Every finding on record at Emerald Care Center Tulsa

Based on record review and interview, the facility failed to ensure a resident was provided with a written notice of transfer when transferred to a hospital for 1 (#5) 2 sampled residents reviewed for hospitalization.The DON identified 18 resident transfers in the past six months.Findings:A facility transfer and discharge policy, dated 05/2017, showed a resident was to be provided a written notice of transfer when practicable before transfer when a resident's urgent medical needs required immediate transfer.A quarterly MDS assessment for Res #5, dated 06/18/25, showed the resident had a brief interview for mental status score of 15 which indicated cognition was intact for decision making.A progress note for Res #5, dated 09/12/25 at 3:35 p.m., read in part, Resident sent to [hospital name withheld] for evaluation and treatment if indicated related to seizure like activity/High blood pressure and pulse. Resident's [family member] notified of transfer [family member name withheld].On 09/24/25 at 2:59 p.m., Res #5 stated they had been transferred to a hospital on [DATE].On 09/24/25 at 3:40 p.m., the DON was asked about the paperwork provided to residents when they were transferred to a hospital. Their recounting of the paperwork sent with residents did not include a written notice of transfer. They were asked if Res #5 had been provided with a written notice of transfer on 09/12/25 when they were transferred to an acute care hospital. They stated the staff had not given such notice to the resident on 09/12/25. The DON stated they were unaware of the requirement to provide a written notice of transfer.

Based on observation, record review, and interview, the facility failed to ensure foods were labeled, dated, and stored correctly when opened or prepared for 1 of 2 observations in the kitchen.The DON identified 58 residents received nourishment from the kitchen.Findings: On 09/22/25 at 8:18 a.m., a tour of the kitchen was conducted. The following observations were made:a. two undated, unlabeled, plastic pitchers with lids of red juice, was stored on the prep table near the serving area,b. an undated, unlabeled, opened bottle of soy sauce was stored on the bottom shelf of the prep table, andc. an undated, unlabeled, unsealed, opened paper bag of grits was stored on the bottom shelf of the prep table. An undated policy titled Food Safety Requirements Policy, read in part, It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food .this includes the storage, preparations, distribution, and serving food in accordance with professional standards for food service safety. On 09/22/25 at 8:35 a.m., the food service director was shown the items that were not labeled or dated. The food service director stated, The items should be labeled and dated. The food service director stated the opened bag of grits should be in a sealable container of some type.

Based on record review and interview, the facility failed to ensure a resident's dialysis catheter was assessed every shift for 1 (#35) of 2 sampled residents reviewed for dialysis care.The DON identified five residents in the facility received dialysis treatments.Findings:A facility policy titled Special Needs - Dialysis Transportation, dated 01/2024, read in part, Fistula/shunt site will be checked every shift for bruits, bleeding, increased pain, and signs of infection.A physician order for Res #35, dated 08/29/25, read in part, Right upper chest Perma Cath - Monitor catheter for bleeding and intact dressing every shift. Notify dialysis center of any concerns every shift. (Permacath is a type of catheter that is inserted into a person's body to provide access into their blood vessels).A September 2025 TAR for Res #35 showed the resident's right upper chest permacath was to be assessed for bleeding and an intact dressing once each shift. The TAR showed no documentation of the assessments having been completed on four of the 46 scheduled assessment dates on and between 09/01/25 and 09/23/25. The date and shifts of the missing assessment documentation were 09/02/25 1st and 2nd shifts, 09/17/25 1st shift, and 09/22/25 2nd shift. On 09/24/25 at 1:49 p.m., LPN #1 was asked to explain the assessment process for Res #35's dialysis treatments. During the explanation LPN #1 stated they assessed the resident's catheter that had been placed in their chest. They stated they checked the catheter every shift and before dialysis. They were asked how someone would know the checks of the catheter had been completed. LPN #1 stated the checks were documented in the resident's TAR. LPN #1 was asked to look at the resident's September 2025 TAR and explain what they observed. They stated four of the entries were not documented. They were asked if they worked any of those shifts. LPN #1 stated they did and they believed they did the checks, but may have pushed the wrong bottom on the computer. They stated they should have made sure the documentation was on the TAR.On 09/24/25 at 2:10 p.m., the DON was asked to look at the permacath assessment section on Res #35's September 2025 TAR. The DON stated when the assessments were completed the nurses put the information into the EMR's. They stated they were confident the assessments were done, but understood there was no documentation to prove it. They stated they believed the nurse made an error when they tried to put the information into the EMR. The DON stated they understood the assessments were important as was the documentation.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was created for 1 (#56) of 16 sampled residents reviewed for care plans.The DON identified 58 residents resided in the facility required MDS assessments.Findings:A facility policy titled Care Plan Process, dated 09/2019, read in part, 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 MDS admission assessment for Res #56, dated 06/25/25, showed the resident had a facility entry date of 06/19/25. The assessment showed activities of daily living functioning, urinary incontinence, nutritional status, and pressure ulcers were selected to be care planned. The assessment showed MDS coordinator #1 had signed the assessment as completed on 06/25/25.Res #56's EMR was reviewed. The care plan section did not contain a comprehensive care plan. A baseline care plan, dated 06/20/25, was found in the EMR. On 09/24/25 at 11:15 a.m., the DON was asked to review Res #56's EMR for a comprehensive care plan. They stated they did not find a comprehensive care plan for Res #56. They were asked if there should be one for the resident. They stated the comprehensive care plan should have been created by that time. They stated it was their policy to complete the baseline care plans and comprehensive care plans in a timely manner.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and enhanced barrier precautions were followed during pressure ulcer treatment for one (#5) of three sampled reviewed for wound care. The ADON identified 10 residents who had pressure ulcers. Findings: An MDRO PPE-Enhanced Barrier Precautions policy, revised January 2024, read in parts, 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 .may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status .requires that staff participate in initial and on-going training on the facility's expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE. Resident #5 had diagnoses which included type two diabetes and COPD. On 01/24/25 at 9:55 a.m., Resident #5 was observed to have a pillow in their wheelchair seat. On 01/27/25 at 10:10 a.m., RN #1 was observed to complete wound care for Resident #5 with the assistance of medical records CNA. RN #1 and medical records CNA were not observed to wear gowns. The wound dressing removed was dated 01/26/25. The wounds were observed to have white beds and were observed to be healing stage threes on the buttocks and left ischium. RN #1 was not observed to sanitize their hands between glove changes and did not change gloves consistently between dirty and clean. The medical records CNA was observed to wear gloves while holding Resident #5 on their right side during the dressing change. They were observed to hold the dressing in place with their dirty gloved hand while RN #1 secured the dressing with tape. On 01/27/25 at 10:50 a.m., RN #1 stated hands should be sanitized when entering and exiting a resident room and between glove changes. They stated they did not sanitize between glove changes. RN #1 stated EBP were not followed during the wound treatment.

Based on record review and interview, the facility failed to ensure timely incontinent care was provided for one (#6) of three sampled residents reviewed for ADLs. The administrator identified 66 residents who resided at the facility. Findings: Resident #6 had diagnoses which included anxiety, depression and diabetes. Review of the resident council meeting minutes for December 2024 revealed four out of five residents reported a concern the night shift was not changing people at night. Review of the clinical record for Resident #6 revealed a general note, dated 01/26/25 at 9:49 p.m., the note read in part, This morning at [7:54 a.m.], I got a call from the Tulsa PD. Resident had called them and said that [they] had been wet all night. [They] told them that [They] been calling, but no one responded. Another call came in at [7:56 a.m.] from Pst [name withheld], who claimed to be the resident's pastor. [They] also noted that resident had called [them] for the same reason. I asked the oncoming aides to come in and clean her up. They changed [them] and helped [them] get into [their] wheelchair. On 01/27/25 at 12:36 p.m., Resident #6 was observed sitting up in their chair, eating lunch, with no odors present, and dressed. Resident #6 stated, I tell you what is not good, the late night care. They stated on Saturday morning (01/25/25) they were wet up to their waist and their sheets and gown were also. Resident #6 stated staff did not check and change them all night Friday night. They stated staff ignored them. Resident #6 stated they used their call light, but staff did not come. They stated they posted their concerns on social media and called their pastor and the police. Resident #6 stated the day shift had changed them when they came on shift. On 01/27/25 at 1:48 p.m., CNA #2 stated their day started with report, walking the hall, and check and change everyone before breakfast. They stated they completed rounds every two hours and documented when residents had been changed. CNA #2 stated if residents were soaked when they arrived they would change them and report it to the nurse. On 01/27/25 at 1:52 p.m., LPN #1 stated the CNAs did a check/change every two hours. They stated the nurse monitors by following up with the residents and reviewing their documentation at the end of their shift. LPN #1 stated verbal communication and paying attention to lights worked the best. They stated if a CNA had not done their duties it was documented and reported to the DON/ADON/administrator. On 01/27/25 at 1:56 p.m., the administrator stated the charge nurses monitored to ensure staff completed their rounds and checked/changed the residents by running a report from the electronic medical record. The administrator stated Resident #6 should not have had to call the police. They stated they had spoken to the CNA who worked the night shift on Saturday (01/25/25) and they had reported they had asked Resident #6 if they needed anything, were told no, and left after their shift. The administrator stated they do not think the CNA knew how long the light had been activated.

Based on interview and record review, the facility failed to ensure dialysis services for one (#1) of four residents who were reviewed for dialysis services. This deficient practice resulted in Resident #1 being hospitalized with a diagnosis of metabolic acidosis from missed dialysis. The DON identified 11 residents who resided in the facility who required dialysis. Findings: A facility policy for dialysis was requested but not provided by the end of the survey. Resident #1 had diagnoses which included end stage renal disease. A physician order, dated 05/24/24, documented Resident #1 was to receive dialysis three times a week on Monday, Wednesday, and Friday. A care plan, dated 05/23/24, documented Resident #1 had a 9:30 a.m. appointment at a dialysis center on Monday, Wednesday and Friday. A progress note, dated 07/05/24, at 11:48 a.m., documented the facility was called and asked to come back to the dialysis center and pick up Resident #1. Transportation was sent and Resident #1 returned to the facility with a note taped to their wheelchair that stated Resident #1 may not return to the dialysis center without a sitter, due to behaviors at the dialysis center. There was no documentation the resident went to dialysis after 07/05/24. A progress note, dated 07/09/24, at 12:40 p.m., documented Resident #1 was sent to a hospital due to not receiving dialysis services. A hospital History and Physical assessment plan for Resident #1, dated 07/09/24, read in part, .Admit to inpatient status. I anticipate that this patient will require a stay exceeding at least 2 midnights for the following reasons. Altered mental status with missing multiple dialysis sessions and inability to get dialysis on an outpatient setting . 1. Altered mental status suspect acute metabolic encephalopathy due to missing dialysis. Baseline appears to be nonverbal answering yes/no questions per care everywhere .2. Metabolic acidosis-multifactorial but likely from missing dialysis . Metabolic acidosis is to much acid accumulated in the body, causes include kidney failure. On 07/18/24 at 11:05 a.m., the administrator stated Resident #1 was sent to dialysis on 07/08/24 but was sent back to the facility without receiving dialysis because no sitter was provided. The administrator stated the facility was not required to provide a sitter. On 07/18/24 at 11:08 a.m., the DON stated Resident #1 was sent to the hospital on 07/09/24 to receive dialysis. On 07/19/24 at 10:53 a.m., LPN #1 stated they had sent Resident #1 to dialysis on 07/05/24 around 9:00 a.m. LPN #1 stated since the resident returned about 25 minutes later, and dialysis usually took around 4-5 hours, they had assumed Resident #1 did not receive dialysis. LPN #1 stated they were unsure if they notified the ADON, and stated they did not notify the physician.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed and/or implemented to address the residents' needs related to a urinary catheter for one (#49), pain for one (#24), and cardiovascular status for one (#22) of 24 residents whose care plans were reviewed. The corporate administrator identified 53 residents who resided in the facility. The ADON identified seven residents with a urinary catheter. Findings: A facility policy titled Pain Management, revised 01/24, read in part, .The facility must ensure that pain management is provided to residents who require services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . 1. Res. #49 had diagnoses which included obstructive and reflux uropathy and benign prostatic hyperplasia without lower urinary tract symptoms. An admission assessment, dated 12/12/23, documented the resident was cognitively intact, dependent with toileting, and had a urinary catheter. A care plan, dated 12/12/23, documented the resident had an indwelling catheter related to BPH. The care plan documented to position the catheter bag and tubing below the level of the bladder. No additional interventions related to catheter maintenance and urinary tract infection prevention were documented. There was no physician order for a urinary catheter documented in the resident's medical record since 2/27/24. There was no documentation of catheter care or maintenance in the resident's medical record since 2/27/24. On 04/08/24 at 7:53 a.m., Res #49 was observed lying in bed. A urinary catheter bag with medium yellow urine was observed attached to the bed frame. Res #49 stated they had a urinary catheter for a long time since their stroke. They stated having spent time in the hospital a few weeks ago due to burning at the catheter entry site and a severe urinary tract infection. Res #49 stated the staff had performed catheter care intermittently during their stay in the facility. On 04/10/24 at 10:49 a.m., the ADON stated all residents with a urinary catheter should have a physician order for the catheter and orders in place for maintenance and infection prevention including catheter care every shift, catheter change every 30 days, and catheter flushes every shift for patency. The ADON stated these interventions should have been documented on the care plan. On 04/10/24 at 10:41 a.m., LPN #1 stated catheter care is normally performed each shift. They stated having not realized Res #49 did not have a current physician order for the urinary catheter or catheter care in the medical record. They stated that they did not know if Res #49's catheter care had been performed routinely since his return from the hospital on 03/01/24. On 04/10/24 at 11:45 a.m., MDS coordinator #1 stated the maintenance of a urinary catheter should be documented on the care plan. They stated they assumed if the presence of a urinary catheter was documented on the care plan, then the nurses would complete all interventions related to catheter maintenance and infection prevention. MDS coordinator #1 stated they were not aware Res #49 had no current physician order for a urinary catheter. 42171 2. Res #24 had diagnoses which included spinal stenosis and scoliosis. A quarterly assessment, dated 02/26/24, documented the resident was cognitively intact, independent with toileting and frequently in pain. A physician's order, dated 11/21/23, documented the resident was to be monitored for pain, all pain must be addressed, and that uncontrolled pain should be reported to the physician. A physician's order, dated 11/22/23, documented Res #24 was to be referred to a pain management physician. A care plan most recently revised on 01/11/24, documented no care plan for pain. On 04/04/23 at 1:00 p.m., Res #24 stated they have been taking medication for pain, but it is not really helping. They stated the facility does not do a good job addressing pain. On 04/10/24 at 11:51 a.m., MDS coordinator #1 stated that the care plan didn't address pain for Resident #24 because they sometimes complained of pain and then refused pain medications. On 04/11/24 at 9:09 a.m., LPN #4 stated that pain is what the resident says it is and they should treat that pain to the best of their ability. 46387 3. Res #22 had diagnoses which included diabetes mellitus, atrial fibrillation, atherosclerotic heart disease, hypertension, and heart failure. A physician order, dated 05/18/23, documented to administer insulin glargine subcutaneous injection 59 units twice daily for diabetes. A physician order, dated 05/26/23, documented to administer carvedilol 3.125 mg two times a day related to atherosclerotic heart disease and heart failure. The order documented to hold the medication for systolic blood pressure below 90 or heart rate below 55. A physician order, dated 09/16/23, documented to administer lisinopril 10 mg one time per day for hypertension. The order documented to hold the medication for systolic blood pressure below 90 or heart rate below 55. A care plan most recently revised on 03/26/24, documented no care plans for cardiovascular status or diabetes. On 04/11/24 at 9:10 a.m., MDS coordinator #1 stated they would not have thought to add the blood pressure medication or cardiovascular status to the care plan. On 04/11/24 at 9:14 a.m., MDS coordinator #1 stated there was no care plan for diabetes for the resident because they had initially not been informed to add diagnoses to the care plan. They stated they had not added Res #22's diagnoses yet.

Based on observation, record review, and interview, the facility failed to ensure wound care was provided as ordered for one (#22) of one sampled resident who was observed for non pressure related wounds. The ADON identified five residents who had non pressure related wounds. Findings: Res #22 had diagnoses which included peripheral vascular disease, non pressure chronic ulcer of right foot, and diabetes. An assessment, dated 02/08/24, documented Res #22's cognition was intact, had no behaviors of rejection of care, was dependent on staff for dressing, personal hygiene, and transfers, had diabetic foot ulcers, and moisture associated skin damage. A physician's order, dated 04/03/24, documented to cleanse wound to right shin and knee with normal saline, pat dry, apply xeroform and cover with a bordered gauze dressing daily. A TAR, dated 04/01/24 through 04/09/24, documented the wound care had not been completed on 04/05/24, 04/06/24, and 04/09/24. On 04/08/24 at 9:47 a.m., Res #22 was asked about the dressing on their right shin dated 04/04/24. They stated they had diabetic sores. Res #22 stated they did not know how often the dressing was supposed to be changed, obviously it needed to be changed with the date of 04/04/24. Res #22 was observed to have two blisters on their right shin above the dressing. On 04/09/24 at 11:30 a.m., LPN #1 stated the wound care nurse usually completed the wound care. On 04/10/24 at 8:39 a.m., Res #22's dressing to right lower leg was dated 04/08/24. On 04/10/24 at 08:44 a.m., the DON stated the wound care for the right shin and knee was to be completed daily on the day shift. On 04/10/24 at 08:49 a.m., the DON observed the dressing on Res #22's right shin. The dressing was dated 04/08/24. On 04/10/24 at 8:50 a.m., the DON was made aware of the observation of dressing dated 04/04/24, when observed on 04/08/24. The DON stated the physician's orders for wound care were not being followed. The DON stated either the wound care nurse or the nurse who was assigned to care for the resident that day was responsible for completing the wound care. The DON stated the wound care orders should be documented on the TAR. On 04/10/24 at 10:15 a.m., the DON stated when the wound care was completed the nurse performing the wound care was supposed to initial the TAR. The DON stated the TAR was not initialed indicating the wound care had been completed on 04/05/24. They stated the TAR had a code of 9 which documented other/see nurses note for 04/06/24. The DON stated there was not a nurses note for not completing the wound care on 04/06/24. The DON stated RN #2 initialed the wound care had been completed on 04/07/24. On 04/10/24 at 3:40 p.m., RN #2 stated they had not completed Res #22's wound care for Res #22 over the past weekend 04/06/24 or 04/07/24. On 04/11/24 at 9:20 a.m., RN #1 stated they were scheduled to be in the facility to complete the wound care on Monday and Wednesdays. They stated the nurses were aware they needed to complete the wound care when they were not there. RN #1 stated they were aware the dressing had not been changed on 04/09/24 as ordered.

Based on observation, record review, and interview, the facility failed to ensure physician orders for an indwelling urinary catheter and failed to ensure a resident with an indwelling urinary catheter received services to help prevent urinary tract infections for one (#49) of one resident reviewed for catheters. The ADON identified seven residents with an indwelling urinary catheter. Findings: Res #49 had diagnoses which included obstructive and reflux uropathy and benign prostatic hyperplasia without lower urinary tract symptoms. A physician order, dated 12/06/23, documented to perform catheter care and record output every shift. The order was discontinued on 02/27/24. A physician order, dated 12/10/23, documented to change the catheter anchor and bag weekly on Sunday. The order was discontinued on 02/27/24. An admission assessment, dated 12/12/23, documented the resident was cognitively intact, dependent with toileting, and had a urinary catheter. A care plan, dated 12/12/23, documented the resident had an indwelling catheter related to BPH. The care plan documented to position the catheter bag and tubing below the level of the bladder. No additional interventions related to catheter maintenance and urinary tract infection prevention were documented. A physician order, dated 01/01/24, documented to change the catheter every month and as needed for patency. The order was discontinued on 02/27/24. A nurse note, dated 02/23/24 at 1:12 a.m., documented the resident complained of burning in the penis and requested the catheter to be changed. The note documented the catheter was replaced and the resident was educated on the increased risk of infection with frequent catheter changes. A nurse note, dated 02/23/24 at 11:59 a.m., documented the nurse notified the physician of the resident's complaint of pain at the catheter entry site. The note documented green discharge was observed with possible UTI. The note documented the physician ordered a urinalysis and antibiotics. A nurse note, dated 02/24/24 at 7:41 a.m., documented the resident had screamed all night related to catheter burning pain and nausea/vomiting. The note documented the physician ordered the resident to be transferred to the hospital for possible UTI and sepsis. A Hospitalist History and Physical, dated 02/24/24, documented Res #49 had a urinary tract infection present on admission catheter associated and acute kidney injury. The assessment documented the catheter was reportedly changed the previous day at the nursing facility but had been improperly positioned likely in the prostrate. A nurse note, dated 03/01/24 at 3:22 P.M., documented the resident returned to the facility. There was no documentation of an order for an indwelling urinary catheter or catheter care/maintenance in the resident's medical record since 2/27/24. On 04/08/24 at 7:53 a.m., Res #49 was observed lying in bed. A urinary catheter bag with medium yellow urine was observed attached to the bed frame. Res #49 stated they had a urinary catheter for a long time since their stroke. They stated having spent time in the hospital a few weeks ago due to burning at the catheter entry site and a severe urinary tract infection. Res #49 stated the staff had performed catheter care intermittently during their stay in the facility. On 04/10/24 at 10:41 a.m., LPN #1 stated catheter care is normally performed each shift. They stated having not realized Res #49 did not have a current physician order for the urinary catheter or catheter care in the medical record. They stated that they did not know if Res #49's catheter care had been performed routinely since their return from the hospital on 03/01/24. On 04/10/24 at 10:49 a.m., the ADON stated all residents with a urinary catheter should have a physician order for the catheter and orders in place for care including catheter care every shift, catheter change every 30 days, and catheter flushes every shift for patency. The ADON stated they were unaware of the lack of an order for a catheter and catheter care for Res #49. They stated the orders were discontinued when the resident was admitted to the hospital and must not have been reinstated upon their return to the facility. The ADON stated they were unable to ensure the catheter had been changed or cared for since Res #49's return from the hospital due to the lack of documentation. The ADON stated the nurses probably had not completed catheter care since it was not listed on the TAR as a task to have been completed.

