Every finding on record at Burford Manor

Based on observation and record review, the facility failed to provide housekeeping and maintenance to maintain a sanitary and comfortable facility for: a. 1 (North hall shower room) of 2 sampled shower rooms; andb. 1 (North hall carpet) of 3 sampled halls reviewed for a homelike environment. The DON identified 16 residents were located on North hall.Findings: On 07/14/26 at 1:26 p.m., an observation of North hall shower room was completed. The North hall shower had a leaking shower head and cracked tiles with caulk peeling in multiple areas. A black substance was observed on tile of the shower wall. On 07/15/26 at 9:50 a.m., the North hall shower head was observed leaking. On 07/17/26 at 9:59 a.m. the maintenance supervisor stated the North hall shower leaked from the handheld shower head and equipment needed repaired. They stated the shower tile needed repaired and caulking applied to cracks in tile needed replaced. They stated black marks on the shower wall/tile were from resident wheelchairs. On 07/17/26 at 10:09 a.m., CNA #1 stated approximately 16 residents used the shower on North hall. They described the shower as leaking from handheld shower equipment, nasty, dirty, and the floor tile was coming up. 2.On 07/14/26 at 1:36 p.m., the North hall carpet was observed to have a black, tacky substance at the entrance to the common area. On 07/16/26 at 9:53 a.m., Housekeeper #1 stated the facility's carpet was vacuumed daily and spritzed with cleaner. They stated the carpet had been shampooed one time in the past year, and it didn't help much. Housekeeper #1 stated the carpet did not appear clean to them. On 07/17/26 at 10:14 a.m., CNA #1 stated the carpet on North hall is nasty and needed to be replaced. CNA #2 stated they had not seen the carpet being cleaned.

On 07/02/25 at 2:10 p.m., the OSDH was notified and verified the existence of an IJ situation related to the facility's failure to provide supervision and interventions to prevent elopement from the facility. Resident #1 had a history of eloping and left the facility unattended. Resident #1 crossed a busy, four-lane street and was located on the side of a highway approximately one mile from the facility. On 07/02/25 at 5:10 p.m., the DON was notified of the IJ and provided the IJ template. On 07/03/25 at 11:55 a.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, [NAME] Manor, 7-2-25, Plan of RemovalResident [Resident #1] not currently in the building. Currently 46 residents in the facility. Nurses have completed wandering assessments on all 46 residents in house and have identified no additional wander risks. Administrator/Owner [name deleted] in-serviced [name deleted] RN of facility elopement policy and procedures, reviewed all safety measures in place relating to elopement monitoring/prevention. Signage posted on all unarmed doors to remain closed and locked when not in use. Signage posted on coded doors alerting visitors of wander risk environment, not to allow other individuals to leave facility when exiting. Obtained owners manual to key pads. Deleted all previously existing codes and changed to new code. Codes will now be changed on a monthly basis, at minimum, and as needed. New elopement alarm ordered for facility placed 7/2/25. System has transmitter for resident to wear with sensor on door that will alarm when transmitter detected exiting past monitor. This will be initiated upon its arrival. *facility in-service held @ [NAME] Manor 7/2/25 @ 1930/All staff will be in-serviced for the following prior to working next scheduled shift:1. All unarmed/uncoded doors are to remain closed and locked when not in use. Failure to do so will result in immediate reprimand. 2. Review of facility Elopement policy & procedures3. Keypad doors - all keypad door codes to be kept confidential, not verbally given to others. Do not allow residents to know door codes. Staff to immediately notify Charge Nurse and DON if any resident has learned the door code. Door codes will be updated monthly at minimum and on an as needed basis. Code will be located in a secured location not visible to residents. *facility in-service held @ [at] [NAME] Manor 7/2/25 @ 1930When resident returns to the facility they will continue on Q [every] 15 minute elopement monitoring. As ordered on 06/27/25. Resident has been moved to room [ROOM NUMBER]B which is closer to the nursing desk on 07/03/25. Resident will be required to eat all meals in main dining room. On 07/03/25, after interviews with facility staff, review of elopement/wandering risk assessments, review of in-services, and door/alarm safety checks, the immediacy was lifted. 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 provide supervision and interventions to prevent elopement for 1 (#1) of 1 sampled resident reviewed for elopement. Resident #1 had eloped from the facility two times previously with a tracking device in place in the resident's shoe. The resident eloped a third time after changing shoes and leaving the facility. The director of nursing reported one resident currently at risk for wandering/elopement. Findings: On 07/02/25 at 9:30 a.m., during an initial tour of the facility, the code to the alarm keypad of the front door was observed to be posted on a small piece of paper near the keypad. Other exit doors were observed to have keypads in place and found to be locked. An Elopements policy, dated December 2007, read in part, Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. A care plan, updated 02/2025, showed Resident #1 was admitted on [DATE] with diagnoses which included Schizoaffective disorder, impulse disorder, osteoarthritis, diabetes, hypertension, depression, and insomnia. A physician order summary, dated 02/05/25, showed Resident #1 was to have elopement monitoring every 30 minutes. A care plan for Resident #1, dated 02/05/25, showed the resident had an air tag in the sole of their shoe, placed by the resident's family, and showed the resident was not aware of the tracking device. The care plan showed the resident ambulated independently. The care plan was updated on 05/05/25 and showed the resident was not to leave the facility with anyone except the resident's son/guardian. An OSDH incident report form 283, dated 05/07/25, showed Resident #1 was unable to be located at 12:20 p.m. The resident's tracking device, located in the resident's shoe, was activated and the resident was shown to be approximately 5 blocks from the facility. The resident was located and found to be walking back to the facility at 12:44 p.m. The resident reported they were upset because they were almost out of bananas. The resident was counseled and asked to speak with the charge nurse or DON when upset instead of leaving the facility. An OSDH incident report form 283, dated 05/15/25, showed Resident #1 was unable to be located at 3:30 p.m. The report showed a CNA searching nearby streets located the resident at 3:56 p.m. at a diner approximately 0.5 miles from the facility. The report showed Resident #1 stated they just wanted to take a walk. The report showed the DON spoke with the Ombudsman and the resident's guardian regarding potential placement of the resident in a secured/locked facility. A quarterly MDS assessment for Resident #1, dated 06/02/25, showed the resident had a brief interview for mental status score of 14, which showed the resident was cognitively intact. The assessment showed the resident was independent with activities of daily living. An OSDH incident report form 283, dated 06/26/25 at 6:10 p.m., showed Resident #1 was found to be missing and could not be located in the facility. The report showed the resident was found one mile from the facility on Highway 77 and returned to the facility at approximately 7:20 p.m. The report showed the resident stated they did not remember leaving the facility. The report showed the resident was not wearing the shoes that contained the tracking device, placed by the resident's family, and therefore could not be tracked using the device. The report showed the resident was kept on 1:1 supervision until the resident left with their guardian for a geriatric psychiatric evaluation. On 07/02/25 at 10:19 a.m., the DON reported Resident #1 was currently out of the facility for a geriatric psychiatric evaluation and treatment. The DON reported they had a recent new admission they were watching for potential wandering/elopement risks, but those precautions had been discontinued. The DON reported Resident #1 was the only resident who had eloped. On 07/03/25 at 1:55 p.m., the DM reported they were aware Resident #1 liked to go outside and walk. The DM reported they had tried to give the resident opportunities to go outside supervised, and the resident had spent time outside with maintenance staff, but it did not seem to make a difference when the resident decided they wanted to leave. The DM reported the staff was somewhat limited on what they could offer Resident #1 due to restrictions placed by the resident's guardian, such as not wanting the resident to go outside. On 07/03/25 at 2:05 p.m., RN #1 reported the staff had involved Resident #1 in lots of activities and given the resident opportunities to go outside the facility on supervised outings. RN #1 reported they did not think it made a difference in satisfying the resident and felt the resident would still attempt to leave given the opportunity. On 07/03/25 at 3:00 p.m., the DON reported upon their return to the facility, Resident #1 will be kept on every 15 minute checks until the new alarm system is installed. The DON reported the resident's guardian and facility staff agree it is not safe for the resident to go out on their own due to their impulse disorder. The DON reported the resident's room has been moved closer to the nursing station. The DON reported the resident was aware staff were busy and distracted during meals, so the resident would now be required to have all meals in the main dining room. The DON reported although Resident #1 was cognitively intact, the resident's diagnosis of impulse disorder presented a safety risk for the resident.

