Every finding on record at Broadway Care & Rehab Center

Based on record review and interview, the facility failed to ensure that 1 (#1) of 3 residents reviewed for elopement received adequate supervision to prevent elopement. The Administrator reported a census of 83.Findings:A facility incident report, dated 7/22/23, showed Resident #1 eloped from the locked unit and was returned to the facility by local law enforcement. A tour of the facility was conducted on 07/22/23 to observe the corrective changes made in the window mechanisms. A review of the facility's investigation did not indicate how far the resident went after leaving the facility or the exact time frame the resident had left the facility. Resident records were reviewed for updated elopement status. Maintenance logs were reviewed for daily checks on windows in the locked unit and weekly checks on the windows in the rest of the building.A quarterly assessment, dated 07/14/25, for Resident #1 showed a diagnosis of unspecified dementia and BIMS score of 3 which indicated severe cognitive impairment.On 07/23/25 at 1:53 p.m., the administrator reported they were notified around 6:00 a.m. by the DON Resident #1 could not be located. They were told the facility was being searched and the police had been notified. The administrator reported the resident was returned to the facility at 6:30. The resident reported they had left the facility through a window. The administrator stated they took immediate actions on 07/22/25 to ensure the safety of all residents, and provided documentation of the following:A census audit was conducted on all residents to ensure they were in the building. All windows in the facility were checked to ensure they were safe. All residents were reassessed for elopement.Maintenance replaced all the screws that enabled windows to be partially opened. These screws were put in place on the outside of the window to ensure they could not be tampered with from the inside of the facility.Weekly audits on windows were increased to every day for the locked unit. All staff were educated on elopement risks and how to identify elopement behavior. Resident #1 was assessed for any physical injury and checks were conducted every 15 minutes. On 07/23/25 at 2:35 p.m., Resident #1 stated they left because they wanted to go to (name-withheld city) to get to the bank. Resident #1 did not recall how they got out of the building or how far away from the facility they were when found by law enforcement.On 07/23/25 at 3:00 p.m., interviews with 5 staff from different departments were conducted regarding knowledge of elopement risks and behaviors, and to confirm re-education by the facility.

Based on record review and interview, the facility failed to follow physician orders for 1 (#4) of 3 sampled residents reviewed for physician orders. The administrator identified 83 residents resided in the facility. Findings:A physician order, dated 04/21/25, showed the following medications were to be held starting 04/21/25:aspirin EC 9enteric coated) delayed release 81 mg (an antiplatelet medication used to prevent blood clots) for a procedure scheduled on 04/24/25.Plavix oral tablet 75 milligrams (antiplatelet medication used to prevent blood clots). A physician order, dated 04/24/25, showed Plavix )an anti-platelet) oral tablet was to be held on 04/26/25 for pacemaker placement. A review of the discontinued medications for Resident #4 showed these medications were not discontinued or held as ordered. A quarterly clinical assessment, dated 06/25/25, showed Resident #4 had diagnoses which included metabolic encephalopathy and cerebral ischemia. The assessment showed Resident #4 had a BIMS score of 6 which indicated severe cognitive impairment for decision making. On 07/30/25 at 2:48 p.m. the DON reported Resident #4 had two scheduled procedures to place a pacemaker and because a medication, ordered to be held prior to the procedure, was not withheld for the appropriate length of time, the resident was not able to have the pacemaker placed. The procedures were scheduled for 04/24/25 and 04/25/25. Resident #4 had the pacemaker placed on 05/08/25. The DON reported they were not informed of the first missed procedure, but were notified after the second missed procedure. The DON reported education was provided to all staff who provided medications to residents, and a system was put into place to monitor for resident procedures to ensure this situation did not reoccur. The DON reported the importance of following physician orders was addressed in the quality assurance committee and also at their weekly stand-up meeting. The DON reported the monitoring had begun on 05/01/25 and would continue indefinitely. On 07/30/25 at 4:09 p.m. the administrator provided documentation of:QAPI meeting held on 6/17/25 that addressed following physician ordersEducation dated 05/12/25 for medication aides and nurses that addressed following physician orders. Monitoring documentation for scheduled surgeries that document physician orders reviewed and entered correctly. On 07/30/25, interviews were conducted with LPN #1, CMA #1 and CMA #2. All reported education had been received and demonstrated their knowledge of following physician orders and policy and procedures in place for when residents have scheduled procedures.

On 05/21/25, the OSDH determined an IJ situation was determined to exist related to accident hazards. 1.The facility failed to ensure hot liquids were served at a safe temperature. A resident assessment, dated 04/24/25, showed Resident #38 had severely impaired cognition and required supervision for eating. A May 2025 active physician's order summary showed Resident #38 had diagnoses which included dementia, delusional disorders, and blister unspecified thigh. An untitled document, dated 05/08/25, showed Resident #38 sustained a superficial burn injury on their upper left and right thigh after coming in contact with hot coffee. 2. The facility failed to ensure chemicals were properly secured when Resident #52 ingested Pine-Sol that was kept in a Styrofoam cup. A care plan, dated 03/07/25, showed Resident #52 had diagnoses which included intellectual disability, psychotic disorder, cerebral palsy, acute respiratory failure, and pneumonitis due to aspiration of vomit. A quarterly resident assessment, dated 03/12/25, showed Resident #52 had severe cognitive impairment and required supervision for eating. An incident report, dated 05/15/25, showed Resident #52 ingested less than half a cup of Pine-Sol when a housekeeper put it in a Styrofoam cup and placed it on the cart. On 05/21/25 at 5:01 p.m., the OSDH was notified and verified the existence of the IJ situation. On 05/21/25 at 5:10 p.m., the administrator was informed of the existence of an IJ situation and was provided the IJ template. On 05/22/25 at 1:17 p.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, Broadway Care and Rehab 5/21/2025 [at] 5:10 p.m. Nature of IJ: Resident sustained burns from spilling hot coffee on [their] legs on 5-8-25. 1. Immediate Corrective Action Taken for Affected Resident(s): Immediate Actions to Prevent Further Harm: Facility immediately provided first aide and orders to ensure proper care. Facility provided ice coffee and cup with a lid for safety of the resident, and provided a lap blanket for an additional layer of protection. 1. Evidence of IJ Removal .No further incidents involving hot beverage burns have occurred since corrective actions were implemented on 5-8-25. .100% staff education on hot liquids, see attached education on 5/22/2025, will be completed by 2:30 p.m. for all staff. .The facility educated all kitchen staff on 5/22/2025 to ensure temperature is 140 degrees or below when placed in carafes for serving, completed by 2:30 p.m. .The facility created a daily coffee audit on 5/22/2025 with the updated temperature in place, kitchen staff all educated on new coffee temperature process by 2:30 p.m. .Broadway did 100% hot liquid assessments on all current residents on 5-22-25 to be completed by 2:30 p.m. .The facility educated all alert and oriented residents with a BIMS of 8 or greater regarding hot liquids and best practices when using hot liquids on 5-22-25 by 2:30 p.m. .Care plans and Kardex updated to reflect all residents requiring additional safety interventions with hot liquids on 5-22-25 by 2:30 p.m. .The facility added a hot liquids assessment to the admission checklist for new admissions and/or readmissions, changes in condition on 5-22-2025 by 1:00 p.m. .The facility added the education and an example of a hot liquids assessment to place in new hire orientation packet on 5-22-2025 by 1:00 p.m. .Staff who are not currently at work or unable to be contacted via telephone will be educated prior to returning to work. On 05/22/25 at 3:23 p.m., after interviews with facility staff, review of in-services, resident assessments, care plans, and audits related to hot liquids the immediacy was lifted, effective 05/22/25 at 2:30 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure: a. coffee was served at a safe temperature for 1 (#38); and b. chemicals were properly secured for 1 (#52) of 3 sampled residents reviewed for accident hazards. The administrator identified 75 residents resided in the facility and 73 residents received services from the kitchen. Findings: 1. On 05/21/25 at 11:29 a.m., Resident #38 was observed to have a brown foam dressings on their right and left inner thighs. On 05/21/25 at 11:36 a.m., Resident #38 was observed feeding themselves lunch. They were observed to pick up their cup of purple liquid and was shaking while bringing the cup up to their mouth. On 05/21/25 at 11:50 a.m., Resident #38 was observed to receive a cup of coffee and took a sip of the coffee and placed the cup back on the table. On 05/21/25 at 11:54 a.m., a cup of coffee was dispensed from an insulated portable coffee dispenser on B hall. The temperature of the cup of coffee was 155.9 degrees F. The cup of coffee was sampled. Steam was observed coming off the coffee in the cup. The coffee was very hot and there was an instant sting on the surveyor's lip. On 05/21/25 at 12:05 p.m., Resident #38's wound care was observed. Wounds were observed to the left and right inner thighs. Both wounds were observed covered with yellow slough. On 05/21/25 at 12:17 p.m., coffee was obtained from an insulated portable coffee dispenser on A hall. The temperature of the coffee was 150.6 degrees F. The cup of coffee was sampled. Steam was observed coming off the coffee in the cup. The coffee was very hot and there was an instant sting on the surveyor's lip. On 05/21/25 at 12:36 p.m., dietary cook #1 dispensed coffee from the coffee machine in the kitchen. They were was observed to take a temperature of the coffee. The thermometer was observed to read 166 degrees F. Resident #38's Annual Assessment, dated 04/24/25, showed Resident #38's BIMS score was 3 which indicated Resident #38's cognition was severely impaired. The assessment showed Resident #38 required supervision/touch assistance with eating tasks. A May 2025 active physician's order summary showed Resident #38 had diagnoses which included dementia, lack of coordination, other symptoms and signs involving cognitive functions and awareness, and blister to unspecified thighs A Nurse's Note, dated 05/08/25, read in part, CNA [certified nursing assistant] reported to this nurse that resident spilled hot coffee in [their] lap in the dining room. Evaluated skin, pinkness noted to front of bilateral thighs. This nurse asked resident what happened, resident stated, 'I just dropped my cup.' Evaluated resident's thighs, pinkness noted, applied cool cloths to both thighs.Reevaluated and noted pinkness went to redness in small area of groin on both thighs. Notified [name withheld] new order to apply Silvadene [used to treat or prevent serious infection on areas of skin with second-or third-degree burns] to redness until resolved. Applied Silvadene at this time. An untitled document, dated 05/08/25, showed Resident #38 sustained a superficial burn injury on their upper left and right thigh after coming into contact with hot coffee. The document showed first aid was applied to the affected area, resident monitored, incident reported to registered nurse and facility leadership, family and physician notified, incident documented, and care plan was updated with new interventions. The document showed new interventions were a lid was to be placed on Resident #38's beverage and ice was to be added to cool prior to serving the beverage. The document showed the Root Cause Analysis contributing factors were coffee served at a hot temperature and inadequate staff awareness of burn risk protocols. The document showed all direct care staff were in-serviced on proper temperatures for serving in memory care and those requiring lids for coffee. The document showed coffee temperatures 120 degrees or below were in place. The document showed audit initiated immediately post-incident included all hot beverage delivery processes across the facility, a standardized checklist included temperature check before serving. The document showed compliance rate with checklist completed 100% of audit on 05/08/25. There was no documentation of all staff in-serviced or checklist of temperature checks. An undated resident list showed 18 residents resided on B hall. The list showed check marks by 16 residents' names. Resident #38's name was circled and lid and ice cubes were wrote next to their name. Resident #38's Order Summary Report, dated 05/09/25, showed: a. wound care physician may consult related to non-pressure ulcers to bilateral thighs, and b. Silvadene to left inner thigh and right inner thigh every day shift and as needed. A Direct Care Staff in-service for Hot Liquids, dated 05/09/25, read in part, Please make sure you are putting a few ice cubes in [Resident #38]'s coffee to cool it down and that [they are] utilizing [their] new cup with the lid on it before serving it to [them]. Please sign signature page to acknowledge. Thank you, [Administrator]. There were 13 staff signatures with the in-service. The staff members were from different departments. The dates ranged from 05/09/25 to 05/20/25. There was no documentation all staff had been in-serviced. Resident #38's care plan, revised 05/14/25, showed Resident #38 had a skin injury by sustaining a burn to their lap from spilling hot coffee on 05/08/25. The care plan showed interventions included Resident #38 used a cup with a lid to prevent spillage and staff were to place ice cubes to hot drinks. A Wound Evaluation and Management Summary, dated 05/14/25, showed Resident #38 had wounds to their left and right thighs. The summary showed burn wound of the right thigh full thickness. The summary showed burn wound of the left thigh full thickness. On 05/20/25 at 1:05 p.m., a family member stated Resident #38 had been burned by coffee. They stated they did not think the staff were giving Resident #38 coffee anymore. The family member stated they told the staff to give cold coffee. They stated they told the staff they should not be giving residents hot coffee when the residents were shaky. The family member stated they told the staff the coffee should not be hot enough to cause blisters. On 05/21/25 at 9:51 a.m., an anonymous resident group was asked how about the coffee temperature. They stated it had been hot since the staff had used the new dispensers. They were asked if they were able to drink the coffee right when they were served it. They stated it would burn their mouth. On 05/21/25 at 12:02 p.m., the wound care doctor stated they did not diagnosis the degree of the burn because they did not see it initially. They stated they saw it approximately a week later. The wound doctor stated they would observe the wounds and would see what they were. On 05/21/25 at 12:07 p.m., the wound doctor stated they thought both wounds were 3rd degree, but the wounds were still pretty covered. They stated they planned to debride the wounds next week and thought they would probably observe muscle after debridement. On 05/21/25 at 12:24 p.m., CMA #2 stated Resident #38 spilled coffee on themselves. They stated Resident #38 used a special cup with a lid and handle now. CMA #2 stated staff added a few ice cubes to the coffee. They stated they would feel the outside of the cup to see how hot it was prior to giving it to the residents. On 05/21/25 at 12:27 p.m., CMA #2 was asked how staff ensured the coffee was a safe temperature for residents. They stated they knew what residents had shaky hands. CMA #2 stated they knew who would wait for the coffee to cool down. They stated the residents knew not to spill it on themselves. CMA #2 was asked what if the residents accidentally spilled the coffee on themselves. They stated, I don't have an answer for that. On 05/21/25 at 12:29 p.m., the DON stated Resident #38 spilled coffee on themselves. They stated staff completed a skin assessment, applied cool compresses, notified the physician and received an order for Silvadine. The DON stated Resident #38 used a special cup and they added ice cubes to their coffee. On 05/21/25 at 12:30 p.m., the DON was asked how burns from hot liquids were prevented to other residents. They stated dietary checked the temperature in the dining room before the drinks went out to the halls, prior to serving each meal. On 05/21/25 at 12:32 p.m., dietary aide #1 was asked if staff checked the temperature of the coffee before serving. They stated, I don't know. On 05/21/25 at 12:34 p.m., the dietary manager was asked what the procedure was for taking temperatures of the coffee. They stated they did not know and would need to ask dietary cook #1. On 05/21/25 at 12:35 p.m., dietary cook #1 was asked if staff took temperatures of the coffee prior to serving. They stated, Not really. They want it to be 155-175 for the halls. On 05/21/25 at 2:02 p.m., the administrator stated Resident #38 spilled coffee on their lap. They stated the resident's skin was pink in color and the next day it had blisters. The administrator stated the incident happened on B hall during breakfast time. They stated staff obtained an order for Silvadene on the same day. On 05/21/25 at 2:03 p.m., the administrator and regional director were asked what had been implemented to prevent the incident from recurring. The administrator stated the resident used a cup with a lid and staff cooled the coffee before giving it to the resident. They stated they educated the staff and completed an ad hoc QAPI. The regional director stated they completed an audit on other residents. On 05/21/25 at 2:05 p.m., the administrator was asked what was a safe temperature for coffee. They stated coffee needed to be brewed to 160 degrees for safe consumption and then cooled to 120 degrees or below. On 05/21/25 at 2:06 p.m., the administrator was asked what the temperature of coffee was currently being served to the residents. They stated 160-165 degrees out of the pot, and then cool it to 120 degrees. The administrator was asked how staff knew what the temperature of the coffee was. They stated, Kitchen would have to get them a thermometer. They were asked if that had been done. They stated, Should be. On 05/21/25 at 2:07 p.m., the administrator was asked to provide the policy and any documentation related to the incident with Resident #38. On 05/21/25 at 2:36 p.m., the administrator stated they did not have a policy. They were asked what residents had been assessed to be at risk. They stated all the residents on B hall because that was where the incident occurred. 2. On 05/21/25 at 11:18 a.m., Resident #52 was observed on B hall propelling themselves in a wheelchair in the hallway. A care plan, dated 03/07/25, showed Resident #52 had diagnoses which included acute/chronic respiratory failure with hypoxia and psychotic disorder. The care plan showed Resident #52 had impaired cognitive function. A quarterly resident assessment, dated 03/12/25, showed Resident #52 sometimes understands, rarely/never made decisions, and required supervision for eating. A Nurse's Note, dated 05/15/25 at 9:24 a.m., read in part, Text: Housekeeper called this nurse into resident's room. Housekeeper stated this resident had consumed a small amount of Pine Sol in a small Styrofoam cup. Resident was sitting in [their] wheelchair in [their] room. [Resident #52] appeared ok. Asked resident what happened, [they] stated, I want coffee. Notified Poison Control Center. Poison Control Center stated to monitor resident and watch for excessive vomiting and diarrhea and should be able to treat [them] in facility. Shortly after, resident began to dry heave, then tried to vomit but kept swallowing it when it reached [their] throat/mouth.Resident then projectile vomited x1., [DON] went to resident's room and assessed resident. Staff came to door at end of unit to let this nurse know that resident had vomited and that [DON], stated to get paperwork together because [Resident #52] is going to hospital because [Resident #52] was having trouble breathing. O2 Sat at this time 77%RA [room air]. EMS notified. Oxygen applied, O2 sat [saturation] 85%. Resident began to have trouble staying alert, awake, and became lethargic off and on, staff kept trying to keep resident stimulated. EMS arrived x2 attendants. Resident O2 sat 87% with EMS oxygen on. EMS transferred resident to gurney and transported resident to [local hospital]. A Nurses Note, dated 05/15/25 at 11:22 a.m., read in part, Note Text: Spoke with Hospital nurse, resident has been admitted with Dx [diagnoses]: Respiratory Failure with Hypoxia and Aspiration Pneumonitis. An all-staff in-service, dated 05/15/25, showed all housekeeping carts were to remain locked when unattended and all chemicals were to be kept out of the reach of residents. An ad-hoc QAPI meeting report, dated 05/15/25, showed a problem of chemical ingestion. The report showed staff had been in-serviced and audits were conducted to ensure residents did not have access to chemicals. The report showed audit tools were used to monitor chemical storage. A hospital note, dated 05/19/25, showed Resident #52 had been admitted to the hospital on [DATE] with diagnoses of acute respiratory failure secondary to possible aspiration pneumonia. An admit/readmit note, dated 05/20/25 at 6:08 p.m., read in part, Note Text: resident to arrive back from [hospital] .residents' vitals are blood pressure 149/79, pulse of 84, temp [temperature] of 98.7, spo2 [peripheral oxygen saturation] of 96% on rm [room] air, and rr [respiratory rate] 17. resident alert to self. perrla [pupils equal, round, reactive to light and accommodation]. resident respirations are regular and unlabored. lung sounds arecta [are cta] [clear to auscultation]. no shortness of breath noted. On 05/21/25 at 2:10 p.m., CNA #4 was asked how they ensured residents did not have access to chemicals. They stated by making sure everything was put up and locked up in the supply closet. CNA #4 was asked how they were aware of which chemical was being used. They stated the chemicals were labeled. On 05/21/25 at 2:13 p.m., LPN #3 was asked how they ensured residents did not have access to chemicals. They stated chemicals were supposed to be put up. LPN #3 stated when they did rounds, they checked to see if any chemicals were in resident rooms and made sure the carts were locked. They stated the staff met every shift to remind all staff to keep chemicals put up. LPN #3 stated chemicals should be in labeled containers. On 05/20/25 at 9:56 a.m., housekeeper #1 was asked what the policy was for storing chemicals. They stated chemicals were to be put up, locked up, labeled, and carts locked when unattended. On 05/21/25 at 2:58 p.m., the administrator was asked how staff ensured chemicals were not accessible to residents. They stated per their most recent chemical audits to check to see that housekeeping carts were locked, and nothing was in the reach of residents. They stated they checked the entire building three times daily for one week, then daily for one week, and then weekly. The administrator stated they put the chemical education in with the new hire packet.