Based on record review and interview, the facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The ADON reported 52 residents received services from the kitchen. Findings: A facility policy titled Food Safety Requirements, reviewed 01/24, read in part, .Factors implicated in foodborne illnesses .inadequate cooking and improper holding temperatures .foods require adequate cooking and proper holding temperatures to reduce the rapid and progressive growth of illness producing microorganisms . The facility food temperature log was reviewed from 03/29/24 through 04/08/24. For this review period, the facility failed to document the holding temperatures for 10 of 33 meals. On 04/10/24 at 9:53 a.m., the DM stated the cook on duty was responsible for logging the holding temperature of each meal in the food temperature log. They stated the DM was responsible for ensuring the cook logged the temperatures.

Based on record review and interview, the facility failed to ensure a resident did not receive unnecessary psychotropic medications for two (#17 and #22) of five sampled residents reviewed for unnecessary medications. The ADON identified eight residents received psychotropic medications. Findings: 1. Res #22 had diagnoses which included depression and anxiety. A physician order, dated 02/28/23, documented to administer Depakote oral tablet 125 mg three times per day for anxiety. A physician order, dated 03/20/23, documented to administer olanzapine 5 mg, one tablet one time per day for anxiety. A monthly drug regimen review, dated 07/04/23, documented a request to reduce the olanzapine and/or Depakote. The medical record did not contain a documented response from the physician. A MAR for July 2023 documented Res #22 received olanzapine 5 mg 27 out of 27 opportunities after the request to reduce was made. A MAR for July 2023 documented Res #22 received Depakote 125 mg 77 out of 81 opportunities after the request to reduce was made. A MAR for August 2023 documented Res #22 received olanzapine 5 mg 25 out of 31 opportunities after the request to reduce was made. A MAR for August 2023 documented Res #22 received Depakote 125 mg 70 out of 93 opportunities after the request to reduce was made. A MAR for September 2023 documented Res #22 received olanzapine 5 mg 29 out of 30 opportunities after the request to reduce was made. A MAR for September 2023 documented Res #22 received Depakote 125 mg 91 out of 93 opportunities after the request to reduce was made. A MAR for October 2023 documented Res #22 received olanzapine 5 mg 31 out of 31 opportunities after the request to reduce was made. A MAR for October 2023 documented Res #22 received Depakote 125 mg 92 out of 93 opportunities after the request to reduce was made. A MAR for November 2023 documented Res #22 received olanzapine 5 mg 26 out of 30 opportunities after the request to reduce was made. A MAR for November 2023 documented Res #22 received Depakote 125 mg 82 out of 93 opportunities after the request to reduce was made. A MAR for December 2023 documented Res #22 received olanzapine 5 mg 26 out of 31 opportunities after the request to reduce was made. A MAR for December 2023 documented Res #22 received Depakote 125 mg 92 out of 93 opportunities after the request to reduce was made. A MAR for January 2024 documented Res #22 received olanzapine 5 mg 31 out of 31 opportunities after the request to reduce was made. A MAR for January 2024 documented Res #22 received Depakote 125 mg 92 out of 93 opportunities after the request to reduce was made. A monthly drug regimen review, dated 02/01/24, documented a request to reduce the olanzapine and/or Depakote. The medical record did not contain a documented response from the physician. A MAR for February 2024 documented Res #22 received olanzapine 5 mg 29 out of 29 opportunities after the request to reduce was made. A MAR for February 2024 documented Res #22 received Depakote 125 mg 86 out of 87 opportunities after the request to reduce was made. A MAR for March 2024 documented Res #22 received olanzapine 5 mg 30 out of 31 opportunities after the request to reduce was made. A MAR for March 2024 documented Res #22 received Depakote 125 mg 86 out of 93 opportunities after the request to reduce was made. A MAR for April 1-9 2024 documented Res #22 received olanzapine 5 mg eight out of eight opportunities after the request to reduce was made. A MAR for April 1-9 2024 documented Res #22 received Depakote 125 mg 24 out of 24 opportunities after the request to reduce was made. On 04/09/24 at 12:26 p.m., the DON stated the ADON was responsible for the monthly drug regimen reviews. They stated the responses from the physician should be scanned into the chart. On 04/09/24 at 12:42 p.m., the DON stated they were unsure where the response would be if they were not scanned into the chart. On 04/09/24 at 2:06 p.m., the ADON was asked to provide the documentation of physician response to the monthly drug regimen reviews mentioned above. On 04/11/24 at 10:10 a.m., the ADON was asked again to provide the documentation of physician response to the monthly drug regimen reviews mentioned above. On 04/11/24 at 11:36 a.m., the ADON stated she was unsure what the facility's response time for monthly drug regimen reviews should be. They stated they had only been made responsible for them two weeks ago. They stated there was not a policy that dictated the turnaround time for monthly drug regimen reviews. They stated they were not provided policies nor had access to any policies regarding monthly drug regimen reviews. On 04/11/24 at 11:38 a.m., the ADON stated they were unable to locate documentation the physician responded to the GDR requests from 07/04/23 or 12/01/23. 42171 2. Res #17 had diagnoses including depression and anxiety disorder. A physician's order, dated 03/20/24, documented the resident was to receive sertraline (an antidepressant) 100 mg by mouth every day. A care plan, revised on 03/28/24, documents that Res #17 receives an antidepressant and that they should be monitored for adverse reactions to antidepressant therapy. A review of Res #17's orders did not document a physician order for antidepressant side effect monitoring. A review of Res #17's TAR did not document the resident was being monitored for side effects of antidepressant therapy. On 04/11/24 at 9:09 a.m., LPN #4 stated there should be a physician's order for side effect monitoring and a place to document on the TAR. On 04/11/24 at 10:21 a.m., LPN #1 stated side effect monitoring for antidepressants should be documented on the TAR. On 04/11/24 at 11:36 a.m., the ADON stated they were told that side effect monitoring is now done by exception and should be charted in a nurse note.

Based on record review and interview, the facility failed to: a. develop and maintain policies and procedures for the monthly drug regimen review to include time frames for the different steps in the process, b. ensure a physician responded to a monthly medication review for one (#22) of five sampled residents reviewed for unnecessary medications, and c. ensure the facility followed up on requests made on the monthly medication review for one (#14) of five sampled residents reviewed for unnecessary medications. The corporate administrator identified 53 residents resided in the facility. Findings: A Drug Regiment Review policy, dated 2021, documented in part .The physician provides a written response of the report to the facility within one month after the report is sent .The facility maintains copies of signed reports on file for at least one year .Nursing personnel provide a written response to the review within two weeks after the report is received .The facility maintains copies of completed reports on file for at least one year . 1. Res #14 had diagnoses which included hypertension. A physician order, dated 06/05/23, documented to administer carvedilol 12.5 mg two times per day for heart. A physician order, dated 06/05/23, documented to administer losartan 100 mg one time per day for hypertension. A monthly drug regimen review, dated 07/04/23, documented a request to add hold parameters to the orders for carvedilol and losartan. A physician order, dated 09/11/23, documented to administer carvedilol 12.5 mg two times per day for heart. The order documented to hold the medication for systolic blood pressure below 95, diastolic blood pressure below 55, or heart rate below 55. A physician order, dated 09/11/23, documented to administer losartan 100 mg one time per day for hypertension. The order documented to hold the medication for systolic blood pressure below 95, diastolic blood pressure below 55, or heart rate below 55. A monthly drug regimen review, dated 09/15/23, documented a request to add hold parameters to the orders for carvedilol and losartan. 2. Res #22 had diagnoses which included depression and anxiety. A physician order, dated 02/28/23, documented to administer Depakote oral tablet 125 mg three times per day for anxiety. A physician order, dated 03/20/23, documented to administer olanzapine 5 mg, one tablet one time per day for anxiety. A physician order, dated 05/15/23, documented to administer pregabalin oral capsule 150 mg, give 150 mg by mouth three times a day for -. A physician order, dated 05/15/23, documented to administer senna-docusate sodium oral tablet 8.6-50 mg, give 2 tablets by mouth one time per day for -. A physician order, dated 05/15/23, documented to administer acarbose 25 mg tablet, give 25 mg by mouth with meals for -. A monthly drug regimen review, dated 06/02/23, documented a request to add a diagnosis for the senna, pregabalin, and acarbose orders. A monthly drug regimen review, dated 07/04/23, documented a request to reduce the olanzapine and/or Depakote. The medical record did not contain a documented response from the physician. A monthly drug regimen review, dated 12/01/23, documented Res #22's vitamin D level in November 2023 was 9.3 ng/ml. The review documented a request to add ergocalciferol 50,000 units weekly for eight weeks. The medical record did not contain a documented response from the physician. A monthly drug regimen review, dated 02/01/24, documented a request to reduce the olanzapine and/or Depakote. The medical record did not contain a documented response from the physician. On 04/09/24 at 12:26 p.m., the DON stated the ADON was responsible for the monthly drug regimen reviews. They stated the responses from the physician should be scanned into the chart. On 04/09/24 at 12:42 p.m., the DON stated they were unsure where the response would be if they were not scanned into the chart. On 04/09/24 at 2:06 p.m., the ADON was asked to provide the documentation of physician response to the monthly drug regimen reviews mentioned above. On 04/11/24 at 10:10 a.m., the ADON was asked again to provide the documentation of physician response to the monthly drug regimen reviews mentioned above. On 04/11/24 at 11:36 a.m., the ADON stated she was unsure what the facility's response time for monthly drug regimen reviews should be. They stated they had only been made responsible for them two weeks ago. They stated there was not a policy that dictated the turnaround time for monthly drug regimen reviews. They stated they were not provided policies nor had access to any policies regarding monthly drug regimen reviews. On 04/11/24 at 11:38 a.m., the ADON stated they were unable to locate documentation the physician responded to the GDR requests from 07/04/23 or 12/01/23.

Based on record review and interview, the facility failed to administer medications in accordance with physician orders for one (#22) of five sampled residents reviewed for unnecessary medications. The corporate administrator identified 53 residents resided in the facility with 17 residents receiving insulin. Findings: Res #22 had diagnoses which included diabetes mellitus, and anxiety. A physician order, dated 02/28/23, documented to administer Depakote tablet delayed release 125 m.g three times per day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. for anxiety. A physician order, dated 02/28/23, documented to administer Humalog subcutaneous injection according to sliding scale before meals and at bedtime at 6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. A physician order, dated 05/18/23, documented to administer Insulin Glargine subcutaneous injection 59 units twice daily at 6:00 a.m. and 9:00 p.m. for diabetes mellitus. A MAR/TAR for February 2024 documented blanks in the insulin administration for the 6:00 a.m. dose of insulin glargine on 02/06/24, 02/07/24, 02/14/24, and 02/20/24. A MAR/TAR for February 2024 had a blank for Depakote oral tablet 2:00 p.m. administration on 02/23/24. A MAR/TAR for February 2024 had blanks for Humalog administration at 6:00 a.m. on 02/06/24, 02/07/24, 02/14/24, 02/20/24; the 11:00 a.m. administration was blank on 02/19/24; the 4:00 p.m. administration was blank on 02/02/24 and 02/12/24. On 04/09/24 at 12:35 p.m. LPN #2 stated the blanks on the MAR/TAR meant the medication or treatment was either not administered or not documented. They stated there was no way to verify the medication or treatment was completed if it was not documented in the computer. On 04/09/24 at 12:42 p.m., the DON stated they had never seen blanks on the MAR/TAR like those for Res #22 before. They stated they did not know what it meant when the administration was blank.

Based on observation, record review, and interview, the facility failed to post the required staffing information. The corporate administrator identified 53 residents who resided in the facility. Findings: Resident Council Meeting minutes, dated 02/27/24, documented the the staff were not introducing themselves to the residents and they did not know which staff members were working on their hall. The document titled, Resident Council Response form, dated 02/28/24, documented proposed action of a white board for daily nursing assignments. On 04/08/24 at 7:00 a.m., a working schedule with the staff assigned to each hall and shift was in a book at the nurse's station. The working schedule documented the census was 55. There was no white boards with staffing on the walls and the census was not correct. On 04/09/24 at 1:49 p.m., the dry erase board on hall B documented the nurse, CMA, and CNAs assigned to the hall. The board did not document the resident census. On 04/09/24 at 1:51 p.m., CNA #4 was asked about the dry erase board hanging on the wall on hall B. They stated the dry erase board had just been hung. On 04/11/24 at 8:08 a.m., a dry erase board was observed hanging on the wall on hall C. The board documented the nurse, CMA, and CNAs assigned to C hall. The resident census was not posted on the dry erase board. On 04/11/24 at 1:10 p.m., the regional director of scheduling stated the posted schedule should have the census dates and number of hours worked if it is up to date.

Based on record review and interview, the facility failed to provide sufficient staff to meet the needs of the residents for six (#7, 14, 16, 17, 27, and #43) of seven sampled residents who were reviewed for sufficient staffing. The corporate administrator identified 53 residents who resided in the facility. Findings: A document titled, Resident Council Minutes, dated 02/27/24, read in part, .Resident not getting medicine on time on weekends .Number of residents who share the concern 8 . The schedule for 03/31/24 was reviewed and compared with punch detail records. The schedule documented one CMA, one RN, and two LPNs were scheduled who had the qualifications to administer medications. 1. Res #7 had diagnoses which included constipation, essential hypertension, GERD, chronic rhinitis, history of venous thrombosis, and chronic pain. A MAR, dated 03/01/24 through 03/31/24 documented the following medications were not initialed as administered as ordered on 03/31/24: daily Vitamin, docusate sodium, Flomax, fluticasone propionate, lidocaine external gel, lisinopril, vitamin B-12, vitamin D3, Eliquis (blood thinner), tizanidine, diazepam, Metamucil, baclofen, and dantrolene. On 04/08/24 at 8:19 a.m., Res #7's family member stated at the end of March 2024 the residents on C hall did not get their medications. They stated there was only one CMA and the nurse was new and was not able to pass any of the medications on the C hall. Res #7's family member stated the residents are not getting their showers. 2. Res #14 had diagnoses which included diabetes and right below the knee amputation. The ADL care plan, dated 03/07/24, documented Res #14 had functional deficit with current ADLs and usually required assistance with bathing. On 04/11/24 at 7:54 a.m., Res #14 was observed sitting in their wheelchair in the hall. Res #14 reported to the MDS coordinator she wanted to take a shower. On 04/11/24 at 8:42 a.m., Res #14 stated they had not given them a shower. Res #14 stated the staff told them they had to wait until after lunch. Res #14 stated it had been nine days since they had their last shower. On 04/11/24 at 9:42 a.m., LPN #4 stated the CNA assigned to A and C hall went home sick and they were relying on the CNAs working on the other halls to help the residents. On 04/11/24 at 9:55 a.m., CMA #1 stated the CNAs were overwhelmed and rushed to get the work done. CMA #1 was asked why Res #14 was not able to take a shower that morning. They stated the CNA assigned to that hall had been sick and had to leave. 3. Res #16 had diagnoses which included end stage renal disease, ischemic heart disease, and type II diabetes mellitus. A quarterly assessment, dated 02/27/24, documented the resident was cognitively intact and dependent on staff for bathing and hygiene. A care plan, revised 03/21/24, documented the resident had functional deficits with ADLs and usually required the assistance of one staff member with bathing. The care plan documented the resident wished to complete bathing hygiene three times a week. A facility shower schedule documented Res #16 was to receive a bath/shower every Tuesday and Friday on the 3-11 shift. The April 2024 shower sheets had no documentation Res #16 had received a bath from 04/01/24 through 04/11/24. There was no documented refusals during this time frame. On 04/10/24 at 9:41 a.m., LPN #3 stated there had been times the residents had not received a shower on their shower days due to not having enough staff. On 04/10/24 at 12:07 p.m., the ADON stated only one bath was documented for Res #16 from 03/26/24 until present. On 04/11/24 at 9:53 a.m., Res #16 was observed lying shirtless in bed. A strong smell of body odor was observed. Res #16 stated they had not been bathed since the first interview on 04/08/24. Res #16 stated no staff had offered to assist them with bathing all week. 4. Res #17 had diagnoses which included depression, hypertension, and closed femur fracture. A MAR, dated 03/01/24 through 03/31/24 documented the following medications were not initialed as administered as ordered on 03/31/24: amlodipine, losartan potassium, multivitamin, polyethylene glycol, sertraline, spironolactone, and senna docusate. 5. Res #27 had diagnoses which included atherosclerotic heart disease, GERD, hypertension, depression, chronic kidney disease, end stage renal disease, and diabetes. A MAR, dated 03/01/24 through 03/31/24 documented the following medications were not initialed as administered on 03/31/24 as ordered: amlodipine, aspirin, Colace, escitalopram, fluconazole, fluticasone propionate, polyethylene glycol, lidocaine external patch, methocarbamol, pantoprazole, Ticagrelor, gabapentin, losartan potassium, and sevelamer. On 04/09/24 at 1:17 p.m., Res #27 stated they did not get their medication on 03/31/24. Res #27 stated the medication aide who works the weekends called in and the facility did not get a replacement for the medication aide. They stated the nurses were working as CNAs and they did not have anyone to administer their medications. On 04/10/24 at 3:13 p.m., the ADON stated on 03/31/24 one of the CMA's had called in and RN #2 had to administer the medications on hall A and hall C. The ADON was asked if they knew why the medications were not signed out for Res #17. They stated they did not know. The ADON was asked why Res #7 and #27 did not get their medications on 03/31/24 on the day shift. They stated they did not know. On 04/10/24 at 3:42 p.m., RN #2 stated the facility was short one CMA on 03/31/24. RN #2 stated they had administered medications on A hall. They stated they did not administer the medications to the residents on the C hall. On 04/11/24 at 9:42 a.m., LPN #4 stated they did not administer medications to the residents on 03/31/24. LPN #4 stated they did not pass medications because the facility had CMAs who passed the medications. 6. Res #43 had diagnoses which included diabetes mellitus and arthritis. A quarterly assessment, dated 04/01/24, documented the resident was cognitively intact, dependent on staff for toileting and that bathing did not occur during the assessment period. On 04/08/24 at 10:28 a.m., Res #43 stated that they did not get many showers. The shower book documented Res #43 was to receive a shower on Tuesdays and Thursdays. Res #43's shower documentation was reviewed from 03/21/24 through 04/10/24. The resident was given a shower on 03/25/24 and refused a shower on 03/28/24, there is no documentation for the other four scheduled shower days. On 04/10/24 at 11:12 a.m., CNA #6 stated that the CNAs were responsible for giving showers on their assigned hall and that the facility did not have shower aides. On 04/10/24 at 1:48 p.m., LPN #3 stated CNAs give showers based on who has one scheduled for that day. They also stated the nurse on duty should ensure that showers are being given. On 04/11/24 at 12:58 p.m., the ADON stated they had provided the book containing all of the shower sheets. No shower sheets were found for the evening shift for 04/09/24. On 04/11/24 at 1:07 p.m., the regional director of scheduling was asked about the CNA staffing for 04/09/24. They stated they had some employees call in on 04/09/24 on the evening shift. The regional director of scheduling stated the CMA and/or nurses would be responsible for giving showers if the CNAs was unable to give the showers. They stated they would offer the residents a shower the next day if they missed their shower day.

Based on record review and interview, the facility failed to ensure an accurate code status was documented for one (#8) and residents were offered the choice to formulate an advanced directive for two (#22 and #24) of three sampled residents reviewed for advanced directives. The corporate administrator identified 53 residents who resided in the facility. Findings: An Advance Directive Policy and Procedure, revised 01/2024, read in part, .Upon admission, identify if the resident has an advanced directive and if not, determine if the resident wishes to formulate an advanced directive .Examples include a Living Will .DNR .Facility staff will provide the resident and/or the resident representative with written description of the facility's policies to implement an advance directive .All advanced directive document copies will be obtained and located in the resident chart . 1. Res #8 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction. A signed DNR form, dated 10/02/23, was located in the miscellaneous tab in the electronic record. The face sheet, and active physician orders in the electronic clinical record documented Resident #8 was a full code. On 04/09/24 at 10:29 a.m., LPN #2 stated Res #8's code status was documented on the TAR and the electronic face sheet. They stated Res #8 was a full code. On 04/09/24 at 10:33 a.m., the SSD stated Res #8 was a full code according to the electronic record. The SSD stated Res #8 also had a signed DNR dated 10/02/23 in the electronic record. On 04/09/24 at 10:51 a.m., the SSD was asked if they had any documentation Res #8 revoked the DNR. They stated no, they had the hospital discharge paperwork which documented Res #8 was a full code. On 04/09/24 at 12:09 p.m., the ADON stated they did not know if the staff called the physician to clarify Res #8's code status upon readmission from the hospital. The ADON stated they did not have any documentation Res #8 revoked the DNR. They stated if the Res #8 revoked the DNR it should be documented in their record. 2. Res #22 had diagnoses which included congestive heart failure, osteoarthritis, and non pressure chronic ulcer. The resident's clinical records did not document the resident and/or their representative was offered the choice to formulate an advanced directive. On 04/08/24 at 1:23 p.m., the SSD stated there was not an advanced directive or advanced directive acknowledgment in Res #22's clinical record. 42171 3. Res #24 had diagnoses which included spinal stenosis and scoliosis. A quarterly assessment, dated 02/26/24, documented the resident was cognitively intact, independent with toileting, and frequently in pain. A physician's order, dated 11/27/23, documented the resident was a full code. Review of the clinical record did not reveal the resident had been offered the option to formulate an advance directive. On 04/11/24 at 1:02 p.m., the SSD stated that they did not have documentation regarding formulating an advance directive for Resident #24.

