Every finding on record at Garland Road Nursing & Rehab Center

On 12/23/25 at 12:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to ensure a comprehensive care plan was developed for Resident #8 to prevent an elopement.Resident #8 was cognitively impaired with a BIMS score of 2. Resident #8 had two elopement assessments which identified Resident #8 as a moderate risk for elopement.Resident #8's care plan did not show elopement as a risk and did not contain any interventions.On 12/09/25, Resident #8 eloped from the facility. The resident was located nearby at a church with scratches. On 12/23/25 at 12:31 p.m., the administrator, DON, ADON, corporate nurse #1, dietary manager, and RDO were notified of the immediate jeopardy (IJ) situation and provided the IJ template.On 12/23/25 at 4:38 p.m., an acceptable plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal showed,a. Residents with an elopement score greater than 11 should have interventions in their care plan,b. Resident #8 was discharged from the facility on 12/19/25,c. the DON or designee will in- service all clinical licensed staff on completion of elopement risk assessment by 12/23/25 at 12:59 p.m. and staff unable to complete education will not be allowed to work until education is completed,d. an audit of all residents' elopement assessments will be completed by 12/23/25,e. the DON or designee will update all care plans for residents identified as a moderate or high elopement risk,f. the DON or designee will monitor elopement risk assessments completion quarterly with the MDS assessment completion and update the care plans,g. a QAPI committee was held on 12/23/25 to discuss the plan of removal,h. the medical director was notified of the immediate jeopardy on 12/23/25, [NAME]. the DON would track, tend, and analyze audit results and forward to the QAPI committee.On 12/23/25, the immediate jeopardy was lifted, when all components of the POR had been verified as corrected. a. Resident #8's health record was reviewed. The health record showed Resident #8 discharged from the facility to a different facility on 12/19/25,b. in-service documentation, dated 12/23/25, showed seventy-seven staff members were in-serviced over elopement policies, prevention, and care plans,c. seven residents' care plans, dated 12/23/25, were reviewed. The care plans showed seven residents' care plans were updated by 12/23/25 to ensure wandering and elopement risk had a focus and interventions to prevent elopement,d. two newly admitted residents' elopement assessments were reviewed. The assessments showed they were completed and residents were not an elopement risk, e. the off cycle QAPI notes, dated 12/23/25, were reviewed. The QAPI notes showed the facility had a meeting with the medical director and discussed all residents with a score of 11 or higher should be care planned for an elopement risk, andf. on 12/29/25, nine direct care staff were interviewed from multiple disciplines and shifts regarding in-service education over elopement procedures and updating the care plan. Staff were able to communicate they have been educated on elopement and care plan updating.The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure:a. a comprehensive care plan was developed to prevent elopement for 1 (#8) of 3 residents sampled for comprehensive care plans to prevent elopement; andb. a comprehensive care plan was developed for a resident requiring transferring assistance with a mechanical lift for 1 (#7) of 3 residents sampled for comprehensive care plans for lift assistance. The administrator identified seven residents were an elopement risk and 20 residents required a mechanical lift to transfer. Findings:1.On 12/22/25 at 3:30 p.m., the exterior of the facility was observed. The facility was located on a two-lane busy main street. There was an open golf course with ponds located adjacent to the facility. A facility policy titled Comprehensive Care Plans, revised 02/12/20, read in part, It is the policy of this facility to develop and implementation a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. A facility policy titled Elopement Management, dated 02/12/20, read in part, Document Requirements in the EHR: .Update the Care Plan.Resident #8's care plan, dated 02/06/25, from a previous EHR, no longer active, and not accessible to staff, showed a focus Resident #8 was exit seeking. The care plan interventions showed:a. analyze keys times, places and circumstances, triggers, and what deescalated behavior dated 05/30/24,b. encourage activities dated 02/06/25,c. frequent visual checks dated 02/06/25, d. maintain behavior log dated 02/06/25, ande. provide a pleasant home-like environment dated 02/06/25.Resident #8's elopement assessment, dated 08/19/25, showed the resident was scored as a moderate risk for elopement with a score of 19 Resident #'8s quarterly assessment, dated 08/25/25, showed their cognition was significantly impaired with a BIMS score of 2. The assessment showed Resident #8 was admitted on [DATE] with diagnoses which included schizophreniform disorder and chronic kidney disease. The assessment showed Resident #8 did not wander during the look back period. The assessment showed Resident #8 was independent for ambulating.Resident #8's elopement assessment, dated 11/20/25, showed the resident was scored as a moderate risk for elopement with a score of 16. A facility reported incident combined initial and final report, dated 12/09/25, showed Resident #8 was missing from the facility and found during a search. The report showed Resident #8 was found North of the building near a church parking lot with scratches on their elbow and was returned to the facility and placed on one-on-one supervision. The national weather service showed the temperature in [NAME], Oklahoma on 12/09/25 was 50 degrees Fahrenheit at 6:00 p.m.Resident #8's nursing note, dated 12/10/25, showed an unidentified CNA noticed Resident #8 was missing on 12/09/25 at 6:00 p.m. The note showed another unidentified resident admitted to letting Resident #8 out of the facility. The note showed the facility notified the family, police, and started to search for Resident #8. The note showed Resident #8 was located at 7:20 p.m. and returned to the facility. Resident #8's care plan, developed 12/10/25, showed a focus for elopement risk was added on 12/10/25. The care plan showed the following interventions:a. all staff were to be aware of high elopement risk and visually monitor the resident in the common areas and near exits,b. attempt to redirect the resident when they fixate on the exits, andc. signage placed at the primary entrance and exits to alert visitors of exit seeking residents. On 12/22/25 at 1:58 p.m., the DON was shown Resident #8's elopement assessments, dated 08/19/25 and 11/20/25. The DON stated Resident #8 was a moderate risk for elopement and the care plan should have a focus and interventions after the elopement assessments. The DON stated the facility went with a new EHR earlier in the year. The DON stated Resident #8 did not have a focus or interventions to address Resident #8's elopement risk from 06/12/25 through 12/10/25 because the old focus and interventions were never carried over to the new EHR and they did not follow their policy and update the care plan after the elopement assessments showed Resident #8 was a moderate risk for elopement. On 12/23/25 at 8:36 a.m., CNA #2 stated they have their charting system, but it did not tell them all the details all the time. CNA #2 stated they went to the nurses and fellow aides to find out about residents at risk for elopement to learn about the care plan. CNA #2 stated they did not have access to the care plan. On 12/23/25 at 9:12 a.m., the DON stated Resident #8 eloped from the facility after being let out by another resident on 12/09/25. The DON stated Resident #8 was located a block away from the facility near a church and may have went across a golf course located adjacent to the facility. The DON stated the resident returned with scratches on their arm.2.Resident #7's quarterly assessment, dated 07/23/25, showed the residents cognition was intact with a BIMS score of 15. The assessment showed Resident #7 was admitted on [DATE] with a diagnosis of end stage renal disease. The assessment showed Resident #7 had lower extremity impairments, was dependent for dressing, toilet hygiene, and all transfers.An OSDH facility reported incident, dated 12/16/25, showed Resident #7 fell from the mechanical lift sling breaking during a transfer.Resident #7's hospital records, dated 12/16/25, showed Resident #7 was diagnosed with fracture of the left tibia and fracture of the right clavicle after a fall during transfer using a mechanical lift at the facility on 12/16/25.Resident #7s care plan, dated 12/22/25, did not have a focus or interventions for transfers prior to 12/22/25.On 12/22/25 at 3:28 p.m., corporate nurse #1 stated Resident #7's care plan did not have a focus for transferring. Corporate Nurse #1 stated transferring should be included in the care plan focus for residents who were dependent for transfers.On 12/22/25 at 3:30 p.m., the DON stated residents who required a lift to transfer should be included in the care plan. The DON stated Resident #7's care plan did not have any focus or intervention for transferring assistance prior to 12/22/25.On 12/23/25 at 8:19 a.m., Resident #7 stated two aides were helping them transfer with a lift from the bed to a wheelchair when the strap on one side of the sling broke and they fell from the lift. Resident #7 stated their shoulder and leg were broken when they fell. Resident #7 stated the staff had to feed them which was embarrassing. Resident #7 stated they had a brace on their leg, experienced a lot of pain, and was fearful of transfers. On 12/23/25 at 8:36 a.m., CNA #2 stated they were transferring Resident #7 with another aide present from the bed to a wheelchair with a mechanical lift and the white sling broke on one side resulting in Resident #7 falling from 3 feet in the air. CNA #2 stated Resident #7 hurt their left foot as they fell. CNA #2 stated they had their charting system, but they went to a nurse to learn about specific residents because they did not have access to the care plan.