Based on observation, record review, and interview, the facility failed to ensure proper PPE was used for 1 (#24) of 3 sampled residents observed for EBP. The administrator identified 75 residents resided in the facility. Findings: On 05/29/25 at 8:39 a.m., the door frame to Resident #24's room was observed to have EBP signage and a tube feeding was observed hanging on a pole next to the resident's bed. On 05/29/25 at 8:57 a.m., LPN #1 entered Resident #24's room, closed the door, turned off the tube feeding, and checked placement with a stethoscope and syringe. LPN #1 had on gloves, but did apply a gown prior to accessing the resident's feeding tube. On 05/29/25 at 9:00 a.m., LPN #1 exited Resident #24's room to get water from a cart, returned to the resident's room, applied gloves, but still no gown was applied. PPE was observed inside the resident's room, on the back of the door, which included yellow gowns, gloves, and masks. A policy titled Enhanced Barrier Precautions, dated 05/15/24, read in part, The facility may expand the use of PPE [and] refer to the use of gown [and] gloves during high-contact resident care activities that provides the opportunities for transfer of MDROs [multidrug-resistant organism] to hands/clothing. Examples of High-Contact Resident Care Activities requiring Gown [and] Glove Use for EBP .Device Care .Enteral Tube. On 05/29/25 at 9:08 a.m., LPN #1 stated Resident #24 was on EBP for a tracheostomy and catheter. LPN #1 was asked about the feeding tube. They stated, Oh, yes. On 05/29/25 at 9:09 a.m., LPN #1 stated the policy and procedure for EBP was to wear a yellow gown and gloves. LPN #1 stated they did not apply the required PPE. On 05/29/25 at 9:10 a.m., the DON stated the requirements for EBP was to wear gloves, a gown, and a mask. The DON stated they had given all staff badges with the EBP information on it and had completed in-services with all the staff.

Based on record review and interview, the facility failed to access, monitor, and intervene for a resident at risk for pressure ulcers for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The director of nursing identified 11 residents residing in the facility had pressure ulcers. Findings: Resident #1 admitted on [DATE] with diagnoses which included dementia and cognitive communication deficit. Resident #1's Skilled Nursing Note, dated 01/16/25, showed the resident's skin was intact and no breakdown noted. Resident #1's admission assessment, dated 01/27/25, showed no pressure ulcers. The assessment showed Resident #1 was dependent of one to two persons with transfers and toilet hygiene. Resident #1's Physician's Order, dated 02/05/25, showed zinc oxide ointment 20%, apply to buttocks/sacrum topically every shift for prophylaxis skin integrity. Resident #1's Skin Observation Tool, dated 02/11/25, showed the resident had no skin breakdown or wounds. The tool showed to continue with pillow program (a turn and reposition program that moves the red pillow every two hours with repositioning). On 02/14/25, Resident #1 was transferred to the emergency room for evaluation due to a change in condition. A hospital wound assessment, dated 02/14/25, showed a DTI pressure injury to the sacrum area measuring 7.0 cm by 10.0 cm and a DTI pressure injury to the left heal measuring 4.0 cm by 4.0 cm. There was no documentation the facility had accessed and intervened to prevent Resident #1's wound. On 03/05/25 at 11:09 a.m., the wound care nurse stated on 02/05/25 Resident #1's buttock started a little red. They stated they got orders to apply zinc. On 03/05/25 at 11:11 a.m., the wound care nurse stated when Resident #1 left for the hospital the buttock/sacral area was a DTI. They stated they could not provide a note as they had not documented the wound.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and EBP were followed during the provision of wound care for 1 (#6) of 3 sampled residents reviewed for pressure ulcers. The administrator identified 30 residents required enhanced barrier precautions. Findings: On 03/04/25 at 2:24 p.m., the wound care nurse was observed to enter Resident #6's room, wash their hands, don gloves, and provide wound care to Resident #6 who required EBP precautions. The wound care nurse did not wear a gown or mask to provide the care. An Enhanced Barrier Precautions, policy, dated 02/28/23, read in part, The Use of Gown & Gloves during High Contrast Resident Care Activities as indicated, when Contact Precautions do not otherwise apply, for Facility Residents with Wounds. Resident #6 admitted on [DATE] with diagnoses which included pressure ulcer of sacral region and resistance to multiple antimicrobial drugs. Resident #6's care plan, created on 02/10/25, showed enhanced barrier precautions approach to reduce multi-drug resistant organisms in a healthcare setting. On 03/04/25 at 2:53 p.m., the wound care nurse stated the sign outside Resident #6's room was to alert staff to take more precautions in the room. They stated like a gown and a mask. On 03/04/25 at 2:54 p.m., the wound care nurse stated they did not don a gown or put on a mask prior to entering the resident's room.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident to resident abuse for 1 (#2) of 3 sampled residents reviewed for abuse. The administrator identified 79 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents .Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. Resident #2 had diagnoses which included cognitive communication and unspecified intellectual disabilities. Resident #2's quarterly assessment, dated 10/30/24, showed a brief score for mental illness scored of three, indicating the resident's cognition was severely impaired. An unlabeled document, dated 11/19/24, read in part, Upon thorough investigation collecting statements from staff and residents, it appears [name withheld] mumbled a statement to the effect of 'get away from me'. [Name withheld] proceeded to self-propel up to [name withheld] and grab [them] by the neck and was verbally aggressive until a staff member had to physically release [name withheld] had off of [name withheld] neck. The staff member deescalated the situation and separated the two residents immediately. A Final State Reportable Incident form, received 11/21/24, read in part, A staff member and other witnesses claim to have witnessed resident [name withheld] grab [name withheld] by the neck as [name withheld] was wheeling past [them] in the dining room. There was no documentation of staff or resident interviews. On 03/06/25 at 10:04 a.m., the administrator stated they did not have any other staff or resident statements or interviews other than the one provided with the final report.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of three sampled residents reviewed for abuse. The administrator identifed 75 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: visitors, and any other individual Abuse: The willful infliction of injury, unreasonable confinement, intimidation with refusing physical harm, and pain. Abuse may be visitor-to-resident. 1. Resident #1 had diagnoses which included anxiety, repeated falls, nicotine dependence, and alcoholic polyneuropathy. A Quarterly Resident Assessment, dated 11/13/24, documented Resident #1's cognition was severly impaired. It documented the resident made themselves understood and was able to understand others. A Incident Report OSDH form, dated 11/18/24, read in part, At approximately 3:45 a.m. resident noted yelling out from room, nurse immediately went to room and noted resident being physically restrained by roommates [visitor]. Nurse immediately told [visitor] to let go of resident right now. [Visitor] let go and stated no [they] is fine, [they] fine. Staff escorted resident [Resident #1] out of room and to nurses desk, assessments for pain and skin done immediately. Staff offered resident a new room and resident declined. Staff went to room and told visitor they would have to leave facility, visitor refused to leave and local police were called. Police escorted visitor out of building. A 911 service detail report, dated 11/18/24 at 4:18 a.m., read in part, when [visitor]refused the roommate attempted to get a nurse to remove [visitor]] and the [visitor] held the roommate down and refused to let them leave the room .subject was being loud and .[Resident #1] asked [visior] to leave. An Alert Note dated 11/18/24 at 5:22 a.m., read in part, At approximately 3:45a.m. resident noted yelling out from room, nurse immediately to room and noted resident being physically restrained by roommate's [visitor]. Nurse immediately told visitor to let go of resident right now. [Visitor] let resident go and stated, No, no [they are] fine [they] fine. [They are] ok. Escorted resident to nurses desk, assessments done .Verbal altercation per resident occurred, resident attempted to eave room. That's when [visitor] physically tried to restrain resident from leaving the room per residents statement. This nurse noted that resident was standing up next to doorway when [visitor] was noted holding both arms. This nurse asked resident if [they] would like a new room to go to. Declined new room, stating that [they] wanted to stay in [their] current room. This nurse [sic] residents' room, educated [visitor] that [they] needed to leave the building .[visitor] refused to leave room. ADON and DON notified. Police were called. [Visitor] escorted by police from [facility name withheld]. Skin and Pain assessment. On 11/20/24 at 2:24 p.m., Resident #1 was interviewed and stated their roommate had a visitor come into the facility to visit around 3:45 a.m. The resident stated the visitor was being loud in their room and they asked the visitor to not be so loud. The resident stated the visitor was asked several times and would not be quite. The resident stated they got up from their bed to get staff for help and the visitor grabbed both of their wrists at the doorway and would not let go. The resident stated staff heard them yelling for help and came immediately. The resident stated the visitor was not twisting their wrists, just holding both of them. On 11/21/24 at 5:24 a.m., CNA #1 was interviewed regarding the incident that occurred on 11/18/24 between Resident #1 and their roommates visitor. CNA #1 stated they heard LPN #1 telling the visitor of the roommate they would need to leave the facility. CNA #1 stated they heard Resident #1 saying the visitor pulled them away from the door to prevent them from leaving. CNA #1 stated then the police came. On 11/21/24 at 5:33 a.m., LPN #1 was interviewed regarding the incident that occurred on 11/18/24. LPN #1 stated a visitor of Resident #1's roommate came in about 3:40 a.m. and went to their room. LPN #1 stated they kept hearing Resident #1's voice. LPN #1 stated they went to the room and the roommate's visitor had Resident #1 by their wrist at the doorway. LPN #1 stated the visitor was not letting Resident #1 leave the room. LPN #1 stated they escorted Resident #1 to the nurses desk for safety. LPN #1 stated they did offer another room to Resident #1 and the resident declined another room. LPN #1 stated they went back to the room and told the visitor they would have to leave the facility and the visitor refused. LPN #1 stated they then called the police, DON, and ADON. LPN #1 stated the police got to the facility quick and escorted the visitor out of the building. On 11/21/24 at 9:21 a.m., the DON was asked what was the facility policy for abuse. The DON stated they were to report abuse immediately, call the police, APS, and the family. The DON was asked about the incident on 11/18/24 regarding Resident #1 and roommates visitor. They stated the roommate's visitor was not allowed back in facility at this time and had not been back since incident happened. The DON also stated the facility changed all the codes to entrance and exit doors and an in person inservice was completed regarding aggressive visitors.