Based on record review and interview, the facility failed to ensure a missing laptop was replaced for one (#22) of one sampled resident who was reviewed for misappropriation of property. The corporate administrator identified 53 residents who resided in the facility. Findings: The facility's Abuse, Neglect and Exploitation policy, revised 01/2024, read in part, .Each resident has the right to be free from .misappropriation of resident property and exploitation . An assessment dated [DATE]. doucmented Res #22's cognition was intact. A document titled, Incident Report Form, dated 01/24/24, read in part, .Initial .Misappropriation of Resident Property .Resident reported to the morning aide, that [they] were missing [their] 13 inch mac book pro computer .administrator had resident contact [electronic store] where the resident did purchase online May 2023. [Electronic Store] did confirm price 1,463.89 and model number . A document titled, Incident Report Form, dated 01/29/24, read in part, .Final .Misappropriation of Resident Property .Administrator confirmed with the ADON and other staff that resident did own a 13 inch mac book pro computer .After doing staff interviews and investigation the facility could not locate the missing laptop [sic] and the facility is working on replacing residents laptop [sic] . On 04/08/24 at 11:15 a.m., Res #22 stated their laptop was stolen. Res #22 stated the former administrator had investigated the missing laptop and was supposed to see about replacing it. On 04/09/24 at 2:01 p.m., the corporate administrator stated they called corporate purchasing and there was not a record for replacement of the laptop. They stated they would not have expected it to take this long to replace the laptop. The corporate administrator was asked what the next step would be to replace the laptop. They stated they would discuss it with the finance department and purchasing to replace the laptop.

Based on observation, record review, and interview, the facility failed to ensure a. the correct amount of water was administered via peg tube as ordered by the physician; b. the head of the bed was elevated during administration of water flushes and tube feeding through the peg tube; and c. a dietary recommendation was sent to the physician for one (#8) of one sampled resident who was administered nutrition through a peg tube. 1. Res #8 had diagnoses which included dysarthria (weakness in the muscles used for speech), hemiparesis and hemiplegia (Partial to complete paralysis on one side of the body) following a cerebral infarction. An assessment, dated 01/20/24, documented Res #8's cognition was moderately impaired, was dependent on staff assistance for eating and repositioning, had loss of liquids or solids from mouth when eating or drinking, coughed or choked during meals or when swallowed medications, had difficulty or pain with swallowing, and received nutrition through a peg tube. A physician's order, dated 02/29/24, documented to administer Isosource 1.5 250 ml bolus and flush with 185 ml of free water after bolus feeding five times a day. An Enteral Feeding care plan, dated 03/15/24, read in part, .The resident will be free of aspiration .The resident will maintain adequate nutritional and hydration status .The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed . A document titled, Dietitian's Recommendations for Primary Care Provider, dated 03/25/24, read in part, .Note: Current TF provides 1875 calories, 85 grams protein, and 950 ml free water. Current tube feeding meets nutritional needs and RDA requirements .RECOMMENDATION: 1) Continue with current TF, but change water flushes to 95 ml before and after each feeding. 2) Vitamin B 12 as methylocobalamin for better absorption, Statin and proton pump inhibitors decrease levels of Vitamin B 12 and CoQ10. 3) CoQ10 as Ubiquinol. It is a vitamin like substance that improves health condition in many ways as this is a very important antioxidant and has a crucial role in energy production within our cells . There was no documentation the dietary recommendation was provided to the physician. On 04/09/24 at 12:37 p.m., LPN #1 began to flush the peg tube with 30 ml of water with the HOB laying flat. LPN #1 was stopped and asked if the HOB should be elevated during administration of the water and tube feeding. LPN #1 elevated the HOB. LPN #1 was observed to administer 30 ml of water prior to the tube feeding and 30 ml after the tube feeding was administered. On 04/09/24 at 12:55 p.m., LPN #1 stated the physician's orders documented to administer 185 ml of water. The LPN stated they had not administered 185 ml as ordered. The LPN administered 60 ml of water 125 ml less than what was ordered. On 04/09/24 at 1:10 p.m., LPN #1 stated the HOB needed to be raised 30 degrees while administering the tube feeding to prevent aspiration (When food or liquid enters the airway and eventually the lungs by accident.) LPN #1 stated they had forgotten to raise the HOB. On 04/11/24 at 8:51 a.m., the DON stated the dietitian had seen the resident on 03/25/24 and made dietary recommendations. The DON stated the recommendations had not been followed up by the physician. They stated the physician had ordered B-12 1000 mcg but they did not see any changes in the amount of flush or the recommendation for the CoQ10. The DON was made aware of the observation of the 60 ml amount of flush administered. The DON stated the LPN had not administered the correct amount of water.

Based on observation, record review, and interview, the facility failed to ensure baths and incontinent care were provided as ordered for three (#8, 16 and #43) of three residents reviewed for assistance with ADL's. The ADON identified 36 residents who required assistance with incontinent care and 39 residents who required assistance with showers. Findings: The facility's Activities of Daily Living (ADL) policy, revised 01/2024, read in part, .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming .personal and oral hygiene . A Shower Schedule Process policy, undated, read in parts, .All showers are to be conducted per the paper shower schedule provided at the front desk in the shower binders .Every shower is to be documented on a shower sheet and turned in to the DON basket on DON door .All refused showers are to be documented on a shower sheet and signed by the resident .Inform your nurse of refusals to allow for education and documentation of refusal .All residents have a right to request a shower at any time on any shift. Please accommodate per preference . A document titled, Resident Council Meeting, dated 02/27/24, read in part, .Not receiving showers. Number of residents who share concern 8/10 [eight out of 10] . A document titled, Resident Council Department Response Form, dated 02/28/24, read in part, .Department response .Monitor alerts for no showers . 1. Res #8 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction. An assessment, dated 01/20/24, documented Res #8's cognition was moderately impaired, was dependent on staff assistance for toileting and transfers and was incontinent of bowel and bladder. An ADL care plan, revised 01/30/24, documented Res #8 had functional deficit with ADLs related to hemiplegia and hemiparesis following a cerebral infarction. The care plan documented Res #8's needs would be met and was dependent for toileting and transfers. On 04/09/24 at 12:37 p.m., LPN #1 and CNA #2 transferred Res #8 in bed. The back of Res #8's pants were observed to be wet. The staff did not check the resident for incontinence and did not change the resident. On 04/09/24 at 2:14 p.m., Res #8 was observed in bed wearing the same grey pants that were wet at 12:37 p.m. On 04/09/24 at 2:15 p.m., CNA #5 transferred Res #8 from the bed to the wheelchair. Res #8's pants were observed to be wet. The CNA did not check the resident for incontinence or change the resident. CNA #5 stated they were not working on that hall, they were just helping CNA #1. On 04/09/24 at 2:20 p.m., CNA #1 stated Res #8 was incontinent. CNA #1 was asked if there was a reason Res #8 was not checked for incontinence when the resident was assisted out of the bed. They stated no. On 04/09/24 from 2:20 p.m. through 2:46 p.m., Res #8 was observed in their wheelchair wearing the wet pants. On 04/09/24 at 2:49 p.m., CNA #2 and CNA #3 were observed to provide incontinent care to Res #8. Res #8's adult incontinent brief, pants, shirts, and bottom sheet were wet with urine. On 04/09/24 at 3:03 p.m., CNA #3 stated Res #8's incontinent brief, pants, sheet were wet. On 04/10/24 at 10:22 a.m., the DON was asked how often incontinent care was provided. They stated the standard was every two hours. The DON stated the staff should check residents who are incontinent to ensure they are not wet or soiled when they assisted them to bed and/or when they assisted the resident out of bed. The DON stated the staff had not provided timely incontinent care if the resident was assisted to bed wet and not checked. 46582 2. Res #16 had diagnoses which included end stage renal disease, ischemic heart disease, and type II diabetes mellitus. A quarterly assessment, dated 02/27/24, documented the resident was cognitively intact and dependent on staff for bathing and hygiene. A care plan, revised 03/21/24, documented the resident had functional deficits with ADLs and usually required the assistance of one staff member with bathing. The care plan documented the resident wished to complete bathing hygiene three times a week. A facility shower schedule documented Res #16 was to receive a bath/shower every Tuesday and Friday on the 3-11 shift. The March 2024 shower sheets documented Res #16 was bathed on one out of three opportunities from 03/20/24 through 03/31/24. There was no documented refusals during this time frame. The April 2024 shower sheets had no documentation Res #16 had received a bath from 04/01/24 through 04/11/24. There was no documented refusals during this time frame. On 04/08/24 at 7:38 a.m., Res #16 was observed lying shirtless in bed. A strong smell of body odor was observed. Res #16 stated they had not received a shower routinely. They stated having had one shower in the last two weeks. Res #16 stated they had requested a shower from the staff numerous times but the staff had ignored them. They stated they would prefer to have been bathed two to three times weekly but that had not happened. On 04/10/24 at 8:20 a.m., CNA #2 stated all baths are documented on the shower sheets and then provided to the nurse for review. They stated a resident's refusal of a bath must be documented on the sheet and the nurse should be notified of the refusal. On 04/10/24 at 12:07 p.m., the ADON stated all baths should be documented on the shower sheets and provided to the nurse for review. They stated they were aware of Res #16's body odor. The ADON stated Res #16 tended to refuse baths but the staff should have documented the refusals on the the shower sheets. They stated only one bath was documented for Res #16 from 03/26/24 until present. On 04/11/24 at 9:53 a.m., Res #16 was observed lying shirtless in bed. A strong smell of body odor was observed. The resident was wiping their chest with a damp washcloth. Res #16 stated they had taken it upon themselves to try and clean up. They stated they had not been bathed since the first interview on 04/08/24. Res #16 stated no staff had offered to assist them with bathing all week. 42171 3. Res #43 had diagnoses which included diabetes mellitus and arthritis. A quarterly assessment, dated 04/01/24, documented the resident was cognitively intact, dependent on staff for toileting and that bathing did not occur during the assessment period. On 04/08/24 at 10:28 a.m., Res #43 stated that they did not get many showers. The shower book documented Res #43 was to receive a shower on Tuesdays and Thursdays. Res #43's shower documentation was reviewed from 03/21/24 through 04/10/24. The resident was given a shower on 03/25/24 and refused a shower on 03/28/24. There was no documentation for the other four scheduled shower days. On 04/10/24 at 11:12 a.m., CNA #6 stated that the CNAs were responsible for giving showers on their assigned hall and that the facility did not have shower aides. On 04/10/24 at 1:48 p.m., LPN #3 stated CNAs give showers based on who has one scheduled for that day. They also stated the nurse on duty should ensure that showers are being given.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure CPR was provided to Resident #66 who had a physician ordered full code status. On [DATE] at 7:30 p.m., a hospice nurse had came to evaluate Resident #66 for services and found resident without audible heart tones, absent respirations and unable to obtain palpable blood pressure. There was no documentation a facility staff member assessed the resident during this time. On interview, CMA #1 and an agency nurse had been in there 15 minutes prior to reposition resident. RN #1 stated they were alerted the resident had expired and knew the resident was a full code. CPR was not provided. On [DATE] at 9:07 a.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 9:13 a.m., the Administrator and the DON were notified of the IJ situation. On [DATE] at 2:14 p.m., an acceptable plan of removal was submitted to The Oklahoma State Department of Health. The plan of removal read in part, .Meeting Date: [DATE] .Meeting Attendees .Medical Director .ADMIN .DON .ADON .MDS .SSD .HR .Identified Opportunity for Improvement/Deficient Practice .Code Status Process and Not performing CPR .1. Immediate Corrective Action for those affected by the deficient practice .Resident affected is deceased .2. Process/Steps to identify others having the potential to be impacted by the same deficient practice .All nurses including agency staff are educated on the CPR policy with a focus on checking chart-electronic medical record for code status (Dashboard). Immediate initiation. Assure that no one works until educated on this policy. Compliance date [DATE] 00:01 .Sweep of all Residents charts to see that advance directives/code status match what is in PCC and care planned. All areas of chart match. Compliance date [DATE] 1800 .Audit to assure that all nurses and necessary ancillary staff are CPR certified and current .Orientation for Emerald staff and/or agency reviewed and revised to include process of where to find code status .First mock code drill initiated within same week on every shift .All Code status will be removed from report sheets Immediately .Pending review to verify accuracy-will put back on once verified .3. Measures put in to place/systematic changes to ensure the deficient practice does not recur .Admission Coordinator educated on obtaining advance directives on admission with an immediate upload to PCC .Medical Records will upload final signed copy into PCC miscellaneous .ADON or Designee (DON) will be notified of advance directives upon admission to place an order into PCC on dashboard .Clinical stand-up will be initiated to include code status follow up and verification .Resuscitation Policy reviewed and revised for updated procedure .Quarterly Education to all staff on Resuscitation Policy .4. Plan to monitor performance to ensure solutions are sustained .Random audit of 6 CPR certified staff questioning procedure when finding a resident without a pulse and respirations. Weekly audit X 4 weeks for 1 month, then monthly X3 .Daily audit in clinical start up to assure code status is accurate in PCC, care plan, dashboard, etc-on-going .On-going quarterly Mock Code drills .The plan of correction reviewed in Adhoc QAPI on .The plan of correction will be reviewed monthly by the QAPI committee for the next 3 months and longer if needed . On [DATE], staff were interviewed regarding recent training/updates in regards to the CPR policy and protocol. Staff stated information provided in the in-service pertaining to the plan of removal. On [DATE] at 9:49 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of [DATE] at 5:00 a.m. The deficiency remained as an isolated event at level of potential harm. Based on record review and interview, the facility failed to ensure CPR was provided to one (#66) of one sampled resident reviewed for a death in the facility. The Resident Census and Conditions of Residents report, dated [DATE], documented 63 residents resided in the facility. The DON identified 53 residents had full code status. Findings: A Procedure for CPR policy, dated ,d+[DATE], read in parts, .The facility shall provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with the resident's advance directives and physician orders .Identify code status/advance directive preferences .If no DNR order .begin resuscitation efforts .If no pulse, begin CPR . Resident #66 had diagnoses which included hypertension. An Order Summary Report, dated [DATE], documented Resident #66 was a full code. A Social Service note, dated [DATE] at 3:16 p.m., read in part, .Care plan meeting held with patient. Guardian .No plan for discharge needs LTC. No Directives. Code status is full code . A Physician Follow up note, dated [DATE], documented Resident #66 was a Full code. A Physician Follow up note, dated [DATE], documented Resident #66 was a Full code. An Alert Note, dated [DATE] at 7:30 p.m., read in part, .[hospice nurse] here in facility to perform assessment intake on this resident. Upon entering resident room, resident was noted without audible heart tones, absent respirations and unable to obtain palpable blood pressure. [Physician #1] was notified and declared resident expired [at 7:30 p.m.] . The note did not document the facility notified the physician Resident #66 was a full code. There was no documentation in Resident #66's clinical record CPR was attempted. On [DATE] at 8:01 a.m., LPN #2 was asked how the staff knew the residents' code status. They stated, I'm sure we have it in the chart. LPN #2 was asked what the process was if they found a resident without heart tones, respirations and blood pressure. They stated they would call someone to help and check if the resident had a DNR. LPN #2 was shown Resident #66's EHR. They were asked if they would have started CPR if the resident didn't have heart tones, respirations or blood pressure. They stated, Yes. On [DATE] at 8:19 a.m., RN #1 was asked how staff were aware of the residents' code status. They stated they would look in the EHR. RN #1 was asked what they would do if they found a resident without heart tones, respirations, and blood pressure. They stated they would start CPR if the resident was a full code. On [DATE] at 8:27 a.m., RN #1 and CMA #1 stated there were here the day Resident #66 expired. CMA #1 stated they had been in Resident #66's room about 15 minutes prior to the hospice nurse evaluating the resident. CMA #1 stated Resident #66 was alive and the resident had their eyes open. RN #1 stated CMA #1 told them when the hospice nurse went in to admit the resident, [the resident] was gone. RN #1 stated they knew Resident #66 was a full code. RN #1 stated they didn't assess Resident #66. RN #1 was asked if they had a copy of a DNR for Resident #66. They shook their head no. RN #1 and CMA #1 were asked if Resident #66 had been admitted to hospice. CMA #1 stated, No. [The resident] was being evaluated.