On 12/23/25 at 12:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to ensure Resident #7 was not dropped from a mechanical lift during a transfer.Resident #7's quarterly assessment, dated 07/23/25, showed their cognition was intact with a BIMS score of 15. The assessment showed Resident #7 was dependent for all transfers.A facility incident report, dated 12/16/25, showed Resident #7 had a fall from a mechanical lift on 12/16/25 when a sling broke resulting in a fracture to the right clavicle and the left tibia.On 12/23/25 at 12:31 p.m., the administrator, DON, ADON, corporate nurse #1, dietary manager, and RDO were notified of the immediate jeopardy (IJ) situation and provided the IJ template.On 12/23/25 at 4:38 p.m., an acceptable plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal showed,a. Resident #7 was sent to the hospital on [DATE] and returned to the facility for continued treatment,b. Resident #7s care plan was updated with interventions and focus to include transfers on 12/23/25,c. the DON or designee would perform audits of residents who required assistance with transfers using a mechanical lift and update care plans accordingly on 12/23/25,d. the DON or designee would reeducate nursing staff on choosing the proper slings and weight requirement on 12/23/25 at 06:00 p.m.,e. staff who did not receive education by 6:00 p.m., would not be allowed to work until educated,f. the medical director was notified of the IJ on 12/23/25,g. a QAPI meeting was held on 12/23/25 with the medical director, the facility administrator, and director of nursing to review the plan of removal, andh. the director of nursing would track, trend, and analyze audit results and forward results of audits monthly to the QAPI Committee for review and/or action. On 12/29/25, the IJ was lifted, when all components of the POR had been verified as corrected.a. on 12/16/25, in-service documentation, dates 12/23/25, showed sixty-three direct care staff were in-serviced over safe lift and transferring for dependent residents,b. on 12/29/25, nine direct care staff were interviewed from multiple disciplines and shifts regarding in-service education on transferring dependent residents safely. All staff were able to communicate understanding of proper lift and transfer policy and procedures to ensure dependent residents would be transferred safely,c. Resident #7's care plan, dated 12/24/25, was reviewed. The care plan showed a focus Resident #7 required a mechanical lift to transfer,d. eighteen dependent residents for transfers care plans were reviewed. The care plans showed they were updated to include lift and transfers focus and interventions on 12/27/25, ande. the off cycle QAPI notes, dated 12/23/25, were reviewed. The QAPI notes showed the facility had a meeting with the medical director and discussed education over slings and care plans being updated.The deficient practice remained at pattern with a potential for harm.Based on observation, record review, and interview, the facility failed to:a. safely transfer a dependent resident using a lift for 1 (#7) of 3 residents sampled for safe lifting and transfers; andb. provide adequate supervision to prevent elopement for 1 (#8) of 3 residents sampled for adequate supervision. The administrator identified 20 residents were dependent for mechanical lift transfers and seven residents were at risk for elopement. Findings:1. On 12/23/25 at 8:18 a.m., Resident #7 was observed in their bed. Resident #7 was observed receiving a breakfast tray on their bed side table from CNA #2. CNA #2 was observed telling Resident #7 they will assist Resident #7 with eating and placed the bed side table in front and over Resident #7's chest and abdomen area. A facility policy titled ADL [activities of daily living] Care -Transfer Techniques, revised 02/12/20, read in part, Staff will provide safe effective transfer techniques for residents in accordance to standard practice guidelines.Mechanical Lift (Hoyer/Sit to Stand) Utilize manufactures' guidelines.An undated facility document for the care of slings titled Section1-General Guidelines, read in part, After each laundering in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching.Resident #7's quarterly assessment, dated 07/23/25, showed Resident #7's cognition was intact with a BIMS score of 15. The assessment showed Resident #7 was admitted with end stage renal disease, had lower extremity impairments, was dependent on staff for all transfers.An OSDH facility reported incident, dated 12/16/25, showed Resident #7 fell from left sling breaking during a transfer resulting in a fracture to the right clavicle and the left tibia.Resident #7's hospital records, dated 12/16/25, showed Resident # 7 was diagnosed with fracture of the left tibia and fracture of the right clavicle after a fall during a transfer using a mechanical lift at the facility on 12/16/25.Resident #7's nursing note, dated 12/16/25, read in part, 11:00- resident was being transferred from the bed to w/c [wheelchair] when [they] fell out of sling onto the floor. [They] had landed on the back of [his] head, bilateral shoulders, bilateral hips and left knee where [they] has c/o [complained of] pain.Resident #7s care plan, dated 12/22/25, did not have a focus or interventions for transfers on 12/16/25 when the accident occurred.On 12/23/25 at 8:19 a.m., Resident #7 stated two aides were helping them transfer with a lift from the bed to a wheelchair when the strap on one side of the sling broke and they fell from the lift. Resident #7 stated their shoulder, and leg was broken when they fell. Resident #7 stated the staff had to feed them due to their broken clavicle and not being able to use their arms which was embarrassing. Resident #7 stated they had a brace on their leg, experienced a lot of pain, and was fearful of transfers. On 12/23/25 at 8:36 a.m., CNA #2, stated they went to the laundry to get a sling because the blue sling Resident #7 usually had one in their room that was not available. CNA #2 stated they had bigger and smaller sizes. CNA #2 stated they got a medium white colored sling based upon their best judgement if it would fit the resident and they just guessed what size to use. CNA #2 stated they did not usually check for sizes. CNA #2 stated they were never trained on how to determine what size sling to use. CNA #2 stated the DON told them the white slings were disposable and should not have been used. CNA #2 stated they were transferring Resident #7 with another aide present from the bed to a wheelchair with a mechanical lift and the white sling broke on one side resulting in Resident #7 falling from 3 feet in the air. CNA #2 stated Resident #7 hurt their left foot as they fell. CNA #2 stated they did not know the white slings were disposable and did not understand why they would have been hanging in the laundry room. On 12/23/25 at 9:12 a.m., the DON stated the slings were kept in a resident's room unless they were soiled. The DON stated an aide went to the laundry room and grabbed a medium size sling which was appropriate for the resident's weight. The DON stated the strap on the sling broke while two aides were transferring Resident #7. The DON stated they did not specify sling sizes because residents weight changes and the slings have the weight on them. The DON stated residents are weighed monthly and that was how the aides who were trained determined the sling to use. The DON stated the correct sling was used and the only reason a disposable sling would have been in the laundry room was if a resident came back from the hospital with one. 2.On 12/22/25 at 3:30 p.m., the exterior of the facility was observed. The facility was located on a two-lane busy main street. There is a golf course with ponds located adjacent to the facility. A facility policy titled Elopement Management, dated 02/12/20, read in part, Document Requirements in the EHR: .Incident/Accident report, .Nursing Notes should reflect an accurate account of the situation and outcome.Social Services note needs to address emotional account of the situation and outcome.Update the elopement Risk Assessment .Update the Care Plan.Resident #8's care plan, dated 02/06/25, showed a focus that Resident #8 was exit seeking. The care plan interventions showed:a. analyze keys times, places, circumstances, triggers, and what deescalated behavior dated 05/30/24,b. encourage activities dated 02/06/25,c. frequent visual checks dated 02/06/25, d. maintain behavior log dated 02/06/25, ande. provide a pleasant home-like environment dated 02/06/25.Resident #8's elopement assessment, dated 08/19/25, showed the resident was scored as a moderate risk for elopement with a score of 19.Resident #'8s quarterly assessment, dated 08/25/25, showed their cognition was significantly impaired with a BIMS score of 2. The assessment showed Resident #8 was admitted on [DATE] with diagnoses which included dementia with behavior disturbances and chronic kidney disease. The assessment showed Resident #7 did not wander during the look back period. The assessment showed Resident #8 was independent for ambulating.Resident #8's elopement assessment, dated 11/20/25, showed the resident was scored as a moderate risk for elopement with a score of 16.A facility reported incident combined initial and final report, dated 12/09/25, showed Resident #8 missing from the facility and found during a search. The report showed Resident #8 was found North of the building near a church parking lot with scratches on their elbow and was returned to the facility and placed on one-on-one supervision. The national weather service showed the temperature in [NAME], Oklahoma on 12/09/25 was 50 degrees Fahrenheit at 6:00 p.m.Resident #8's nursing note, dated 12/10/25, showed an unidentified CNA noticed Resident #8 was missing on 12/09/25 at 6:00 p.m. The note showed another unidentified resident admitted to letting Resident #8 out of the facility. The note showed the facility notified the family, police, and started to search for Resident #8. The note showed Resident #8 was located at 7:20 p.m. and returned to the facility. Resident #8's care plan, revised 12/10/25, showed Resident #8 had a focus added for being an elopement risk. The care plan showed Resident #8 had interventions added to the care plan to address elopement on 12/10/25:a. staff was to be aware of Resident #8 in common area and visually monitor them,b. attempt to redirect the resident when they fixated on exits, andc. signage placed on exits to alert visitors of exit seeking residents. Resident #8's care plan, revised 12/10/25, did not have a focus and interventions to address Resident #8's elopement risk and did not have interventions for increased supervision from the previous care plan dated 02/06/25. On 12/22/25 at 1:58 p.m., the DON was shown Resident #8's elopement assessments, dated 08/19/25 and 11/20/25. The DON stated Resident #8 was a moderate risk for elopement and the care plan should have a focus and interventions after the elopement assessments. The DON stated the facility went with a new EHR earlier in the year. The DON stated Resident #8 did not have a focus or interventions to address Resident #8's elopement risk and need for increased supervision from 06/12/25 through 12/10/25 because the old focus and interventions from the care plan, dated 02/06/25, were never carried over to the new EHR and they did not follow their policy and update the care plan after the elopement assessments showed Resident #8 was a moderate risk for elopement. On 12/23/25 at 8:36 a.m., CNA #2 stated Resident #8 would always watch the doors and exit seek for the last few months. On 12/23/25 at 9:12 a.m., the DON stated Resident #8 eloped from the facility after being let out by another unidentified resident on 12/09/25. The DON stated Resident #8 was located a block away and may have cut across the golf course which was adjacent to the facility to a nearby church where they were located. The DON stated Resident #8 had scratches to their arms when they returned to the facility.