Based observation, record review, and interview, the facility failed to protect a resident from physical and verbal abuse by a staff member for 1 (#3) of 3 residents sampled for abuse. The director of nursing reported 46 residents resided in the facility. Findings: A Preventing Resident Abuse policy, dated February 2014, read in part, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse.The facility's goal is to achieve and maintain an abuse-free environment.Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: .b. Allowing staff to express frustration with their job, or in working with difficult residents.f. Helping staff to deal appropriately with stress and emotions. An Oklahoma State Department of Health incident form 283, dated 03/04/25, showed the DON was notified by staff LPN #1 was becoming increasingly aggravated with Resident #3 due to the resident constantly trying to get up from their wheelchair. The report showed LPN #1 was becoming louder toward the resident and demanding the Resident #3 to sit down. The report showed LPN #1 was observed by staff to push the Resident #3 back into the wheelchair after the resident attempted to get up. The report showed staff removed the Resident #3 away from the LPN and notified the DON. The report showed an investigation was initiated and LPN #1 was ultimately terminated. A quarterly MDS assessment for Resident #3, dated 04/07/25, showed the resident had a brief interview for mental status score of 0, which indicated severe cognitive impairment. A care plan for Resident #3, dated 06/23/25, showed the resident had altered cognition related to Alzheimer's. The care plan showed the resident was dependent on staff for assistance with all activities of daily living and had repeated falls. On 07/03/25 at 10:00 a.m., Resident #3's POA/family member reported when the incident happened with the LPN #1, the facility notified them immediately and updated them on how the matter was handled. The POA reported they had never been concerned about abuse toward the resident and had not witnessed anyone be rude or disrespectful. The POA reported they did not feel the resident was bothered by the incident, probably would not remember it, and did not feel there was any harm done to the resident. On 07/03/25 at 1:55 p.m., the DM reported they witnessed the incident with LPN #1 and Resident #3. The DM reported the resident was trying to get up from their wheelchair and the LPN pushed the resident back down to the wheelchair. The DM reported the incident happened during the evening meal service. The DM reported they removed Resident #3 to another area and suggested LPN #1 take a break. The DM reported they immediately informed the DON. The DM stated the DON initiated an investigation and staff were in-serviced on abuse. On 07/03/25 at 2:04 p.m., RN #1 reported they did not witness the incident between LPN #1 and Resident #3, but could hear the LPN repeatedly saying, Sit down, sit down. The RN reported the incident was loud and caught their attention, but they were not in the same area to visually witness the incident. RN #1 reported the DON immediately addressed the situation and staff were in-serviced on abuse and de-escalation following the incident.

Based on observation, record review, and interview, the facility failed to use enhanced barrier precautions for two (#13 and #25) of two sampled residents identified with the need for enhanced barrier precautions. Findings: The DON identified nine residents with the need for enhanced barrier precautions. A Multidrug-Resistant Organisms policy, read in part, .Appropriate precautions will be taken when caring for individuals known or suspected to have infection with a multi-drug resistant organism .Note: Infection means that the organism is present and is causing illness. Colonization means that the organism is present in or on the body but it is not causing illness . A Personal Protective Equipment policy, read in part, .Personal protective equipment appropriate to specific task requirements is available at all times .All tasks do not involve the same type or degree of risk, and therefore will not all require the same kind or extent of protection . 1. Resident #13 had diagnoses which included Alzheimer's, depression, and high blood pressure. Resident #13's plan of care, dated 05/28/24, documented an alteration in skin integrity AEB a pressure wound to the coccyx and indwelling catheter. Resident #13's physician order, dated 10/13/24, documented to change treatment to coccyx/sacrum to cleanse with NSS, pat, dry, apply collagen to wound beds, cover with Calcium Alginate, and cover with dressing every day and as needed for soiled or drainage. On 10/31/24 at 10:20 a.m., LPN #1 was observed to perform wound care for Resident #13. There was no signage observed for EBP and no PPE kit was observed to be available for EBP. On 10/31/24 at 10:34 a.m., the DON was asked to submit the EBP policy and procedure. They presented the policy for multidrug-resistant organisms and reported they did not have an EBP policy. On 10/31/24 at 10:35 a.m., LPN #1 was asked about EBP. The LPN reported they had some residents on precautions last week, but no one at this time was on precautions. 34333 2. Resident #25 had diagnoses which included, acute respiratory failure, dementia, chronic kidney disease, and chronic obstructive pulmonary disease. Resident #25's care plan, dated 07/17/24, documented the resident was at risk for alteration in nutritional status and required tube feedings. The care plan documented to check for high residual and to check PEG tube placement before meds, flushes, and feedings. On 10/31/24 at 2:10 p.m., LPN #1 was observed to administer Resident #25 their scheduled tube feeding as ordered. No EBP signage was observed and no PPE kit was observed to be available for EBP. On 10/31/24 at 2:38 p.m., the DON was asked for the facility's EBP policy. The DON reported they had used precautions with a particular resident the previous week. The DON was asked if they were talking about TBP and they stated yes. The DON was unaware of the need for EBP and reported they did not have a policy.

Based on observation and interview, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary and safe environment for 47 of 47 residents who reside in the facility. Census: 47 Findings: On 07/16/24 at 8:40 a.m., maintenance was asked about the holes in the wood flooring located on the South Hall. They reported they could fill the holes with something, but it was the foundation. Maintenance was asked about the black areas that outline the base in the shower on the East/West Hall. They reported it was soap/grime around the base of shower. They reported they would caulk it every three months or so. They reported the North Hall shower was the same way and they were looking for contractors to replace that tile, because of the black/scum around the base of the shower. On 07/16/24 at 11:45 a.m., DON reported there were holes in the wood flooring on the South Hall and they were going to get that fixed. The East/West Hall observed with a black colored area at the base of the shower. They reported they were looking to hire a contractor to repair all the showers. Chips were observed in the wood flooring in the dining room floor between the common area and the main dining room. The DON reported that needed to be repaired. On 07/16/24 at 12:42 p.m., the DON was asked about the policy for housekeeping/maintenance services. They reported if there was anything not functioning, they would notify maintenance, then they would follow up and repair it. They reported they had discussed the showers with maintenance before and that was something they could not repair.

Based on record review and interview, the facility failed to notify the resident's representative of a change of condition for one (#2) of three sampled residents reviewed for notifications related to changes of condition. The DON reported 47 residents resided in the facility. Findings: A Change in a Resident's Condition or Status policy, dated 09/01/23, read in part Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental conditions and/or status .Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's family or representative when: The resident is involved in any accident or incident that results in an injury; There is a significant change in the resident's physical, mental or psychosocial status; and/or it is necessary to transfer the resident to a hospital/treatment center . Resident #2 had diagnoses which included Alzheimer's disease and dysphagia. A nurse's notes, dated 11/27/23, documented resident #2 had a laceration to side of head and was sent to the emergency room for treatment. A nurse's written statement, dated 11/27/23, documented LPN #1 stated Resident #2's representative had not answered the phone when they notified them of the resident's fall and a transfer to the ER. A nurse's note, dated 12/04/24, documented, sutures intact to right forehead and son here to visit. A nurse's note, dated 12/22/23, documented purulent drainage to wound on right forehead .A new order for Bactrim DS 800-160 mg twice a day for 7 days for wound infection .Resident #2's son was called to notify of new medication, no answer, a voice mail was left . Resident #2's care plan meeting notes, dated 12/04/23, documented the Resident #2's representative was upset because they had not been called when the resident had a fall. The care plan meeting notes documented family member #1 was not coming to the care plan meeting because the facility did not call when asked. An in-service/training, dated 12/04/23, read in part, Topic: Notifying family members .When you need to notify a family member of a resident and can not [sic] reach them, please write attempted to notify family and chart if message was left and that family did not answer .Keep attempting to call family until they answer, even if continues on next shift or takes days .Chart every time an attempt is made to contact family. A comprehensive assessment, dated 03/14/24, documented Resident #2's cognition was severely impaired. On 07/15/24 at 3:45 p.m., resident representative #1 reported not being informed of a fall Resident #2 had on 11/27/23. The resident representative #1 reported not being aware of the fall or the Resident #2's transfer to ER for treatment until a visit on 12/04/23 and the Resident #2 had sutures and bruising to forehead. The resident representative reported #1 they had not been notified of all falls or medication changes. On 07/16/24 at 2:00 p.m., LPN #1 reported residents' representatives should be notified when residents had any changes in condition or were being sent out to the ER. The LPN #1 reported resident's representatives should be repeatedly called until contact was made and each call should be documented. The LPN #1 reported Resident #2's representative was called to notify of the fall and ER visit on 11/27/23 and had not answered. The LPN #1 reported the resident's representative had not called back. On 07/16/24 at 2:27 p.m., the DON reported any increase in medications, physician order changes, or changes in health status should be reported to the resident's representative.

