Every finding on record at Emerald Care Center Midwest

Based on interview, record review, and facility policy review, the facility failed to maintain a clean, comfortable, homelike environment for 1 (300 Hall) of 4 halls reviewed for environment. Specifically, room [ROOM NUMBER] had stained linens and stained privacy curtains, and the 300 Hall was dirty with food particles, paper, and stained, discolored areas on the floor. Findings included: A facility policy titled, Resident Rights, revised 01/2024, indicated, 9. Safe Environment. The resident has a right to a safe, clean, comfortable, and Homelike environment, including but not limited to receiving treatment and support for daily living safely. A facility policy titled, Cleaning and Disinfectant of Environmental Surfaces, revised 01/2024, indicated, Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Blood borne Pathogens Standard. The policy continued, 9. Housekeeping surfaces (e.g. [exempli gratia, for example], floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week, and when surfaces are visibly soiled. 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. An observation of room [ROOM NUMBER] on 07/13/2026 at 9:32 AM revealed brown stains across the entire privacy curtain and the bed linen. A second observation of room [ROOM NUMBER] on 07/14/2026 at 11:54 AM revealed the privacy curtain remained soiled with small and large brown stains, and the bed sheets with food residue and red and brown stains from the day prior. A third observation of room [ROOM NUMBER] on 07/15/2026 at 2:15 PM revealed the same soiled bed sheets with food particles, crumbs, and red and brown stains from two days prior. The privacy curtain remained hanging with quarter-size brown stains and black linear marks across the middle and bottom area of the curtain. An observation of the 300 Hall on 07/13/2026 at 9:54 AM revealed the floor from the entrance of the hall to the back door was observed with food particles, pieces of paper, and red and brown discolored areas. A second observation of the 300 Hall on 07/14/2026 at 11:44 AM revealed the floors on the hall were stained with red and brown discoloration and with food particles as observed the day prior. A third observation of Hall 300 on 07/15/2026 at 2:15 PM revealed the floors remained discolored with red and brown stains the size of golf balls; brown stains with food particles were affixed to the baseboards, and pieces of paper were on the floor. During an interview on 07/15/2026 at 2:32 PM, the Housekeeping Supervisor stated that each day there were two housekeepers in the building, each being responsible for two halls. She stated that the privacy curtains for the entire facility were checked once every two weeks and were taken down and cleaned, but if staff reported they were dirty prior to then, then they would be cleaned sooner. She stated that the 300 Hall had a lot of traffic due to the kitchen being on that hall, so it was hard to keep the floors on that hall clean due to the food carts spilling stuff all the time. During an interview on 07/15/2026 at 3:00 PM, the Assistant Director of Nursing (ADON) stated that the housekeeping staff were responsible for keeping the facility clean. During an interview on 07/15/2026 at 3:15 PM, the Administrator stated that the certified nursing assistants were responsible for taking the linen to the laundry room to be washed, and that laundry personnel were in the facility until 10:00 PM. She stated that it was her expectation of the housekeeping staff to keep the privacy curtains clean and to deep clean rooms.

Based on interview, record review, and facility document and policy review, the facility failed to release medical records within two working days of the initial written request for 2 (Residents #79 and #81) of 3 residents reviewed for release of medical records. Findings included: An undated facility policy titled, Release of Information, revealed, 10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services. Medical records request [sic] submitted to Ethics and Compliance Committee for prior approval. 1. An admission Record revealed the facility admitted Resident #79 on [DATE]. According to the admission Record, Resident #79 was their own authorized representative. A 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated Resident #79 admitted to the facility on [DATE] from a short-term general hospital. An Affidavit of Kinship, dated [DATE], signed by Family Member (FM) #30, indicated Resident #79 had deceased . An email from a law firm to the facility, dated [DATE] at 11:02 AM, revealed Kindly find attached our formal request for copies of MEDICAL RECORD. The email also indicated, Your prompt attention to this matter is appreciated. A letter from a law firm, dated [DATE], revealed, Our law firm represents [Resident #79] and is authorized to request their patient records. The letter revealed, Enclosed a signed authorization form granting permission for release of the patient's complete: Medical Record - [DATE] to [DATE]. An Oklahoma Standard Authorization to Use or Share Protected Health Information (PHI), dated and signed by FM #30 on [DATE], revealed, I hereby authorize [Facility Name] to release the following information to [Name and address of a law firm], and the information to be shared included the entire medical record. An email from Medical Record Request to the Medical Records Clerk, dated [DATE] at 12:42 PM, revealed, We have received and reviewed the record request dated [DATE] relating to [Resident #79]. The email continued, After review, we have determined that these records can be immediately released to the requestor as requested, An email from the Medical Records Clerk to the law firm, dated [DATE] at 4:45 PM, revealed a handwritten note that indicated Records released to law firm and included an attachment titled with Resident #79's last name. 2. An admission Record revealed the facility admitted Resident #81 on [DATE]. A letter from a law firm, dated [DATE], revealed, Our law firm represents [Resident #81's Personal Representative (PR) #31]. The letter revealed, Please provide complete copies of the medical and facility records from the date the patient was admitted to your facility through the date the patient was discharged or otherwise released from your care. An Oklahoma Standard Authorization to Use or Share Protected Health Information (PHI), dated and signed by PR #31 on [DATE], revealed, I hereby authorize [Facility Name] to release the following information to [Name and address of a law firm], and the information to be shared included Psychotherapy Notes, and Mental Health Records. An email from Medical Record Request to the Medical Records Clerk, dated [DATE] at 1:33 PM, revealed, We have received and reviewed the record request dated [DATE] relating to [Resident #81]. The email continued, After review, we have determined that these records can be immediately released to the requestor as requested, An email from the Medical Records Clerk to the law firm, dated [DATE] at 11:42 AM,revealed a handwritten note that indicated Records requested sent to law office and included an attachment titled with Resident #81's last name. During an interview on [DATE] at 10:19 AM, the Medical Records Clerk stated when a resident or resident representative requested records, they would have the requestor fill out a form to release the records. The Medical Records Clerk stated that once the release of records form was completed, the form was sent to the corporate office for review. The Medical Records Clerk stated that the corporate office reviewed the request and, if appropriate, sent an email back authorizing the release of the records. The Medical Records Clerk stated that the request for Resident #79 was received on [DATE], approved by the corporate office on [DATE], and records were emailed to the requestor on [DATE]. During a follow-up interview on [DATE] at 1:20 PM, the Medical Records Clerk stated medical records were sent outside of the 48-hour timeline for Residents #79 and #81. During an interview on [DATE] at 9:08 AM, the Assistant Director of Nursing (ADON) stated that the expectation was that medical records be provided in a timely manner. During an interview on [DATE] at 9:12 AM, the Administrator (ADM) stated that the expectation was that medical records would be released within the regulatory time frame.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain their infection control program to help prevent the development and transmission of infections. Specifically, the facility failed to ensure clean linen was stored separately from dirty linen, which had the potential to affect all residents who had their laundry done at the facility. The facility also failed to follow enhanced barrier precautions (EBP) for 1 (Resident #26) of 6 residents reviewed during infection control and failed to ensure staff performed hand hygiene and followed EBP for 1 (Resident #40) of 3 residents reviewed during medication administration. Findings included: 1. A facility policy titled, Laundry, revised 01/2024, indicated, Transport 6. Clean linens are stored separately, away from soiled linens, always. An observation of the soiled laundry area of the laundry room on 07/15/2026 at 9:56 AM revealed clean, bagged linen was stored in the soiled laundry sorting room. Laundry Aide (LA) #23 stated that supervisors told him to store some of the clean linen in the soiled laundry sorting room and not the clean linen room. During an interview on 07/15/2026 at 1:42 PM, the Housekeeping Supervisor stated that she had been employed by the facility since 01/2026, and when she started at the facility the clean linen that was currently stored in the soiled laundry sorting room was already there. The Housekeeping Supervisor stated the clean linens should be stored in the clean linen room. During an interview on 07/15/2026 at 1:19 PM, the Assistant Director of Nursing (ADON) stated she was not aware that the laundry room staff were keeping clean linen with dirty linen. The ADON stated her expectation was for the clean linen to be stored in a place where it was not cross contaminated with dirty linen. During an interview on 07/15/2026 at 3:14 PM, the Administrator stated her expectation was for clean linens not to be stored in the dirty linen room and stated they should have been stored in the clean linen room. 2. A facility policy titled, MDRO [Multidrug Resistant Organism] PPE [Personal Protective Equipment]-Enhanced Barrier Precautions, revised 01/2024, revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy revealed, EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following, which included Wounds or indwelling medical devices, regardless of MDRO colonization status. The policy revealed, Indwelling medical device examples included feeding tubes. The policy revealed, For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities, which included Changing briefs or assisting with toileting and Device care or use, which included feeding tube. The facility policy titled, Infection Control Standard Precautions- Handwashing, revised 01/2024, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed, 2. All personnel shall follow the hand washing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy revealed, 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc. [et cetera, and so forth]) Shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The policy revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) add water for the following situations, which included b. Before and after direct contact with residents; c. Before preparing or handling medications; e. Before and after handling an invasive device; and i. After contact with a residence intact skin. The policy revealed, 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. The policy revealed, The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. An admission Record, indicated the facility admitted Resident #40 on 07/02/2026. According to the admission Record, the resident had a medical history that included an encounter for surgical aftercare following a procedure on the digestive system, unspecified severe protein calorie malnutrition, and dysphagia. An admission Minimum Data Set (MDS), with an Assessment Reference Dart (ARD) of 07/08/2026, revealed Resident #40 had Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS further indicated that the resident relied on a feeding tube daily during the assessment's seven-day lookback period. Resident 40's, Care Plan Report, included a focus area dated 07/03/2026, that indicated the resident required enteral feeding related to dysphagia. Interventions directed staff to monitor and document signs and symptoms of infection, dislodging, or malfunction of the tube (initiated 07/03/2026). Resident 40's, Order Summary Report, with active orders as of 07/15/2026, included an order, dated 06/24/2026, for enteral feed every shift, may crush medications and combine with 10-20 cubic centimeters (cc) tap water for administration. During an observation of medication pass on 07/14/2026 at 10:23 AM, Certified Medication Aide (CMA) #1 entered Resident 40's room with a blood pressure monitor. He donned gloves and checked the resident's blood pressure. After checking the resident's blood pressure, CMA #1 doffed the gloves and exited the room without performing hand hygiene. He opened the medication cart and prepared the resident's medications and re-entered the room. CMA #1 then donned gloves and administered the medications via the resident's feeding tube. He later doffed the gloves and performed hand washing before exiting the room. No hand hygiene was performed in-between glove changes or before entering the resident's room, nor was any gown worn for the medication administration. During an interview on 07/14/2026 at 9:01 AM, CMA #1 stated that he was supposed to perform hand hygiene between residents after having contact with them and between gloves changes. During an interview on 07/14/2026 at 10:39 AM, CMA #1 stated that he had EBP training but could not remember when. He stated that to his knowledge he was supposed to wear a gown and gloves when passing medication via an enteral tube. CMA #1 stated that there should have been a personal protective equipment (PPE) cart set up by the resident's room, but there was not one that would have reminded him to wear it. He stated that he saw the EBP signage posted on the resident's door, but he did not pay attention to what it said. During an interview on 07/14/2026 at 12:05 PM, The Assistant Director of Nursing (ADON), who is also the Infection Preventionist, stated that staff should be performing hand hygiene upon entering a resident's room and when exiting, after performing care, and washing when visibly soiled. She stated that it was her expectation that staff followed EBP signage and instructions and wore PPE as per protocol. During an interview on 07/15/2026 at 3:21 PM, the Administrator stated that she was not a clinician, but staff should be following regulations for infection control. She stated that it was her expectation that staff followed the protocol. An admission Record revealed the facility admitted Resident #26 on 05/31/2026. According to the admission Record, the resident had a medical history that included a diagnosis of an encounter for surgical aftercare following surgery on the digestive system. An admission MDS, with an ARD of 06/04/2026, revealed Resident #26 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had an unhealed Stage II Pressure ulcer during the assessment timeframe. Resident #26's Care Plan Report, included a focus area initiated 05/31/2026, that indicated the resident had actual impairment of skin integrity to the right buttock related to pressure. Interventions directed staff to use EBP and utilize contact precautions during high-contact resident care activities. An observation on 07/13/2026 at 10:03 AM revealed Resident #26's room door had an undated CDC sign, titled, Enhanced Barrier Precautions, that revealed, Everyone Must: Clean their hands, including before entering and when leaving the room. The sign revealed, Providers And Staff Must Also, which specified, Wear gloves and a gown for the following High-Contact Resident Care Activities, which included Providing Hygiene; and Changing briefs or assisting with toileting. The observation revealed that Certified Nursing Assistant (CNA) #24 secured a brief on Resident #26. CNA #24 was wearing gloves but no gown. During an interview on 07/13/2026 at 10:08 AM, CNA #24 stated that he provided incontinence care on Resident #26. The CNA stated that gloves were worn when providing incontinence care, and a gown was worn if the resident was on EBP. CNA #24 stated that Resident #26 was on EBP, and he should have worn a gown when providing incontinence care for the resident. During an interview on 07/14/2026 at 3:16 PM, Nurse Practitioner #15 stated PPE such as a gown and gloves were required for residents on EBP to prevent the spread of disease and contamination. Nurse Practitioner #15 stated that she expected staff to always don the appropriate PPE for residents on EBP when the staff were providing high-contact care for residents. During an interview on 07/16/2026 at 9:01 AM, the ADON, who was also the facility's IP, stated staff should wear a gown and gloves when a resident was on EBP. During an interview on 07/16/2026 at 9:25 AM, the Administrator stated the expectation was that staff would wear appropriate PPE when a resident was on EBP.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #49) of 2 sampled residents observed with medications in their rooms was assessed to determine safety and the clinical appropriateness of medication self-administration. Findings included: An undated facility policy titled, Self -Administration of Medications by Residents, indicated, Policy - Each resident who desires to self-administer his or her medication is permitted to do so if the facility's interdisciplinary team and/or facility policy allows or has determined that the practice would be safe for the resident and other residents of the facility. Resident #49's admission Record indicated the facility admitted the resident on 04/21/2016. According to the admission Record, the resident had a medical history that included diagnoses of chronic sinusitis, chronic respiratory failure, and chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2026, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #49's Care Plan Report included a focus area, revised 06/23/2022, that indicated the resident had COPD, a pulmonary nodule, recurring upper respiratory infections, and seasonal allergies. Interventions directed staff to give medications per the physician's orders. Resident #49's Care Plan Report included a focus area, revised 02/21/2023, that indicated the resident desired to be as independent as possible. Interventions did not include the self-administration of medications. Resident #49's Order Summary Report, with active orders as of 07/13/2026, included:- Flonase nasal suspension (a corticosteroid, fluticasone propionate) 50 micrograms per actuation (mcg/ACT), two sprays in both nostrils in the morning for allergies and - ipratropium bromide (antihistamine and decongestant) 0.06% nasal solution, one spray in both nostrils two times a day for COPD. Resident #49's Order Summary Report did not include any order for the self-administration of medication. Resident #49's record review revealed no assessments for the self-administration of medication. On 07/13/2026 at 9:41 AM, an observation revealed Resident #49 self-administering fluticasone propionate nasal spray and ipratropium bromide nasal spray. During an interview on 07/13/2026 at 9:45 AM, Resident #49 stated that staff gave the medications daily for the resident to use and then would return later in the day to retrieve the medications. An observation on 07/14/2026 at 11:30 AM revealed fluticasone propionate nasal spray and ipratropium bromide nasal spray on the overbed table by Resident #49's bedside. On 07/14/2026 at 4:55 PM, Licensed Practical Nurse (LPN) #6, who was the unit supervisor, stated that Resident #49 was not permitted to self-administer medications and the resident had not been evaluated for medication self-administration. On 07/15/2026 at 8:41 AM, Certified Medication Aide (CMA) #1 stated that when he started working in the facility, he was told that in the mornings when he came in, he was to set Resident #49 up because Resident #49 liked to be independent. CMA #1 stated that he left the medications at Resident #49's bedside and did not check to see if there was an assessment or evaluation conducted to allow Resident #49 to self-administer medications. CMA #1 stated that he did not complete an assessment/evaluation for Resident #49, nor did he inform his superiors about the resident self-administering medications. During an interview on 07/15/2026 at 8:54 AM, the Assistant Director of Nursing (ADON) stated that Resident #49 did not have a medication self-administration form that would allow self-administration privileges. The ADON stated that Resident #49 should not be self-administering medications. The ADON stated that the staff should not be leaving any medications at the bedside and should be watching residents take their medications before exiting the room.