Based on record review and interview, the facility failed to ensure resident's rights to receive visitors of the resident's choice for one (#1) of three residents reviewed for visitation. The DON reported the census was 71. Findings: A Visitation Policy, revised 02/17, read in part, .Our facility permits residents to receive visitors subject to the resident's wishes .The facility provides 24-hour access to all individuals visiting with the consent of the resident . Resident #1 had diagnoses which included hypertension and anxiety disorder. A progress note, dated 03/25/24 at 2:19 pm, documented that a friend of Resident #1 called and wanted to visit the resident. The note further documented the facility contacted Resident #1's POA and the POA did not want the friend to visit. The note also documented that the friend was called back by the facility and informed the POA did not want him to visit. A progress note, dated 04/03/24 at 9:26 am, documented that a friend of Resident #1 called and wanted to visit the resident. The note further documented the facility contacted Resident #1's POA and the POA instructed the facility to call the police if the friend tried to visit Resident #1. The note also documented that the resident was notified that the friend would not be allowed to visit. On 07/10/24 at 1:30 pm, LPN #1 stated the facility should not restrict visitation based on the wishes of the POA. On 07/10/24 at 1:40 pm, the SSD stated that after they had the care plan meeting last week, they are no longer restricting Resident #1's visitors. On 07/10/24 at 1:50 pm, the DON stated that the ombudsman had informed them during the care plan meeting last week that the facility could not restrict visitation based on the wishes of the POA. On 07/10/24 at 2:17 pm, the Corporate Administrator stated they could not restrict visitation based on the wishes of a POA.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the need and an informed consent was obtained prior to the use of shepherds hook bed rails for two (#14 and #38) of two residents reviewed for bed rails. The administrator identified six residents whose beds were equipped with a bed rail of any type. Findings: A Bed Mobility Assistive Devices/Bed Rails policy, dated July 2018, read in parts, .If a bed rail is determined to be the most effective intervention for resident positioning/safety, the following requirements must be met: Bed/Bedrail assessment .Review of risks and benefits of bed rails with the resident or resident representative .Obtain informed consent prior to installation . 1. Res #14 had diagnoses which included heart failure, anxiety, and repeated falls. A physician order, dated 01/17/23, documented the resident may have a shepherd hook on bed for turning and repositioning. A quarterly assessment, dated 11/17/23, documented Res #14 was severely impaired in cognition, required supervision or touch assistance with bed mobility, and had not fallen. On 02/12/24 at 12:28 p.m., Res #14 was observed sitting on the side of the bed. A shepherd hook bed rail was observed on the upper left side of the bed closest to the wall. Res #14 stated they did not use the bed rail for transfers or positioning and did not know why it was there. 2. Res #38 had diagnoses which included heart failure, muscle wasting, and depression. A physician order, dated 01/17/23, documented the resident may have a shepard hook on bed for turning and repositioning. An annual assessment, dated 11/03/23, documented Res #38 was intact in cognition, required substantial to maximum assistance with bed mobility, and did not ambulate. On 02/12/24 at 1:08 p.m., Res #38 was observed lying in bed. [NAME] hook bed rails were observed on both sides of the upper bed. Res #38 stated they had the bed rails for a while now to assist with turning left and right in the bed. On 02/15/24 at 11:24 a.m., the DON stated there was no documentation of an assessment of the appropriateness of the shepherds hook bed rails and no documentation of informed consent prior to installation for Res #14 and Res #38. On 02/15/24 at 11:33 a.m., the administrator stated an assessment for appropriateness and informed consent should have been obtained prior to installation of the shepherds hook bed rails for Res #14 and Res #38.

Based on record review and interview, the facility failed to provide a bed hold policy to a resident prior to transfer for one (#49) of one resident reviewed for hospitalization . The administrator reported the census was 71. Findings: A notification of Bed Hold policy, dated December 2018, read in part .When a resident/patient is discharged to a hospital, the facility will notify the resident/patient and responsible party of bed hold days remaining .Document communication in the medical records . Resident #49 had diagnoses which included anxiety disorder and anemia. A physician order, dated 02/07/24 at 11:45 a.m., documented the resident was to be sent to the hospital for evaluation and treatment. A review of Resident #49's health record did not document the resident, or their representative had been given notice of the bed hold policy at the time of transfer. On 02/15/24 at 11:38 a.m., the administrator stated they did not have documentation the resident or their representative had been provided with a copy of the bed hold policy at the time of transfer.

Based on record review and interview, the facility failed to ensure a level II PASRR referral was made to the Oklahoma Health Care Authority for one (#15) of four residents who were reviewed for PASARR. The administrator reported the census was 71. Findings: A Policy titled PASRR Determination, dated November 2023, read in part .Level 2 screens are conducted when necessary to insure that a beneficiary requires nursing facility level of care and/or specialized services within the nursing facility .It is the responsibility of the NF to ensure a Level II is completed on a beneficiary that meets previous criteria .A yes answer to any of the six questions in Section E of the LTC-300R form .Requires a Screening for Level II PASRR . Resident #15 had diagnoses which included unspecified intellectual disabilities and anemia. A PASRR level 1 form, dated 12/08/23, documented the social worker from the hospital Resident #15 was admitted from contacted the OHCA regarding a 30-day PASRR exemption letter as the resident was being admitted for skilled care. The level I PASRR also documented in section E that Resident #15 had a diagnosis of mental retardation or a related condition. On 2/15/24 at 11:35 a.m., the administrator stated a Level II PASRR was not completed because of the 30-day exemption. A review of the resident's record documented the resident had been in the facility 46 days.

Based on observation and interview, the facility failed to ensure that expired medications were removed from the medication room. The administrator reported the census was 71. Findings: A Medication Storage in the facility policy, dated April 2018, read in part, .Outdated, contaminated, or deteriorated medications .are immediately removed from inventory . On 02/15/24 at 9:23 a.m., a tour of the medication storage room for halls A and B was conducted with RN #1. A medication card containing ondansetron 4 mg for Resident #8 was observed to have an expiration date of 01/17/24. On 02/15/24 at 9:25 a.m., RN #1 stated the expired medication should have been removed from the medication room. On 2/15/24 at 9:30 a.m., the DON stated expired medications should be disposed of.

Based on record review, observation, and interview, the facility failed to ensure resident records were accurately documented and readily accessible for two (#8 and #39) of 20 residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #39 had diagnoses which included congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. An admission assessment, dated 12/29/22, documented Res #39 was severely impaired in cognition and required extensive assistance with ADLs. A nurse note, dated 01/07/23, documented the resident was found unresponsive and was sent to the hospital for evaluation. A nurse note, dated 01/08/23, documented the resident had been sent to a separate hospital for a possible cerebral vascular accident. No notes were documented after date of 01/08/23 and the resident had not returned to the facility at the time of the survey. The resident task records documented cares were being provided to the resident until the date of 01/15/23. On 01/18/23 at 11:10 a.m., the DON reported the resident had chose not to come back to the facility and had went somewhere else. The DON was shown the resident's task records and stated he did not know why the CNAs were documenting cares on the resident until 01/15/23. The DON stated the CNAs should not have documented they had provided cares to a resident when the resident was not at the facility. 38495 2. Res #8 had diagnoses which included peripheral vascular disease, diabetes mellitus, and chronic pain syndrome. An admission assessment, dated 12/13/22, documented the resident was severely impaired with cognition and required extensive assistance with ADLs. The assessment documented the resident required oxygen and was on hospice care. A care plan could not be located in the resident record. On 01/11/23 at 3:25 p.m., Res #8 was observed on a low bed with oxygen at 2L per nasal cannula tubing, which was not dated. On 01/18/23 at 9:58 a.m., the corporate nurse consultant stated Res #8's care plan was one of three care plans that disappeared when electronic record updated. She stated she would continue to try and get the resident's care plan. On 01/18/23 at 11:10 p.m., the care plan coordinator stated the facility had called the electronic record company because the resident's care plan was gone. She stated a staff member who worked for the company was working to get the missing care plans back. She stated the update happened on 12/22/22 and there would be another update on 01/19/23.

Based on record review and interview, the facility failed to ensure an Oklahoma DNR consent form was: a. followed-up on when residents were admitted to the facility for #48. b. was signed by an eligible person to make decisions for Res #24. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included psychosis, dementia, and Parkinson's disease. A DNR form, dated 08/09/21, was in the resident's medical record. The DNR was not signed. The form documented a consent was obtained from a resident representative over the telephone. The DNR was completed while the resident was in the hospital. A physician order, dated 08/31/21, documented the resident's status was DNR. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. On 01/17/23 at 10:27 a.m., corporate nurse #1 stated there was no POA documentation for the resident in the record. She stated the staff should always follow-up when a DNR was received from the hospital for a resident without a signature. 34945 2. Res #48 had diagnoses which included acute pancreatitis with uninfected necrosis, chronic kidney disease, and heart failure. A physician signed DNR form, dated 12/19/22, documented the resident was not to be resuscitated in the event on cardio pulmonary arrest. Physician orders, dated 12/21/22, documented the resident was to be admitted to hospice services and a signed DNR was on the resident's chart. An admission assessment, dated 01/02/23, documented Res #48 had intact cognition and required supervision and set up for most ADLs. On 01/11/23 at 12:07 p.m., the resident was observed sitting in a chair in his room. He stated he had little memory of being in the hospital and just came back to himself after he was admitted to the facility. On 01/18/23 at 9:05 a.m., the DON and administrator were interviewed. They stated they had not checked with the resident after his admission to assess if being a DNR was his wishes. On 01/18/23 at 9:20 a.m., the administrator stated she had spoke with the resident and he told her he did not know if he wanted to be a DNR or not. She stated he would speak with his family and get back to her.

Based on record review, observation, and interview the facility failed to ensure assessments accurately reflected the resident's status for four (#24, 27, 34, and #55) of 22 residents who were reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included psychosis, diabetes mellitus, dementia, and Parkinson's disease. A physician order, dated 10/21/22, documented to administer quetapine an (antipsychotic medication) 25mg at bedtime. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. The assessment documented the resident received an antipsychotic medication 7 days during the 7 day look back period. The assessment also documented the resident had not received antipsychotics on a regular basis. A care plan, last reviewed 12/07/22, did not document the resident was receiving an antipsychotic medication. On 01/17/23 at 4:39 p.m., the MDS coordinator stated the assessment should have been coded as the resident received antipsychotics. She stated she would do a correction. 2. Res #34 had diagnoses which included cellulitis of right lower limb and pressure ulcer of the sacral region. A wound note, dated 10/14/22 at 2:49 p.m., documented the resident had two sacral wounds which measured 0.4 x 0.3 x 0.3 cm. and 4.0 x 0.8 x 0.3 cm. An admission assessment, dated 12/07/22, documented the resident had one stage IV pressure ulcer. A wound note, dated 12/15/22 at 2:47 p.m., documented the resident had two sacral wounds which measured 0.5 x 1.0 x 0.3 cm and 1.5 x 0.5 cm. On 01/13/23 at 4:40 p.m., the MDS coordinator stated the wound section of the MDS was incorrect. 3. Res #55 had diagnoses which included aphasia following cerebral infarction and gastrostomy status. On 12/16/22 at 9:01 a.m., the resident weight was documented in the EHR as 133.4 pounds. A dietary note, dated 12/19/22 at 1:38 p.m., documented the resident's weight was 133 pounds and had a weight gain of 13 pounds since last months weight report. A quarterly assessment, dated 12/23/22, documented the resident's cognition was intact and the resident's weight was 112 pounds. On 01/11/23 at 2:40 p.m., Res #55 stated she had started gaining weight. She stated she has been on a feeding tube about a year. She said she could eat food also and have thickened liquids. On 01/13/23 at 4:39 p.m., the MDS coordinator stated she did not fill out the weight section on the MDS. She stated the dietitian did that section. The MDS coordinator stated the weight in the computer for the look back period was 133.4 pounds. 34945 4. Res #27 had diagnoses which included dementia, retention of urine, muscle wasting and atrophy, and abnormalities of gait and mobility. A post fall progress note, dated 11/16/22, documented the resident had experienced an unwitnessed fall in her room. A quarterly assessment, dated 12/08/22, documented Res #27 was was always incontinent of urine and had not fallen. On 01/11/23 at 12:22 p.m., the resident was observed in her room laying on a mattress with bolsters. A fall mat was observed at the side of the bed. The resident was observed to have an indwelling catheter. On 01/17/23 at 2:32 p.m., the MDS coordinator reviewed the quarterly MDS and stated she had incorrectly coded the resident as incontinent of urine when she had a catheter. She stated she also should have captured the resident had a fall with minor injury.

