM Fiber 28.3% administer 1 tbsp q am in liquid of choice .diarrhea, unspecified . On 05/04/21 at 8:00 a.m., during observation of medication administration, the medication label was observed to read, administer one tsp (teaspoon) po (by mouth) daily. Prior to administration of the medication, CMA #1 was asked what the physician order was for the HM fiber dosage. She stated one tablespoon daily. She was asked what the dosage was for HM Fiber documented on the medication label. She stated one teaspoon daily. She stated she needed to report the error to the charge nurse to have the medication label changed and attach a pink change sticker to the label. 2. Resident #14 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated May 2021, documented the resident was to receive the following: ~[MEDICATION(S)] 10mg (milligram) / 0.5ml (milliliter) sublingual TID (three times a day); ~[MEDICATION(S)] 0.5mg (0.25ml) sublingual every four hours routinely for anxiety; and ~[MEDICATION(S)] 0.25ml sublingual every four hours PRN (as needed) for anxiety. A MAR (Medication Administration Record), dated may 2021, documented the following: ~[MEDICATION(S)] 10mg / 0.5ml sublingual TID; ~[MEDICATION(S)] 0.5mg (0.25ml) sublingual every four hours routinely for anxiety; and ~[MEDICATION(S)] 0.25ml sublingual every four hours PRN for anxiety. On 05/04/21, during observation of medication administration, the following medication labels were observed: ~[MEDICATION(S)] 10mg / 0.5ml, take the contents of one syringe, by mouth, under tongue, twice daily, routine; and ~[MEDICATION(S)] 0.5mg / 0.25ml, take the contents of one syringe, by mouth, under tongue, every four hours, as needed, for anxiety. On 05/10/21 at 1:30 p.m., CMA (certified medication aide) #2 was asked what the procedure was when a medication was received from the pharmacy. She stated the CMA would count the medication received, compare the medication label to the medication sheet included with the medication, and if the medication was a narcotic, complete a narcotic sheet. She was asked what documentation was used to complete a narcotic sheet. She stated the medication label was used. She was asked who was responsible for ensuring the medication label matched the physician order. She stated she was sure the medication aide would be responsible. She was asked if resident #14's physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated no it needed to have a pink sticker indicating a change. At 1:40 p.m., the ADON (assistant director of nursing) was asked what the procedure was when medication was received from the pharmacy. She stated the medication would be checked in by the medication aide. She was asked who was responsible for clarifying the order. She stated the charge nurse was responsible. She was asked if resident #14's physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated no. She was asked if resident #14's physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated no. She was asked who was responsible for ensuring the medication label matched the physician order. She stated the mediation aide was responsible. She stated if the medication label did not match the physician order, the medication aide would notify a nurse, and attach a pink change sticker to the label. She stated the nurse would be responsible for clarifying the order, as needed.

Based on record review and interview, it was determined the facility failed to: ~Ensure hospice records were accessible for two (#7 and #21) of two sampled residents whose records were reviewed for hospice services. The facility identified four residents who received hospice services. Findings: 1. On 05/04/21 hospice records were requested for resident #7 and resident #21. The charge nurse stated the records were not in the facility and he would have to call hospice. At 12:35 p.m., the charge nurse stated hospice was going to bring the resident records back to the facility as soon as possible. The charge nurse was asked how hospice care was coordinated with the facility. He stated, through word of mouth and through the nurses. He was asked how staff knew what services they were to provide for the resident as opposed to what hospice was going to provide. He stated, We are all responsible for resident care no matter what. He was asked who was responsible to ensure hospice records remained in the facility. He stated, I guess I am. He was asked what the facility policy was regarding resident records. He stated he was not sure. On 05/10/21 at 3:48 p.m., the ADON was asked why hospice records were not kept in the facility. She stated, They usually are.

Based on observation, interview, and record review, it was determined the facility failed to ensure equipment was properly stored and the room locked for one of 12 resident rooms on the west hall. The facility identified 15 residents who resided on the west hall. Findings: An undated facility policy titled, Space and Equipment, documented, .areas will have space for storing and utilizing mobility devices, assistive technology, physical therapy or adaptive equipment . On 05/03/21 at 11:25 a.m., an unlocked and unoccupied resident room on the west hall was observed to contain the following: ~Five beds; ~One floor buffing machine; ~Three wheelchairs (one lying on top of a bed); ~Four walkers (two lying on top of a bed); ~One commode sitting on top of a bed; ~One chair sitting on top of a bed; ~One night stand sitting on top of a bed; ~Lamp and lamp shade sitting on top of a bed; and ~Pictures lying on top of a bed. At approximately 11:30 a.m., LPN (licensed practical nurse) #2 was asked how many residents wandered in the facility. He stated three. At 12:00 p.m., maintenance was asked how long the unoccupied resident room had been used for storage. He stated about one week. He stated they were working on floors, painting, and making repairs in other rooms. The maintenance supervisor was asked what kept residents from entering the resident room being used for storage. He stated they had placed a stop sign barrier across the door but it had been removed. He was asked if a resident entering the room was a potential accident hazard. He stated yes.

