Every finding on record at Elmbrook Home

Based on record review and interview, the facility failed to ensure the proper repositioning of a dependent resident was performed for 1 (#3) of 3 sampled residents reviewed for safe transfers.The regional nurse consultant identified 65 residents resided in the facility. Findings:On 02/11/26 at 12:00 p.m., Res #3 was observed sitting in their recliner with their feet elevated. A bandage and dark purple bruising were observed on their right forearm.On 02/11/26 at 1:24 p.m., Res #3 was observed sitting in their recliner and watching television. A bandage and dark purple bruising were observed to their right forearm.An undated face sheet for Res #3 showed the resident was admitted to the facility with diagnosis which included unspecified pain.A quarterly assessment for Res #3, dated 12/03/25, showed the resident's cognition level was moderately impaired with a BIMS score of 11. The assessment showed the resident was dependent with activities of daily living and required the assistance of two staff.On 02/11/26 at 1:24 p.m., Res #3 was asked about the bruising and the bandage on their right forearm. Res #3 stated CNA #1 and LPN #1 tried to pull them up in bed. When CNA #1 leaned over them and pushed down on their arm while trying to move them up in bed. Res #3 stated they hollered and told CNA #1 and LPN #1 their arm was hurting, but they continued to move them up in bed.On 02/12/26 at 5:25 a.m., LPN #1 stated Res #3 had just returned from the emergency room, and they assisted the resident to bed. LPN #1 stated CNA #1 reached over Res #3 and grabbed the draw sheet that was under the resident while LPN #1 put their arm under the resident's knees to help move the resident up in bed. LPN #1 stated the resident stated, Ow my arm. LPN #1 stated they stopped and readjusted the resident then finished moving the resident up in bed.On 02/12/26 at 10:01 a.m., CNA #1 stated them and LPN #1 assisted Res #3 to bed after they returned from the emergency room. CNA #1 stated the resident needed to be moved up in the bed, so they reached across the resident and grabbed the draw sheet that was under the resident on both sides and LPN #1 grabbed under the resident's knees and they moved Res #3 up in bed. CNA #1 stated they never heard the resident complain of pain. CNA #1 was asked if that was the correct way to move a resident up in the bed. They stated, No, that one person should have been on each side of the bed and pulled the resident up in bed using the draw sheet.On 02/12/26 at 10:12 a.m., the DON stated on 02/06/26 at 4:30 p.m., Res #3's family member had called and informed them of the bruising to the resident's right forearm with a hematoma in the middle of it. The DON stated CNA #1 stated they did not hear Res #3 say Ow, my arm and LPN #1 stated they heard it and just assumed the resident referred to their chronic arm pain. The DON stated both employees were written up and re-educated on the proper way to move a resident up in bed.In-service training documentation, dated 02/06/26, was reviewed. The documentation showed all staff were re-educated on proper transfers, repositioning techniques, and pain management/assessments.A quality assurance meeting, dated 02/09/26, showed a performance improvement plan was established for improper lifts/transfers and pain assessment/re-assessment compliance documentation.On 02/13/26 at 9:56 a.m., CNA #2 stated to assist a resident up in the bed they had to have one person on each side and use the draw sheet to move the resident up.On 02/13/26 at 10:00 a.m., LPN #2 stated if a resident complained of pain, you repositioned first. LPN #2 stated pain medication was administered if the resident was still having pain and charted in the medication administration record and nurses' notes. LPN #2 stated if it was not an everyday pain then they documented in the nurse' notes, monitored, and notified the physician.On 02/13/26 at 10:10 a.m., CNA #3 stated you lowered the head of the bed, one person was on each side of the bed, and they used the pad or draw sheet to move the resident up.On 02/13/26 at 10:20 a.m., CNA #3 stated to move a resident up in bed you had to have one person on each side of the bed. CNA #3 stated they used the draw sheet to move the resident up in bed.On 02/13/26 at 10:35 a.m., restorative aide #1 stated you had to have one person on each side of the bed and used the draw sheet or pad to move the resident up in bed.On 02/13 26 at 10:45 a.m. LPN #3 stated if the resident complained of pain they assessed, checked physician orders, notified the physician if it was not chronic pain, completed a report sheet, and charted in the nurses' notes.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for pain while being repositioned in bed for 1 (#3) of 4 sampled residents reviewed for pain.The regional nurse consultant identified 65 residents resided in the facility. Findings:On 02/11/26 at 12:00 p.m., Res #3 was observed sitting in their recliner with their feet elevated. A bandage and dark purple bruising were observed on their right forearm.On 02/11/26 at 1:24 p.m., Res #3 was observed sitting in their recliner and was watching television. A bandage and dark purple bruising were observed to their right forearm.A Pain-Clinical Protocol policy, dated 10/2022, read in part, the staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognition level.An undated face sheet for Res #3 showed the resident was admitted to the facility with diagnosis which included unspecified pain.A physician order for Res #3, dated 08/28/23, showed Tylenol Arthritis Pain (pain reliever) 650 milligrams every six hours as needed.A quarterly assessment for Res #3, dated 12/03/25, showed the resident had a cognition level that was moderately impaired with a BIMS score of 11. A nurse's note for Res #3, dated 02/05/26 at 2:44 a.m., showed the resident received Tylenol as requested.A care plan for Res #3, revised 02/08/26, showed to monitor any skin changes, notify physician of blood blister and changes as necessary until area resolved, and to monitor for pain and/or discomfort.On 02/11/26 at 1:24 p.m., Res #3 stated when they returned from the emergency room, CNA #1 and LPN #1 tried to pull them up in bed. Res #3 stated CNA #1 leaned over them and pushed down on their arm while trying to move them up in bed. Res #3 stated they hollered and told CNA #1 and LPN #1 their arm was hurting. Res #3 stated they continued to move them up in bed.On 02/12/26 at 5:25 a.m., LPN #1 stated Res #3 had just returned from the emergency room, and they assisted the resident to bed. LPN #1 stated CNA #1 reached over Res #3 and grabbed the draw sheet that was under the resident while they put their arm under the resident's knees to help move the resident up in bed. LPN #1 stated the resident stated, Ow my arm. LPN #1 stated they stopped and readjusted the resident then finished moving the resident up in bed. LPN #1 stated they did not assess the resident for new pain, just assumed it was the chronic shoulder pain they complained about. LPN #1 stated they should have assessed the resident to see where the pain was, reported they just administered the resident's pain medication, and made sure it was effective.On 02/12/26 at 10:01 a.m., CNA #1 stated them and LPN #1 assisted Res #3 to bed after they returned from the emergency room. CNA #1 stated the resident needed to be moved up in the bed, so they reached across the resident and grabbed the draw sheet that was under the resident on both sides and LPN #1 grabbed under the resident's knees and they moved Res #3 up in bed. CNA #1 stated they never heard the resident complain of pain. CNA #1 was asked if that was the correct way to move a resident up in the bed. They stated, No, that one person should have been on each side of the bed and pulled the resident up in bed using the draw sheet.On 02/12/26 at 10:12 a.m., the DON stated on 02/06/26 at 4:30 p.m. Res #3's family member had called and informed them of the bruising to the resident's right forearm. The DON stated CNA #1 reported they did not hear the Res #3 say Ow, my arm and LPN #1 stated they heard it and just assumed the resident referred to their chronic arm pain. The DON stated both employees were written up and re-educated on the proper way to move a resident up in bed. The DON stated LPN #1 was reprimanded for their failure to assess the complaint of pain from Res #3 during transfer.

Based on observation, record review, and interview, the facility failed to ensure medications were administered according to physicians' orders for 1 (#2) of 6 residents sampled for medications administered according to physician orders. The administrator identified 68 resident received medication from the facility. Findings:On 08/25/25 at 2:10 p.m., the medication room was observed. The room was locked and secured with a camera for monitoring. The room was clean, and all medications were labeled. RN #1 showed the e-kit (emergency medication kit) and the process for accessing the emergency medications. The e-kit was locked with a control log process when accessing medications. There was an inventory sheet attached which showed all the medications in the e-kit. The e-kit was labeled with medications set to expire on 10/2025. Macrobid antibiotic in capsules were observed in the e-kit. A facility policy titled Pharmacy Services Overview, dated 04/2019, read in part, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the service of a licensed pharmacist.Residents have sufficient supply of their personal medications and receive medications (routine, emergency or as needed) in a timely manner.Resident #2's admission record, dated 04/30/21, showed they were admitted with diagnoses which included malignant neoplasm of the right kidney, Alzheimer disease, dementia, malignant neoplasm of the left lung, and stage 3 chronic kidney disease.Resident #2's quarterly assessment, dated 04/02/25, showed their cognition was moderately impaired with a BIMS score of 13.Resident #2's physician order, dated 05/20/25, showed to send Resident #2's urine out for culture and cytology. Resident #2's lab results, dated 05/23/25, showed Resident #2's urine was positive for Escherichia coli greater than 100,000 cells/ml. Resident #2's nursing note, dated 05/23/25, read in part, 1400-2200 [2:00 p.m. - 10:00 p.m.] N/O [new order] per [name of physician withheld] Macrobid 100 mg x 14 days for E. coli.Resident #2's physician orders, dated 05/24/25, read in part, Macrobid (antibiotic) (nitrofurantoin monohyd/m-cryst) capsule; 100 mg; amt (amount) 1 tab; oral twice a day.A facility document titled Grievance/Complaint Report, dated 05/24/25, showed Resident #2's family representative was concerned Resident #2 did not receive their antibiotic on 05/24/25. The document showed the medications were in the building and nursing staff were in-serviced on use of the e-kit. Resident #2's MAR (medication administration record), dated 05/23/25 through 05/25/25, did not document Resident #2 received the antibiotic Macrobid 100 mg two times a day. Resident #2's nursing note, dated 05/25/25, showed Resident #2s family was present and Resident #2 was confused. The note showed Resident #2's physician was notified and ordered Resident #2 to be sent to the hospital for IV fluids. The note showed Resident #2 left the facility by ambulance to be transported to the hospital.Resident #2's hospital record, dated 05/25/25, showed Resident #2 was admitted to the hospital for a complicated UTI and was not septic. A facility document titled Performance Improvement Plan: Privileged Work Document, dated 05/25/25, showed LPNs, RNs, and CMAs were in-serviced on 05/25/25 regarding the use of the e-kit for medications and utilizing the emergency pharmacy phone number. The document showed the facility was going to conduct medication audits weekly for two weeks, then weekly thereafter. A facility document with no title, dated 05/25/25 through 06/07/25, showed daily monitoring was in place to ensure residents received their medications as ordered. The document showed weekly monitoring was conducted from 06/09/25 through 08/13/25. The daily/weekly monitoring document included the following key points:a. MAR matches current provider,b. medications given in 1-hour window, c. PRNs include indication, effectiveness documentation, and d. Any omitted or missed doses.The document showed medications were available in the facility and proper medication protocols were being followed.A facility handwritten statement from CMA #1, dated 05/26/25, read in part, Saturday 05/24/25, I was med (medication) aide on 2 p.m. to 10 p.m., I was supposed to give Macrobid around [3:00 p.m.] but it wasn't there, and I let [LPN #5] know it wasn't there and that I put it down as not given. [They] said OK and went to working on getting it from the pharmacy.A facility document titled Corrective Action Notice, dated 05/26/25, read in part, [LPN #5] displayed unprofessionalism toward family members. [LPN#5] did not ensure medications were in the building in a timely manner and did not follow the facility protocols on ensuring meds were given, and the emergency kit was utilized. The note showed LPN #5 was suspended for 4 days. The note was signed by the DON on 05/27/25.A facility document titled Resident Concern Form, dated 05/26/25, showed Resident #2 did not receive their scheduled antibiotics on 05/24/25 and 05/25/25. The note showed actions taken included internal investigation, corrective action, implement a PIP on medication adherence, and audits. A facility document titled In-service Training Report, dated 05/26/25, showed the DON in-serviced 16 nurses and CMAs on the following topics:a. e-Kit,b. ensuring medications were in the building, andc. the emergency phone number for the pharmacy. Resident #2's urine culture lab results, dated 05/28/25, showed Resident #2's urine was positive for Escherichia coli with [NAME] 10,000-50,000 cfu/ml (colony forming unit per milliliter). A facility document titled Monthly QA/PI Committee Meeting, dated 06/16/25, showed a QAPI meeting was held. The QAPI meeting addressed the e-kit for medications, medications being available, and regulatory compliance. On 08/25/25 at 8:00 a.m., physician #1 stated Resident #2 was very ill with kidney cancer and they had UTI's consistently due to their disease process. Physician #1 stated based upon the lab values from the urine sample taken at the hospital on [DATE], they would have discontinued the antibiotic Macrobid prescribed on 05/23/25. Physician #1 stated Resident #2 was not harmed as a result of not getting the prescribed antibiotic for two days. On 08/25/25 at 11:28 a.m., CMA #1 was asked about Resident #2's medication administration. CMA #1 stated on 05/24/25, they were passing medications when they realized Resident #2's Macrobid antibiotic was not available. CMA #1 stated they notified LPN #5 the medication was not available and marked on the MAR the antibiotic was not given to the resident. CMA #1 stated they were in-serviced on ensuring medications were available and given following physician orders.On 08/25/25 at 11:53 a.m., NP #1 stated they prescribed the Macrobid antibiotic on 05/23/25 for Resident #2. NP #1 stated Resident #2 would not have been harmed as a result of not receiving the antibiotic because Resident #2 has bleeding from the kidneys related to their diagnosed illness of kidney cancer. On 08/26/25 at 8:30 a.m., the DON stated Resident #2 not receiving their prescribed antibiotic on 05/24/25 and 05/25/25 was a failure on the staff for not utilizing the e-kit. The DON stated they did a PIP, in-serviced all CMAs and nurses on medication policy and procedure, did corrective action on involved staff, and QA/PI the event on 06/16/25.