Based on record review, observation, and interview, the facility failed to update resident care plans to reflect the residents' current needs for three (#34, 55, and #62) of 18 residents whose care plans were reviewed. The facility failed to update the care plans to reflect: a. pressure ulcers for Res #34. b. the diet status of Res #55. c. behaviors including pilfering in other resident rooms for Res #62. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #62 had diagnoses which included myocardial infarction, anemia, and chronic lymphocytic leukemia of B-cell type. A nurse note, dated 08/05/22, documented the resident had been taking food off the other residents' plates. The note documented the resident had walked into another resident room and ate her dinner. A nurse note, dated 08/8/22, documented the resident was frequently found removing items from other resident rooms. A nurse note, dated 08/10/22, documented the resident wandered around the facility and into other resident rooms removing other resident belongings without permission particularly television remotes. A nurse note, dated 08/20/22, documented the resident frequently roamed into other resident rooms and was confused. A nurse note, dated 08/27/22, documented the resident was easily confused and had a pleasant disposition. The note documented the resident was frequently confused of taking things from other resident rooms. A nurse note, dated 08/28/22, documented the resident was frequently noted to take items from the rooms of other residents. The note documented the resident was easily confused and did not remember taking the items. A nurse note, dated 09/3/22, documented the resident could be found frequently wandering the halls, going from room to room, and had been accused of taking items from other resident rooms. A significant change assessment, dated 10/20/22, documented Res #62 was severely impaired in cognition and required set up and supervision with ADLs. The assessment documented the resident did not have any behaviors during the seven day assessment period. On 01/12/23 at 9:17 a.m., Res #62 was observed lying in her bed watching television. The resident stated she did not like it when the facility chopped her food up. She stated sometimes if another resident did not want their food, such as a piece of chicken, they would give it to her to eat. She stated the facility gave out candy once a month too and she would get the candy and keep it in her room. She stated she thought she had gained weight at the facility. On 01/13/23 at 4:10 p.m., the DON stated he had no knowledge of the resident taking things from resident rooms. He stated if he had known he would have done a behavior care plan. On 01/13/23 at 4:19 p.m., CNA #1 reported the resident used to go in other resident rooms but they had not seen her do that recently. On 01/13/23 at 4:20 p.m., the care plan coordinator stated she had no knowledge of the resident entering other resident rooms and taking things. She stated had she been notified she would have initiated a behavior care plan. 38495 2. Res #55 had diagnoses which included aphasia following cerebral infarction and gastrostomy status. A physician order, dated 06/28/22, documented a regular diet, pureed texture, nectar thick consistency and a dietary waiver was signed. A care plan, last reviewed 12/20/22, documented the resident had a gastrostomy tube secondary to swallowing disorder (dysphagia) associated with cerebral infarction. The care plan documented the resident was NPO. A physician order, dated 12/21/22, documented Nutren 2.0 at 50 ml/hr. On 01/11/23 at 11:28 a.m., a CNA asked Res #55 if she wanted her noon meal. Res #55 stated she did. The tube feeding was observed running at 50ml/hr. On 01/11/23 at 2:40 p.m., Res #55 stated she had started gaining weight. She stated she has been on a feeding tube about a year. She said she could eat food also and have thickened liquids. On 01/13/23 at 4:52 p.m., the care plan coordinator stated the care plan should be updated when an order changes. She stated under the anemia care plan she talked about po foods. She stated its in care plan all over the place where she is getting po intake just not in gastroscopy care plan it still had NPO. The LPN stated the resident refused po intake for a long time. 3. Res #34 had diagnoses which included cellulitis of right lower limb and pressure ulcer of the sacral region. A wound note, dated 10/14/2022, documented the resident had two sacral wounds. A care plan, last reviewed on 10/18/22, documented the resident had damage to the skin and subcutaneous tissue associated with friction and shearing secondary to immobility. An admission assessment, dated 12/07/22, documented the resident was intact with cognition and had one stage four pressure ulcer. A wound note, dated 12/15/2022 at 2:47 p.m., documented the resident had two sacral wounds. On 01/13/23 at 5:00 p.m., the care plan coordinator stated the resident should have had a care plan which included pressure ulcers. She stated she had been out of the facility for 10 days and had missed updating the doing the care plan.

Based on record review, observation, and interview, the facility failed to provide medications to residents per physician order and facility policy for two (#20 and #40) of seven residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #20 had diagnoses which included diabetes mellitus. A physician order, dated 07/29/22, documented the facility was to administer Aspart Insulin by sliding scale with a FSBS of 0-150 = 0u; 151-200 = 2u; 201-250 = 4u; 251-300 = 6u, subcutaneously as needed for elevated blood sugar. A review of the resident's insulin administration records documented the resident had a FSBS of 279 on 10/21/22 and should have received 6 units of Aspart insulin. The records indicated the resident did not receive insulin at that time. A quarterly assessment, dated 12/16/22, documented the resident was severely impaired in cognition and received insulin seven days of the seven day assessment period. A care plan, last reviewed on 12/16/22, documented the resident had diabetes and to administer medications as prescribed. A review of the resident's insulin administration records documented the resident had a FSBS of 175 on 12/14/22 and should have received 2 units of Aspart insulin. The records indicated the resident did not receive insulin at that time. On 01/12/23 at 5:00 p.m., LPN #2 reviewed Res #20's insulin records and confirmed the resident should have received Aspart insulin on the above dates but did not. On 01/12/23 at 5:14 p.m., the DON stated Res #20's insulin orders had not been put in the computer correctly and the FSBS was not populating the order for Aspart insulin. He stated it did not instruct the staff to administer Aspart based on the FSBS reading and the staff did not administer the insulin as ordered. 2. A facility policy, titled Specific Medication Administration Procedures, dated April 2018, read in part: .F. Administer medication and remain with resident while medication is swallowed . Res #41 had diagnoses which included insomnia. A physician order, dated 11/15/22, documented to administer Melatonin 10 mg by mouth at bedtime. An admission assessment, dated 11/22/22, documented Res #41 was intact in cognition and required supervision to limited assistance with ADLs. On 01/13/23 at 7:57 a.m., during observation of a medication pass, Res #41 was observed to grab a medication cup sitting on his window sill, which contained two small white tablets, and stated he forgot to take his medication the previous night. On 01/13/23 at 8:08 a.m., LPN #3 stated she would have to look up the tablets to see what they were. On 01/13/23 at 8:15 a.m., LPN #3 reported the tablets were melatonin tablets. On 01/13/23 at 4:06 p.m., the DON stated he had heard about the melatonin tablets which the resident had not taken and were found in a medication cup on the resident's windowsill. He confirmed the facility policy was for staff to stay with the resident until the medications were swallowed.

Based on record review and interview, it was determined the facility failed to ensure a physician responded to the monthly pharmacist recommendations in a timely manner for three (#20, 21 and #24) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents report documented 71 residents resided in the facility. Findings: The facilities Drug Regimen Review policy, dated December 2018, read in part .9. The resident's physician will be notified of the Pharmacy Recommendations. The facility will allow 10 days for the physician response to the recommendations. Any recommendations not completed within 10 days will be referred to the Medical Director . 1. Resident #21 was admitted to the facility on [DATE] and had diagnoses which included psychosis, paranoid schizophrenia, depression, abnormal involuntary movement, and anxiety disorder. A pharmacist MRR, dated 08/13/22, documented a recommendation to decrease Trazodone 50 mg to 25 mg. The MMR documented the physician agreed to the GDR on 09/01/22. A quarterly assessment, dated 10/05/22, documented the resident was moderately impaired with cognitive skills. The assessment documented the resident had verbal aggression behaviors. The assessment documented the resident received an antipsychotic, antidepressant, antianxiety, diuretic, and opioid medications every day of seven day assessment period. On 01/13/23, at 10:30 A.M. the corporate nurse was asked about the GDR for resident #21 and and what the policy and procedure stated in regards to the time the physician had to respond. The corporate nurse stated that the physician should have responded in 10 days. 38495 2. Res #24 had diagnoses which included psychosis, dementia, and Parkinson's disease. A physician order, dated 10/21/22, documented to administer quetapine an (antipsychotic medication) 25mg at bedtime for anxiety related to unspecified psychosis not due to a substance or known physiological condition. A pharmacy MRR, dated 11/09/22, documented Res #24 was receiving Seroquel 25mg at bed time for anxiety. Please clarify the diagnosis to one of the following, which are considered appropriate diagnoses/conditions per CMS guidelines: Tourette's, psychosis, schizophrenia or schizophrenic condition, dementia/refractory depression/unresolved delirium, delusional disorder, ect. with documented and ongoing behaviors that are deemed dangerous to self or others. If none of these conditions apply, please consider instituting a gradual dose reduction process and ultimate discontinuation of this therapy. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and received an antipsychotic medication seven days during the look back period. A physician order, dated 01/02/23, documented quetiapine 25mg at bedtime for unspecified psychosis not due to a substance or known physiological condition. On 01/05/23, the MRR, dated 11/09/22, documented the physician agreed and signed to change the diagnosis to unspecified psychos. The MRR was noted on 01/05/23. On 01/17/23 at 9:41 a.m., the corporate nurse consultant stated there was not a response within ten days per policy. 34945 3. Res #20 had diagnoses which included hypertension and depression. A consultant pharmacist MRR, dated 04/16/22, documented a request for the physician to consider a switch of the long acting metoprolol to a non-extended release metoprolol which could be crushed. The physician agreed to the request on 05/05/22. A consultant pharmacist MRR, dated 08/13/22, documented a request for the physician to reduce the resident's dose of Zoloft from 50 mg to 25 mg. An agreement response was received by the physician on 09/01/22. A quarterly assessment, dated 12/16/22, documented Res #20 was severely impaired in cognition and received antidepressant medication for seven days of the seven day assessment period. On 01/13/23 at 10:40 a.m., the corporate nurse and the DON confirmed the physician responded to the medication regimen reviews beyond the time frame described in the facility policy.