On 01/25/21 at 5:05 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to report results of laboratory data to the ordering practitioner for resident #10, which indicated the need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/17/20, the resident was started on an antibiotic for a urinary tract infection. The results of the culture and sensitivity revealed that the organism causing the infection, Proteus Mirabilis, was not sensitive to the antibiotic the resident was receiving. The physician was not notified of the results of the urine culture and sensitivity. Resident #10 was hospitalized on [DATE] with [CONDITION(S)], and subsequently passed away on 03/26/20. The immediate cause for death was septic shock due to Proteus Mirabilis. On 01/25/21 the IJ situation was verified with the Oklahoma State Department of Health. On 01/25/21 at 5:05 p.m., the administrator and the assistant director of nurses were notified of the IJ situation related to failures in communicating pertinent lab results to the ordering physician. On 01/26/21 at 11:30 a.m., the plan of removal for the Immediate Jeopardy pertaining to notification of the physician was accepted. The plan of Removal for the Immediate Jeopardy documented: Plan of Removal 1. Facility licensed Nurses will be educated on the facility antibiotic and lab protocol. a. Current and outstanding labs will be addressed immediately by the Licensed Nurse. b. Abnormal labs will be called into the physician by the Licensed Nurse by the end of the shift for abnormal results. With critical abnormal results; the Licensed Nurse will notify the Primary Care Physician immediately upon receiving the results. c. When receiving the results of a Culture and Sensitivity; the Licensed Nurse is to call the Primary Care Physician and provide results to ensure the resident is on the proper antibiotic therapy. d. Documentation will be completed listing the contact time and orders given by the Licensed Nurse. e. If antibiotic is ordered, the Licensed Nurse will fax and call new order into pharmacy and request it be sent out immediately within 4 hours, in the event that the medication is not received in that time frame, the ordering physician will be notified and a hold order will be obtained until the medication is available and in the facility to administer. f. Upon receipt of the antibiotic the receiving nurse will document arrival and initial dose will be given. g. Licensed Nurse should document on the antibiotic each shift for the duration of the order. h. Any adverse reaction will be reported to the ordering practitioner by Licensed Nurse. i. Policies and procedures will be updated, and all CMA's and Licensed Nursing staff will be educated to reflect the above noted protocols. 2. Current facility residents' labs for the previous 30 days will be reviewed to ensure the Primary Care Physician has been notified of the results. Lab results that have a Culture and Sensitivity will be reviewed with the Primary Care Physician to ensure resident is on the proper antibiotic. This will be completed by the Nurse Management Team. 3. During the morning Clinical Meeting the Nurse Managers will review current orders for Labs and Antibiotics to ensure the resident is receiving the appropriate antibiotic. 4. The Nurse Managers will call the Primary Care Physician if the resident is not on the antibiotic that the Culture and Sensitivity shows sensitivity to. 5. This plan of removal will be in compliance January 26, 2021 by 5pm On 01/27/21 interviews were conducted with the nursing staff regarding education in-services pertaining to antibiotic and lab protocol for immediate jeopardy removal. The staff stated an in-service was provided on 01/26/21. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 01/27/21 at 12:30 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to report results of lab data to the ordering practitioner for three (#4, #10 and #11) of five sampled residents. The facility failed to notify the physician of significant laboratory results. The physician was not notified of urinary culture and sensitivity lab results for resident #10, which indicated the infection the resident had was resistant to the antibiotic prescribed. The resident developed urinary [CONDITION(S)], was hospitalized , and subsequently passed away. The facility identified 10 residents who currently received antibiotic therapy. Findings: The facility policy for Laboratory Services documented, the facility will notify the physician promptly of laboratory results. The policy documented laboratory results would be reviewed by the physician on a timely basis. The policy documented the facility would have a system to reconcile physician orders, labs ordered, the time labs were drawn, when the results were received, and when the physician was notified. The policy documented reports would be filed in the medical record. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/30/19, documented a resident goal was to remain free from complications related to urinary tract infections (UTIs) over the next 90 days. Care plan interventions included observing for signs and symptoms of UTI such as complaint of burning with urination, flank pain, presence of blood in urine, discharge, elevated temperature, increased confusion and agitation, or decreased level of consciousness. The care plan documented staff were to alert the charge nurse of any signs and symptoms so the physician could be notified. The admission assessment, dated 12/24/19, documented the resident was moderately impaired for daily decision-making, required extensive assistance with activities of daily living (ADLs), and had a urinary catheter. A progress note, dated 03/16/20 at 8:19 a.m., documented the urinary catheter was patent to bedside drainage with pale yellow urine and a large amount of sediment. The note documented the resident reported a sensation of urinary urgency. The note documented the urinary catheter was irrigated with 100 cubic centimeters (cc) of sterile saline and continued to drain pale urine with sediment. The note documented the physician was contacted regarding urine for analysis and they were waiting for a return call. A progress note, dated 03/16/20 at 9:42 a.m., documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 03/16/20 at 10:57 a.m., documented laboratory (lab) called to pick up the stat urinalysis. A progress note, dated 03/16/20 at 5:05 p.m. documented the stat urinalysis results were faxed to the physician's office. A urinalysis lab report, dated 03/16/20, documented the resident had a UTI. A physicians order, dated 03/17/20, documented the resident was to receive [MEDICATION(S)] tablet 800-160 milligram (MG) two times a day for 7 days. A progress note, dated 03/18/20 at 10:15 a.m., documented the resident continued on [MEDICATION(S)] for a UTI his temperature was 98.1 degrees Fahrenheit (F). The note documented the resident denied any pain or burning. A urine culture and sensitivity report, dated 03/19/20 at 9:23 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The progress notes for March 2020 did not document the physician was notified of the culture and sensitivity results. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration record (MAR) dated March 2020 documented the resident continued to receive [MEDICATION(S)] for a UTI. A progress note, dated 03/19/20 at 10:16 a.m., documented the resident continued on [MEDICATION(S)] for a UTI, his temperature was 97.9 degrees (F) and had no signs or symptoms of an adverse reaction. The note documented the resident complained of pressure to the abdominal area on the previous shift but had no complaints on this shift. A progress note, dated 03/24/20 at 1:15 p.m., documented the resident complained of the catheter leaking and the feeling of pain and pressure when moving. The note documented the nurse was unable to flush the catheter. The note documented the catheter was replaced and the resident tolerated it well. A progress note, dated 03/24/20 at 10:46 p.m., documented the nurse was called into the resident's room by a certified medication aid (CMA). The note documented the resident had uncontrollable tremors, his oxygen saturation was 68 percent on room air, and the resident had a temperature of 99.5 degrees F. The note documented staff were not able to obtain a blood pressure due to the tremors. The note documented the resident's face was flushed and his nail beds were blue. The note documented an ambulance arrived and transported the resident to the hospital for evaluation and treatment per doctor orders. The note documented the daughter, the director or nurses (DON), and the assistant director of nurses (ADON) were notified. An emergency medicine note, dated 03/24/20, documented clinical impressions of septic shock and acute respiratory failure with [CONDITION(S)]. A details of hospital stay report, dated 03/26/20 at 3:18 p.m., documented the patient was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented the patient had proteus bacteria in his blood, was being treated with a broad spectrum antibiotic, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented on the previous night the patient had labored breathing and became acutely hypotensive. The report documented a chest X-ray showed a probable aspiration pneumonia. The report documented the patient required multiple medications to maintain his blood pressure. The report documented the patient was placed on comfort measures after consulting with family and passed away at 1:35 p.m. on 03/26/20. A death certificate, dated 03/30/20, documented the immediate cause for death was septic shock due to Proteus Mirabilis. On 01/22/21 at 10:10 a.m., the assistant director of nurses (ADON) stated the process for lab orders was to put the order into the medical record, then order the lab through the laboratory website. The requisition would then be put in the lab book and the lab would be called for pick-up. She stated the charge nurse would check the lab website for the results and should notify the physician of any abnormal results. On 01/25/21 at 2:02 p.m., physician #1 was interviewed regarding lab results. He stated that he expected to be made aware of abnormal lab results. He stated that the lab company will call the facility and the physician with critical results, but culture and sensitivity results were not critical labs. Physician #1 stated the facility did not notify him of the culture and sensitivity results for resident #10. On 01/27/21 at 10:25 a.m., licensed practical nurse (LPN) #3 stated that it was the responsibility of the charge nurse to monitor the lab website for results and to report abnormal results to the physician. On 01/27/21 at 10:30 a.m. LPN #4 stated the physician should be notified of culture and sensitivity reports and the charge nurse was responsible for monitoring and reporting lab results. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual assessment, dated 10/27/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter and received antibiotics. A progress note, dated 01/13/21 at 3:02 p.m., documented the resident's urine was thick and the tube required milking and flushing for urine to flow adequately. The note documented the resident denied painful, urination, other symptoms, and was afebrile. The note documented water was available and accepted after prompting. A progress note, dated 01/14/21 at 7:36 a.m., documented the resident's urine continued to be thick and [MEDICATION(S)] like in consistency. The note documented the urine did not want to flow through tubing and it was slow at times with a cloudy appearance. The note documented a urinalysis was collected at that time to rule out UTI. The note documented the resident was afebrile and fluids were within reach. A final urinalysis report, dated 01/14/21 at 9:33 p.m., documented the urine had elevated protein, elevated blood, elevated white blood cell count and elevated red blood cell count. The progress notes for January 2020 did not document the physician was notified of the urinalysis report from 01/14/21 until 01/20/21. A final culture and sensitivity report, dated 01/16/21 at 8:34 a.m., documented probable collection contamination with skin flora and no susceptibility test was performed. The progress notes for January 2020 did not document the physician was notified of the culture and sensitivity report from 01/16/21 until 01/20/21. A progress note, dated 01/20/21 at 11:02 a.m., documented the suprapubic catheter was found on the floor beside the bed with a large amount of leaking urine to the abdominal region. The note documented the suprapubic catheter was replaced per physicians order, was draining to gravity and the the resident tolerated the procedure well. A progress note, dated 01/20/21 at 4:38 p.m., documented the urinalysis results were received, and were positive for a UTI. The note documented the physician was notified and orders were received for [MEDICATION(S)] intramuscular (IM) once a day for five days for UTI. The note documented the medication administration record (MAR) was updated and the power of attorney was made aware. A progress note, dated 01/21/21 at 12:32 p.m., documented the resident continued on an intramuscular (IM) antibiotic for a UTI. The note documented the resident has had no signs or symptoms of an adverse reaction. The note documented the resident was afebrile and the suprapubic catheter was patent and draining to gravity, and received catheter care every two hours and as needed. A progress note, dated 01/24/21 at 2:37 a.m., documented the resident had only received one dose of [MEDICATION(S)] on or about 01/21/21. The note documented the medication appeared on the medication administration record (MAR) and not the treatment administration record (TAR). The note documented the medication was being checked off as administered by the medication aids who were not actually giving the medication or notifying the nurse. The note documented the nurse administered the second dose on 01/23/21 and the order was updated on the TAR. On 01/26/21 at 12:45 p.m., the assistant director of nurses (ADON) stated she was aware of the missed doses of [MEDICATION(S)]. The ADON stated she interviewed the nurse who discovered the medication had not been given and that nurse told her the physician was not contacted. She stated the nurse should have been notified the medication was on the MAR and not the TAR. She stated the physician should have been notified. On 01/27/21 at 10:10 a.m., physician #1 stated he expected to be notified by the facility when medication he had ordered was not administered. On 01/27/21 at 10:10 a.m., certified medication aid (CMA) #2 stated that IM meds should be on the TAR. She stated if she noticed an IM med on the MAR and not the TAR she would notify the charge nurse so the medication could be administered. 3. Resident #11 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission assessment, dated 12/11/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter. A progress note, dated 12/23/20 at 2:47 p.m., documented cloudy urine was noted in the catheter bag; a urine analysis was obtained per primary care physician, and a new order was received for [MEDICATION(S)] one time a day for five days until results of urinalysis were received. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A final urinalysis report, dated 12/24/20 at 8:20 p.m., documented the result was abnormal with protein, leukocyte [MEDICATION(S)] (A screening test used to detect a substance that suggests there are white blood cells in the urine; this may mean you have a urinary tract infection.) bacteria and [MEDICATION(S)], and the specimen was sent for culture. A final culture and sensitivity report, dated 12/26/20 at 11:11 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The TAR documented the resident was administered [MEDICATION(S)] one time a day for five days on 12/23/20 through 12/27/20. No other antibiotic was documented as administered. The progress notes did not document the physician was notified of the culture and sensitivity results and did not document an antibiotic effective to treat the bacteria was ordered or administered to the resident. On 01/26/21 at 12:51 p.m., the ADON stated the antibiotic the resident was administered was resistant to the bacteria and was not the correct antibiotic. She reviewed the progress notes and stated the facility did not notify the physician of the culture and sensitivity results. The ADON stated the physician should have been notified of the culture and sensitivity results and a different antibiotic should have been ordered.

On 01/25/21 at 5:05 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure resident's physicians were notified of laboratory data which indicated the need to change treatments, and ensure residents received antibiotic therapy that was effective to treat their infection for resident #10. On 03/16/20, the physician ordered a urinalysis and a culture and sensitivity of the urine. On 03/17/20, the resident was started on an antibiotic for a urinary tract infection. The results of the culture and sensitivity revealed that the organism causing the infection, Proteus Mirabilis, was not sensitive to the antibiotic the resident was receiving. The physician was not notified of the results of the urine culture and sensitivity. Resident #10 was hospitalized on [DATE] with [CONDITION(S)], and subsequently passed away on 03/26/20. The immediate cause for death was septic shock due to Proteus Mirabilis. On 01/25/21 the IJ situation was verified with the Oklahoma State Department of Health. On 01/25/21 at 5:05 p.m., the administrator and the assistant director of nurses were notified of the IJ situation related to failures in communicating pertinent lab results to the ordering physician. On 01/26/21 at 11:30 a.m., the plan of removal for the Immediate Jeopardy pertaining to notification of the physician was accepted. The plan of Removal for the Immediate Jeopardy documented: Plan of Removal 1. Facility licensed Nurses will be educated on the facility antibiotic and lab protocol. a. Current and outstanding labs will be addressed immediately by the Licensed Nurse. b. Abnormal labs will be called into the physician by the Licensed Nurse by the end of the shift for abnormal results. With critical abnormal results; the Licensed Nurse will notify the Primary Care Physician immediately upon receiving the results. c. When receiving the results of a Culture and Sensitivity; the Licensed Nurse is to call the Primary Care Physician and provide results to ensure the resident is on the proper antibiotic therapy. d. Documentation will be completed listing the contact time and orders given by the Licensed Nurse. e. If antibiotic is ordered, the Licensed Nurse will fax and call new order into pharmacy and request it be sent out immediately within 4 hours, in the event that the medication is not received in that time frame, the ordering physician will be notified and a hold order will be obtained until the medication is available and in the facility to administer. f. Upon receipt of the antibiotic the receiving nurse will document arrival and initial dose will be given. g. Licensed Nurse should document on the antibiotic each shift for the duration of the order. h. Any adverse reaction will be reported to the ordering practitioner by Licensed Nurse. i. Policies and procedures will be updated, and all CMA's and Licensed Nursing staff will be educated to reflect the above noted protocols. 2. Current facility residents' labs for the previous 30 days will be reviewed to ensure the Primary Care Physician has been notified of the results. Lab results that have a Culture and Sensitivity will be reviewed with the Primary Care Physician to ensure resident is on the proper antibiotic. This will be completed by the Nurse Management Team. 3. During the morning Clinical Meeting the Nurse Managers will review current orders for Labs and Antibiotics to ensure the resident is receiving the appropriate antibiotic. 4. The Nurse Managers will call the Primary Care Physician if the resident is not on the antibiotic that the Culture and Sensitivity shows sensitivity to. 5. This plan of removal will be in compliance January 26, 2021 by 5pm On 01/27/21 interviews were conducted with the nursing staff regarding education in-services pertaining to antibiotic and lab protocol for immediate jeopardy removal. The staff stated an in-service was provided on 01/26/21. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 01/27/21 at 12:30 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to: ~ report results of lab data to the ordering practitioner which indicated the need to change treatments, and/or ensure residents received antibiotic therapy that was effective to treat their infection for three (#4, #10 and #11) of five sampled residents who required antibiotic treatment; and ~ failed to provide wound care and diabetic care for one (#9) of four sampled residents who were reviewed for quality of care issues. The physician was not notified of urinary culture and sensitivity lab results for resident #10, which indicated the infection the resident had was resistant to the antibiotic prescribed. The resident developed urinary [CONDITION(S)], was hospitalized , and subsequently passed away. The facility identified 10 residents who currently received antibiotic therapy. The facility identified 21 residents who had wounds and 14 residents who had diabetes. Findings: The facility policy for Laboratory Services documented, the facility will notify the physician promptly of laboratory results. The policy documented laboratory results would be reviewed by the physician on a timely basis. The policy documented the facility would have a system to reconcile physician orders, labs ordered, the time labs were drawn, when the results were received, and when the physician was notified. The policy documented reports would be filed in the medical record. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/30/19, documented a resident goal was to remain free from complications related to urinary tract infections (UTIs) over the next 90 days. Care plan interventions included observing for signs and symptoms of UTI such as complaint of burning with urination, flank pain, presence of blood in urine, discharge, elevated temperature, increased confusion and agitation, or decreased level of consciousness. The care plan documented staff were to alert the charge nurse of any signs and symptoms so the physician could be notified. The admission assessment, dated 12/24/19, documented the resident was moderately impaired for daily decision-making, required extensive assistance with activities of daily living (ADLs), and had a urinary catheter. A progress note, dated 03/16/20 at 8:19 a.m., documented the urinary catheter was patent to bedside drainage with pale yellow urine and a large amount of sediment. The note documented the resident reported a sensation of urinary urgency. The note documented the urinary catheter was irrigated with 100 cubic centimeters (cc) of sterile saline and continued to drain pale urine with sediment. The note documented the physician was contacted regarding urine for analysis and they were waiting for a return call. A progress note, dated 03/16/20 at 9:42 a.m., documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 03/16/20 at 10:57 a.m., documented laboratory (lab) called to pick up the stat urinalysis. A progress note, dated 03/16/20 at 5:05 p.m. documented the stat urinalysis results were faxed to the physician's office. A urinalysis lab report, dated 03/16/20, documented the resident had a UTI. A physicians order, dated 03/17/20, documented the resident was to receive [MEDICATION(S)] tablet 800-160 milligram (MG) two times a day for 7 days. A progress note, dated 03/18/20 at 10:15 a.m., documented the resident continued on [MEDICATION(S)] for a UTI his temperature was 98.1 degrees Fahrenheit (F). The note documented the resident denied any pain or burning. A urine culture and sensitivity report, dated 03/19/20 at 9:23 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The progress notes for March 2020 did not document the physician was notified of the culture and sensitivity results. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration record (MAR) dated March 2020 documented the resident continued to receive [MEDICATION(S)] for a UTI. A progress note, dated 03/19/20 at 10:16 a.m., documented the resident continued on [MEDICATION(S)] for a UTI, his temperature was 97.9 degrees (F) and had no signs or symptoms of an adverse reaction. The note documented the resident complained of pressure to the abdominal area on the previous shift but had no complaints on this shift. A progress note, dated 03/24/20 at 1:15 p.m., documented the resident complained of the catheter leaking and the feeling of pain and pressure when moving. The note documented the nurse was unable to flush the catheter. The note documented the catheter was replaced and the resident tolerated it well. A progress note, dated 03/24/20 at 10:46 p.m., documented the nurse was called into the resident's room by a certified medication aid (CMA). The note documented the resident had uncontrollable tremors, his oxygen saturation was 68 percent on room air, and the resident had a temperature of 99.5 degrees F. The note documented staff were not able to obtain a blood pressure due to the tremors. The note documented the resident's face was flushed and his nail beds were blue. The note documented an ambulance arrived and transported the resident to the hospital for evaluation and treatment per doctor orders. The note documented the daughter, the director or nurses (DON), and the assistant director of nurses (ADON) were notified. An emergency medicine note, dated 03/24/20, documented clinical impressions of septic shock and acute respiratory failure with [CONDITION(S)]. A details of hospital stay report, dated 03/26/20 at 3:18 p.m., documented the patient was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented the patient had proteus bacteria in his blood, was being treated with a broad spectrum antibiotic, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented on the previous night the patient had labored breathing and became acutely hypotensive. The report documented a chest X-ray showed a probable aspiration pneumonia. The report documented the patient required multiple medications to maintain his blood pressure. The report documented the patient was placed on comfort measures after consulting with family and passed away at 1:35 p.m. on 03/26/20. A death certificate, dated 03/30/20, documented the immediate cause for death was septic shock due to Proteus Mirabilis. On 01/22/21 at 10:10 a.m., the assistant director of nurses (ADON) stated the process for lab orders was to put the order into the medical record, then order the lab through the laboratory website. The requisition would then be put in the lab book and the lab would be called for pick-up. She stated the charge nurse would check the lab website for the results and should notify the physician of any abnormal results. On 01/25/21 at 2:02 p.m., physician #1 was interviewed regarding lab results. He stated that he expected to be made aware of abnormal lab results. He stated that the lab company will call the facility and the physician with critical results, but culture and sensitivity results were not critical labs. Physician #1 stated the facility did not notify him of the culture and sensitivity results for resident #10. On 01/27/21 at 10:25 a.m., licensed practical nurse (LPN) #3 stated that it was the responsibility of the charge nurse to monitor the lab website for results and to report abnormal results to the physician. On 01/27/21 at 10:30 a.m. LPN #4 stated the physician should be notified of culture and sensitivity reports and the charge nurse was responsible for monitoring and reporting lab results. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual assessment, dated 10/27/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter and received antibiotics. A progress note, dated 01/13/21 at 3:02 p.m., documented the resident's urine was thick and the tube required milking and flushing for urine to flow adequately. The note documented the resident denied painful, urination, other symptoms, and was afrebrile. The note documented water was available and accepted after prompting. A progress note, dated 01/14/21 at 7:36 a.m., documented the residents urine continued to be thick and [MEDICATION(S)] like in consistency. The note documented the urine did not want to flow through tubing and it was slow at times with cloudy appearance. The note documented a urinalysis was collected at that time to rule out UTI. The note documented the resident was afebrile and fluids were within reach. A final urinalysis report, dated 01/14/21 at 9:33 p.m., documented the urine had elevated protein, elevated blood, elevated white blood cell count and elevated red blood cell count. The progress notes for January 2020 did not document the physician was notified of the urinalysis report from 01/14/21 until 01/20/21. A final culture and sensitivity report, dated 01/16/21 at 8:34 a.m., documented probable collection contamination with skin flora and no susceptibility test was performed. The progress notes for January 2020 did not document the physician was notified of the culture and sensitivity report from 01/16/21 until 01/20/21. A progress note, dated 01/20/21 at 11:02 a.m., documented the suprapubic catheter was found on the floor beside the bed with a large amount of leaking urine to the abdominal region. The note documented the suprapubic catheter was replaced per physicians order, was draining to gravity and the the resident tolerated the procedure well. A progress note, dated 01/20/21 at 4:38 p.m., documented the urinalysis results were received, and were positive for a UTI. The note documented the physician was notified and orders were received for [MEDICATION(S)] intramuscular (IM) once a day for five days for UTI. The note documented the medication administration record (MAR) was updated and the power of attorney was made aware. A progress note, dated 01/21/21 at 12:32 p.m., documented the resident continued on an intramuscular (IM) antibiotic for a UTI. The note documented the resident has had no signs or symptoms of an adverse reaction. The note documented the resident was afebrile and the suprapubic catheter was patent and draining to gravity, and the resident received catheter care every two hours and as needed. A progress note, dated 01/24/21 at 2:37 a.m., documented the resident had only received one dose of [MEDICATION(S)] on or about 01/21/21. The note documented the medication appeared on the medication administration record (MAR) and not the treatment administration record (TAR). The note documented the medication was being checked off as administered by the medication aids who were not actually giving the medication or notifying the nurse. The note documented the nurse administered the second dose on 01/23/21 and the order was updated on the TAR. On 01/26/21 at 12:45 p.m., the assistant director of nurses (ADON) stated she was aware of the missed doses of [MEDICATION(S)]. The ADON stated she interviewed the nurse who discovered the medication had not been given and that nurse told her the physician was not contacted. She stated the nurse should have been notified the medication was on the MAR and not the TAR. She stated the physician should have been notified. On 10/27/21 at 10:10 a.m., physician #1 stated he expected to be notified by the facility when medication he had ordered was not administered. On 01/27/21 at 10:10 a.m., certified medication aid (CMA) #2 stated that IM meds should be on the TAR. She stated if she noticed an IM med on the MAR and not the TAR she would notify the charge nurse so the medication could be administered. 3. Resident #11 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission assessment, dated 12/11/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter. A progress note, dated 12/23/20 at 2:47 p.m., documented cloudy urine was noted in the catheter bag; a urine analysis was obtained per primary care physician, and a new order was received for [MEDICATION(S)] one time a day for five days until results of urinalysis were received. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A final urinalysis report, dated 12/24/20 at 8:20 p.m., documented the result was abnormal with protein, leukocyte [MEDICATION(S)] (A screening test used to detect a substance that suggests there are white blood cells in the urine; this may mean you have a urinary tract infection.) bacteria and [MEDICATION(S)], and the specimen was sent for culture. A final culture and sensitivity report, dated 12/26/20 at 11:11 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The TAR documented the resident was administered [MEDICATION(S)] one time a day for five days on 12/23/20 through 12/27/20. No other antibiotic was documented as administered. The progress notes did not document the physician was notified of the culture and sensitivity results and did not document an antibiotic susceptible to the bacteria was ordered or administered to the resident. On 01/26/21 at 12:51 p.m., the ADON stated the antibiotic the resident was administered was resistant to the bacteria and was not the correct antibiotic. She reviewed the progress notes and stated the facility did not notify the physician of the culture and sensitivity results. The ADON stated the physician should have been notified of the culture and sensitivity results and a different antibiotic should have been ordered. 4. a. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 08/18/20 at 10:02 p.m., documented the resident informed staff that she was a diabetic and received scheduled insulin at home. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented the resident was to be given 2 units [MEDICATION(S)] insulin for a blood sugar between 151-200, 4 units for a blood sugar between 201-250, 6 units for a blood sugar between 251-300, 8 units for a bloodsugar between 301-350, and 10 units for a blood sugar between 351-400. The order documented the physician was to be notified if the residents blood sugar was above 400. The admission assessment, dated 08/24/20, documented the resident was cognitively intact for daily decision-making and required limited assistance with activities of daily living (ADLs). On 04/15/21 at 11:58 a.m. LPN #3 was asked what should be done if you suspect a resident is diabetic and is not receiving treatment. She stated that the physician should be notified immediately. b. An admission note, dated 08/17/20, documented resident #9 had a [CONDITION(S)] port on the left side of her chest, redness under both breasts, and redness to her coccyx area. It did not document other skin issues. A skin assessment, dated 08/18/20 at 2:51 p.m., documented the resident had a diabetic foot ulcer to the right foot measuring 2.5 cm x 2.3 cm x undetermined. The assessment also documented a scab to the left breast measuring 7.5 cm x 0.5 cm x 0 cm. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the treatment administration record (TAR) did not document wound care to the right foot was provided on 08/18/20. A nurse's note, dated 08/23/20 at 7:43 p.m., documented the resident was complaining of discomfort to the left breast. The note documented upon assessment there was an open area on the left breast with drainage. It documented the physician was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order also documented the wound physician would evaluate the wound when he was in the facility on 08/24/20. A review of the treatment administration record (TAR) did not document wound care to the left breast was provided on 08/23/2020. A nurse's note, dated 08/24/20 at 9:01 a.m., documented the resident refused to see the wound care physician because she was leaving the facility against medical advice (AMA). The note documented the wound to the foot looked the same as it did upon admission and the scab on the left breast was now open. The note documented the nurse re-dressed both wounds and let the charge nurse know the resident was possibly leaving AMA. The admission assessment, dated 08/24/20, documented the resident was cognitively intact for daily decision-making and required limited assistance with activities of daily living (ADLs).

