Every finding on record at Family Care Center of Kingston

Based on observation, record review, and interview, the facility failed to provide dignity for 1 (#1) of 1 sampled resident reviewed an indwelling urinary catheter. The DON identified three residents with indwelling urinary catheters. Findings: On 07/28/25 at 2:23 p.m., Res #1 was observed lying in bed with their eyes closed. The resident's indwelling urinary catheter bag was hanging from the bedside uncovered. On 07/29/25 at 9:53 a.m., Res #1 was observed lying in bed watching television. The resident's indwelling urinary catheter bag was hanging from the bedside and did not have a privacy cover. On 07/30/25 at 12:21 p.m., Res #1's indwelling urinary catheter bag was observed hanging from the bedside uncovered and was in full view from the resident's doorway. A facility policy titled Quality of Life - Dignity, revised 08/2009, read in part, Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered An undated transfer/discharge report showed Res #1 had diagnoses which included cerebral infarction, chronic pain, urinary tract infection, and benign prostatic hyperplasia. An annual assessment, dated 07/07/25, showed Res #1's memory was ok and was independent for daily decision making. The assessment showed the resident had an indwelling catheter. On 07/30/25 at 1:33 p.m., certified nursing assistant #1 stated Res #1's indwelling urinary catheter bag was not covered and should be placed in a privacy bag. On 07/30/25 at 1:39 p.m., LPN #1 stated indwelling urinary catheter bags should be in a privacy bag. On 07/30/25 at 2:33 p.m., the DON stated residents with indwelling urinary catheters should have their catheter bags in a privacy bag.

Based on record review and interview, the facility failed to ensure residents were offered the opportunity to create an advance directive for 2 (#38 and #43) of 3 sampled residents reviewed for advanced directives.The administrator identified 38 residents resided in the facility.Findings: An Advance Directive policy, revised 12/2016, read in part, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.Written information will include a description of the facility's policies to implement advance directives.Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive.Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. 1. An undated Transfer/Discharge report for Resident #38 showed the resident was admitted to the facility on [DATE]. A review of Resident #38's electronic health record showed no advance directive information had been provided. 2. An undated Transfer/Discharge report for Resident #43 showed the resident was admitted to the facility on [DATE]. A review of Resident #43's electronic health record showed no advance directive information had been provided. On 07/30/25 at 11:36 a.m., the MDS coordinator stated, As of right now we do not have an advance directive for [Resident #38] or [Resident #43].

Based on record review and interview, the facility failed to complete a significant change assessment for 1 (#30) of 12 sampled residents whose assessments were reviewed. The administrator identified 38 residents resided in the facility.Findings:An undated discharge/transfer report showed Res #30 had diagnoses which included acute kidney failure, dementia, and disorder of the skin and subcutaneous tissue. A physician order, dated 06/13/25, showed Res #30 had an order to admit to hospice service for a diagnosis of heart disease with heart failure. The electronic record for Res #30 showed a significant change assessment, dated 06/18/25, was in progress. On 08/04/25 at 11:22 a.m., the MDS coordinator was interviewed regarding a significant change assessment still in progress dated 06/18/25 for Resident #30. The MDS coordinator stated a significant change assessment was to be completed 14 days after a resident was admitted for hospice services. The MDS coordinator stated a significant change assessment was not completed in the required time frame and was an oversite.

Based on record review and interview, the facility failed to ensure care plans were revised for 2 (#3 and #25) of 12 sampled residents reviewed for care plans.The administrator identified 38 residents resided in the facility.Findings:1. A physician's order for Resident #3, dated 04/16/25, showed to admit the resident to hospice for diagnosis of dementia.A review of Resident #3's care plan showed no documentation of the resident being on hospice.On 07/30/25 at 1:22 p.m., the MDS coordinator stated Resident #3's care plan did not reflect the resident was on hospice.2. Resident #25's Order Summary Report, dated 07/31/25, showed the resident had diagnosis of gastro-esophageal reflux disease.A review of Resident #25's electronic health record showed the resident weighed 190 pounds on 05/29/25 and 163.4 pounds on 07/30/25. This was a 14% weight loss in two months.A review of Resident #25's care plan showed no documentation or interventions for Resident #25's weight loss.On 08/04/25 at 11:24 a.m., the MDS coordinator stated Resident #25's care plan had not been updated to reflect the resident having weight loss.