Based on observation, record review, and interview, the facility failed to ensure a resident's care plan was updated with interventions to prevent wandering into other residents' room for 1(#4) of 3 sampled residents reviewed for care plans interventions. The administrator identified 102 residents resided in the facility.Findings: On 09/23/25 at 3:30 p.m., Resident #5 was observed seated on their walker at the nurses' station with a fast-food bag in their hands. Resident #5's care plan, dated 6/20/25, showed Resident #5 had a focus for wandering into other residents' rooms. The interventions were dated 06/20/25 which included redirecting the resident and analyzing the circumstances, times, and places to deescalate the resident's behavior.Resident #5's nursing note, dated 07/08/25, read in part, .resident found in [gender withheld] residents' bed. Resident asleep near private area. Both residents fully clothed. Resident removed from [gender withheld] residents' bed and took back to [their] own room. Resident #5's nursing note, dated 07/10/25, read in part, .Resident found trying to enter a [gender withheld] resident room. Resident was redirected. [They] did not do well with the redirect. Resident tried to punch me in the face multiple times. [They] did finally go back to [their] room, and a close watch was kept to ensure [they] would not enter another resident's room.Resident #5's nursing note, dated 07/12/25, showed resident #5 was going into other residents' rooms and was redirected. The showed the resident became violent with staff and was hitting, kicking, and trying to bite the staff when they redirected them. Resident #5s nursing note, dated 08/03/25, showed the resident was in another resident bathroom. The note showed the resident hit a CNA on the left cheek when they were redirected from the resident's bathroom. Resident #5's re-admission assessment, dated 09/02/25, showed their cognition was significantly impaired and was unable to complete the BIMS assessment. The assessment showed the resident had wandering behaviors that occurred 4 to 6 days during the look back period. The assessment showed Resident #5 had diagnoses which included dementia, cardiac murmur, and hypertension.Resident #5s nursing note, dated 09/04/25, showed they were wondering into other residents' bathrooms. The note showed the resident was easily redirected. Resident #5's nursing note, dated 09/18/25, read in part, .Resident was briefly in another resident's room looking in [their] closet. The roommate was upset by this and called their daughter. The daughter insisted the police be called so that a report could be filed.A facility document titled Incident Case report, dated 09/21/25, read in part, .CNA [name withheld] reported to this RN that pt was out of bed during bed checks at 3:00 am. [They] tried to redirect [them] to bed in which [they] tried to hit [CNA]. Per [CNA] statement, [Resident #5] took thee swings and on the last swing [they] fell. The CNA was not harmed or hit. The RN went to assess the patient. [They] had gotten up on their own.There were no revisions made to Resident #5s care plan after each documented incident Resident #11 wandered into other residents' rooms. 2. On 09/23/25 at 2:51 p.m., Resident #4 was observed lying in bed. The resident was able to sit up on the side of the bed without assistance. The resident presents as alert and oriented time four. Resident #4's re-admission assessment, dated 07/10/25, showed their cognition was intact with a BIMS score of 14. The assessment showed the resident was admitted with diagnoses which included acute kidney failure, nontraumatic intracerebral hemorrhage, and type 2 diabetes.Resident #4's nurses notes, dated 09/18/25, read in part, .Late Entry for 09/1825 05:15 AM resident was upset to find another resident in her room going through [her] roommates' closet. 3. On 09/24/25 at 9:35 a.m., Resident #11 was observed lying in bed with head of bed elevated at twenty degrees. Their call light was in reach, the bed was low, and a fall mat was in place. The resident only smiles and did not respond to any questions. A facility document titled Incident Case report, dated 07/08/25, read in part, .Resident found in female residents' room [they] had fallen asleep with [their] on [other residents] bed. Both residents fully clothed. Resident removed from [gender withheld] residents' bed and took back to [their] own room. PCP, DON, and left voice mail on [family representatives] phone to call back.Resident #11s annual assessment, dated 09/01/25, showed their cognition was significantly impaired and was unable to participate in the BIMS assessment. The assessment showed Resident #4 was dependent for toileting and hygiene and required supervision or touching assistance for bed mobility. The assessment showed the resident required partial to moderate assistance with transfers and they used a wheelchair for mobility. The assessment showed Resident #4 had diagnoses which included type 2 diabetes, pseudobulbar affect, and bradycardia. On 09/23/25 at 2:51 p.m., Resident #4 stated Resident #11 was coming into their room and their closet. Resident #4 stated they requested to be moved rooms to prevent it from happening again and feels safe in the facility. On 09/24/25 at 10:41 a.m., family representative #3 stated they were notified Resident #5 was found lying clothed in Resident #11's bed. They stated the police were called and the physician has been adjusting resident #5's Seroquel due to the resident becoming increasingly confused in the evening. On 09/24/25 at 11:20 a.m., CNA #2 stated Resident #5 was found lying in Resident #11s bed sleeping fully clothed half on the bed and half on the floor. CNA #2 stated Resident #11's room was changed, the police were called, family was notified, and a report was made. CNA #2 stated Resident #5 continues to go into the same room where Resident #4 is now located. CNA #2 stated that there has been nothing done to prevent Resident #5 from going into other resident's room. On 09/09/25 at 1:30 p.m., RN #1 stated Resident #5 had wandering behaviors which included wandering into other resident rooms. RN #1 stated the intervention to prevent the resident wandering into other residents' room was to redirect the resident. On 09/09/25 at 2:12 p.m., the ADON stated Resident #5 was reported to wander into Resident #11's room and get in their bed and fell asleep. The ADON stated they moved Resident #11's room. On 09/24/25 at 3:20 p.m., the DON stated Resident #5 has behaviors of wandering in and out of other resident's room. The DON stated there was an incident on 07/08/25 where Resident #5 was found sleeping in Resident #11's bed with Resident #11. The DON stated there was another incident recently when Resident #5 wandered into Resident #4's roommates closet. The DON stated the interdisciplinary team should have met and care planned interventions after each incident of wandering. The DON stated Resident #5's care plan was not updated with interventions to prevent wandering after 06/20/25. On 09/24/25 at 4:24 p.m., family representative #4 stated they were notified on 07/08/25, Resident #11 was found in bed with Resident #11. Family representative #4 stated the police were notified, they consented to Resident #11's room being changed, and Resident #11 was not harmed. On 09/29/25 at 5:15 p.m., corporate nurse # 1 stated the facility did not have a policy for ensuring care plans were revised and reevaluated after an incident. Corporate nurse #1 states the facility follows the RAI manual.

Based on record review and interview, the facility failed to notify the physician when a resident:a. missed their prescribed antibiotic dose; and b. had an abnormal heart rate for 1 (#6) of 3 sampled residents reviewed for medication administration.The administrator identified 97 residents resided in the facility.Findings:A MEDICATION-GUIDELINES ON CLINICAL PRACTICE policy, revised 01/12/20, read in part, Staff will provide medications in accordance with standard practice guidelines.Resident #6's quarterly resident assessment, dated 08/09/25, showed the resident had diagnoses which included congestive heart failure and unspecified atrial fibrillation.A physician's order, dated 07/24/25, showed metoprolol succinate (an antihypertensive) 50 mg tablet, extended release for essential primary hypertension. Give one tablet by mouth three times a day. Take one 50mg tablet if systolic blood pressure is less than 110.A physician's order, dated 08/03/25, read in part, ciprofloxacin hydrochloride (an antibiotic) 500 mg tablet for urinary tract infection. Start 08/04/25 at 08:00 [8:00 a.m.]. Give 500 mg by mouth twice a day at 8:00 a.m. and 8:00 p.m. Stop on 08/11/25 at 8:00. Finish all of this medication unless otherwise directed.An August 2025 Medication Record for;a. ciprofloxacin hydrochloride showed Resident #6 had a missed dose on 08/04/25 for 8:00 a.m. and 8:00 p.m. dose, and on 08/11/25 for 8:00 a.m. dose; andb. metoprolol showed the resident had missed their metoprolol dose on 08/15/25 for the 12:00 p.m. and 8:00 p.m. doses. The record showed the resident received metoprolol on 08/16/25 at 8:00 a.m. with a heart rate of 120 bpm.On 08/22/25 at 11:39 a.m., LPN #2 stated they could not locate documentation the physician was notified of the missed antibiotic doses.On 08/22/25 at 11:53 a.m., LPN #2 stated they would notify the physician of the elevated heart rate and rechecked until the resident returned to their baseline heart rate.On 08/22/25 at 11:56 a.m., LPN #2 stated they could not locate documentation the physician was notified of the elevated heart rate.On 08/22/25 at 1:10 p.m., the DON stated the metoprolol parameters meant to take one 50 mg tablet if systolic blood pressure is less than 110.On 08/22/25 at 1:29 p.m., the DON stated notification to the physician on elevated heart rate depended on the physician's preference. They stated the facility's physician informed facility staff verbally of their notification preference. The DON stated the facility's physician wanted to be notified of residents' heart rate above 150 bpm for non-frequent episodes or 130 bpm if regularly elevated.On 08/22/25 at 1:39 p.m., the DON stated the physician should be notified of the missed antibiotic doses.