On 01/25/21 at 5:05 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician of results of a urine culture and sensitivity test that revealed the organism causing the infection was resistant to the antibiotic being used for resident #10. On 03/16/20, the physician ordered a urinalysis and a culture and sensitivity of the urine. On 03/17/20, the resident was started on an antibiotic for a urinary tract infection. The results of the culture and sensitivity revealed that the organism causing the infection, Proteus Mirabilis, was not sensitive to the antibiotic the resident was receiving. The physician was not notified of the results of the urine culture and sensitivity. Resident #10 was hospitalized on [DATE] with [CONDITION(S)], and subsequently passed away on 03/26/20. The immediate cause for death was septic shock due to Proteus Mirabilis. On 01/25/21 the IJ situation was verified with the Oklahoma State Department of Health. On 01/25/21 at 5:05 p.m., the administrator and the assistant director of nurses were notified of the IJ situation related to failures in communicating pertinent lab results to the ordering physician. On 01/26/21 at 11:30 a.m., the plan of removal for the Immediate Jeopardy pertaining to notification of the physician was accepted. The plan of Removal for the Immediate Jeopardy documented: Plan of Removal 1. Facility licensed Nurses will be educated on the facility antibiotic and lab protocol. a. Current and outstanding labs will be addressed immediately by the Licensed Nurse. b. Abnormal labs will be called into the physician by the Licensed Nurse by the end of the shift for abnormal results. With critical abnormal results; the Licensed Nurse will notify the Primary Care Physician immediately upon receiving the results. c. When receiving the results of a Culture and Sensitivity; the Licensed Nurse is to call the Primary Care Physician and provide results to ensure the resident is on the proper antibiotic therapy. d. Documentation will be completed listing the contact time and orders given by the Licensed Nurse. e. If antibiotic is ordered, the Licensed Nurse will fax and call new order into pharmacy and request it be sent out immediately within 4 hours, in the event that the medication is not received in that time frame, the ordering physician will be notified and a hold order will be obtained until the medication is available and in the facility to administer. f. Upon receipt of the antibiotic the receiving nurse will document arrival and initial dose will be given. g. Licensed Nurse should document on the antibiotic each shift for the duration of the order. h. Any adverse reaction will be reported to the ordering practitioner by Licensed Nurse. i. Policies and procedures will be updated, and all CMA's and Licensed Nursing staff will be educated to reflect the above noted protocols. 2. Current facility residents' labs for the previous 30 days will be reviewed to ensure the Primary Care Physician has been notified of the results. Lab results that have a Culture and Sensitivity will be reviewed with the Primary Care Physician to ensure resident is on the proper antibiotic. This will be completed by the Nurse Management Team. 3. During the morning Clinical Meeting the Nurse Managers will review current orders for Labs and Antibiotics to ensure the resident is receiving the appropriate antibiotic. 4. The Nurse Managers will call the Primary Care Physician if the resident is not on the antibiotic that the Culture and Sensitivity shows sensitivity to. 5. This plan of removal will be in compliance January 26, 2021 by 5pm On 01/27/21 interviews were conducted with the nursing staff regarding education in-services pertaining to antibiotic and lab protocol for immediate jeopardy removal. The staff stated an in-service was provided on 01/26/21. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 01/27/21 at 12:30 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to notify the physician of significant laboratory results for five (#2, 4, 6, 10 and #11) of five sampled residents reviewed for laboratory services. The physician was not notified of urinary culture and sensitivity lab results for resident #10, which indicated the infection the resident had was resistant to the antibiotic prescribed. The resident developed urinary [CONDITION(S)], was hospitalized , and subsequently passed away. The facility identified 63 residents who received laboratory services. Findings: The facility policy for Laboratory Services documented, the facility will notify the physician promptly of laboratory results. The policy documented laboratory results would be reviewed by the physician on a timely basis. The policy documented the facility would have a system to reconcile physician orders, labs ordered, the time labs were drawn, when the results were received, and when the physician was notified. The policy documented reports would be filed in the medical record. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/30/19, documented a resident goal was to remain free from complications related to urinary tract infections (UTIs) over the next 90 days. Care plan interventions included observing for signs and symptoms of UTI such as complaint of burning with urination, flank pain, presence of blood in urine, discharge, elevated temperature, increased confusion and agitation, or decreased level of consciousness. The care plan documented staff were to alert the charge nurse of any signs and symptoms so the physician could be notified. The admission assessment, dated 12/24/19, documented the resident was moderately impaired for daily decision-making, required extensive assistance with activities of daily living (ADLs), and had a urinary catheter. A progress note, dated 03/16/20 at 8:19 a.m., documented the urinary catheter was patent to bedside drainage with pale yellow urine and a large amount of sediment. The note documented the resident reported a sensation of urinary urgency. The note documented the urinary catheter was irrigated with 100 cubic centimeters (cc) of sterile saline and continued to drain pale urine with sediment. The note documented the physician was contacted regarding urine for analysis and they were waiting for a return call. A progress note, dated 03/16/20 at 9:42 a.m., documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 03/16/20 at 10:57 a.m., documented laboratory (lab) called to pick up the stat urinalysis. A progress note, dated 03/16/20 at 5:05 p.m. documented the stat urinalysis results were faxed to the physician's office. A urinalysis lab report, dated 03/16/20, documented the resident had a UTI. A physicians order, dated 03/17/20, documented the resident was to receive [MEDICATION(S)] tablet 800-160 milligram (MG) two times a day for 7 days. A progress note, dated 03/18/20 at 10:15 a.m., documented the resident continued on [MEDICATION(S)] for a UTI his temperature was 98.1 degrees Fahrenheit (F). The note documented the resident denied any pain or burning. A urine culture and sensitivity report, dated 03/19/20 at 9:23 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The progress notes for March 2020 did not document the physician was notified of the culture and sensitivity results. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration record (MAR) dated March 2020 documented the resident continued to receive [MEDICATION(S)] for a UTI. A progress note, dated 03/19/20 at 10:16 a.m., documented the resident continued on [MEDICATION(S)] for a UTI, his temperature was 97.9 degrees (F) and had no signs or symptoms of an adverse reaction. The note documented the resident complained of pressure to the abdominal area on the previous shift but had no complaints on this shift. A progress note, dated 03/24/20 at 1:15 p.m., documented the resident complained of the catheter leaking and the feeling of pain and pressure when moving. The note documented the nurse was unable to flush the catheter. The note documented the catheter was replaced and the resident tolerated it well. A progress note, dated 03/24/20 at 10:46 p.m., documented the nurse was called into the resident's room by a certified medication aid (CMA). The note documented the resident had uncontrollable tremors, his oxygen saturation was 68 percent on room air, and the resident had a temperature of 99.5 degrees F. The note documented staff were not able to obtain a blood pressure due to the tremors. The note documented the resident's face was flushed and his nail beds were blue. The note documented an ambulance arrived and transported the resident to the hospital for evaluation and treatment per doctor orders. The note documented the daughter, the director or nurses (DON), and the assistant director of nurses (ADON) were notified. An emergency medicine note, dated 03/24/20, documented clinical impressions of septic shock and acute respiratory failure with [CONDITION(S)]. A details of hospital stay report, dated 03/26/20 at 3:18 p.m., documented the patient was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented the patient had proteus bacteria in his blood, was being treated with a broad spectrum antibiotic, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented on the previous night the patient had labored breathing and became acutely hypotensive. The report documented a chest X-ray showed a probable aspiration pneumonia. The report documented the patient required multiple medications to maintain his blood pressure. The report documented the patient was placed on comfort measures after consulting with family and passed away at 1:35 p.m. on 03/26/20. A death certificate, dated 03/30/20, documented the immediate cause for death was septic shock due to Proteus Mirabilis. On 01/22/21 at 10:10 a.m., the assistant director of nurses (ADON) stated the process for lab orders was to put the order into the medical record, then order the lab through the laboratory website. The requisition would then be put in the lab book and the lab would be called for pick-up. She stated the charge nurse would check the lab website for the results and should notify the physician of any abnormal results. On 01/25/21 at 2:02 p.m., physician #1 was interviewed regarding lab results. He stated that he expected to be made aware of abnormal lab results. He stated that the lab company will call the facility and the physician with critical results, but culture and sensitivity results were not critical labs. Physician #1 stated the facility did not notify him of the culture and sensitivity results for resident #10. On 01/27/21 at 10:25 a.m., licensed practical nurse (LPN) #3 stated that it was the responsibility of the charge nurse to monitor the lab website for results and to report abnormal results to the physician. On 01/27/21 at 10:30 a.m. LPN #4 stated the physician should be notified of culture and sensitivity reports and the charge nurse was responsible for monitoring and reporting lab results. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual assessment, dated 10/27/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter and received antibiotics. A progress note, dated 01/13/21 at 3:02 p.m., documented the resident's urine was thick and the tube required milking and flushing for urine to flow adequately. The note documented the resident denied painful, urination, other symptoms, and was afrebrile. The note documented water was available and accepted after prompting. A progress note, dated 01/14/21 at 7:36 a.m., documented the residents urine continued to be thick and [MEDICATION(S)] like in consistency. The note documented the urine did not want to flow through tubing and it was slow at times with cloudy appearance. The note documented a urinalysis was collected at that time to rule out UTI. The note documented the resident was afebrile and fluids were within reach. A final urinalysis report, dated 01/14/21 at 9:33 p.m., documented the urine had elevated protein, elevated blood, elevated white blood cell count and elevated red blood cell count. The progress notes for January 2020 did not document the physician was notified of the urinalysis report from 01/14/21 until 01/20/21. A final culture and sensitivity report, dated 01/16/21 at 8:34 a.m., documented probable collection contamination with skin flora and no susceptibility test was performed. The progress notes for January 2020 did not document the physician was notified of the culture and sensitivity report from 01/16/21 until 01/20/21. A progress note, dated 01/20/21 at 11:02 a.m., documented the suprapubic catheter was found on the floor beside the bed with a large amount of leaking urine to the abdominal region. The note documented the suprapubic catheter was replaced per physicians order, was draining to gravity and the resident tolerated the procedure well. A progress note, dated 01/20/21 at 4:38 p.m., documented the urinalysis results were received, and were positive for a UTI. The note documented the physician was notified and orders were received for [MEDICATION(S)] intramuscular (IM) once a day for five days for UTI. The note documented the medication administration record (MAR) was updated and the power of attorney was made aware. A progress note, dated 01/21/21 at 12:32 p.m., documented the resident continued on an intramuscular (IM) antibiotic for a UTI. The note documented the resident has had no signs or symptoms of an adverse reaction. The note documented the resident was afebrile and the suprapubic catheter was patent and draining to gravity, and the resident received catheter care every two hours and as needed. A progress note, dated 01/24/21 at 2:37 a.m., documented the resident had only received one dose of [MEDICATION(S)] on or about 01/21/21. The note documented the medication appeared on the medication administration record (MAR) and not the treatment administration record (TAR). The note documented the medication was being checked off as administered by the medication aids who were not actually giving the medication or notifying the nurse. The note documented the nurse administered the second dose on 01/23/21 and the order was updated on the TAR. On 01/26/21 at 12:45 p.m., the assistant director of nurses (ADON) stated she was aware of the missed doses of [MEDICATION(S)]. The ADON stated she interviewed the nurse who discovered the medication had not been given and that nurse told her the physician was not contacted. She stated the nurse should have been notified the medication was on the MAR and not the TAR. She stated the physician should have been notified. On 10/27/21 at 10:10 a.m., physician #1 stated he expected to be notified by the facility when medication he had ordered was not administered. On 01/27/21 at 10:10 a.m., certified medication aid (CMA) #2 stated that IM meds should be on the TAR. She stated if she noticed an IM med on the MAR and not the TAR she would notify the charge nurse so the medication could be administered. 3. Resident #11 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission assessment, dated 12/11/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter. A progress note, dated 12/23/20 at 2:47 p.m., documented cloudy urine was noted in the catheter bag; a urine analysis was obtained per primary care physician, and a new order was received for [MEDICATION(S)] one time a day for five days until results of urinalysis were received. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A final urinalysis report, dated 12/24/20 at 8:20 p.m., documented the result was abnormal with protein, leukocyte [MEDICATION(S)] (A screening test used to detect a substance that suggests there are white blood cells in the urine; this may mean you have a urinary tract infection.) bacteria and [MEDICATION(S)], and the specimen was sent for culture. A final culture and sensitivity report, dated 12/26/20 at 11:11 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The TAR documented the resident was administered [MEDICATION(S)] one time a day for five days on 12/23/20 through 12/27/20. No other antibiotic was documented as administered. The progress notes did not document the physician was notified of the culture and sensitivity results and did not document an antibiotic susceptible to the bacteria was ordered or administered to the resident. On 01/26/21 at 12:51 p.m., the ADON stated the antibiotic the resident was administered was resistant to the bacteria and was not the correct antibiotic. She reviewed the progress notes and stated the facility did not notify the physician of the culture and sensitivity results. The ADON stated the physician should have been notified of the culture and sensitivity results and a different antibiotic should have been ordered. 4. Resident #2 was admitted to the facility 07/01/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of laboratory reports revealed the following laboratory tests were completed: 07/07/20: ~ Basic Metabolic Panel; ~ Lipid Panel; ~ TSH (thyroid stimulating hormone); ~ Vitamin B-12; ~ Complete Blood Count /Auto Diff (differential): and ~ Hemoglobin A1C. 01/08/21: ~ Complete Blood Count; and ~ CMP (comprehensive metabolic panel). A review of the medical record revealed there was no documentation to support the facility had notified the physician of the laboratory results. A quarterly assessment, dated 01/08/21, documented the resident was cognitively intact, received [CONDITION(S)], and received a diuretic seven out of seven days of the look back period. On 01/25/21, the assistant director nurses (ADON) provided the surveyor copies of the 01/08/21 laboratory reports. The reports documented they had been reviewed by the physician's nurse on 01/08/21. A review of the nurse's notes dated 01/25/21, revealed the ADON contacted the physician's office regarding the laboratory reports for 01/08/21. 5. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nurse's notes, dated 10/12/20, revealed a physician's verbal order for a stat BUN (blood urea nitrogen) and a creatinine laboratory test. A review of laboratory reports revealed a stat BUN and creatinine had been completed on 10/13/20. A review of the progress notes for 10/12/20-10/21/20 revealed there was no documentation to support the facility had notified the physician of the stat laboratory results. A quarterly assessment, dated 11/10/20, documented the resident was modified independent in cognition for daily decision making, required extensive assistance with hygiene, totally dependent on staff for bathing, and always incontinent of bowel and bladder. On 01/22/21 at 10:10 a.m., the ADON was interviewed regarding laboratory services. She stated they had switched the company that provided laboratory services in November 2020. She stated the lab process consisted of the following: ~ Receive physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] (Note: if the physician ordered stat lab tests, the nurse would call [name withheld] to inform them of the stat lab order) ~ Nurse would enter the lab order into [name withheld]'s electronic lab system and the facility's electronic health care system; ~ Nurse would print the lab requisition and place it in the lab book; ~ On lab visit, [name withheld] would retrieve the lab requisition from the lab book; ~ Charge nurses were responsible for accessing [name withheld]'s electronic lab system to obtain lab results; ~ Lab would notify charge nurse, by phone, of any critical lab results; ~ Charge nurses were responsible for notifying the physician, by phone and fax, of abnormal lab results. She was asked how the physician was informed of laboratory test results. She stated the physician had access to [name withheld]'s electronic lab system but the charge nurse was responsible for notifying the physician of abnormal test results. On 01/22/21 at 10:20 a.m., LPN (licensed practical nurse) #6 was interviewed regarding laboratory services. She stated when the physician ordered lab tests she would enter the order in the electronic medical record then access the lab's electronic system to complete a requisition. She stated if the order was for stat lab, she contacted the lab by phone. She stated at least once during her shift she would access [name withheld]'s electronic lab system to check for lab results. She stated she would check the system for stat lab results every one to one and a half hours. She stated if stat lab results had not been accessed in the lab system by the end of her shift, she would report the pending stat lab to the next shift's charge nurse. On 01/26/21 at 12:45 p.m., the ADON was asked where it would be documented that the physician had been notified of a resident's laboratory results. She stated in the progress notes. She was asked who was responsible for notifying the physician of laboratory results. She stated the charge nurse was responsible.