Based on observation, record review, and interview, the facility failed to implement their policy for enhanced barrier precautions and hand hygiene for 1 (#19) of 1 sampled resident reviewed for enhanced barrier precautions.The DON identified seven residents on enhanced barrier precautions. Findings:On 07/31/25 at 10:34 a.m., LPN #1 was observed providing wound care for Resident #19. No signage was posted at the door for enhanced barrier precautions. LPN #1 gathered wound care supplies per the physician orders and placed them on the barrier on the bedside table. LPN #1 donned a pair of gloves and removed the old dressing. LPN #1 did not wash their hands prior to donning gloves. LPN #1 changed their gloves and used gauze with wound wash to clean the wound. LPN #1 placed the calcium alginate dressing (wound dressing) on the wound to the right foot. LPN #1 did not wash their hands with each glove change. LPN #1 was not wearing a gown.An undated facility form titled Enhanced Barrier Precautions (EBP) Decision Making-Algorithm showed if a resident had a wound or indwelling medical device and was not infected, enhanced barrier precautions should be used. The form showed chronic wounds included, but were not limited to: pressure ulcers, diabetic foot ulcers, unhealed/dehisced surgical wound, and venous stasis ulcers. Undated facility signage titled ENHANCED BARRIER PRECAUTIONS EVERYONE MUST, read in part, Wear gloves and a gown for the following High-Contact Resident Care Activities.Wound Care: any skin opening requiring a dressing A facility policy titled Handwashing/Hand Hygiene, revised 08/2015, read in part, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:.Before and after direct contact with residents.Before donning sterile gloves.Before handling clean or soiled dressings, gauze pads, etc.After removing gloves An undated transfer/discharge report showed Res #19 had diagnoses which included altered mental status, morbid obesity, and encounter for change or removal of surgical wound. A physician order, dated 07/17/25, showed staff were to clean a stage 3 pressure ulcer to the right lateral ankle with saline, pat dry, apply calcium alginate, wrap with Kerlix (gauze bandage roll), and secure with an ACE wrap (elastic bandage) every other day. On 07/31/25 at 10:50 a.m., LPN #1 stated enhanced barrier precautions were not required for Res #19 with a wound because it was not a chronic wound. LPN #1 was asked when handwashing was to be performed. LPN #1 stated handwashing should be with glove changes, when visibly soiled, and when moving from clean to unclean surfaces. LPN #1 stated they did not wash their hands when entering Res #19's room or with each glove change and should have. On 07/31/25 at 10:55 a.m., the DON stated enhanced barrier precautions were used for chronic unhealing wounds, not wounds that could be healed. On 07/31/25 at 11:14 a.m., the DON reviewed the facility policy for enhanced barrier precautions and stated they had misread the policy. The DON stated enhanced barrier precautions should be used for wounds with an open healing area and dressing. On 07/31/25 at 11:40 a.m., the DON stated staff should wash their hands when entering a resident room for care and with each glove change.

Based on observation, record review, and interview, the facility failed to maintain the ice machine in a safe and sanitary manner. The Administrator reported 34 residents resided in the facility. Findings: On 03/19/24 at 11:15 a.m., the ice machine in the main hallway near the facility dining room was observed to be unlocked. The ice machine was observed to remain unlocked throughout the day. On 03/20/24 at 9:54 a.m., the ice machine was observed to remain unlocked. A scoop was observed to be kept in a holder mounted on the wall beside the machine. The surveyor used a white paper towel and wiped along the upper inside of the ice machine. A jelly-type, brownish-orange substance was observed on the paper towel. The substance on the paper towel was shown to the dietary manager and maintenance staff. The dietary manager reported dietary staff were responsible for cleaning the scoop. She stated there was a lock and key for the ice machine but she didn't know where it was located. Maintenance staff reported the ice machine was maintained by an outside company and that he usually scheduled the cleaning to be done monthly. On 03/20/24 at 10:25 a.m., preventive maintenance reports from an outside company were provided. The most recent report/invoice documented the ice machine was cleaned and serviced on 01/23/24. On 03/20/24 at 10:30 a.m., the administrator reported the ice machine should be locked when not in use. The administrator stated since the ice machine is in the hallway and exposed to all traffic, it was her expectation it should be locked when not in use.

Based on record review and interview, the facility failed to complete a significant change assessment, when the resident required hospice services, for one (#25) of one resident reviewed for significant change. The Administrator reported 34 residents resided in the facility. Findings: A Resident Assessment Instrument policy, dated September 2010, documented the assessment coordinator would be responsible for ensuring the interdisciplinary assessment team conducted timely resident assessments and reviews when there had been a significant change in the resident's condition. Resident #25 had diagnoses which included protein-calorie malnutrition and diabetes mellitus. A progress note, dated 09/18/23 at 5:51 p.m., documented staff had talked with the resident's son and it was agreed the resident would benefit from hospice services. The note documented the resident's primary care physician was notified of the resident's decline and the physician ordered a hospice evaluation. A physician's order, dated 09/19/23, documented the resident would receive hospice care for a diagnosis of protein-calorie malnutrition. A progress note, dated 09/28/23 at 5:04 p.m., documented resident #25 was now on hospice. The note documented the resident was refusing meals and continued to lose weight. A quarterly MDS assessment, dated 11/03/23, documented the resident received hospice care. Resident #25's care plan, dated 02/22/24, documented the resident was admitted to hospice care for protein-calorie malnutrition. On 03/21/24 at 10:30 a.m., the MDS coordinator reported a significant change assessment should have been completed when the resident had a decline and required hospice services. The MDS coordinator stated she had updated the resident's care plan about a week later but failed to complete the significant change assessment.

Based on record review and interview, the facility failed to ensure the resident assessment was transmitted within seven days of completion for one (#19) of one sampled resident reviewed for discharge assessments. The Administrator identified 34 residents resided in the facility. Findings: A Submission and Correction of the MDS Assessments document, read in part, .All Medicare and/or Medicaid-certified nursing homes and swing beds or agents of those facilities, must transmit required (MDS) data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system . On 03/20/24 at 4:32 p.m., the clinical record documented resident #19 was admitted on [DATE] and discharged on [DATE]. The facility EMR showed a discharge, return anticipated, in progress and dated 11/20/23. On 03/21/24 at 3:45 p.m., the MDS coordinator reported the discharge assessment for resident #19 was completed on 11/22/23 but had not been signed by the registered nurse. On 03/21/24 at 3:45 p.m., the RN/DON reported they had not signed the discharge assessment, which resulted in the assessment not being transmitted as required.

Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#2) of 12 residents sampled for care plans. The Administrator identified 34 residents resided in the facility. Findings: The Resident Care Plan Policy, revised December 2016, read in part, .Each discipline will assess each resident starting from the time of admission and periodically thereafter until discharged from the facility. Through these progressive, serial assessments, the needs of the resident will be identified, monitored, and updated .Resident care plans will be reviewed at least every three months, with significant changes and as indicated to ensure that timely updating of problems, goals, and interventions are being done by the Multidisciplinary Team . The McGeer Criteria for Infection Surveillance Checklist for resident #2 read in part, .date of infection 2/27/24 .UTI without indwelling catheter .Acute dysuria or pain, swelling .New or marked increase in urgency .New or marked increase in frequency .Meropenem (antibiotic) 1 GM 3x daily for 10 days .ESBL (Extended-spectrum beta lactamases) . Resident #2's care plan, dated 12/27/23, did not identify a current or history of urinary tract infections. Resident #2's admission assessment, dated 01/05/24, documented the resident was alert and oriented with a history of urinary tract infections. The assessment documented the resident was always continent of urine and was independent with care for her ostomy appliance. On 03/21/24 at 8:45 a.m., the RN/DON reported resident #2's care plan did not address urinary tract infections and should have been included. The DON reported the resident's most recent UA result was obtained on 02/24/24 and the urine culture results were received on 02/27/24. On 03/21/24 at 8:50 a.m., the MDS coordinator reported they were responsible for developing and updating resident care plans. They reported they would normally update the care plan quarterly, unless there was a change, and resident #2's care plan should have addressed a history of urinary tract infections when the resident was admitted .

Based on observation, record review, and interview, the facility failed to revise the care plan to include fall interventions for one (#17) of five residents reviewed for care plans. The Administrator reported 34 residents resided in the facility. Findings: A Care Plan policy, dated December 2016, documented resident care plans would be reviewed at least every three months, with significant changes and as indicated, to ensure timely updating of problems, goals, and interventions were being done by the multidisciplinary team. Resident #17 was admitted with a history of falls, arthritis, and age-related cognitive decline. A quarterly MDS assessment, dated 02/07/24, documented the resident was severely impaired with cognition. The assessment documented no falls since admission. A discharge-return anticipated MDS assessment, dated 02/19/24, documented the resident had a fall with injury. Resident #17's care plan, dated 02/19/24, documented the resident was at high risk for falls and had a previous fall at home prior to admission. The care plan documented the resident ambulated with a rolling walker. Interventions to prevent falls included keeping the call light within reach and to encourage the resident to use the call light. An incident report, dated 02/19/24, documented resident #17 fell in their room, hit the back of their head, and sustained a laceration. The report documented the resident was sent to the hospital and received staples to the laceration. The report documented the cause of the fall was related to the resident ambulating without their walker. No interventions to prevent future falls were documented. A progress note, dated 02/20/24 at 10:15 a.m., documented facility staff received a report from a nurse at the hospital who stated the resident had five staples to the back of the head, and a CT scan had cleared the resident of any other injuries or broken bones. The note documented physical therapy was working with the resident in the hospital. A progress note, dated 02/23/24 at 5:00 p.m., documented resident #17 returned to the facility from the hospital. The note documented the resident was readmitted to skilled services for fall with injury, weakness, inability to ambulate, and severe pain with movement. On 03/21/24 at 1:49 p.m., resident #17 was observed sitting on the couch in their room. The resident was asked if they could use their call light if they needed assistance. The resident did not understand and the surveyor pointed out the call light stretched across the back of the couch. The resident shook their head no, and stated they didn't know how to use it. On 03/21/24 at 1:53 p.m., the MDS coordinator was interviewed regarding the resident's fall on 02/19/24. The MDS coordinator reported they didn't document any interventions right away because the resident was sent to the hospital. She stated the resident was started on therapy when they returned from the hospital. On 03/21/24 at 1:53 p.m., the DON was interviewed regarding the resident's fall on 02/19/24. the DON reported the resident was using a regular walker with therapy but no longer used the rolling walker. The DON stated the resident would use the call light on occasion but most of the time would get up and find someone when they needed assistance.

Based on record review, observation, and interview, the facility failed to follow the menu and provide pureed foods listed on the menu for one (#12) of one sampled resident reviewed for pureed foods. The Administrator identified one resident which required a pureed diet. Findings: Review of the facility policy titled Menus, revision date October 2017, read in parts .Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy . Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal .If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs . Resident #12 was admitted with diagnoses of Alzheimer's disease and chronic obstructive pulmonary disease. The Care Plan, for resident #12, documented the resident had a chewing difficulty, which increased the risk of nutritional deficit related to the need for an altered diet of puree. A Physician Order, for resident #12, dated 04/27/22, documented regular diet, pureed texture, and regular consistency. Review of the Tuesday lunch menu documented ground beef cube steak with gravy, broccoli and cheese rice baked, creamed corn, dinner roll/margarine, cinnamon diced pears, and beverage would be served. On 01/31/23 at 12:00 p.m., cook #1 was observed preparing the meal for the resident requiring a pureed diet. The cook was observed to puree the meat, broccoli and cheese, and corn. The cook was observed to place the items on the steam table as she pureed each item. Cook #1 was asked about bread for the resident. The cook stated she wasn't sure about the process to puree bread so did not include bread for the resident requiring the pureed diet. On 01/31/23 at 12:30 p.m., resident #12 was observed during the noon meal. The resident's tray had pureed meat, broccoli and cheese, corn, and ice cream. There was no pureed bread. On 02/01/23 at 10:37 a.m., the DM reported the menu included the food guide pyramid. The DM reported if all the food was not on the tray, the resident would not get the correct amount of food servings or calories. The DM reported all foods on the menu should have been on the pureed plate. The DM stated the bread could have been included in the meat or there was a guide to instruct staff how to puree the bread. The DM stated she would educate the staff member on how to include the bread in the pureed diet. On 02/02/23 at 9:47 a.m., the DON reported the facility followed the state menu. The DON stated she would expect everything on the menu to be included on the pureed diet unless there was an approved alternate. On 02/02/23 at 9:51 a.m., the Administrator reported staff should follow the menu to ensure residents were provided appropriate nutrition and a balanced diet.