Based on record review and interview, the facility failed to ensure responsible parties were notified of a change in condition for 1 (#1) of 3 sampled residents reviewed for notifying responsible parties of a change in condition. The administrator identified 68 resided in the facility. Findings:A facility policy titled Change in a Resident's Condition or Status, dated 02/2021, read in part, Unless otherwise instructed by the resident, a nurse will notify the representative when: .it is necessary to transfer the resident to a hospital/treatment center.Except in Medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residents' medical/mental condition or status.Resident #1's admission health record, dated 11/15/24, showed they were admitted with diagnoses which included atrial flutter, epilepsy, nutritional disorder, and chronic kidney disease. An annual assessment for Resident #1, dated 01/07/25, showed Resident #1's cognition was moderately impaired with a BIMS score of 12.A progress note for Resident #1, dated 01/31/25, showed Resident #1's physician ordered them to be sent to the emergency room. A hospital record for Resident #1, dated 01/31/25 though 02/07/25, showed Resident #1 was admitted to the hospital on [DATE] with a diagnosis of acute CVA (cerebrovascular accident). A facility form titled Corrective Action Notice, dated 02/07/25, showed LPN #3 was suspended and received a written notice for failing to notify family representatives when sending Resident #1 to the hospital.A facility document titled Performance Improvement Plan: Privileged Work Document, dated 02/19/25, showed in-service training was conducted on timely notifying family representatives of change in condition and hospital transfers. The document showed auditing events and hospital transfers to ensure timely notification of transfers and change in condition were completed daily for two weeks, weekly for four weeks, and periodically.A facility document titled Inservice Training Report, dated 02/19/25 through 02/20/25, showed 22 staff received in-service training over notification to family representatives after a change in condition. A facility document titled Daily Stand-up Rounds report, dated 02/19/25 through 03/28/25, showed the facility was monitoring for notification to family representatives in the event of a hospital transfer daily for two weeks from 02/19/25 through 03/05/25. The document showed notification of family representatives in the event of a change in condition was monitored weekly from 03/05/25 through 03/28/25.A facility document titled Monthly QA/PI Committee Meeting, dated 03/11/25, showed notification to family representatives after a change in condition was reviewed in the meeting QA/PI meeting. On 08/25/25 at 2:50 p.m., family representative #1 stated Resident #1 was sent to the hospital on [DATE]. Family representative #1 stated they were not notified that Resident #1 was being sent to the hospital on [DATE] by the facility staff. Family Representative #1 stated they were notified of Resident #1's transfer when the medical flight transport pilot contacted them. On 08/25/25 at 8:58 a.m., LPN #3 stated notification to family representatives should be documented in the progress notes. LPN #3 stated there was no documentation in Resident #1's progress notes, dated 01/31/25, the family was notified when Resident #1 was sent to the hospital. LPN #3 stated they received a written warning for not notifying Resident #1's family representative on 01/31/25. LPN #3 stated they had an in-service training on notification to family representatives after a change in condition. On 08/26/25 at 8:30 a.m., the DON stated LPN #3 did not notify the family representative of Resident #1 on 01/31/25 when the resident was sent to the hospital. The DON stated the family representative was notified by the medical flight pilot. The DON stated they did a PIP and in-service over notifying family representatives after a change in condition. The DON stated LPN #3 received a written corrective action on 02/07/25 for not notifying the family representative of Resident #1.

Based on observation, record review, and interview, the facility failed to follow their policy to ensure a safe environment for smokers for two (#45 and #55) of two residents sampled for accident hazards. The administrator reported 10 residents who smoked, seven of which were unsupervised smokers. Findings: A Smoking Policy - Residents policy, dated July 2017, read in parts, A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff .Residents shall have the supervision of a staff member, family member, visitor or volunteer worker at all times while smoking .Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under supervision. 1. Resident #45 had diagnoses which included Alzheimer's dementia, diabetes, asthma, chronic kidney disease, visual loss, muscle spasm, anxiety, depression, psychosis, and a history of falls. A smoking assessment for Resident #45, dated 12/19/24, documented the resident was a safe smoker with a smoking risk of 0. The assessment documented the resident could smoke independently. An MDS assessment, dated 12/20/24, documented the resident was cognitively intact and independent with activities of daily living. A care plan for Resident #45, dated 12/24/24, documented the resident was at risk for injury related to being a smoker. The care plan documented the resident would smoke in designated areas. The care plan documented the resident required oxygen as needed. On 01/15/25 at 10:47 a.m., Resident #45 reported they smoked independently. The resident was asked if staff kept their cigarettes and they stated, No. They stated that was only for residents who got caught smoking in their room. The resident was noted to have oxygen in place per nasal cannula. The resident reported they used oxygen most of the time. On 01/15/25 at 10:58 a.m., CNA #2 reported Resident #45 was fairly independent and was allowed to keep their cigarettes in their room. On 01/15/25 at 11:03 a.m., LPN #3 reported they only kept cigarettes for one resident on the hall. The LPN reported Resident #45 and all other unsupervised smokers kept their own cigarettes in their rooms. On 01/15/25 at 4:51 p.m., RN #2 confirmed Resident #45 kept their cigarettes and lighter in their room. The RN reported the resident smoked independently. The RN reported the resident normally only went out to smoke two or three times a day because the resident usually did not feel like going out. 2. Resident #55 had diagnoses which included Alzheimer's disease, pain, depression, anxiety, essential tremor, and a history of falls. A progress note, dated 11/24/24 at 6:47 p.m., documented Resident #55 was outside smoking with family members. The note documented the family reported the resident got up to walk over and get a cigarette when they tripped and fell . The note documented the resident was assessed for injury. A smoking assessment for Resident #55, dated 01/07/25, documented the resident smoked every few hours. The assessment documented a smoking risk of 0. The assessment documented the resident was a safe smoker and could smoke independently. An MDS assessment, dated 01/07/25, documented the resident was severely impaired with cognition. A care plan for Resident #55, dated 01/09/25, documented the resident was at risk for injury related to smoking. The care plan documented the resident would smoke in designated areas. The care plan documented the resident had cognitive impairment related to Alzheimer's disease. On 01/14/25 at 11:17 a.m., the social services director reported Resident #55 frequently walked the halls often looking for someone to take them outside to smoke. On 01/14/25 at 11:25 a.m., Resident #55 was observed to walk to the outside door near the designated smoking area. An unidentified staff member was observed to open the door for the resident and the resident was observed to smoke with three staff members. On 01/15/25 at 11:05 a.m., LPN #3 reported they kept Resident #55's cigarettes at the nurse's station. The nurse reported the resident did not typically request to go smoke, but staff would take the resident out a couple of times a day. The nurse reported the resident was always supervised with a staff member. On 01/15/25 at 4:06 p.m., CNA #3 reported Resident #55 did not actually get staff to take them out, but would often go to the door to see if anyone else was smoking. The CNA reported staff usually took the resident out a couple of times a day and the resident was always supervised. On 01/16/25 at 9:45 a.m., the DON reported Resident #55's smoking assessment was correct. The DON reported they would normally keep cigarettes for a resident with dementia, so the nurses kept the resident's cigarettes at the nurse's station. The DON reported Resident #55 could smoke safely with no concern related to how they held a cigarette and no concern with lighting a cigarette. On 01/16/25 at 9:50 a.m., the DON reported the MDS nurse usually completed the resident smoking assessments. The DON reported if residents were considered unsupervised, they could go outside and smoke independently without supervision. The DON reported they had some residents who kept their cigarettes and lighter in their room, and were free to go out and smoke whenever they wanted without notifying staff. The DON reported a resident with dementia usually required staff to keep their cigarettes and required supervision while smoking. On 01/16/25 at 9:58 a.m., the DON was asked about the facility's policy for all smokers to be supervised at all times and that residents would not keep any smoking articles except under supervision. The DON reported often residents wanted to keep their own cigarettes, so it was a nursing judgement as to who would be allowed to keep their cigarettes and lighter with them. The DON stated the facility policy probably needed to be re-worded to reflect their process more accurately.