Based on observation, interview, record review, and facility policy review the facility failed to ensure prescribed medications were stored securely for 1 (Resident #80) of 2 residents observed with medication in their rooms and for 1 of 4 medication carts observed unlocked and unattended.Findings included: 1. An undated facility policy titled, Medication Storage in the Facility, revealed, Medications and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier. The policy revealed, 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. [exempli gratia, for example] medication aides) are allowed unsupervised access to medication. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. An admission Record revealed the facility admitted Resident #80 on 07/09/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, pneumonia due to other gram-negative bacteria, and acute chronic diastolic (congestive) heart failure. Resident #80's Care Plan Report, initiated 07/10/2026, did not include the self-administration of medication. Resident #80's Order Summary Report, with active orders as of 07/13/2026, revealed, Nystatin [an antifungal medication] External Powder 100000 UNIT/GM [units/gram] (Nystatin (Topical)) - Apply to affected area topically two times a day for redness. Resident #80's Order Summary Report did not include a physician's order for medication to be kept at the resident's bedside or for Resident #80 being safe to self-administer medication. An observation on 07/13/2026 at 9:50 AM revealed Resident #80 lying in bed, appearing asleep. The observation revealed nystatin powder at Resident #80's bedside, with bottle instructions to keep the bottle in the resident's room in locked drawer. An observation on 07/13/2026 at 11:54 AM revealed nystatin powder at Resident #80's bedside and not in a locked drawer.An observation on 07/14/2026 at 8:04 AM revealed nystatin powder on Resident #80's bedside table and not in a locked drawer.During a concurrent observation and interview on 07/15/2026 at 8:35 AM, Certified Nursing Assistant (CNA) #9 confirmed a bottle of nystatin powder was present at the bedside in Resident #80's room. The observation revealed a small mound of white powdery substance on a brown napkin at Resident #80's bedside. CNA #9 stated that medication should not be in Resident #80's room. During a concurrent observation and interview on 07/15/2026 at 8:43 AM, Licensed Practical Nurse (LPN) #6, who was the unit manager, confirmed a bottle of nystatin powder was present at Resident #80's bedside, and there was a small mound of white powdery substance on a brown napkin at the bedside. During an interview on 07/15/2026 at 11:25 AM, the Assistant Director of Nursing (ADON) stated her expectation was for staff to retrieve medications and store them properly when they were found during the admission process. During an interview on 07/15/2026 at 2:26 PM, the Administrator (ADM) stated her expectation was that medications were locked and secured in the medication cart, not left at the bedside, and medications needed to be locked in the medication cart after administration. 2. A facility policy titled, Medication Storage in the Facility, dated 2021, revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2. Only licensed nurses and those lawfully authorized to administer medications (e.g. [exempli gratia, for example] medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. An observation of the 100 Hall on 07/13/2026 at 11:53 AM revealed a medication cart that contained insulin pens (injectable insulin, a hormone to regulate blood glucose), epinephrine pens (an adrenaline injector to treat severe allergic reactions), and naloxone (an opioid antagonist to reverse the effects of opioids) was unlocked. The observation revealed a nurse was not present at the medication cart or within line of sight of the medication cart. During an interview on 07/13/2026 at 11:54 AM, Licensed Practical Nurse (LPN) #29 stated the medication cart was unlocked and contained medications. LPN #29 stated the cart should have been locked. An observation of the 100 Hall on 07/15/2026 at 9:44 AM revealed a medication cart that contained insulin pens, epinephrine pens, and naloxone was unlocked. The observation revealed a nurse was not present at the medication cart or within line of sight of the medication cart. The observation revealed one resident was present in the hallway, in proximity of the unlocked medication cart. An observation of the 100 Hall on 07/15/2026 at 9:48 AM revealed a visitor walked past the unlocked medication cart. During an interview on 07/15/2026 at 9:50 AM, LPN #19 stated the medication cart was unlocked and contained medications. LPN #19 stated the cart should have been locked. During an interview on 07/16/2026 at 9:06 AM, the Assistant Director of Nursing (ADON) stated medication carts should be locked when staff were not present. During an interview on 07/16/2026 at 9:17 AM, the Administrator (ADM) stated the expectation was that medication carts should be locked when staff were not present.

Based on observation, interview, and facility policy review, the facility failed to ensure expired medications were disposed of properly for 1 (400 Hall medication cart) of 4 medication carts reviewed for medication storage.Findings included: A facility policy titled, Medication Storage in the Facility, undated, indicated, Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. An observation of the 400 hall medication cart on 07/14/2026 at 9:45 AM, accompanied by Licensed Practical Nurse (LPN) #8, revealed the following: - 1 bottle of triamcinolone acetonide lotion with an expiration date of 09/22/2025 - 1 second bottle of triamcinolone acetonide lotion with an expiration date of 10/15/2025- 1 jar of zinc oxide with an illegible expiration date- 1 bottle of Nystop nystatin powder 100,000 United States Pharmacopeia (USP) units per gram with an expiration date of 08/27/2025. During an interview on 07/14/2026 at 10:00 AM, LPN #8 stated she started working in the facility a week prior and was never educated on checking her cart for expired medications during her orientation process. She stated that she had never checked the cart for expired medications nor removed any from the cart since her employment at the facility. During an interview on 07/14/2026 at 12:31 PM, the Assistant Director of Nursing (ADON) stated that once per week the staff should go through their cart, checking for, removing expired medications, and reordering them as needed. She stated that it should be done on Tuesdays by whoever was responsible for the cart at that time. The ADON stated that there was a box in the medication storage room for expired medications that were destroyed by the pharmacy on their monthly facility visits. She stated that the information was provided to all employees during orientation. During an interview on 07/15/2026 at 3:21 PM, the Administrator stated that if medication was expired, then it should be discarded.

Based on facility policy review, record review, and interview, the facility failed to ensure ongoing communication between a dialysis facility and the nursing home after dialysis treatments for 1 (Resident #2) of 1 resident reviewed for dialysis.Findings included: A facility policy titled, Special Needs-Dialysis Transportation, revised 01/2024, revealed, This policy is to outline care and services for dialysis residents in order to reduce the risk of infections, complications, and to provide for ongoing monitoring and interventions. The policy revealed, 2. A contract and plan will be developed between the dialysis center and the facility in order to coordinate care and services. The policy continued, a. The Dialysis center will be asked to provide information with regards to the resident's visit, weights and any other pertinent information. An admission Record revealed the facility admitted Resident #2 on 04/06/2026. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease and dependence on renal dialysis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #2 received dialysis within the assessment timeframe. Resident #2's Care Plan Report, included a focus area revised 04/22/2026, that indicated the resident received hemodialysis. Interventions indicated that the Resident had dialysis treatments scheduled three times a week, Tuesday, Thursday, and Saturday (initiated 04/22/2026). Resident #2's, electronic medical record (EMR) revealed no documentation of communication provided back to the facility following dialysis treatments. During an interview on 07/15/2026 at 1:52 PM, Licensed Practical Nurse (LPN) #19 stated that she had not seen any communication sheets for Resident #2 from the dialysis facility. During an interview on 07/16/2026 at 12:50 PM, LPN #21 stated that when Resident #2 returned from the dialysis center in the past, she had not received anything from them, and she did not receive any documentation after the resident's dialysis treatment that day. She stated she had not been trained or instructed to contact the dialysis facility for any documentation for the resident, but she could call the dialysis center if she needed to. During an interview on 07/16/2026 at 12:15 PM, LPN #8 stated that she had not received any information from the dialysis center regarding Resident #2 and had not been trained on what to do if no documentation had been received from the dialysis center. She stated that if she had received information, she would document the information in the EMR but had not been told what to do. During an interview on 07/16/2026 at 1:19 PM, the Dialysis Center Administrator stated that the dialysis center communicated information to the skilled nursing facility (SNF) at least once a month by the dialysis dietician and dialysis clinical coordinator and with monthly medication reconciliation. He stated that the dialysis center was not required to send back information from each treatment to the SNF. He stated that the nursing home normally sent a book and/or folder to the dialysis center, but the facility had not sent anything with Resident #2. The Dialysis Center Administrator stated that usually only weights were sent back to the facility if anything was sent. During an interview on 07/16/2026 at 9:12 AM, the Medical Director (MD) stated that he expected the dialysis center to send back information to the facility at least by note or verbal communication after each dialysis treatment. During an interview on 07/15/2026 at 2:10 PM, the Assistant Director of Nursing (ADON) stated that Resident #2 was sent to the dialysis center with a form from the facility that included the resident's vital signs, weights, and medication list. She stated the facility usually did not receive anything back from the dialysis facility about the resident's treatment. She stated the dialysis facility, or the nephologist called the nursing home when laboratory work would be needed, otherwise, the nursing home did not hear from the dialysis center. During an interview on 07/16/2026 at 8:44 AM, the Administrator stated that residents who attended dialysis were provided with a form and face sheet that they took with them to dialysis. She stated that she expected some form of communication to come back with the resident from the dialysis facility.