On [DATE] at 3:20 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide cardiopulmonary resuscitation (CPR) to a resident who had no vital signs. Clinical records revealed the resident was a full code. At 3:35 p.m., the facility administrator and DON were informed of the IJ situation related to the facility's failure to provide CPR for a resident. A plan of removal for the IJ situation was requested. On [DATE] at 6:42 p.m., the administrator provided an acceptable plan of removal. The facility's plan of removal, documented, .PLAN OF REMOVAL The facility will notify each staff member either in person or by phone by the end of the day [DATE] to in-service on what to do in a code status. Per our current policy, all DNR residents are identified by having a bright yellow signed DNR paper in the inside cover of the chart just as it is opened. There is a red DNR sticker on the spine of the chart to alert staff. The CODE status is also printed on the electronic face sheet on admission and will be updated by the ADON. If a resident is a full code, as per our current policy there will be a bright red sticker on the spine of the chart as well as a bright red paper on the inside cover of the chart indicating this is a FULL CODE resident. We will also be adding by the end of tomorrow [DATE] a revision to the policy to alert staff in the rooms who are FULL CODE residents by placing a red heart with the residents name on it on the resident's door. This will indicate that resident is a FULL CODE resident. All FULL CODE residents must have CPR initiated and EMSA called immediately upon noting that the resident no longer has a heart rate or respirations. CPR must continue until EMSA arrives and takes over. The doctor must be notified as soon as possible for further orders. The following not compatible with life situations would not be a considered candidate for CPR: resident who suffers from decapitation (complete separation of the head from the body), lividity (reddish to bluish-purple discoloration of the skin due to the settling and pooling of blood in the dependent portion of the body that is in contact with the surface following death) transection (complete division of the body) and rigor mortis (stiffening of the joints and muscles of the body a few hours after death, usually [MEDICATION NAME] from one to four days). A chart review will be done by the DON on [DATE] to make sure that all alert stickers are in place and DNR/FULL CODE papers are in the front of the chart. The ADON/MDS Coordinator will review all orders on [DATE] to make sure all code status' match in the electronic chart with the paper forms. A chart review will be done daily thru the weekdays for the next 14 days by the DON to ensure that compliance is met. Addendum: One dietary employee (initials withheld) has been unable to be reached after multiple attempts to be inserviced. The administrator will contact this employee and ensure that she is Inserviced prior to Returning to work. (Administrator's name withheld) [DATE] 5:45 pm On [DATE], interviews were conducted with a total of twenty-two employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. The facility policy was updated to include the use of red hearts to indicate which residents were a full code status. All eight of the resident's doors who had a physician order [REDACTED]. All 24 resident charts were observed to have either a signed DNR form or a paper which stated the resident was full code in the front of the chart. The ADON provided documentation all 24 resident's code status orders in the electronic record coincided with the paper charts. The deficient practice remained at a level of actual harm, isolated. On [DATE] at 5:46 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:35 p.m. Based on record review and interview, it was determined the facility failed to: ~ provide CPR for one (#1) of one sampled resident who had no vital signs and was designated as a full code; and ~ clearly identify the code status for one (#2) of four sampled residents whose code status was reviewed. The facility identified eight residents with a full code status. Findings: An undated policy, titled Cardiopulmonary Resuscitation, documented, .Delegate specific individual to check resident care plan for CPR or no CPR order; have individual call paramedics, attending physician and administrative personnel per facility policy and report back to you as soon as possible .General Documentation Guidelines .Exact time attending physician was called and exact time reached . 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated [DATE], documented, .She has chosen a full code for her code status . Physician orders, dated [DATE], documented, XXX[DATE]-FULL CODE . Review of the clinical record revealed documentation the resident had a full code status. The resident's chart was observed to have a red sticker on the front cover and the spine of the chart which documented the resident's code status was full code. A physician telephone order, dated [DATE] at 6:00 a.m., documented, .May release body to funeral home of families choice . The order documented it had been received by RN #1. A nurse progress note, dated [DATE] at 6:31a.m., documented, 05:15 (5:15 a.m.) - This nurse enters residents room to give morning meds. Resident is non responsive to verbal and tactile stimuli. On further assessment vital signs are noted to be absent. Sister (name withheld) was notified by this nurse. She instructed that residents (sic) final wishes were already taken care of with (funeral home name withheld) in (town withheld). (Funeral home name withheld) was contacted at 0540 (5:40 a.m.) and they stated they would be to facility to get resident this morning. The progress note had been signed by RN #1. A nurse progress note, dated [DATE] at 7:42 a.m., documented, 07:30 (7:30 a.m.)