Based on record review and interview, the facility failed to provide residents with beneficiary notices for three (#155, 156, and #157) of three sampled residents reviewed for beneficiary notices. The facility identified six residents discharged from Medicare covered part A stay with benefit days remaining in the previous six months. Findings: SNF Beneficiary Protection Notification Review forms, for resident #155, 156, and #157, documented the skilled nursing facility advanced beneficiary notice (SNF ABN, Form CMS-10055) form was not provided to residents and/or their representative. On 08/16/23 at 10:30 a.m., the BOM was interviewed regarding the facility policy for providing skilled residents with notice of Medicare non-coverage. The BOM reported she was not aware of a policy and was not familiar with any particular form used, but would check with the corporate office and other staff members. On 08/17/23 at 9:53 a.m., the BOM reviewed the SNF ABN Form (CMS-10055) and reported she had never used this form. She stated she did give the same information to the resident and/or their representative verbally, but did not have them sign anything to document the information had been provided to them. On 08/17/23 at 11:32 a.m., the administrator reported he had talked with the BOM and confirmed the required information, related to notice of Medicare non-coverage, was provided verbally when residents were admitted to the facility. The administrator stated he understood the need to have the required form signed by the resident or their representative to document they had received the information related to potential non-coverage.

Based on observation, record review, and interview, the facility failed to maintain a clean and sanitary kitchen floor and ice machine equipment. The facility failed to: a. maintain a floor which could be sanitized and cleaned appropriately, b. maintain the ice machine in a sanitary manner, and; c. ensure a covered container for trash was available. The Administrator reported all 52 residents were served foods and beverages from the kitchen. Findings: A kitchen Sanitization policy read in part, .the food service area shall be maintained in a clean and sanitary manner .ice machines and ice storage containers will be drained, cleaned and sanitized . kitchen and dining room surfaces .shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime [sic] . On 08/14/23 at 9:59 a.m., a tour of the kitchen was conducted. The kitchen floor was observed to be a concrete base with black and dark gray residue build-up in areas resulting in an uneven surface. A concentrated build-up of residue was observed under the hand sink, three compartment sink, and dishwasher area. The dietary manager reported the floor was not cleanable. No covered trash container was observed to be available for trash disposal at the hand washing sink. On 08/14/23 at 10:10 a.m., the ice machine was observed to have a heavy build-up of white calcium deposits on the outside surface with rust-colored areas on the lid frame and hinged surfaces. The inside of the ice machine was observed to have a rusted/brown-colored deposit on the stainless steel surfaces, and black residue on the ice guard of the ice dispenser. The black residue continued down the sides of the collection compartment. The lid was observed to not have a seal in place and the insulated panel was separated from the lid. The base of the ice machine was elevated off the floor and supported with different sized blocks of wood pieces, revealing coated white discolored flooring underneath the machine and surrounding area. On 08/14/23 at 10:30 a.m., the DM was made aware of the above findings. The DM was asked if a closed trash container should be used at the employee hand washing sink located in the back of the kitchen. The DM indicated the covered trash container in the dining room was available for use. On 08/14/23 at 12:02 p.m., the maintenance staff reported monthly cleaning of the ice machine as running cleaner through the system and wiping down the surfaces. They reported it continued to make calcium deposits on visible seams and surfaces and rusted areas inside and outside. They reported they did not think it could be cleaned or repaired and stated, probably just need a new one. They provided documentation and the last date of cleaning the ice machine was documented as 05/06/23. The Kitchen and Dietary Department Audit, dated 04/18/23, 05/16/23, 06/20/23, and 07/17/23, documented N/I for the kitchen floor, ice machine cleaning, and trash containers covered. On 08/14/23 at 3:55 p.m., the DM was asked the meaning of N/I. They reported N/I meant needs improvement. On 08/17/23 at 10:00 a.m., the administrator reported the staff had tried to scrape off the epoxy coating on the kitchen floor with little success. The administrator acknowledged the condition of the ice machine was in need of cleaning and repair.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent an elopement for one (#23) of two residents reviewed for elopement risk. The director of nurses reported three residents wandered throughout the facility and were at risk for elopement. Findings: Resident #23 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] disease, cognitive deficits, dementia, [CONDITION(S)], and mood disorder. An admission assessment, dated 10/03/21, documented the resident was severely impaired with cognition and exhibited wandering behaviors daily. A care plan, dated 10/09/21, documented the resident wandered and was at risk for elopement. The care plan documented the staff was to check the residents whereabouts every 30 minutes. The care plan documented for the staff to provide one on one as needed throughout the day. The care plan documented the resident would exit seek and go out unlocked doors. The care plan documented the resident would walk around outside or around the building and would come back in the facility. A nurse's note, dated 10/10/21 at 12:00 noon, documented the resident walked in the front door from attempted elopement. The note documented the nurse told the resident not to go outside. The note documented the resident tried to leave the building many times. A nurse's note, dated 10/10/21 at 5:00 p.m., documented the resident was outside and entered through the back door. The note documented the staff reminded the resident not to leave the facility. The note documented the resident was constantly pacing and trying to elope. A nurse's note, dated 10/20/21 at 8:00 a.m., documented the resident wandered throughout the facility and would go out the back door and come around to the front door. The note documented the resident had never left the facility grounds. A nurse's note, dated 10/25/21 at 11:30 a.m., documented the resident had gone outside and ambulated around the building and came back in the front of the building. The physician was notified. The physician ordered for the resident to have one on one supervision. A wandering check list, dated 11/28/21 through 12/01/21, documented the resident was to be checked for her whereabouts every 30 minutes. The check list had lines drawn down the page throughout the day. On 11/30/21 at 3:24 p.m., the resident was observed lying in bed with her eyes closed. On 12/01/21 at 8:17 a.m., the resident was not in her room. Her uneaten breakfast tray was on her overbed table. On 12/01/21 at 8:21 a.m., the ADON reported the resident had been across the hall in another residents room roaming. On 12/01/21 at 11:27 a.m., the resident was observed lying in bed with her eyes closed. On 12/01/21 at 2:01 p.m., CNA #1 reported the resident was at risk for wandering. The CNA reported we watch her closely and redirect her when needed. The CNA reported she had not known of the resident eloping. The resident was not in her room. On 12/01/21 at 2:04 p.m., CNA #1 reported the resident wandered a lot. The CMA reported the resident would go outside. The CMA reported the resident had went out the doors at the dining room. The CMA reported she was outside at the staff smoking area and the resident had went out the door by the vending machine and walked around the corner to the staff smoking area about a week to a week and a half ago. The CMA reported she helped her get back into the building. The CMA reported she would consider that an elopement and reported to the charge nurse. On 12/01/21 at 2:11 p.m., the door by the vending machine was observed unlocked. The area outside of the door was not fenced. On 12/01/21 at 2:18 p.m., the resident was not in her room. CNA #1 reported she was unaware where the resident was. The CNA reported the resident may be down on the Covid hall. The CNA reported the resident wandered down there at times. The CNA reported the staff was supposed to check on the resident at least every 30 minutes. The CNA could not remember when she checked the resident last. The CNA reported they were short staff at times and it was hard to check on her that often. The CNA searched the Covid hall and found the resident in the bathroom between rooms 34 and 35. On 12/01/21 at 2:28 p.m., the DON and administrator both reported the resident would go outside and come back in at times. They both reported they had not been made aware of her going outside unsupervised. They both reported she used to work in the facility. They both reported she was to be checked every 30 minutes by the charge nurse. The administrator reported at one time they had placed her one on one and were in the process of trying to find her placement in a locked unit. On 12/01/21 at 2:51 p.m., CNA #1 reported she had not visually checked her at 2:00 p.m., but had asked one of the aides and they told her she was in bed. The LPN reported the resident was at the door a lot trying to go outside.