Based on observation, interview, record review, and facility document and policy review, the facility failed to provide bathing for 2 (Resident #57 and Resident #26) of 3 residents reviewed for activities of daily living (ADLs).Findings included: A facility policy titled, Activities of Daily Living (ADLs), dated 01/2024, indicated, 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.1. Resident #57's admission Record indicated the facility admitted the resident on 08/10/2022. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, anxiety disorder, parkinsonism, and major depressive disorder.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2026, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident had no behavioral episodes and was dependent on staff for toilet hygiene, showers, and dressing during the seven-day look back period.Resident #57's Care Plan Report, included a focus area, revised 10/30/2024, that indicated the resident had a behavior problem of refusing showers at times. Interventions directed staff to document refusals and notify the charge nurse.During a concurrent observation and interview on 07/13/2026 at 9:24 AM, Resident #57 was observed lying in bed with hair that looked greasy and dirty. Resident #57 stated that they had not had a shower, or their hair shampooed in about three or four weeks. Resident #57 stated that they had one bed bath the week prior. A facility document titled, Hall 100 Shower List, undated, revealed Resident #57 was scheduled to receive showers on the 3:00 PM to 11:00 PM shift on Tuesdays and Fridays based on the resident's room number. The list also indicated, All Shower sheets must be filled out and returned to the nurse. All refusals should be brought to the charge nurse to be charted all showers as well need to be charted in PCC [Point Click Care (an electronic medical record system)]. All Showers and refusals will be monitored daily by management and failure to complete can and will result in disciplinary actions.Resident #57's Documentation Survey Report, for ADL Bathing revealed documentation for two days in the month of June 2026 and one day in the month of July 2026. On 06/12/2026, documentation revealed the resident received a shower with substantial/maximal assistance from staff and on 06/16/2026 documentation indicated the resident refused. On 07/07/2026, documentation revealed the resident received a bed bath. There was no additional documentation that the resident was offered a bath during the months of June 2026 and July 2026. During an interview on 07/14/2026 at 1:30 PM, the Assistant Director of Nursing (ADON) stated that when a resident received a bed bath or shower, staff were supposed to document the bathing activity and type on a shower sheet and document in the electronic record. The ADON stated if a shower sheet was not completed and there was no documentation in the electronic record, a shower was not offered to the resident. During an interview on 07/14/2026 at 3:30 PM, Certified Nursing Assistant (CNA) #4 stated that he was the regular CNA for the 300 Hall and stated that he always informed the nurse when a resident refused their shower. He said he also documented it in PCC and on the resident's shower sheet. CNA #4 stated that Resident #57 was scheduled for showers on the evening shift, and he was not aware if the resident ever refused. During an interview on 07/14/2026 at 3:50 PM, CNA #5 stated that she was familiar with Resident #57 and that the resident was always receptive to care and she was not aware of the resident refusing showers. CNA #5 stated that if a resident refused a shower, she would reapproach, and if they still refused, then she would document the refusal and inform the nurse. During an interview on 07/14/2026 at 3:57 PM, Licensed Practical Nurse (LPN) #6 stated that she had worked in the facility for over a year. LPN #6 stated that if a resident refused a shower and the staff informed her, she would try to convince the resident by informing them of the benefits, and she sometimes would give the shower herself if the resident allowed. LPN #6 stated that the CNAs should have documented in PCC whether Resident #57 received or refused their shower. She stated that she had never been informed that Resident #57 refused a shower. During a follow-up interview on 07/15/2026 at 9:05 AM, the ADON stated that staff were supposed to document anytime a shower or bed bath was given and if the resident refused. The ADON stated Resident #57's documentation indicated that the resident had not been offered showers appropriately. The ADON said the lack of showering could negatively affect the resident's emotional status and could cause increased skin issues. During an interview on 07/15/2026 at 3:22 PM, the Administrator stated that it was her expectation that staff bathe the residents. 2. An admission Record revealed the facility admitted Resident #26 on 05/31/2026. According to the admission Record, the resident had a medical history that included a diagnosis of encounter for surgical aftercare following surgery on the digestive system. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2026, revealed Resident #26 had a Brief Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for bathing during the seven-day lookback period. Resident #26's Care Plan Report, included a focus area initiated on 05/31/2026, that indicated the resident had a functional deficit with activities of daily living due to weakness. The Care Plan Report did not include a focus area or intervention for bathing. During an interview on 07/13/2026 at 10:21 AM, Resident #26 stated they had been given one bed bath since admission to the facility and would like to have regular showers or baths. The resident stated they did not know if they had scheduled shower days. A facility document titled, Hall 100 Shower List, undated, revealed Resident #26 was scheduled to receive showers on the 3:00 PM to 11:00 PM shift on Tuesdays and Fridays based on the resident's room number. The list also indicated, All Shower sheets must be filled out and returned to the nurse. All refusals should be brought to the charge nurse to be charted all showers as well need to be charted in PCC [Point Click Care (an electronic medical record system)]. All Showers and refusals will be monitored daily by management and failure to complete can and will result in disciplinary actions. A document titled, Skin Worksheet[s], for Resident #26 revealed the resident was bathed on 06/09/2026 and 06/12/2026. Resident #26's Task: ADL Bathing documentation for the timeframe from 06/14/2026 to 07/14/2026, revealed the resident refused a bath on 06/16/2026, and received a bed bath on 06/26/2026 and 07/14/2026. There was no additional documentation that the resident was offered a bath during the months of June 2026 and July 2026. During an interview on 07/14/2026 at 1:30 PM, the Assistant Director of Nursing (ADON) stated that when a resident received a bed bath or shower, staff were supposed to document the bathing activity and type on a shower sheet and document in the electronic record. The ADON stated if a shower sheet was not completed and there was no documentation in the electronic record, a shower was not offered to the resident. During a telephone interview on 07/16/2026 at 12:48 PM, Certified Nursing Assistant (CNA) #17 stated they worked from 3:00 PM to 11:00 PM and provided showers to residents during their shift. CNA #17 stated they worked with Resident #26, and the resident was dependent on staff for bathing. CNA #17 stated they did not recall Resident #26 refusing showers. CNA #17 stated they recalled giving Resident #26 a shower that week; however, they did not recall giving the resident a shower in previous weeks. During a follow-up interview on 07/16/2026 at 8:45 AM, the ADON stated the facility had a shower list to ensure residents were offered a shower twice a week and that the lists were posted in the halls, and showers were completed by room number. The ADON reviewed Resident #26's electronic record and stated the resident did not receive a shower between 06/27/2026 and 07/13/2026. The ADON stated the expectation was that residents would receive showers twice a week. During an interview on 07/16/2026 at 9:20 AM, the Administrator stated the expectation was residents would receive showers or bed baths on their scheduled shower days unless they refused.

Based on interview, record review, and facility document and policy review, the facility failed to develop a care plan to address bathing for 1 (Resident #26) of 3 residents reviewed for care plans.Findings included: A facility policy titled, Care Plan Process, revised 09/2019, revealed, The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. The policy further indicated, the Purpose was, To ensure a care plan will be developed that is appropriate for each resident's needs and/or wishes based on the assessment and reassessment (Resident Assessment Instrument-RAI)process within the required timeframes. An admission Record revealed the facility admitted Resident #26 on 05/31/2026. According to the admission Record, the resident had a medical history that included a diagnosis of encounter for surgical aftercare following surgery on the digestive system. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2026, revealed Resident #26 had a Brief Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for bathing during the seven-day lookback period. Resident #26's Care Plan Report, included a focus area initiated on 05/31/2026, that indicated the resident had a functional deficit with activities of daily living (ADLs) due to weakness. The Care Plan Report did not include a focus area or intervention for bathing. A facility document titled, Hall 100 Shower List, undated, revealed Resident #26 was scheduled to receive showers on the 3:00 PM to 11:00 PM shift on Tuesdays and Fridays based on the resident's room number. During an interview on 07/13/2026 at 10:21 AM, Resident #26 stated they had been given one bed bath since admission to the facility and would like to have regular showers or baths. The resident did not know if they had scheduled shower days. During an interview on 07/13/2026 at 10:45 AM, Certified Nursing Assistant (CNA) #9 stated that when it was a resident's scheduled shower day, the CNA checked the electronic record to see what level of assistance the resident needed with bathing and then perform the bed bath or shower. CNA #9 said they documented the bed bath or shower on a shower sheet and in the electronic record. During an interview on 07/16/2026 at 10:02 AM, the Assistant Director of Nursing (ADON) stated it was her expectation that the nurses periodically review residents' care plans and follow the documented interventions. During an interview on 07/16/2026 at 10:15 AM, the Administrator stated that it was her expectation that staff follow the resident's care plan to provide the care and services to meet the resident's needs.