- Resident is taken from facility by (funeral home name and town withheld), without incident. The progress note had been signed by RN #1. An incident report on ODH Form 283, documented, .Incident date [DATE] .Incident Type Allegations of Neglect .Description of incident .RN Charge Nurse failed to perform CPR on a full code Resident. Resident deceased . Nurse suspended. Investigation Initiated .Summary of the investigation .Nurse stated the resident was not Responsive to verbal or tactile stimuli, Pulse was absent and extremities cold. Breath sounds were checked and absent. Nurse didn't check Resident chart to check for DNR. Nurse admitted to not checking and stated she should have. The facility finds with allegation substantiated. Nurse had one on one education w/ Director of Nursing. Nurse also assigned (Learning course name withheld) on Advance Directives to be completed by [DATE] . A statement, written by CNA #1, dated [DATE], documented, .I was in room [ROOM NUMBER] doing bed checks when the nurse walked into room [ROOM NUMBER] and found the resident deceased . I then continued doing rounds . An investigation statement, dated [DATE], documented, .I entered (residents name withheld) room at 05:15 a.m. (5:15 a.m.) on [DATE] to give morning medications. Resident was not responsive to verbal or tactile stimuli. Her carotid pulse was absent, extremities were cold. Breath sounds are checked by stethoscope and absent. This nurse notified her sister of her passing and was instructed by sister to call (funeral home name withheld) in (town name withheld) to have her picked up. The funeral home was contacted and residents (sic) remains were picked up later that morning . The statement had been signed by RN #1. A verbal warning/counseling form, dated [DATE], documented, .Incident: Nurse did not check the chart when a resident expired & was a FULL CODE. No CPR was performed. Inservice: Nurse is to ALWAYS check the chart for CODE STATUS when a resident expires. There was a RED STICKER on the front of the resident's chart indicating 'FULL CODE' & it is written on the resident's face sheet. We must always check the chart & if resident is not a DNR, EMS is to be notified & CPR is to be initiated. Nurse will be assigned learning classes on Advance Directives etc by the Administrator on our distance learning system . The verbal warning/counseling form was signed by RN #1 and the DON. On [DATE] at 11:30 a.m., CNA #2 was asked how she knew a resident's code status. She stated, It's usually on the chart it says full code or DNR. We have quite a few that's not a full code. At 11:44 a.m., LPN #1 was asked how she knew a resident's code status. She stated from the monthly charting the nurses completed. She stated she knew most of them but could look at the chart if needed. At 2:00 p.m., CNA #1 was what interaction she had with resident #1 on the night shift of [DATE] through [DATE]. She stated the resident was okay during the first bed check at 9:50 p.m. She stated the nurse then went into the resident's room at 5:15 a.m. for medication while she completed rounds on other residents. She was asked how often she checked on the resident during her shift. She stated she checked on the resident's roommate four or five times but did not check on resident #1. She stated she glanced at the resident as she walked by to assist the roommate. She was asked why she had not checked the resident when she came in to check the roommate. She stated, She's not a brief check. She was asked what happened when the nurse entered the room at 5:15 a.m. She stated the nurse made some phone calls and she continued doing rounds on the other residents. She was asked how she knew a resident's code status. She stated, It's on some of our charts but we really don't know. She was asked if RN #1 asked her for assistance regarding the resident. She stated no. At 2:13 p.m., RN #1 was asked about the incident with resident #1. She stated she was working with CNA #1 and went into the room to give the resident her morning medication between 5:00 a.m. and 5:30 a.m. on [DATE]. She stated she turned the light on and noticed the resident had been gone quite a while. She was asked how she determined the amount of time the resident had been deceased . She stated the resident was grayish/greenish in color around her hairline and she did not have a pulse. She stated she called for CNA #1 to come to the room while she obtained her stethoscope. She stated, I made my mind up she had been dead at least an hour. She stated she asked CNA #1 what the resident's status was at the first bed check. She was asked who she notified about the residents condition. She stated she first called the resident's sister and then contacted the funeral home. She was asked if she had notified anyone else. She stated just the resident's sister, the funeral home, and the administrator. She was asked how she knew a resident's code status. She stated it was in the electronic medical records orders and on the spine of the resident's chart. She was asked why she did not check the resident's chart for her code status and perform CPR. She stated, Because she'd been dead a long time. I could tell by looking. I know that was wrong but that's why. I've been inserviced. On [DATE] at 3:35 p.m., the DON stated RN #1 knew to check the resident's chart for code status and perform CPR if they were a full code. She stated the nurses knew to notify the physician for orders first then notify the funeral home. 2. Resident #2 had [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a signed DNR dated [DATE] and a face sheet which documented the resident was a DNR. Review of the EMR monthly physician orders, dated February 2020, documented the resident was Full Code on [DATE]. The printed monthly physician orders, dated February 2020, documented, XXX[DATE] - FULL CODE . The bottom of the physician orders [REDACTED]. A nurse progress note, dated [DATE] at 4:50 a.m., documented, 04:40 (4:40 a.m.) - CNA is doing incontinence checks and reports to this nurse that resident appears to be deceased . This nurse observes resident to be lying in bed on her back. Respirations, BP, and pulse are absent. (Hospice name withheld) is notified and at this time I am awaiting a call back from on call nurse. A nurse progress note, dated [DATE] at 5:28 a.m., documented, 0500 (5:00 a.m.) - (Hospice name withheld) nurse (name withheld) returned call and states that she is enroute to facility at this time. A physician telephone order, dated [DATE] at 6:00 a.m., documented, May release body to funeral home of families (sic) choice . A nurse progress note, dated [DATE] at 8:26 a.m., documented, 0800 (8:00 a.m.) Funeral home here to pick up body. Hospice here to assist in final needs. On [DATE] at 3:35 p.m., the DON stated she would have to investigate as to why the resident's code status was not clarified when she signed the DNR with hospice. She stated the nurses knew to contact the physician promptly when a resident was found to be without vital signs. On [DATE] at 6:30 p.m., the ADON looked at the resident's full code order which was dated [DATE] in the electronic record. She stated the date was related to the last time the order was updated.