Based on observation, record review, and interview, the facility failed to transcribe a physician order and schedule a mammography in a timely manner as requested for one (#41) of one resident reviewed for a physician ordered mammography. The administrator reported 67 residents resided in the facility. Findings: A Transportation, Diagnostic Services policy, dated December 2008, read in parts, Should it become necessary for the facility to provide transportation, the Social Service Designee will be responsible for arranging the transportation through the business office .A member of the Nursing Staff, or Social Services, will accompany the resident to the diagnostic center when the resident's family is not available. An Acute Condition Changes-Clinical Protocol policy, dated March 2018, read in parts, Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison .The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status .The nursing staff will contact the medical director for additional guidance and consultation if they do not receive timely or appropriate response. A Resident's Council Meeting minutes, dated 08/08/24, documented an elder stated doctor appointments were taking too long to set up. Progress notes for Resident #41, dated 11/13/24, documented past surgical history, partial mastectomy left. A nurse's note for Resident #41, dated 12/26/24, read in parts, resident has a lump in breast tissue under the left arm .[physician name withheld] notified. New orders .Schedule mammogram for resident as soon as possible. The note was documented by RN #3. Resident #41's Physician Order, dated 01/16/25, read in part, diagnostic mammogram due to lump on the left side [DX: Unspecified lump in the left breast, upper outer quadrant]. LPN #1 presented the physician's order on the day of the survey. On 01/16/25 at 8:29 a.m., LPN #4 performed a skin assessment with Resident #41. A lump to the left breast area was noted and Resident #41 reported they were supposed to schedule them for a mammogram. The resident reported a history of breast cancer. On 01/16/25 at 11:08 a.m., LPN #1 was asked when Resident #41 was scheduled for a mammography. They reported the referral was sent this morning to the hospital. They were asked when they received notification to schedule the mammography. They stated they were notified around the end of December 2024 and the physician order was received this morning. They were asked about the nurse's note stating to schedule as soon as possible. LPN #1 stated that meant, As soon as we can get it done. The nurse was asked if it had been arranged as soon as possible. They stated, No. They stated it had been 16 or 17 days and they hoped they would have an appointment scheduled this afternoon or in the morning. They were asked about Resident #41's breast cancer history. The nurse reviewed records and reported the resident had a partial mastectomy on the left side dated 05/22/24. On 01/16/25 at 11:38 a.m., the DON was asked about the facility policy related to referrals for testing. The DON reported the doctor would put in the order and they would get it scheduled in a timely manner. The DON was asked about the scheduling for the mammography for Resident #41. They stated it sounded like it had taken a couple of weeks to get it scheduled. On 01/16/25 at 12:15 p.m., RN #3 was asked if they wrote the physician order related to the nurse's note dated 12/26/24. They stated they thought they had, but did not see the order when the record was reviewed today. The RN reported they were aware of the residents' history of breast cancer. The RN reported there had been a scheduling issue in getting the resident's mammography scheduled. On 01/16/25 at 2:30 p.m., LPN #1 reported they had called the hospital to get Resident #41's mammography scheduled. The LPN reported the hospital staff stated since the resident had a lump and would need a 3-D mammography, so the process was started with receiving a physician order for a 3-D mammography.

Based on record review and interview, the facility failed to refer a resident with newly diagnosed mental illness diagnoses to the OHCA for a level II PASARR evaluation for one (#40) of two sampled residents reviewed for PASARR. The administrator reported 67 residents resided in the facility. Findings: Resident #40 was admitted to the facility on [DATE]. A level I PASARR, dated 02/09/21, documented no level II PASARR was required. Resident #40 had diagnoses added since admission which included mood disorder, date diagnosed [DATE], and unspecified psychosis, date diagnosed [DATE]. On 01/14/25 at 4:33 p.m., the regional nurse consultant reported the resident's PASARR had not been reevaluated after the new mental illness diagnoses. The regional nurse consultant reported the facility had no policy for PASARR.

Based on observation, record review, and interview, the facility failed to ensure proper disposal of blood contaminated glucometer strips for one (#52) of two sampled residents reviewed for finger stick blood sugar levels. The DON reported 25 residents received finger stick blood sugar levels. Findings: A policy for Blood Sampling, dated 09/14/14, read in parts, The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees .Equipment and supplies, sharps container .Discard lancet and platform into the sharps container. Resident #52's Physician Order, dated 04/28/24, documented FSBS BID notify provider if over 300 and below 60. Resident #52's Care Plan, dated 05/13/24, documented nutritional status, resident has a diagnosis of diabetes mellitus. On 01/14/25 at 5:10 p.m., RN #2 was observed to gather supplies for a FSBS, which included a glucometer, gauze, lancet, and glucometer strip. The RN obtained a blood sample from Resident #52 and the glucometer had timed out. The RN removed the bloody strip and disposed of it in the resident's trashcan in their room. The RN was then observed to repeat the procedure and again disposed of the bloody test strip in the resident's trashcan. The RN reported they were nervous and normally would have disposed of the contaminated strip in the sharps container. On 01/16/25 at 2:25 p.m., the DON reported their policy was to dispose of contaminated supplies in the sharps container.

Based on observation, record review, and interview, the facility failed to treat a resident with dignity and respect while providing assistance with eating for one (#33) of one resident sampled for resident rights. The administrator reported 67 residents resided in the facility. A Telephones, Employees Use of policy, dated July 2010, read in part, cellular phones may be used for personal calls and text messaging ONLY when the employee was on authorized meal and break periods. Employee cell phones will remain off and/or silent during all other work hours. Failure to comply with cellular phone policies may result in disciplinary action. Resident #33 had diagnoses which included Alzheimer's disease, depression, and seizure disorder. An MDS assessment for Resident #33, dated 11/18/24, documented the resident had severely impaired decision making. A care plan for Resident #33, dated 11/18/24, documented the resident required assistance with activities of daily living. On 01/14/25 at 1:02 p.m., during the noon meal, CNA #2 was observed to be watching a video on their personal cell phone while feeding Resident #33 a pureed meal. On 01/14/25 at 1:20 p.m., LPN #3 reported the use of cell phones while providing resident care was not allowed and stated they would address the situation with CNA #2. On 01/14/25 at 2:10 p.m., CNA #1 reported CNA #2 used their cell phone on a daily basis while feeding the residents. CNA #1 was asked if they were allowed to use their cell phone while providing care and the CNA stated it was not recommended. On 01/16/25 at 9:57 a.m., the DON reported they expected no cell phone use from staff while providing care to residents. The DON reported cell phone use had been an ongoing problem and staff were reminded frequently to put their phones away except during breaks.

Based on observation, record review, and interview, the facility failed to maintain a comfortable room temperature for one (#16) of four residents sampled for the environment. The administrator reported 67 residents resided in the facility. Findings: An undated Resident Rights policy, read in parts, The facility must provide a safe, clean, comfortable, home-like environment .The facility will provide housekeeping and maintenance services .The facility will provide you with comfortable and safe temperature levels. Resident #16 had diagnoses which included atrial fibrillation, Alzheimer's dementia, muscle weakness, anxiety, coronary artery disease, iron deficiency anemia, chronic pain, and diabetes. An MDS assessment, dated 11/02/24, documented Resident #16 was moderately impaired with cognition. The assessment documented the resident used a wheelchair for mobility. On 01/14/25 at 2:40 p.m., Resident #16 was observed lying in bed covered up with blankets. The resident reported they were cold and was noted to have blankets on the windowsill underneath the blinds. The resident reported they had put the blankets on the windowsill because they were always cold. On 01/14/25 at 2:49 p.m., RN #2 reported Resident #16's room was always cold. The RN reported they had told maintenance about the room being cold the previous week. The RN reported they remembered maintenance saying there were blankets on the vent and those had been removed to get some heat flowing. The RN stated they did not think the room had gotten any warmer and maintenance had not done anything further as far as they were aware. The RN reported sometimes Resident #16's hands were so cold it was hard to get a pulse oximetry reading when doing the resident's assessment. On 01/14/25 at 3:40 p.m., a room temperature was obtained in Resident #16's room, using a digital thermometer, which read 67.6 degrees Fahrenheit. On 01/16/25 at 10:25 a.m., Resident #16 reported their room was still cold. A room temperature was obtained and the temperature was 71.4 degrees Fahrenheit. The administrator and maintenance staff obtained a similar temperature reading using their own thermometer. The resident was observed sitting in their wheelchair wearing a jacket. The surveyor asked the resident if they had been asked about possibly changing rooms. The administrator then asked the resident if they would want to change rooms and the resident stated, Yes, I would. On 01/16/25 at 10:37 a.m., the administrator reported they had just learned the previous day the resident had complained of their room being too cold and they had started a grievance report related to the resident's complaint. The administrator was informed the resident had complained to the charge nurse the previous week and the charge nurse had reported the complaint to maintenance. The administrator reported they would check into finding a different room for the resident.

Based on record review and interview, the facility failed to complete a MDS discharge assessment when the resident was discharged from the facility for one (#63) of one sampled resident reviewed for comprehensive assessments. The administrator reported 67 residents resided in the facility. Findings: The regional nurse consultant reported the facilty had no policy for comprehensive assessments. Resident #63 was admitted to the facility on [DATE] with a diagnosis of right femur fracture. A progress note, dated 09/07/24, documented the resident discharged from the facility. On 01/15/25 at 11:10 a.m., the MDS coordinator reported the discharge assessment was missed for Resident #63. The MDS coordinator reported the discharge assessment would be completed and submitted.

Based on observation and interview, the facility failed to ensure medications were stored properly and according to facility policy. The Administrator reported 66 residents resided in the facility. Findings: The Storage and Medications policy, revised, April 2019, read in part .Policy Statement The facility stores all drugs and biologicals in a safe , secure, and orderly manner . On 04/25/24 at 4:29 p.m., it was observed that resident #8's medications were laying on the top of the counter, at the north hall nurses station. No staff was in sight. On 04/25/24 at 4:30 p.m., RN#1 reported resident #8's medications should be locked in a medication cart. On 04/25/24 at 4:31p.m., ADON reported resident #8's medications are supposed to be locked and stored in the medication cart.

Based on record review and interview, the facility failed to follow the physician's order related to a midline dressing change for one (#1) of two residents reviewed for dressing changes. The Resident and Conditions of Residents report documented 70 residents resided in the facility. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 06/28/22, read in part, .Change dressing to midline weekly, Once a Day on Fri; 22:00 - 06:00.'' A TAR was reviewed and contained no documentation of treatment being performed for the midline dressing change. On 10/04/22 at 1:20 p.m., the DON was asked to review the TAR for the midline dressing change. The DON was asked if there was documentation the treatment was performed as ordered. The DON stated, I cannot say it was or was not performed. The DON was asked if they had any documentation showing the treatment was performed. They stated they would look. On 10/04/22 at 3:00 p.m., the DON stated I cannot find any documentation that the treatment was or was not performed.