Based on observation, interview, record review, and facility policy review, the facility failed to develop/implement person-centered baseline care plans within 48 hours of a resident's admission for 2 (Resident #80 and Resident #66) of 3 residents reviewed for respiratory care. Specifically, the facility did not include a care plan for the use of supplemental oxygen therapy administration for Resident #80, and did not include a care plan for Resident #66's use of a continuous positive airway pressure (CPAP) machine (a machine that uses mild pressure to keep breathing airways open while you sleep). Findings included: A facility policy titled, Baseline Care Plan, dated 01/2004, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The policy revealed, 1. The baseline care plan will, which included a. Be developed within 48 hours of a resident's admission; and b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to, which included i. Initial goals based on admission orders; and ii. Physician Orders. 1. An admission Record revealed the facility admitted Resident #80 on 07/09/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, pneumonia due to other gram-negative bacteria, and acute chronic diastolic (congestive) heart failure. Resident #80's baseline care plan revealed there was no goal or intervention to direct staff on the care and administration of supplemental oxygen therapy. An observation on 07/13/2026 at 9:50 AM revealed Resident #80 lying in bed receiving supplemental oxygen via nasal cannula with the oxygen concentrator set at 3.5 liters per minute. An observation on 07/13/2026 at 11:54 AM revealed Resident #80 was receiving supplemental oxygen via nasal cannula with the oxygen concentrator set at 3.5 liters per minute. During a concurrent observation and interview on 07/14/2026 at 8:04 AM, Resident #80 was lying in bed on her phone and was receiving supplemental oxygen via nasal cannula with the oxygen concentrator set at 3.5 liters per minute. Resident #80 stated they had been admitted to the facility for pneumonia and prior to being hospitalized , they had been receiving 3 liters per minute of continuous oxygen therapy at home. During a concurrent observation and interview on 07/15/2026 at 8:18 AM, Certified Nursing Assistant (CNA) #9 walked to Resident #80's room and stated that Resident #80 was receiving oxygen therapy via nasal cannula at 4 liters per minute. During a concurrent observation and interview on 07/15/2026 at 8:43 AM, Licensed Practical Nurse (LPN) #6 entered Resident #80's room. LPN #6 stated that the resident was receiving oxygen therapy via nasal cannula at 4 liters per minute. She stated that the admissions nurse was responsible for the baseline care plan for new admissions. She further stated that the baseline care plan for Resident #80 did not include goals or interventions for oxygen therapy. During an interview on 07/15/2026 at 10:55 AM, admission Nurse #16 stated that she was responsible for the admission assessments and for making sure that baseline care plans were developed within 48 hours of admission. admission Nurse #16 stated that Resident #80 was admitted on [DATE] and that the resident had supplemental oxygen in use upon arrival at the facility. During an interview on 07/15/2026 at 2:26 PM, the Administrator stated her expectation was that baseline care plans were accurately completed within 48 hours of admission by the nurse responsible for the admission. 2. An admission Record revealed the facility admitted Resident #66 on 07/01/2026. According to the admission Record, the resident had a medical history that included chronic obstructive pulmonary disease (COPD), asthma, and obstructive sleep apnea (OSA). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2026, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #66's Nursing admission Data Collection, dated 07/02/2026 revealed that in Section 3, Part D. Respiratory indicated that the resident used a continuous positive airway pressure CPAP machine as an intervention. The record revealed that Section 14 titled, Interim Care Plan/Baseline included a focus area initiated 07/02/2026, that indicated the resident had altered respiratory status/difficulty breathing as evidenced by OSA. The Interim Care Plan/Baseline did not include interventions for the resident's use of CPAP machine. During an observation on 07/13/2026 at 9:25 AM, there was a CPAP machine on top Resident #66's dresser next to the bed and a CPAP mask lying on the resident's bed. Resident #66 was not in the room at the time of the observation. During a concurrent interview and record review on 07/14/2026 at 10:39 AM, Licensed Practical Nurse (LPN) #8 stated that when a resident used a CPAP, she looked in the resident's orders or care plan for the settings for the CPAP machine. LPN #8 stated that the use of the CPAP machine was not on the resident's care plan. LPN #8 stated she assumed Resident #66 took off and put on the CPAP mask themself, and she was not sure when the resident was supposed to wear it. During an interview on 07/14/2026 at 1:57 PM, the Assistant Director of Nursing (ADON) stated that when a resident was admitted to the facility with a CPAP machine, the facility got orders from the physician for the settings of the CPAP machine. She stated the staff assisted the resident in putting on and taking off the CPAP machine. The ADON reviewed Resident #66's physician orders and stated the resident did not have orders for their CPAP machine, and it should have been included in the care plan as well. During an interview on 07/14/2026 at 2:32 PM, the MDS Coordinator stated that the admissions nurse completed the baseline care plans. The MDS Coordinator stated that the baseline care plan was in the Nursing Data Collection area of the electronic record. She stated that the interim care plan was the baseline care plan and when the baseline care plan was finalized, it brought up the information in the MDS admission assessment. During an interview on 07/14/2026 at 3:47 PM, Admissions Nurse #16 stated that when she had a new admission, she completed the assessment and entered all the data. She stated that at the end of the assessment was the baseline care plan; she completed the baseline care plan based on the medications the resident was taking and the resident's diagnoses. Admissions Nurse #16 stated that when she was completing the assessment and checked off that Resident #66 used a CPAP, there was not an entry available on the resident's baseline care plan. She stated that normally, a CPAP would be on the respiratory care plan, but she did not know how to include the CPAP on the baseline care plan. During an interview on 07/15/2026 at 3:14 PM, the Administrator stated her expectation was that the baseline care plan be implemented with the admission assessment when the resident was admitted to the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure there were physicians orders for medical treatments/devices for 3 (Residents #80, #6 and #66) of 4 resident reviewed for physician's orders. Specifically, Resident #80 and Resident #6 were receiving supplemental oxygen without a physician's order, and Resident # 66 was using was using a continuous glucose monitoring device (a tiny sensor under the skin that automatically tracks blood sugar levels), a Continuous Positive Airway Pressure (CPAP is a machine that uses mild pressure to keep breathing airways open while you sleep) machine, and intermittent urinary self-catheterization (commonly called a straight catheter, which involves inserting a tube into the bladder to drain urine and removing the tube when the bladder empties) without a physician's order.Findings included: A facility policy titled Oxygen Administration, revised 09/2024, revealed, The purpose of this procedure is to provide guideline for safe oxygen administration. The policy also revealed, 1. Verify that there is a physician's order for this procedure, review the physician's orders or the facility protocol for oxygen administration. 1. An admission Record revealed the facility admitted Resident #80 on 07/09/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, pneumonia due to other gram-negative bacteria, and acute chronic diastolic (congestive) heart failure. Resident #80's Order Summary Report, with active orders as of 07/13/2026, revealed no evidence of a physician's order for supplemental oxygen usage. An observation on 07/13/2026 at 9:50 AM revealed Resident #80 lying in bed receiving supplemental oxygen, and the concentrator was set at 3.5 liters per minute. An observation on 07/13/2026 at 11:54 AM revealed Resident #80 was receiving supplemental oxygen via nasal canula, and the oxygen concentrator was set at 3.5 liters per minute. During a concurrent observation and interview on 07/14/2026 at 8:04 AM, Resident #80 was observed lying in bed on their phone. The observation revealed the resident was receiving supplemental oxygen via nasal canula, and the oxygen concentrator was set at 3.5 liters per minute. Resident #80 stated they were admitted to the facility for pneumonia and prior to being hospitalized they had been receiving 3 liters per minute of continuous oxygen therapy at home. During an observation on 07/15/2026 at 8:18 AM, Resident #80 was receiving oxygen therapy via nasal cannula at 4 liters per minute. During a concurrent observation and interview on 07/15/2026 at 8:43 AM, Licensed Practical Nurse (LPN) #6 entered Resident #80's room. LPN #6 stated that the resident was receiving oxygen therapy via nasal cannula at 4 liters per minute. She stated that the nurse completing the admission was responsible for ensuring physician orders were obtained. LPN #6 stated that there was no active oxygen therapy order for Resident #80. During an interview on 07/15/2026 at 10:55 AM, Admissions Nurse #16 stated that she was responsible for completing the admission assessment and for ensuring that there were physicians' orders for any equipment the resident may need. Admissions Nurse #16 stated that Resident #80 was admitted on [DATE] and that the resident had supplemental oxygen in use upon arrival at the facility. She stated that she normally called the doctor to get an oxygen order, but it looked like it was an oversight on her part during the admission process. During an interview on 07/15/2026 at 11:25 AM, the Assistant Director of Nursing stated her expectation was for the nurse who completed the admission to transcribe and clarify all orders for admitted residents. During an interview on 07/15/2026 at 2:26 PM, the Administrator stated that she expected the nurse who completed the admission to clarify and follow orders as they were written. 2. An admission Record revealed the facility admitted Resident #6 on 02/04/2026. According to the admission Record, the resident had a medical history that included diagnoses of emphysema and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/18/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated significant cognitive impairment. The MDS indicated the resident had shortness of breath or trouble breathing with exertion and when lying flat. Resident #6's Care Plan Report revealed a focus area initiated 02/05/2026, that indicated the resident received oxygen therapy. Interventions directed staff to monitor for signs and symptoms of respiratory distress and oxygen saturation levels (initiated 02/05/2026). Resident #6's Order Summary Report, with active orders as of 07/13/2026, revealed there was no physician order for supplemental oxygen. An observation on 07/13/2026 at 9:29 AM revealed Resident #6 was receiving supplemental oxygen via nasal cannula, and a portable oxygen tank on the back of the wheelchair was set at 2 liters per minute. An observation on 07/14/2026 at 11:02 AM revealed Resident #6 was receiving supplemental oxygen via nasal cannula, and the concentrator was set on 3 liters per minute. An observation on 07/14/2026 at 1:18 PM revealed Resident #6 was lying in bed receiving supplemental oxygen via nasal cannula and the concentrator was set at 3 liters per minute. During an observation on 07/15/2026 at 8:18 AM, Resident 80 was receiving oxygen therapy via nasal cannula at 2 liters per minute. During a concurrent observation, record review, and interview on 07/15/2026 at 8:45 AM, Licensed Practical Nurse (LPN) #6 entered Resident #6's room and stated that the resident was receiving oxygen therapy via nasal cannula at 2.5 liters per minute. LPN #6 stated that the nurse doing the admission was responsible for ensuring physicians orders were entered and completed for new admissions. LPN #6 stated that there were no active oxygen therapy orders for Resident #80. During an interview on 07/15/2026 at 11:25 AM, the Assistant Director of Nursing (ADON) stated her expectation was for the nurse who completed the admission to transcribe and clarify all orders for admitted residents. During an interview on 07/15/2026 at 2:26 PM, the Administrator stated that she expected the nurse who completed the admission to clarify and follow orders as they were written. 3. During an interview on 07/15/2026 at 1:04 PM, the Regional Administrator stated the facility had no specific diabetic care policy. During an interview on 07/15/2026 at 4:23 PM, the Regional Administrator stated that the facility had no specific policy for CPAP. An admission Record revealed the facility admitted Resident #66 on 07/01/2026. According to the admission Record, the resident had a medical history that included chronic obstructive pulmonary disease (COPD), asthma, obstructive sleep apnea (OSA), type 2 diabetes mellitus (DMII), and postural urinary incontinence. Resident #66's Systems Review portion of the Nursing admission Data Collection-V2, completed 07/02/2026, revealed the resident used a CPAP machine. The Interim Care Plan/Baseline portion of the Nursing admission Data Collection-V2 assessment, completed 07/02/2026, revealed the resident had an intermittent catheter related to neurogenic bladder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2026, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #66's Order Summary Report, for active orders as of 07/01/2026 revealed no physician orders for the resident's use of a CPAP machine, continuous glucose monitoring device, or an intermittent straight catheter. During an observation on 07/13/2026 at 9:25 AM, there was a CPAP machine on Resident #66's dresser next to the bed and a CPAP mask was on the resident's bed. Resident #66 was not in the room at the time of the observation. During an observation on 07/13/2026 at 11:25 AM, Resident #66 was observed checking their blood sugar via a continuous glucose monitoring device. During a concurrent observation and interview on 07/13/2026 at 12:20 PM, Resident #66 was observed with an object in their hand entering the bathroom in their room. Resident #66 stated the object in their hand was a straight catheter. During an interview on 07/15/2026 at 9:38 AM in Resident #66's room, the resident stated they utilized the CPAP mask and machine on their own. During a concurrent interview and record review on 07/14/2026 at 10:39 AM, Licensed Practical Nurse (LPN) #8 reviewed Resident #66's physician orders and stated there were no physician orders for the use of a CPAP machine. LPN #8 stated that she assumed Resident #66 utilized the CPAP mask themself and was not sure when the resident was supposed to wear the CPAP device. During an interview on 07/15/2026 at 9:16 AM, LPN #19 stated Resident #66 used the restroom that morning and used a straight catheter. She stated the resident managed the straight catheter themself. LPN #19 stated she knew an order was needed for the use of a straight catheter but did not see an order for Resident #66. LPN #19 stated that regarding the resident's CPAP machine, the resident utilized the mask and machine themself. LPN #19 stated she would have expected to see a physician's order for the CPAP machine settings, but Resident #66 did not have an order. LPN #19 stated she was aware that Resident #66 had a continuous glucose monitoring device, and she would have expected to see a physician's order for the use of the device but stated that there was no order. During an interview on 07/14/2026 at 3:47 PM, Admissions Nurse #16 stated if a resident was admitted directly from home, she had physician orders from home health or hospice or she called the facility's Medical Director for orders. Admissions Nurse #16 stated that when a resident was admitted from home, the Admissions Coordinator got the settings for the resident's CPAP machine. During an interview on 07/14/2026 at 4:01 PM, the Admissions Coordinator stated that when a resident was admitted from home, the clinical team reviewed the clinical portion of the admission paperwork, and the admissions team did the rest of the paperwork. She stated the admissions team did not handle anything clinical, and that the admissions nurses from the clinical team gathered the information needed for a resident's CPAP machine. During an interview on 07/14/2026 at 1:57 PM, the Assistant Director of Nursing (ADON) stated that when a resident was admitted to the facility with a CPAP machine, the facility got orders from the physician for the machine. The ADON reviewed Resident #66's physician orders and stated the resident did not have orders for a CPAP machine. The ADON also stated that they should have entered physician orders for Resident #66's continuous glucose monitoring machine when the resident was admitted to the facility. During a follow-up interview on 07/15/2026 at 9:40 AM, the ADON stated she was not aware Resident #66 was using a straight catheter. She stated there should have been an order for a straight catheter upon admission. During an interview on 07/15/2026 at 3:00 PM, the Medical Director stated that there were no standing orders for new resident admissions at the facility. He stated that the orders for new admissions were obtained when the facility's Admissions Nurse completed the admission. He stated that the Admissions Nurse would call him or another doctor in the group practice and obtain admission orders. The Medical Director stated they should have confirmed the resident's CPAP settings with him or the pulmonologist. He stated he preferred blood glucose finger sticks as opposed to continuous glucose monitoring, but if the resident had insisted on having the device, he would have written an order for the use of the device. The Medical Director stated that if a resident were admitted and used a urinary straight catheter, the facility would have needed to contact him for orders for the resident to use the catheter. During an interview on 07/15/2026 at 3:14 PM, the Administrator stated she expected to have a physician's order if an order was needed for any type of care.

Based on observation, interview, record review, and facility document and policy review, the facility failed to treat a resident with dignity and respect for 1 (Resident #26) of 2 sampled residents reviewed for dignity. Specifically, when Resident #26 told Certified Nursing Assistant (CNA) #11 they needed toileting assistance during a meal, CNA #11 refused to assist Resident #26 with toileting and stated CNA #11 would clean Resident #26 after the meal.Findings included: A facility policy titled, Resident Rights, revised 01/2024, revealed, 1. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy also indicated, 5. The resident has the right to be treated with respect and dignity. An admission Record revealed the facility admitted Resident #26 on 05/31/2026. According to the admission Record, the resident had a medical history that included a diagnosis of encounter for surgical aftercare following surgery on the digestive system. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2026, revealed Resident #26 had a Brief Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for toileting hygiene, the helper did all the effort, and the resident did none of the effort to complete the activity. The MDS indicated Resident #26 was occasionally incontinent of urine. Resident #26's Care Plan Report, included a focus area, revised 06/05/2026, that indicated the resident had bladder incontinence. Interventions directed staff to routinely check and change Resident #26 for incontinence. During an observation of the meal service on 07/13/2026 at 11:45 AM, Resident #26 stated to CNA #11 they were going to pee my pants and asked CNA #11 if the resident should press their call light. CNA #11 told Resident #26 not to press the call light, that CNA #11 could not change the resident during lunch, and that CNA #11 would clean the resident up after the resident finished lunch. During an interview on 07/13/2026 at 11:58 PM, CNA #11 stated they did not change Resident #26 because they thought there would be a concern with cross contamination if they changed the resident while providing one-to-one meal assistance (one staff member assigned to assist one resident during a meal). CNA #11 stated the CNAs did not perform toileting and brief changes during meal service. During an interview on 07/15/2026 at 11:16 AM, Resident #26 stated they did not feel good when they were told to wait when they had to urinate or had urinated, and it was embarrassing. Resident #26 stated they pushed their call light that morning because they had urinated, and a staff member came in and told the resident the staff member did not change residents during meal service. Resident #26 stated they could not get up and go to the bathroom because they could not see and did not stand well, so the staff changed their briefs. During an interview on 07/16/2026 at 8:55 AM, the Assistant Director of Nursing (ADON) stated staff were instructed not to toilet or change residents while passing trays for meal service. The ADON stated the expectation was if a resident was receiving a one-to-one meal assistance and needed to be toileted or changed, the CNA should stop assisting the resident with the meal, perform hand hygiene, toilet or change the resident, perform hand hygiene, and resume assisting the resident with the meal. The ADON stated not toileting or changing a resident when the resident had asked was a dignity issue. The ADON stated the CNA should have changed Resident #26 when the resident asked. During an interview on 07/16/2026 at 9:22 AM, the Administrator (ADM) stated the expectation was that a resident would be treated with dignity and respect. The ADM stated if a resident needed to be changed, the resident should be changed.

Based on observation, record review, and interview, the facility failed to ensure residents had access to the grievance procedure and file an anonymous grievance.The DON identified 61 residents resided in the facility.Findings:On 06/10/26 at 4:11 p.m., a tour of the facility was completed. There was no information regarding the facility's grievance procedure or location of grievance forms.On 06/15/26 at 9:44 a.m., CNA #1 with the DON's assistance located grievance forms in the copier room in an open cabinet on the wall by the DON's office.On 06/15/26 at 9:54 a.m., grievance forms were located in a file cabinet at the nurse's station. The cabinet had other facility forms. There was no information to show the grievance forms were located in the file cabinet. A policy titled Grievance Policy, dated 01/2024, read in part, The facility will inform residents orally and in writing of their right to make Complaints and Grievances and the process to do so during admission, readmission and the care planning process.On 06/15/26 at 9:45 a.m., the DON stated the copier room was not locked and residents had access to the grievance forms. The DON stated a resident in a wheelchair would not have access to the forms.On 06/15/26 at 9:46 a.m., CNA #1 stated they had not seen any posted grievance process in the facility.On 06/15/26 at 9:47 a.m., the social services director stated they were responsible for grievances in the facility.On 06/15/26 at 9:50 a.m., the social services director stated they could not locate the facility's grievance process or who the grievance official was in the admission agreement. On 06/15/26 at 9:52 a.m., the social services director stated they were not sure if a resident could file an anonymous grievance.On 06/15/26 at 9:54 a.m., the social services director stated the grievance forms were located in the copier room, in their office, and behind the nurse's station.On 06/15/26 at 9:58 a.m., the social services director stated the facility's grievance procedure was not posted.On 06/15/26 at 10:03 a.m., the administrator was unable to locate a posted facility grievance procedure.