Based on interview and record review, it was determined the facility failed to notify the physician for a change in status for two (#1 and #2) of four sampled residents whose records were reviewed for notification of change. This had the potential to affect all 24 residents who resided in the facility. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated [DATE], documented, .She has chosen a full code for her code status . Physician orders, dated [DATE], documented, XXX[DATE]-FULL CODE . Review of the clinical record revealed documentation the resident was a full code status. The resident's clinical chart was observed to have a red sticker on the front cover and the spine of the chart which documented the resident's code status was full code. A physician telephone order, dated [DATE] at 6:00 a.m., documented, .May release body to funeral home of families choice . The order was received by RN #1. A nurse progress note, dated [DATE] at 6:31a.m., documented, 05:15 (5:15 p.m.)- This nurse enters residents room to give morning meds. Resident is non responsive to verbal and tactile stimuli. On further assessment vital signs are noted to be absent. Sister (name withheld) was notified by this nurse. She instructed that residents (sic) final wishes were already taken care of with (funeral home name withheld) in (town withheld). (Funeral home name withheld) was contacted at 0540 (5:40 p.m.) and they stated they would be to facility to get resident this morning. The progress note was signed by RN #1. A nurse progress note, dated [DATE] at 7:42 a.m., documented, 07:30 (7:30 a.m.) - Resident is taken from facility by (funeral home name and town withheld), without incident. The progress note was signed by RN #1. An investigation statement, dated [DATE], documented, .I entered (residents name withheld) room at 05:15 a.m. (5:15 a.m.) on [DATE] to give morning medications. Resident was not responsive to verbal or tactile stimuli. Her carotid pulse was absent, extremities were cold. Breath sounds are checked by stethoscope and absent. This nurse notified her sister of her passing and was instructed by sister to call (funeral home name withheld) in (town name withheld) to have her picked up. The funeral home was contacted and residents (sic) remains were picked up later that morning . The statement was signed by RN #1. At 2:13 p.m., RN #1 was asked who she had notified about the resident's change in condition. She stated she first called the resident's sister and then contacted the funeral home. She was asked if she had notified anyone else. She stated just the resident's sister, the funeral home, and the administrator. Review of the clinical record revealed the physician had not been notified of the resident's change in condition/death until the nurse had called the physician at 6:00 a.m. and received the order to release the body to the funeral home. 2. Resident #2 had [DIAGNOSES REDACTED]. A nurse progress note, dated [DATE] at 4:50 a.m., documented, 04:40 (4:40 a.m.) - CNA is doing incontinence checks and reports to this nurse that resident appears to be deceased . This nurse observes resident to be lying in bed on her back. Respirations, BP, and pulse are absent. (Hospice name withheld) is notified and at this time I am awaiting a call back from on call nurse. A nurse progress note, dated [DATE] at 5:28 a.m., documented, 0500 (5:00 a.m.) - (Hospice name withheld) nurse (name withheld) returned call and states that she is enroute to facility at this time. A physician telephone order, dated [DATE] at 6:00 a.m., documented, May release body to funeral home of families choice . Review of the clinical record did not reveal the physician was notified of the resident's change of condition at 4:40 a.m. when the nurse determined the resident was without vital signs. The telephone order had not been written until 6:00 a.m. On [DATE] at 3:35 p.m., the DON stated the nurses knew to notify the physician for orders first then notify the funeral home. She stated the physician was to be notified of any change in the residents' condition.

Based on interview and record review, it was determined the facility failed to implement their policy and procedure related to: ~ Protection of a resident during an investigation of Neglect by allowing the alleged perpetrator to return to work during the investigation; and ~Not initiating an investigation for an allegation of Neglect in a timely manner. For one (#1) of one sampled residents whose records were reviewed for an allegation of Neglect. This had the potential to affect all 24 residents who resided in the facility. Findings: A policy, titled Abuse Policy and Procedure, dated [DATE], documented, .The administrator or designee initiates an investigation immediately, and notifies the State Department of Health within two hours of the alleged abuse .The resident's safety is always our main priority and the employee may be suspended during the investigation under the discretion of administration . Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated [DATE], documented, .She has chosen a full code for her code status . Physician orders, dated [DATE], documented, XXX[DATE]-FULL CODE . Review of the clinical record revealed documentation the resident had a full code status. The resident's clinical chart was observed to have a red sticker on the front cover and the spine of the chart which documented the resident's code status was full code. A physician telephone order, dated [DATE] at 6:00 a.m., documented, .May release body to funeral home of families (sic) choice . The order was received by RN #1. A nurse progress note, dated [DATE] at 6:31a.m., documented, 05:15 (5:15 a.m.) - This nurse enters residents room to give morning meds. Resident is non responsive to verbal and tactile stimuli. On further assessment vital signs are noted to be absent. Sister (name withheld) was notified by this nurse. She instructed that residents (sic) final wishes were already taken care of with (funeral home name withheld) in (town withheld). (Funeral home name withheld) was contacted at 0540 (5:40 a.m.) and they stated they would be to facility to get resident this morning. The progress note was signed by RN #1. A nurse progress note, dated [DATE] at 7:42 a.m., documented, 07:30 (7:30 a.m.) - Resident is taken from facility by (funeral home name and town withheld), without incident. The progress note was signed by RN #1. An incident report on ODH Form 283, documented, .Incident date [DATE] .Incident Type Allegations of Neglect .Description of incident .RN Charge Nurse failed to perform CPR on a full code Resident. Resident deceased . Nurse suspended. Investigation Initiated . A statement, dated [DATE], documented, .I was in room [ROOM NUMBER] doing bed checks when the nurse walked into room [ROOM NUMBER] and found the resident deceased . I then continued doing rounds . The statement was signed by CNA #1 An investigation statement, dated [DATE], documented, .I entered (residents name withheld) room at 05:15 a.m. on [DATE] to give morning medications. Resident was not responsive to verbal or tactile stimuli. Her carotid pulse was absent, extremities were cold. Breath sounds are checked by stethoscope and absent. This nurse notified her sister of her passing and was instructed by sister to call (funeral home name withheld) in (town name withheld) to have her picked up. The funeral home was contacted and residents (sic) remains were picked up later that morning . The statement was signed