On 01/25/21 at 5:05 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to develop and implement an antibiotic use protocol which included reporting results of laboratory data to the ordering practitioner for resident #10. Resident #10 was hospitalized and subsequently passed away. On 01/25/21 the IJ situation was verified with the Oklahoma State Department of Health. On 01/25/21 at 5:05 p.m., the administrator and the assistant director of nurses were notified of the IJ situation related to failures in communicating pertinent lab results to the ordering physician. On 01/26/21 at 11:30 a.m., the plan of removal for the Immediate Jeopardy pertaining to notification of the physician was accepted. The plan of Removal for the Immediate Jeopardy documented: Plan of Removal 1. Facility licensed Nurses will be educated on the facility antibiotic and lab protocol. a. Current and outstanding labs will be addressed immediately by the Licensed Nurse. b. Abnormal labs will be called into the physician by the Licensed Nurse by the end of the shift for abnormal results. With critical abnormal results; the Licensed Nurse will notify the Primary Care Physician immediately upon receiving the results. c. When receiving the results of a Culture and Sensitivity; the Licensed Nurse is to call the Primary Care Physician and provide results to ensure the resident is on the proper antibiotic therapy. d. Documentation will be completed listing the contact time and orders given by the Licensed Nurse. e. If antibiotic is ordered, the Licensed Nurse will fax and call new order into pharmacy and request it be sent out immediately within 4 hours, in the event that the medication is not received in that time frame, the ordering physician will be notified and a hold order will be obtained until the medication is available and in the facility to administer. f. Upon receipt of the antibiotic the receiving nurse will document arrival and initial dose will be given. g. Licensed Nurse should document on the antibiotic each shift for the duration of the order. h. Any adverse reaction will be reported to the ordering practitioner by Licensed Nurse. i. Policies and procedures will be updated, and all CMA's and Licensed Nursing staff will be educated to reflect the above noted protocols. 2. Current facility residents' labs for the previous 30 days will be reviewed to ensure the Primary Care Physician has been notified of the results. Lab results that have a Culture and Sensitivity will be reviewed with the Primary Care Physician to ensure resident is on the proper antibiotic. This will be completed by the Nurse Management Team. 3. During the morning Clinical Meeting the Nurse Managers will review current orders for Labs and Antibiotics to ensure the resident is receiving the appropriate antibiotic. 4. The Nurse Managers will call the Primary Care Physician if the resident is not on the antibiotic that the Culture and Sensitivity shows sensitivity to. 5. This plan of removal will be in compliance January 26, 2021 by 5pm On 01/27/21 interviews were conducted with the nursing staff regarding education in-services pertaining to antibiotic and lab protocol for immediate jeopardy removal. The staff stated an in-service was provided on 01/26/21. The staff was able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 01/27/21 at 12:30 p.m., the IJ was removed when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to develop and implement an antibiotic use protocol which included reporting results of lab data to the ordering practitioner for three (#4, #10 and #11) of five sampled residents reviewed for implementation of an antibiotic use protocol. The facility failed to notify the physician of significant laboratory results. The physician was not notified of urinary culture and sensitivity lab results for resident #10. The resident developed urinary [CONDITION(S)], was hospitalized , and subsequently passed away. The facility identified 10 residents who currently received antibiotic therapy. Findings: The facility policy for Laboratory Services documented, the facility will notify the physician promptly of laboratory results. The policy documented laboratory results would be reviewed by the physician on a timely basis. The policy documented the facility would have a system to reconcile physician orders, labs ordered, the time labs were drawn, when the results were received, and when the physician was notified. The policy documented reports would be filed in the medical record. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/30/19, documented a resident goal was to remain free from complications related to urinary tract infections (UTIs) over the next 90 days. Care plan interventions included observing for signs and symptoms of UTI such as complaint of burning with urination, flank pain, presence of blood in urine, discharge, elevated temperature, increased confusion and agitation, or decreased level of consciousness. The care plan documented staff were to alert the charge nurse of any signs and symptoms so the physician could be notified. The admission assessment, dated 12/24/19, documented the resident was moderately impaired for daily decision-making, required extensive assistance with activities of daily living (ADLs), and had a urinary catheter. A progress note, dated 03/16/20 at 8:19 a.m., documented the urinary catheter was patent to bedside drainage with pale yellow urine and a large amount of sediment. The note documented the resident reported a sensation of urinary urgency. The note documented the urinary catheter was irrigated with 100 cubic centimeters (cc) of sterile saline and continued to drain pale urine with sediment. The note documented the physician was contacted regarding urine for analysis and they were waiting for a return call. A progress note, dated 03/16/20 at 9:42 a.m., documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 03/16/20 at 10:57 a.m., documented laboratory (lab) called to pick up the stat urinalysis. A progress note, dated 03/16/20 at 5:05 p.m. documented the stat urinalysis results were faxed to the physician's office. A urinalysis lab report, dated 03/16/20, documented the resident had a UTI. A physicians order, dated 03/17/20, documented the resident was to receive [MEDICATION(S)] tablet 800-160 milligram (MG) two times a day for 7 days. A progress note, dated 03/18/20 at 10:15 a.m., documented the resident continued on [MEDICATION(S)] for a UTI his temperature was 98.1 degrees Fahrenheit (F). The note documented the resident denied any pain or burning. A urine culture and sensitivity report, dated 03/19/20 at 9:23 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The progress notes for March 2020 did not document the physician was notified of the culture and sensitivity results. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication administration record (MAR) dated March 2020 documented the resident continued to receive [MEDICATION(S)] for a UTI. A progress note, dated 03/19/20 at 10:16 a.m., documented the resident continued on [MEDICATION(S)] for a UTI, his temperature was 97.9 degrees (F) and had no signs or symptoms of an adverse reaction. The note documented the resident complained of pressure to the abdominal area on the previous shift but had no complaints on this shift. A progress note, dated 03/24/20 at 1:15 p.m., documented the resident complained of the catheter leaking and the feeling of pain and pressure when moving. The note documented the nurse was unable to flush the catheter. The note documented the catheter was replaced and the resident tolerated it well. A progress note, dated 03/24/20 at 10:46 p.m., documented the nurse was called into the resident's room by certified medication aid (CMA). The note documented the resident had uncontrollable tremors, his oxygen saturation was 68 percent on room air, and the resident had a temperature of 99.5 degrees F. The note documented staff were not able to obtain a blood pressure due to the tremors. The note documented the resident's face was flushed and his nail beds were blue. The note documented the ambulance arrived and transported resident to the hospital for evaluation and treatment per doctor orders. The note documented the daughter, the director or nurses (DON), and the assistant director of nurses (ADON) were notified. An emergency medicine note, dated 03/24/20, documented clinical impressions of septic shock and acute respiratory failure with [CONDITION(S)]. A details of hospital stay report, dated 03/26/20 at 3:18 p.m., documented the patient was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented the patient had proteus bacteria in his blood, was being treated with a broad spectrum antibiotic, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented on the previous night the patient had labored breathing and became acutely hypotensive. The report documented a chest X-ray showed a probable aspiration pneumonia. The report documented the patient required multiple medications to maintain his blood pressure. The report documented the patient was placed on comfort measures after consulting with family and passed away at 1:35 p.m. on 03/26/20. A death certificate, dated 03/30/20, documented the immediate cause for death was septic shock due to Proteus Mirabilis. On 01/22/21 at 10:10 a.m., the assistant director of nurses (ADON) stated the process for lab orders was to put the order into the medical record, then order the lab through the laboratory website. The requisition would then be put in the lab book and the lab would be called for pick-up. She stated the charge nurse would check the lab website for the results and should notify the physician of any abnormal results. On 01/25/21 at 2:02 p.m., physician #1 was interviewed regarding lab results. He stated that he expected to be made aware of abnormal lab results. He stated that the lab company will call the facility and the physician with critical results, but culture and sensitivity results were not critical labs. Physician #1 stated the facility did not notify him of the culture and sensitivity results for resident #10. On 01/27/21 at 10:25 a.m., licensed practical nurse (LPN) #3 stated that it was the responsibility of the charge nurse to monitor the lab website for results and to report abnormal results to the physician. On 01/27/21 at 10:30 a.m. LPN #4 stated the physician should be notified of culture and sensitivity reports and the charge nurse was responsible for monitoring and reporting lab results. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual assessment, dated 10/27/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter and received antibiotics. A progress note, dated 01/13/21 at 3:02 p.m., documented the resident's urine was thick and the tube required milking and flushing for urine to flow adequately. The note documented the resident denied painful, urination, other symptoms, and was afrebrile. The note documented water was available and accepted after prompting. A progress note, dated 01/14/21 at 7:36 a.m., documented the residents urine continued to be thick and [MEDICATION(S)] like in consistency. The note documents the urine does not want to flow through tubing and it is was slow at times with cloudy appearance. The note documented a urinalysis was collected at that time to rule out UTI. The note documented the resident was afebrile and fluids were within reach. A final urinalysis report, dated 01/14/21 at 9:33 p.m., documented the urine had elevated protein, elevated blood, elevated white blood cell count and elevated red blood cell count. The progress notes for January 2020 did not document the physician was notified of the urinalysis report from 01/14/21 until 01/20/21. A final culture and sensitivity report, dated 01/16/21 at 8:34 a.m., documented probable collection contamination with skin flora and no susceptibility test was performed. The progress notes for January 2020 did not document the physician was notified of the culture and sensitivity report from 01/16/21 until 01/20/21. A progress note, dated 01/20/21 at 11:02 a.m., documented the suprapubic catheter was found on the floor beside the bed with a large amount of leaking urine to the abdominal region. The note documented the suprapubic catheter was replaced per physicians order, was draining to gravity and the the resident tolerated the procedure well. A progress note, dated 01/20/21 at 4:38 p.m., documented the urinalysis results were received, and were positive for a UTI. The note documented the physician was notified and orders were received for [MEDICATION(S)] intramuscular (IM) once a day for five days for UTI. The note documented the medication administration record (MAR) was updated and the power of attorney was made aware. A progress note, dated 01/21/21 at 12:32 p.m., documented the resident continued on an intramuscular (IM) antibiotic for a UTI. The note documented the resident has had no signs or symptoms of an adverse reaction. The note documented the resident is afebrile and the suprapubic catheter was patent and draining to gravity, and received catheter care every two hours and as needed. A progress note, dated 01/24/21 at 2:37 a.m., documented the resident had only received one dose of [MEDICATION(S)] on or about 01/21/21. The note documented the medication appeared on the medication administration record (MAR) and not the treatment administration record (TAR). The note documented the medication was being checked off as administered by the medication aids who were not actually giving the medication or notifying the nurse. The note documented the nurse administered the second dose on 01/23/21 and the order was updated on the TAR. On 01/26/21 at 12:45 p.m., the assistant director of nurses (ADON) stated she was aware of the missed doses of [MEDICATION(S)]. The ADON stated she interviewed the nurse who discovered the medication had not been given and that nurse told her the physician was not contacted. She stated the nurse should have been notified the medication was on the MAR and not the TAR. She stated the physician should have been notified. On 10/27/21 at 10:10 a.m., physician #1 stated he expected to be notified by the facility when medication he had ordered was not administered. On 01/27/21 at 10:10 a.m., certified medication aid (CMA) #2 stated that IM meds should be on the TAR. She stated if she noticed an IM med on the MAR and not the TAR she would notify the charge nurse so the medication could be administered. 3. Resident #11 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission assessment, dated 12/11/20, documented the resident was cognitively intact for daily decision-making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had a catheter. A progress note, dated 12/23/20 at 2:47 p.m., documented cloudy urine was noted in the catheter bag; a urine analysis was obtained per primary care physician, and a new order was received for [MEDICATION(S)] one time a day for five days until results of urinalysis were received. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A final urinalysis report, dated 12/24/20 at 8:20 p.m., documented the result was abnormal with protein, leukocyte [MEDICATION(S)] (A screening test used to detect a substance that suggests there are white blood cells in the urine; this may mean you have a urinary tract infection.) bacteria and [MEDICATION(S)], and the specimen was sent for culture. A final culture and sensitivity report, dated 12/26/20 at 11:11 a.m., documented the presence of the bacteria Proteus Mirabilis. The urine culture documented the bacteria was resistant to [MEDICATION(S)]. The TAR documented the resident was administered [MEDICATION(S)] one time a day for five days on 12/23/20 through 12/27/20. No other antibiotic was documented as administered. The progress notes did not document the physician was notified of the culture and sensitivity results and did not document an antibiotic susceptible to the bacteria was ordered or administered to the resident. On 01/26/21 at 12:51 p.m., the ADON stated the antibiotic the resident was administered was resistant to the bacteria and was not the correct antibiotic. She reviewed the progress notes and stated the facility did not notify the physician of the culture and sensitivity results. The ADON stated the physician should have been notified of the culture and sensitivity results and a different antibiotic should have been ordered.

Based on observation, resident and staff interviews, and record review, it was determined the facility failed to implement interventions to aid in the prevention of severe weight loss for two (#1 and #4) of six sampled residents who were reviewed for weight loss. This resulted in actual harm for resident #4 who had a severe weight loss of 16.4 pounds (11.2%) in three months,19.2 pounds (13.1%) in six months, and had developed a stage II pressure ulcer. A facility policy titled, System for Obtaining Height and Weight, documented: Weight is one of the most important points of objective data used in evaluating nutritional and clinical status, diet planning, calculating medication dosage as well as other clinical considerations for the patient .Weighing may also be pertinent if there is a significant change in condition, food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status . A facility policy titled, Mealtime Observation, documented: .Positive interactions between staff and patient occur .physical assistance/guidance: feeds patient or guides patient to feed self .verbal instruction and prompting: 'pick up your spoon and take a bite.' 'swallow' . 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 04/01/13, documented, .Focus: ADL Self care deficit related to physical limitations . Goal: Will receive assistance necessary to meet ADL needs . Interventions/Tasks: Provide assistance with meals . A laboratory result, dated 05/14/14, documented, .ALB ([MEDICATION NAME]) 3.3 (3.4 - 4.7) . A dietician progress note, dated 09/24/2015, documented, .Sept wt 162.6#. Wt down 7# x 1 month. Wt stable x 6 mos. BMI 22.1 - healthy wt range. Diet Mech Soft, Enhanced. Eating 37% x last 15 meals. Receiving nutritious treats btw meals and at HS. On [MEDICATION NAME] for appetite. Res is on antibiotic therapy for UTI. No pressure areas reported. Labs noted. Will monitor. Cont POC . A weights and vitals report, dated 10/07/15, documented, .Height 72.0 .Current BMI: 20.6 .-5.0% change (Comparison Weight 9/10/2015, 162.6 lbs, -5.2%, -8.4 lbs); -7.5% change (Comparison Weight 7/9/2015, 170.2 lbs, - 9.4%, -16.0 lbs) . A significant change assessment, dated 10/08/15, documented the resident was severely impaired in cognitive skills for daily decision making. He required extensive assistance from staff with eating. He weighed 154 lbs. He did not have any pressure ulcers during the look back period. A dietician progress note, dated 10/15/15, documented, .Oct wt 154.2#. Rewt 152.6#. Wt down 8.4# x 1 month. Sig wt loss of 5.2% x 1 month and 9.4% x 3 mos. BMI: 20.7 - healthy wt range. Diet: Mech Soft, Enhanced. Eating 58% x last 15 (sic). Receiving nutritious treats btw meals and at HS. On [MEDICATION NAME] for appetite. No pressure areas reported. Labs noted. Has had several UTIs lately. Fluids encouraged. Will monitor. Rec d/c nutritious treats. Rec add Two Cal HN btw meals BID (provides: 475 kcal, 20g prot per can). A care plan, updated 10/18/15, documented, .Focus: Nutritional status as evidenced by significant weight loss. Poor appetite. Now extensive assist with meals/intake . Goal: Will experience no further significant weight loss . Interventions/Tasks: Administer medications as ordered . Enhanced foods . Obtain labs as ordered and notify physician of results . Provide diet as ordered . Provide supplements as ordered . A dietician progress note, dated 11/12/15, documented, .Nov wt. 152#. Wt down 2.2# x 1 month. Sig wt loss of 10.4% x 3 mos. BMI: 20.6 - healthy wt range. Diet: Mech Soft, Enhanced. Eating 52% x last 15 meals. Receiving Two Cal HN btw meals BID. On [MEDICATION NAME] for appetite. No pressure areas reported. No new labs. Will monitor. Nutritional interventions in place. Cont POC . A physician telephone order, dated 11/14/15, documented, .CBC, CMP STAT . A laboratory report, dated, 11/14/15, documented, .ALB .1.9 (3.6-5.1) . On 11/30/15 at 8:30 a.m., the resident was observed seated at the dining table for the breakfast meal. He was observed feeding himself scrambled eggs and drank a glass of orange juice. He was observed during the meal to have dropped butter on his pants. He was observed to struggle to get his fork with food on it into his mouth. No staff person was observed at the table to assist the resident during the meal. At 11:20 a.m., the resident was observed in his bed with his eyes closed. A Two Cal health shake was open with a straw in the carton. The shake was observed on his bedside table. The carton was observed to be full with approximately 237 ml. At 2:37 p.m., a carton of Two Cal health shake was observed on the resident's bedside table. Approximately 237 ml were observed in the carton. On 12/02/15 at 8:10 a.m., the resident was observed seated at the dining table for the breakfast meal. CNA #4 was observed to have placed a plate of cut up biscuits and sausage in front of the resident. She handed him a fork loaded with food. His hand was observed to be shaking while trying to get the food into his mouth. He then pushed his plate over to the left, almost pushing it off the table. CNA #5 was observed to take the plate away and returned with a bowl of cottage cheese and peaches. A plate guard was applied to the plate. She cut up the peaches, handed the resident a spoon and walked away. The resident's hand was shaking when he tried to get the spoon to his mouth. He then put the spoon down and picked up the peaches with his fingers. CNA #5 was then observed to have sat down to help the resident with his meal. On 12/02/15 at 9:00 a.m., CNA #6 was asked how often were health shakes provided to the resident. She stated between breakfast and lunch and one again after lunch. She was asked if the resident consumed all of the shakes. She stated yes. At 10:00 a.m., CNA #5 was asked what the care plan stated about feeding assistance for the resident. She stated he should be assisted with his meals however, we let him do what he can for himself. She was asked if she was aware he struggled with feeding himself during breakfast. She stated he sometimes has problems and sometimes he doesn't. At 10:45 a.m., CNA #4 was asked if she was aware of the resident's difficulty with getting food to his mouth. She stated, I didn't notice he needed help as I was busy passing out plates. At 10:50 a.m., the resident was observed lying in bed with his eyes closed. A full, opened carton of Two Cal health shake with straw was observed on the bedside table. On 12/02/15 at 11:00 a.m., CNA #2 was asked what would you do if you saw a resident struggling to get food into his mouth during a meal. She stated she would wash her hands and assist the resident. She was asked what does limited assistance mean to you. She stated she would feed the resident if needed, clean their mouth, and give drinks. A telephone physician's orders [REDACTED].Coccyx - clean wound c NS, pat dry, skin prep to periwound and apply Tiod (sic) paste to open area q shift . At 3:05 p.m., CNA #4 and CNA #6 were asked to weigh the resident. The weight was observed to be 146.2#. At 3:20 p.m., CNA #6 was asked if the resident accepts the Two Cal health shakes. She stated, Mostly he won't drink them. I tell the charge nurse and then try again later. At 3:55 p.m., RN #2 was asked what occurred which caused him to go from limited assistance to extensive assistance with meals. She stated she did not know. She was asked if she was aware he had lost weight. She stated, Yes, he is on the list. She was asked how often the dietician visits. She stated she did not know. At 4:15 p.m., the dietician was asked how she determines if a resident is getting the supplements she had recommended. She stated she asks the nurses and aides. She was asked if she had reviewed the laboratory results from 11/14/15. She stated she had not reviewed them and needed to discuss it further with the physician. She further stated the resident needed to be moved to the assisted table and discussed adding additional protein to his meals. On 12/03/15 at 9:30 a.m., physician #1 was asked if he was aware of the resident's weight loss. He stated he had been the resident's primary care physician for many years and was aware of the weight issues. He stated a nutritional and weight review occurred every six weeks with the residents on his service. He was asked if he was aware of the December weight obtained on 12/02/15. He stated no, he had not seen the resident yet however, he would be reviewing labs and weights today. He was asked if the [MEDICATION NAME] level listed on the 11/14/15 laboratory report had been faxed to him for review. He stated his physician's assistant was notified according to the documentation on the laboratory sheet. He then stated he had not received a copy and found the decline in the [MEDICATION NAME] alarming. He further stated he would be addressing it today during rounds. He was asked if his weight loss was avoidable or unavoidable. He stated he was not surprised about the weight loss due to his medical history and advanced age. He further stated changes could be made to improve his care. He further stated he would not consider the weight loss unavoidable because there were other interventions which had not been tried yet. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan provided by the facility on 11/30/15, documented, Focus .Need for feeding tube/potential for complications of feeding tube use . .Interventions .Monitor tube feeding adequacy . Monitor weights and report any significant weight changes to physician and responsible party . .Focus .Nutritional status as evidenced by actual/potential weight loss/gain related to enteral/[MEDICATION NAME] nutrition . .Goal .Will experience no significant weight change . Monthly physician's orders [REDACTED]. .Diets .11/04/15-NPO (nothing by mouth) Tube Feeding Orders .Glucerna 1.5 at 70 ml per hour start at 4 pm infuse until 1200 ml infused with auto flush 30 ml water per hour . .Weight Order .11/04/15-Weekly Weight for 28 days (4 weeks) . A treatment administration record, dated November 2015, documented, Weekly weights x4 weeks then monthly. According to the treatment administration record, weights were to be done by the day shift on 11/4/15, 11/11/15, 11/18/15, and 11/25/15. The weights were reviewed on the treatment record. The admission weight on 11/4/15 was documented as 178.6. The space for the weight documentation on 11/11/15 was blank. The space for the weight documentation on 11/18/15 had the initials of an LPN, but no weight. The space for the weight documentation on 11/25/15 was blank. On 12/1/15 at 10:10 a.m., the administrator was asked for the weekly weights for the resident. She stated the weights should be documented on the treatment administration record. She then stated she would ask the DON to provide the requested documentation to the surveyor. At 10:15 a.m., the DON reviewed the November 2015 treatment administration record with the surveyor. The treatment administration record had all four weekly weights recorded in the spaces which were previously blank. The DON was advised the weights had been added since the previous day. She was then asked who had recorded the weights. The DON provided a blue sticky note which documented, Wt Weekly .178.6 .178.4 .179.8 .177.6. This was the only documentation on the sticky note. These weights corresponded to the four weights recorded on the treatment administration record. The DON stated she was unaware of who had documented the weights, but would look into it. At 10:30 a.m., the administrator approached this surveyor and stated she was unhappy regarding the late documentation of weights on the resident, and there would be an internal investigation into the situation. On 12/2/15 at 3:15 p.m., the facility was asked to weigh the resident using the same technique as the admission weight. CNA #8 and CNA #9 were observed using the mechanical lift to weigh the resident. He was placed in the sling and raised above his bed until no body parts were in contact with the bed. The weight was observed to be 154 pounds. At 3:30 p.m., the DON was asked if the weights on the resident's treatment administration record were accurate. She stated she only had confidence in the admission weight documented on 11/04/15. She was then asked who had recorded the weights after the copy had been provided on 11/30/15. She stated, I don't know. That's the investigation we are working on. She was asked which staff had initialed the weight box for 11/18/15 but not recorded the weight. She stated LPN #4 had confirmed during the facility investigation she had weighed the resident but did not know why it was not in the computer. The DON was informed about the resident's observed weight earlier in the day. She was asked if the resident weighed 178.6 pounds at admission and 154 pounds on 12/2/15, would this be considered severe weight loss. She stated yes, she would call the doctor and notify the family and dietician. She was asked if accurate weights were obtained as ordered by the physician, could this have prevented the resident's significant weight loss. She stated interventions could have been implemented sooner. At 3:40 p.m., LPN #4 was asked if she had weighed the resident on 11/18/15. She stated she had weighed the resident and entered it into the computer system but must not have saved it because it is not on the record. She was then asked if she remembered the resident's weight that day. She stated she did not remember exactly but it was in the high 150's. She compared it against the admission weight on 11/4/15 and noticed a 20 pound loss. LPN #4 noticed the weight for 11/11/15 had not been documented. She was asked if she considered this a significant weight loss. She said yes. She was asked if she notified the physician regarding the significant weight loss. She stated, No. I should have but didn't. At 4:05 p.m., the registered dietician was asked if she had been notified by the facility regarding nutritional concerns for the resident. She stated she had not. She was asked if the facility should contact her in instances of significant weight changes, and she stated, Yes. She was asked if she would consider a weight loss of 13.7% in one month severe. She stated, Yes. On 12/03/15 at 11:35 a.m., physician #2 was interviewed regarding the resident's weight loss. He was asked when he had first been contacted by the facility about the resident's weight loss. He stated 12/02/15. He was then asked if weights were important in determining if the caloric needs were being met for a resident who was getting all nutrition via PEG tube. He stated, Yes. He then stated he would be in later today to assess the resident's nutritional status.