Based on record review and interview, the facility failed to provide laboratory services as ordered by a physician for 1 (#1) of 3 sampled residents reviewed for laboratory services. The DON identified 61 residents resided in the facility. Findings:A facility policy titled Laboratory Services and Reporting, revised 02/03/23, read in part, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.A physician's order for Resident #1, dated 05/28/26, showed the resident was to have a CBC and CMP drawn weekly on Sundays.A review of Resident #1's electronic medical record did not show any results for a CBC or CMP on (Sunday) 05/31/26 or (Sunday) 06/07/26.An admission assessment for Resident #1, dated 06/04/26, showed the resident was admitted to the facility on [DATE] with diagnoses which included polycythemia vera (a blood cancer that causes the bone marrow to produce too many red blood cells), and surgical aftercare of the gastrointestinal system.On 06/11/26 at 1:56 p.m., LPN #5 stated the nurses entered laboratory orders into their laboratory provider's website and the provider would obtain blood draws from residents in the facility. LPN #5 stated they could not find any CBC or CMP results for Resident #1 in their system.On 06/11/26 at 2:04 p.m., the DON stated Resident #1 was to have a CBC and CMP completed weekly on Sundays, but they did not see the results in the system. On 06/11/26 at 2:18 p.m., the DON stated the facility nurse did not enter the CBC or CMP orders, so Resident #1 had missed their laboratory draws on (Sunday) 05/31/26 and (Sunday) 06/07/26.

Based on record review and interview, the facility failed to administer intravenous medication as ordered for 1 (#2) of 4 sampled residents reviewed for medication administration.The DON identified 61 residents resided in the facility and one resident received intravenous medication.Findings:A policy titled Medication Administration and General Guidelines, dated 2021, read in part, Medications are administered as prescribed.A physician's order for Resident #2, dated 06/05/26, showed ampicillin sodium (antibiotic medication) injection. Use two grams intravenously every six hours due to cellulitis for 10 Days.A 06/2026 treatment administration record showed the 12:00 p.m. dose of ampicillin was not administered on the 06/06/26. The record showed to see nurse's notes.A nursing note for Resident #2, dated 06/06/26 at 6:23 p.m., showed the ampicillin order was on the medication administration record but then switched to the treatment administration record.On 06/10/26 at 6:44 p.m., LPN #2 stated they did not administer the intravenous ampicillin medication because it did not alert the nurse to administer the medication at 12:00 p.m. LPN #2 stated the medication should have been transcribed under the treatment record so nurses would have been alerted to give it.On 06/11/26 at 1:15 p.m., the DON stated medications were transcribed into the electronic health system and administered as ordered. The DON stated they were aware of the missed medication for Resident #2.

Based on record review and interview, the facility failed to provide adequate supervision to prevent an elopement for 1 (#6) of 3 sampled residents reviewed for elopement. The DON identified two residents at high risk for elopement. Findings:A care plan for Resident #6, dated 11/01/24, showed the resident was an elopement risk. Interventions shown for elopement were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and or a book. A quarterly comprehensive assessment for Resident #6, dated 06/17/25, showed the resident was admitted to the facility on [DATE] with a diagnosis of dementia. The assessment showed Resident #6 had a brief interview for mental status score of 1, which indicated severe cognitive impairment. An incident report, dated 07/01/25, read in part, [Resident #6] was observed by a visitor sitting in the facility's south parking lot in a wheelchair. The visitor alerted staff of [Resident #6's] where abouts, the staff immediately went to [Resident #6] in the parking lot to bring [them] back into the facility. A nurse's note, dated 07/01/25, read in part, Patient [Resident #6] was found in the parking lot of the care center, patient was taken back in and assessed for injuries i [sic] have contacted PCP [name withheld] and daughter [name withheld] about elopement from facility. An elopement in-service document, dated 07/01/25, showed staff were educated about the elopement policy and how to prevent and respond to an elopement. An elopement risk assessment, dated 07/01/25, showed Resident #6 was reassessed for elopement risk post elopement. A review of an elopement risk binder, located at the nurse's station, showed two residents at risk for elopement. A review of the facility's Quality Assurance and Performance Improvement agenda, dated 09/24/25, showed the facility met and discussed Resident #6's elopement and potential elopement of other residents. On 06/11/26 at 9:50 a.m., CNA #3 stated they had received training on elopement prevention and response. On 06/11/26 at 10:03 a.m., CMA #2 stated they had received training on elopement prevention and response. On 6/11/26 at 11:19 a.m., LPN #1 stated Resident #6 followed a family outside in July of 2025. They stated the resident was found unharmed in the parking lot by a visitor. LPN #1 stated Resident #6 was brought inside and assessed, and an elopement in-service was completed.On 06/11/26 at 11:46 a.m., the DON stated Resident #6 was alert and oriented to self only when they eloped. They stated the activity director had excused themselves from the front lobby for approximately 10-15 minutes while Resident #6 had been sitting up front. Upon returning to the front lobby Resident #6 was not present. The DON stated a visitor came inside and alerted the facility that Resident #6 was sitting outside in their wheelchair. They stated the resident was brought back inside, assessed, and physician and family were notified. The DON stated Resident #6 was unharmed. They stated the resident's care plan was updated, and staff was educated on elopement. On 06/12/26 at 9:57 a.m., the DON stated residents were assessed for elopement risk on admission and with any changes. They stated only Resident #6 had been reassessed for elopement risk following their elopement. The DON stated to ensure safety from elopement for all other residents, the facility placed a sign on the door stating that no visitor may let anyone out with them and updated the elopement binder.

Based on record review and interview, the facility failed to:a. develop a comprehensive person-centered care plan, andb. include the resident and/or representative for care planning for 1 (#3) of 11 sampled residents whose care plans were reviewed.The administrator identified 61 residents resided in the facility.Findings:A policy titled Care Plan Process, revised 09/2019, read in part, When a resident is discharge return not anticipated, returns at a later date, the care plan must be re-written, and the dates must change.Every effort will be made to involve the resident and family or responsible party in the development, implementation, maintenance, and evaluation of the resident plan of care.A minimum data set entry for Resident #3, dated 03/27/26, was completed for Discharge Return Not Anticipated. A comprehensive care plan for Resident #3, dated 02/20/26, was canceled on 04/09/26 due to the resident's discharge.A minimum data set entry for Resident #3, dated 04/13/26, showed the resident was readmitted to the facility with diagnoses which included urinary tract infection, malignant neoplasm of duodenum, type 2 diabetes mellitus without complications, and chronic obstructive pulmonary disease. A care plan for Resident #3, dated 04/15/26, showed two care planned areas for nutrition and activities. The care plan did not address all the aspects of the resident's care. On 06/11/26 at 1:19 p.m., the unit director stated Resident #3 should have had a comprehensive care plan to address the needs of the resident after admission on [DATE], but did not.On 06/11/26 at 1:31 p.m., the social services director stated Resident #3's comprehensive care plan had not been developed to address all their needs.On 06/11/26 at 2:25 p.m., the social services director stated there should have been a care planning meeting for Resident #3 after admission on [DATE], but one had not been completed.

Based on observation, record review and interview, the facility failed to evaluate residents for smoking safely for 2 (#19 and #25) of 3 sampled residents reviewed for smoking. The DON reported six residents were smokers. Findings: 1. On 04/08/25 at 1:51 p.m., Resident #19 was in bed wearing oxygen via nasal cannula. The resident's wheelchair was observed with a portable oxygen tank attached to the back of it. A policy titled Resident Smoking, dated 01/01/24, showed all residents would be asked about tobacco use during the admission process and during comprehensive MDS assessments. The policy showed all residents would be evaluated, using the smoking/nicotine devices, to determine adaptive equipment and level of supervision required for smoking or if the resident was safe to smoke. Resident #19's care plan, dated 03/14/25, showed no smoking interventions. Resident #19's admission assessment, dated 3/17/25, showed the resident's cognition was moderately impaired with a BIMS score of 11. The assessment showed the resident was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease and the resident did not use tobacco. A smoking list provided by the DON on 04/08/25 showed Resident #19 was a smoker. Resident #19's clinical record was reviewed and did not contain a smoking assessment. On 04/09/25 at 12:50 p.m., Resident #19 reported being a smoker, but had not smoked in a few days. On 04/10/25 at 12:58 p.m., CNA #3 reported Resident #19 had been a smoker since being admitted to the facility, but only smoked occasionally. 2. On 04/09/25 at 1:16 p.m., Resident #25 was observed outside smoking in the smoking area with staff present. Resident #25's care plan, dated 03/07/25, showed no smoking interventions. Resident #25's admission assessment, dated 03/12/25, showed the resident was admitted to the facility on [DATE] with diagnosis which included diabetes mellitus. The assessment showed the resident's cognition was intact with a BIMS score of 15 and the resident did not use tobacco. A smoking list provided by the DON on 04/08/25 showed Resident #25 was a smoker. Resident #25's clinical record was reviewed and did not contain a smoking assessment. On 04/10/25 at 12:58 p.m., CNA #3 reported Resident #25 had smoked daily since being admitted to the facility. On 04/10/25 at 1:00 p.m., the DON reported a smoking assessment for Resident #19 and #25 was not completed because they were not aware the residents smoked until 04/07/25. The DON reported the smoking assessment should have been completed as soon as staff were aware Resident #19 and #25 were smoked.

Based on observation, record review and interview, the facility failed to develop a smoking care plan for 2 (#19 and 25) of 3 sampled residents reviewed for smoking. The DON identified six smokers resided in the facility. Findings: A policy titled Care Plan Process, dated 09/01/19, showed the plan of care must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. The policy showed high-risk areas such as smoking. 1. Resident #19's care plan, dated 03/14/25, showed no smoking interventions. Resident #19's admission assessment, dated 3/17/25, showed the resident's cognition was moderately impaired with a BIMS score of 11. The assessment showed the resident was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease. A smoking list provided by the DON on 04/08/25 showed Resident #19 was a smoker. On 04/09/25 at 12:50 p.m., Resident #19 reported being a smoker and had smoked since being admitted to the facility, but had not smoked in a few days. On 04/10/25 at 12:58 p.m., CNA #3 reported Resident #19 has been a smoker since being admitted to the facility, but only smokes occasionally. 2. On 04/09/25 at 1:16 p.m., Resident #25 was observed outside smoking in the smoking area with staff present. Resident #25's care plan, dated 03/07/25, showed no smoking interventions. Resident #25's admission assessment, dated 03/12/25, showed the resident was admitted to the facility on [DATE] with diagnosis which included diabetes mellitus. The assessment showed the resident's cognition was intact with a BIMS score of 15. A smoking list provided by the DON on 04/08/25 showed Resident #25 was a smoker. On 04/10/25 at 12:58 p.m., CNA #3 reported Resident #25 has smoked daily since being admitted to the facility. On 04/10/25 at 1:00 p.m., the DON reported smoking was added to Resident #19's and #25's care plan on 04/09/25. The DON reported smoking should be included on the care plan as soon as they become aware the resident smokes.

Based on record review and interview, the facility failed to ensure assessments were coded accurately for 4 (#19, 23, 25 and #69) of 17 sampled residents whose assessments were reviewed. The administrator reported 68 residents resided in the facility. Findings: 1. On 04/09/25 at 1:02 p.m., Resident #23 was observed outside smoking without difficulty. Staff supervision was observed during smoke time. Resident #23 admitted to the facility on [DATE]. An undated medical diagnoses list showed diagnoses which included alcohol dependence, HTN, and aphasia. Resident #23's annual assessment, dated 3/15/25, showed the resident's cognition was intact. The assessment showed the resident did not use tobacco. Resident #23's care plan, last revised on 03/26/25, showed the resident smoked. On 04/09/25 at 2:24 p.m., CNA #1 and certified medication aide #1 both reported the Resident #23 smoked. On 04/09/25 2:39 p.m., the MDS coordinator stated the assessment was incorrect and it should have been yes instead of no. 2. Resident #69 admitted to the facility on [DATE]. An undated medical diagnoses list showed diagnoses which included HTN, atrial fibrillation, and diabetes mellitus. Resident #69's discharge assessment, dated 01/09/25, showed the resident was discharged to the hospital. Resident #69's discharge summary, dated 01/09/25, showed the resident was discharged home with home health in place. On 04/10/25 at 12:33 p.m., the MDS coordinator stated the assessment was inaccurate. 41873 3. Resident #19's care plan, dated 03/14/25, showed no smoking interventions. Resident #19's admission assessment, dated 3/17/25, showed the resident was admitted on [DATE] and had diagnoses which included hypertension and chronic obstructive pulmonary disease. The assessment showed the resident's cognition was moderately impaired with a BIMS score of 11 and did not use tobacco. A smoking list provided by the DON on 04/08/25 showed Resident #19 was a smoker. On 04/09/25 at 12:50 p.m., Resident #19 reported being a smoker, but had not smoked in a few days. On 04/10/25 at 12:40 p.m., the MDS coordinator reported tobacco use had not been put on the admission assessment because they were not aware Resident #19 was a smoker. The MDS coordinator reported a smoking assessment had not been completed by the clinical nurse, which was used for completing the admission assessment. The MDS coordinator reported the MDS should reflect the resident was a smoker. On 04/10/25 at 12:58 p.m., CNA #3 reported Resident #19 had been a smoker since being admitted to the facility, but only smoked occasionally. 4. On 04/09/25 at 1:16 p.m., Resident #25 was observed outside smoking in the smoking area with staff present. Resident #25's care plan, dated 03/07/25, showed no smoking interventions. Resident #25's admission assessment, dated 03/12/25, showed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus. The assessment showed the resident's cognition was intact with a BIMS score of 15 and the resident did not use tobacco. A smoking list provided by the DON on 04/08/25 showed Resident #25 was a smoker. On 04/10/25 at 12:40 p.m., the MDS coordinator reported tobacco use had not been put on the admission assessment because they were not aware Resident #25 was a smoker. The MDS coordinator reported a smoking assessment had not been completed by the clinical nurse, which was used for completing the admission assessment. The MDS coordinator reported the MDS should reflect the resident was a smoker. On 04/10/25 at 12:58 p.m., CNA #3 reported Resident #25 had smoked daily since being admitted to the facility. On 04/10/25 at 1:00 p.m., the DON reported a smoking assessment should be completed as soon as they were aware residents were smokers.