Based on record review, observation, and interview, the facility failed to date foods stored in the freezer with the received and/or use-by dates. The Resident Census and Condition of Residents form documented 31 residents received meals from the facility kitchen. Findings: A facility policy, Food Receiving and Storage, revised July 2014, documented in part .all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 01/30/23 at 2:29 p.m., a tour of the kitchen was conducted and the following foods were observed in the freezer, in sealed bags, undated: ~14 bags green beans ~8 bags yellow squash ~12 bags of corn ~2 bag zucchini ~4 bags mixed bell peppers ~17 bags mixed vegetables ~1 bag of breaded squash ~6 bags of sweet potato fries ~whole chicken 4 bags ~1 bag of pretzels On 01/30/23 at 2:45 p.m., cook #1 reported once the food was received in the kitchen, the food should be dated and placed in the freezer. On 02/01/23 at 10:37 a.m., the DM reported the frozen vegetables did not have use-by dates on them. The DM stated all food items should have been labeled and dated when the food was received and opened. The DM stated she had not labeled the foods because the marker would not stay on the bags due to condensation. On 02/02/23 at 9:47 a.m., the DON reported every food item should be dated with the date it was received. On 02/02/23 at 9:51 a.m., the Administrator reported all food items should be dated and labeled when received.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent a fall with major injuries for one (resident #2) of three residents reviewed for falls. The facility failed to: a) Thoroughly assess fall risks for resident #2 who was considered high risk for falls. b) Develop and implement a person-centered care plan with interventions to prevent falls. On 11/27/19, a hospital record documented the resident was evaluated and determined to have a post fall concussio[DIAGNOSES REDACTED], nasal bone fracture, severe urinary tract infection, and required sutures to a two centimeter laceration to her forehead. The facility reported 36 residents lived in the facility. Findings: A facility fall risk management policy, dated March 2018, documented, .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 03/15/19, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive assistance with bed mobility, transfers, and dressing. The assessment documented the resident was not ambulatory and had unilateral impairment of her upper and lower extremities. The assessment documented the resident was always incontinent of bowel and required an indwelling urinary catheter. A care plan, dated 03/18/19, documented the resident was at high risk for falls. The care plan documented for the staff to follow the facility fall protocol. The care plan contained no person-centered interventions to prevent falls. A quarterly assessment, dated 09/15/19, documented the resident was moderately impaired with cognition. The assessment documented the resident required limited assistance of one person with transfers, bed mobility, and dressing. The assessment documented the resident was non-ambulatory and required a wheelchair for locomotion. The assessment documented the resident was incontinent of bowel and required an indwelling urinary catheter. A fall risk assessment, dated 09/16/19, documented the resident was at high risk for falls. A nurses' note, dated 11/27/19 at 9:20 p.m., documented, Called to resident's room, resident in floor face down. (name deleted) licensed practical nurse with resident holding pressure to bleeding wound to forehead, resident is alert and communicating with staff, resident assessed laceration to forehead noted, 4 x 4 gauze and coban dressing applied to stop bleeding, large skin tear to outer aspect of right knee noted and bandaged, bleeding from nose and nasal deformation noted. No other obvious injuries noted. A Oklahoma State Department of Health incident report, dated 11/27/19 documented the resident was found on the floor and was unable to explain cause of unwitnessed fall. The report documented the resident was found to have a laceration to the head and her nose was bleeding and visibly deformed. The report documented the resident was sent to the emergency room . The report documented the resident was found to have a nasal bone fracture and required stitches to the [MEDICAL CONDITION]. The report documented, .NHA (nursing home administrator), DON (director of nursing), and resident's family to have a care plan meeting on 12/02/19 at 10:30 a.m. to discuss the best way to keep resident safe by either initiating a concave mattress, lowered bed, or something of the sort and will initiate intervention immediately thereafter. On 11/27/19, a hospital record documented the resident was evaluated and determined to have a post fall concussio[DIAGNOSES REDACTED], nasal bone fracture, severe urinary tract infection, and required sutures to a two centimeter laceration to her forehead. The clinical record contained no documentation of interventions to prevent falls prior to the resident's fall on 11/27/19. On 12/11/19 at 3:00 p.m., certified nurse aide (CNA) #1 reported the resident was not able to help much due to her weakness on the left side of her body. The CNA reported the resident required one to two people to assist with care. The CNA reported the resident had a regular bed and did not have a fall mat in place. The CNA reported the resident had no fall precaution interventions. On 12/11/19 at 3:15 p.m., CNA #2 reported the staff did not have access to resident care plans. The CNA reported the resident required two CNAs to provide care. The CNA reported the resident had a regular bed and did not have a fall mat in place. The CNA reported the resident had no fall precaution interventions. On 12/11/19 at 3:30 p.m., registered nurse (RN) #1, who was charge nurse at the time of the incident, reported the resident had a regular bed and no fall mat at the time of the fall. The RN reported she assessed the resident and applied gauze bandages and coban wrap to her head until the emergency medical system (EMS) arrived. On 12/11/19 at 4:15 p.m., the resident's power of attorney (POA), reported the resident did not have a fall mat and had a regular bed at the time of the fall. On 12/12/19 at 1:25 p.m., LPN #1 reported she heard the resident moaning so she went to her room and found the resident on the floor next to her bed. The LPN reported the resident had a regular bed without a fall mat. On 12/12/19 at 3:05 p.m., the DON reported the resident's bed rails were removed on 11/25/19. The DON reported there were no person-centered fall interventions. The DON reported the staff were to follow the facility fall protocol. The DON and the ADM reported they were to have a care plan meeting with the family on 12/02/19 to talk about implementing a low bed instead of a regular bed.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one (#2) of three residents reviewed for falls. Findings: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 03/15/19, documented the resident was moderately impaired with cognition. The assessment documented the resident required extensive assistance with bed mobility, transfers, and dressing. The assessment documented the resident was not ambulatory and had unilateral impairment of her upper and lower extremities. The assessment documented the resident was always incontinent of bowel and bladder. A care plan, dated 03/18/19, documented the resident was at high risk for falls. The care plan documented for the staff to follow the facility fall protocol. The care plan contained no person-centered interventions to prevent falls. A nurses' note, dated 11/27/19 at 9:20 p.m., documented, Called to resident's room, resident in floor face down. (name deleted) licensed practical nurse with resident holding pressure to bleeding wound to forehead, resident is alert and communicating with staff, resident assessed laceration to forehead noted, 4 x 4 gauze and coban dressing applied to stop bleeding, large skin tear to outer aspect of right knee noted and bandaged, bleeding from nose and nasal deformation noted. No other obvious injuries noted. On 12/12/19 at 4:10 p.m., the ADM reported the care plan should have had person-centered interventions for the resident and updated accordingly.