Based on record review and interview, the facility failed to provide showers as scheduled for 3 (#2, 5, and #6) of 3 sampled residents reviewed for showers.The DON identified 97 residents required assistance with bathing. Findings:A BATHING (NOT PARTIAL OR COMPLETE BED BATH) policy, revised 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines.1. Resident #2's quarterly resident assessment, dated 07/31/25, showed the resident had diagnoses which included unspecified hemiplegia affecting left nondominant side. The assessment showed the resident's cognition was intact with a BIMS of 15. The assessment showed the resident required setup or clean-up assistance with showers.There was no documentation the resident had a shower on 06/03/25, 06/05/25, 06/07/25, 06/24/25, and 06/26/25.The June 2025 shower sheets showed the resident refused a shower on 06/12/25, 06/14/25, 06/19/25, and 06/25/25.Resident #2 had three out of 12 showers for the month of June 2025.There was no documentation the resident had a shower on 07/01/25, 07/03/25, 07/08/25, 07/15/25, 07/19/25, 07/22/25, 07/24/25, 07/26/25, 07/29/25, and 07/31/25.The July 2025 shower sheets showed the resident refused a shower on 07/10/25 and 07/17/25.Resident #2 had two out of 14 showers for the month of July 2025.There was no documentation the resident had a shower on 08/02/25, 08/05/25, 08/14/25, and 08/16/25.Resident #2 had four out of eight showers from 08/01/25 through 08/19/25.On 08/20/25 at 11:22 a.m., Resident #2 stated their shower schedule was on Tuesday, Thursday, and Saturday. They stated they went five days without a shower about three weeks ago. They stated they took showers at night, and staff would say they refused showers because they did not want to give them showers at night.On 08/21/25 at 3:02 p.m., CNA #1 stated they provided residents showers as scheduled. They stated showers were scheduled per beds in resident rooms.On 08/21/25 at 3:02 p.m., CNA #1 stated if a resident refused a shower, they would make multiple attempts and notify the nurse. They stated they would document refusal on the shower sheets. They stated they had residents signed off on the refusal documentation a couple of times, but did not see any sign off on the shower sheets provided to the surveyor.On 08/21/25 at 3:07 p.m., CNA #1 stated Resident #2's shower schedule was on Tuesday, Thursday, and Saturday. They stated they did not see any showers for the dates above. 2. Resident #5's discharge assessment return not anticipated, dated 07/12/25, showed the resident had diagnoses which included personal history of transient ischemic attack and cerebral infarction without residual deficits. The assessment showed the resident required supervision or touching assistance with showers.There was no documentation the resident had a shower on 06/25/25 and 06/30/25.The June 2025 shower sheets showed the resident refused a shower on 06/20/25.Resident #5 had three out of five showers from 06/18/25 through 06/30/25.There was no documentation the resident had a shower on 07/04/25, 07/07/25, 07/09/25, 07/11/25.Resident #5 had one out of five showers from 07/01/25 through 07/11/25.On 08/21/25 at 3:32 p.m., CNA #1 stated they did not see any showers for the dates above. 3. Resident #6's quarterly resident assessment, dated 08/09/25, showed the resident had diagnoses which included chronic obstructive pulmonary disease and unspecified osteoarthritis. The assessment showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident required partial to moderate assistance with showers.There was no documentation the resident had a shower on 06/03/25, 06/05/25, 06/07/25, 06/10/25, 06/14/25, 06/19/25, 06/24/25, and 06/28/25.Resident #6 had four out of 12 showers for the month of June 2025.There was no documentation the resident had a shower on 07/01/25, 07/03/25, 07/05/25, 07/08/25, 07/12/25, 07/17/25, 07/22/25, 07/24/25, 07/26/25, and 07/31/25.The July 2025 shower sheets showed the resident refused a shower on 07/29/25.Resident #6 had three out of 14 showers for the month of July 2025.There was no documentation the resident had a shower on 08/05/25, 08/09/25, 08/12/25, and 08/14/25.Resident #6 had four out of eight showers from 08/01/25 through 08/19/25.On 08/20/25 at 12:41 p.m., Resident #6 stated they went 10 days without a shower. They stated they never refused a shower.On 08/20/25 at 12:42 p.m., Resident #6's representative stated staff would write refuse on the paper but that was false.On 08/21/25 at 3:27 p.m., CNA #1 stated Resident #6's shower schedule was on Tuesday, Thursday, and Saturday. They stated they did not see any showers for the dates above.On 08/21/25 at 3:34 p.m., LPN #1 stated the CNAs would inform the nurse of resident refusal of showers and the nurse would encourage the resident to have a shower. They stated the CNA would document refusal on the shower sheet. LPN #1 stated the facility was going to implement resident sign off on refusals, but they had not implemented the process at this time.On 08/21/25 at 3:41 p.m., the DON stated they expected staff to follow resident shower schedules to provide showers.

Based on record review and interview, the facility failed to administer medication as ordered for 2 (#5 and #6) of 3 sampled residents reviewed for medication administration.The administrator identified 97 residents resided in the facility. Findings:A MEDICATION-GUIDELINES ON CLINICAL PRACTICE policy, revised 01/12/20, read in part, Staff will provide medications in accordance with standard practice guidelines.1. A physician's order for Resident #5, dated 06/18/25, showed insulin glargine 100units/1mL, give 30 units subcutaneous at bedtime for type 2 diabetes mellitus without complications.A June 2025 Medication Record showed M on 06/20/25 for 9:00 p.m. dose. Resident #5's discharge assessment return not anticipated, dated 07/12/25, showed the resident had diagnoses which included type 2 diabetes mellitus without complications.On 08/22/25 at 11:32 a.m., LPN #2 stated they were not sure what the M meant on the medication record. They stated the medication record did not show the insulin was administered on 06/20/25.On 08/22/25 at 11:33 a.m., LPN #2 stated if a resident refused their blood sugar checks or medications, they would mark it as refused, notify the physician, and document in the nurses' notes. 2. A physician's order for Resident #6, dated 03/18/25, showed magnesium oxide (an electrolyte supplement) 400 mg. Give one tablet by mouth one time daily for constipation.A physician's order for Resident #6, dated 07/24/25, showed metoprolol succinate (an antihypertensive) 50 mg tablet, extended release for essential primary hypertension. Give one tablet by mouth three times a day. Take one 50mg tablet if systolic blood pressure is less than 110.A physician's order, dated 08/03/25, read in part, ciprofloxacin hydrochloride (an antibiotic) 500 mg tablet for urinary tract infection. Start 08/04/25 at 08:00. Give 500 mg by mouth twice a day at 8:00 a.m. and 8:00 p.m. Stop on 08/11/25 at 8:00. Finish all of this medication unless otherwise directed.Resident #6's quarterly resident assessment, dated 08/09/25, showed the resident had diagnoses which included congestive heart failure and unspecified atrial fibrillation. The assessment showed the resident's cognition was intact with a BIMS of 14.There was no documentation magnesium was administered twice a day from 08/01/25 through 08/21/25.An August 2025 Medication Record for ciprofloxacin hydrochloride showed;a. H on 08/04/25 for 8:00 a.m. dose,b. M on 08/04/25 for 8:00 p.m. dose, andc. M on 08/11/25 for 8:00 a.m. dose.An August 2025 Medication Record for metoprolol showed;a. M on 08/15/25 for 12:00 p.m. dose,b. H on 08/15/25 for 8:00 p.m. dose with BP of 106/67 mmHg and HR of 116 bmp, and c. H on 08/18/25 for 8:00 p.m. dose with BP of 102/60 mmHg and HR of 109 bmp.On 08/20/25 at 12:50 p.m., Resident #6 stated they sometimes had a problem getting their medications from the nurses even if they asked. They stated they missed some of their medications.On 08/22/25 at 10:38 a.m., CMA #1 stated they were to administer antibiotics as ordered. They stated the H on the resident's August 2025 medication record could mean held. They stated the antibiotic could have been held because the medication was not in the facility.On 08/22/25 at 10:46 a.m., CMA #1 stated the reason documented for holding the antibiotic was due to vital signs parameters.On 08/22/25 at 10:56 a.m., CMA #1 stated they notified the nurse because that was their process, but could not remember who the nurse on duty was on 08/04/25.On 08/22/25 at 10:57 a.m., CMA #1 stated they were not sure what M meant on the resident's August 2025 medication record for the medications above.On 08/22/25 at 11:02 a.m., CMA #1 stated the parameter on the metoprolol could mean only give if the systolic blood pressure was less than 110.On 08/22/25 at 11:04 a.m., CMA #1 stated they were not sure the reason for holding the metoprolol on 08/15/25 and 08/18/25.On 08/22/25 at 11:05 a.m., CMA #1 stated the medication record did not show the medications above were administered.On 08/22/25 at 11:38 a.m., LPN #2 stated the process for holding medications was per physician orders and if the resident refused.On 08/22/25 at 11:45 a.m., LPN #2 stated the resident did not receive the antibiotic as ordered.On 08/22/25 at 11:50 a.m., LPN #2 stated they would had clarified the metoprolol parameters order prior to administering or holding it due to the exclamation mark in the order. They stated they did not know what M meant on the resident's medication record.On 08/22/25 at 11:52 a.m., LPN #2 stated the metoprolol was not administered as ordered for the dates above.On 08/22/25 at 12:56 p.m., CMA #1 stated they did not remember administering any magnesium for Resident #6. They stated the medication did not show up for staff to administer it.On 08/22/25 at 1:08 p.m., the DON stated the medication record did not show Resident #6 received their magnesium oxide from 08/01/25 through 08/21/25.On 08/22/25 at 1:10 p.m., the DON stated the metoprolol parameters meant to take one 50 mg tablet if systolic blood pressure is less than 110.On 08/22/25 at 1:18 p.m., the DON stated according to the metoprolol order, it should not have been held on 08/15/25 at 8:00 p.m. dose. They stated the medication record showed the medication was held on 08/18/25 and they could not determine the medication was administered on 08/15/25 at 12:00 p.m.