On 07/13/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to follow physician's orders for a resident who had a [MEDICATION NAME] drain that was to be changed every other day. The resident was sent to the emergency room per family request and was admitted with a [DIAGNOSES REDACTED]. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 4:00 p.m.,the Administrator and the DON were informed of the IJ situation. At 7:20 p.m., the Administrator presented an acceptable plan of removal which was dated 07/13/15. The plan of removal documented: Manor Care of Midwest City This plan of correction serves as Manor Care of Midwest City's response to Immediate Jeopardy Notification, in the areas of residents highest practical well being, received at the center on July 13,2015. The center does not admit nor concede the citations cite in the Notification. However, to the extent that any legitimate deficiencies exist at the center, the center is taking appropriate actions to correct any deficiences that may be present at the center including, the actions listed in the Plan of Correction. The following steps were immediately implemented: 1. The identified patient is no longer in the facility. 2. An audit for omissions in documentation was completed of resident's treatment administration records on July 13 at 4:30 pm. 3. Education will be provided to licensed nursing staff related to: - Following physician orders and the process for the shift to shift reconciliation of treatment administration documentation. Will be completed by 5:00 pm on 7-15-15 - Education on identification of resident change of conditions. Will be completed by 5:00 pm on 7-15-15 - The education of licensed staff will be completed by 7/15/2015 at 5:00 pm. - No licensed staff will work until they have received the education. 4. A QAA committee meeting was held on July 13, 2015 at 5:00 pm to confirm the audit in #2 was completed and to discuss the abatement plan. 5. An audit of all current residents' orders, admitted within the last 30 days, to validate orders were implemented per physician order will be completed by 5:00 pm, July 15, 2015. On 07/15/15 at 5:00 p.m., the immediate jeopardy situation was removed after determining by interviews and record review all components of the plan of removal had been implemented, including in-service for all licensed staff on following physician orders, identification of resident changes of condition and audits of current resident orders. The deficient practice remained isolated with actual harm. Based on interview and record review, it was determined the facility failed to follow physician orders for two (#1 and #3) of five sampled residents whose clinical records were reviewed for physician orders. Resident #1 was sent to the emergency room per family request and was admitted to the hospital with [REDACTED]. This had the potential to affect all 79 residents who resided in the facility. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A physician's order, dated 03/14/15, documented, .The catheter was placed for refractive pleural effusion and requires drainage.Every other day.signed (Physician name deleted). A facility new patient notice, dated 03/23/15, documented .Lung mass, Mag Pleural Effusion [MEDICATION NAME] drain. L (sic). Last drain 20th-1000cc drainage systems sent. An admission nurse's note, dated 03/23/15, documented the resident had modified independence in cognitive skills for daily decision making. He had a [MEDICATION NAME] cath in the left rib area. He had continuous oxygen use at 2 liters. Admission physician orders, dated 03/23/15, documented, [MEDICATION NAME] Drainage Kits Drain L (sic) Chest QOD (kits in med Room. A administration record, dated 03/23/15, documented the [MEDICATION NAME] drains were to be changed on 03/24/15, 03/26/15 and 03/28/15 at 10 a.m. There was no documentation in the clinical record the drain was changed during the resident stay in the facility. A nurse's note, dated 03/28/15, documented, .11:23.Pt. is AA x 3. C/O SOB, respirations are even but shallow. Lungs slightly coarse, Left lower lobe very diminished, sats 82. Placed patient on 5L/NC sats 86. Notified Dr. (Physician name deleted) of patients situations (sic) at 1123, no new orders given.Daughter at bedside. Will continue to monitor. A nurse's note, dated 03/28/15, documented, .16:26.@ 1600 spoke with DR.o2 sat at 83%.daughter (name deleted) here at patient bed side.EMSA called. A ED Provider note, dated 03/28/15 at 5:10 p.m., documented, . Chief Complaint. Shortness of Breath 83% on 5L/NC. He was at (Nursing facility name deleted) and they checked his SpO2 and it was 85% on 5L NC O2 so they called EMS to bring him in.Reports he has a 'plurex' in his left lung that hasn't been drained since last Sunday. Patient with worsening pleural effusion. Hasn't had pleurex drained since Sunday. A History and Physical, dated 03/29/15, documented, .According to his family the Pleur-x drain was not utilize during his stay at the nursing home. Last night he had 600cc drained. This morning he had an additional 1650 cc drained. He w as (sic) on 6 liters of oxygen by nasal cannula this morning but is currently on 2 L after his additional drainage. On 07/13/15 at 8:45 a.m., the next of kin was asked how many drainage kits were brought to the facility at the time of admission. They stated that there was a bag of four brought and given to the nursing staff. They were asked how many of those kits were returned with the resident's personal belongings. They stated four were given at the time of discharge. At 1:09 p.m., the DON was asked if the [MEDICATION NAME] was changed as ordered. She stated, It is not documented but I made sure all the nurses knew and were comfortable with doing it, but no, they were not done. We were not aware until after he was sent to the hospital. She was asked who made the facility aware. She stated the son informed the facility when he came to pick up the resident's personal belongings. At 2:40 p.m., LPN #1 was asked what the condition of the resident was during her shift the day he was discharged to the hospital. She stated, When I first received him his sats were in the 70's. She was asked what time did she assume his care. She stated that she was working the 7-3 day shift. She was asked what she did for the decreased saturations. She stated, I increased his oxygen to 5 liters to get them up. He had no lung sounds on the left and decreased sounds in the right side. I called the physician and called family. The physician wanted to keep the saturations above 80%. I continued to monitor him and his 02 sats came up to 83% but during the next shift he worsened while I was still there, so I called the physician to let him know the family wanted him sent out to the hospital. He gave the order to send him to the hospital. She was asked if she noticed anything different with the [MEDICATION NAME] drain. She stated, The pleur vac drain was full. No one had been changing. She was asked if she changed it at that time. She stated, No, I didn't. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A hospital discharge order, dated 06/13/15, documented, .Weigh daily and notify physician if gain 2-3 lbs overnight or 5 lbs in one week. There was no documentation in the resident clinical record the order for daily weights were transcribed to the facility admission orders [REDACTED] A facility weight and vital sign summary, dated 6/01/15-7/31/15, documented, .Weight Summary 06/17/2015 08:54 180 There was no documentation in the weight and vital sign summary the resident daily weights were done. An admission assessment, dated 06/20/15, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of two people for transfers and toileting. She required extensive assistance of one person for mobility, dressing and bathing. On 07/13/15 at 2:20 p.m., LPN #2 was asked if there were any residents with orders to have daily weights performed. She stated, We don't have anyone in the facility with daily weights. At 2:25 p.m., the resident was asked if the facility weighed her daily. She stated, No. I haven't been weighed here since I came in. On 07/16/15 at 4:39 p.m., LPN #4 was asked how the facility ensured admission orders [REDACTED]. She stated, I do the orders from the hospital discharge orders. She was asked if anyone verifies that the orders are correctly transcribed. She stated, Sometimes. At 4:43 p.m., LPN #3 was asked who is responsible for writing admission orders [REDACTED]. She was asked how the facility ensured the orders were transcribed correctly. She stated that sometimes another nurse will look at them. On 07/17/15 at 8:05 a.m., the DON was asked how the facility ensured orders were transcribed correctly upon admission to the facility. She stated there was an admission nurse, orders are placed on the report sheets and the oncoming nurse should look at them.

Based on observation, interview and record review, it was determined the facility failed to ensure: ~ supervision to prevent falls and accidents for one (#11) of six sampled residents whose clinical records were reviewed for falls. ~ lint traps were properly cleaned for two of two dryers. There were 101 residents who resided in the facility. Findings: A document, titled FALLS PRACTICE GUIDE FLOWCHART, documented, "...Is there a change in patient's risk factors or fall occurrence...Yes Complete Fall Evaluation Develop/revise Initial or Interdisciplinary Care Plan as applicable Initiate/Update Patient Information Worksheet, Kardex, Task List Implement Ongoing Fall Prevention Strategies Patient/Family Education Staff Education Evaluate Change in Condition or Fall Occurrence Eagle Room Review Quality Assurance and Performance Improvement 1. Resident #11 had [DIAGNOSES REDACTED]. A care plan, revised on 06/25/14, documented, "... Focus At risk for falls due to impaired cognition and mobility along with potential medication side effects and history of falls... Goals Minimize risk for falls, Date Initiated 3/31/2014... Interventions... Administer medication per physician's orders [REDACTED]. Have commonly used articles within easy reach, Date Initiated 3/31/2014... Encourage resident to wear proper foot wear, Date Initiated 4/11/2014... Assure that non skid socks/proper footwear is in place when up, Date Initiated 7/15/2014..." An incident report, dated 09/20/14, documented, "... Date of Incident 09/20/14 3:00 p.m... Type: Fall without injury..." There were no new interventions implemented with the fall. There was no documentation of a fall assessment in the clinical records. A significant change in status assessment, dated 09/22/14, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance of one person for transfers, dressing and bathing. She required limited assistance of one person for bed mobility, toilet use and personal hygiene. She used a wheelchair for primary mobility. She had one fall with injury since the prior assessment. An incident report, dated 10/10/14, documented, "...Date of Incident 10/10/14 4:00 p.m... Type: Fall without injury..." There were no new interventions implemented with the fall. There was no documentation of a fall assessment in the clinical records. An incident report, dated 10/19/14, documented, "...Date of Incident 10/19/14 8:00 p.m... Type: Fall without injury... INCIDENT DESCRIPTION... Resident was found sitting on the floor in front of the sink in her room. She has a large hematoma on her left forehead and lacerations both above and below her left eye that are bleeding moderately. When asked what happened resident states she 'just fell ' but does not recall any details..." There were no new interventions implemented with the fall. On 10/20/14 at 9:00 a.m., the resident was observed sitting on the side of her bed eating breakfast. The call light was positioned across the headboard of the bed out of reach of the resident. At 9:30, LPN #2 was asked how the resident let the staff know she needed something. She stated, "Sometimes she will call out or she will get up and come out to the hallway." She was asked if the resident can use the call light. She stated, "Sometimes." On 10/22/14 at 10:30 a.m., the DON was asked when were interventions implemented for a fall. She stated, "It is taken to the eagle room for discussion." She was asked how long it took for an intervention to be placed. She stated, "As a nurse I would implement them immediately and to investigate." She was asked if interventions are implemented after every fall. She stated, "There should be." On 10/23/14 at 1:00 p.m., the DON was asked if there were any interventions implemented for the 09/20/14 and 10/10/14 falls. She stated, "I don't see any." 2. On 10/20/14 at 8:30 a.m., observation was made of the lint traps in the dryers located in the laundry. There were two dryers and the lint traps for both dryers was covered completely with approximately one to two inches of white colored lint. Laundry worker #1 was asked how often the lint traps for the dryers were to be cleaned. He stated, "The schedule is every 30 minutes to every hour. I cleaned it out yesterday, the night shift must not have cleaned it out." A copy of the 'Lint Trap Cleaning Schedule' for the months of August 2014 and September 2014 were provided from laundry worker #1. He was asked where the October 2014 schedule was and he stated, "I haven't gotten a new sheet yet." The schedule documented the lint traps for the dryers were to be checked at 9:00 a.m., 11:00 a.m., and 1:00 p.m. on the day shift and at 6:00 p.m., 8:00 p.m., and 10:00 p.m. on the evening shift. There was no documentation the lint traps were cleaned on 08/29/14 through 08/31/14, 09/01/14, 09/03/14 through 09/05/14, 09/08/14 through 09/10/14, 09/12/14 and 09/13/14 or 09/14/14 through 09/30/14 on the AM shift. There was no documentation the lint traps were cleaned on 09/06/14 or 09/14/14 through 09/30/14 on the PM shift. There was no documentation provided for the October AM or PM shifts.