Based on interview and record review, the facility failed to provide sufficient staff to ensure call lights were answered in a timely manner. The administrator reported 47 residents lived in the facility. Findings: Resident council meeting minutes, dated November 2021, documented residents complained call lights were not being answered in a timely manner. On 11/29/21 at 10:13 a.m., resident #44 reported it took a long time for his call light to be answered. On 11/29/21 at 10:24 a.m., resident #14 reported it took too long for call light to be answered. On 11/29/21 at 10:50 a.m., resident #4 reported it took awhile for call light to be answered. On 11/30/21 at 10:14 a.m., resident #19's representative reported there was still not enough staff but it was getting better. The representative reported the resident was not checked for 3 to 5 hours at times unless she turned her call light on. On 12/02/21 at 9:15 a.m. CMA #1 reported there was not enough staff to meet the residents needs. On 12/02/21 at 9:20 a.m., CNA #2 reported there was not enough staff. On 12/02/21 at 9:25 a.m., CNA #3 reported there was not enough staff to care for the residents. On 12/02/21 at 9:30 a.m., CNA #4 reported there was not enough staff to take care of the residents.

Based on observation, interview, and record review the facility failed to complete a comprehensive care plan for one (#38) of 19 residents reviewed. The administrator reported 47 residents lived in the facility. Findings: Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 11/03/21, documented the resident was moderately impaired with cognition, exhibited no depression or behaviors. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident received an anti-psychotic, an anti-depressant, a diuretic, and an opioid for seven days of the look back period. The assessment documented the resident required oxygen therapy. The clinical record contained no comprehensive care plan. On 11/30/21 at 9:31 a.m., the resident was observed sitting up in her recliner. On 12/01/21 at 9:04 a.m., the minimum data set (MDS) coordinator reported the resident's comprehensive care plan had not been completed.

Based on interview and record review, it was determined the facility failed to provide adequate staff to meet the residents needs. The facility reported 50 residents resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with dianoses which included dysphagia, heart failure, hyypertension, and [MEDICAL CONDITIONS]. An annual assessment, dated 09/18/2020, documented the resident was cognitively impaired. The assessment documented the resident required assistance with most activities of daily living. The assessment documented the resident had unclear speech and was sometimes able to make self understood. A phone interview was conducted with the resident's daughter on 11/20/20 at 12:15 p.m. The daughter reported the family had placed a camera in the resident's room so they could monitor the resident. The daughter reported the resident requires assistance with activities of daily living. The daughter reported staff did not check on the resident frequently. The daughter reported the resident was observed one day last week, via the camera, lying over her lunch tray, and appeared to be asleep. The daughter reported a phone call was made to the facility to request assistance for her mother. The daughter reported it took more than 30 minutes for a staff member to enter the resident room. On 11/20/20, at 01:09 p.m., LPN (licensed practical nurse) #1 reported the facility did not have enough staff to properly care for, assess, and document on the Covid positive residents. The LPN reported all the positive residents had been placed on skilled care services. The LPN identified 28 positive residents who were on skilled care services. The LPN was asked how frequently assessments and vital signs were to be obtained and documented. The LPN reported assessments and vitals signs were to be completed every shift. The LPN reported it was difficult to complete all skilled assessments and charting, and supervise the staff. Medical record review revealed ommitted documentation for resident #3 for six of seven days, both shifts. Medical record review revealed ommitted documentation for resident #2 for seven of seven days, both shifts. On 11/23/20, at 08:00 a.m., a phone interview was conducted with a family of resident #1. The family member reported his mother called him on numerous occasions to report staff had taken an hour to an hour and a half to answer her call light. On 11/23/20, at 11:20 a.m., resident #8 reported it took up to one hour before staff would respond to her call light. On 11/23/20, at 04:00 p.m., LPN #1 reported 35 positive residents on the Covid unit. The LPN reported all 35 residents were on skilled care services. The LPN reported five of the 35 residents had not yet had orders noted for admission to skilled care services. The LPN reported not all of the skilled assessments had been completed. The direct care staffing report for September, 2020, documented staffing shortages for four of 81 shifts. The direct care staffing report for October, 2020, documented staffing shortages for three of 93 shifts. The administrator reported contracts had been executed and signed with three staffing agencies within the past two weeks.

Based on observation, interview and record review, it was determined the facility failed to ensure staff followed proper infection control procedures to reduce the risk of transmission of the novel Coronavirus. Findings: On 11/20/20, at 09:35 a.m., an initial tour of the Covid-19 positive unit was conducted. Staff members were observed to be assisting residents in their rooms without the use of gloves. Staff was observed going into resident rooms to retrieve water pitchers. The staff filled the water pitchers in the hallway and returned the pitchers to the resident's bedside tables. No gloves were worn. Certified medication aide (CMA) #1 was observed assisting a resident with drinking. The CMA's hand was in close proximity to the resident's mouth and nose. No gloves were worn. An unmasked resident was observed sitting beside Licensed practical nurse (LPN) #1. The resident was observed blowing his nose into his bare hand. The resident was not redirected to wash his hands. The resident was not educated on proper droplet etiquette. The resident was not offered a tissue. The resident continued to sit at the table, touching the table and objects on the table. The table was not disinfected. The objects that were touched were not disinfected. CMA #1 was asked what transmission based precautions were in place. The CMA reported the staff donned full PPE (personal protective equipment) to include gown, N95 respirator, face shield, gloves and booties. CNA (certified nurse aide) #4 was asked what transmission based precautions were in place. The CNA reported staff wore gowns, gloves, respirators, face shields and booties. The CNA reported frequent use of alcohol based hand gel. CNA #6 was asked what transmission based precautions were in place. The CMA reported staff wore gowns, respirators, face shields, gloves and booties. When asked if staff should be wearing gloves to provide resident care, CNA reported they should. The MDS (minimum data set) nurse was asked about facility transmission based precautions. The MDS nurse reported staff had slacked off washing hands or using alcohol based hand gel. The MDS nurse reported staff required reminders to utilize PPE. A policy, titled Novel [MEDICAL CONDITION] Covid-19, documented the facility would conduct education, surveillance and infection control prevention strategies to reduce the risk of transmission of the novel Coronavirus. The policy documented staff would apply appropriate PPE to include gloves, gown, isolation mask and eye protection. The DON (Director of nurses) was asked why staff was not wearing gloves while providing care to Covid positive residents. The DON reported gloves provided a false sense of security. The DON reported staff washed their hands more frequently when gloves were not worn. On 11/23/20 at 02:40 p.m., the maintenance director was asked how frequently biohazard waste was picked up. The maintenance director reported biohazard had been picked up every two weeks. He reported he had requested more frequent pick up with increased waste. The locked storage room was observed to have 33 boxes of biohazardous waste. The maintenance director was asked if biohazard had been stored in any other area of the facility. He reported he had stored approximately 20 boxes in an empty resident room on the Covid unit because the locked storage was full. He reported those biohazard boxes had since been picked up.

Based on observation, interview, and record review, it was determined the facility failed to provide sufficient staff to meet the needs of the residents. The facility reported 62 residents lived in the facility. Findings: On 12/11/19 at 8:35 a.m., upon entrance to the facility there was one registered nurse (RN), two licensed practical nurses (LPN), two certified medication aides (CMA), and three certified nurse aides (CNA) on duty. On 12/11/19 at 12:35 p.m., resident #4 reported there was not enough staff. The resident reported he did not receive his bath/shower as scheduled. On 12/11/19 at 4:02 p.m., resident #5 reported the facility was frequently short staffed on the two to ten shift. The resident and family member reported the facility had been short staffed the last couple of weeks. The resident and family member reported it took up to an hour for the staff to answer call lights. On 12/11/19 at 4:04 p.m., resident #6 reported there was not enough staff. The resident reported she had to wait over an hour for the staff to answer her call light. The resident reported she could not remember when she had a bath/shower. On 12/11/19 at 4:10 p.m., resident #7's family member reported the resident had the same clothes on for the past three days. On 12/11/19 at 4:15 p.m., an unidentified staff member reported there was not enough staff. The staff member reported there were times the facility had only one CNA on the two to ten shift. On 12/12/19 at 8:30 a.m., the staff for the six to two shift consisted of one RN, two LPNs, two CMAs, and four CNAs. The facility reported a census of 57 for this date. On 12/12/19 at 9:35 a.m., an unidentified staff member reported she had worked a total of eight shifts this week. The staff member reported there was not enough staff to cover all of the shifts. The staff member reported one day the previous week there was no CNAs to work the two to ten shift. The staff member reported a couple of the day shift stayed to ensure the residents received care. The staff member reported there were times the pharmacy would not send medications due to nonpayment. On 12/12/19 at 9:40 a.m., an unidentified staff member reported the facility was short staffed almost every day. The staff member reported they were asked to work extra every day. On 12/12/19 at 10:50 a.m., the administrator reported she was aware of the short staffing issues and had placed multiple help wanted adds.