Based on interview and record review, it was determined the facility failed to notify family of changes in care or treatment for two (#2 and #3) of three residents reviewed. The facility reported 36 residents lived in the facility. Findings: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 12/11/19 at 2:12 p.m., resident #2's guardian reported he had not received a letter in the mail from the facility prior to the removal of the bed rails. On 12/11/19 at 5:15 p.m., resident #2's power of attorney (POA) reported she had not received a letter in the mail informing her the bed rails were going to be removed. On 12/12/19 at 10:30 a.m., resident #3's POA reported he had not received a letter in the mail regarding the removal of the bed rails. On 12/12/19 at 11:00 a.m., the Director of Nursing (DON) reported she had typed up a letter and had the administrative assistant mail them out to the residents' families who had bed rails two weeks prior to the removal of the bed rails. On 12/12/19 at 2:30 p.m., the DON reported she should have contacted the families to ensure they received the letter.

Based on observation, interview, and record review, it was determined the facility failed to update the care plan to include urinary tract infections and routine antibiotic use for one (#5) of 17 residents reviewed for revision of care plans. The facility reported a census of 34 residents. Findings: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/27/18, documented the resident required extensive assistance with ADLs and was always incontinent of bowel and bladder. The assessment documented the resident received a diuretic seven of seven days previous and did not document antibiotic use. An infection control entry, dated 02/07/19, documented the resident was started on [MEDICATION NAME] 100 milligrams (mg) by mouth, twice a day for 10 days, for a urinary tract infection [MEDICAL CONDITION]. The log documented the resident's antibiotic was changed on 02/11/19 to [MEDICATION NAME], 1 gram intramuscularly (IM) daily for 5 days, for a UTI. A physician order, dated 03/15/19, documented to give [MEDICATION NAME] 100 mg daily for UTI prevention maintenance. A care plan, updated 03/25/19, documented the resident was incontinent of bowel and bladder. The care plan documented the resident required total assist with toileting. The care plan did not document the resident had been prescribed [MEDICATION NAME] daily for UTI prevention maintenance. On 03/26/19 at 12:05 p.m., the resident was observed in the main dining room for the noon meal. The resident was observed to have fluids and observed to drink independently. On 03/26/19 at 2:43 p.m., the director of nursing (DON) reported the resident's physician prescribed routine [MEDICATION NAME] for recurrent UTIs. The DON reported there was no physician documentation related to the initiation of this medication, other than the physician order.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services in a timely manner for two (#17 and #11) of 17 residents reviewed. The facility failed to follow up with the physician and obtain treatment orders. The facility reported 34 residents lived in the facility. Findings: 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/27/19, documented the resident was severely impaired with cognition and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident was at risk for developing pressure ulcers. A care plan, dated 02/11/19, documented the resident was at risk for impaired skin integrity. The care plan documented for the staff to monitor and document location, size and treatment of [REDACTED]. A nurse's note, dated 03/24/19 at 9:30 p.m., documented, Resident had open area from dry cracked skin to coccyx. Skin protectant applied every shift for healing and protection. A facility fax form, dated 03/24/19, documented, Resident has 2 centimeter (cm) x 0.1 cm opening in center of coccyx applied skin protectant please advise of perferred (sic) treatment. The form had not been signed by the physician. A physician's orders [REDACTED]. On 03/27/19 at 11:51 a.m., licensed practical nurse (LPN) #1 reported she had faxed the physician on Sunday and had not received anything back. The LPN reported the skin protectant she had applied to the resident's wound was Zinc. The LPN reported she had already administered the treatment that morning. The LPN was asked if she had administered the treatment without a physician's orders [REDACTED]. The LPN reported she should have followed up with the physician. On 03/27/19 at 1:57 p.m., the resident's coccyx was observed to have no open wound. The resident's buttocks was observed to be red in color and excoriated. On 03/27/19 at 2:34 p.m., the director of nursing (DON) reported the nurse should have followed up to ensure a physician's orders [REDACTED]. 2. Resident #11 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/10/19, documented the resident was occasionally incontinent of bladder and always incontinent of bowel. The assessment documented the resident required one person limited assistance with toileting. A laboratory report, dated 03/07/19, documented a positive result for a urinary tract infection [MEDICAL CONDITION]. A physician's orders [REDACTED]. An infection control log, dated (MONTH) 2019, documented the resident had a UTI with an onset date of 03/14/19. On 03/27/19 at 8:28 a.m., the resident was observed to be dressed for the day and the call light was within reach. On 03/27/19 at 11:25 a.m., LPN #1 reported the fax machine had not been working and was unsure of when the lab result was received. On 3/27/19 at 1:38 p.m., the DON and registered nurse (RN) #1 reported they could not explain the seven day lapse of time between the positive lab report and the physician order [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to ensure a baseline care plan was completed with goals and interventions for the care of one (#30) of two residents reviewed. The facility reported two residents admitted within the last 30 days. Findings: Resident #30 was admitted with [DIAGNOSES REDACTED]. The resident had new placement of a peg tube. The clinical record contained a baseline care plan, date 03/02/19, with a problem list. The baseline care plan contained no documentation regarding specific care areas, goals, or interventions. On 03/26/19 at 8:32 a.m., the resident was observed lying in bed in their room. On 03/26/19 at 2:24 p.m., the director of nursing reported the baseline care plan had not been completed to include goals and interventions.