Based on record review and interview, the facility failed to ensure the amount of insulin administered was documented on a resident who received sliding scale insulin for 1 (#5) of 3 sampled residents reviewed for medication administration.The DON identified 28 residents received insulin resided in the facility. Findings:A MEDICATION-GUIDELINES ON CLINICAL PRACTICE policy, revised 01/12/20, read in part, Staff will provide medications in accordance with standard practice guidelines.A physician's order for Resident #5, dated 06/21/25, showed Humalog kwikpen 200 units/1mL solution. Give one dose subcutaneous for blood sugar 70-100= 0 units, 100-150= 4 units, 151-200= 6 units, 201-250= 8 units, 251-300= 10 units, 301-350= 12 units, 351-400= 14 units, 401-500= 16units, over 500, give 5 additional fast acting units before meals and bedtime for type 2 diabetes mellitus with ketoacidosis without coma.A Medication Record reviewed from 06/21/25 through 06/30/25 did not show how many units of the sliding scale insulin was administered for all blood sugars above 100.A physician's order for Resident #5, dated 07/06/25, showed Humalog kwikpen 200 units/1mL solution. Give one dose subcutaneous for blood sugar 70-100= 0 units, 100-150= 2 units, 151-200= 4 units, 201-250= 6 units, 251-300= 8 units, 301-350= 10 units, 351-400= 12 units, 401-500= 14units, over 500, give 5 additional fast acting units before meals and bedtime for type 2 diabetes mellitus with ketoacidosis without coma.A Medication Record reviewed from 07/01/25 through 07/12/25 did not show how many units of the sliding scale insulin was administered for all blood sugars above 100. Resident #5's discharge assessment return not anticipated, dated 07/12/25, showed the resident had diagnoses which included type 2 diabetes mellitus without complications.On 08/21/25 at 2:44 p.m., the DON stated staff followed the sliding scale order. They stated what they should give was in the order.The DON could not provide documentation on how much of the Humalog was administered for blood sugars above 100 on the dates reviewed.On 08/21/25 at 4:14 p.m., LPN #4 stated the electronic health system the facility used for medication administration may or may not given them an option to document the amount of insulin administered. They stated they personally put that information in a note. LPN #4 stated the facility should provide the option to input what was administered.On 08/21/25 at 4:25 p.m., LPN #4 stated it was important to know what was previously administered for insulin treatment, interventions, and emergencies.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician's order and a self-administration of medication assessment for 1 (#6) of 3 sampled residents reviewed for medication administration.The administrator identified 97 residents resided in the facility. Findings: On 08/20/25 at 12:49 p.m., fluticasone propionate (a corticosteroid) nasal spray was observed on Resident #6's bedside table.A MEDICATION PROGRAM policy, revised 12/01/23, read in part, Residents who self-administration their medication and keep them locked in their room must be counseled at least monthly by community staff to ascertain if the residents continue to be capable of self-administering their medications/treatments and if security of the medications can continue to be maintained. The community must keep a written record of such counseling.A physician's order, dated 03/11/25, showed fluticasone propionate nasal spray 50 micrograms, give one spray twice a day for unspecified cough.Resident #6's quarterly resident assessment, dated 08/09/25, showed the resident had diagnoses which included congestive heart failure and chronic obstructive pulmonary disease. The assessment showed the resident's cognition was intact with a BIMS score of 14.On 08/20/25 at 12:50 p.m., Resident #6 stated they took the nasal spray once a day.On 08/20/25 at 1:48 p.m., LPN #3 stated the resident had to have a physician's order to self-administer medications.On 08/20/25 at 1:54 p.m., LPN #3 stated the resident had fluticasone propionate nasal spray on bedside table. They stated the nasal spray should be administered twice a day. LPN #3 stated they could not locate a resident self-administration assessment for the nasal spray.On 08/20/25 at 1:57 p.m., LPN #3 stated they could not locate an order for self-administration of the nasal spray.On 08/20/25 at 1:58 p.m., LPN #3 stated they initially educated Resident #6 on the administration of the nasal spray, but no other education was provided since then.On 08/20/25 at 2:00 p.m., the DON stated residents would need an order and a self-administration assessment to self-administer medications.On 08/20/25 at 2:04 p.m., the DON stated they could not locate an order and an assessment for self-administration of the nasal spray.

Based on record review and interview, the facility failed to ensure a resident with low blood sugar received appropriate care for 1 (#5) of 3 sampled residents reviewed for medication administration.The DON identified 28 residents received insulin resided in the facility. Findings:A HYPOGLYCEMIA TREATMENT policy, revised 02/12/20, read in part, Guidelines for Mild Hypoglycemia: Treat, even if biochemical hypoglycemia is not present with a. glucose-15 40% oral gel (Dextrose) gm gel, b. Glucose 15 gm tablets.Repeat blood glucose level in fifteen (15) minutes.A physician's order, dated 06/21/25, showed Humalog kwikpen 200 units/1mL solution. Give one dose subcutaneous for blood sugar 70-100= 0 units, 100-150= 4 units, 151-200= 6 units, 201-250= 8 units, 251-300= 10 units, 301-350= 12 units, 351-400= 14 units, 401-500= 16units, over 500, give 5 additional fast acting units before meals and bedtime for type 2 diabetes mellitus with ketoacidosis without coma.A Medication Record for Humalog sliding scale on 07/06/25 for 7:00 a.m. dose, showed insulin was held due to vital signs parameters. The record showed the resident's blood sugar was 39.There was no documentation Resident #5's blood sugar was rechecked in 15 minutes according to the facility's hypoglycemia policy.There was no documentation interventions were implemented for the resident's low blood sugar according to the facility's hypoglycemia policy.Resident #5's discharge assessment return not anticipated, dated 07/12/25, showed the resident had diagnoses which included type 2 diabetes mellitus without complications.On 08/21/25 at 3:59 p.m., the ADON stated they could not see what interventions were done for Resident #5's low blood sugar on 07/06/25.On 08/21/25 at 4:05 p.m., the ADON stated they could not locate documentation to show a recheck was performed.