Based on interview and record review, the facility failed to implement their infection control policy related to water management for the prevention of Legionnaires' disease. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: A facility procedure, titled Legionnaires' Disease, dated September 2019, read in part, .Assess the facility's wear [sic] system risk of Legionella. Develop a water management strategies to reduce the risk of the growth and spread of Legionella if a risk assessment determines the facility to be at risk .1. Complete a facility assessment of the water system. A map/diagram will be developed which will show how the water enters and travels through the building. 2. Develop water management strategies for the facility's hot and cold water distributions system . On 01/18/23 at 2:58 p.m., the corporate administrator reported the facility did not know anything about water management for the prevention of Legionella. She confirmed the Legionnaires' Disease policy had not been implemented.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to ensure staff competency related to assessing and monitoring and physician notification. Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], [DATE], and [DATE], the resident exhibited signs of symptoms of a change in her respiratory status. Staff did not assess for the cause of the change in respiratory status. The staff did not monitor the resident after showing signs of a change in condition. The staff did not notify the physician of a significant change in the resident's condition. On [DATE], the resident was found unresponsive. Cardiopulmonary resuscitation was started but was unsuccessful. The resident expired on [DATE]. At 11:46 a.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 11:49 a.m., the administration, director of nursing, and corporate administrator were notified of the IJ situation related to the facility's failure to ensure competency of staff related to assessing and monitoring and physician notification of a significant change in condition. On [DATE] at 3:57 p.m., an acceptable plan of removal was provided. The plan of removal documented, . 1. All residents in the facility who currently have oxygen will be reassessed by a Licensed Nurse to ensure that the oxygen liter flow being delivered matches the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All findings will be documented in their medical record. [Physician name withheld] will be notified of any abnormal findings . '' 2. In-services will be initiated immediately for all Licensed Nurses concerning respiratory assessment. These in-services will be continued/conducted for Licensed Nurses as they report to work for their shifts to ensure all Licensed Staff receive training. This will include: ~ Symptoms of low O2 [oxygen] sats [saturation] and high O2 sats, ~ Following treatment orders for breathing treatments such as nebulizers which will include checking MD order for the treatment and documentation on the MARS/TARS [medication administration sheets/treatment administraton sheets] after the treatment is administered. ~ Ensuring all oxygen flow is delivered per physician order ~ Notifying the physician for any abnormal pulse ox reading, changes in mental status complaints of SOB [shortness of breath], cough, and abnormal lung sounds . 3. In-service will be initiated immediately for all Licensed Nurses concerning notification of physician for any resident change in condition. This will include any new resident complaints, any subtle changes in resident's ADL [activities of daily living] abilities, subtle changes in resident's level of consciousness or cognition, changes in vital signs, increased SOB, etc. This in-service will also include notification of physician if any medication is not available for administration - Nurse may not 'hold' a medication without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 4. In-service will be initiated immediately for all Licensed Nurses concerning addressing O2 flow rates . 5. Pharmacy will conduct medication audit for all residents in the facility to ensure that all ordered medications are present for administration. These audits will be initiated this afternoon . 6. Direct Care Nursing staff to be in-serviced immediately concerning notification to Charge Nurse any changes noted in a resident's condition. This will include any resident complaint of discomfort, changes in resident's ability to perform ADLs, changes in resident's cognition, changes in resident's level of alertness, changes in resident's communication, noted increased weakness or balance issues . 7. Direct Care staff will be questioned upon completion of the above in-service, if they have any resident that has had changes in condition. Any resident noted will be reassessed by a Licensed Nurse with the assessment documented in the resident's medical record and notification of the changes, if noted, to the physician . 8. Nurse Managers will check the Oxygen Administration for all residents receiving oxygen daily x the next week to ensure that the oxygen flow rates are being administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9. Facility has posted the INTERACT Care Path for symptoms of SOB and the INTERACT Care Path for Acute Mental Status Change . 10. Any employee who was unable to come to facility for in service will be taken off of the schedule until they can be in services . The immediate jeopardy was removed on [DATE] at 10:20 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on interview and record review, it was determined the facility failed to ensure staff competency related to assessing and monitoring and physician notification of a significant change in condition for one (#68) of 24 sampled residents reviewed for change in condition after the resident exhibited signs of a change in respiratory status. This had the potential to affect 64 of 64 residents who resided at the facility. Findings: A hospital history and physical report for resident #68, dated [DATE] and located in the facility's scanned documents, documented, . PMH [past medical history] of . [CONDITION(S)] previously on [MEDICATION(S)] who presents . with CC [chief complaint] of numbness and tingling to her left lower leg . intermittent numbness and tingling to left lower leg and occasionally similar symptoms to the right lower leg and bilateral wrists. Her symptoms have been progressive. Over the last month, she has had more constant numbness and tingling to the left lower leg and foot. She now reports a cold feeling to the limb. She had not previously sought medical attention after losing her job and health insurance . No chest pain or shortness of breath . palpitation intermittently. She stopped taking her [MEDICATION(S)] about 3 to 5 days ago after running out of medication . Hospital discharge documentation, dated [DATE] and located in the facility's scanned documents, documented, . Your Diagnosis[:] [CONDITION(S)] Flutter, physical deconditioning, right leg [CONDITION(S)] (DVT) . multiple rib fractures due to CPR, pneumonia, acute hypoxemic [CONDITION(S)], cardiogenic shock, acute intraoperative massive pulmonary embolism - s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Home needs: oxygen; 'Contact physician for: increased swelling, chest pain' 'Contact physician for: increased shortness of breath . ' Education: . [CONDITION(S)] Flutter . get help right away if you have: . shortness of breath . [CONDITION(S)] . get help right away if: . you have chest pain or trouble breathing . [CONDITION(S)] . get help right away if: . you have . shortness of breath . Cardiogenic shock . what are the signs or symptoms . shallow, quick breathing, or shortness of breath . Get help right away if you: . Have shortness of breath . Discharge physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication administration note, dated [DATE] at 8:23 p.m., documented, . waiting on pharmacy . A medication administration note, dated [DATE] at 9:10 a.m., documented, . [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth two times a day related to chronic embolism and [CONDITION(S)] of unspecified deep veins of unspecified lower extremity . A medication administration note, dated [DATE] at 9:44 a.m., documented, . Pharmacy notified that medication [MEDICATION(S)] has not made it to facility, pharmacist stated the medication needed insurance approval and he would be sending a form over to the facility to fill out. [MEDICATION(S)] Tablet 5 MG placed on hold until paperwork can be submitted to insurance . Review of facility medication administration records revealed the resident did not receive [MEDICATION(S)], as ordered by the physician from admission on [DATE] until 8:00 p.m. on [DATE]. The resident's care plan, dated [DATE], documented the resident had a problem related to an imbalance between oxygen supply and demand. The goal was the resident would maintain blood pressure, pulse, and respirations within prescribed limits during activity through the review date. Interventions included to administer medications as prescribed; assess for signs and symptoms of activity intolerance such as statements of fatigue and weakness, exertional dyspnea, and chest pain; and to report decreased activity tolerance to the physician. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making; required limited assistance for most activities of daily living; had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident was not receiving an anticoagulant medication. A progress note, dated [DATE] at 4:34 p.m., documented, . Resident arrived in facility . No acute distress or discomfort noted . One person limited assist is required for transfers and ambulation due to general weakness. Continent of bowel and bladder with occasional episodes of incontinence requiring extensive assist. Staff strive to keep call light and fluids within easy reach. A progress note, dated [DATE] at 1:40 a.m., documented, . respirations unlabored via nasal cannula, in place and patent . A health status note, dated [DATE] at 7:13 a.m., documented, . Respirations are even and unlabored, clear to auscultation . Resident uses oxygen via nasal cannula, respirations unlabored . O2 at 2LPM [two liters per minute] via nasal cannula . for Shortness of Breath related to acute [CONDITION(S)] with [CONDITION(S)] . A health status note, dated [DATE] at 7:45 a.m., documented, . respirations easy on room air 02 off for awhile giving nose a rest continues with good 02 Sat on room air . A health status note, dated [DATE] at 9:57 a.m., documented, . Respiration with ease 02 flowing at 2LPM via NC. [nasal cannula] . A health status note, dated [DATE] at 11:40 a.m., documented, . focused assessment r/t [related to] resident requesting breathing treatment. no orders for breathing treatment. [physician name withheld] office notified with a request of breathing treatments . Review of the resident's clinical record revealed no documentation the resident's respiratory status was assessed and monitored. There was no documentation the physician's office was notified of the resident's request for a breathing treatment. There was no documentation an order was received for a breathing treatment or that one was provided. A health status note, dated [DATE] at 1:48 p.m., documented, . focused assessment r/t resident continues to tell staff she can't breath, 02 sat 99%. 02 bumped up to 3L/NC. resident setting on side of bed leaning forward, nurse spoke with resident about trying to relax and breath in through her nose out through her mouth . Review of the resident's clinical documentation reveals no documentation the resident's physician was notified after the resident complained of being unable to breath on [DATE]. There was no documentation the facility assessed and monitored the resident for a change in condition except checking her blood oxygen level. There was no documentation the facility notified the physician of the increase in the oxygen flow rate. There was no documentation of any previous reports that the resident was unable to breath. A health status note, dated [DATE] at 11:10 a.m., documented, . focused assessment r/t residents breathing pattern. Resident is breathing with her mouth open and her oxygen in her mouth. Residents O2 sat 94 on 3L . Review of the resident's clinical record revealed no documentation the resident's physician was notified of the resident's decreased blood oxygenation level and continued difficulties with breathing on [DATE]. There was no documentation the facility assessed and monitored the resident for a change in condition except for checking her blood oxygen level. A health status note, dated [DATE] at 1:49 a.m., documented, . [12:50 a.m.] entered resident room and noted resident wasn't breathing. Resident assisted to floor with assist of 3 staff CPR [cardiopulmonary resuscitation] started nurse from back nurses station called EMS [Emergency Medical Services]. EMS here at 1 am CPR stopped at that time. EMT's [emergency medical technicians] received order to stop CPR at that time . On [DATE] at 9:59 a.m., licensed practical nurse (LPN) #5, who was the resident's nurse, was asked what the resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #5 was asked what things were monitored for with these diagnoses. She stated, Pulse ox [blood saturation level], breathing, color of the skin, if diaphoretic. LPN #5 was asked what the facility did when the resident requested a breathing treatment on [DATE]. She stated, I guess I should have followed up with that. She stated she had notified the physician, received an order, and then started with the breathing treatment he had ordered. She was asked where the order was documented. She reviewed the clinical record and stated, I don't see it do I. I don't see one. She stated there was no documentation a breathing treatment had been given. LPN #5 was asked what the facility did after the resident complained of being unable to breath on [DATE]. She stated, I made sure the head of the bed was raised and repositioned her. She stated, With mouth breathing, I put the oxygen in her mouth and turned it up to make sure she was breathing it in. She stated the resident's blood oxygen saturation levels were in the middle 90's. She stated, I didn't do very good charting. LPN #5 was asked if she notified the physician. She stated, I always fax him. She was asked where it was documented the physician was notified of the resident's complaint of being unable to breath and that she had turned the oxygen flow rate up. She stated, Should be in the chart. LPN #5 was asked how the resident was assessed and monitored following the change in condition. She stated, I just kept watching her, making sure she did not turn blue, that her O2 sats were in the 90s. She stated she tried to do some relaxing with the resident and tried to get her to breath through her mouth and not her nose. LPN #5 was asked how the resident was assessed and monitored on [DATE] after she was noted to have a change in her breathing pattern and continued with mouth breathing and using the oxygen nasal cannula in her mouth and where it was documented. She stated, Clearly, it's not there. She was asked if the physician was notified on [DATE] and how he was notified. She stated, We have to fax him every time. She was asked if she faxed him on this date. She shook her head in a yes motion and stated it should be on the chart. LPN #5 was asked what the facility did after the resident continued to have a change in her breathing patterns on [DATE]. She stated, She [the resident] wouldn't let me send her to the hospital. I just kept monitoring her O2 sats. She was asked where that was documented. She stated, I didn't chart that either. LPN #5 was asked if there was any other place the information might be documented. She stated, Everything I would have charted would be in this area right here [pointed at the progress note section of the electronic medical record]. Other than me doing it, it it's not charted, it's not done. On [DATE] at 10:18 a.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked where the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They reviewed the clinical record, and the ADON stated, I don't see an order. The DON stated, I don't either. They were asked where the documentation was the resident received a breathing treatment. The ADON stated, I don't see it on any MAR [medication administration sheet]. The DON and ADON were asked what the staff did when the resident began to have complaints of being unable to breath on [DATE]. The ADON stated, It looks like they did the deep breathing and breathing through her mouth for that day. They were asked where it was documented the physician was notified. They reviewed the clinical record, and the ADON stated, I did not see any in the notes. They were asked where it was documented the staff assessed and monitored the resident after complaining of being unable to breathe. The ADON stated, I don't see that. The DON and ADON were asked how the staff assessed and monitor the resident on [DATE] after she was noted to have a change in her breathing pattern, breathing with her mouth open, and her oxygen in her mouth. The ADON stated, I don't see any assessments. They were asked what the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They were asked what the staff should have been monitoring for in relation to the resident's diagnoses. The ADON stated, All the respiratory stuff, shortness of breath, fluid overload. The DON and ADON were asked how often the resident's oxygen saturation levels were monitored. They reviewed the clinical record and stated the levels were being checked once to twice daily through [DATE]. The ADON stated when a resident was admitted on Intermediate Care, their levels were usually charted for 72 hours and then stopped, but if there was a change in condition, staff should chart on them for that length of care again. They were asked if the resident was exhibiting signs of a condition change. The ADON stated, Yes, she was with the breathing problems. They were asked what happened to the resident. The ADON stated, She expired after she coded. The DON and ADON were asked how the physician was notified of the resident's continued difficulties with breathing. The ADON stated the staff would have notified him via fax. She was asked where that information was. She stated it should be on the chart. The surveyor informed her there was no documentation the physician was notified. They were asked why the staff did not notify the physician. The ADON stated, I can't answer that. I'm not the nurse. They were asked why the staff did not assess and monitor the resident after she began to have difficulties breathing. The ADON stated, I can't answer that either. I don't know what else to say other than they didn't do it. The DON and ADON were asked how they ensured the nursing staff was competent to care for the residents with cardiac issues. They stated competency checks were done yearly. They were asked if the staff was assessed for competency related to cardiac and respiratory concerns. The ADON stated it was added into their evaluations. They were asked if, in their professional opinion, the staff acted with competency with the resident's care. The ADON stated, I don't think they did. The DON stated, I have to agree with that. On [DATE] at 11:09 a.m., the resident's physician was asked if the facility had notified him the resident had missed dosage of [MEDICATION(S)] from admission on [DATE] until 8:00 p.m. on [DATE]. He stated he did not recall it, but they may have. He stated sometimes they had trouble getting insurance companies to pay for [MEDICATION(S)]. He was asked what the dangers were of a resident not receiving their [MEDICATION(S)]. He stated they could certainly have a pulmonary embolis or stroke. He stated he would normally place a resident on [MEDICATION(S)] (an anticoagulant) until a resident was able to get their [MEDICATION(S)]. The physician was asked what the staff should have been monitoring the resident for. He stated oxygen levels, normal vitals signs, and respiratory status. He was asked if the facility notified him on [DATE] when the resident stated she was have difficulty breathing. He stated he could remember being called on her, but he could not state what days or for what reason. He was asked if staff had notified him they had increased her oxygen flow rate. He stated he did not specifically remember the conversation. He was asked if the facility notified him on [DATE] when the resident continued to have difficulties breathing. He stated he did not remember. He was asked what his expectation was if a resident began to have a change in condition or began to show signs and symptoms of distress. He stated he expected to be notified.