Based on observation, interview, and record review, it was determined the facility failed to provide a completed discharge summary for one (#35) of three residents reviewed for discharge procedures. Findings: Resident #35 was admitted to the facility on [DATE]. A discharge form, dated 12/28/18, contained no documentation of the recapitulation of the resident's stay. The form contained no documentation regarding the resident's status upon discharge. On 03/27/19 at 3:15 p.m., the director of nursing reported the discharge summary would be revised to include required components.

Based on observation, interview, and record review, it was determined the facility failed to provide clinical rationale for the use of an antipsychotic medication for one (#17) of five residents reviewed for unnecessary medications. The facility reported 11 residents were prescribed antipsychotic medications. Findings: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 07/27/18, documented the resident was severely impaired with cognition, exhibited moderate depression, exhibited no behaviors, and required extensive assistance for activities of daily living (ADLs). The assessment documented the resident received an antipsychotic and an antidepressant for seven days of the look back period. The assessment documented the resident received an antianxiety for five days of the look back period. A quarterly assessment, dated 01/27/19, documented the resident was severely impaired with cognition, exhibited moderate depression, exhibited behaviors of delusions, and required extensive assistance with ADLs. The assessment documented the resident received an antipsychotic, an antianxiety, and an antidepressant for seven days of the look back period. A care plan, dated 02/11/19, documented the resident required [MEDICAL CONDITION] medications related to behavior management for mood disorder. A physician's orders [REDACTED]. [MEDICATION NAME] 0.25 milligram (mg) every 8 hours as needed (PRN) for 14 days then re-evaluate ordered on [DATE]; [MEDICATION NAME] 25 mg twice a day (BID) for anxiety ordered on [DATE]; [MEDICATION NAME] 0.25 mg daily for anxiety 12/21/18; [MEDICATION NAME] 50 mg at bedtime for mood disorder 03/23/18; and [MEDICATION NAME] 10 mg daily for unspecified dementia without behavioral disturbance dated 01/24/18. The clinical record contained no documented behaviors for the past 120 days. On 03/26/19 at 11:38 a.m., the resident was observed sitting up in her wheelchair in the dining room visiting with another resident. On 03/27/19 at 2:34 p.m., the director of nursing (DON) reported anxiety and mood disorder were probably not appropriate [DIAGNOSES REDACTED].