Based on observation, record review and interview, the facility failed to ensure MDS assessments were accurate for 2 (#28 and #81) of 24 residents sampled for MDS assessments. The administrator identified 91 residents resided in the facility. Findings: A policy titled Resident Assessment, dated 09/13/17, read in part, It is the standard of Care to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual.The assessment process included direct observation, the medical record, as well as communication with the resident and direct care staff across all shifts. 1. Resident #28's admission record, dated 09/14/24, showed they were admitted with diagnoses which included end stage renal disease and displaced fracture of the lower right leg. Resident #28's physician orders, dated 09/14/24, read in part, Dialysis Monday, Wednesday and Friday on 1 time per day Monitor shunt/graft/fistula. Resident #28's admission assessment, dated 9/17/24, did not show in section O the resident received dialysis services. Resident #28's quarterly assessment, dated 12/18/24, did not show in section O the resident received dialysis services. Resident #28's quarterly assessment, dated 3/20/25, showed their cognition was intact with a BIMS score of 15. The assessment did not show the resident received dialysis in section O. On 04/29/25 at 9:22 a.m., Resident #28 was asked about their dialysis services. They stated they went to dialysis on Monday, Wednesday, and Friday since admission. On 05/01/25 at 10:41 a.m., the DON was asked about Resident #28's dialysis services. They stated the resident went to dialysis and had orders since 09/14/24 when they were admitted . On 05/01/25 at 10:45 a.m., MDS coordinator #1 was asked how they ensured MDS assessments were accurate and reflected the current status of the resident. They stated they interviewed residents, staff, and reviewed documentation in look back period. They were asked what did section O show in Resident #28's 09/17/24, 12/18/24, and 03/20/25 assessments. MDS Coordinator #1 stated it showed none of the above for special treatments in section O. They were asked if the resident received dialysis during the look back period for each of the assessments. MDS Coordinator #1 stated, Yes, that's an error on my part. They stated they missed the dialysis on the admission assessment and did not go through and check on the next assessments to ensure dialysis was selected in special treatments section O of the assessments. 2. On 05/05/25 at 2:02 p.m., Resident #81 was observed with no natural teeth and was edentulous (no natural teeth or tooth fragments). Resident #81's admission record, dated 01/28/25, showed the resident was admitted with diagnoses which included alcoholic cirrhosis of the liver, chronic hepatic failure, and liver cell carcinoma. Resident #81's admission assessment, dated 01/31/25, showed moderate cognitive impairment with a BIMS score of 12, required set up or clean up assist for oral hygiene, and section L showed the resident was not edentulous. On 04/28/25 at 2:27 p.m., Resident #81 stated they needed dentures and had no natural teeth. They stated they were never offered dental services, they ate a regular diet, and they had trouble eating some things that were hard. Resident #81 stated they had pain and discomfort in their mouth and would like to get dentures. On 05/05/25 at 2:04 p.m., LPN #3 was asked about Resident #81's oral care needs. They stated the resident was admitted with no teeth. On 05/05/25 at 2:10 p.m., the DON was asked about Resident #81's teeth. They stated the resident was edentulous. The DON was asked to review Resident #81's admission assessment, dated 01/28/25, section L. They stated the assessment showed the resident had all their natural teeth and was not edentulous. They stated the assessment was not correct. On 05/05/25 at 2:19 p.m., MDS coordinator #1 was asked what the RAI manual said on how section L should be assessed. They stated, I can not tell you what I did at that time. They were asked what did section L show on Resident #81's admission assessment dated [DATE]. MDS Coordinator #1 stated the assessment did not show the resident was edentulous. They stated they relied upon chart reviews before interviews for a lot of information and did not do a visual assessment of Resident #81's teeth.

Based on observation, record review, and interview, the facility failed to ensure: a. a physician's order was obtained for a medication kept at beside to treat an abrasion for 1 (#55); b. a physician's order was in place for a treatment that was provided for 1 (#55); c. an abrasion was assessed routinely for 1 (#55) of 2 sampled residents reviewed for skin conditions; and d. communication was maintained with hospice for 1 (#68) of 1 sampled resident reviewed for hospice services. The administrator identified 91 residents resided in the facility. The ADON identified 10 residents received hospice services. Findings: 1. On 04/28/25 at 2:10 p.m., LPN #1 was observed to go into Resident #55's room, pick up a tube of mupirocin (topical antibiotic) ointment from the resident's bedside table, and apply it to Resident #55's head. On 05/06/25 at 12:55 p.m., the back of Resident #55's head was observed. A ribbon of cotton was observed on the left side of Resident #55's head. A medication box of triple antibiotic ointment was observed on the dresser next to the resident. The directions on the box showed to Apply to forehead twice a day. The box was dated 12/19/24. A policy titled Skin Data Collection, dated July 2018, read in part, A licensed nurse will collect data during weekly skin evaluations. A policy titled Non-Pressure Wounds: Abrasions, dated July 2018, read in part, To provide care for abrasions consistent with professional practice standards. A Quarterly Assessment, dated 03/13/25, showed Resident #55's BIMS score was 15, which indicated the resident's cognition was intact. An Incident Care Report, dated 04/12/25, showed Resident #55 sustained an abrasion to their head. There were no assessments or physician's orders located in Resident #55's clinical record regarding the abrasion on the back of Resident #55's head. On 05/06/25 at 12:56 p.m., Resident #55 stated the beauty operator washed their hair today, cleaned the abrasion on their head, and placed cotton on it. They stated staff applied ointment to the abrasion because it was difficult for them to do. On 05/06/25 at 12:58 p.m., the beauty operator stated they had washed Resident #55's hair. They stated they put a ribbon of cotton on the area on the back of Resident #55's head because it was bleeding. They stated the abrasion opened every time they washed Resident #55's hair. On 05/06/25 at 1:01 p.m., LPN #1 stated Resident #55 had fallen and obtained a wound on the back of their head. On 05/06/25 at 1:07 p.m., LPN #1 stated the directions on the medication box showed to Apply to forehead twice a day. LPN #1 stated the box was dated 12/19/24. LPN #1 was asked when Resident #55 had fallen. They stated, About a month ago. LPN #1 was asked if the ointment was used to treat the abrasion on the back of Resident #55's head. They stated, Yes. On 05/06/25 at 1:11 p.m., LPN #1 stated they could not locate a physician's order for the medication for Resident #55. On 05/06/25 at 1:17 p.m., the DON stated if the resident had an abrasion, there would be an active order and weekly assessments. The DON stated they were not able to locate an active order or assessments for Resident #55. The DON stated they were not able to locate an order for mupirocin. 46702 2. On 04/30/25 at 10:06 a.m., an oxygen concentrator and two oxygen tanks were observed in Resident #68's room. On 04/30/25 at 10:20 a.m., an oxygen concentrator and two oxygen tanks were observed in Resident #68's room. Resident #68's admission record, dated 10/30/24, showed they were admitted with diagnoses which included cirrhosis of the liver and nonalcoholic steatohepatitis. Resident #68's hospice medication report, dated 12/02/24, read in part, Oxygen Gas for Inhalation .Reason: Dyspnea/O2 .Administer 2 L oxygen as needed for respiratory comfort. Resident #68's quarterly assessment, dated 03/11/25, showed their cognition was intact with a BIMS score of 15. Resident #68's physician orders, dated 04/30/25, showed the resident had an order for hospice services with a start date on 12/02/24. The physician orders did not document Resident #68 had an order for oxygen. On 04/29/25 at 9:01 a.m., Resident #68 was asked about their hospice services. They stated they were on hospice and was not sure who to contact to discuss their care. On 04/30/25 at 10:20 a.m., LPN #2 was asked if Resident #68 had orders for oxygen. They stated the resident did not have orders for oxygen in the resident's physician orders. They checked the hospice orders in a book and stated they had some problems with hospice communicating physician orders. They stated the resident had hospice orders for oxygen dated 12/02/24. They stated somebody just missed adding the hospice orders to the physician orders. On 04/30/25 at 10:46 a.m., the DON was asked if Resident #68 had orders for oxygen. They stated there were no physician orders for oxygen. The DON reviewed the hospice orders, dated 12/02/24, and stated the resident had an order for oxygen since 12/02/24. The DON was asked why there was no oxygen orders in the resident's physician orders. The DON stated it was a lack of communication problem with hospice.