Based on observation, interview, and record review, it was determined the facility failed to: A. Ensure diabetic residents' blood sugar levels were monitored and interventions were followed as ordered by the physicians, and/or per facility protocol for 3 (#128, #139, and #218) of the 3 diabetic residents whose charts were reviewed for FSBS monitoring. This resulted in an immediate jeopardy situation for residents #128 and #139. The DON identified 20 diabetic residents who had FSBSs that were to be monitored; B. Recognize pain, develop and/or implement pain management interventions, and/or monitor the effectiveness of pain management interventions for 2 (#26 and #207) of 3 sampled residents with pain issues. The facility's failure to manage pain resulted in actual harm for residents #26 and #207. Eight residents triggered for pain issues; and C. Ensure consistent communication with the [MEDICAL TREATMENT] center and failed to monitor fluid restrictions as ordered by the resident's physician for 1 (#149) of 1 sampled resident who received [MEDICAL TREATMENT] treatments. The facility identified 2 residents who received [MEDICAL TREATMENT] treatments outside the facility. Findings: The facility's [MEDICAL CONDITION] treatment policy and procedure, dated 03-16-01, documented for high blood sugar levels of 400 or above, the staff were to monitor the resident's vital signs every 5 - 15 minutes until stable; assess the resident's clinical status using airway, breathing, and circulation; monitor blood glucose levels every 15 minutes until results were within normal limits for the resident; and notify the physician immediately of the resident's clinical condition, including vital signs, and blood glucose levels. The policy indicated staff were to document the resident's blood glucose levels, clinical condition, vital signs, and subsequent interventions including communications with the physician. The facility's [DIAGNOSES REDACTED] treatment policy and procedure, dated 03-16-01, documented for low blood glucose levels of 69 or below, the staff were to monitor the resident's vital signs every 15 minutes until stable; administer a rapidly absorbed carbohydrate such as OJ, soda, apple juice, or commercially prepared glucose tablets or gels; and recheck the blood glucose level a minimum of 15 minutes after carbohydrate was taken. If teh blood glucose level was less than 60 mg/dl, they were to repeat the above steps, giving rapidly absorbed carbohydrates. If the blood glucose level was greater than 69 mg/dl and 1/2 hour or more remained until the next meal; they were to give the resident a snack such as milk, sandwich, cheese and crackers, or peanut butter and crackers. The policy indicated the staff was to document the resident's glucose levels, clinical condition, vital signs, and subsequent interventions including communications with the physician. The facility's glucose blood monitoring policy, dated 03-16-01, documented the facility's suggested documentation of blood glucose levels was to document the blood glucose result and any sliding scale insulin given and subsequent interventions including communications with the physician. 1. Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, updated on 03-25-10, documented; ~ "Focus Endocrine System need for monitoring related to: Insulin Dependent Diabetes Date Initiated: 03-25-2010...revision on: 03-25-2010..." ~"...Goals...To Maintain compliance with diet. Date Initiated: 03-25-2010...Revision on: 03-25-2010..." ~" ...Interventions...Administer medication as per MD orders and monitor effectiveness Date Initiated: 03-25-2010...Revision on: 03-25-2010..." The August 2011 monthly physician's orders documented: "...11/23/10 (initial order date) - If BS (blood sugar) is 151-200 give 2 units SQ If BS is 201-250 give 4 units SQ If BS is 251-300 give 6 units SQ If BS is 301-350 give 8 units SQ If BS is 351-400 give 12 units Recheck in 15 mins If BS is >401 Notify Doctor 07/01/11 (initial order date) - [MEDICATION NAME] 100 U/1ml ins. (insulin)...45 units sub-q every 12 hrs 05/28/11 - [MEDICATION NAME] R 100unit/1ml...15 units sub-q before meals 11/02/10 - FSBS before meals and at bedtime 11/02/10 - [MEDICATION NAME]-R give according to sliding scale..." The August 2011 TAR documented: On 08-03-11 at 9:00 p.m., the FSBS was 667. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-04-11 at 11:30 a.m., the FSBS was 446. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. At 4:30 p.m., the FSBS was 416. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. At 9:00 p.m., the FSBS was 588. Twelve units of sliding scale insulin were given as ordered. The FSBS was rechecked and the result was 452. There was no documentation to show the physician was notified as ordered. On 08-05-11 at 11:30 a.m., the FSBS was 533. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-10-11 at 11:30 a.m., the FSBS was 459. The injection site and the administering nurse's initials were documented, but the amount of sliding scale insulin given was not documented. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-11-11 at 11:30 a.m., the FSBS was 474. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-16-11 at 11:30 a.m., the FSBS was 457. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-17-11 at 11:30 a.m., the FSBS was 479. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-19-11 at 11:30 a.m., the FSBS was 414. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-25-11 at 9:00 p.m., the FSBS was 424. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 08-26-11 at 9:00 p.m., the FSBS was 503. Twelve units of sliding scale insulin were given as ordered. The FSBS was rechecked and the result was 474. There was no documentation to show the physician was notified as ordered. On 08-28-11 at 11:30 a.m., the FSBS was 402. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the physician was notified as ordered. On 08-28-11 at 4:30 p.m., the FSBS was 407. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the physician was notified as ordered. On 08-28-11 at 9:00 p.m., the FSBS was 406. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the physician was notified as ordered. On 08-28-11, the TAR documented two rechecks of the resident's FSBS, with results of 350 and 400, with no times documented. A nurse's note, dated 08-28-11 at 2:40 p.m., documented, "Resident in bed most of day. Afebrile. FSBS very high. Checked on frequently." The September 2011 monthly physician's orders documented: "...11/23/10 (initial order date) - If BS (blood sugar) is 151-200 give 2 units SQ If BS is 201-250 give 4 units SQ If BS is 251-300 give 6 units SQ If BS is 301-350 give 8 units SQ If BS is 351-400 give 12 units Recheck in 15 mins If BS is >401 Notify Doctor 07/01/11 (initial order date) - [MEDICATION NAME] 100 U/1ml ins. (insulin)...45 units sub-q every 12 hrs 05/28/11 - [MEDICATION NAME] R 100unit/1ml...15 units sub-q before meals 11/02/10 - FSBS before meals and at bedtime 11/02/10 - [MEDICATION NAME]-R give according to sliding scale..." The September 2011 TAR documented: On 09-01-11 at 6:30 a.m., the FSBS was 413. Twelve units of sliding scale insulin were given as ordered. At 11:30 a.m., the FSBS was 412. Twelve units of sliding scale insulin was given as ordered. One recheck result of 389 was documented with no time documented. There was no documentation to show the FSBS was rechecked at the other time or that the physician was notified as ordered. On 09-07-11 at 4:30 p.m., the FSBS was 428. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 09-08-11 at 11:30 a.m., the FSBS was 402. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. At 4:40 p.m., the FSBS was 437. Twelve units of sliding scale insulin were given as ordered. There was no documentation to show the FSBS was rechecked or the physician was notified as ordered. On 09-16-11 at 8:59 a.m., LPN #1 was asked regarding documentation on the resident's September 2011 TAR. She stated she had already been told about not documenting every time she rechecked the FSBS and every time she notified the physician of elevated results. She was asked about the recheck which should have been done on 09-08-11, 15 minutes after the 11:30 a.m. FSBS. She stated, "Normally we write it up here (she pointed to the top of the TAR). She was asked if it had been documented. She stated, "No." She was asked about the untimed recheck result documented on 09-01-11. She stated it was for the 6:30 a.m. recheck. She was asked if she rechecked the resident's FSBS at 11:30 a.m. She stated she could not tell me what it was, but that since it was not documented it was below 401. She was asked if she notified the physician of this resident's FSBS results when the recheck was greater than 401. She stated she notified the physician of elevated results on her daily fax to the physician. When asked for the faxes, she stated the faxes were probably not kept. She stated she put the faxes in the medical records basket after she had faxed the physician. On 09-16-11 at 9:21 a.m., LPN #1 was asked how the physician responded to her faxes of elevated FSBS results. She stated if he had orders concerning FSBS results, he usually called those in. She stated most of the time with this resident, he did not even respond. She was asked what they did if the physician didn't respond. She stated, "We don't do anything with her." She then stated, "If it was an emergency I would call back, he has a nurse who takes calls." She stated she never got faxes back on this resident. She stated, "It is what it is, what else can I say." On 09-16-11 at 10:22 a.m., LPN #2 was asked to look at the resident's TARs and clinical record to see if she could locate documentation of FSBS rechecks and notification of the physician for the resident's following FSBSs: For 08-03-11, 08-04-11, and 08-05-11, she stated, "No documentation." For 08-10-11, she stated, "No, you can see where sliding scale insulin was given. They did not document units twice, but did document site and initials." She was asked if she could tell how much insulin was given. She stated, "No." For 08-11-11, 08-16-11, 08-17-11, 08-19-11, and 08-25-11, she stated, "No documentation." For 08-26-11, she stated, "I do not see documentation of what we did." For 08-28-11, she stated the 2:40 p.m. nurse's note led her to believe the recheck was done but the result and whether the physician was notified was not documented. She was asked which FSBS was being referred to in the note. She stated, "I believe she was referring to the 7:30 and 11:30 fingerstick blood sugars and that she rechecked it throughout the day." She stated she did not see any documentation regarding the elevated FSBS at 4:30 p.m. For 08-30-11, she stated, "I do not see documentation." For 09-01-11, she stated there was a recheck result documented, but she was not able to tell for which elevated FSBS. She stated she did not see documentation of physician notification. For 09-07-11, she stated she found documentation of the resident with increased blood sugars and eating candy, coverage was given as ordered. She was asked if she found a recheck. She stated she did not see documentation of a recheck or physician notification. She stated, "It didn't state either way in the documentation." For 09-08-11, she stated the resident had two blood sugars over 400 and she saw no documentation of rechecks or physician notification. She stated the physician was aware of the resident's non-compliance. She then stated, "In her thinned record you will find a statement from the resident that states 'If I slip into a coma, just call my mom, I will continue to eat my donuts'." Requested to see the above mentioned documentation. After looking through the thinned record, she was unable to provide the documentation. On 09-21-11 at 6:40 p.m., physician #1 was asked if the facility staff notified him of all of the resident's elevated blood sugars. He stated he was doubtful, because she had so many elevated blood sugars, there were probably instances in which he was not notified. He was asked how important was it that he be made aware of FSBSs over the parameters he had set for a resident. He stated, "It's important. In (Resident #128's Name deleted) case...her compliance is so poor, it's hard to get a handle on it, but it's important to know..." 2. Resident #139 had [DIAGNOSES REDACTED]. The resident's admission assessment, dated 05-30-11, documented the resident was cognitively intact; required extensive assistance with 2 plus person physical help with bed mobility, transfer and toilet use; and extensive assistance with 1 person physical help with locomotion on unit and off, dressing, personal hygiene and bathing. The assessment documented the resident had a [DIAGNOSES REDACTED]. The resident's care plan, dated 06-02-11, did not address the care related to monitoring the resident's blood sugar. The June monthly physician's orders documented, "[MEDICATION NAME] HCL 500mg tablet...1 tab by mouth twice daily...FSBS AC & HS...Sliding Scale 0 - 150 = 0 units 151 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 100 = 10 units > 400 = call MD..." The June 2011 FSBS form documented, "below 60 < give glytrose & repeat FSBS & if < 60 give glytrose call MD." The June 2011 FSBS form documented: On 06-12-11 at 11:30 a.m., the FSBS was 34. There was no other documentation of what care the resident received. On 06-13-11 at 4:30 p.m., the FSBS was documented as 164. No sliding scale insulin was documented as given. On 06-18-11 at 7:00 a.m., the FSBS was 43. The back of the form documented the resident was given food to bring blood sugar (BS) up. There was no documentation of a re-check of her FSBS. On 06-30-11 at 4:30 p.m., the FSBS was documented as 153. No sliding scale insulin was documented as given. The July 2011 monthly physician's orders documented, "[MEDICATION NAME] HCL 500mg tablet...1 tab by mouth twice daily...FSBS before meals and at [MEDICATION NAME] 100u/1ml Ins. (insulin) vial use per sliding scale 0 - 150 = 0 units If BS is 151-200 give 2 units SQ If BS is 201-250 give 4 units SQ If BS is 251-300 give 6 units SQ If BS is 301-350 give 8 units SQ If BS is 351-400 give 10 units SQ If BS is >400 call doctor..." On 07-05-11 at 11:30 a.m., the July 2011 FSBS form documented the FSBS was 41. There was no documentation related to what care the resident received. A nurse's note, dated 07/11/11 at 2:00 p.m., documented, "AAO - FSBS recorded (75 at 6:30 a.m., and 96 at 11:30 a.m.) - (up) to W/C for therapy session - pt. became unresponsive during AM therapy services. Bp at the time 84/60 AM V/S was 100/55. Pt was assisted to bed - after nap pt. was up in W/C stated she feels better. pt. daughter says over weekend outing c family pt. ate a piece of chicken & later spit up lg amts of phelem (sic) - c little coughing - SLP performed & is requesting CXR be obtained. Will get order. Daughter is c pt. @ bedside. 