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to assess and monitor a resident with a significant change in condition. Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], [DATE], and [DATE], the resident exhibited signs of symptoms of a change in her respiratory status. Staff did not assess for the cause of the change in respiratory status. The staff did not monitor the resident after showing signs of a change in condition. On [DATE], the resident was found unresponsive. Cardiopulmonary resuscitation was started but was unsuccessful. The resident expired on [DATE]. At 11:46 a.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 11:49 a.m., the administration, director of nursing, and corporate administrator were notified of the IJ situation related to the facility's failure to assess and monitor the resident. On [DATE] at 3:57 p.m., an acceptable plan of removal was provided. The plan of removal documented, . 1. All residents in the facility who currently have oxygen will be reassessed by a Licensed Nurse to ensure that the oxygen liter flow being delivered matches the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All findings will be documented in their medical record. [Physician name withheld] will be notified of any abnormal findings . '' 2. In-services will be initiated immediately for all Licensed Nurses concerning respiratory assessment. These in-services will be continued/conducted for Licensed Nurses as they report to work for their shifts to ensure all Licensed Staff receive training. This will include: ~ Symptoms of low O2 sats [oxygen saturation] and high O2 sats, ~ Following treatment orders for breathing treatments such as nebulizers which will include checking MD order for the treatment and documentation on the MARS/TARS [medication administration sheets/treatment administration sheets] after the treatment is administered. ~ Ensuring all oxygen flow is delivered per physician order ~ Notifying the physician for any abnormal pulse ox reading, changes in mental status complaints of SOB [shortness of breath], cough, and abnormal lung sounds . 3. In-service will be initiated immediately for all Licensed Nurses concerning notification of physician for any resident change in condition. This will include any new resident complaints, any subtle changes in resident's ADL [activities of daily living] abilities, subtle changes in resident's level of consciousness or cognition, changes in vital signs, increased SOB, etc. This in-service will also include notification of physician if any medication is not available for administration - Nurse may not 'hold' a medication without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 4. In-service will be initiated immediately for all Licensed Nurses concerning addressing O2 flow rates . 5. Pharmacy will conduct medication audit for all residents in the facility to ensure that all ordered medications are present for administration. These audits will be initiated this afternoon . 6. Direct Care Nursing staff to be in-serviced immediately concerning notification to Charge Nurse any changes noted in a resident's condition. This will include any resident complaint of discomfort, changes in resident's ability to perform ADLs, changes in resident's cognition, changes in resident's level of alertness, changes in resident's communication, noted increased weakness or balance issues . 7. Direct Care staff will be questioned upon completion of the above in-service, if they have any resident that has had changes in condition. Any resident noted will be reassessed by a Licensed Nurse with the assessment documented in the resident's medical record and notification of the changes, if noted, to the physician . 8. Nurse Managers will check the Oxygen Administration for all residents receiving oxygen daily x the next week to ensure that the oxygen flow rates are being administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9. Facility has posted the INTERACT Care Path for symptoms of SOB and the INTERACT Care Path for Acute Mental Status Change . 10. Any employee who was unable to come to facility for in service will be taken off of the schedule until they can be in services . The immediate jeopardy was removed on [DATE] at 10:20 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on interview and record review, it was determined the facility failed to assess and monitor one (#68) of 24 sampled residents reviewed for change in condition after the resident exhibited signs of a change in respiratory status. This had the potential to affect 64 of 64 residents who resided at the facility. Findings: A hospital history and physical report for resident #68, dated [DATE] and located in the facility's scanned documents, documented, . PMH [past medical history] of . [CONDITION(S)] previously on [MEDICATION(S)] who presents . with CC [chief complaint] of numbness and tingling to her left lower leg . intermittent numbness and tingling to left lower leg and occasionally similar symptoms to the right lower leg and bilateral wrists. Her symptoms have been progressive. Over the last month, she has had more constant numbness and tingling to the left lower leg and foot. She now reports a cold feeling to the limb. She had not previously sought medical attention after losing her job and health insurance . No chest pain or shortness of breath . palpitation intermittently. She stopped taking her [MEDICATION(S)] about 3 to 5 days ago after running out of medication . Hospital discharge documentation, dated [DATE] and located in the facility's scanned documents, documented, . Your Diagnosis[:] [CONDITION(S)] Flutter, physical deconditioning, right leg [CONDITION(S)] (DVT) . multiple rib fractures due to CPR, pneumonia, acute hypoxemic [CONDITION(S)], cardiogenic shock, acute intraoperative massive pulmonary embolism - s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Home needs: oxygen; 'Contact physician for: increased swelling, chest pain' 'Contact physician for: increased shortness of breath . ' Education: . [CONDITION(S)] Flutter . get help right away if you have: . shortness of breath . [CONDITION(S)] . get help right away if: . you have chest pain or trouble breathing . [CONDITION(S)] . get help right away if: . you have . shortness of breath . Cardiogenic shock . what are the signs or symptoms . shallow, quick breathing, or shortness of breath . Get help right away if you: . Have shortness of breath . Discharge physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication administration note, dated [DATE] at 8:23 p.m., documented, . waiting on pharmacy . A medication administration note, dated [DATE] at 9:10 a.m., documented, . [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth two times a day related to chronic embolism and [CONDITION(S)] of unspecified deep veins of unspecified lower extremity . A medication administration note, dated [DATE] at 9:44 a.m., documented, . Pharmacy notified that medication [MEDICATION(S)] has not made it to facility, pharmacist stated the medication needed insurance approval and he would be sending a form over to the facility to fill out. [MEDICATION(S)] Tablet 5 MG placed on hold until paperwork can be submitted to insurance . Review of facility medication administration records revealed the resident did not receive [MEDICATION(S)], as ordered by the physician from admission on [DATE] until 8:00 p.m. on [DATE]. The resident's care plan, dated [DATE], documented the resident had a problem related to an imbalance between oxygen supply and demand. The goal was the resident would maintain blood pressure, pulse, and respirations within prescribed limits during activity through the review date. Interventions included to administer medications as prescribed; assess for signs and symptoms of activity intolerance such as statements of fatigue and weakness, exertional dyspnea, and chest pain; and to report decreased activity tolerance to the physician. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making; required limited assistance for most activities of daily living; had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident was not receiving an anticoagulant medication. A progress note, dated [DATE] at 4:34 p.m., documented, . Resident arrived in facility . No acute distress or discomfort noted . One person limited assist is required for transfers and ambulation due to general weakness. Continent of bowel and bladder with occasional episodes of incontinence requiring extensive assist. Staff strive to keep call light and fluids within easy reach. A progress note, dated [DATE] at 1:40 a.m., documented, . respirations unlabored via nasal cannula, in place and patent . A health status note, dated [DATE] at 7:13 a.m., documented, . Respirations are even and unlabored, clear to auscultation . Resident uses oxygen via nasal cannula, respirations unlabored . O2 at 2LPM [two liters per minute] via nasal cannula . for Shortness of Breath related to acute [CONDITION(S)] with [CONDITION(S)] . A health status note, dated [DATE] at 7:45 a.m., documented, . respirations easy on room air 02 off for awhile giving nose a rest continues with good 02 Sat on room air . A health status note, dated [DATE] at 9:57 a.m., documented, . Respiration with ease 02 flowing at 2LPM via NC. [nasal cannula] . A health status note, dated [DATE] at 11:40 a.m., documented, . focused assessment r/t [related to] resident requesting breathing treatment. no orders for breathing treatment. [physician name withheld] office notified with a request of breathing treatments . Review of the resident's clinical record revealed no documentation the resident's respiratory status was assessed and monitored. There was no documentation the physician's office was notified of the resident's request for a breathing treatment. There was no documentation an order was received for a breathing treatment or that one was provided. A health status note, dated [DATE] at 1:48 p.m., documented, . focused assessment r/t resident continues to tell staff she can't breath, 02 sat 99%. 02 bumped up to 3L/NC. resident setting on side of bed leaning forward, nurse spoke with resident about trying to relax and breath in through her nose out through her mouth . Review of the resident's clinical documentation reveals no documentation the resident's physician was notified after the resident complained of being unable to breath on [DATE]. There was no documentation the facility assessed and monitored the resident for a change in condition except checking her blood oxygen level. There was no documentation the facility notified the physician of the increase in the oxygen flow rate. There was no documentation of any previous reports that the resident was unable to breath. A health status note, dated [DATE] at 11:10 a.m., documented, . focused assessment r/t residents breathing pattern. Resident is breathing with her mouth open and her oxygen in her mouth. Residents O2 sat 94 on 3L . Review of the resident's clinical record revealed no documentation the resident's physician was notified of the resident's decreased blood oxygenation level and continued difficulties with breathing on [DATE]. There was no documentation the facility assessed and monitored the resident for a change in condition except for checking her blood oxygen level. A health status note, dated [DATE] at 1:49 a.m., documented, . [12:50 a.m.] entered resident room and noted resident wasn't breathing. Resident assisted to floor with assist of 3 staff CPR [cardiopulmonary resuscitation] started nurse from back nurses station called EMS [Emergency Medical Services]. EMS here at 1 am CPR stopped at that time. EMT's [emergency medical technicians] received order to stop CPR at that time . On [DATE] at 9:59 a.m., licensed practical nurse (LPN) #5, who was the resident's nurse, was asked what the resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #5 was asked what things were monitored for with these diagnoses. She stated, Pulse ox [blood saturation level], breathing, color of the skin, if diaphoretic. LPN #5 was asked what the facility did when the resident requested a breathing treatment on [DATE]. She stated, I guess I should have followed up with that. She stated she had notified the physician, received an order, and then started with the breathing treatment he had ordered. She was asked where the order was documented. She reviewed the clinical record and stated, I don't see it do I. I don't see one. She stated there was no documentation a breathing treatment had been given. LPN #5 was asked what the facility did after the resident complained of being unable to breath on [DATE]. She stated, I made sure the head of the bed was raised and repositioned her. She stated, With mouth breathing, I put the oxygen in her mouth and turned it up to make sure she was breathing it in. She stated the resident's blood oxygen saturation levels were in the middle 90's. She stated, I didn't do very good charting. LPN #5 was asked if she notified the physician. She stated, I always fax him. She was asked where it was documented the physician was notified of the resident's complaint of being unable to breath and that she had turned the oxygen flow rate up. She stated, Should be in the chart. LPN #5 was asked how the resident was assessed and monitored following the change in condition. She stated, I just kept watching her, making sure she did not turn blue, that her O2 sats were in the 90s. She stated she tried to do some relaxing with the resident and tried to get her to breath through her mouth and not her nose. LPN #5 was asked how the resident was assessed and monitored on [DATE] after she was noted to have a change in her breathing pattern and continued with mouth breathing and using the oxygen nasal cannula in her mouth and where it was documented. She stated, Clearly, it's not there. She was asked if the physician was notified on [DATE] and how he was notified. She stated, We have to fax him every time. She was asked if she faxed him on this date. She shook her head in a yes motion and stated it should be on the chart. LPN #5 was asked what the facility did after the resident continued to have a change in her breathing patterns on [DATE]. She stated, She [the resident] wouldn't let me send her to the hospital. I just kept monitoring her O2 sats. She was asked where that was documented. She stated, I didn't chart that either. LPN #5 was asked if there was any other place the information might be documented. She stated, Everything I would have charted would be in this area right here [pointed at the progress note section of the electronic medical record]. Other than me doing it, it it's not charted, it's not done. On [DATE] at 10:18 a.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked where the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They reviewed the clinical record, and the ADON stated, I don't see an order. The DON stated, I don't either. They were asked where the documentation was the resident received a breathing treatment. The ADON stated, I don't see it on any MAR [medication administration sheet]. The DON and ADON were asked what the staff did when the resident began to have complaints of being unable to breath on [DATE]. The ADON stated, It looks like they did the deep breathing and breathing through her mouth for that day. They were asked where it was documented the physician was notified. They reviewed the clinical record, and the ADON stated, I did not see any in the notes. They were asked where it was documented the staff assessed and monitored the resident after complaining of being unable to breathe. The ADON stated, I don't see that. The DON and ADON were asked how the staff assessed and monitor the resident on [DATE] after she was noted to have a change in her breathing pattern, breathing with her mouth open, and her oxygen in her mouth. The ADON stated, I don't see any assessments. They were asked what the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They were asked what the staff should have been monitoring for in relation to the resident's diagnoses. The ADON stated, All the respiratory stuff, shortness of breath, fluid overload. The DON and ADON were asked how often the resident's oxygen saturation levels were monitored. They reviewed the clinical record and stated the levels were being checked once to twice daily through [DATE]. The ADON stated when a resident was admitted on Intermediate Care, their levels were usually charted for 72 hours and then stopped, but if there was a change in condition, staff should chart on them for that length of care again. They were asked if the resident was exhibiting signs of a condition change. The ADON stated, Yes, she was with the breathing problems. They were asked what happened to the resident. The ADON stated, She expired after she coded. The DON and ADON were asked how the physician was notified of the resident's continued difficulties with breathing. The ADON stated the staff would have notified him via fax. She was asked where that information was. She stated it should be on the chart. The surveyor informed her there was no documentation the physician was notified. They were asked why the staff did not notify the physician. The ADON stated, I can't answer that. I'm not the nurse. They were asked why the staff did not assess and monitor the resident after she began to have difficulties breathing. The ADON stated, I can't answer that either. I don't know what else to say other than they didn't do it. The DON and ADON were asked how they ensured the nursing staff was competent to care for the residents with cardiac issues. They stated competency checks were done yearly. They were asked if the staff was assessed for competency related to cardiac and respiratory concerns. The ADON stated it was added into their evaluations. They were asked if, in their professional opinion, the staff acted with competency with the resident's care. The ADON stated, I don't think they did. The DON stated, I have to agree with that. On [DATE] at 11:09 a.m., the resident's physician was asked if the facility had notified him the resident had missed dosage of [MEDICATION(S)] from admission on [DATE] until 8:00 p.m. on [DATE]. He stated he did not recall it, but they may have. He stated sometimes they had trouble getting insurance companies to pay for [MEDICATION(S)]. He was asked what the dangers were of a resident not receiving their [MEDICATION(S)]. He stated they could certainly have a pulmonary embolis or stroke. He stated he would normally place a resident on [MEDICATION(S)] (an anticoagulant) until a resident was able to get their [MEDICATION(S)]. The physician was asked what the staff should have been monitoring the resident for. He stated oxygen levels, normal vitals signs, and respiratory status. He was asked if the facility notified him on [DATE] when the resident stated she was have difficulty breathing. He stated he could remember being called on her, but he could not state what days or for what reason. He was asked if staff had notified him they had increased her oxygen flow rate. He stated he did not specifically remember the conversation. He was asked if the facility notified him on [DATE] when the resident continued to have difficulties breathing. He stated he did not remember. He was asked what his expectation was if a resident began to have a change in condition or began to show signs and symptoms of distress. He stated he expected to be notified.