Based on observation, interview, and record review, it was determined the facility failed to provide interventions in a timely manner to prevent weight loss for two (#1 and #5) of four residents reviewed for weight loss. The facility reported 62 residents lived in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 07/02/19, documented the resident was severely impaired with cognition and required total assistance with activities of daily living. The assessment documented the resident weighed 119 pounds. A vitals report, dated 01/01/20 through 06/19/20, documented the residents weight as follows: 01/01/20- 131.5 pounds; 02/07/20- 134 pounds; 03/25/20- 138 pounds; 04/06/20- 139 pounds; 05/12/20- 137.6 pounds; 06/05/20- 115 pounds; and 06/11/20- 111 pounds. A quarterly assessment, dated 04/02/20, documented the resident was severely impaired with cognition and required total assistance with activities of daily living. The assessment documented the resident weighed 138 pounds. A care plan, updated 04/08/20, documented the resident required a pureed diet and was at risk for weight loss. The care plan documented for the staff to assist the resident with meals. The care plan documented for the staff to monitor the residents intake and to monitor weights as ordered by the physician. The care plan documented for the staff to offer house supplements when needed. The care plan documented the resident was at risk for aspiration due to impaired swallowing. A physician's orders [REDACTED]. The order documented for the resident to receive honey thick mighty shakes with breakfast and dinner. The order documented for the resident to receive [MEDICATION NAME] 40 mg daily.(used to treat loss of appetite). The order documented for the staff to weigh the resident monthly. A care plan, updated 06/05/20, documented for the staff to encourage oral intake of food and fluids, monitor and record intake, monitor lab as ordered, and offer substitutes when needed. A dietary progress note, dated 06/10/20, documented the resident's current weight was 111 pounds. The note documented medications included [MEDICATION NAME] and to add Med Pass 60 milliliters (ml) twice a day. The note documented to continue to monitor weights and intake and to notify the primary care provider. The physician had been notified regarding the residents weight loss on 06/11/20. A physician's orders [REDACTED]. The clinical record documented the resident had received medications and supplements as ordered by the physician. A medical and dental equipment repair letter, dated 06/15/20, documented, On June 3 and June 12, 2020 we calibrated your two Detecto Wheelchair Scales and Vanderlift Digital Lift Scale and Detecto Stand-Up Scale. We adjusted and calibrated these scales using weights traceable to the National Institute of Standards and Technology. Your scales are due a calibration again on December 2020 . On 08/04/20 at 11:00 a.m., the director of nurses(DON) reported the physician should have been notified of the resident's weight loss in a timely manner. The DON reported interventions to prevent further weight loss should have been implemented in a timely manner. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A vitals report, dated 04/10/20 through 07/30/20, documented the residents weight as follows: 04/10/20- 144.6 pounds; 05/12/20- 156.2 pounds; 06/11/20- 134 pounds; 07/02/20- 138.4 pounds; 07/09/20- 141.4 pounds; 07/24/20- 138 pounds; and 07/30/20- 139.5 pounds. A medical and dental equipment repair letter, dated 06/15/20, documented, On June 3 and June 12, 2020 we calibrated your two Detecto Wheelchair Scales and Vanderlift Digital Lift Scale and Detecto Stand-Up Scale. We adjusted and calibrated these scales using weights traceable to the National Institute of Standards and Technology. Your scales are due a calibration again on December 2020 . A physician's orders [REDACTED]. An annual assessment, dated 07/28/20, documented the resident was severely impaired with cognition, and required extensive care with most activities of daily living. The assessment documented the resident required supervision with meals. The assessment documented the resident weighed 138 pounds. A care plan, updated 07/29/20, documented the resident required a pureed diet due to at risk for weight loss. The care plan documented for the staff to allow resident time to eat, assist resident if needed, monitor intake of meals, monitor weight as ordered, and offer supplements if needed. A printed physician's orders [REDACTED]. The order documented med pass supplement 2.0 give 60 ml twice a day was added on 10/26/19. The order documented a pureed diet with nectar thick liquids had been ordered on [DATE]. The clinical record contained no documentation the physician had been notified of the resident's weight loss. The clinical record contained no new interventions until 06/30/20. On 08/04/20 at 9:49 a.m., the resident was observed sitting up in her recliner with her eyes closed. On 08/04/20 at 11:00 a.m., the director of nurses(DON) reported the physician should have been notified of the resident's weight loss in a timely manner. The DON reported interventions to prevent further weight loss should have been implemented in a timely manner.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate staff to meet the needs of the residents for eight (#48, 28, 54, 53, 126, 74, 27, and #49) of 31 residents reviewed. The facility reported 84 residents required assistance with bathing. Findings: 1. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 05/26/19, documented the resident was cognitively intact and required extensive assistance with activities of daily living (ADL). The assessment documented the resident was at risk for developing pressure ulcers. A care plan, dated 08/12/19, documented the resident required extensive assistance with ADLs. The care plan documented for the staff to assist with ADLs as needed. On 11/04/19 at 2:21 p.m., the resident reported she had went a month without a shower in September. The resident reported she only received one shower or bath a week for the past two months. On 11/05/19 at 3:40 p.m., the resident was observed lying in bed with her eyes closed. On 11/06/19 at 11:05 a.m., the resident reported she had not had a bath or shower since last Tuesday or Thursday. 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/12/19, documented the resident was cognitively intact and was totally dependent for activities of daily living. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident was at risk for pressure ulcers. A care plan, dated 09/12/19, documented the resident was incontinent of bowel and bladder. The care plan documented the resident would be assisted with routine toileting. The care plan documented to bathe the resident as necessary to prevent odors. The care plan documented briefs would be changed as needed and the resident would be kept clean and dry at all times. The care plan documented for the staff to provide pericare after each incontinent episode. On 11/04/19 at 3:28 p.m., the resident reported she could not get the staff to give her a bath. The resident reported she had not had a bath/shower for two weeks. The resident reported the staff won't get me up out of bed like I would like. The resident reported the staff would tell her it would be a minute but never come back. On 11/05/19 at 3:19 p.m., two unidentified staff members reported they were the only two certified nurse aides (CNA) in the building on the evening shift last Thursday. The CNAs reported being short of staff happened very frequently. On 11/06/19 at 1:38 p.m., the resident reported she still had not had a bath/shower. On 11/06/19 at 3:09 p.m., the DON reported she could not find any documentation the resident had received a bath/shower in the past two months. 3. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A significant change assessment, dated 10/15/19, documented the resident was cognitively intact and was totally dependent for most activities of daily living and bathing. A care plan, dated 10/16/19, documented the resident was at risk for deterioration with ADLs. The care plan documented for the staff to assist with ADLs the resident was unable to provide for self. On 11/04/19 at 1:08 p.m., the resident reported there was not enough staff. The resident reported the staff would say they would be back but don't come back. The resident reported she wanted to be placed on hospice so she could get her baths. On 11/05/19 at 2:15 p.m. the resident was observed lying in bed with her eyes closed. 4. Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 10/03/19, documented the resident required extensive assistance with ADLs. The care plan documented for the staff to assist with ADLs as needed. An admission assessment, dated 10/08/19, documented the resident was moderately impaired with cognition, required extensive assistance with activities of daily living, required a urinary catheter and was always continent of bowel. The assessment documented the resident was at risk for pressure ulcers. On 11/04/19 at 3:01 p.m., a family member reported the resident had not had a bath/shower for the past week. The family member reported the resident had been in the same clothes for three days and had slept in them. The family member reported she had found the resident soaked from head to toe in urine. The family member reported there were only three aides for the entire building several evenings the last two weeks. 5. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/13/19, documented the resident was cognitively intact and required limited assistance with activities of daily living (ADL). The assessment documented the resident was frequently incontinent of bowel and bladder. A care plan, dated 08/14/19, documented the resident was incontinent of bowel and bladder. The care plan documented for the nursing staff to assist the resident with toileting routinely and to provide a bath as necessary to prevent odors. The care plan documented for the staff to change the resident's brief as needed and keep the resident clean and dry at all times. The care plan documented for the staff to provide pericare after each incontinence episode. On 11/04/19 at 1:56 p.m., the resident reported not being clean made her feel undignified. On 11/06/19 at 8:44 a.m., the resident's room was noted to have a strong odor of urine. The resident reported staff would provide pericare when she asked them to. The resident reported they do not routinely provide pericare. The resident reported the facility was frequently short staffed. The resident reported last Saturday was her bath day and she did not receive a bath. The resident reported it had been six days since she had received a bath. The resident reported she told the administrator (ADM) on Monday of this week and she was told it would be fixed. The resident reported she still had not received a bath. 6. Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/10/19, documented the resident was cognitively intact. The assessment documented the resident required limited assistance with activities of daily living. The assessment documented the resident was always continent to bowel and bladder. A care plan, updated 09/13/19, documented the resident required assistance with ADLs as needed. The care plan documented the nursing staff was to encourage the resident to ask for help as needed. On 11/06/19 at 9:08 a.m., the resident complained of not getting assistance. The resident reported she had waited over an hour for assistance. The resident reported the facility needed more staff. The resident reported staff would answer call lights and advise they would return to provide assistance but would not come back. The resident reported she was unsure when her last bath was completed. 7. Resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 10/07/19, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living (ADL). The assessment documented the resident was occasionally incontinent of bowel and bladder. A care plan, updated 10/14/2019, documented the resident had ADL self-care deficit due to weakness and unsteadiness and required nursing assistance with ADLs as needed. The care plan documented staff was to encourage the resident to ask for help as needed. On 11/04/19 at 3:19 p.m., the resident reported there was not enough staff. The resident reported it would take an hour or more to get assistance on all shifts. The resident also reported when there was enough staff they would come in and say they would return and then not come back. On 11/06/19 at 10:32 a.m., the resident reported he was due a bath last night but turned it down on his own due to not enough staff. The resident reported he had not been bathed since last Thursday. The resident reported there was one certified nursing aide (CNA) and a hospitality aide on duty last night. 8. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/14/19, documented the resident was moderately impaired with cognition. The assessment documented the resident required assistance with bathing. A care plan, dated 08/28/19, documented the resident required assistance with ADLs as needed. A bath schedule documented the resident was to receive a shower on Tuesday, Thursday, and Saturdays. On 11/06/19 at 12:00 p.m., the resident reported she had not had a bath since the first of last week. The resident reported she was unaware of her scheduled bath days. The resident reported her daughter would give her a bath when the staff did not. On 11/07/19 at 11:51 a.m., licensed practical nurse (LPN) #1 reported the resident's scheduled bath days were Tuesdays, Thursdays, and Saturdays. The LPN also reported it was difficult to get baths completed many times due to staff shortage. 9. Resident council minutes, dated 08/01/19, documented, .Still having issues with not getting showers and still not answering call lights . Resident council minutes, dated 09/05/19, documented, .Still not getting showers and still not answering call lights .we need more aids . Resident council minutes, dated 10/03/19, documented, Still not getting showers and still not answering call lights .Residents voted for DON to be in the meeting to address concerns . 10. Staffing documentation for the past two weeks were reviewed. The staffing documentation contained 24 shifts without sufficient staffing. On 11/04/19 at 11:40 a.m. upon entering the facility three call lights were flashing on the southwest hall. On 11/05/19 at 1:39 p.m., certified medication aide #1 reported there was only one certified nurse aide (CNA) for SE and SW halls for today's shift. The CMA reported there was a total of 22 residents. On 11/05/19 at 1:40 p.m., licensed practical nurse (LPN) #1 reported there was one CNA for both halls. The LPN reported there were only three CNAs for the entire building. On 11/05/19 at 2:16 p.m., CNA #1 reported she was the only CNA on SE and SW halls. The CNA reported none of the residents received a bath or shower today. On 11/06/19 at 2:30 p.m., a group meeting was conducted with nine alert and oriented residents. The residents reported there was not enough staff. The residents reported they could not get their showers as scheduled and call lights were not answered in a timely manner. On 11/06/19 at 2:33 p.m., an unidentified CMA reported last Friday she was the only CMA/CNA on the hall passing medications with two hospitality aides. On 11/07/19 at 11:49 a.m., LPNs #1 and #2 were listed on the staffing board. LPN #1 reported she could not provide resident care due to medical restrictions.

Based on interview and record review the facility failed to develop and implement plans of action to ensure there was enough staff to meet the residents needs. The facility reported 87 residents lived in the facility. Findings: On 11/07/19 at 12:06 p.m., the administrator (ADM) reported she was aware of the staffing issues. The ADM reported there had not been a quality assessment and assurance meeting regarding the staffing shortage.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate incontinent care to prevent urinary tract infections for one (#27) of four residents reviewed for urinary tract infections. The facility reported 87 residents lived in the facility. Findings: Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/13/19, documented the resident was cognitively intact and required limited assistance with activities of daily living (ADL). The assessment documented the resident was frequently incontinent of bowel and bladder. A care plan, dated 08/14/19, documented the resident was incontinent of bowel and bladder. The care plan documented for the nursing staff to assist the resident with toileting routinely and provide a bath as necessary to prevent odors. The care plan documented for the staff to change the resident's brief as needed and keep the resident clean and dry at all times. The care plan documented for the staff to provide pericare after each incontinence episode. A urinary analysis (UA), dated 08/14/19, documented the resident had a urinary tract infection [MEDICAL CONDITION]. The UA at the top right corner documented the resident complained of abdominal pain. The UA documented the UA results were faxed to the provider on 08/15/19. A progress note, dated 08/17/19, documented the laboratory culture report was sent to the physician. No new orders were obtained. A physician's orders [REDACTED]. The order was completed on 08/31/19. The clinical records documented various urinary tract infection [DIAGNOSES REDACTED]. A nurse's note, dated 09/26/19 at 5:44 p.m., documented the resident's arm was clammy and cold, finger tips and tip of nose were cyanotic. The resident stated she did not feel well and that she was about to faint. The resident was sent to the hospital for further evaluation and treatment. On 11/04/19 at 1:51 p.m., the resident reported she had multiple UTIs in the past year due to staff not cleaning her properly. The resident reported she had been hospitalized for [REDACTED]. On 11/06/19 at 8:44 a.m., the resident's room was noted to have a strong odor of urine. The resident reported staff would provide pericare when she asked them to. The resident reported the staff do not routinely change her. The resident reported the facility was frequently short staffed. The resident reported last Saturday was her bath day and she did not receive a bath. The resident reported it had been six days since she had received a bath. The resident reported she told the administrator (ADM) on Monday of this week and she was told it would be fixed. The resident reported she still had not received a bath. On 11/06/19 at 9:06 a.m., the resident reported if she had been provided proper incontinent care it could have prevented a hospitalization . On 11/06/19 at 9:34 a.m., the director of nurses reported she was unsure why there was a seven day delay in obtaining the antibiotic order.