by RN #1. A verbal warning/counseling form, dated [DATE], documented, .Incident: Nurse did not check the chart when a resident expired & was a FULL CODE. No CPR was performed. Inservice: Nurse is to ALWAYS check the chart for CODE STATUS when a resident expires. There was a RED STICKER on the front of the resident's chart indicating 'FULL CODE' & it is written on the resident's face sheet. We must always check the chart & if resident is not a DNR, EMS is to be notified & CPR is to be initiated. Nurse will be assigned learning classes on Advance Directives etc by the Administrator on our distance learning system . The verbal warning/counseling form was signed by RN #1 and the DON. Review of RN #1's punch detail revealed she worked from 8:00 p.m. to 8:00 a.m. on [DATE] and [DATE]. On [DATE] at 11:00 a.m., the DON was asked when she was made aware RN #1 had not performed CPR on the resident. She stated she was out of town and the ADON notified her by phone on the evening of [DATE]. She was asked what action she took once she was made aware of the incident. She stated she called RN #1 and asked her if she performed CPR. She stated RN #1 could not give her a definite answer. She was asked if further investigation had been conducted at that time. She stated she had not completed further investigation. She was asked why RN #1 worked on [DATE] and [DATE] after the facility had been made aware of the allegation of neglect, and before education had been provided to her regarding a residents' code status. She stated the RN knew what to do she just had not done it. She was asked how the residents were protected after the allegation of neglect. She stated she did not know. On [DATE] at 11:12 a.m., the administrator was asked why the allegation of neglect had not been investigated on [DATE]. He stated he was not aware of the allegation on [DATE]. He was asked when he had been made aware of the allegation of neglect. He stated [DATE]. He was asked who notified him of the allegation. He stated the ADON. He was asked what action had been taken on [DATE]. He stated he called RN #1 and CNA #1. He was asked where the phone conversation was documented. He stated he had not documented the phone conversation. He stated he sent an incident report to OSDH on Wednesday, [DATE]. He was asked how the residents were protected when the staff knew of the allegation on [DATE] and the RN worked on [DATE] and [DATE]. He stated, They weren't. I was told she didn't receive CPR. I wasn't told anything else. Tuesday I found out she was a full code and she didn't do CPR. I should have looked into it sooner, I failed to do that. On [DATE] at 11:35 a.m., the ADON was asked when she had been made aware the resident had not received CPR and was a full code. She stated on [DATE]. She was asked what action she had taken when she found out. She stated she notified the DON and the administrator. She was asked what she had reported to the DON and administrator. She stated she had informed them that the resident was a full code and the nurse had not initiated CPR. She was asked how the residents were protected after she had been made aware of the allegation of neglect. She stated she thought the DON had called RN #1 and provided training.

Based on interview and record review, it was determined the facility failed to report an allegation of neglect to the State Agency in a timely manner for one (#1) of four residents who were reviewed for neglect. This had the potential to affect all 24 residents who resided in the facility. Findings: A policy, titled Abuse Policy and Procedure, dated [DATE], documented, .all alleged incidents of resident abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property be reported to the OSDH within 2 hours of being reported .The charge nurse notifies the Administrator/DON of the allegation. The administrator or designee initiates an investigation immediately, and notifies the State Department of Health within two hours of the alleged abuse .The resident's safety is always our main priority and the employee may be suspended during the investigation under the discretion of administration . Resident #1 had [DIAGNOSES REDACTED]. A care plan, updated [DATE], documented, .She has chosen a full code for her code status . Physician orders, dated [DATE], documented, XXX[DATE]-FULL CODE . Review of the clinical record revealed the resident had a full code status. The resident's clinical chart was observed to have a red sticker on the front cover and the spine of the chart which documented the resident's code status was full code. A physician telephone order, dated [DATE] at 6:00 a.m., documented, .May release body to funeral home of families choice . The order was received by RN #1. A nurse progress note, dated [DATE] at 6:31a.m., documented, 05:15 (5:15 a.m.) - This nurse enters residents room to give morning meds. Resident is non responsive to verbal and tactile stimuli. On further assessment vital signs are noted to be absent. Sister (name withheld) was notified by this nurse. She instructed that residents (sic) final wishes were already taken care of with (funeral home name withheld) in (town withheld). (Funeral home name withheld) was contacted at 0540 (5:40 a.m.) and they stated they would be to facility to get resident this morning. The progress note was signed by RN #1. A nurse progress note, dated [DATE] at 7:42 a.m., documented, 07:30 (7:30 a.m.) - Resident is taken from facility by (funeral home name and town withheld), without incident. The progress note was signed by RN #1. An incident report on ODH Form 283, documented, .Incident date [DATE] .Incident Type Allegations of Neglect .Description of incident .RN Charge Nurse failed to perform CPR on a full code Resident. Resident deceased . Nurse suspended. Investigation Initiated . The fax transmission sheet, attached to the initial incident report, documented the report was sent to OSDH on [DATE] at 11:39 a.m. On [DATE] at 11:00 a.m., the DON was asked when she was made aware RN #1 had not performed CPR on resident #1. She stated she was out of town and the ADON notified her by phone on the evening of [DATE]. She was asked who was responsible to report allegations of neglect to OSDH. She stated the administrator. She was asked when she had notified the administrator. She stated when he had returned to work on [DATE]. On [DATE] at 11:12 a.m., the administrator was asked when he was made aware of the allegation of neglect. He stated [DATE]. He was asked who notified him of the allegation. He stated the ADON. He was asked what action was taken on [DATE]. He stated he called RN #1 and CNA #1. He was asked where the phone conversation was documented. He stated he did not document he had talked to them on the phone. He stated he sent an incident report to OSDH on Wednesday. He was asked what the facility policy was for reporting allegations of neglect to OSDH. He stated, To report immediately. He was asked why the allegation had not been reported to OSDH until [DATE] at 11:39 a.m. when the incident had occurred on [DATE]. He stated they were trying to figure out what the resident's code status was. He stated, We didn't know if she had a DNR or full code. He stated there was a discrepancy and no one really knew the code status. He was asked if he had referred to the resident's clinical record. He stated he did not look at the clinical record. He stated he talked to the ADON and she reported to him the nurse did not perform CPR but they did not know if the resident was a full code or a DNR. He stated when he was told the resident had not received CPR he should have investigated further at that time. On [DATE] at 11:35 a.m., the ADON was asked when she had been made aware the resident had not received CPR and was a full code. She stated on [DATE]. She was asked what action she took when she found out. She stated she notified the DON and the administrator. She was asked what she had reported to the DON and administrator. She stated she notified them the resident was a full code and the nurse had not initiated CPR. She stated she assumed they had reported the incident to OSDH in a timely manner.