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to notify the physician when a resident had a significant change in condition. Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], [DATE], and [DATE], the resident exhibited signs of symptoms of a change in her respiratory status. Staff did not notify the physician when the resident showed signs of a change in her respiratory status. On [DATE], the resident was found unresponsive. Cardiopulmonary resuscitation was started but was unsuccessful. The resident expired on [DATE]. At 11:46 a.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 11:49 a.m., the administration, director of nursing, and corporate administrator were notified of the IJ situation related to the facility's failure to notify the physician of a significant change in condition. On [DATE] at 3:57 p.m., an acceptable plan of removal was provided. The plan of removal documented, . 1. All residents in the facility who currently have oxygen will be reassessed by a Licensed Nurse to ensure that the oxygen liter flow being delivered matches the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All findings will be documented in their medical record. [Physician name withheld] will be notified of any abnormal findings . '' 2. In-services will be initiated immediately for all Licensed Nurses concerning respiratory assessment. These in-services will be continued/conducted for Licensed Nurses as they report to work for their shifts to ensure all Licensed Staff receive training. This will include: ~ Symptoms of low O2 sats [oxygen saturation] and high O2 sats, ~ Following treatment orders for breathing treatments such as nebulizers which will include checking MD order for the treatment and documentation on the MARS/TARS [medication administration sheets/treatment administration sheets] after the treatment is administered. ~ Ensuring all oxygen flow is delivered per physician order ~ Notifying the physician for any abnormal pulse ox reading, changes in mental status complaints of SOB [shortness of breath], cough, and abnormal lung sounds . 3. In-service will be initiated immediately for all Licensed Nurses concerning notification of physician for any resident change in condition. This will include any new resident complaints, any subtle changes in resident's ADL [activities of daily living] abilities, subtle changes in resident's level of consciousness or cognition, changes in vital signs, increased SOB, etc. This in-service will also include notification of physician if any medication is not available for administration - Nurse may not 'hold' a medication without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 4. In-service will be initiated immediately for all Licensed Nurses concerning addressing O2 flow rates . 5. Pharmacy will conduct medication audit for all residents in the facility to ensure that all ordered medications are present for administration. These audits will be initiated this afternoon . 6. Direct Care Nursing staff to be in-serviced immediately concerning notification to Charge Nurse any changes noted in a resident's condition. This will include any resident complaint of discomfort, changes in resident's ability to perform ADLs, changes in resident's cognition, changes in resident's level of alertness, changes in resident's communication, noted increased weakness or balance issues . 7. Direct Care staff will be questioned upon completion of the above in-service, if they have any resident that has had changes in condition. Any resident noted will be reassessed by a Licensed Nurse with the assessment documented in the resident's medical record and notification of the changes, if noted, to the physician . 8. Nurse Managers will check the Oxygen Administration for all residents receiving oxygen daily x the next week to ensure that the oxygen flow rates are being administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9. Facility has posted the INTERACT Care Path for symptoms of SOB and the INTERACT Care Path for Acute Mental Status Change . 10. Any employee who was unable to come to facility for in service will be taken off of the schedule until they can be in services . The immediate jeopardy was removed on [DATE] at 10:20 p.m. when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on interview and record review, it was determined the facility failed to notify the physician of a significant change in condition for one (#68) of 24 sampled residents reviewed for change in condition after the resident exhibited signs of a change in respiratory status. This had the potential to affect 64 of 64 residents who resided at the facility. Findings: A hospital history and physical report for resident #68, dated [DATE] and located in the facility's scanned documents, documented, . PMH [past medical history] of . [CONDITION(S)] previously on [MEDICATION(S)] who presents . with CC [chief complaint] of numbness and tingling to her left lower leg . intermittent numbness and tingling to left lower leg and occasionally similar symptoms to the right lower leg and bilateral wrists. Her symptoms have been progressive. Over the last month, she has had more constant numbness and tingling to the left lower leg and foot. She now reports a cold feeling to the limb. She had not previously sought medical attention after losing her job and health insurance . No chest pain or shortness of breath . palpitation intermittently. She stopped taking her [MEDICATION(S)] about 3 to 5 days ago after running out of medication . Hospital discharge documentation, dated [DATE] and located in the facility's scanned documents, documented, . Your Diagnosis[:] [CONDITION(S)] Flutter, physical deconditioning, right leg [CONDITION(S)] (DVT) . multiple rib fractures due to CPR, pneumonia, acute hypoxemic [CONDITION(S)], cardiogenic shock, acute intraoperative massive pulmonary embolism - s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Home needs: oxygen; 'Contact physician for: increased swelling, chest pain' 'Contact physician for: increased shortness of breath . ' Education: . [CONDITION(S)] Flutter . get help right away if you have: . shortness of breath . [CONDITION(S)] . get help right away if: . you have chest pain or trouble breathing . [CONDITION(S)] . get help right away if: . you have . shortness of breath . Cardiogenic shock . what are the signs or symptoms . shallow, quick breathing, or shortness of breath . Get help right away if you: . Have shortness of breath . Discharge physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication administration note, dated [DATE] at 8:23 p.m., documented, . waiting on pharmacy . A medication administration note, dated [DATE] at 9:10 a.m., documented, . [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth two times a day related to chronic embolism and [CONDITION(S)] of unspecified deep veins of unspecified lower extremity . A medication administration note, dated [DATE] at 9:44 a.m., documented, . Pharmacy notified that medication [MEDICATION(S)] has not made it to facility, pharmacist stated the medication needed insurance approval and he would be sending a form over to the facility to fill out. [MEDICATION(S)] Tablet 5 MG placed on hold until paperwork can be submitted to insurance . Review of facility medication administration records revealed the resident did not receive [MEDICATION(S)], as ordered by the physician from admission on [DATE] until 8:00 p.m. on [DATE]. There was no documentation to show the physician was notified the resident did not receive the ordered medication. The resident's care plan, dated [DATE], documented the resident had a problem related to an imbalance between oxygen supply and demand. The goal was the resident would maintain blood pressure, pulse, and respirations within prescribed limits during activity through the review date. Interventions included to administer medications as prescribed; assess for signs and symptoms of activity intolerance such as statements of fatigue and weakness, exertional dyspnea, and chest pain; and to report decreased activity tolerance to the physician. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making; required limited assistance for most activities of daily living; had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident was not receiving an anticoagulant medication. A progress note, dated [DATE] at 4:34 p.m., documented, . Resident arrived in facility . No acute distress or discomfort noted . One person limited assist is required for transfers and ambulation due to general weakness. Continent of bowel and bladder with occasional episodes of incontinence requiring extensive assist. Staff strive to keep call light and fluids within easy reach. A progress note, dated [DATE] at 1:40 a.m., documented, . respirations unlabored via nasal cannula, in place and patent . A health status note, dated [DATE] at 7:13 a.m., documented, . Respirations are even and unlabored, clear to auscultation . Resident uses oxygen via nasal cannula, respirations unlabored . O2 at 2LPM [two liters per minute] via nasal cannula . for Shortness of Breath related to acute [CONDITION(S)] with [CONDITION(S)] . A health status note, dated [DATE] at 7:45 a.m., documented, . respirations easy on room air 02 off for awhile giving nose a rest continues with good 02 Sat on room air . A health status note, dated [DATE] at 9:57 a.m., documented, . Respiration with ease 02 flowing at 2LPM via NC. [nasal cannula] . A health status note, dated [DATE] at 11:40 a.m., documented, . focused assessment r/t [related to] resident requesting breathing treatment. no orders for breathing treatment. [physician name withheld] office notified with a request of breathing treatments . Review of the resident's clinical record revealed no documentation the resident's respiratory status was assessed and monitored. There was no documentation the physician's office was notified of the resident's request for a breathing treatment. There was no documentation an order was received for a breathing treatment or that one was provided. A health status note, dated [DATE] at 1:48 p.m., documented, . focused assessment r/t resident continues to tell staff she can't breath, 02 sat [blood oxygen level] 99%. 02 bumped up to 3L/NC. resident setting on side of bed leaning forward, nurse spoke with resident about trying to relax and breath in through her nose out through her mouth . Review of the resident's clinical documentation reveals no documentation the resident's physician was notified after the resident complained of being unable to breath on [DATE]. There was no documentation the facility notified the physician of the increase in the oxygen flow rate. There was no documentation of any previous reports that the resident was unable to breath. A health status note, dated [DATE] at 11:10 a.m., documented, . focused assessment r/t residents breathing pattern. Resident is breathing with her mouth open and her oxygen in her mouth. Residents O2 sat 94 on 3L . Review of the resident's clinical record revealed no documentation the resident's physician was notified of the resident's decreased blood oxygenation level and continued difficulties with breathing on [DATE]. A health status note, dated [DATE] at 1:49 a.m., documented, . [12:50 a.m.] entered resident room and noted resident wasn't breathing. Resident assisted to floor with assist of 3 staff CPR [cardiopulmonary resuscitation] started nurse from back nurses station called EMS [Emergency Medical Services]. EMS here at 1 am CPR stopped at that time. EMT's [emergency medical technicians] received order to stop CPR at that time . On [DATE] at 9:59 a.m., licensed practical nurse (LPN) #5, who was the resident's nurse, was asked what the resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #5 was asked what things were monitored for with these diagnoses. She stated, Pulse ox [blood saturation level], breathing, color of the skin, if diaphoretic. LPN #5 was asked what the facility did when the resident requested a breathing treatment on [DATE]. She stated, I guess I should have followed up with that. She stated she had notified the physician, received an order, and then started with the breathing treatment he had ordered. She was asked where the order was documented. She reviewed the clinical record and stated, I don't see it do I. I don't see one. She stated there was no documentation a breathing treatment had been given. LPN #5 was asked what the facility did after the resident complained of being unable to breath on [DATE]. She stated, I made sure the head of the bed was raised and repositioned her. She stated, With mouth breathing, I put the oxygen in her mouth and turned it up to make sure she was breathing it in. She stated the resident's blood oxygen saturation levels were in the middle 90's. She stated, I didn't do very good charting. LPN #5 was asked if she notified the physician. She stated, I always fax him. She was asked where it was documented the physician was notified of the resident's complaint of being unable to breath and that she had turned the oxygen flow rate up. She stated, Should be in the chart. LPN #5 was asked if the physician was notified on [DATE] and how he was notified. She stated, We have to fax him every time. She was asked if she faxed him on this date. She shook her head in a yes motion and stated it should be on the chart. LPN #5 was asked if there was any other place the information might be documented. She stated, Everything I would have charted would be in this area right here [pointed at the progress note section of the electronic medical record]. Other than me doing it, it it's not charted, it's not done. On [DATE] at 10:18 a.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked where the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They reviewed the clinical record, and the ADON stated, I don't see an order. The DON stated, I don't either. They were asked where the documentation was the resident received a breathing treatment. The ADON stated, I don't see it on any MAR [medication administration sheet]. The DON and ADON were asked what the staff did when the resident began to have complaints of being unable to breath on [DATE]. The ADON stated, It looks like they did the deep breathing and breathing through her mouth for that day. They were asked where it was documented the physician was notified. They reviewed the clinical record, and the ADON stated, I did not see any in the notes. The DON and ADON were asked how the staff assessed and monitor the resident on [DATE] after she was noted to have a change in her breathing pattern, breathing with her mouth open, and her oxygen in her mouth. The ADON stated, I don't see any assessments. The DON and ADON were asked how the physician was notified of the resident's continued difficulties with breathing on [DATE]. The ADON stated the staff would have notified him via fax. She was asked where that information was. She stated it should be on the chart. The surveyor informed her there was no documentation the physician was notified. They were asked why the staff did not notify the physician. The ADON stated, I can't answer that. I'm not the nurse. On [DATE] at 11:09 a.m., the resident's physician was asked if the facility had notified him the resident had missed dosage of [MEDICATION(S)] from admission on [DATE] until 8:00 p.m. on [DATE]. He stated he did not recall it, but they may have. He stated sometimes they had trouble getting insurance companies to pay for [MEDICATION(S)]. He was asked what the dangers were of a resident not receiving their [MEDICATION(S)]. He stated they could certainly have a pulmonary embolis or stroke. He stated he would normally place a resident on [MEDICATION(S)] (an anticoagulant) until a resident was able to get their [MEDICATION(S)]. The physician was asked what the staff should have been monitoring the resident for. He stated oxygen levels, normal vitals signs, and respiratory status. He was asked if the facility notified him on [DATE] when the resident stated she was have difficulty breathing. He stated he could remember being called on her, but he could not state what days or for what reason. He was asked if staff had notified him they had increased her oxygen flow rate. He stated he did not specifically remember the conversation. He was asked if the facility notified him on [DATE] when the resident continued to have difficulties breathing. He stated he did not remember. He was asked what his expectation was if a resident began to have a change in condition or began to show signs and symptoms of distress. He stated he expected to be notified.