Based on observation, interview, and record review, it was determined the facility failed to provide activities of daily living to include personal hygiene for eight (#48, 28, 54, 53, 126, 74, 27, and #49) of 31 residents reviewed. The facility reported 84 residents required assistance with bathing. Findings: 1. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 05/26/19, documented the resident was cognitively intact and required extensive assistance with activities of daily living (ADL). The assessment documented the resident was at risk for developing pressure ulcers. A care plan, dated 08/12/19, documented the resident required extensive assistance with (ADLs The care plan documented for the staff to assist with ADLs as needed. On 11/04/19 at 2:21 p.m., the resident reported she had went a month without a shower in September. The resident reported she had only received one shower or bath a week for the past two months. On 11/05/19 at 3:40 p.m., the resident was observed lying in bed with her eyes closed. On 11/06/19 at 11:05 a.m., the resident reported she had not had a bath or shower since last Tuesday or Thursday. 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/12/19, documented the resident was cognitively intact and was totally dependent on staff for activities of daily living. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident was at risk for pressure ulcer. A care plan, dated 09/12/19, documented the resident was incontinent of bowel and bladder. The care plan documented the resident would be assisted with routine toileting. The care plan documented to bathe the resident as necessary to prevent odors. The care plan documented briefs would be changed as needed and the resident would be kept clean and dry at all times. The care plan documented for the staff to provide pericare after each incontinent episode. On 11/04/19 at 3:28 p.m., the resident reported she could not get the staff to give her a bath. The resident reported she had not had a bath/shower for two weeks. The resident reported the staff would not get her up out of bed as often as she would like. The resident reported the staff would tell her it would be a minute but never come back to provide assistance. On 11/05/19 at 3:19 p.m., two unidentified staff members reported they were the only two certified nurse aides (CNA) in the building on the evening shift last Thursday. The CNAs reported being short of staff happened very frequently. On 11/06/19 at 1:38 p.m., the resident reported she still had not had a bath/shower. On 11/06/19 at 3:09 p.m., the DON reported she could not find any documentation the resident had received a bath/shower in the past two months. 3. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A significant change assessment, dated 10/15/19, documented the resident was cognitively intact and was totally dependent for most activities of daily living to include bathing. A care plan, dated 10/16/19, documented the resident was at risk for deterioration with ADLs. The care plan documented for the staff to assist with ADLs. On 11/04/19 at 1:08 p.m., the resident reported there was not enough staff. The resident reported the staff would say they would come back but do not return to offer assistance. The resident reported she requested to be placed on hospice so she could get baths/showers. On 11/05/19 at 2:15 p.m. the resident was observed lying in bed with her eyes closed. 4. Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 10/03/19, documented the resident required extensive assistance with ADLs. The care plan documented for the staff to assist with ADLs as needed. An admission assessment, dated 10/08/19, documented the resident was moderately impaired with cognition, required extensive assistance with activities of daily living, required a urinary catheter and was always continent of bowel. The assessment documented the resident was at risk for pressure ulcers. On 11/04/19 at 3:01 p.m., a family member reported the resident had not had a bath/shower for the past week. The family member reported the resident had been in the same clothes for three days and had slept in them. The family member reported she had found the resident soaked from head to toe in urine. The family member reported there were only three aides for the entire building several evenings the last two weeks. On 11/06/19 at 3:09 p.m., the DON reported she could not find any documentation the resident had received a bath/shower in the past two weeks. 5. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/13/19, documented the resident was cognitively intact and required limited assistance with activities of daily living (ADL). The assessment documented the resident was frequently incontinent of bowel and bladder. A care plan, dated 08/14/19, documented the resident was incontinent of bowel and bladder. The care plan documented for the nursing staff to assist the resident with toileting routinely and to provide a bath as necessary to prevent odors. The care plan documented for the staff to change the resident's brief as needed and keep the resident clean and dry at all times. The care plan documented for the staff to provide pericare after each incontinence episode. On 11/04/19 at 1:56 p.m., the resident reported not being clean made her feel undignified. On 11/06/19 at 8:44 a.m., the resident's room was noted to have a strong odor of urine. The resident reported staff would provide pericare when she asked them to. The resident reported the staff do not routinely provide pericare. The resident reported the facility was frequently short staffed. The resident reported last Saturday was her bath day and she did not receive a bath. The resident reported it had been six days since she had received a bath. The resident reported she told the administrator (ADM) on Monday of this week and she was told it would be fixed. The resident reported she still had not received a bath. 6. Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/10/19, documented the resident was cognitively intact. The assessment documented the resident required limited assistance with activities of daily living. The assessment documented the resident was always continent to bowel and bladder. A care plan, updated 09/13/19, documented the resident required assistance with ADLs as needed. The care plan documented the nursing staff was to encourage the resident to ask for help as needed. On 11/06/19 at 9:08 a.m., the resident complained of not getting assistance. The resident reported she had waited over an hour for assistance. The resident reported the facility needed more staff. The resident reported staff would answer call lights and advise they would return to provide assistance but would not come back. The resident reported she was unsure when her last bath was completed. 7. Resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 10/07/19, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with activities of daily living (ADL). The assessment documented the resident was occasionally incontinent of bowel and bladder. A care plan, updated 10/14/2019, documented the resident had ADL self-care deficit due to weakness and unsteadiness and required nursing assistance with ADLs as needed. The care plan documented staff was to encourage the resident to ask for help as needed. On 11/04/19 at 3:19 p.m., the resident reported there was not enough staff. The resident reported it would take an hour or more to get assistance on all shifts. The resident also reported when there was enough staff they would come in and say they would return and then not come back. On 11/06/19 at 10:32 a.m., the resident reported he was due a bath last night but turned it down on his own due to not enough staff. The resident reported he had not been bathed since last Thursday. The resident reported there was one certified nursing aide (CNA) and a hospitality aide on duty last night. 8. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/14/19, documented the resident was moderately impaired with cognition. The assessment documented the resident required assistance with bathing. A care plan, dated 08/28/19, documented the resident required assistance with ADLs as needed. A bath schedule documented the resident was to receive a shower on Tuesday, Thursday, and Saturdays. On 11/06/19 at 12:00 p.m., the resident reported she had not had a bath since the first of last week. The resident reported she was unaware of scheduled bath days. The resident reported her daughter would give her a bath when staff did not. On 11/07/19 at 11:51 a.m., licensed practical nurse (LPN) #1 reported the resident's scheduled bath days were Tuesdays, Thursdays, and Saturdays. The LPN also reported it was difficult to get baths completed many times due to staff shortage.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision to prevent a fall with a fracture for one (#72) of three residents reviewed for falls. The facility reported 87 residents lived in the facility. Findings: Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 05/09/19 at 7:35 a.m., documented the resident was found on the floor in the hallway. The note documented the resident had forgotten her walker. The note documented the resident had no injuries. A care plan, dated 05/15/19, documented the resident was at risk for falls due to unsteadiness. The care plan documented a goal was for the resident to be free of falls. The care plan documented for the staff to assess and treat for orthostatic [MEDICAL CONDITION], increase staff supervision, and provide toileting interventions based on needs or patterns. A nurse's note, dated 05/23/19 at 5:15 a.m., documented, Elder sitting in floor at side of bed. Elder unable to tell how she got there. Unknown if she hit her head. Assisted to bed and c/o left leg hurting. Skin tear noted to left outer wrist area. 911 notified of transfer to ER for treatment . A state reportable incident report, dated 05/23/19, documented the resident was found sitting in the floor at side of bed. The report documented the resident was sent to the emergency room for further evaluation. The report documented the resident had an acute, displaced [MEDICAL CONDITION] femoral neck. The report documented the resident underwent [REDACTED]. A significant change assessment, dated 07/11/19, documented the resident was severely impaired with cognition and required extensive assistance with activities of daily living. The assessment documented the resident was always incontinent of bowel and bladder. On 11/04/19 at 12:13 p.m., the resident was observed in the lobby visiting with the hospice chaplain. On 11/05/19 at 8:25 a.m., the resident was observed being fed breakfast by a CN[NAME] On 11/05/19 at 4:30 p.m., a family member reported a certified nurse aide (CNA) had placed a recliner next to the resident's bed thinking it would keep the resident from getting out of bed. The family member reported she believed this was the reason the resident had fell trying to get out of bed and fractured her hip. On 11/06/19 at 11:35 a.m., CNA #2 reported she assisted the resident to the bathroom at the beginning of shift, after breakfast, and after lunch. The CNA reported the resident needed assistance with transfers. The CNA reported the resident would try to get up by herself. The CNA reported the resident could walk with the assistance of a walker. The CNA reported the resident was at risk for falls. On 11/06/19 at 4:30 p.m., CNA #3 reported the resident liked to get up early in the morning around 5:00 a.m. The CNA reported she was working the night the resident fell and fractured her hip. The CNA reported the recliner had been placed next to the resident's bed to try to keep the resident from getting out of bed the night the resident fell and fractured her hip. The CNA stated, I think that is why she fell . The CNA stated, We don't do that anymore. On 11/07/19 at 9:10 a.m., licensed practical nurse (LPN) #1 reported current fall interventions for the resident were a bed alarm, frequent bed checks, and toileting the resident frequently. On 11/07/19 at 10:55 a.m., the director of nurses, (DON) reported the resident had been checked 30 minutes prior to her fall when she sustained the fracture. The DON reported the resident forgot to ask for assistance. The DON reported the resident's brief was dry when she fell and sustained the fracture. The DON reported the root cause for falls was the resident was impulsive. The DON reported she questioned the nurse and the CNAs when she investigated the fall. On 11/07/19 at 11:59 a.m., the DON reported she was not aware of the recliner being placed beside the resident's bed to keep her from falling. The DON reported the staff should not have placed the recliner next to the resident's bed.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident rights were provided to include dignity for one (#27) of 31 residents reviewed. The facility reported 87 residents lived in the facility. Findings: Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/13/19, documented the resident was cognitively intact and required limited assistance with activities of daily living (ADL). The assessment documented the resident was frequently incontinent of bowel and bladder. A care plan, dated 08/14/19, documented the resident was incontinent of bowel and bladder. The care plan documented for the nursing staff to assist the resident with toileting routinely and provide a bath as necessary to prevent odors. The care plan documented for the staff to change the resident's brief as needed and keep the resident clean and dry at all times. The care plan documented for the staff to provide pericare after each incontinence episode. On 11/04/19 at 1:56 p.m., the resident reported not being clean made her feel undignified.