Based on observation, record review, and interview, it was determined the facility failed to provide services to maintain the highest practicable physical well-being for one (#5) of six sampled residents reviewed for highest practicable well-being. Resident #5 experienced bruises to her face and neck and a skin tear on the cheek and leg. The facility failed to assess and monitor the resident after a head injury to determine if intervention was needed. The facility census was 104. Findings: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/05/12, documented the resident's cognition was moderately impaired with memory problems. The assessment documented the resident had moderate difficulty hearing and used a hearing aid. The assessment documented the resident required extensive assistance from one staff person with transfer, ambulation, and toilet use. The assessment documented the resident's balance was unsteady and was stabilized by assistance from the staff. The assessment documented the resident frequently yelled out. The assessment documented the resident had no falls since the previous assessment. The care plan, dated 07/16/12, documented the resident had a potential for decreased function in toileting and required one person supervision and physical assist for safety, had a history of [REDACTED]. A significant change assessment, dated 08/14/12, documented the resident's cognition was moderately impaired with memory problems. The assessment documented the resident had moderate difficulty hearing and used a hearing aid. The assessment documented the resident required extensive assistance from one staff person with transfer, ambulation, and toilet use. The assessment documented the resident's balance was unsteady and was stabilized by assistance from the staff. The assessment documented the resident frequently yelled out. The assessment documented the resident had no falls since the previous assessment. An incident report, dated 09/22/12, documented, "...INCIDENT DESCRIPTION AND INVESTIGATION Date of incident: 9/22/12 10:00 am Description of incident: Pt was noticed to have bruises on left eye, neck and a skin tear on left cheek and leg of unknown origin...Was medical device involved? No Was physician notified? Yes...Date 9/22/12 12:00 pm Physician name (name deleted)...CENTER ACTION: PATIENT'S CARE Was patient seen by a physician at the center? No...Describe care and medications, if any provided to patient following incident, and by whom provided. Pt's skin tears measured, cleaned and dressings applied...Was patient taken to hospital? No...CENTER ACTION: PATIENT FAMILY/GUARDIAN NOTIFICATION Name of person notified (name deleted) Date notified 9/22/12 12:00 pm Notification method: Left message, requested call name of staff notifying..." The first initial and last name of the licensed practical nurse (LPN) was documented on the form. The section for the name and title of the person preparing the report was blank. The signature and date were omitted from the form. The administrator signed the report on 09/24/12 and the director of nurses signed the report on 09/25/12. The form documented the incident was reported by the (name deleted) LPN and the status was completed. The form documented the date/time created was 09/23/12 12:49 a.m. and the form was printed on 09/24/12. The clinical record did not document neurological checks or routine vital signs had been monitored to determine if the resident exhibited changes in condition. The clinical record did not include a physician's orders [REDACTED]. The initial incident report to the Oklahoma State Department of Health (OSDH), dated 09/22/12, documented the incident occurred on 09/22/12 at 8:30 a.m. The type of incident was documented as an injury of unknown source. The box for allegations of abuse/mistreatment was not checked. The boxes for notifications made were all blank. The description of the incident was documented as a scratch to the resident's face possibly caused by the resident's glasses with a handwritten entry related to bruising to the upper cheek and a scratch to the lower leg. The report documented the resident's cognition was poor. The report did not document protective measures while the investigation was conducted. The fax time stamp was dated 09/22/12 at 10:47. A handwritten facility witness statement, dated 09/22/12, documented, "On 9-21-2012 (named deleted resident) didn't have any bruises. When I was in the dinning (sic) room for breakfast I looked at (name deleted resident) and said what happened to her and finished feeding my patient. When I got back on the hall I asked the nurse (name deleted) what happen (sic) she didn't know so we asked (name deleted resident) and she said she was hit by a aide." The statement was dated and signed by a facility employee. A handwritten facility witness statement, dated 09/22/12, documented, "CNA (certified nurse aide) (name deleted) on day shift reported to me that resident has a bruise to left eye and cheek also noted to have a approx 3 cm (centimeter) scratch/cut to left cheek. A small round bruise was on her neck. I raised up her pant leg and she has a skin tear to left leg. I ask resident 'how she got the bruises she said 'the girl that put me in bed, hit me three times, and told me to shut up, and stop yelling.' I reported this information to weekend supervisor (name deleted) LPN (licensed practical nurse)." The statement was dated and signed by a facility employee. A facility witness statement, dated 09/24/12 at 8:30 a.m., documented, "I received a call at 0830 on [DATE] from (name deleted) CNA. She wanted to know why she had been sent home for her Saturday, [DATE]-7 shift. Explained to her that (name deleted resident) had some injuries that apparently occurred during her shift on [DATE] and that while this was under investigation by administration she was on suspension until the matter was resolved. I asked her if she knew anything about the bruise and skin tear on (name deleted resident's) face or the skin tear on her left lower leg. She stated that she was getting the patient up to toilet her when she slipped and hit her head on the bedside table causing a small skin tear and bruise on her face. (Name deleted) stated she toileted (name deleted resident) and got her back into bed. (Name deleted) also stated that she got a wash cloth and dampened it and wiped some blood off resident's face which made the skin tear bleed more. I asked her if she told the nurse about the incident and she stated that she did not. When I asked her why she didn't tell the nurse about the injuries, she did not have an explanation." The statement was signed by a facility registered nurse (RN). A facility witness statement, dated 09/24/12, documented the social services director had asked the resident what happened to her face. The statement documented the resident stated "I don't know. Someone hit me. I don't know." The statement documented the resident was asked if she had fallen and the resident stated "No. I don't know, someone hit me. I don't know." The statement was signed by the social services director. A police report, dated 10/01/12, documented, "On 09/24/12 at approximately 16:30 (4:30 p.m.) (name deleted) and myself visited with (name deleted employee) by phone. (Name deleted employee) said resident fell . States she was taking resident to the bathroom. Resident had a hold of grab bar. She started to fall. (Name deleted employee) states the wheelchair was in the (sic) her getting to (name deleted resident) so she ran around to the other bathroom door and (name deleted resident) was on the floor. I asked (name deleted employee why she didn't notify the nurse of the fall. She couldn't give me an answer." The report was signed by the administrator. The report documented the signature of the police officer. A police report, dated 10/01/12, documented, "On 09/24/12 approx 4 pm myself and the administrator received a call from (name deleted) CNA when she stated she was assisting (name deleted resident) to the bathroom and was standing behind the wheelchair as (name deleted resident) pulled herself up (with) grab bar. (Name deleted) stated (name deleted resident) said she was falling so she left the room attempting to get into the next room with adjoining bathroom. She stated when she opened the door the pt had already fallen. She said she assisted her back into the wheelchair and put her back into bed and gave her a washcloth. She stated she did not notice injury until later and admitted she did not report the incident to the nurse. She was terminated at that time from employment." The report was signed by the director of nurses. The report documented the signature of the police officer. The final incident report sent to OSDH documented a check mark in the box for allegations of abuse/mistreatment. The document was fax time stamped 10/01/12 at 10:22 a.m. The electronic progress notes documented an entry on 09/20/12 related to the resident's weight and nutrition. The next electronic progress note, dated 09/22/12 at 3:30 p.m., documented, "Received report from 7-3 nurse about (name deleted) having a bruised left eye and cheek with a scratch down her left cheek. Resting in bed at this time." There was no documentation for 09/21/12 or 09/22/15 prior to 3:30 p.m. The next electronic progress note was dated 09/25/12 at 4:06 a.m. The note documented the resident was resting in bed with respirations even and unlabored. The note documented the resident received incontinent care as needed and denied pain at that time. The note documented the staff would continue to monitor the resident and the bed was in the lowest position with the call light within reach. On 10/04/11 at 11:00 p.m., the resident was observed in bed. Resolving bruising was noted around the resident's left eye and on the left cheek and neck. On 10/08/12 at 4:30 p.m., the resident was observed in bed. The resident did not have evidence of bruising around the eye or on the cheek and neck at that time. On 10/10/12 at 4:00 p.m., the director of nurses (DON) was interviewed regarding the protocol if someone had a head injury. The DON stated neurochecks were routinely done with a head injury and usually an x-ray was obtained. The DON was asked to provide a copy of the neurochecks, physician's orders [REDACTED]. The DON stated neurochecks had not been done and an x-ray was not ordered or obtained.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received adequate supervision and/or assistive devices to prevent accidents for 2 (#1 and #2) of 3 sampled residents who had sustained falls with injury. A. The facility failed to provide two person assistance to resident #2 during the provision of care as specified in the care plan. The resident rolled off the side of the bed, hit her head, sustained an intracranial bleed, and was admitted to the hospital. B. The facility failed to place bed bolsters on the bed of resident #1. The resident was found with her face to the floor with blood coming from the upper forehead. The resident was sent to the hospital for evaluation and treatment. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, created on 04/26/09, documented a history of falls due to imbalance and poor safety awareness. The care plan for this risk was initiated on 02/01/10. The goal was to minimize the risk for injury related to falls. The interventions were initiated on 02/01/10. Among the interventions was to provide assistance with transfer and must have two people to do turns, changes, and transfers. The care plan documented the resident was to be transferred with a full body lift due to her limitations related to contractures. The quarterly assessment, dated 10/22/10, documented the resident's cognition was intact. The assessment documented the resident required extensive assist of two persons for transfers and bed mobility. The resident information work sheet which each certified nurse aide (CNA) carried in their pocket had documentation that resident #1 needed assistance of two people with the mechanical sling lift and that she could be up in the wheel chair with the lift and two person assistance. The worksheet had been checked for two person assistance with turns and incontinent care. Nurse's Notes, dated 01/05/11 at 2:30 p.m., documented the physcian was notified of the resident falling out of bed and of her head "landing" up against an oxygen concentrator. The note documented the physcian gave an order to transfer to the hospital. The admitting hospitalist's history and physical, dated 01/05/11, documented, " . . .Intracranial bleed due to fall out of bed at nursing home." A neurosurgery consult, dated 01/06/11, documented, ". . . (Resident #2) is status [REDACTED]." An investigative interview report, dated 01/06/11, documented the administrator interviewed CNA #9. The report documented the CNA stated, "(Resident #2) requested I come change her. I had the other side of the hall. I was changing (resident) by myself. I turned to get a wipe and she fell off the side of the bed. States she ran out and got her nurse." The report documented, "I (the administrator) asked the employee if she rolled resident away from her? She states resident was in the middle of the bed on left side. (She) states she never left the resident alone. Only time she left her alone is when she fell and she went to get help." An undated, untimed, and unsigned hand written report was included in the investigative report data. It documented on 01/05/11 at approximately 3:00 p.m., CNA #9 was changing resident #2 when the resident rolled off the bed hitting her head on the oxygen concentrator. The report documented CNA #9 stated she turned to get a wipe when the resident rolled off the bed. The report documented Resident #2 told her mother the CNA left her on her side while she went to get some linen and that is when she rolled off the bed. The report documented CNA #9 had been suspended pending investigation. An addendum written on report, dated 01/07/11 at 7:30 a.m., documented, "Talked with (CMA #9) and terminated her employee." The discharge summary, dated 01/08/11, documented the discharge [DIAGNOSES REDACTED]. The Incident Report Form submitted to the Oklahoma State Department of Health, checked as the final report and dated 01/11/11, documented in part C the following: "Employee was changing resident when resident rolled off the bed hitting her head on the oxygen concentrator. Employee states she turned and reached for a wipe and resident rolled off the bed. Employee has been suspended pending investigation. Resident told family that employee was changing her when she saw that she had soiled her linen she left her unattended on her left side while she went and got new linen. She states this is when she fell . . . Employee was terminated." On 01/21/11 at 11:20 a.m., the resident was observed in her room. She was in bed and was awake and alert. When asked about the incident when she fell off the bed on 01/05/11, the resident stated she was "almost" on her stomach and that the "aid left to get linen." On 01/21/11 at 3:00 p.m., CNA #5 stated every nurse aide had a worksheet that was updated daily and included the care required for each of their residents. CNA #5 stated, "(There is) no excuse. They all have resident's needs in their pocket." On 02/08/11 at 4:00 p.m., the Director of Nursing stated, "The CNAs all have the Resident Information Worksheet which has all the care plan data for care. They just didn't follow their work sheets." 2. Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/02/10, documented the resident had a history of [REDACTED]. One of the interventions, initiated on 11/04/10, documented, "Ensure that bolsters are in place when in bed. Bed in low position with fall mats on floor beside bed." A significant change assessment, dated 07/23/10, and a quarterly assessment, dated 01/26/11, documented the resident required extensive to total assistance with all activities of daily living. The resident was readmitted to the facility on [DATE] after a hospitalization for acute care and treatment of [REDACTED]. Nurse's Notes, dated 01/15/11 at 9:30 a.m., documented, "I was walking into rm (room adjoining the rm of resident #1), when I heard moaning coming from (resident #1's room), went into the room & found the resident face down on the floor in a small puddle of blood. . .the resident had a laceration on the right side of her forehead that measured 1cm in length & width..." Nurse's notes at 9:45 a.m. documented the resident was sent to the hospital for evaluation and treatment. The History and Physical that was dictated on admission to the hospital on [DATE], documented under the review of systems: "There is a minor soft tissue injury on the right forehead which has been dressed by the emergency room doctor with a dressing, clean, dry and intact. There appears to be blood in the patient's mouth and on her teeth. . . ." An investigative statement, dated 01/15/11 and written by licensed practical nurse (LPN) #4, documented, "On January 14, 2011 (resident #1's husband) came up to me at my med (medication) cart and said, 'She (resident #1) needs those things on her bed.' I said bolsters, and he said yah. I told him I would have my aids look for some because while she was in the hospital be (sic) had to use hers for another pt (patient). (The resident's husband) seemed to get upset at this point. This happened around 1900 (7:00 p.m.). I turned to CNA (certified nurse aide #7) who was standing behind me and heard the conversation. I asked her to look for some. I than (sic) went to the nurses supply room & couldn't find any. I than (sic) went to the shower room by the nurses supply room & again there wasn't any. About 2000 (8:00 p.m.) CNA (#10) was walking down my hall & I asked him to help me with this same pt. We went into this pt's room & did a head to toe assessment . . . Sometime after this I asked (CNA # 7) if she had found any boulsters (sic) and she said no. After giving my shift to shift report to the oncoming night nurse, (LPN #3) & myself walked down to this pt room about 10:50 pm-10:55 pm. . . . Pt eyes were open. Call light was in reach and bed was positioned low to floor as far down as it would go. We than (sic) left the room. . .Than (sic) I clocked out and went home. . ." A statement written by CNA #8, dated 01/15/11, documented, "Came in @ 0700 (7:00 a.m.). There wasn't anyone here to do bed checks w/ (with) me or the other aide's. Started helping the nurse get vitals. When I got to (resident #1's) room to get her vitals she was sound asleep laying on her back, head elevated & bed in low position. Left the room & came back w/ the other aide @ 0730 (7:30 a.m.) to help get resident up & I checked on (resident #1) again & she was still laying in the same position. I nor the other aide never even noticed that (resident #1) didn't have bolsters b/c (because) she had pillows on each side. I finished passing breakfast trays & picking them up went to take hall cart back to kitchen & on my way back (RN#1) the nurse said that (resident #1) had fallen out of bed. When I got into the room resident was face first on the floor w/ a cut to her R (right) forehead & to the bridge of her nose." Another statement in the investigative file, dated 01/15/11, was not signed. The statement documented, "Re: (Resident #1) Received a call from D.O.N. (director of nursing) concerning resident fall. Ms (resident #1) had rolled out of bed. Resident returned from hospital on Friday. Saturday morning she fell . Resident had bolsters on her bed previously. However bolsters were not applied when she returned. . . ." A Statement by Witness, dated 01/17/11, written by RN #3, documented, "0930 (9:30 a.m.) received call from (RN#1) @ facility to report (resident #1) fell OOB (out of bed) resulting in a head laceration. Nurse reports that bed was in the low position, 0 (no) bolsters, 0 fall mats. Nurse states she made 1st round around 0645ish (6:45 a.m.), she didn't realize that there weren't bolsters on the bed because there were pillows sticking up on either side of her. States they were covered by a sheet so you couldn't physically see if they were bolsters vs. (versus) pillows. Nurse states she did not receive anything in report regarding bolsters. Spouse states that he told (description deleted) nurse & (description deleted) girl that his wife needs those things on her bed. Stated the nurse said she would get them before she left. (LPN #4), called & said that the pt's spouse did come up to her when she was standing at the cart with a CNA, whom she thought was (CNA #7), but wasn't really sure & said that his wife needed those things on her bed. Told him ok & that they would get them. (LPN #4) states she then turned to (CNA #7) & told her to get bolsters & put on the bed. (CNA #7) states she looked in A hall storage closet, didn't see any, & that is where she left it. She never reported to the nurse that she didn't find any. (CNA #7) said that she didn't think the pt. really needed them because she wasn't moving that much, they got busy, and they, her & (name deleted), left it at that. The 11/7 nurse states she didn't receive it in report. The 7/3 nurse states she didn't receive anything about it in report. (RN #1) on 7/3 states she personally found bolsters in the A hall closet & she sent (CNA #4) to the shed to get bolsters which she did & found without difficulty." The Incident Report Form, submitted to the Oklahoma State Department of Health and checked as the final report documented, "Resident was in a low bed and rolled our of bed. Had small cut on her forehead. Resident had been in the hospital for approximately 4 weeks. Resident returned to our facility on January 14th. Resident had bolsters on her bed before she left. However while she was in the hospital they were used for another resident. The Charge Nurse and the Nurse Aide were suspended pending investigation because the bolsters were not put on the resident's bed." Nurse's Notes, dated 01/19/11 4:45 p.m., documented the resident had arrived back to the facility. The note documented, "Scab to rt (right) forehead 3.3 cm (centimeters) x 2 cm. Bruising fading to forehead. . ." The hospital discharge summary, dated 01/19/11, documented in the final [DIAGNOSES REDACTED]."

Based on observation, interview, and record review, it was determined the facility failed to provide the needed care and/or needed equipment that had been documented in the care plan for two (#1 and #2) of three sampled residents who had sustained falls with injury. A. The facility failed to provide two person assistance to resident #2 during the provision of care as specified in the care plan. The resident rolled off the side of the bed, hit her head, sustained an intracranial bleed, and was admitted to the hospital. B. The facility failed to place bed bolsters on the bed of resident #1 as specified by the resident's care plan. The resident was found with her face to the floor with blood coming from the upper forehead. The resident was sent to the hospital for evaluation and treatment. Findings: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, created on 04/26/09, documented a history of falls due to imbalance and poor safety awareness. The care plan for this risk was initiated on 02/01/10. The goal was to minimize the risk for injury related to falls. The interventions were initiated on 02/01/10. Among the interventions was to provide assistance with transfer and must have two people to do turns, changes, and transfers. The care plan documented the resident was to be transferred with a full body lift due to her limitations related to contractures. The quarterly assessment, dated 10/22/10, documented the resident's cognition was intact. The assessment documented the resident required extensive assist of two persons for transfers and bed mobility. The resident information work sheet which each certified nurse aide (CNA) carried in their pocket had documentation that resident #1 needed assistance of two people with the mechanical sling lift and that she could be up in the wheel chair with the lift and two person assistance. The worksheet had been checked for two person assistance with turns and incontinent care. Nurse's Notes, dated 01/05/11 at 2:30 p.m., documented the physcian was notified of the resident falling out of bed and of her head "landing" up against an oxygen concentrator. The note documented the physcian gave an order to transfer to the hospital. The admitting hospitalist's history and physical, dated 01/05/11, documented, " . . .Intracranial bleed due to fall out of bed at nursing home." A neurosurgery consult, dated 01/06/11, documented, ". . . (Resident #2) is status [REDACTED]." An investigative interview report, dated 01/06/11, documented the administrator interviewed CNA #9. The report documented the CNA stated, "(Resident #2) requested I come change her. I had the other side of the hall. I was changing (resident) by myself. I turned to get a wipe and she fell off the side of the bed. States she ran out and got her nurse." The report documented, "I (the administrator) asked the employee if she rolled resident away from her? She states resident was in the middle of the bed on left side. (She) states she never left the resident alone. Only time she left her alone is when she fell and she went to get help." An undated, untimed, and unsigned hand written report was included in the investigative report data. It documented on 01/05/11 at approximately 3:00 p.m., CNA #9 was changing resident #2 when the resident rolled off the bed hitting her head on the oxygen concentrator. The report documented CNA #9 stated she turned to get a wipe when the resident rolled off the bed. The report documented Resident #2 told her mother the CNA left her on her side while she went to get some linen and that is when she rolled off the bed. The report documented CNA #9 had been suspended pending investigation. An addendum written on report, dated 01/07/11 at 7:30 a.m., documented, "Talked with (CMA #9) and terminated her employee." The discharge summary, dated 01/08/11, documented the discharge [DIAGNOSES REDACTED]. The Incident Report Form submitted to the Oklahoma State Department of Health, checked as the final report and dated 01/11/11, documented in part C the following: "Employee was changing resident when resident rolled off the bed hitting her head on the oxygen concentrator. Employee states she turned and reached for a wipe and resident rolled off the bed. Employee has been suspended pending investigation. Resident told family that employee was changing her when she saw that she had soiled her linen she left her unattended on her left side while she went and got new linen. She states this is when she fell . . . Employee was terminated." On 01/21/11 at 11:20 a.m., the resident was observed in her room. She was in bed and was awake and alert. When asked about the incident when she fell off the bed on 01/05/11, the resident stated she was "almost" on her stomach and that the "aid left to get linen." On 01/21/11 at 3:00 p.m., CNA #5 stated every nurse aide had a worksheet that was updated daily and included the care required for each of their residents. CNA #5 stated, "(There is) no excuse. They all have resident's needs in their pocket." On 02/08/11 at 4:00 p.m., the Director of Nursing stated, "The CNAs all have the Resident Information Worksheet which has all the care plan data for care. They just didn't follow their work sheets." 2. Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/02/10, documented the resident had a history of [REDACTED]. One of the interventions, initiated on 11/04/10, documented, "Ensure that bolsters are in place when in bed. Bed in low position with fall mats on floor beside bed." A significant change assessment, dated 07/23/10, and a quarterly assessment, dated 01/26/11, documented the resident required extensive to total assistance with all activities of daily living. The resident was readmitted to the facility on [DATE] after a hospitalization for acute care and treatment of [REDACTED]. Nurse's Notes, dated 01/15/11 at 9:30 a.m., documented, "I was walking into rm (room adjoining the rm of resident #1), when I heard moaning coming from (resident #1's room), went into the room & found the resident face down on the floor in a small puddle of blood. . .the resident had a laceration on the right side of her forehead that measured 1cm in length & width..." Nurse's notes at 9:45 a.m. documented the resident was sent to the hospital for evaluation and treatment. The History and Physical that was dictated on admission to the hospital on [DATE], documented under the review of systems: "There is a minor soft tissue injury on the right forehead which has been dressed by the emergency room doctor with a dressing, clean, dry and intact. There appears to be blood in the patient's mouth and on her teeth. . . ." An investigative statement, dated 01/15/11 and written by licensed practical nurse (LPN) #4, documented, "On January 14, 2011 (resident #1's husband) came up to me at my med (medication) cart and said, 'She (resident #1) needs those things on her bed.' I said bolsters, and he said yah. I told him I would have my aids look for some because while she was in the hospital be (sic) had to use hers for another pt (patient). (The resident's husband) seemed to get upset at this point. This happened around 1900 (7:00 p.m.). I turned to CNA (certified nurse aide #7) who was standing behind me and heard the conversation. I asked her to look for some. I than (sic) went to the nurses supply room & couldn't find any. I than (sic) went to the shower room by the nurses supply room & again there wasn't any. About 2000 (8:00 p.m.) CNA (#10) was walking down my hall & I asked him to help me with this same pt. We went into this pt's room & did a head to toe assessment . . . Sometime after this I asked (CNA # 7) if she had found any boulsters (sic) and she said no. After giving my shift to shift report to the oncoming night nurse, (LPN #3) & myself walked down to this pt room about 10:50 pm-10:55 pm. . . . Pt eyes were open. Call light was in reach and bed was positioned low to floor as far down as it would go. We than (sic) left the room. . .Than (sic) I clocked out and went home. . ." A statement written by CNA #8, dated 01/15/11, documented, "Came in @ 0700 (7:00 a.m.). There wasn't anyone here to do bed checks w/ (with) me or the other aide's. Started helping the nurse get vitals. When I got to (resident #1's) room to get her vitals she was sound asleep laying on her back, head elevated & bed in low position. Left the room & came back w/ the other aide @ 0730 (7:30 a.m.) to help get resident up & I checked on (resident #1) again & she was still laying in the same position. I nor the other aide never even noticed that (resident #1) didn't have bolsters b/c (because) she had pillows on each side. I finished passing breakfast trays & picking them up went to take hall cart back to kitchen & on my way back (RN#1) the nurse said that (resident #1) had fallen out of bed. When I got into the room resident was face first on the floor w/ a cut to her R (right) forehead & to the bridge of her nose." Another statement in the investigative file, dated 01/15/11, was not signed. The statement documented, "Re: (Resident #1) Received a call from D.O.N. (director of nursing) concerning resident fall. Ms (resident #1) had rolled out of bed. Resident returned from hospital on Friday. Saturday morning she fell . Resident had bolsters on her bed previously. However bolsters were not applied when she returned. . . ." A Statement by Witness, dated 01/17/11, written by RN #3, documented, "0930 (9:30 a.m.) received call from (RN#1) @ facility to report (resident #1) fell OOB (out of bed) resulting in a [MEDICAL CONDITION]. Nurse reports that bed was in the low position, 0 (no) bolsters, 0 fall mats. Nurse states she made 1st round around 0645ish (6:45 a.m.), she didn't realize that there weren't bolsters on the bed because there were pillows sticking up on either side of her. States they were covered by a sheet so you couldn't physically see if they were bolsters vs. (versus) pillows. Nurse states she did not receive anything in report regarding bolsters. Spouse states that he told (description deleted) nurse & (description deleted) girl that his wife needs those things on her bed. Stated the nurse said she would get them before she left. (LPN #4), called & said that the pt's spouse did come up to her when she was standing at the cart with a CNA, whom she thought was (CNA #7), but wasn't really sure & said that his wife needed those things on her bed. Told him ok & that they would get them. (LPN #4) states she then turned to (CNA #7) & told her to get bolsters & put on the bed. (CNA #7) states she looked in A hall storage closet, didn't see any, & that is where she left it. She never reported to the nurse that she didn't find any. (CNA #7) said that she didn't think the pt. really needed them because she wasn't moving that much, they got busy, and they, her & (name deleted), left it at that. The 11/7 nurse states she didn't receive it in report. The 7/3 nurse states she didn't receive anything about it in report. (RN #1) on 7/3 states she personally found bolsters in the A hall closet & she sent (CNA #4) to the shed to get bolsters which she did & found without difficulty." The Incident Report Form, submitted to the Oklahoma State Department of Health and checked as the final report documented, "Resident was in a low bed and rolled our of bed. Had small cut on her forehead. Resident had been in the hospital for approximately 4 weeks. Resident returned to our facility on January 14th. Resident had bolsters on her bed before she left. However while she was in the hospital they were used for another resident. The Charge Nurse and the Nurse Aide were suspended pending investigation because the bolsters were not put on the resident's bed." Nurse's Notes, dated 01/19/11 4:45 p.m., documented the resident had arrived back to the facility. The note documented, "Scab to rt (right) forehead 3.3 cm (centimeters) x 2 cm. Bruising fading to forehead. . ." The hospital discharge summary, dated 01/19/11, documented in the final [DIAGNOSES REDACTED]."