On [DATE] at 2:25 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to provide CPR and notify 911 when resident #1 was found to be pulseless, not breathing, and unresponsive to verbal or physical stimuli. The resident was a full code status. On [DATE] at 2:35 p.m., the OSDH verified an immediate jeopardy situation existed related to the facility's failure to provide CPR and activation of the 911 emergency system. On [DATE] at 2:43 p.m., the ADM and the DON were informed of the IJ situation which consisted of substandard quality of care. On [DATE] at 4:19 p.m., the ADM and the DON provided the plan of removal for the immediate jeopardy. The plan of removal was accepted and documented the following: PLAN OF REMOVAL FULL CODE VS. (versus) DNR INSERVICE ALL STAFF ON DNR AND FULL CODE STATUS BY 5:00 PM [DATE] INSERVICE ALL STAFF ON INITIATING CPR ON FULL CODE RESIDENT BY 5:00 PM [DATE]: 1. GET HELP 2. DESIGNATE SOMEONE TO CALL 911 3. GRAB CRASH CART 4. INITIATE CPR UNTIL EMS ARRIVES IMPLEMENT RED MEANS STOP/GREEN MEANS GO PROGRAM BY 5:00 PM [DATE]. RED STAR ON DOOR BY NAME MEANS DNR STATUS. GREEN STAR ON DOOR MEANS FULL CODE STATUS. NURSING ADMINISTRATION WILL AUDIT CHARTS FOR DNR OR FULL CODE MONTHLY AND WILL AUDIT CODE IDENTIFICATION OR DOOR WEEKLY. FUTURE PLAN OF ACTION FOR NEXT IN SERVICE ([DATE]) WILL BE M(NAME)K CODE DRILL TO EDUCATE ALL STAFF ON PROPER ACTION OF UNRESPONSIVE RESIDENT. On [DATE] at 9:00 a.m., on duty staff members were asked when had they received education for the CPR and DNR residents. All staff members were able to verbalize the plan of removal instituted on [DATE]. On [DATE] at 9:30 a.m., telephone interviews were conducted with five off duty staff members. The staff verbalized an inservice was conducted on [DATE] in regard to residents' code status. On [DATE] at 10:00 a.m., a tour of the facility was conducted. The red star for DNR and the green star for CPR were identified on each resident door. On [DATE] at 10:00 a.m., the facility was informed the IJ was removed effective [DATE] at 5:00 p.m. The deficient practice remained at actual harm at an isolated level. Based on observation, record review, and interview, it was determined the facility failed to provide basic life support, including CPR, to a resident who required emergency care related to a physician's orders [REDACTED].#1) of three residents reviewed for provision of basic life support. The ADM reported ten residents resided in the facility who had a physician's orders [REDACTED]. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission physician's orders [REDACTED]. The resident was discharged from (name deleted) hospital on [DATE] with discharge instructions to the facility for the resident to be a full code. An Advanced Directive, dated [DATE], documented the resident had not executed an Advance Directive at that time. A CNA care plan, dated [DATE], documented for the resident to be a full code. On [DATE], the resident's diet order was changed from a mechanical soft diet with nectar thick liquids to a pureed diet and to continue nectar thick liquids. A five day admission assessment, dated [DATE], documented the resident was alert and oriented to person, time, and place. The assessment documented the resident required extensive assistance of two or more staff members to transfer and dress. The assessment documented the resident required supervision with set-up to eat. The assessment documented the resident had impaired range of motion of both lower extremities. The assessment documented the resident was always continent of bowel and bladder. The five day admission assessment, dated [DATE], documented the resident experienced coughing or choking during meals or when swallowing medications. The assessment documented the resident received a mechanically altered diet. A nurse's note, dated [DATE], documented, Nectar thick liquids encouraged, resident conts. (continues) to cough when small sips H2O (water) given denies pain. Call light within reach. A nurse's note, dated [DATE] at 6:00 a.m. to 10:00 p.m., documented, Res. (resident) observed c (with) freq. (frequent) chocking/coughing especially when attempting to eat or drink. Res. becomes frustrated et embarrassed et will stop eating p (after) ,[DATE] bites @ most. Res. rec. (received) a puree diet c thickened liquids encouraged to tuck her head when taking a bite et swallowing c no good results, noted to have spasmodic movements c coughing episodes. Rec'd (received) [MEDICATION NAME] for muscle spasms c good results. Spouse left facility stating I'll be back around an hour if she asks. Eveing (sic) meal came out shortly after. Tray took room @ Res. request et was informed that this SN (staff nurse) would be there shortly she was assisting another res. et passing trays in DRM (dining room) SN enter res .@ 1800 (6:00 p.m.) to assist res c meal et SN observed this Res s (without) resp. (respirations) or pulse. No v/s (vital signs) present as SN left room spouse was observed amb. (ambulating) (down) hall toward res. room. informed spouse @ this x (time) res. condition. et if there was anyone he would like for nurse to call. Spouse stated I knew this was coming could you please hold her remains et personal effects while I make the arrangements. (Name deleted) funeral home notified. A fax transmission log, dated [DATE] at 8:22 p.m., documented an initial state reportable incident form was submitted to OSDH. The OSDH incident report contained a witness statement, dated [DATE] at 7:30 a.m., which documented, On [DATE], (resident name deleted) had been observed coughing every time she swallowed, at morning meal and noon meal she only ate ,[DATE] bites of meal related to coughing even c this nurse and staff encouraging her to tuck her chin when swallowing. Family came in to visit spouse stated to me (name deleted) LPN that this was not new that it has only gotten worse since her [MEDICAL CONDITION]. Further stating she is jerking now when she cough (sic). I stated the cough may be triggering muscle spasms and had the CMA on duty give her a [MEDICATION NAME] for muscle spasms and had offered the spouse to send Resident to hospital which Spouse stated no that's not necessary. Spouse later came to me and stated she is resting and looks better. I'm gonna go get her some clean clothes if she wakes tell her I'll be back in a hour, I went to check on Resident who was awake and said, 'I would like to eat supper in here. It's too embarrassing to be coughing and everyone staring at me.' I told her that would be fine I would have her tray brought to her room and I would be in to assist her Res. stated OK. I (name deleted) LPN had checked on another resident who was eating supper in his room also who usually eats in DRM (dining room). I brought hall cart down to this Res. room so as to place tray on completion meal. I then entered Resident room stated Mrs. (name deleted) it's (name deleted) I'm here to assist you and noted that Resident was without life signs, no carotid pulse, respirations or heart rate was present, Resident was noted to be cool to touch c mottling noted to inner thighs. Resident was nonresponsive to verbal and tactile stimulus as I shook her and called her name. I then performed sternal rubs without any response followed by cardio thump x 2 continue to be no response, I then exited room with the intent to initiate CPR and call 911. I noticed Residents spouse walking toward Residents room I stopped Spouse and explained what was occurring and that I was on my way to get crash cart & make call to 911 along with CPR. Spouse placed arms on treatment cart and stated, 'I had a feeling this was coming .this was gonna happen, no let her go she has been through enough', then stated would ya'll hold her remains and personal effects until I make arrangements.' .I asked spouse if there was someone I could call for him to which he responded no . The OSDH incident report contained a witness statement by CNA #1, dated [DATE], which documented LPN #1 had entered the dining room and asked for assistance. The CNA asked the LPN what she needed help with. The LPN reported the resident had passed away. The CNA report documented, I ask are we going to do CPR. She said she was already gone. When I step inside the room (name deleted) lip wear (sic) blue and her body was releasing fluid . A final OSDH incident report, dated [DATE] at 1:10 p.m., documented the investigative findings were submitted by the ADM. The investigation documented, It was reported to the Administrator on [DATE] by the ADON (name deleted), that (name deleted), the 6am to 2 pm charge nurse had reported and allegation that CPR was not done by the shift nurse (name deleted), LPN on the above noted resident at time of death on [DATE]. After review of the chart showing that the above resident had not executed an advanced directive and was a full code, it was determined that the charge nurse (name deleted) did not initiate CPR or dialed 911 at the time of death . (Name deleted), lpn will continue to be suspended until further investigation is completed and/or training/in-service is done by the facility and/or further direction from the Oklahoma Board of Nursing is received. On [DATE] at 8:55 a.m., a tour of the facility was conducted. Interviews were conducted with staff members. The CNAs, CMAs, LPNs, and RN staff were interviewed. The staff was asked how a resident was identified who was to have CPR performed. The staff members reported the resident's chart would be reviewed prior to initiating CPR. When a resident was identified as a full code, CPR would be initiated and 911 would be called. Housekeeping and maintenance staff were asked if a resident was observed to be in distress or without signs or symptoms of life, what were they to do. The staff reported they were to notify the nurse immediately. On [DATE] at 10:10 a.m., the ADM was interviewed. The ADM reported when she arrived to the facility on the morning of [DATE], the ADON reported CPR had not been conducted by LPN #1. The ADM reported the resident's chart was reviewed and it was determined the resident was to have had CPR performed. The ADM reported LPN #1 had been suspended and had not returned to work at that time. The ADM reported a full investigation had been conducted, witness statements obtained, and the OSDH and the Oklahoma Board of Nursing had been notified. The ADM was asked if an inservice had been conducted with staff for residents who had CPR physician orders. The ADM reported the DON was on vacation and was waiting for her return for the inservice to be conducted. On [DATE] at 11:55 a.m., the DON was interviewed. The DON was asked should the LPN have followed a physician's orders [REDACTED]. On [DATE] at 3:15 p.m., a telephone interview was conducted with LPN #1. The LPN reported the resident had been coughing during the noon meal and requested to have her evening meal served in the room. The LPN reported the evening tray was served in the resident's room. The resident did not have any complaints of pain. The LPN reported when she returned to the resident's room ,[DATE] minutes later the resident was not breathing and did not have a pulse. The LPN reported she left the resident and returned to the nurses' station to determine if the resident was to have CPR. The LPN reported the husband entered the facility at that time and she explained the situation to the spouse. The LPN reported the spouse did not want the resident to have CPR performed. On [DATE] at 4:00 p.m., a telephone interview was conducted with CNA #1. The CNA reported the resident was sitting in bed when she took the meal tray into the resident's room. The resident reported she was not hungry at that time. The CNA reported the resident drank a few sips of water at that time. The CNA was asked what type of water did the resident drink. The CNA reported the resident drank nectar thick water. The CNA reported the meal tray was left in the resident's room at that time. CNA #1 reported after the resident passed away, she removed the meal tray. The CNA was asked how much of the meal the resident had eaten. The CNA reported the meal had not been touched by the resident.