Based on interview and record review, it was determined the facility failed to respond to suggestions/concerns brought forth from the resident council group. This had the potential to affect all 33 residents who resided in the facility. Findings: On 02/11/19 at 1:30 p.m., a group meeting was held with ten alert and oriented residents. The group was asked if the facility acted upon grievances, concerns, and/or recommendations of the resident council group. They collectively stated no. They stated they never knew if the issue had been addressed by the facility. On 02/12/19 at 4:09 p.m., the social services director was asked how the facility addressed grievances, suggestions, and/or recommendations voiced during the resident council group meetings. She stated she shared the meeting notes with the DON (Director of Nursing) and administrator. She stated the concerns were discussed during QA (Quality Assurance) meetings. She was asked where it was documented the grievance, concern, and/or recommendation from the resident council group had been addressed by the facility. She stated on the resident council meeting minutes. Review of the resident council meeting minutes for the past six months did not reveal the resident council had been informed of the facility's response to their grievances, concerns, and/or recommendations. On 02/13/19 at 3:32 p.m., the administrator was asked how the resident council group was informed of the facility's response to their grievances, concerns, and/or recommendations. He stated he did not communicate to the group the response from the facility once the concern went to the QA committee. He stated, Someone needs to notify the residents of the solution.

Based on observation and interview, it was determined the facility failed to ensure a statement was posted and available with contact information regarding a resident's right to file a complaint with the state survey agency and the state Ombudsman contact information. This had the potential to affect all 33 residents who resided in the facility. Findings: An undated policy titled, Policy of Posting Ombudsman and State Contact Information, documented, .It is the policy of Barnsdall Nursing Home that information to contact the local Ombudsman and the State Department of Health be located on the bulletin board located outside of the dining room . On 02/11/19 at 10:20 a.m., the bulletin board across from the dining room was observed to have a medication cart that obstructed it's view which did not allow the Ombudsman information to be seen. The contact information for filing a complaint with the state agency was also obstructed. On 02/11/19 at 1:30 p.m., a group meeting was held with ten alert and oriented residents. The group was asked if they knew how to contact the state agency with complaints. They collectively stated no. They were asked if they knew how to contact their Ombudsman. Nine residents stated no. Resident #7 stated he knew where the Ombudsman information was posted. He stated it was on the bulletin board but could not be seen. He stated he was able to stand and read information at eye level but someone who utilized a wheelchair would not be able to see it, especially if the medication cart was parked in front of the bulletin board. Throughout the survey the medication cart was observed in front of the bulletin board and the contact information for the state agency and the Ombudsman were obstructed from view. On 02/13/19 at 10:07 a.m., the administrator was asked where the Ombudsman contact information was posted. He stated it was posted on the bulletin board across from the dining room. He was asked why the information was obstructed from view, and not accessible to the residents. He stated at one point the information was posted in the lobby but it had been moved. He was asked how residents were made aware of their right to file a complaint with the state survey agency. He stated they were informed upon admission to the facility and it was posted on the bulletin board but was not accessible. The administrator went to the bulletin board removed two pieces of paper which covered the contact information for the state survey agency but the Ombudsman information was still obstructed from view.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident bathrooms had hot water for eight (rooms 102, 104, 105, 107, 106, 108, 110, and 112) of 12 rooms observed for homelike environment on the west hall. The facility identified six resident bathrooms on the west hall. Findings: An undated policy titled, Temperature Checks, documented, .If the water temperatures are above or below state recommended parameters the maintenance director will adjust the temperature accordingly . On 02/10/19 at 4:00 p.m., the following hot water temperatures were obtained from the residents' bathroom sinks: ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 69.9 degrees F (Fahrenheit); ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 88.7 degrees F; ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 79.2 degrees F; and ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 76.9 degrees F. On 02/10/19 at 4:08 p.m., resident #26 was asked how long it took for the water to get warm in her bathroom sink. She stated, It takes forever to heat up. She stated usually at least 15 minutes but it was still not very warm. At 4:09 p.m., resident #16 was asked if she had warm water in her bathroom sink. She stated, No. I'd sure like to have some. At 4:28 p.m., the administrator and the maintenance supervisor was informed of the water temperatures. They stated they would look into it and begin monitoring. On 02/11/19 at 1:30 p.m., the resident council group was asked if they had warm water in their bathrooms. The collectively stated no. They stated they utilized cold water. On 02/12/19 at 1:05 p.m., the following hot water temperatures were obtained: ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 76.6 degrees F; ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 72.6 degrees F; and ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 71.4 degrees F. On 02/12/19 at 1:09 p.m., CNA (Certified Nurse Aide) #1 stated, A lot of them don't have any hot water. She was asked how long the residents had been without hot water in their bathrooms. She stated about a year. Review of the maintenance water temperature logs, dated 10/30/18-02/05/19, documented the water temperature for the residents' hot water ranged from 74.9 to 106.1 degrees F. On 02/13/19 at 12:36 p.m., the administrator was asked why the lack of hot water in the residents' bathrooms had not been addressed prior to the survey team identifying it, when the maintenance water temperature logs documented temperatures as low as 74.9 degrees F. He stated, I never looked at them. He was supposed to let me know if there was an issue.