4 pm N.O. to obtain CXR." On 07-12-11 at 11:30 a.m., the July 2011 FSBS form documented the FSBS was 48. A nurse's note, dated 07-12-11, documented that food was given, a [MEDICATION NAME] injection was given, the FSBS was re-checked at 11:45 a.m., with the result of 95, the patient was alert during that time, and there were no signs & symptoms (s/s) of [DIAGNOSES REDACTED]. The note documented that the MD was notified of above. On 07-12-11 at 4:30 p.m., the July 2011 FSBS form documented the FSBS was 171. No sliding scale insulin was documented as given. On 09-16-11 at 10:39 a.m., an interview was conducted with LPN #2. The nurse was asked related to the FSBS of 34 on 06-12-11 at 11:30 a.m., what was done for the resident. The nurse stated "below 60 give glytrose & repeat FSBS if less than 60 call MD" which was documented on the 07-2011 FSBS form. The LPN was asked where it was documented that was done. She reviewed nursing notes and stated she did not see documentation on it. The LPN was asked if there was a physician's order to give the glytrose and that guidance. She reviewed the record and stated she did not see one. The surveyor showed the LPN the resident's 06-18-11 FSBS result of 43. The LPN was asked if she could tell the surveyor what was done for the resident. She stated it was documented the nurse gave food to bring BS up. The LPN was asked if the resident's FSBS was re-checked. She stated she could not tell by the documentation. The LPN was asked if the resident's physician was made aware of the 34 and 43 FSBS results. The nurse reviewed the resident's clinical record and stated she could not find that documented. The LPN was shown the resident's 07-05-11 FSBS result of 41 and was asked what care was provided to the resident. She stated she could not tell by the documentation. When asked, the nurse stated the nurses no longer worked at the facility. The LPN was asked if sliding scale insulin was administered on 06-13-11, 06-30-11, and 07-12-11, as required based on the resident's FSBS levels. The nurse stated it was not documented. The LPN was asked if the resident's Sliding Scale Insulin was given. She stated she could not tell by the documentation. The LPN was asked if the physician was made aware when the resident became unresponsive during therapy, as documented in the nurse's note, dated 07-11-11 at 2 p.m. The nurse reviewed the resident's clinical record and stated it said that ST had requested a chest x-ray. She wanted to check ST notes. The telephone order stated to get chest x-ray, the nurse stated she assumed that the nurse told the MD about the unresponsiveness. The LPN was asked to read the nursing note, dated 07-12-11 at 11:30 a.m., r/t the resident's FSBS result was 48, that food was given and [MEDICATION NAME] was given via injection. The LPN was asked if she saw an order for [REDACTED]. On 09-16-11 at 10:53 a.m., LPN #3 was asked what care did she provide to the resident r/t the 07-12-11 FSBS result of 48 at 11:30 a.m. She stated she gave her food. The LPN was asked why did she give her a [MEDICATION NAME] injection. The nurse checked the resident's chart. The LPN was asked where was the physician's order for the [MEDICATION NAME] injection. She stated she did not not write the PO and did not document the sequence of what happened during that time frame. The nurse stated after she gave the resident food, she called the resident's physician, received the order for [MEDICATION NAME], and re-checked the resident's FSBS within that 15 minute time frame. On 09-21-11 at 11:52 am, registered nurse (RN) minimum data set/care plan (MDS/CP) coordinator #1 was asked to show the surveyor where the resident's monitoring of finger stick blood sugars (FSBS) were on the care plan. The MDS/CP nurse reviewed the resident's care plan. She stated it should have been, but I care planned whatever triggered off the MDS. Immediate Jeopardy Identified On 09-16-11 at 12:52 p.m., OSDH was notified and verified the existence of an Immediate Jeopardy (IJ) situation related to the facility's failure to ensure diabetic residents' blood sugar levels were monitored and interventions were followed as ordered by the physicians. At 1:12 p.m., the administrator and regional director were informed of the IJ situation related to the facility's failure to monitor residents' blood sugar levels and follow interventions as ordered by the physicians and this placed the facility in an extended survey. Plan of Removal for Immediate Jeopardy On 09-16-11 at 4:51 p.m., the facility submitted an acceptable plan of removal, which documented: "Facility administrator and Director of Nursing will insure (sic) that all patients will have their blood sugar monitored per physician order and the physician will be notified per the parameters defined in the physician orders. Facility will initiate the following steps to insure (sic) compliance: All licensed nurses will be in-serviced by the Director of Nurses by 8:00 PM on 09/16/11 on following physician orders regarding the monitoring of blood sugars. Nurses will be in-serviced by the Director of Nursing by 8:00 PM on 09/16/11 on: timely MD notification if outside physician ordered parameters, education of rechecking finger sticks, parameters for hypo/hyper glycemia per sliding scale, signs and symptoms of hypo/hyper glycemia and appropriate documentation in nurse's notes. In-service completed 9/16/11 by 8:00 PM. Physician orders have been checked for all patient's with blood sugar sliding scales to validate that there are high and low parameters. Validation completed 9/16/11. All nurses will be in-serviced by the Director of Nursing on the proper monitoring of blood sugar sliding scales. In-service will be completed 9/16/2011 by 8:00 PM. Compliance for 9/16/11 11-7 shift (name deleted RDO (regional director of operations) 9/17/11 7-3 shift (name deleted LPN 3-11 shift (name deleted RN 11-7 shift (name deleted Administrator) 9/18/11 7-3 shift (name deleted LPN) 3-11 shift (name deleted RN) 11-7 shift (name deleted Administrator) 9/19/11 7-3 shift (name deleted (DON)) Director of Nursing, Assistant Directors of Nursing and their designees will monitor treatment records to determine licensed nurse compliance with blood sugar monitoring. Administrator will be immediately notified of any instances of non compliance with physician orders regarding blood sugars. Medical Director will be notified regarding any instance of failure to properly monitor blood sugar levels. Facility compliance with monitoring of blood sugars will be presented to the QAA committee for further consideration." Immediacy Removed On 09-19-11 at 9:55 a.m., the survey team received a copy of the facility's re-education of blood sugar checking from the administrator. At 12:15 p.m., the survey team received a copy of the nursing active employee list from the administrator. At 2:45 p.m., the survey team began getting nursing staff inservice interviews. At 5:20 p.m., the surveyor spoke to the LPN via phone who had been inserviced last. The LPN verified she had been inserviced as the facility had stated at approximately 7:00 p.m. on 09-16-11. At 5:37 p.m., the survey team met together and reviewed the obtained information. The IJ was removed, effective 09-16-11 at 7:00 p.m. At 5:47 p.m., the administrator was made aware that the IJ had been lifted effective 09-16-11 at 7:00 p.m. when the last nurse had been inserviced. The deficient practice remained at a level of actual harm at a pattern that was not immediate jeopardy. Additional Findings 3. Resident #218 had [DIAGNOSES REDACTED]. The resident's care plan, dated 08-23-11, did not address the care related to monitoring the resident's blood sugar. The resident's admission assessment, dated 08-28-11, documented the resident was cognitively intact, required assistance with ADLs, had a [DIAGNOSES REDACTED]. The resident's current monthly physician orders for the month of 09-2011, documented an original physician's order, dated 08-21-11, which did not address what care was to be provided if the resident's BS was below 100. On 09-15-11 at 4:20 p.m., the surveyor checked the FSBS books on the 400 hall. Resident #218 had a documented 54 FSBS on 09-14-11 on his standard treatment record. The nursing notes did not document the resident's FSBS or the interventions, and there was no documentation that the physician was notified of the resident's low BS. The resident's current physician's orders did not include a parameter for contacting the physician if the resident's BS was low. At 4:35 p.m., LPN #6 was asked what the 86 was documented on the resident's FSBS. She stated that was the resident's FSBS re-check result. On 09-15-11 at 4:50 p.m., LPN #9 was asked if the MD was made aware of the resident's low BS. The LPN stated she was not the nurse that morning. The LPN thought LPN #3 had given the resident OJ but was not sure. LPN #9 was asked if the resident had parameters to call the MD if the resident's BS was low. She stated only if the BS was too high. On 09-16-11 at 10:12 a.m., LPN #2 was made aware of the resident's 09-14-11 FSBS result of 54. The LPN was asked if she could tell the surveyor the care that was provided the resident after the low FSBS. She reviewed the resident's clinical record. She stated no she did not see the documentation. The LPN was asked if the facility usually had parameters to call the physician if the BS was low. She stated, yes, she agreed there were no parameters for resident #139 or resident #218. On 09-16-11 at 10:45 a.m., LPN #3 was asked what she had done after the resident's 09-14-11 7 a.m. FSBS result of 54. She stated LPN #10 had given him a health shake and 15 minutes later his FSBS was 86. LPN #3 was asked if she had notified the resident's physician. She stated LPN #10 took the 7 a.m. FSBS and LPN #3 took the FSBS 15 min later. LPN #3 was asked if a resident had a low blood sugar do you notify the physician. She stated if a resident's FSBS was below 70, we gave them food, or glytrose if they are alert, if not a [MEDICATION NAME] inject, and re-check the FSBS in 15 mins., and if the FSBS was still low repeat the process then notify the MD. LPN #3 was asked if that was written down some where. She stated she did not know where the whole policy was written. LPN #3 was asked if the nurses needed to obtain a physician's order to administer the glytrose or [MEDICATION NAME]. She stated, yes. LPN #3 was asked if there usually were physician's orders for parameters for the residents who experienced low FSBS's. She stated, yes, the medical director used the "below 70 FSBS result." She stated if the residents were diabetic, nurses are supposed to get all those orders when the nurses get the residents' insulin instructions. LPN #3 was asked since the resident was already identified as being a diabetic would she have thought he would already have those orders. She stated yes. On 09-16-11 at 11:10 a.m., LPN #10 was asked after the resident had a FSBS of 54 on 09-14-11 what care she had provided the resident. She stated she had given the resident a sugar free health shake and had failed to document the care that was provided the resident after his low FSBS. The LPN was asked if she notified the physician of the low FSBS. She stated no she did not. She stated in the past on the nurses papers there would have instructions of what to do, "give food, call MD if less than." She was asked who was responsible for obtaining low FSBS parameter orders. She stated, the nurses. The nurse would call the physician. The LPN showed the surveyor what care she had provided the resident on 09-14-11 on her report sheets that she kept for 30 days. 4. Resident #207 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physicians orders, dated 07-22-11, documented: ~ "[MEDICATION NAME] 100mg po BID..." ~ "[MEDICATION NAME]/APAP ([MEDICATION NAME]) 10 (one to two) po q 4 (hrs) as needed for mod./severe pain..." ~ "...Tylenol (one-two) po q 4 (hrs) as needed for mild pain/fever..." ~ "[MEDICATION NAME] 5% ADH (adhesive). Patch apply to shoulder 12 hours on and 12 hrs off..." A physician's order, written on a prescription pad slip, dated 07-22-11, documented "[MEDICATION NAME] ([MEDICATION NAME]) 10/325 (one-two) po q 4 (hrs) prn pain..." A telephone order, dated 07-25-11, documented, "...Clarification [MEDICATION NAME] ([MEDICATION NAME]) 10/325mg 2 PO q 4 (hrs) PRN (severe) pain...Tylenol 325mg 2 PO q 4 (hrs) PRN pain..." A telephone order, dated 07-27-11, documented, "...order clarification: [MEDICATION NAME] ([MEDICATION NAME]) 10/325 (one-two) po q 4 (hr) prn pain...Tylenol 325mg (one-two) tab q 4 (hrs) prn for pain..." A telephone order, dated 07-27-11, documented, "...(increase) [MEDICATION NAME] to 100mg po TID x 3d then 100mg po q AM; 100mg po q noon & 300mg po @ HS..." The admission assessment, dated 07-29-11, documented the resident was cognitively intact and exhibited no signs and symptoms of [MEDICAL CONDITION] or behaviors. The assessment documented the resident exhibited the following symptoms of mood problems for 2 to 6 of the prior 14 days: feeling down, depressed, or hopeless. The resident also had trouble falling or staying asleep or sleeping too much for 7 to 11 of the prior 14 days. The assessment documented the resident was in moderate pain almost constantly and that pain had made it hard to sleep at night over the past 5 days. The resident's care plan, dated 07/25/11 and last updated on 08/02/11, documented: ~ "Focus Pain related [MEDICAL CONDITION] and throbbing in right shoulder and leg Date Initiated: 7/25/11...revision on: 8/2/2011..." ~ "Goals...Pain will be resolved within 1 hour of intervention Date Initiated: 7/25/2011...Will express that pain management is within acceptable limits Date Initiated: 7/25/2011..." ~ "Interventions...Administer medication as per MD orders and note the effectiveness. Date Initiated: 7/28/2011...Revision on: 7/28/2011...Give routine and PRN meds as per MD orders and note the effectiveness. Date Initiated: 7/25/2011..." The August 2011 monthly physician's orders documented: ~ "[MEDICATION NAME] 100mg...IE [MEDICATION NAME] 1 cap by mouth twice daily..." ~ "...APAP 325mg tablet...IE [MEDICATION NAME] 1 or 2 tablets by mouth every 4 hrs as needed for pain..." ~ "[MEDICATION NAME]/APAP ([MEDICATION NAME]) 10/325 tablet...1 or 2 tablets by mouth every 4 hrs as needed for pain..." ~ "[MEDICATION NAME] 5% ADH. Patch apply to shoulder 12 hours on and 12 hrs off..." A telephone order, dated 08-01-11, documented, "...(change) [MEDICATION NAME] to 300mg TID..." A nurse's note, dated 08-02-11 at 2:20 p.m., documented, "Pt verb (verbalized) pain (not) resolved & he had been en (in) pain all night...notified MD n.o. receeved (sic)..." A nurse's note, dated 08-02-11 at 10:00 p.m., documented, "...Pt states hip pain is better today but not gone..." A telephone order, dated 08-02-11, documented, "[MEDICATION NAME] ([MEDICATION NAME])10-325mg po tid...DC current [MEDICATION NAME] orders..." A nurse's note, dated 08-04-11 at 7:00 a.m., documented, "c/o (right) arm and leg pain Medicated c tyl (Tylenol). pt. called mother and brother. explains (sic) to mother that pt received tyl and calls right after med for pain med..." A nurse's note, dated 08-04-11 at 4:10