Based on observation, interview, and record review, it was determined the facility failed to notify the physician when venous stasis ulcers had not improved for one (#50) of one resident reviewed with venous stasis ulcers. The facility reported six residents had non pressure ulcers. Findings: Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physical exam, dated 04/11/19, upon admission, documented the resident had a venous stasis ulcer to both lower extremities. A physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. A care plan, dated 04/11/19, documented the resident had been admitted to the facility with non pressure ulcers to bilateral lower extremities. The care plan documented to treat as ordered by the physician. The care plan documented for the staff to monitor and document the non pressure ulcers weekly progress and to consult with the physician as needed. An admission assessment, dated 04/22/19, documented the resident was cognitively intact and required limited assistance of one staff member for activities of daily living. The assessment documented the resident had two venous and arterial ulcers. The assessment documented the resident required dressings to feet. A weekly body audit form documented: 04/11/19-R inner leg 10 cm X 9 cm X 0.1------Left outer leg-12 cm X 17 cm X 0.1. 04/16/19-R inner 10 cm X 9 cm X 0.1-----Left outer 12 cm X 17 cm X 0.1. 04/23/19- R inner 10 cm X 9 cm X 0.1----Left 10 cm X 10 cm X x 0.1. 04/30/19-R inner 10 cm X 9 cm X 0.2----Left 10 cm X 10 cm X 0.1 05/07/19-R inner 8.0 cm X 10 cm X 0.1----Left 11 cm X 10 cm X 0.1. The clinical record contained no documentation the physician had been notified when the non pressure ulcers had no change or improvement with current treatment orders. On 05/07/19 at 10:43 a.m., the resident was observed to have bandages to both lower extremities. The resident reported she had been admitted with the venous stasis ulcers to bilateral lower extremities. On 05/08/19 at 12:09 p.m., the resident was observed with bandage to bilateral lower extremities to be clean, dry and intact. On 05/08/19 at 3:05 p.m., LPN #3 reported the physician should have been notified when the wounds had not improved. On 05/08/19 at 3:21 p.m., the director of nurses (DON) was shown wound measurement documentation and asked when she expected staff to notify the physician. The DON reported the physician would usually be notified if no changes within a couple of weeks or if the wound worsened. The DON reported the physician should have been notified regarding the wound measurements having no change over the past two to three weeks. On 05/09/19 at 9:35 a.m., LPN #1 was observed to provide wound care to the resident. The venous stasis ulcers were observed to be pink and without drainage. The LPN reported both extremities were looking much better.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents while smoking for one (#30) of two residents reviewed for accidents and supervision. The facility did not provide smoking supervision for a resident with a known history of a burn while smoking. The facility identified two residents who smoked. Findings: Resident #30 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 03/02/19, documented the resident was moderately cognitively impaired. The assessment documented the resident required minimal assistance with activities of daily living (ADLs). A smoking assessment, updated 03/20/19, documented the resident's cigarettes were to be kept at the nursing station. The assessment documented staff was to light the cigarette for the resident. The assessment documented the resident was not cognitively able to recognize safety issues while smoking. The assessment documented the resident had a physical condition which limited his ability to safely handle cigarettes. The assessment documented the resident was prescribed a psychoactive or pain medication which could impair the resident's safety. A care plan, dated 03/26/19, documented the resident had an alteration in vision related to [MEDICAL CONDITION]. The care plan documented the resident received assistance with ADLs as needed. The care plan documented the resident smoked cigarettes and those were to be kept behind the nursing station in a drawer. The care plan documented the resident was to be supervised while smoking, staff was to light cigarettes for the resident, and the resident would not be allowed to keep a lighter. The care plan documented the resident had a history of [REDACTED]. On 05/07/19 at 9:50 a.m., the resident was observed lying in his bed watching television. The resident reported he usually smoked in the smoking room and not outside. The resident reported he did not require supervision when smoking. On 05/09/19 at 8:15 a.m., the resident was observed to walk unsteadily to the smoking room and enter the smoking room alone. The resident was observed to light a cigarette with a lighter then slowly smoke the cigarette with a fairly steady right hand. On 05/09/19 at 8:30 a.m., certified nurse aide (CNA) #1 reported she normally worked the evening shift and was filling in for someone on day shift. The CNA reported the resident didn't smoke much in the evenings and she wasn't sure if staff supervised the resident while smoking. On 05/09/19 at 8:45 a.m., licensed practical nurse (LPN) #1 reported the resident's cigarettes and lighter were kept at the nursing station. On 05/09/19 at 9:15 a.m., the director of nursing (DON) reported staff did not go with the resident to supervise the resident while smoking. The DON reported there had been no incidents or injuries reported for this resident related to smoking. On 05/09/19 at 10:00 a.m., LPN #2 reported she had completed a smoking assessment on the resident and determined the resident required supervision while smoking. The LPN reported the resident was known to smoke his cigarettes down to the butt, which was a cause for concern. The LPN reported the resident had a cigarette burn to his nose on 04/18/14 but was not aware of any recent injuries. On 05/09/19 at 10:20 a.m., LPN #1 reported the resident carried his cigarettes with him in his pocket but did not have a cigarette lighter. The LPN reported the resident was not allowed to keep a lighter because he was known to keep his cigarette butts for smoking later. The LPN reported CNAs were supposed to go with the resident to light his cigarette and to supervise the resident while smoking. On 05/09/19 at 10:35 a.m., the resident was interviewed in his room. The resident reported someone had just come to his room and taken his cigarettes from him. The resident was unable to give the staff member's name. The resident denied he had a cigarette lighter and reported he gave the lighter back to that lady that gave it to him. The resident reported the lady was another resident who smoked with him sometimes. On 05/09/19 at 10:50 a.m., resident #37 reported a staff member had just come to her room and informed her she could no longer loan her cigarette lighter to resident #30. The resident reported resident #30 used her lighter on a regular basis and seldom had a staff member present for supervision while smoking. On 05/09/19 at 10:55 a.m., LPN #2 reported the resident should not have had any cigarettes in his possession. The LPN reported the resident should have been supervised while smoking. On 05/09/19 at 12:01 p.m., LPN #2 and the administrator (ADM) reported the resident could possibly smoke with less supervision if he received his cigarettes and lighter from the staff, and if staff were aware of when the resident was smoking. The LPN and ADM reported the resident had experienced no reported injury since 2014. The LPN and ADM reported the care plan had not been updated to reflect the resident's current condition related to smoking safety. The LPN reported the previous smoking assessment and care plan had not been completed accurately.