On 07/15/14 an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure hot water temperatures were at a safe level to prevent burns. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 10:38 a.m., the administrator and DON were informed of the IJ regarding hot water temperatures and a plan of removal was required. They were informed this placed the facility in an extended survey. At 5:08 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: "...PROBLEM: Hot water temperatures too high in Resident Rooms 102, 115, 116, 119 and 120. PLAN OF REMOVAL: The Maintenance man was immediately notified upon awareness of temperatures being too hot in above resident's rooms. The bathrooms were closed off for resident use until water temperatures were fixed and at the desired temperature, 115-120 max degrees. All staff have been inserviced to immediately report to Administration if water temperatures in any area feel too warm to the touch so that Maintenance can immediately correct the problem. The last staff member was inserviced at 3:30 pm. Any staff member that is unable to be inserviced today (list attached) will not be allowed to return to work until inservice training has been provided. Maintenance will check and document water temps daily for one week to ensure temperature stability, then every week on a routine basis and document the readings in a temperature log. The maintenance man will be given a copy of the state regulations on 07/15/14 and receive further education and training by the Administrator to ensure compliance with state and federal regulations. This will be monitored closely by the Administrator. Employees unable to come in due to unforeseen circumstances will not be allowed to return to work until they have been properly inserviced on hot water temperatures..." Information was provided to indicate all staff would not be inserviced until 07/17/14. On 07/16/14 at 10:15 a.m., an IJ situation was determined to exist due to the facility's failure to provide supervision to prevent elopements and ensure measures were in place to prevent future elopements for a resident who was at high risk for elopements. OSDH was notified and verified the Immediate Jeopardy situation. At 10:36 a.m., the administrator and DON were notified of the IJ situation and a plan of removal was required. On 07/16/14 at 1:28 p.m., an acceptable plan of removal was received. The plan of removal documented: "...PROBLEM: Need a plan to ensure the safety of residents at risk for elopement; Resident (name deleted) is a 'potential at risk resident' for elopement and has a Wander guard bracelet on... PLAN OF REMOVAL: The above named resident is on every 15 minute checks until the additional alarms on (sic) placed on the main entrance doors; all staff will be inserviced on checking resident's whereabouts for safety, and documenting on the frequent check sheet. A staff member on each shift will be assigned to assure this is done. The resident has been informed of this safety plan. The resident will not be left unattended at any time while outside. The last staff member inserviced on this will be at 3:00pm. Any staff unable to be here will be inserviced by phone by (name deleted), LPN/ADON, which will be verified by a member of the survey team. The administrator is getting a bid on additional Wander guard alarms on the main entrances for further protection against elopements..." Information was provided to indicate all staff would not be inserviced until 07/17/14. The IJ's were removed on 07/17/14 at 2:30 p.m., when all components of both plans of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ ensure hot water temperatures in resident bathrooms were at a safe temperature for six (Rooms #102, 111, 115, 116, 119 and #120) of eight resident bathrooms whose hot water temperature were checked. The administrator identified 10 resident bathrooms utilized by 32 residents in the facility. ~ provide supervision to prevent elopements and to ensure three of six exit doors were equipped to alarm for one (#8) of one sampled residents with wanderguards who had eloped from the facility. The DON identified 3 residents who are at high risk for elopement. Findings: An undated facility policy on water temperatures, documented, "...1. The maintenance director of the Barnsdall Nursing Home will check the water temperature in resident's rooms on long and short halls, laundry and kitchen. 2. If the water temperatures are above or below state recommended parameters the maintenance director will adjust the temperature accordingly. 3. The water temperature checks will be done weekly or on an as needed basis and will be charted in the water temperature log book..." 1. On 07/15/14, between 9:28 a.m. and 9:45 a.m., the following hot water temperatures were taken from the sink faucets on long and short halls. Room 102 - 134.0 degrees F Room 111 - 126.0 degrees F Room 115 - 136.0 degrees F Room 116 - 134.0 degrees F Room 119 - 134.6 degrees F Room 120 - 146.8 degrees F (therapy room only) On 07/15/14 at 9:50 a.m., the DON was asked if there were any residents who were confused or had decreased ability to remove their hand if the water temperature was too hot. She stated resident #19 was confused, forgetful, and toileted herself. Resident #20 had paranoid schizophrenia and had multiple health issues. Resident #21 was forgetful at times, however toileted herself without staff assistance. On 07/15/14 at 10:47 a.m., the maintenance director was asked if he had received on the job training when he started one month prior. He stated no. He was asked if he was aware of the state and federal regulations regarding hot water temperatures. He stated no. He was asked how often he had taken the temperatures of the hot water in the resident bathrooms. He stated once a month. The water temperature log was reviewed. The log did not show documentation of hot water checks in May 2014. The documentation showed the last hot water check was dated 06/02/14. He was asked how often the thermometer was calibrated. He stated he had not done any calibration to the thermometer. 2. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 12/10/13, documented the resident was severely impaired cognitively, required supervision for all activities of daily living, ambulated independently, was continent of bowel and bladder, had no behaviors, wandered daily, and was on an antipsychotic medication for seven days out of seven days during the look back period. A behavior care plan, dated 12/17/13, documented, "...I wander about the facility on a near daily basis. At this time I do not wander into other resident's rooms or mess with other resident's belongings...I wish to have no episodes of elopement over the next 90 days..." The care plan documented a handwritten approach, dated 11/27/13, which documented a wander guard bracelet would be in use. A quarterly assessment, dated 06/12/14, documented the resident was severely impaired cognitively, required supervision for all activities of daily living, ambulated independently, was continent of bowel and bladder, had no behaviors, no wandering, and was on an antipsychotic medication for seven out of seven days during the look back period. A nurse's note, dated 07/01/14 at 3:15 p.m., documented the resident was observed outside of the fence attempting to return to facility. The resident was escorted into the facility without incident. "She was trying to visit her sister who lives across the street, when no one was home she returned to the facility." An incident report, dated 07/01/14, documented, "... Resident has been observed closely on hourly checks and has not attempted to elope, isolated incident..." On 07/15/14 at 11:50 a.m., the resident was observed sitting at the dining table. She was asked simple questions for which she replied in simple, understandable answers. There was a wander guard bracelet observed on her left wrist. On 07/15/14 at 12:00 p.m., LPN #2 was asked if the resident wandered. She stated she did not wander into other people's rooms however, she liked to go outside to the gate. LPN #2 was asked if the resident wore a wander guard. She stated yes. She stated the two side doors and the front door are not connected to the alarm system however, the back door was connected to the wander guard alarm system as there had been problems in the past with elopement. LPN #2 was asked how the resident walked out the front door. She stated the resident knew the code and goes out herself. On 07/15/14 at 3:30 p.m., the resident was observed sitting on the front patio with family. On 07/16/14 at 6:55 a.m., CNA #1 was asked if the resident had tried to elope during the night shift. She stated no, she had not tried to elope during the night. She stated the resident sleeps through the night and toilets herself independently. CNA #1 stated the front door will alarm after 15 seconds if it stays open however, her wander guard alarm does not set off the door alarm. On 07/16/14 at 7:00 a.m., LPN #1 was asked how many people wandered and were at risk for elopement in the facility. He stated three. LPN #1 was asked how the residents who were at high risk for elopement were monitored. He stated wanderguard's and the doors connected to the wander guard system are checked each night and documented. LPN #1 was asked which doors in the facility were alarmed for the wander guards. He stated the laundry room door, the dietary office door and the patio door. LPN #1 was asked if the front door was alarmed. He stated yes however, it was not connected to the wander guard system. On 07/16/14 at 8:40 a.m., the DON was asked who determined a resident was at high risk for elopement and required a wander guard. She stated the team makes the decision based on family input. She stated the family told the facility on admission she wandered at home. The DON was asked if the resident was at high risk for elopement. She stated there was always a possibility however, it had not happened until recently. The DON stated prior to the most recent elopement, a discussion to discontinue the wander guard was to take place. The DON was asked if the facility changed the codes to the front door frequently. She stated no. The DON stated the alarm on the front door will go off after 15 seconds if opened. The DON stated the wander guard system is not connected to the front door or the two side doors. On 07/16/14 at 9:45 a.m., CNA #2 was asked if the resident knew the code to the front door and was able to let herself outside. She stated no, she does not remember the code. CNA #2 stated she liked to sit on the patio all day and other alert and oriented residents would let her out when they went outside. CNA #2 was asked if there was documentation of frequent checks on the resident while she was outside. She stated no. On 07/16/14 at 9:50 a.m., CNA #3 was asked if the resident knew the code to leave the facility. He stated no. He stated if she is standing near the door and another resident or family left, she may follow behind them. On 07/16/14 at 10:00 a.m., this surveyor observed the front door to the facility. There was a key pad to the right of the front door on the inside of the facility. The code to exit was written on a small piece of paper. This surveyor used the code and the front door was observed to unlock and this surveyor went outside. The front door to the facility was observed to have remained unlocked for 15 seconds before automatically relocking allowing for anyone to exit the building without the door alarming. No wander guard alarm was observed inside the front door to alert staff of an elopement.