Based on observation, interview, and record review, it was determined the facility failed to have an effective administration who ensured: a. there was sufficient competent licensed nursing staff to ensure physicians were notified when there was a significant change in a resident's respiratory status and assessed and monitored a resident with changes in respiratory status; b. nursing staff identified and implemented non-pharmalogical interventions before initiating [CONDITION(S)] medications and monitored for adverse consequences of [CONDITION(S)] medications; and c. nursing staff identified and implemented interventions to aid in the prevention of falls. This had the potential to affect 64 of 64 residents who resided at the facility. Findings: 1. The facility failed to notify the physician of a significant change in condition for one (#3) of 24 sampled residents reviewed for change in condition after the resident exhibited signs of a change in respiratory status. This had the potential to affect 64 of 64 residents who resided at the facility. The findings at F580 are incorporated here by reference. 2. The facility failed to assess and monitor one (#3) of 24 sampled residents reviewed for change in condition after the resident exhibited signs of a change in respiratory status. This had the potential to affect 64 of 64 residents who resided at the facility. The findings at F684 are incorporated here by reference. 3. The facility failed to identify and implement non-pharmalogical interventions before initiating [CONDITION(S)] medications and/or failed to monitor for adverse consequences of [CONDITION(S)] medications for two (#19 and #53) of five sampled residents reviewed for unnecessary medications. The facility identified 62 residents as receiving [CONDITION(S)] medications. The findings at F758 are incorporated here by reference. 4. The facility failed to ensure two (#42 and #53) of three sampled residents who were reviewed for falls were provided supervision to prevent accidents when the facility did not identify and implement interventions to aid in the prevention of falls. Resident #42 suffered repeated falls without appropriate intervention with one fall resulting in a left femoral neck fracture. Resident #53 suffered repeated falls without appropriate intervention with one fall resulting in a left ulna fracture. The facility identified five residents with falls and major injury in the last six months. The findings at F689 are incorporated here by reference. On 08/17/21 at 12:32 p.m., the administrator, director of nursing (DON), and assistant director of nursing (ADON) were asked how they thought the harm level deficiency in falls and immediate jeopardy deficiencies related to physician notification and assessing and monitoring came to be. The administrator stated the immediate jeopardy situations came to be because of failure to follow up on concerns. She stated the harm level deficiency was because of ineffective interventions. She was asked how she would know there was a problem related to physician notification, assessing and monitoring, and fall interventions. She stated by someone telling her and reviewing the incident reports. The DON and ADON were asked how they identified concerns that needed to be brought to the administrator. The ADON stated by reviewing the production of the nurse, determining what they are lacking, documentation reviews, and reviewing physician orders. She was asked when she reviewed the clinical documentation. She stated she reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, it was determined the facility failed to ensure two (#42 and #53) of three sampled residents who were reviewed for falls were provided supervision to prevent accidents when the facility did not identify and implement interventions to aid in the prevention of falls. Resident #42 suffered repeated falls without appropriate intervention with one fall resulting in a left femoral neck fracture. Resident #53 suffered repeated falls without appropriate intervention with one fall resulting in a left ulna fracture. The facility identified five residents with falls and major injury in the last six months. Findings: The facility's guideline on accident/incident monthly log and follow-up, dated 12/2018, documented, . Track and trend all unusual occurrences (accidents/incidents), investigations, and the necessary follow-up action taken . Identify a particular resident and/or patient who is having repeated accidents/incidents . Analyze the data collected and calculated to determine how to reduce/prevent accidents/incidents from occurring . Attempt to identify trends and/or consistency to types, times, location, etc. of incidents . 1. Resident #42 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)], and gait/mobility abnormalities. A quarterly assessment, dated 03/11/21, documented the resident was severely impaired in cognitive skills for daily decision making. It was documented the resident required extensive assistance with bed mobility and transfers, had no functional impairments to the upper or lower extremities, and had no falls. An incident note, dated 04/13/21 at 5:27 p.m., documented, . CNA [certified nurse aide] reported to this nurse that resident was on fall mat beside bed. Upon entering room resident was observed lying on left side on fall mat wrapped up in blankets . No obvious s/s [signs or symptoms] injury noted . Resident assisted to bed x [by] 2 staff. New intervention for bed alarm to alert staff to needs . A facility accident/incident report, dated 04/14/31, documented, . resident to [sic] close to edge of bed rolled off . was reasonable cause of occurrence established . [marked yes] . state cause . resident rolled out of bed . place resident away from edge of bed while lying down . An incident note, dated 04/20/21 at 5:04 p.m., documented, . Resident observed on floor beside bed . What safety interventions were in place at the time of the occurrence: Fall mat in place, bed in low position, call light within reach, room well lit and clutter free . New interventions . Bed bolsters . A facility accident/incident report, dated 04/21/21, documented, . res observed on floor beside bed . AA [alert and oriented] x1 . was fall observed . no . resident room . lying in bed . slid out of bed . new interventions: bed bolsters . An incident note, dated 04/22/21 at 4:42 a.m., documented, . resident lying on left side beside bed with pillow under head and blankets on her body . What safety interventions were in place at the time of the occurrence: bed in lowest position, fall mat in place, call light within reach . New interventions added at time of incident to prevent re-occurrence: hourly safety checks . A facility accident/incident report, dated 04/22/21, documented, . rolled out of bed . new intervention - hourly checks . An incident note, dated 05/08/21, documented, . Describe occurrence in resident's words: I don't know how I fell . Resident lying on floor with blankets under her and pillow under her head . Factors that could have contributed to incident . Resident placed to [sic] close to edge of bed when turning on side . New interventions . Place resident in center of bed and to make sure she is not on the edge of the bed . New order received to x-ray left hip . A facility accident/incident report, dated 05/08/21, documented, . Summoned to room by CNA Resident lying on floor on fall matt [sic] c [with] blankets and under her and pillow. Resident slipe [sic] out of bed to floor r/t [related to] being placed to [sic] close to edge of bed . describe immediate action taken: to place resident in center of bed to prevent sliding out . A radiology report, dated 05/09/21, documented, . There is clear evidence of a fracture of the left femoral neck, with severe cephalad [towards the head] displacement of the distal fragment . A progress note, dated 05/13/21 at 9:30 a.m., documented, . return from hospital after left hip fracture . physicians have decided to left the fracture heal naturally . reconstruction was not possible . Staff will continue to monitor . An incident note, dated 05/16/21 at 10:30 p.m., documented, . Resident lying in floor at bed side. Lying on blankets and sheet . Fall matt [sic]. Call light in easy reach. Bolster placed in air mattress. Bed in lowest position. Bed locked . Continue checking on resident q [every] 1 [one] hour . The resident's care plan, dated 05/16/21, documented a problem related to being at moderate to high risk of falls. The goals included the resident would be free of falls through the review date. Interventions included bed bolsters, bed alarm, anticipate needs, to answer the call light promptly, simplify the environment, minimize environmental hazards, low bed, and to communicate fall risk and interventions to caregivers on every shift. A facility accident/incident report, dated 05/16/21, documented, . when nurse entered room found resident on floor with blanket [and] pillow; sheets under resident c/o [complain of] stomach hurting. when removed to side noted large hard stool on chuck [incontinent pad] . Was the fall observed . [marked no] . Outcome of interview with staff: Resident using the side of bed to strain to have bowel movement pulled self off in floor . Resident was placed in bed on [left] side facing wall . On 08/12/21 at 2:44 p.m., CNA #2 stated the resident was at risk for falls. She stated the resident tried to move and scoot in the bed. She stated the resident had not suffered any falls on her shift. She stated they placed a long pillow behind her back to help prevent falls. On 08/12/21 at 2:53 p.m., CNA #3 stated the resident could be at risk for falls if she was too close to the edge of the bed. She stated the resident could pull herself out of bed. She stated the resident had a fall mat and bed alarm and they kept her bed in the low position, but those things did not prevent falls. She stated at the facility she learned about fall interventions through inservices and report. On 08/12/21 at 3:04 p.m., CNA #4 stated the resident was at high risk for falls and had fallen. She stated the facility used a floor mat, did hourly checks, and turned and repositioned the resident. She stated she knew residents were at risk for falls when they had a fall mat. She stated the nurses let them know what interventions were in place to prevent falls. On 08/12/21 at 3:08 p.m., licensed practical nurse (LPN) #4 stated the resident was at high risk for falls. She stated the interventions that were in place were using a bed alarm because the resident could not verbalize her needs, keeping the call light within reach, a fall mat to prevent injury, keeping the bed in the lowest position, and bolsters on the bed. On 08/12/21 at 3:31 p.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked what the resident could do for herself. The ADON stated it depended on the side on which the resident was lying. She stated the resident moved one side better than the other. She stated the resident could move one of her upper extremities pretty good. She stated the resident could pull herself to the side of the mattress; however, her legs were pretty much contracted. They were asked if the resident could reposition herself in bed. The ADON stated the resident could grab onto the grab bar or the side of the bed with the arm she had the most strength in. They were asked what caused the resident's fall on 04/13/21. The ADON reviewed the clinical record and stated the resident had been too close to the edge of the bed and rolled off. She stated the intervention of repositioning the resident away from the side of the bed was implemented. They were asked what caused the fall on 04/20/21. The ADON stated the resident slid out of the bed. She stated bed bolsters were put into place. She stated it was a concave mattress with bolsters at the top and the bottom of the mattress, with a gap between the bolsters. The DON and ADON were asked what caused the resident's fall on 04/22/21. The ADON stated the resident rolled out of bed. She stated the intervention put into place to prevent future falls were hourly checks. The ADON was asked if the bed bolsters were being used that were supposed to be put into place on 04/20/21, how did the resident roll out of the bed on this fall. She stated there was a gap in the bolsters that was not raised, and the resident slipped between the bolsters. The DON and ADON were asked what caused the resident's fall on 05/08/21. The ADON stated the resident rolled out of bed again onto the fall mat. She stated the resident was placed too close to the edge of the bed. The ADON was asked if the resident suffered an injury at that time. She stated yes, a hip fracture. The ADON was asked what interventions were put into place after the fall on 05/08/21. She stated it was to place the resident in the center of the bed to prevent her from sliding out. She was asked if that was a new intervention. She stated no. The ADON was asked if the resident had already suffered a fall due to being placed too close to the edge of the bed. She stated yes, from what the documentation showed. The DON and ADON were asked what caused the fall on 05/16/21. The ADON stated the resident slid out of the bed while she was trying to have a bowel movement. She was asked how the nurse knew that since the fall was unwitnessed. The DON stated the nurse probably deduced that from seeing the bowel movement. The DON and ADON asked how long the resident had gone without having a bowel movement. The ADON reviewed the clinical record and stated it was five days. The DON and ADON were asked if they had determined the bolster was not an effective intervention. The ADON stated she had not determined that. She stated the resident had more strength on her right side than on the left. She stated the bolsters needed to be the length of the bed, instead of just at the top and bottom. The ADON stated if the bolsters were the whole length of the bed, that would maybe help prevent her from going through the gap between the bolsters. The ADON stated the resident's head was kept elevated due to receiving a tube feeding, and with her head up she had a tendency to slide down, and then she could pull herself through the gap between the bolsters. The ADON was asked why she did not implement a full length bolster after the fall on 04/22/21. She stated she had figured it out while having the interview with the surveyors. The DON and ADON were asked what the facility's process was for conducting a root cause analysis of falls. The ADON stated they found out what the problem was and then what interventions should be implemented. They were asked if the facility conducted a root cause analysis of the resident's falls. The ADON stated, No. They were asked if they conducted root cause analysis of any falls in the facility. The ADON stated, I haven't in a while. The DON stated, No, I have not. The DON and ADON were asked what kind of training had been provided to the staff in regards to fall interventions. The ADON stated most of the time, the resident's falls occurred on the evening and night shift, so she hoped the nurses had educated the staff at the time of the falls. She stated the nurses had been instructed to provide the education. 2. Resident #53 was admitted to the facility with diagnoses that included vascular dementia, restlessness, agitation, anxiety, and adult failure to thrive. An admission assessment, dated 01/04/21, documented the resident was severely impaired in cognitive skills for daily decision making, required limited assistance with bed mobility, extensive assistance with transfers, and was frequently incontinent of bladder and bowel. It was documented the resident had a history of falls prior to admission to the facility. An incident note, dated 02/11/21 at 6:09 p.m., documented, . Called to residents room by CNA where resident was found laying in floor between bed and Tv . A facility accident/incident report form, dated 02/12/21 at 3:30 p.m., documented, . Called to resident's room by CNA where resident was found sitting in floor . staff educated on resident wearing proper footwear . An incident note, dated 02/18/21 at 4:39 p.m., documented, . Called to residents room by CNA where resident was found sitting on her bottom next to bed. No obvious injury noted . An initial incident note, dated 03/06/21 at 6:36 p.m., documented, . Describe occurrence in resident's words: I was transferring from my wheelchair to my bed and got weak and fell down . resident sitting on buttocks with knees pulled up to chest in between wheelchair and bed . New interventions added at time of incident to prevent re-occurrence: directed to use call light for assistance to transfer . An incident note, dated 03/31/21 at 1:45 p.m., documented, . This nurse was called to the room by cma [certified medication aide], cna. Resident was sitting on the pad beside her bed. Resident states she was trying to reach her milk cup when she slid out of her wheelchair onto her right knee then when [sic] on and sat down on the padded mat by her bed . An initial incident note, dated 04/04/21 at 7:10 p.m., documented, . Describe occurrence in resident's words: I was trying to go to bathroom and sat down . when cna's entered the room resident was sitting on tilted trash can beside chair. staff assisted resident to lower to floor while removing trash can. called nurse to room. resident sitting on buttock . Factors that could have contributed to incident . resident trying to transfer self to bsc, incont of urine, briefs utilized, floor dry . call light in easy reach but not on at time of event . New interventions added at time of incident to prevent re-occurrence: encourage resident to utilize assist w/ brp's [bathroom priviledges] . continue to remind resident to seek assistance w/ [with] transfers . An incident note, dated 04/22/21 at 9:20 a.m., documented, . Nurse was called to the room by cna. Resident was laying on her stomach beside her bed. Resident has a skin tear on left forehead, some bleeding noted, initial treatment cleansed with sterile normal saline, patted dry, applied steri strips . An initial incident note, dated 04/24/21 at 11:32 a.m., documented, . Describe occurrence in resident's words: I was trying to help my friend (points to her roommate). Describe scene as observed by staff: Resident was sitting on the pad beside the bed . Resident noncompliant with using call light. The bed alarm was covered with blankets and was not heard by staff. What safety interventions were in place at the time of the occurrence: Bed in low position, pad on floor, call light in reach, bed alarm attached to resident and operating properly . New interventions added at time of incident to prevent re-occurrence: Monitor closely, keep alarm on and functioning properly, remind resident to call for help, pad remains on the floor by the bed . The resident's care plan, dated 04/29/21, documented the resident was a moderate fall risk. The goals included the resident would be free of falls through the review date. Interventions included to provide a shepard's hook for assistance with reposition, anticipate and meet needs, keep needed items within reach at all time, ensure call light is within reach and encourage use, implement fall prevention protocol, and encourage socks with non-slip, non-skid surfaces. A health status note, dated 05/29/21 at 6:20 a.m., documented, . CNA found the resident sitting on the floor leaned up against her bed. Resident had a dime size [sic] to her forehead between her eyes. Resident was awake and alert and had turned her light on for help after she fell . There was a 12 inch puddle of blood on the floor by the end table. Resident stated she had tried to get up and reach her robe that was on her wheelchair but when she stood up she fell forward hitting her head on the table . A health status note, dated 05/29/21 at 12:50 p.m., documented, . Resident returned from the emergency room . Resident has 3 dissolvable stitches in the forehead muscle and 3 stitches in the outer layer of tissue that will need to be removed in a couple of weeks. Resident has a pressure dressing intact to forehead . A radiology report, dated 05/31/21, documented, . Acute nondisplaced oblique fracture of the distal diaphysis of the [left] ulna . A health status note, dated 05/31/21 at 9:27 p.m., documented, . x ray results received of patients of [sic] left arm showing a impression of fracture of left ulna . transfer resident to [hospital name withheld] . A health status note, dated 07/25/21 at 3:41 p.m., documented, . She is no longer weight bearing. She is not ambulatory . She is able to make needs some needs known [sic] . Bed is kept low for safety. She has a personal alarm as fall precaution. Bedside mat in place. Observed often. Will continue to monitor and address needs . An initial incident note, dated 08/06/21 at 9:52 p.m., documented, . resident observed to be sitting on floor in bed . What safety interventions were in place at the time of the occurrence: call light within easy reach . New interventions added at time of incident to prevent re-occurrence: room light on . On 08/09/21 at 1:15 p.m., the resident was observed in her room, sitting in her wheelchair. She had socks on. The socks were not gripper socks. The resident was attempting to propel her wheelchair, without success. An initial incident note, dated 08/09/21 at 11:08 p.m., documented, . Resident . states 'I was headed to the bathroom' . This Nurse and Staff on hall across resident's room overheard a trash bin knocked down. Upon entering room. resident noted sitting on floor next to roommate's bed . asking to be picked up and stating 'I was headed to the bathroom' . Resident AOX2 [alert and oriented to person and place] with unsteady gait out of bed transferring self without use of staff assistance nor assistive device (wheelchair). What safety interventions were in place at the time of the occurrence: call light within reach, room lit, bed at lowest position with bed locks in place and patent. assistive device at bedside with wheelchair locks in place . New interventions added at time of incident to prevent re-occurrence: Educate/encourage/reinforce/remind resident to call for/request assistance/use call light for assistance with transfers, toileting, repositioning . On 08/10/21 at 3:00 p.m., the resident was observed sitting up in her bed. Her fall mat was behind the door to her room. On 08/12/21 at 8:45 a.m. and 1:35 p.m., the resident was observed in bed with her eyes closed. Each time, the resident's fall mat was observed behind the door to the resident's room. A behavior note, dated 08/13/21 at 3:44 a.m., documented, . Noise coming from resident room is overheard from BNS [back nurses' station]. CNA on hall is in resident's room and notifies this Nurse that resident was noted transferring self back to bed after transferring self to bedside commode. This Nurse in room with resident. Resident noted sitting in bed . Resident stating What?, am I wrong? Resident educated that she is not wrong for trying to do more for self but that resident is still in need of staff assistance r/t [related to] unsteady gait balance and history of falls. Resident also educated that is also to uses assistive device of which is at bedside with locks in place . verbalizes agreement to utilize call light for staff assistance. c/l [call light] and fluids within reach . On 08/13/21 at 12:15 p.m., the DON and ADON were asked what interventions were implemented following the fall on 02/11/21. The ADON stated the staff was educated on reducing clutter in the room. She was asked what the cause of the fall was. She stated it was an unwitnessed fall, but the resident was unsteady when she ambulated. The DON and ADON were asked what intervention was implemented after the fall on 02/12/21. The ADON stated the staff was educated to make sure the resident had proper footwear on. She was asked what the cause of the fall was. She stated it was an unwitnessed fall. The DON and ADON were asked if the resident was alert and oriented. The ADON stated she was oriented to her name. They were asked what the resident's memory was like. The DON stated it varied throughout the day. He stated her long term memory was better than her short term memory. They were asked if the resident was always capable of knowing when to use her call light. The ADON stated, No. They were asked what the cause of the fall was on 02/18/21. The ADON stated it was unwitnessed. She was asked what interventions were implemented after the fall. She stated staff educated the resident on wearing proper footwear. The DON and ADON were asked what interventions were implemented after the resident fell on [DATE]. The ADON stated the resident was directed to use her call light for assistance. The DON and ADON were asked what interventions were implemented after the fall on 03/31/21. The ADON stated to remind the resident to lock the wheelchair wheels and call for assistance. The DON and ADON were asked what interventions were implemented after the fall on 04/04/21. The ADON stated, Assist with transfers. The DON and ADON were asked what interventions were put into place after the fall on 04/22/21. The ADON reviewed the documentation and stated, I don't see an intervention. The DON and ADON were asked what interventions were implemented after the fall on 04/24/21. The ADON stated, I don't see another intervention other than the call light. The DON and ADON were asked what interventions were put into place after the resident fell and suffered the laceration to her forehead and fracture to her left ulna on 05/29/21. The ADON reviewed the clinical record and stated, I don't see anything. The DON and ADON were asked what interventions were put into place after the fall on 08/06/21. The ADON reviewed the documentation and stated she did not see any interventions. The DON and ADON were asked what interventions were put into place after the resident's fall on 08/09/21. The ADON stated, Use call light for assist. The DON and ADON were asked if they had conducted root cause analysis on the resident's falls. The ADON stated, No. She stated the resident required assistance when going to the bathroom to keep her from falling. The ADON was asked if the resident was supposed to have a fall mat in place when she was in bed. The ADON stated, Yes. She was asked what kind of socks the resident was to wear. She stated, Nonskid.