Based on record review and interview, it was determined the facility failed to ensure care and services were provided to ensure the highest practicable well-being for one (#54) of 17 residents reviewed for provision of care. The facility failed to monitor and intervene when the resident experienced a change in condition. The resident expired at the facility. The ADM reported 54 residents lived in the facility. Findings: Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was severely impaired in cognition, exhibited no signs of depression, and exhibited behavioral symptoms on ,[DATE] days of the look-back period. The assessment documented the resident required extensive assistance with ADLs. A care plan, dated [DATE], documented the resident was at risk for [MEDICAL CONDITION], MI, or [MEDICAL CONDITION]. One intervention documented for the staff to obtain vital signs and laboratory tests as ordered. The intervention documented for the staff to monitor the values and readings and to report to the physician. The resident's clinical record documented the resident exhibited respiratory distress and was admitted to the hospital on [DATE]. The clinical record documented the resident returned to the facility on [DATE] for skilled services for a [DIAGNOSES REDACTED]. A skilled daily nurse's note form, dated [DATE] at 10:00 a.m., documented the resident was out of the facility to receive two units of blood. At 11:00 a.m., a nurse's note documented the facility was notified by the hospital staff the blood transfusion was not initiated while waiting on notification of the primary care provider of the resident's blood pressure of ,[DATE]. At 4:30 p.m., a nurse's note documented the hospital notified the facility the resident had completed the [MEDICAL CONDITION] and was ready for transport back to the facility. At 6:30 p.m., a nurse's note documented the resident had returned to the facility and her vital signs were within normal limits. At 7:00 p.m., a nurse's note documented the resident exhibited no signs and symptoms of distress. A nurse's note, dated [DATE] at 6:30 p.m., was documented on a different nurse's note form. The nurse's note documented the resident's vital signs of temperature 98.1, blood pressure ,[DATE], pulse 77, respirations 20, and her O2 saturation as 90% on 2 lpm of oxygen. The nurse's note documented the resident's respirations were even and unlabored, she exhibited no signs and symptoms of distress, and she was in the dining room eating her meal. A nurse's note, dated [DATE] at 12:45 a.m., documented the resident had received two units of red blood cells, exhibited signs and symptoms of exhaustion, and went to bed after dinner. The note documented the resident's respirations were labored and even with no signs of acute distress. A nurse's note, dated [DATE] at 7:00 a.m., documented the resident's respirations were labored on oxygen with wheezes noted to both lungs. The note documented a breathing treatment was administered, the resident's oximeter reading was 86% on room air and 90% on oxygen. A nurse's note, dated [DATE] at 7:15 a.m., documented the resident's O2 sat was 98% on 2 liters of oxygen and exhibited generalized weakness. The nurse's note documented the resident was very restless, pulling at oxygen, pushing on the wall, exhibited disorganized thinking, and was confused. A nurse's note, dated [DATE] at 2:00 p.m., documented the resident was resting in bed and exhibited no signs and symptoms of distress. The clinical record contained no further entry in the nurses' notes from 2:00 p.m. until 12:00 a.m. A skilled daily nurses' note form, dated [DATE] with no time of entry documented, contained on the front page an entry of the resident's vital signs of pulse 69, respirations 20, blood pressure ,[DATE], and pulse oximeter reading of 90% on 2 l/m of oxygen. The form documented the resident was alert, disoriented to place and time, had labored breathing, and a cough. The back page of the skilled daily nurses' note form documented the following: [DATE] 0000 (midnight) Skilled for pneumonia, weakness, dysphagia, dementia, Res. very shaky. O2 @ 2 ML, (Up) draft administered, unable to obtain 02 @ this time (due to) shaking. Wheezing noted in (upper) lobes BL (bilateral). Res. was encouraged to breath deep & cough (with) green sputum noted - head up on two pillows, assist x one (with) transfers bed mobility & toileting. (Nurse's name deleted) 0200 Res. continues O2@ mL via n/c, (no) s/s of distress. Resp. labored but even @ 22. Res. hand shaking while trying to obtain O2 Stats Unable to obtain, Cap refill <3 sec. (Nurse's name deleted). 0215 Res. repositioned and changed remains (with)O2 @ 2 (unreadable). (Nurse's name deleted). 0400 Res. easily aroused (with) verbal stimi (sic), (no) accute (sic) distress noted, (no)cough @ this time, O2 @ 2 ml, via n/c, difficulty obtaining O2 status, Pulse ox briefly flashing from 88 to 90%, nail beds remain pink (with) cap refill <3 sec. Changed & repositioned. (Nurse's name deleted) 0450 Walked into Res. room to assess she was not breathing, warm to touch, notified son, DON & Administrator (funeral home name deleted). A separate nurse's note, dated [DATE] at 4:55 a.m., documented, Dr. notified gave orders to release body to (funeral home name deleted) (Nurse's name deleted). The clinical record contained no other vital signs other than the ones on the front of the skilled nurses' note form for [DATE]. A discharge summary, dated [DATE], documented the resident expired in the facility and a DNR was on file. On [DATE] at 10:30 a.m., the DON was shown the resident's clinical record, which documented the resident was shaking and no complete vital signs were obtained. The DON was asked if the nurse should have notified the physician of the resident's change in condition. The DON reported yes. The DON was asked if the resident's vital signs should have been obtained in order for the nurse to adequately assess and monitor the resident's condition. The DON reported yes. On [DATE] at 11:00 a.m., LPN #4, who was on duty the night of [DATE], was contacted by telephone. The LPN reported she could not remember the incident. The LPN was asked if she would contact the physician when a resident had a change in condition. The LPN reported she would call the physician if the resident's change was severe enough. On [DATE] at 11:18 a.m., the resident's physician's office was contacted. The physician's staff reported the physician would call the surveyor back when free. On [DATE] at 11:45 a.m., the ADM and DON were asked for a copy of the facility's policies on physician notification and monitoring post blood transfusion. Neither item was provided by the end of the survey. On [DATE] at 6:05 p.m., the resident's physician returned the surveyor's telephone call. The physician was asked if he expected to be contacted when a resident had a change in condition. The physician reported he expected to be contacted if the resident had significant changes in condition.

Based on record review and interview, it was determined the facility failed to ensure the physician was notified of a change in condition for one (#54) of 17 residents reviewed for provision of care and physician notification. The resident expired at the facility. The ADM reported 54 residents lived in the facility. Findings: Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was severely impaired in cognition, exhibited no signs of depression, and exhibited behavioral symptoms on ,[DATE] days of the look-back period. The assessment documented the resident required extensive assistance with ADLs. A care plan, dated [DATE], documented the resident was at risk for [MEDICAL CONDITION], MI, or [MEDICAL CONDITION]. One intervention documented for the staff to obtain vital signs and laboratory tests as ordered. The intervention documented for the staff to monitor the values and readings and to report to the physician. The resident's clinical record documented the resident exhibited respiratory distress and was admitted to the hospital on [DATE]. The clinical record documented the resident returned to the facility on [DATE] for skilled services for the [DIAGNOSES REDACTED]. A skilled daily nurse's note form, dated [DATE] at 10:00 a.m., documented the resident was out of the facility to receive two units of blood. At 11:00 a.m., a nurse's note documented the facility was notified by the hospital staff the blood transfusion was not initiated while waiting on notification of the primary care provider of the resident's blood pressure of ,[DATE]. At 4:30 p.m., a nurse's note documented the hospital notified the facility the resident had completed the [MEDICAL CONDITION] and was ready for transport back to the facility. At 6:30 p.m., a nurse's note documented the resident had returned to the facility and her vital signs were within normal limits. At 7:00 p.m., a nurse's note documented the resident exhibited no signs and symptoms of distress. A nurse's note, dated [DATE] at 6:30 p.m., was documented on a different nurse's note form. The nurse's note documented the resident's vital signs of temperature 98.1, blood pressure ,[DATE], pulse 77, respirations 20, and her O2 saturation as 90% on 2 lpm of oxygen. The nurse's note documented the resident's respirations were even and unlabored, she exhibited no signs and symptoms of distress, and she was in the dining room eating her meal. A nurse's note, dated [DATE] at 12:45 a.m., documented the resident had received two units of red blood cells, exhibited signs and symptoms of exhaustion, and went to bed after dinner. The note documented the resident's respirations were labored and even with no signs of acute distress. A nurse's note, dated [DATE] at 7:00 a.m., documented the resident's respirations were labored on oxygen with wheezes noted to both lungs. The note documented a breathing treatment was administered, the resident's oximeter reading was 86% on room air and 90% on oxygen. A nurse's note, dated [DATE] at 7:15 a.m., documented the resident's O2 sat was 98% on 2 liters of oxygen and exhibited generalized weakness. The nurse's note documented the resident was very restless, pulling at oxygen, pushing on the wall, exhibited disorganized thinking, and was confused. A nurse's note, dated [DATE] at 2:00 p.m., documented the resident was resting in bed and exhibited no signs and symptoms of distress. The clinical record contained no further entry in the nurses' notes from 2:00 p.m. until 12:00 a.m. A skilled daily nurses' note form, dated [DATE] with no time of entry documented, contained on the front page an entry of the resident's vital signs of pulse 69, respirations 20, blood pressure ,[DATE], and pulse oximeter reading of 90% on 2 l/m of oxygen. The form documented the resident was alert, disoriented to place and time, had labored breathing, and a cough. The back page of the skilled daily nurses' note form documented the following: [DATE] 0000 (midnight) Skilled for pneumonia, weakness, dysphagia, dementia, Res. very shaky. O2 @ 2 ML, (Up) draft administered, unable to obtain 02 @ this time (due to) shaking. Wheezing noted in (upper) lobes BL (bilateral). Res. was encouraged to breath deep & cough (with) green sputum noted - head up on two pillows, assist x one (with) transfers bed mobility & toileting. (Nurse's name deleted) 0200 Res. continues O2@ mL via n/c, (no) s/s of distress. Resp. labored but even @ 22. Res. hand shaking while trying to obtain O2 Stats Unable to obtain, Cap refill <3 sec. (Nurse's name deleted). 0215 Res. repositioned and changed remains (with)O2 @ 2 (unreadable). (Nurse's name deleted). 0400 Res. easily aroused (with) verbal stimi (sic), (no) accute (sic) distress noted, (no)cough @ this time, O2 @ 2 ml, via n/c, difficulty obtaining O2 status, Pulse ox briefly flashing from 88 to 90%, nail beds remain pink (with) cap refill <3 sec. Changed & repositioned. (Nurse's name deleted) 0450 Walked into Res. room to assess she was not breathing, warm to touch, notified son, DON & Administrator (funeral home name deleted). A separate nurse's note, dated [DATE] at 4:55 a.m., documented, Dr. notified gave orders to release body to (funeral home name deleted) (Nurse's name deleted). The clinical record contained no other vital signs other than the ones on the front of the skilled nurses' note form for [DATE]. A discharge summary, dated [DATE], documented the resident expired in the facility and a DNR was on file. On [DATE] at 10:30 a.m., the DON was shown the resident's clinical record, which documented the resident was shaking and no complete vital signs were obtained. The DON was asked if the nurse should have notified the physician of the resident's change in condition. The DON reported yes. The DON was asked if the resident's vital signs should have been obtained in order for the nurse to adequately assess and monitor the resident's condition. The DON reported yes. On [DATE] at 11:00 a.m., LPN #4, who was on duty the night of [DATE], was contacted by telephone. The LPN reported she could not remember the incident. The LPN was asked if she would contact the physician when a resident had a change in condition. The LPN reported she would call the physician if the resident's change was severe enough. On [DATE] at 11:18 a.m., the resident's physician's office was contacted. The physician's staff reported the physician would call the surveyor back when free. On [DATE] at 11:45 a.m., the ADM and DON were asked for a copy of the facility's policies on physician notification and monitoring post blood transfusion. Neither item was provided by the end of the survey. On [DATE] at 6:05 p.m., the resident's physician returned the surveyor's telephone call. The physician was asked if he expected to be contacted when a resident had a change in condition. The physician reported he expected to be contacted if the resident had significant changes in condition.