On 03/24/17 at 2:27 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to provide and care services to maintain the highest well being for resident #2. The facility failed to: a) Provide and administer diuretic medication as ordered by the physician and intervene in a timely manner. b) Assess, intervene, and report to the physician when the resident experienced low oxygen saturations while receiving oxygen and experienced changes in condition with generalized [MEDICAL CONDITION]. c) Consistently monitor daily weights as ordered. e) Administer breathing treatments as ordered by the physician for resident #2. Resident #2 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. A chest x-ray obtained at the hospital on the same day documented an impression of cardiomegaly with mild vascular congestion and small bilateral effusions with the left effusion larger than the right. On 03/24/17 at 3:03 p.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide care and services for a resident as ordered by the physician to ensure the highest levels of well-being for the resident. On 03/24/17 at 3:10 p.m., the corporate nurse was informed of the IJ situation which constituted substandard quality of care. The corporate nurse verbalized understanding. On 03/24/17 at 5:15 p.m., the corporate nurse provided the plan of removal for the immediate jeopardy. The plan of removal was accepted and documented the following: Plan of removal 3-24-2017 Elmbrook home was cited with an immediate Jeopardy and below is the steps taken to remove the immediacy. 1. All licensed Rn's and Lpn's have been placed on suspension until in-serviced on properly assessing, monitoring and intervening when a change in resident status has been identified. 2. All licensed RN's and Lpn's have/will be in-serviced on notification of change to physician. 3. All current residents medications have been checked to ensure all prescribed medications are available for administration per physician orders. 4. All Rn's and Lpn's have/will be in-serviced on ensuring breathing treatment are given per physician orders 5. All Cma's have/will be in-serviced on notifying charge nurse when medication is not available. 6. All Cma's and Cna's have/will be in-serviced on notifying charge nurse when they identify a resident has had a change in condition. 7. All above mentioned steps were completed on 3-24-2017 at 1710 pm. On 03/27/17 at 2:45 p.m., the facility was informed the IJ was removed, effective 03/24/17 at 5:10 p.m., when all components of the plan of removal had been implemented. The deficiency remained at actual harm level at a pattern. Based on observation, record review, and interview, it was determined the facility failed to ensure provision of necessary care to maintain the highest well-being for two (#1 and #2) of three residents reviewed for quality of life and well-being. The facility failed to: a) Thoroughly assess, monitor, and/or report changes in condition for residents #1 and #2. b) Provide and administer a medication as ordered by the physician for resident #2. c) Administer a breathing treatment as ordered for resident #2. d) Obtain daily weight as ordered for resident #2. e) Intervene when resident #2 experienced low oxygen saturations. f) Write a telephone order received from the physician for a laboratory test and failed to obtain the laboratory test for resident #1. The corporate nurse reported 67 residents resided in the facility for care and services. Findings: 1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 01/23/17, documented the resident weighed 100.8 pounds. A nurse's note, dated 01/24/17 at 3:51 a.m., documented the resident had 2+ (plus) [MEDICAL CONDITION] to her lower left extremity. The clinical record contained no entry the physician was notified of the change in condition. The clinical record contained no further assessment or monitoring which addressed the [MEDICAL CONDITION] in the resident's leg. A nurse's note, dated 02/18/17 at 8:21 a.m., documented the resident had generalized [MEDICAL CONDITION] over her entire body which was +2 non [MEDICAL CONDITION]. The nurse's note documented, .Will cont. (continue) to monitor. The resident's clinical record contained no entry the physician was notified of the change in condition at that time. No further assessment was documented in the nurse's notes until the next entry below. A nurse's note, dated 02/18/17 at 5:51 p.m., documented the next entry for assessing or monitoring of the resident. The nurse's note documented, Presents with cough and wheezing to BUL (bilateral upper lobes), N/O (new order) for CXR (chest x-ray) obtained . A nurse's note, dated 02/18/17 at 6:49 p.m., documented an e-page was sent to a PA (physician assistant name deleted) regarding resident's cough, wheezing, and CXR results. The nurse's note documented the staff was waiting on response. The next nurse's note, dated 02/19/17 at 4:56 a.m., documented, Notified (name deleted) PA-C (physician assistant-certified) via phone with SPO2 (saturation pressure of oxygen) at 58% with out O2, b/p (blood pressure) 160/80, respirations shallow at 24, unable to hear lung sounds due to snoring, temp. 102.2 ax (axillary), uncovered resident and temp 101.8ax, left wrist IV (intravenous) site red with blood in tubing, received new order for O2 at 2-4LPM (liters per minute) via n/c (nasal cannula) as needed if SPO2 below 90%, O2 at 3lpm via n/c placed on resident and Tylenol given for temp., DC'd (discontinued) left wrist hep ([MEDICATION NAME]) lock due to infiltration .Resident is [MEDICAL CONDITION] all over . An entry on the vitals report form, dated 02/19/17 at 5:08 a.m., documented the resident's oxygen saturation was 86% with oxygen on at three liters and documented the acceptable range for oxygen saturation was between 88-100%. A nurse's note, dated 02/19/17 at 6:43 a.m., documented the PA (name deleted) ordered an antibiotic for ten days to be administered and [MEDICATION NAME] nebulizer treatments every 4-6 hours to be administered. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nurse's note, dated 02/19/17 at 12:51 p.m., documented the resident had 2+ non pitting generalized [MEDICAL CONDITION] over her entire body. A nurse's note, dated 02/19/17 at 4:04 p.m., a physician assistant ordered [MEDICATION NAME] 40 mg every day, potassium daily, daily weights, and to redraw laboratory tests of BMP and BNP on the 22nd for heart failure. A progress note created by the PA, dated 02/19/17, documented the chest x-ray showed possible upper lobe pneumonia. The progress note documented the resident had developed generalized [MEDICAL CONDITION] and laboratory tests were ordered due to suspect of [MEDICAL CONDITION] issues. An observation report, dated 02/19/17 at 7:00 p.m., documented the resident had diminished breath sounds with bilateral upper lobe wheezing and 2+ [MEDICAL CONDITION] in both lower extremities. The interventions or immediate measures section of the report documented a checkmark for diuretic use. A general administration history form, dated 02/19/17, documented the resident weighed 114.5 pounds. A nurse's note, dated 02/20/17 at 2:58 a.m., documented the resident was receiving [MEDICATION NAME] for a urinary tract infection, [MEDICATION NAME] for pneumonia, and had 1-2+ [MEDICAL CONDITION] to her bilateral upper extremities. A medication administration history, dated 02/20/17 at 7:00 a.m., documented the [MEDICATION NAME] was not administered/item unavailable. A respiratory administration record for [MEDICATION NAME] sulfate solution for nebulization, dated 02/20/17 at 7:00 a.m., was blank for administration. A nurse's note, dated 02/20/17 at 9:58 a.m., documented the physician visited and gave an order to discontinue the [MEDICATION NAME]. The nurse's note documented the physician ordered [MEDICATION NAME] 10 mg one tablet daily and laboratory tests. A treatment administration history, dated 02/20/17, documented the resident's 24 hour urinary output was 400 cc. A nurse's note, dated 02/21/17 at 12:02 a.m., documented the resident's oxygen sats without oxygen on was 60-61%. The note documented the resident oxygen saturation was 89-90% with oxygen at three liters per minute. The nurse's note documented the resident's respirations were 26 and shallow. The note documented wheezing in the left lung with diminished breath sounds and the resident's whole body was [MEDICAL CONDITION]. A medication administration history, dated 02/21/17 at 7:00 a.m., had staff initials for the administration of a dose of [MEDICATION NAME]. Later, the corporate nurse verified the [MEDICATION NAME] had not been given on this date. An entry on the vitals report form, dated 02/21/17 at 12:07 p.m., documented the resident's oxygen saturation was 83% with oxygen on at three liters and documented the acceptable range for oxygen saturation was between 88-100%. A nurse's note, dated 02/21/17 at 6:06 p.m., documented the [MEDICAL CONDITION] continued all over and the [MEDICATION NAME] was not in the facility. The nurse's note documented the resident's respirations were shallow with abdominal muscles noted during breathing. The nurse's note documented the resident had oxygen on at three liters per minute via nasal cannula and her oxygen saturations were 83%. A treatment administration history, dated 02/21/17, documented the resident's 24 hour urinary output was 800 cc. An entry on the vitals report form, dated 02/22/17 at 12:51 a.m., documented the resident's oxygen saturation was 87% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. A nurse's note, dated 02/22/17 at 3:49 a.m., documented 2+ [MEDICAL CONDITION] noted to left upper extremity. A medication administration history, dated 02/22/17 at 7:19 a.m., documented Demedex was not administered as ordered since the drug was not available. An entry on the vitals report form, dated 02/22/17 at 7:45 a.m., documented the resident's oxygen saturation was 85% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. An entry on the vitals report form, dated 02/22/17 at 4:56 p.m., documented the resident's oxygen saturation was 86% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. An entry on the vitals report form, dated 02/22/17 at 6:24 p.m., documented the resident's oxygen saturation was 83% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. A treatment administration history, dated 02/22/17, documented the resident's 24 hour urinary output was 450 cc. An entry on the vitals report form, dated 02/23/17 at 1:20 a.m., documented the resident's oxygen saturation was 84% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. The resident's clinical record did not contain a nurse's progress note on 02/23/17. A medication administration history, dated 02/23/17 at 7:24 a.m., documented Demedex was not administered as ordered since the drug was not available. A respiratory administration record for [MEDICATION NAME] sulfate solution for nebulization, dated 02/23/17 at 7:00 a.m. and 1:00 p.m., was blank for administration. A treatment administration history, dated 02/23/17, documented the resident's 24 hour urinary output was 300 cc (with one shift entry blank). A general administration history form for the resident's daily weights, dated 02/23/17, documented a blank for the resident's weight. A medication administration history, dated 02/24/17 at 7:00 a.m., documented the resident received her first dose of [MEDICATION NAME]. A nurse's note, dated 02/24/17 at 4:08 p.m., had no assessment or monitoring of the resident's [MEDICAL CONDITION]. A treatment administration history, dated 02/24/17, documented the resident's 24 hour urinary output was 625 cc. A general administration history form for the resident's daily weights, dated 02/24/17, documented a blank for the resident's weight. A nurse's note, dated 02/25/17 at 12:38 a.m., documented the resident was [MEDICAL CONDITION] all over and wheezing was noted to bilateral lungs. The note documented the resident's oxygen was at four liters per minute via nasal cannula with the resident's respirations 26 and shallow. A treatment administration history, dated 02/25/17, documented the resident's 24 hour urinary output was 2450 cc. A nurse's note, dated 02/26/17 at 4:46 a.m., documented the resident had 2+ [MEDICAL CONDITION] noted at right elbow area and 1+ [MEDICAL CONDITION] to the left elbow area. A treatment administration history, dated 02/26/17, documented the resident's 24 hour urinary output as 1000 cc. A nurse's note, 02/27/17 at 4:34 p.m., documented the physician had telephoned the facility to send the resident via ambulance to the hospital due to [MEDICAL CONDITION] (high blood sodium), [DIAGNOSES REDACTED] (low blood potassium), and left lower lung infiltrate. A quarterly assessment, dated 02/26/17, documented the resident had short and long-memory problems with moderately impaired cognition and moderate depression. The assessment documented the resident required extensive assistance for toilet use and total assistance for all other activities of daily living (ADLs). The assessment documented the resident was incontinent of bowel and had an indwelling urinary catheter. A care plan, dated 02/27/17, documented the resident had a fluid maintenance problem. One intervention was to assess for signs and symptoms of electrolyte imbalance. A nurse's note, dated 02/27/16 at 4:57 p.m., the physician reported a potassium level of 2.9 and sodium level of 154. A nurse's note, dated 02/27/17 at 5:17 p.m., documented the resident was sent to the hospital. The resident returned to the facility on [DATE]. A hospitalization summary, dated 03/03/17, documented the resident's [DIAGNOSES REDACTED]. On 03/23/17 at 2:15 p.m., the resident was observed in bed on her left side. The bed was in the lowest position near the floor. On 03/23/17 at 5:25 p.m., the corporate nurse was interviewed and asked if the physician should have been notified of the resident's change in condition. The nurse reported yes. At the same time, the corporate nurse was asked if she expected the staff to notify the physician when the resident's oxygen saturations were 83-87% while on oxygen. The nurse reported yes. On 03/24/17 at 1:50 p.m., the corporate nurse was asked if daily weights should have been obtained for the resident as ordered. The nurse reported yes. At the same time, the corporate nurse was asked about the delay in the diuretic medications. The nurse reported the staff should have called the pharmacy first and notified the physician about the medications not being available. At the same time, the corporate nurse was asked if the physician should have been notified and if further assessments should have been conducted, when on 01/24/17, the resident had experienced 2+ [MEDICAL CONDITION] to her left lower leg. The nurse nodded her head yes. At the same time, the corporate nurse was asked if the routine breathing treatments should have been given as ordered. The nurse reported yes. On 03/24/17 at 2:10 p.m., the corporate nurse was asked to give the physician assistant the surveyor's telephone number and request he call the surveyor if possible. The nurse returned and reported the PA was called and he reported he was not aware of the resident's low oxygen saturations while receiving oxygen. The nurse reported the PA had said he did not know about the delay in starting the diuretic medication until after the fact. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/21/17, documented the resident was moderately impaired in cognition, required extensive assistance of one staff member for transfers, dressing, hygiene and bathing, did not ambulate, and was always incontinent of bowel and bladder. The assessment documented the resident required supervision with set-up for meals. The assessment documented the resident had experienced falls since admission to the facility. A nurse's note, dated 03/03/17 at 12:53 p.m., documented the resident was in the dining room and started to shake. The resident's vital signs were blood pressure 104/72, heart rate 56 beats per minute, respiratory rate 18, and pulse oximetry 98%. The nurse's note documented the resident was alert and oriented x 1. The nurse's note documented the resident was assisted to bed and the physician was notified. A nurse's note, documented, N/O (new order) received. CBC, CMP, BNP, & UA. Blood drawn from right AC x 1 stick. Resident tol. well. Straight cath resident, tol. well. Unable to get urine. Residents brief wet. Will try later. A nurse's note, dated 03/04/17 at 4:42 p.m., documented, Resident started shaking at breakfast with a fever of 100.1 F., nasal drainage, and cough. N/O new for a fluswab received and sent to (name deleted) lab. Results positive and influenza type A. The physician was notified of the positive influenza test results and an order for [REDACTED]. The nurse's notes did not contain documentation a urine specimen was obtained. A nurse's note, dated 03/05/17 at 3:21 p.m., documented the initial dose of [MEDICATION NAME] was administered. The vital sign sheet documented temperature 99.2. A nurse's note, dated 03/06/17 at 2:50 p.m., documented, Remains on [MEDICATION NAME] .alert, confused .respirations with ease on room air, occasional non-productive cough . A nurse's note, dated 03/07/17, documented the resident was alert and oriented; and the resident remained in isolation. A nurse's note, dated 03/08/17 at 5:16 a.m., documented the resident complained of generalized pain and was medicated with [MEDICATION NAME]. The nurse note documented the pain medication was effective. A nurse's note, dated 03/08/17 at 9:08 p.m. documented, Resident resting in bed with temp. 101 with tylenol given, tolerated well. CNA did bed bath and noticed left inner heel fluid filled blister intact measure 3.0 cm. x 3.0 cm. Resident ate only 20% of supper, refused to drink health shake .notified Dr. (name deleted) on blister with new order received. A nurse's note, dated 03/09/17 at 9:32 a.m., documented, Aroused to name. Refused breakfast. Refused health shake .Stage 2 decub to left heel 3 x 3 cm clear fluid filled blister . A nurse's note, dated 03/09/17 at 10:53 p.m., documented, Resident resting in bed with temp 101.2 this evening with tylenol given. The resident's temperature was not checked for effectiveness of the Tylenol medication. A nurse's note, dated 03/10/17 at 12:29 p.m., documented, VS-120/70-74-20-98.6. SpO2-96% on RA (room air). Arouses to verbal stimulation. Took 480cc of liquids for breakfast. Discussed residents condition with son. Informed him of room change since resident is over the flu .N/O (new order) to D/C (discontinue isolation) . On 03/10/17 at 4:30 p.m., the vital sign record documented the resident's temperature was 99.6, 68, 20, 112/62. On 03/10/17 at 4:45 p.m., the vital sign record documented the resident's temperature was 100.4 degrees. On 03/10/17 at 8:30 p.m., the vital sign record documented the resident's temperature was 98.7 degrees. A nurse's note, dated 03/10/17 at 10:44 p.m., documented, Resident continues poor appetite, poor fluid intake at supper, lethargic, responds to verbal stimuli, then closes eyes .Venelex applied to fluid fill blister to left inner heel, bil. (bilateral) heels floated on pillows. On 03/10/17 11:00 p.m. to 7:00 a.m. shift, an assessment was not documented. A nurse's note, dated 03/11/17 at 8:21 a.m., documented, Resident is unresponsive to all stimuli. Unable to take medications, food, or fluids. R (respirations) 22 uneven gasps with audible crackling, O2 83% on RA (room air), hypotensive 93/57 .99.9 fever. Resident has PRN (as needed) order for Tylenol, cannot give due to being unresponsive. Placed on O2 2l nc (nasal cannula). E-page sent to (name deleted) PA (physician assistant). Will continue to monitor. On 03/11/17 at 8:47 a.m., received a new order to transfer the resident to the local emergency department. On 3/11/17 at 12:25 p.m., the nurse's note documented, admitted to ICU for [REDACTED]. DON notified, family with resident in the hospital. On 03/24/17 at 10:00 a.m., a telephone interview was conducted with the night LPN on duty the night of 03/10/17 11:00 p.m. to 7:00 a.m. The LPN was asked should an assessment have been conducted since the resident had a recent [DIAGNOSES REDACTED]. The LPN reported the facility documented by exception. The LPN reported the resident was like she always was and did not document and assessment. On 03/24/17 at 10:50 a.m., the corporate RN was interviewed. The RN was asked for the facility policy and procedure for charting by exception. The RN reported the facility did not have a policy to chart by exception. The RN was asked since the resident had experienced a recent [DIAGNOSES REDACTED]. The RN reported yes. The RN reported the issue would be addressed.