Based on record review, observation, staff and resident interviews, it was determined the facility failed to: a) Ensure one (#15) sampled resident, with a history of a compression fracture, was not left in the same position for over four hours, while complaining of lower back pain. The actions of the facility consisted of actual harm by not controlling the pain level of resident #15. Six residents were sampled for pain. This had the potential to affect 40 residents identified by the facility on a pain management program. b) Ensure one (#14) of five sampled diabetic residents, did not experience a hypoglycemic episode, after waiting an extended amount of time, before receiving the evening meal, after receiving an insulin injection. This had the potential to affect 33 diabetic residents identified by the facility. c) Ensure thorough indwelling urinary catheter care was provided for one (#2) of five sampled residents with indwelling urinary catheters. This had the potential to affect 9 residents identified by the facility with indwelling urinary catheters. d) Ensure parameters for high blood sugars were in place for one (#10) of five sampled diabetic residents. This had the potential to affect 33 residents identified by the facility with diabetes. e) Ensure one (#3) of five sampled residents with indwelling urinary catheters had a physician's order and a justification for the use of the catheter. This had the potential to affect 9 residents identified by the facility with indwelling urinary catheters. Findings: 1. Resident #15 had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. A pain assessment dated [DATE], documented, "Cause Orthopedic condition, Gastrointestinal condition, Neurological condition, Cardiovascular condition Pattern Greater than 6 months... Location Lower back Description Somatic: Aching, Throbbing, Stabbing Description Visceral "Hurts all over" Tightness Cramping Gnawing Relieving Factors Medication Repositioning Contributing Factors Position changes Psychological Components Does the pain/discomfort negatively affect any of the following areas? (check all that apply (the following were checked) Sleep Sitting Mood/emotions ADLs Lying Medications Prescription pain medications: Yes Effective/ineffective Effective... Please describe medication history Tylenol 500mg 2 tabs daily @ 5 pm... Intensity Pain score: Present pain 4 Pain at worst 10 Pain at best 4 Patient Goal What is patient's goal for pain/discomfort 3 Care plan Care plan revised" A pain assessment dated [DATE], documented, "Cause Orthopedic condition, Gastrointestinal condition, Cardiovascular condition Pattern Greater than 6 months... Location Lower back Description Somatic: Aching, Throbbing, Stabbing Stiff/sore Description Visceral "Hurts all over" Tightness Cramping Gnawing Relieving Factors Medication Repositioning Contributing Factors Position changes Psychological Components Does the pain/discomfort negatively affect any of the following areas? (check all that apply (the following were checked) Sleep Mood/emotions Medications Prescription pain medications: Yes Effective/ineffective Effective... Please describe medication history Tylenol 500mg 2 tabs daily @ 5 pm... Intensity Pain score: Present pain 4 Pain at worst 10 Pain at best 4 Patient Goal What is patient's goal for pain/discomfort 3 Care plan Care plan revised" An annual assessment, dated 05/23/10, identified the resident with long and short term memory loss, modified independence, required extensive assistance with bed mobility, transfers, walking in room, did not walk in corridor and personal hygiene, required total assistance with dressing and bathing, the wheelchair was the primary mode of locomotion, was frequently incontinent of bladder, totally incontinent of bowel, experienced pain less than daily with moderate back and stomach pain. A RAP narrative, dated 05/23/10, documented, "Mrs. (Resident) is at risk for skin break down, pain, and depression. Will proceed to care plan. Mrs. (Resident) is an [AGE] year old who has been a resident at this facility for several years. She is weak and needs assistance with her ADLs including incontinent care." A care plan revised on 05/11/10, documented, "Focus Generalized pain evidenced by c/o, grimacing related to S/P compression fracture of [MEDICATION NAME] Spine Goals Will express that pain management is within acceptable limits. Stated acceptable level is 3. Interventions Monitor for and report any nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc [MEDICATION NAME] to back every morning & remove at HS Administer pain medication as per MD orders and note the effectiveness Evaluate pain characteristics: intensity, location, precipitating/relieving factors Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective." The resident had physicians' orders, originally ordered on [DATE], and signed on 06/01/10, for "[MEDICATION NAME] 5% ADH patch apply 1 patch to back every morning at 6 AM and remove at 6 PM (DX: Pain) [MEDICATION NAME] 500mg tablet-IE Tylenol extra strength 2 tabs (1000mg) by mouth every day at 5 PM for pain management." A routine medication sheet for June 2010, documented "Monitor pain level using 1-10 scoring scale or behavioral scoring scale on 7-3 shift on even days and 3-11 shift on odd days." The pain score was 4 on the 3-11 shift on 06/01/10. The pain score was 0 on the 7-3 shift on 06/02/10. The pain score was 6 on the 3-11 shift on 06/03/10. A pain assessment dated [DATE], documented, "Cause Orthopedic condition, Gastrointestinal condition, Neurological condition, Cardiovascular condition Pattern Greater than 6 months... Location Denies pain at this time Description Somatic: N/A Description Visceral N/A Relieving Factors Medication Repositioning Contributing Factors Unable to state as she is having no pain now Psychological Components Does the pain/discomfort negatively affect any of the following areas? (check all that apply) the following were checked Sleep Activities ADLs Lying Medications Prescription pain medications: Yes Effective/ineffective Effective... Please describe medication history Tylenol 500mg 2 tabs daily @ 5 pm... Intensity Pain score: Present pain 0 Pain at worst 6 Pain at best 0 Patient Goal What is patient's goal for pain/discomfort 3 Care plan Care plan revised" A nurse's note dated 06/03/10 at 11:45 a.m., documented, "Pain assessment completed @ this time. Phy notified of past 30 days pain scores & current regimen. Phy D/C'd [MEDICATION NAME] Patch to back @ this time as res states it is "not any good" Will continue to monitor pain scores. Res states acceptable level is "3". Pts family notified of order change @ this time." A routine medication sheet for June 2010, documented "Monitor pain level using 1-10 scoring scale or behavioral scoring scale on 7-3 shift on even days and 3-11 shift on odd days." From 06/04/10 until 06/24/10, the resident scored a four 12 times. On 06/23/10 at 6:45 a.m., the resident was observed in the dining room, waiting for the morning meal. At 6:50 a.m., LPN #2 was interviewed. He was asked which residents were awoken early. He stated, "I get up the feeders. We have a get up list. I get those residents up." At 7:00 a.m., LPN #1 was asked which residents are awoken early. She stated, "I have two people on the get up list." She was then asked what time does the facility start waking up residents. She stated, "Between 5:30 and 6:00 a.m." On 06/23/10 at 8:40 a.m., the resident was taken from the dining room to her room. The resident was sitting in a W/C beside the bed. CNA #5 was observed assisting the resident in bed A. Resident #15 was heard groaning. CNA #5 stated, "I can't put you back to bed until I make your bed." The resident stated, "Hurry. The longer I sit up the more it hurts." She was asked by the surveyor what time she got up. She stated, "(LPN #2) said it was 4 o'clock. He believes in getting me up early." At that time, CNA #5 stated, "No wonder her back hurts. She complains of her back hurting every morning." At 8:50 a.m., the resident remained in the W/C at the side of the bed. She continued to complain of her back hurting, stating, "Oh God help me. Please put me to bed." At 9:10 a.m., the resident remained in the W/C, at the side of the bed, stating, "Just to stretch out would be good." At that time, CNA #5 placed a gait belt around the resident and assisted the resident to stand. The resident was heard groaning and stating, "Oh," when her position was changed. On 06/23/10 at 10:30 a.m., the resident's MAR indicated [REDACTED]. At that time, the DON who was also at the medication cart, was asked if anything else had been ordered to control the resident's pain. She reported nothing else had been ordered. She reported the [MEDICATION NAME] would be ordered again and the facility would pay for it. A nurse's note on 06/23/10 at 7:05 p.m., documented, "New order received to give pt. BID [MEDICATION NAME] and [MEDICATION NAME] jelly 2% BID PRN. All new orders noted and faxed by nurse. Nurse also spoke c pharmacy regarding covering cost of [MEDICATION NAME]. Pharmacy will send over approval papers for [MEDICATION NAME]." 2. Resident #10 had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. An initial assessment dated [DATE], identified the resident with short term memory loss, required supervision with dressing, eating and bathing and moderate assist with transfers and ambulation. The resident had a physician's order, on admission, "FSBS before meals and at bedtime, Humalog 100U/1ml Ins. vial PE sliding scale. If FSBS is less than 60 and alert give OJ (orange juice) and snack. If FSBS is less than 60 and not alert give [MEDICATION NAME] IM and call PCP If FSBS us 0-150 give no insulin If FSBS us 151-200 give 2 Units insulin SQ If FSBS us 201-250 give 3 Units insulin SQ If FSBS us 251-300 give 4 Units insulin SQ If FSBS us 301-350 give 6 Units insulin SQ If FSBS is greater than 350 give 8 Units SQ" The sliding scale insulin orders did not include when to call the physician when the FSBS was over 350mg/dl. On 05/06/10, the physician wrote an order to D/C the sliding scale insulin orders, but continued the FSBS AC and at HS. The May 2010, routine medication record documented the following: 28 FSBSs between 300-400mg/dl and 4 FSBS over 400mg/dl. There was no evidence the physician was notified of any of the FSBS between 300 and 400 mg/dl nor of the FSBS over 400. No other interventions were put in place to lower the FSBS. The June 2010, routine medication record documented the following: 11 FSBSs between 300-400mg/dl. There was no evidence the physician was notified of any of the FSBS between 300 and 400 mg/dl. No other interventions were put in place to lower the FSBS. On 06/23/10 at 2:35 p.m., the DON was notified of the high FSBSs without interventions to reduce the FSBSs. She reported the physician did not want him to have insulins related to his blood sugars bottoming out. She reported the physician should have been notified of the high blood sugars. The facility's policy and procedure for "Catheter Care: Indwelling Catheter," follows: "...Procedure: Verify physician's order... Male: Wash area around catheter insertion site, from meatus outward and then wash from tip of penis down to body including scrotum and skin folds. Use alternate sites on washcloth with each downward stroke Rinse using same procedure with clean washcloth Pat dry with towel..." 3. Resident #2's [DIAGNOSES REDACTED]. An annual assessment, dated 10/10/09, identified the resident with poor decision making skills, short and long term memory problems, was occasionally incontinent of bowel, had an indwelling catheter and a UTI the last 30 days. The resident's care plan documented the following: "Focus Use of Foley catheter (size 16, 30ml balloon) needed due to disease process [MEDICAL CONDITION] Goals Will have no acute complications of urinary catheter use. Interventions ...Monitor intake and/or output... Catheter care per MD orders..." A 5 day Medicare assessment, dated 02/22/10, identified the resident had a UTI in the last 30 days. A 14 day Medicare assessment, dated 02/25/10, identified the resident had a UTI in the last 30 days. A 30 day Medicare assessment, dated 03/11/10, identified the resident had a UTI in the last 30 days. The physician's orders for June 2010, documented, "Foley cath care with soap and water every shift." On 06/23/10 at 2:45 p.m., CNA #1 and CNA #2 were observed, providing incontinent care and catheter care for the resident. CNA #2, with gloves on, cleaned the BM from the resident. The CNA then changed the soiled gloves and provided the catheter care. The CNA took peri wipes, wiped the groin areas first and then with another wipe, cleaned around the top sides of the penis. Then using the same peri wipe, the CNA cleaned around the meatus. The CNA, then taking another peri wipe, cleaned straight down the tubing, of the catheter. On 06/24/10 at 1:35 p.m., the DON was informed of the catheter care, observed the day before. The DON was shown the physician's order for the catheter to be cleaned, using soap and water. The DON reported the CNAs did not do the catheter care correctly. 4. Resident #14's [DIAGNOSES REDACTED]. The resident had been admitted to the facility, after a fall at home with fractures. The "Physician's Admission Order," dated 06/03/10, documented, "FSBS AC & HS; Humalog Insulin per sliding scale: if FSBS is 200-250 give 1 unit, 251-300 give 2 units, 301-400 give 3 units (in addition to routine 6 units); Novalog Insulin 6 units SQ c meals; [MEDICATION NAME] 20 units SQ Q HS." A care plan dated 06/04/10, documented: "Focus Endocrine system need for monitoring related to: Insulin dependent diabetes Goals To minimize/be free of complications related disease process Interventions Administer medication as per MD orders and monitor effectiveness Monitor and record % of meals consumed Monitor glucometer readings and lab values as ordered Monitor lab work per MD orders and notify of abnormalities" A 14 day Medicare assessment, dated 06/14/10, identified the resident with poor decision making skills, short and long term memory loss, restlessness, repetitive physical movements, verbally abusive, physically abusive, required extensive assistance with transfers, required extensive assistance with eating, ROM deficits of both arms and one hand. A treatment form, dated June 2010, documented the following: "FSBS AC & HS; Humalog per sliding scale If FSBS < 60 or > 400 Notify Physician 200-250 give 1 unit SQ 251-300 give 2 units SQ 301-400 give 3 units SQ If FSBS 0-60 & unable to swallow give [MEDICATION NAME] & call MD If FSBS 0-60 & able to swallow give OJ and snack & call MD Novalog insulin: Give 6 units SQ c each meal [MEDICATION NAME] 20 units Q HS." A physician's order, dated 06/16/10, documented, "...Change [MEDICATION NAME] to AM & start Thursday AM..." On 06/22/10 at 6:30 p.m., the resident was observed, sitting and slumped over, at a table in her W/C, waiting on her supper meal. The resident had her head down with her eyes closed. The supper meal was late. (Per the treatment sheet, 6 units of the Novalog insulin, had been given to the resident at 5:00 p.m. The order documented given with each meal.) An hour and a half, after the insulin had been given, the resident was observed, still waiting to be fed and was lethargic. Two hours, after the insulin had been injected, at 7:00 p.m., the PT Director was observed speaking to the resident, trying to arouse her. The resident was lethargic and did not respond to verbal or physical stimulation. The PT Director, after the resident did not respond, rolled the resident out of the dining room, down to the resident's room. In the resident's room, the PT Director attempted, to get the resident to drink a glass of orange juice. The PT Director was talking to and patting the resident. The resident remained lethargic and unable to drink the OJ. LPN #3, obtained the resident's FSBS. The glucometer results registered 64. The LPN, then injected [MEDICATION NAME], into the resident's abdomen. Within several minutes, the resident began to respond to verbal stimuli. When alert enough, the resident was able to drink the glass of OJ. A nurse's note, dated 06/22/10 at 7:45 p.m., documented, "1945 Res found in dining room by staff lethargic. Res taken back to room to be accessed by nurse. VS at this time 128/62, 68, 97.5, 16. FSBS @ 64 at this time. Pt. given [MEDICATION NAME] per physician orders. Res also given OJ and milk. FSBS rechecked and was 100. Res alert and responsive at this time. Res was fed dinner by staff at this time. (Physician) on-call paged to notify of low FSBS. Nurse also left a message for family to call nurse back. Nurse will cont to monitor pt's condition." A nurse's note at 8:00 p.m., documented, "Nurse re-paged (Physician) on-call to notify of low BS." A nurse's note at 11:45 p.m., documented, "Nurse notified facility's medical director (Physician) of low FSBS. New orders to hold routine Novalog until seen by physician on 6/23/10 New order also obtained to change pt's [MEDICATION NAME] parameters. Full assessment done on pt. tonight. FSBS of 224 at 2100. Pt. received SSI per orders. Pt. alert at this time c 0 S/S of hyper or hypoglycemic." A nurse's note at 12:00 a.m., documented, "Family notified of pt. low FSBS of 64 today by nurse." The physician's orders dated 06/22/10, documented: "1) D/C previous [MEDICATION NAME] orders. 2) Give [MEDICATION NAME] 1mg. if FSBS 65 or below. 3) Hold routine Novalog until seen by the Dr." On 06/23/10, a physician's order, documented, "D/C before meal Novalog." On 06/23/10 at 8:50 a.m., the resident was observed in her W/C. The PT Director, asked the resident how she felt and the resident stated, "I'm really tired." At 9:10 a.m., the DON was interviewed regarding the incident the night before, with the resident getting insulin and not getting her food. The DON stated, "She's (the resident) to get insulin with meals per the doctor, but we gave her insulin at 5:30, so she could have her meal at 5:45 p.m., but as you know, the meal was late." The DON stated, "The nurse should have called the doctor immediately, after giving the [MEDICATION NAME] and not waited." The DON reported the nurse had told her the reason she hadn't called the physician, after the [MEDICATION NAME] injection, was because she thought she would wait to recheck the BS and then call the doctor. The DON stated, "I told her the order does not say to wait." 5. A significant change assessment dated [DATE], for resident #3, documented the resident had inadequate short term memory, adequate long term memory, had modified independence with decision making, required extensive assistance with bed mobility and with transferring between surfaces, was not ambulatory, incontinent of bowel and utilized an indwelling urinary catheter. A care plan dated 05/24/10, documented: "Focus: Urinary Incontinence related to impaired mobility,[MEDICAL CONDITION] left [MEDICAL CONDITION] Interventions: Provide assistance with toileting or provide incontinence care as needed." The June 2010, physician's orders documented the resident's [DIAGNOSES REDACTED]. The physician's orders did not contain an order for [REDACTED]. On 06/23/10 at 10:20 a.m., the resident was observed lying in her bed. An indwelling urinary catheter bag was observed hanging on the side of the resident's bed. On 06/23/10 at 11:50 a.m., RN #1 was interviewed. She was asked if the resident had a physician's order for the indwelling urinary catheter. The RN later reported the resident had returned from the hospital on [DATE], with the catheter. There had not been a physician's order for the indwelling urinary catheter, but she (RN #1) had contacted the physician and he had ordered the catheter to be discontinued.