Based on observation, record review, and interview, the facility failed to ensure: a. staff donned gloves when applying an ointment to a resident for 1 (#55) of 2 sampled residents reviewed for wound care; b. staff changed gloves while performing peri-care to a resident for 1 (#23) of 1 sampled resident observed for peri-care; c. trends in infections were identified through monthly review of tracking for 3 of 3 sampled months reviewed; and d. respiratory equipment was bagged and labeled for 1 (#24) of 2 sampled residents reviewed for respiratory care. The administrator identified 91 residents resided in the facility. The ADON identified 17 residents received oxygen services and 28 residents had nebulizers. Findings: 1. On 04/28/25 at 2:06 p.m., LPN #1 was observed to apply mupirocin (topical antibiotic) ointment to the back of Resident #55's head with out wearing gloves. A policy titled Non-Pressure Wound, dated July 2018, showed to follow standard precautions and infection control methods. A Quarterly Assessment, dated 03/13/25, showed Resident #55's BIMS score was 15, which indicated the resident's cognition was intact. On 04/28/25 at 3:15 p.m., LPN #1 stated the floor nurses provided wound care when the wound care nurse was not available. LPN #1 stated they would perform handwashing and gather their supplies prior to completing wound care. LPN #1 was asked about wearing gloves when applying an ointment. They stated they did not because they used a lot of soap and water. They stated they did not like using alcohol gel on their hands. On 04/29/25 at 10:18 a.m., the IP stated staff were to wash their hands and wear gloves when they were performing wound care on a resident. 2. On 04/28/25 at 2:25 p.m., Resident #23 was observed laying in bed. CNA #1 and CNA #2 were observed to provide incontinent care to Resident #23. Resident #23 was observed to have had a bowel movement. CNA #2 was observed to wipe Resident #23 and then place clean linen under the resident. CNA #2 was not observed to have changed their gloves after wiping the resident and prior to touching clean linen. CNA #1 was observed to take the soiled linen off Resident #23's bed and place them on the floor. CNA #1 was observed to wipe Resident #23 multiple times and bowel was observed on the wipes. CNA #1 and CNA #2 was observed to assist the resident up in bed. CNA #1 was observed to adjust the resident's gown. CNA #1 was not observed to change their gloves. CNA #1 picked up the soiled linen and placed it back on the floor closer to the resident's door. On 04/28/25 at 2:38 p.m., CNA #1 removed the gloves, but was not observed to provide hand hygiene. CNA #1 was observed to enter another resident's room and adjust the air temperature. CNA #1 was observed to push their hair behind their ears. On 04/28/25 at 2:50 p.m., CNA #1 was observed standing in hall way with their hand on the hand rail. CNA #1 was observed to go to shower room door, push in the code to unlock the door, and go inside. CNA #1 was observed to begin washing another resident's hair. CNA #1 had not been observed to have performed hand hygiene after assisting with peri-care, removing gloves, going into another resident's room, or prior to assisting a resident with their shower. A policy titled Perineal Care, dated 04/28/24, showed to apply clean gloves, provide assistance to a resident, dispose of gloves and perform hand hygiene. The policy showed to apply new gloves before placing a new brief or changing the linen. A policy titled Hand Hygiene, dated February 2025, showed hand hygiene was to be completed before resident contact, after contact with soiled/contaminated items, toileting or assisting other with toileting, or removing gloves. A Quarterly Assessment, dated 03/06/25, showed Resident #23's BIMS score was 5, which indicated the resident's cognition was severely impaired. The assessment showed Resident #23 was dependent on staff for toilet hygiene and was always incontinent of bowel and bladder. On 04/28/25 at 2:59 p.m., CNA #2 stated staff were to use hand sanitizer between glove changes. CNA #2 stated they had been instructed to put soiled linens on the floor. CNA #2 stated staff should change soiled gloves before touching clean linen. CNA #2 did not recall changing their gloves after cleaning bowel off of the resident. On 04/29/25 at 10:18 a.m. the IP stated they tried to have five CNAs complete hand washing check offs each week. They stated staff were to change gloves after removing soiled linen, after cleaning the resident, and when they were finished assisting the resident with peri-care. The IP stated staff were to place soiled linen in a dirty linen cart and not on the floor. On 05/06/25 at 1:23 p.m., the peri-care observation was reviewed with the IP. They stated, This is probably where some of our UTIs are coming from. 3. A January 2025 infection control color coded facility map showed 12 residents had skin infections and nine residents had UTIs. A February 2025 infection control color coded facility map showed 13 residents had skin infections and nine residents had UTIs. A policy titled Infection Prevention, Control & Surveillance, revised February 2025, showed to look at the current month and preceding two months to determine similarities in infections. The policy showed to look for trends in common areas, residents with similar infections, and rooms close together. A March 2025 infection control color coded facility map showed 11 residents had skin infections and nine residents had UTIs. On 05/06/25 at 12:33 p.m., the IP stated they had not identified any trends in infections. On 05/06/25 at 1:23 p.m., January, February, and March 2025 infection control logs were reviewed with the IP. They stated they were counting the same bug. 46702 4. 04/29/25 at 12:11 p.m., a nebulizer machine with a tubing and mouth piece attached, and an oxygen concentrator with humidifier, dated 02/25/25, were observed bedside in the resident's room. The nebulizer mouth piece was laying on a bedside table not bagged and had moisture dripping onto papers on the table. There was no date on the oxygen tubing attached to the oxygen concentrator. A policy titled Respiratory Equipment Change Schedule, dated 01/12/18, read in part, The community will provide a schedule for changing disposable equipment at regular intervals as determined by manufacture recommendations and local community standards.For small volume medication nebulizer's, place in a clean bag, labeled with resident's name and if possible, leave at bedside. Resident #24's admission record, dated 01/11/24, showed they were admitted with diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, COPD (chronic obstructive pulmonary disease), and obstructive sleep apnea. Resident #24's annual assessment, dated 08/20/24, showed their cognition was moderately impaired for decision making with a BIMS score of 10. Resident #24's physician orders, dated 09/30/24, read in part, ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 mL [milliliters] nebulization soln [solution] (IPRATROPIUM BROMIDE/ALBUTEROL SULFATE) 1 VIAL Inhalation 3 times per day Duo nebs [nebulizer] INH [inhale] [at] 0800-1400 [2:00 p.m.]-2000 [8:00 p.m.] for SOB [shortness of breath]. Resident #24's physician orders, dated 03/11/25, read in part, O2 at 2 LPM [liters per minute] by NC [nasal cannula] AS NEEDED. Resident #24's physician orders, dated 04/04/25, read in part, Change Oxygen Cannula and tubing On Night Shift [Frequency: Weekly on Sunday Time: Shift 2]. On 05/05/25 at 10:50 a.m., LPN #3 was asked to discuss Resident #24's respiratory needs. They stated the resident took breathing treatments with a nebulizer machine and had oxygen that was used as needed for shortness of breath. LPN #3 was asked what kind of infection control practices policies they had in place when using oxygen equipment and nebulizers. They stated the hand held nebulizer mouth piece should be bagged, dated, and changed weekly on Sundays. They stated the oxygen tubing got changed weekly, should be bagged when not in use, and the tubing should be dated. On 05/05/25 at 10:57 a.m., LPN #3 stated they observed Resident #24's side table was cluttered with a nebulizer mouth piece not in a bag laying on top of papers and the oxygen tubing attached to the concentrator did not have a date it was administered. On 05/05/25 at 11:06 a.m., the IP stated the infection control policies were not followed due to the nebulizer mouth piece on the side table not being bagged and the oxygen tubing was not labeled with a date it was replaced.

Based on obsevation, record review, and interview, the facility failed to ensure a resident's room was free from odors for 1 (room [ROOM NUMBER]) of 24 rooms observed for odors. The administrator identified 91 residents resided in the facility. Findings: On 04/30/25 at 9:59 a.m., room # 217 was observed to have a strong odor of urine. A policy titled Resident Room Cleaning, dated 11/2021, read in part, To provide a clean, attractive, and safe environment for residents, visitors, and staff. On 04/30/25 at 10:04 a.m., CNA #5 was asked what they smelled in room [ROOM NUMBER]. They stated they smelled urine. CNA #5 stated the urine smell came from the floor and the bathroom because the resident was incontinent. They were asked if the smell facilitated a homelike environment. CNA #5 stated, No, it's not a homelike environment. On 04/30/25 at 10:20 a.m., LPN #2 was asked what the facility's policy and rule was about having a homelike environment. They stated the facility should be kept clean with no odors and made to feel as homelike as possible. LPN #2 was asked what they smelled in room [ROOM NUMBER]. They stated, I smelled urine in the room. They were asked what they thought about the smell. LPN #2 stated, We need to get that smell out of there. I don't think it's home like. I think it's the floor. On 04/30/25 at 10:46 a.m., the DON was asked what they observed in room [ROOM NUMBER]. They stated the room smelled like urine. They were asked if the urine smell facilitated a home like environment. The DON stated it was not their standard and the room should not smell.

Based on observation, record review, and interview, the facility failed to ensure oxygen tanks were stored in a safe place for 1 (#68) of 2 residents sampled for safe oxygen tank storage. The ADON identified 17 residents received oxygen therapy. Findings: On 04/30/25 at 10:06 a.m., an oxygen concentrator and two oxygen tanks were observed in Resident #68's room. One oxygen tank was secured to a cart with a strap. One tank was observed in the corner of the room loose and leaned up against the wall. On 04/30/25 at 10:20 a.m., oxygen tanks were observed in Resident #68's room. One oxygen tank was secured to a cart with a strap. One tank was observed in the corner of the room loose and leaned up against the wall. An undated policy titled Oxygen Storage Handling, read in part, All oxygen cylinders are to be stored in a fire safety closet and locked .Cylinders shall be stored away from doors and secured to its location by a non combustible strap or chain to avoid tipping. Resident #68's admission record, dated 10/30/24, showed they were admitted with diagnoses which included cirrhosis of the liver and nonalcoholic steatohepatitis. Resident #68's hospice medication report, dated 12/02/24, read in part, Oxygen Gas for Inhalation .Reason: Dyspnea/O2 .Administer 2 L oxygen as needed for respiratory comfort. Resident #68's quarterly assessment, dated 03/11/25, showed their cognition was intact with a BIMS score of 15. On 04/30/25 at 10:20 a.m., LPN #2 stated two oxygen tanks were stored in Resident #68's room. LPN #2 was asked what the policy was for storing oxygen. They stated oxygen tanks should be stored in the designated oxygen room. On 04/30/25 at 10:39 a.m., the DON asked what their policy was for storing oxygen tanks. The DON stated it had to be secured and stored in the oxygen room.