On 03/24/17 at 2:27 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to notify the physician with changes in condition, clinical complications, and when the resident was not receiving medications and/or treatments as ordered for resident #2. The facility failed to notify the physician when: a) resident #2 developed overall [MEDICAL CONDITION], b) resident #2's oxygen saturations were low while receiving oxygen, c) resident #2's diuretic medications were not administered as ordered, d) resident #2's daily weights were not obtained as ordered, and e) resident #2's breathing treatments were not administered as ordered. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. A chest x-ray obtained at the hospital on the same day documented an impression of cardiomegaly with mild vascular congestion and small bilateral effusions with the left effusion larger than the right. On 03/24/17 at 3:03 p.m., OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide notification of changes in resident conditions and/or clinical complications to physicians. On 03/24/17 at 3:10 p.m., the corporate nurse was informed of the IJ situation which constituted substandard quality of care. The corporate nurse verbalized understanding. On 03/24/17 at 5:15 p.m., the corporate nurse provided the plan of removal for the immediate jeopardy. The plan of removal was accepted and documented the following: Plan of removal 3-24-2017 Elmbrook home was cited with an immediate Jeopardy and below is the steps taken to remove the immediacy. 1. All licensed Rn's and Lpn's have been placed on suspension until in-serviced on properly assessing, monitoring and intervening when a change in resident status has been identified. 2. All licensed RN's and Lpn's have/will be in-serviced on notification of change to physician. 3. All current residents medications have been checked to ensure all prescribed medications are available for administration per physician orders. 4. All Rn's and Lpn's have/will be in-serviced on ensuring breathing treatment are given per physician orders 5. All Cma's have/will be in-serviced on notifying charge nurse when medication is not available. 6. All Cma's and Cna's have/will be in-serviced on notifying charge nurse when they identify a resident has had a change in condition. 7. All above mentioned steps were completed on 3-24-2017 at 1710 pm. On 03/27/17 at 2:45 p.m., the facility was informed the IJ was removed, effective 03/24/17 at 5:10 p.m., when all components of the plan of removal had been implemented. The deficiency remained at actual harm level at a pattern. Based on observation, record review, and interview, it was determined the facility failed to notify the physician in a timely manner of changes in condition and/or clinical complications for one (#2) of three residents reviewed for physician notification. The facility failed to notify the physician when: a) resident #2 had overall [MEDICAL CONDITION], b) resident #2's oxygen saturations were low while receiving oxygen, c) resident #2's diuretic medications were not administered as ordered, d) resident #2's daily weights were not obtained as ordered, and e) resident #2's breathing treatments were not administered as ordered. The corporate nurse reported 67 residents lived in the facility. Findings: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 01/24/17 at 3:51 a.m., documented the resident had 2+ (plus) [MEDICAL CONDITION] to her lower left extremity. The clinical record contained no entry the physician was notified of the change in condition. The clinical record contained no further assessment or monitoring which addressed the [MEDICAL CONDITION] in the resident's leg. A nurse's note, dated 02/18/17 at 8:21 a.m., documented the resident had generalized [MEDICAL CONDITION] over her entire body which was +2 non [MEDICAL CONDITION]. The nurse's note documented, .Will cont. (continue) to monitor. The resident's clinical record contained no entry the physician was notified of the change in condition at that time. An entry on the vitals report form, dated 02/19/17 at 5:08 a.m., documented the resident's oxygen saturation was 86% with oxygen on at three liters and documented the acceptable range for oxygen saturation was between 88-100%. The resident's clinical record contained no entry the physician was notified the resident's oxygen saturations remained below 88% while oxygen was administered. A nurse's note, dated 02/19/17 at 6:43 a.m., documented the PA (name deleted) ordered an antibiotic to be administered for ten days and [MEDICATION NAME] nebulizer treatments to be administered every 4-6 hours. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nurse's note, dated 02/19/17 at 12:51 p.m., documented the resident had 2+ non pitting generalized [MEDICAL CONDITION] over her entire body. A nurse's note, dated 02/19/17 at 4:04 p.m., documented a physician assistant ordered [MEDICATION NAME] 40 mg every day, potassium daily, daily weights, and to redraw laboratory tests of BMP and BNP on the 22nd for heart failure. A progress note created by the PA, dated 02/19/17, documented the chest x-ray showed possible upper lobe pneumonia. The progress note documented the resident had developed generalized [MEDICAL CONDITION] and laboratory tests were ordered due to suspect of [MEDICAL CONDITION] issues. An observation report, dated 02/19/17 at 7:00 p.m., documented the resident had diminished breath sounds with bilateral upper lobe wheezing and 2+ [MEDICAL CONDITION] in both lower extremities. The interventions or immediate measures section of the report documented a checkmark for diuretic use. A medication administration history, dated 02/20/17 at 7:00 a.m., documented the [MEDICATION NAME] was not administered and that the item was unavailable. A respiratory administration record for [MEDICATION NAME] sulfate solution for nebulization, dated 02/20/17 at 7:00 a.m., was blank for administration. A nurse's note, dated 02/20/17 at 9:58 a.m., documented the physician visited and gave an order to discontinue the [MEDICATION NAME]. The nurse's note documented the physician ordered [MEDICATION NAME] 10 mg one tablet daily and laboratory tests. A nurse's note, dated 02/21/17 at 12:02 a.m., documented the resident's oxygen sats without oxygen on was 60-61%. The note documented the resident oxygen saturation was 89-90% with oxygen at three liters per minute. The nurse's note documented the resident's respirations were 26 and shallow. The note documented wheezing in the left lung with diminished breath sounds and the resident's whole body was [MEDICAL CONDITION]. A medication administration history, dated 02/21/17 at 7:00 a.m., had staff initials for the administration of a dose of [MEDICATION NAME]. Later, the corporate nurse verified the [MEDICATION NAME] had not been given on this date. An entry on the vitals report form, dated 02/21/17 at 12:07 p.m., documented the resident's oxygen saturation was 83% with oxygen on at three liters and documented the acceptable range for oxygen saturation was between 88-100%. A nurse's note, dated 02/21/17 at 6:06 p.m., documented the [MEDICAL CONDITION] continued all over and the [MEDICATION NAME] was not in the facility. The nurse's note documented the resident's respirations were shallow with abdominal muscles noted during breathing. The nurse's note documented the resident had oxygen on at three liters per minute via nasal cannula and her oxygen saturations were 83%. An entry on the vitals report form, dated 02/22/17 at 12:51 a.m., documented the resident's oxygen saturation was 87% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. A nurse's note, dated 02/22/17 at 3:49 a.m., documented 2+ [MEDICAL CONDITION] noted to left upper extremity. A medication administration history, dated 02/22/17 at 7:19 a.m., documented Demedex was not administered as ordered since the drug was not available. An entry on the vitals report form, dated 02/22/17 at 7:45 a.m., documented the resident's oxygen saturation was 85% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. An entry on the vitals report form, dated 02/22/17 at 4:56 p.m., documented the resident's oxygen saturation was 86% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. An entry on the vitals report form, dated 02/22/17 at 6:24 p.m., documented the resident's oxygen saturation was 83% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. An entry on the vitals report form, dated 02/23/17 at 1:20 a.m., documented the resident's oxygen saturation was 84% with oxygen on at four liters and documented the acceptable range for oxygen saturation was between 88-100%. A medication administration history, dated 02/23/17 at 7:24 a.m., documented Demedex was not administered as ordered since the drug was not available. A respiratory administration record for [MEDICATION NAME] sulfate solution for nebulization, dated 02/23/17 at 7:00 a.m. and 1:00 p.m., was blank for administration. A general administration history form for the resident's daily weights, dated 02/23/17, documented a blank for the resident's weight. A general administration history form for the resident's daily weights, dated 02/24/17, documented a blank for the resident's weight. A medication administration history, dated 02/24/17 at 7:00 a.m., documented the resident received her first dose of [MEDICATION NAME]. A quarterly assessment, dated 02/26/17, documented the resident had short and long-memory problems with moderately impaired cognition and moderate depression. The assessment documented the resident required extensive assistance for toilet use and total assistance for all other activities of daily living (ADLs). The assessment documented the resident was incontinent of bowel and had an indwelling urinary catheter. A care plan, dated 02/27/17, documented the resident had a fluid maintenance problem. One intervention was to assess for signs and symptoms of electrolyte imbalance. A nurse's note, 02/27/17 at 4:34 p.m., documented the physician had telephoned the facility to send the resident via ambulance to the hospital due to [MEDICAL CONDITION] (high blood sodium), [DIAGNOSES REDACTED] (low blood potassium), and left lower lung infiltrate. A nurse's note, dated 02/27/16 at 4:57 p.m., the physician reported a potassium level of 2.9 and sodium level of 154. A nurse's note, dated 02/27/17 at 5:17 p.m., documented the resident was sent to the hospital. The resident returned to the facility on [DATE]. A hospitalization summary, dated 03/03/17, documented the resident's [DIAGNOSES REDACTED]. On 03/23/17 at 2:15 p.m., the resident was observed in bed on her left side. The bed was in the lowest position near the floor. On 03/23/17 at 5:25 p.m., the corporate nurse was interviewed and asked if the physician should have been notified of the resident's change in condition. The nurse reported yes. At the same time, the corporate nurse was asked if she expected the staff to notify the physician when the resident's oxygen saturations were 83-87% while on oxygen. The nurse reported yes. On 03/24/17 at 1:50 p.m., the corporate nurse was asked if daily weights should have been obtained for the resident as ordered. The nurse reported yes. At the same time, the corporate nurse was asked about the delay in the diuretic medications. The nurse reported the staff should have called the pharmacy first and notified the physician about the medications not being available. At the same time, the corporate nurse was asked if the physician should have been notified and if further assessments should have been conducted, when on 01/24/17, the resident had experienced 2+ [MEDICAL CONDITION] to her left lower leg. The nurse nodded her head yes. At the same time, the corporate nurse was asked if the routine breathing treatments should have been given as ordered. The nurse reported yes. On 03/24/17 at 2:10 p.m., the corporate nurse was asked to give the physician assistant the surveyor's telephone number and request he call the surveyor if possible. The nurse returned and reported the PA was called and he reported he was not aware of the resident's low oxygen saturations while receiving oxygen. The nurse reported the PA had said he did not know about the delay in starting the diuretic medication until after the fact.