Based on observation, record review, and interview, it was determined the facility failed to ensure RN services were provided on weekends. The ADM reported 54 residents lived in the facility. Findings: On 03/04/18 at 1:40 p.m., the facility was entered. The licensed staffing consisted of two LPNs on the day shift. On 03/04/18 at 3:00 p.m., one alert and oriented resident reported the facility did not have a weekend RN. The staffing schedules were reviewed. The (MONTH) (YEAR) schedule documented no RN coverage for three weekends. The (MONTH) (YEAR) schedule documented no RN scheduled for 03/03/18 and 03/04/18. On 03/05/18 at 4:34 p.m., the ADM was asked if she had a weekend RN. The ADM reported the weekend RN had quit about three weeks ago. The ADM was asked if she reported the facility had no RN coverage seven days a week to the OSDH. The ADM reported she had not. The ADM was asked if she had advertised in newspapers or attempted to engage agency nurses for a weekend RN. She reported she had not. The ADM asked the surveyor if she should report to the local health department, and the surveyor informed her to call the state office in Oklahoma City. On 03/06/18 at 10:00 a.m., the ADM reported the DON had filled in on one of the weekends in February. The ADM reported she had called the local county health department to notify them of no RN coverage. The ADM reported the nurse at the county health department called the OSDH, and an OSDH representative had called the ADM to find out more information. On 03/06/18 at 2:00 p.m., the ADM reported the former DON would be the weekend RN.

Based on record review, observation, and interview, it was determined the facility failed to ensure residents were allowed to make choices about aspects of their lives for two (#44 and #24) of 14 residents reviewed. The ADM reported 54 residents lived in the facility. Findings: 1. Resident #44 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/26/18, documented the resident was severely impaired in cognition, exhibited mild depression symptoms, and no behaviors. The assessment documented the resident required extensive assistance with ADLs. On 03/04/18 at 2:00 p.m., the resident was observed to be wearing a hospital gown, lying in bed. The resident was observed to have long, curled chin whiskers. The resident was alert and oriented, and the resident reported she was tired. The resident's clinical record documented the resident was to have facial hair shaved or tweezed on bath days. The resident's ADL record documented the resident was bathed on 03/03/18 and had her facial hair shaved/tweezed on that day. On 03/05/18 at 10:30 a.m., the resident was observed to be dressed and in an activity. On 03/06/18 at 10:40 a.m., the resident was observed to be sitting in a recliner with a family member present. The resident was asked if she was going to attend activities. The resident reported she was waiting on someone to take her to activities. On 03/06/18 at 10:43 a.m., CNA #2 and CNA #3 were asked if the resident was to be assisted to activities. The CNAs reported the resident had declined to go to activities. On 03/06/18 at 2:31 p.m., the AD was asked if the resident was invited to group activity this morning. The AD reported the resident had refused and did not like group activities. The AD was informed the resident was observed to attend and participate in the group activities on the previous day. The AD was informed the resident had reported she was waiting to go to activities this morning. On 03/07/18 at 10:00 a.m., the DON was shown the resident's ADL record for (MONTH) and (MONTH) (YEAR), which documented the resident's facial hair was removed, and was informed of the observation of 03/04/18. The DON reported she would address the matter and review the CNAs documentation. 2. On 03/05/18 at 3:30 p.m., a group meeting was conducted with seven alert and oriented residents. Three of the residents reported they had to take a bath or shower when scheduled or would have to wait for their next scheduled bath day. One resident reported he/she was offered a shower at 9:00 p.m., which he/she refused because it was late. The resident reported it was too cold for a shower and he/she wanted to go to bed. The resident reported the staff wanted him/her to sign a paper documenting the resident refused the shower. The resident reported he/she refused to sign the paper because he/she did not refuse, just wanted a shower earlier in the day. One resident reported he/she had not received a bath/shower in five days. The resident reported the facility did not have enough staff to give showers as scheduled or when the resident requested one. The same resident complained the staff awakened him/her every morning at 6:30 a.m. for breakfast. The resident stated, Why would I have to get up at 6:30 and wait for breakfast that's not served until 8 o'clock or later? The resident was asked if he/she wanted to get up later. The resident reported getting up at 7:00 a.m. or 7:30 a.m. would be better times. On 03/07/18 at 1:00 p.m., the ADM was informed of the group members report of not being able to make choices on bathing times and getting up for meals. The ADM was asked if the residents have the right to have a bath/shower, to get up for meals, and to receive meals when they want. The ADM reported yes. 3. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 12/23/17, documented the resident was moderately impaired in cognition, exhibited no signs of depression, and exhibited no behavioral symptoms. The assessment documented the resident required supervision with ADLs and physical help with bathing. On 03/05/18 at 12:00 p.m., the resident was observed to be sitting on the side of his bed. The resident reported he was waiting for a bath. The resident reported he had been wanting a bath for 15 days. The resident was asked if he received his showers as needed. The resident shook his head no. The resident stated, Really need shower today. Getting itching. The resident's ADL sheets for (MONTH) (YEAR) documented the resident was to receive his baths on a Monday, Wednesday, and Friday schedule. On 03/07/18 at 1:00 p.m., the ADM was informed of the resident's report of not getting baths as scheduled. The ADM was asked if residents should be bathed according to their preference. The ADM reported yes. 4. On 03/06/18 at 11:14 a.m., a confidential interview was conducted with a family member. The family member reported the resident had not received a bath for five days. The family member reported the facility had documented the resident had received his/her bath/shower, but the family member knew the resident had not been bathed. 5. On 03/08/18 at 9:40 a.m., a confidential interview was conducted with a staff member. The staff member reported the facility did not have enough staff to ensure residents received baths/showers as scheduled. 6. On 03/08/18 at 9:54 a.m., a confidential interview was conducted with an alert and oriented resident. The resident reported some residents were overheard to ask for showers, and the resident reported the staff would not come back to give the residents their showers.