Based on observation, record review, and interview, it was determined the facility failed to ensure the resident environment was free of accident hazards for one (#3) of six sampled residents reviewed for accident hazards. The facility failed to identify side rails as an accident hazard and implement measures to prevent recurrent skin tears for the resident. The resident sustained [REDACTED]. The facility incident log documented seven residents had received skin tears in the previous 30 days. Findings: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 08/09/11, documented the resident's cognition was intact without memory problems. The assessment documented the resident required extensive assistance with bed mobility and transfers. The care plan, dated 08/16/11, documented the resident had a history of [REDACTED]. The care plan had an entry dated 02/12/12, which documented the resident requested full siderails on the bed to make her feel safer. The care plan did not identify siderails as a potential accident hazard and did not include measures to prevent skin tears. The quarterly assessment, dated 05/08/12, documented the resident did not have memory problems and her cognition was intact. The assessment documented the resident required limited assistance with bed mobility and transfers. An incident report, dated 06/24/12, documented the resident was using the siderail for mobility and hit the siderail causing a small skin tear to her left arm. The preventive measures documented the resident used the call light when needing assistance but occasionally would pull herself up by using the rail. The resident was instructed to use the call light and be careful when pulling herself up. An incident report, dated 07/21/12, documented the resident was found in bed with a small skin tear to the right elbow. The preventive measures included to take precautions to make sure the resident was protected during transfers and the call light was within the resident's reach. On 08/13/12 at 1:05 p.m., the resident was observed receiving incontinent care. Certified nurse aide (CNA) #1 cleaned the resident's buttocks, rolled the bed linens under the resident, and instructed the resident to roll onto her right side. The resident attempted to position herself to get over the rolled linens and lost her balance hitting her right elbow on the siderail. The resident sustained [REDACTED]. The siderails were not padded and the resident's skin was not protected at that time. On 08/14/12 at 12:55 p.m., CNA #1 stated the resident had been getting more skin tears recently. The CNA stated the resident seemed to be losing strength because she was not eating properly. The CNA stated the resident frequently refused to eat what was provided as well as what the family brought in. The CNA stated the resident had lost weight since she wasn't eating well. The CNA stated the resident had shingles recently and from that time the resident acted like she didn't care about anything. On 08/14/12 at 1:05 p.m., registered nurse (RN) #1 was asked what measures had been implemented to promote the resident's safety related to skin tears. The RN stated the resident was alert and oriented and could move about in the bed on her own. The RN stated the resident was instructed to use the call light when assistance was needed. On 08/14/12 at 2:30 p.m., the assistant director of nurses (ADON) was asked what measures had been implemented to prevent the resident from recurrent skin tears. The ADON stated a wedge had been placed between the resident and the siderails after the skin tear on the previous day to prevent her from hitting her arms on the rails. The ADON stated no other specific measures had been implemented.