Based on observation, record review and staff interview, it was determined the facility failed to ensure: a) A wound was assessed and monitored which resulted in harm, for one (#2) of one sampled resident who had a wound. This had the potential to affect 15 residents, identified by the DON, who had experienced non-pressure wound issues. b) An indwelling urinary catheter was changed monthly and catheter care was performed, as ordered by the physician, for one (#1) of one sampled resident who required an indwelling urinary catheter. This had the potential to affect one resident, identified by the DON, who required the use of an indwelling urinary catheter. Findings: 1. A facility policy titled, "Skin Integrity Monitoring System," documented: "1. Braden scale will be completed within 24 hours of admission/readmission, quarterly and with any significant change in condition. 2. All residents will receive weekly head to toe skin assessment..." A facility policy titled, "Skin Integrity Management Non-Pressure Sore," documented: "1. Assessment of the skin is documented using 'Weekly Skin Condition Report-Non-Pressure'... 4. Treatment orders are secured and noted on the Treatment Administration Record (TAR)... 6. The 24-hour report is noted indicating the type of skin alteration identified... 8. Continue to assess the area(s) at least weekly and document on 'Weekly Skin Condition Report - Non-Pressure' until healed." A closed record review was conducted for resident #2. The resident had been admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A care plan, dated 08/27/2013, documented a problem of impaired skin integrity related to impaired mobility and incontinence. A goal was for the resident to remain free from tissue injury related to skin tears through preventative nursing measures. Interventions included a licensed nurse would audit the resident's skin at least weekly, apply heel and elbow guards as necessary, skin care to include hydrating lotions after showers and as needed for dry skin, exercise caution during transfers and while providing care, use lift sheet to prevent shearing and to provide incontinent care after each incontinent episode. A quarterly assessment, dated 05/19/14, documented the resident with long and short term memory loss, was moderately impaired with decision making, required extensive assistance with transfers, dressing and hygiene/bathing. The resident was always incontinent of bowel and bladder. The resident was at high risk for pressure ulcers. A Progress Note, dated 08/13/14 at 12:44 p.m., documented, "open area noted to left wrist/hand notified dr (Name deleted) received new orders for Keflex and to apply [MEDICATION NAME] to open area bid until resolved family also notified..." This was signed by (name deleted) LPN. A Progress Note, dated 08/13/14 at 9:50 p.m., documented, "Open area to left wrist/hand, initial dose of Keflex given and [MEDICATION NAME] applied as directed to open area..." This was signed by (name deleted) RN. An Observation Report, dated 08/13/14, documented, "Description - Facility Acquired-open area left hand/wrist... Size (Length x Width x Depth) - 3.8 x 3xutd (unable to determine). Character of Wound Bed - Necrotic tissue (Eschar)-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges; may be softer or harder than surrounding skin. Does ulcer show tunneling, undermining or sinus tract? No. Drainage - Scant. Exudate - Serosanguineous. Wound odor - No odor Surrounding Tissue - Intact. Describe Progress - Wound bed 100% brown/yellow slough. Surrounding tissue pink..." The nurses' notes documented the following: "08/14/14 09:36 (9:36 a.m.)...dr (Name deleted) here new orders for cbc cmp today and repeat on Monday start [MEDICATION NAME] 1 gram im x 5 days dc keflex. 12:22 (12:22 p.m.) ...drsg (dressing) changed to left wrist per dr order wound bed black surrounding tissue remains warm and red..." 08/15/14 12:11 (12:11 p.m.)...6-2 changed dressing to LT (left) wrist wound bed is black..." On 08/15/14 at 7:40 p.m., the resident was admitted to the hospital related to breathing problems. On 10/08/14 at 1:30 p.m., LPN #1, who had first identified the open area on the resident's wrist, was asked about the wound. She reported she had not worked with the resident before the day she saw the wound. She reported the resident had a bandage on the left arm and when she removed the bandage she saw the wound. She was asked who had applied the bandage. She reported she had no idea who had applied the bandage. She was asked if any staff had reported the wound before 08/13/14. She reported no staff had reported the area to her. She reported when she found the open area she had reported it to the wound nurse, ADON and DON. At 1:45 p.m., the DON was asked about the open wound. He reported he was unaware of the wound until the LPN reported the area on 08/13/14. He was asked why the staff had not noticed the wound until the wound was open. He stated, "That's a good question. I don't know." At 1:55 p.m., the corporate nurse was asked why the open area on the hand was not observed or reported by staff. She reported one LPN, who was no longer in the facility, had not been documenting appropriately. At that time, the corporate nurse was notified of the quarterly assessment, on 05/19/14, which identified the resident was high risk for pressure ulcers. She was asked to see the weekly skin assessments, addressed by the resident's care plan. She reported the weekly skin assessments for the resident had not been done. At 4:25 p.m., LPN #2, who no longer worked at the facility, was interviewed via telephone. The LPN was asked about the open area on the resident's left hand. She reported she was not sure of when the area had been found, but thought it had been found in the middle of the month. She reported the resident was sent to the hospital shortly after that and she had not worked with the resident again. The wound was not found until it had eschar, was infected and required several antibiotics, including an intramuscular antibiotic. 2. Resident #1 was admitted with numerous [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." The resident had an indwelling urinary catheter inserted on 06/28/14 to facilitate the healing of pressure wounds. The resident was to have indwelling catheter care every shift. On 06/29/14 and 06/30/14, the indwelling catheter care was documented as being completed. From 07/01/14 until 07/29/14, there was no documentation the indwelling urinary catheter care was completed. A care plan dated 08/11/14, documented the resident required an indwelling urinary catheter due to a pressure ulcer. The goal was for the staff to manage the catheter appropriately. An intervention listed was for staff to provide catheter care and to change the catheter as ordered by the physician. On 08/14/14, the indwelling urinary catheter was changed due to the catheter leaking. There was no documentation the catheter had been changed in the previous 30 days. A quarterly assessment dated , 09/04/14, documented the resident was moderately impaired with cognition and demonstrated mild depression. The resident had a indwelling urinary catheter. The resident had one unstageable pressure ulcer with eschar and one stage two pressure ulcer. On 09/17/14, a nurses progress note documented the indwelling urinary catheter "came out." The progress note documented the resident's urine was thick and honey like in color and had a foul odor. The physician was notified of the resident's urine and orders were received to transport the resident to the emergency room for evaluation. The resident was hospitalized for [REDACTED]. On 09/24/14, the resident returned to the facility. The resident was to receive an antibiotic injection for a urinary tract infection. On 09/30/14, the resident became lethargic and had altered mental status. The physician was notified of the change of condition and orders were received for the resident to be transferred to the emergency room for evaluation. The resident was readmitted to the hospital with [REDACTED]. On 10/08/14 at 4:30 p.m., the Corporate Nurse and the DON reviewed the TAR concerning the lack of indwelling urinary catheter care being completed. The Corporate Nurse reported this would be monitored. At that time, the Corporate Nurse and DON were asked how often an indwelling urinary catheter should be changed. Both reported the indwelling urinary catheter should be changed every 30 days, or sooner if there was a problem. The Corporate Nurse reported the problem would be addressed.