Based on record review and staff interviews, it was determined the facility failed to ensure a staff member used a mechanical lift to transfer a resident for one (#1) of one sampled resident, who required a mechanical lift to be used for transfers. This had the potential to affect 11 residents, identified by the DON, who required assistance with a mechanical lift for transfers. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/23/12, documented the resident was moderately impaired with cognition. The resident was dependent on two persons with transfers, dressing and toilet use. The assessment documented ambulation did not occur during the seven day look back period. The resident was occasionally incontinent of bowel and had an indwelling urinary catheter. A care plan, dated 10/24/12, documented to instruct staff on proper transfer techniques and lift usage. An Incident/Accident report, dated 01/13/13, documented, "...Observed Res.(resident) sitting beside commode in floor c (with) lower R leg outward rotation. C/O pain c R leg. Transfer to AMH for x-r..." The additional comment and/or steps taken to prevent recurrence documented, "Lift for all transfers" A nurse's note, dated 01/13/13 at 8:40 a.m., documented, "Called to pt. (patient) room for report of fall was advised that right lower extremity was rotated outward pt moved foot back into proper position. Aide at pt. side at time of fall. Pt and aide report that pt transferring to use restroom and legs got weak and went out on her. EMS, family, doctor and ADON notified." A nurse's note, dated 01/13/13 at 11:45 a.m., documented, "Report from AMH that pt has fracture to tib-fib non weight bearing, splint placed, pt has splint on RLE being sent home with Lortab for pain 5 mg q4 hrs. pain. Pt to follow up with Dr. ( name deleted) within 24 hrs..." A nurse's note, dated 01/17/13, documented the Lortab order was changed to 10/500 mg every 6 hrs. prn pain due to the resident's increased complaints of pain. A statement, written by the DON as told by the resident, documented, "I was coming down the hall from the breakfast table to go pee and this little girl was standing out there in the hall and she said do you want a free ride and I said well yeah if you have time. She pushed me in front of the commode and she got behind me and said I'm going to put my arms under your arms and I said "I've never done this before " and she said "well were going to do it this way this time." I said no the lift is right outside the door and she said no we can do this. I told her again " I've never done this before." I stood up on my feet and both my knees buckled under me and I let out a scream"get me off my knee, I can't stand it. She told me that I'd have to lay there until she went to get some one to help. She said we can't move you until the ambulance gets here, when she come back..." This statement was signed by the resident. The incident was reported to the OSDH on 01/13/13. On 03/28/13 at 10:00 a.m., CNA #2, #3 and #4 were asked how they knew how a resident was to be transferred and where they could locate the information. They reported all residents' transfer status were tagged on the residents' headboards of their beds. The CNAs were asked if this had always been the facilities policy. The CNAs reported the information was posted just the last couple of months. On 03/28/13 at 11:00 a.m., the MDS coordinator was asked how did the staff know the resident's transfer status. The MDS coordinator reported the residents transfer status was in the resident's care plan and was tagged on the resident's headboard. At 12:30 p.m., LPN # 1 was asked how did the staff know the resident's transfer status. The LPN reported there was an initial care card placed in the ADL book which had the resident's transfer status. She also reported the resident's transfer status was located on the resident's head or footboard. She also reported the information would be in the resident's care plan. At that time, the LPN was asked if the tagged headboard and the initial care card had been in place for the resident prior to the resident's fall. The LPN stated, "No." On 03/28/13 at 12:45 p.m., the DON was asked if the CNA, who had transferred the resident the day the resident fractured her tibia and fibula, had known to transfer the resident with a mechanical lift. The DON reported the CNA had transferred the resident, in the past, with the lift. The DON stated, "Yes, the CNA knew to use the lift." At 2:45 p.m., the resident was interviewed concerning how she fractured her leg. The resident reported the CNA tried to transfer her without using the lift and her knees buckled and she fell . She reported the pain was terrible when she fell . The resident was asked if her leg was still causing her pain. She stated, "Yes."

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to initiate CPR and seek medical attention for one (#1) resident who was found without pulse and respirations, and was a full code status. On [DATE] at 4:00 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 4:10 p.m., the ADM and the DON were notified of the IJ situation, which constituted substandard quality of care. On [DATE] at 5:10 p.m., an acceptable plan of removal was accepted. On [DATE] at 12:55 p.m., the immediate jeopardy was removed when all staff in the facility had been in-serviced. The deficiency remained at the level of no actual harm with potential for more than minimal harm at a pattern (more than a very limited number of residents affected). The plan of removal documented the following: "IJ Removal 1. Revised Code Status Procedure. 2. Red/Green, Stop/Go Code Program implemented. 3. All resident facility name plates have been identified with the Red/Green status symbols. 4. All Full Code status residents are now on Green Paper located in the Medication Books, Quick Reference Book and on Crash Cart. 5. All DNR Code status residents are now on Red Paper located in the same books as above. 6. All Care Plans have been updated as to each resident code status. 7. All Physicians orders have been updated to correct code status. 8. All resident charts updated to each resident's code status. 9. In-Service to new program in progress of all (Facility name deleted) employees to be finished by 3 pm, September, 22, 2011." Based on record review, observation, and staff interviews, it was determined the facility failed to provide CPR for one (#1) of one sampled resident who: a. was found without a pulse and respirations, b. had no advanced directives, and c. whose code status was documented as "full code." The resident expired at the facility. One other resident was sampled who had expired in the facility. This had the likelihood to affect 54 residents residing in the facility. Findings: The facility's policy for Emergency Care documented, "Responsibility: Licensed Nurse Purpose To provide emergency care to a resident in need of urgent service... Procedure... ...7. If a resident expires, initiate CPR unless ordered otherwise. Call paramedics. Call the attending physician and resident's family or responsible party. 8. Record details and exact time of condition change of resident, initiation of emergency procedure and resident's response to emergency care. 9. Record exact time physician was called and exact time physician responded to call. 10. Follow facility policy for notification of supervisors regarding resident's condition change, expiration or transfer..." A closed record review was completed for resident #1. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. A Do Not Resuscitate/Do Not Intubate Request/Order form documented..., "I DO NOT request and agree to a "DO NOT RESUSCITATE" order". The form was signed on [DATE], by the resident's responsible party (Husband). The following was signed by the responsible party on [DATE]. "Name of Resident (Resident's name deleted) do not have an Advanced Directive... I do not Wish to execute an Advanced Directive...(Resident's first name deleted) is a full code at her request & family request. She would not sign a AD (Advanced Directive)." The above was signed by staff member #1. An annual assessment, dated [DATE], identified the resident with long and short term memory loss, impaired decision making skills, required total care with all ADLs, did not ambulate, was totally incontinent of bowel and bladder. The area under Advanced Directives was marked none of the above, indicating the resident had no advanced directives. A quarterly assessment, dated [DATE], identified the resident with long and short term memory loss, impaired decision making skills, required total care with all ADLs, except eating, did not ambulate and was frequently incontinent of bowel and bladder. The care plan, dated [DATE], did not address the resident's code status. A physician's orders [REDACTED]." The nurses' notes documented the following: [DATE] at 2:30 p.m., "In bed ble (both lower extremities) elevated while in bed. trace non-[MEDICAL CONDITION] requests DR. Pepper staff assisted her c soda. ,[DATE] 102 22 97.8..." [DATE] at 2:00 a.m., "Pt calling out. Turned, repositioned provided H2O & Dr. Pepper...0700 (7:00 a.m.) Refused morning lab draw. Counseled 1 on 1 about importance of labs but continued to refuse." [DATE] at 2:15 p.m., "Rounds made to North hall, ^ in recliner drinking fluid c assist of CNA. O (no) S/S of pain/distress observed. Denies C/O. 1430 (2:30 p.m.), Called to room per CNA, resident ^ in chair, O pulse; & B/P, O lung sounds... 1435 (2:35 p.m.) Dr (Physician's name deleted) notified of resident condition, st (states) he will notify funeral home... 1437 (2:37 p.m.) Family notified; ADON notified." On [DATE] at 1:30 p.m., the DON was asked about the system for identifying the code status of the residents in the facility. She reported the residents' names were on the outside of the rooms. If the residents were DNR status, a red heart was at the side of the resident's names. At that time, the doors to the resident's rooms were checked, with the DNR orders. 18 of the 54 resident's, identified on the facility's residents name and room number list, had the incorrect code status by their names. At 2:05 p.m., LPN #1, who had found the resident not breathing, was asked why she had not instituted CPR. She stated, "I found her. She was not breathing." LPN #1 reported she felt like the resident was already gone. She reported the resident did not have a blood pressure and was cold and blue. She reported she was doing treatments at the time and left the resident to get the charge nurse. She was then asked if she had checked the code status on the resident's door. She reported she had not checked the resident's code status. At 3:30 p.m., LPN #2, who was the charge nurse at the time of the incident, was interviewed regarding the lack of CPR being instituted for the resident. She reported she had been called to the room by the treatment nurse. She reported she wasn't sure of the resident's code status, so had walked back up to the nurses' desk to check the code status. She was asked what the resident's code status was. She reported she was a full code. She reported she had then called the resident's husband, who told her not to do CPR. She reported she then went back to the resident's room and told the treatment nurse what the husband had said. She was asked if anyone had started CPR on the resident. She reported no one had started CPR. She was asked what she would have done if the resident's husband had wanted CPR. She reported she would have then started CPR. She stated, "It was only a matter of minutes." From the time the treatment nurse had found the resident, to the time the family was notified, according to the nurses' notes, was a lapse of seven minutes. At 3:55 p.m., the DON was notified of the lack of CPR for the resident. She reported if the resident was not a DNR, CPR should have been started, 911 called and CPR continued until released by the paramedics. At 3:55 p.m., the ADM stated, "They should have started CPR."