Based on observation, record review, and interview, the facility failed to ensure dental services were provided for 1 (#81) of 24 residents sampled for dental services. The ADON identified 73 resident had a payer source of Medicaid and eight residents received dental services. Findings: An undated policy titled 'Availability of Services, read in part, Oral healthcare and dental services will be provided to each resident.Social Services will be responsible for making necessary dental appointments. An undated policy titled Routine Dental Care, read in part, Our facility's routine dental care includes, but is not limited to: .Consultation with the resident, staff, and the dental consultant. Resident #81's admission record, dated 01/28/25, showed the resident was admitted with diagnoses which included alcoholic cirrhosis of the liver, chronic hepatic failure, and liver cell carcinoma. The record showed they had a payer source of Medicaid. Resident #81's admission assessment, dated 01/31/25, showed moderate cognitive impairment with a BIMS score of 12, required set up or clean up assist for oral hygiene, and section L showed the resident was not edentulous (no natural teeth or tooth fragments). On 04/28/25 at 2:27 p.m., Resident #81 was asked about any concerns. The resident stated they needed dentures and had no natural teeth. They stated they were never offered dental services, they ate a regular diet, and they had trouble eating some things that were hard. Resident #81 stated they had pain and discomfort in their mouth and would like to get dentures. On 05/05/25 at 2:04 p.m., LPN #3 was asked about Resident #81's oral care needs. They stated the resident was admitted with no teeth. On 05/05/25 at 2:10 p.m., the DON was asked about Resident #81's teeth. They stated the resident was edentulous since admission. On 05/05/25 at 2:37 p.m., the social services director was asked to discuss Resident #81's dental needs. They stated the resident had not received dental services since admission and transitioned from skilled care to long term care on 02/09/25. They stated the resident had a payer source of Medicaid and they missed offering to set the resident up for dental care and services.

Based on observation, record review, and interview, the facility failed to assess a resident for self administration of medication and obtain a physician order for a resident to self administer medication for 1 (#55) of 1 sampled resident reviewed for self administration of medication. The administrator identified 91 residents resided in the facility. Findings: On 04/28/25 at 2:10 p.m., LPN #1 was observed to go into Resident #55's room, pick up a tube of mupirocin (topical antibiotic) ointment from the resident's bedside table, and apply it to Resident #55's head. On 05/06/25 at 12:55 p.m., Resident #55 was observed sitting in their recliner in their room. A medication box of triple antibiotic ointment was observed on the dresser next to the resident. May keep at bedside was hand written on the box. A policy titled Bedside Medication Storage, dated 01/2024, read in part, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing care center's interdisciplinary resident assessment team. A Quarterly Assessment, dated 03/13/25, showed Resident #55's BIMS score was 15, which indicated the resident's cognition was intact. There was no assessment or physician's orders located in Resident #55's clinical record. On 05/06/25 at 12:56 p.m., Resident #55 stated the nurse applied the ointment to the back of their head because it was difficult for them to apply it. On 05/06/25 at 1:07 p.m., LPN #1 stated they had hand written may keep at bedside on the triple antibiotic ointment box. LPN #1 stated a physician's order was required for residents to keep medication at bedside. On 05/06/25 at 1:11 p.m., LPN #1 stated they could not locate an order for medication to be kept at bedside for Resident #55. On 05/06/25 at 2:26 p.m., the DON was asked what was the policy for residents to keep medication at their bedside. They stated the resident had to have an assessment and a physician's order. On 05/06/25 at 2:27 p.m., the DON was asked if Resident #55 had an assessment or a physician's order to be able to keep medication at their bedside. They stated, No.

Based on record review, observation, and interview, the facility failed to: 1. allow the resident council group to meet without staff present, and 2. act promptly upon grievance about unsanitary practices regarding the ice chests presented to staff for three of three resident council meetings for which minutes were reviewed. The Administrator identified 83 residents resided in the facility. Findings: 1. Regulation 310:675-7-7 Resident's advisory council, read in parts, .(c) No employee or affiliate of the facility shall be a member of the council . On 12/19/23 at 2:11 p.m., this surveyor attended a scheduled resident council meeting at the invite of the council president. There were ten residents and one staff member in attendance. Resident #58 reported the staff member, Activity Asst., was the secretary of the resident council and had been appointed by the Administrator. Resident #58 stated they had been told by the Administrator the secretary of the resident council had to be a staff member. On 12/21/23 at 9:00 a.m., the Administrator was asked if the residents were told they had to have a staff member as the secretary of the resident council. They stated, Yes, it is regulated in the 675 that says the administrator appoints a staff to go in and take notes and monitor. The Administrator then offered to print me a copy of the regulation. Returned and pointed out a passage that read The Administrator shall designate a member of the facility staff to coordinate the council . When informed that this did not say the staff had to be present at the meeting, the Administrator stated, That's how I interpreted it. I guess we have two different interpretations of the same regulation. On 12/21/23 at 9:09 a.m., Resident #58 stated the resident council meeting would be so much better if no staff were there because then the residents would feel free to open up. On 12/21/23 at 9:18 a.m., Resident #65 acknowledged they would prefer not to have staff present in the resident council meeting. 2. Resident Council Meeting Minutes, dated 09/19/23, read in part, .Concern .concerned about residents getting into the ice chest with potentially dirty hands .Response .Dietary .will move ice chest to kitchen for kitchen staff to dispense for residents . Resident Council Meeting Minutes, dated 10/17/23, read in part, .4. The ice chest with ice in the dining room is easily accessed .it is not sanitary due to some residents with dirty hands reaching into the chest to get ice .Resident Council Response Sheet .Dietary .2. The ice chest in dining room will be removed residents will need to ask for ice at the kitchen window in between meals . Resident Council Meeting Minutes, dated 11/22/23, read in part, .2. Concerns that the ice chest are not sanatory [sic] .Resident Council Response Sheet .Residents should not be getting their own ice out of chests . On 12/19/23 at 2:11 p.m., a confidential group meeting was conducted with six cognitive residents. They were asked if the facility acted upon their grievances and/or recommendations presented during their resident council meetings. They stated their concerns during their meetings were not being acted upon. On 12/19/23 at 2:39 p.m., Resident #58 stated, The administration responds very nicely to any grievance or recommendation, but nothing is done. They still haven't done anything about everyone going in and out of those ice chests. On 12/19/23 at 2:42 p.m., Resident #74 was asked how the grievance concerning the ice chest from the last 3 resident council meeting minutes had been handled. They stated, They still have the chest unlocked and on the floor. The one resident just digs his cup in there. That's spreading germs. On 12/19/23 at 3:00 p.m., Activity Asst was asked how grievances and recommendations from the resident council meetings were handled. They stated they were given to the administrator and then forwarded to the different departments for their responses to any concerns. On 12/20/23 at 5:05 a.m., observed an ice chest on hall 200 full of ice and not locked. On 12/20/23 at 5:23 a.m., observed an ice chest in dining room full of ice and not locked. No staff was present. On 12/20/23 at 7:00 a.m., observed Resident #51 go to the ice machine located behind kitchen area, use the scoop and fill a medium sized bucket with ice. They were asked if residents were allowed to get ice from the ice machine themselves. Resident #51 stated I get my own ice every morning. On 12/20/23 at 8:00 a.m., Cert. Dietary Manager was made aware of the above observations and acknowledged the residents' concerns about unsanitary practices regarding the ice chests had not been acted upon, as stated in the resident council meeting minute responses for the past three months.

Based on observation, record review, and interview, the facility failed to ensure the DON did not serve as a charge nurse when the average daily occupancy was more than 60 residents. The Administrator identified 83 residents resided in the facility. Findings: A Census Daily Detail report, dated 12/01/23 to 12/21/23, documented the daily census ranged from 85 to 91 residents. A Schedule Sheet, dated December 2023, documented the DON was assigned as a charge nurse for the following days: 12/02/23, 12/03/23, 12/04/23, 12/09/23, and 12/18/23. On 12/18/23 at 2:26 p.m., the DON was observed sitting at the nurses' station on the phone. The receptionist stated the DON was working the floor today. On 12/20/23 at 11:10 a.m., the Administrator stated the DON had been working the floor. The Administrator stated, I have no nurses. On 12/21/23 at 2:09 p.m., the DON was asked how often she worked the floor. She stated whenever she needed to fill in. She was asked if the days her name was on the schedule, were the days she worked the floor. She stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure medications were administered per physician's orders for two (#83 and #89) of seven sampled residents reviewed for medications. The Administrator identified 83 residents resided in the facility. Findings: A Medication Administration policy, dated 09/2018, read in part, .Medications are administered as prescribed .within 60 minutes of scheduled time, except before .meal orders, which are administered based on mealtimes . 1. Resident #83 had diagnoses which included hypomagnesium. Resident #83's Consolidated Order summary, dated 07/28/23, documented the resident was to receive two tablets of magnesium twice a day. On 12/20/23 at 7:11 a.m., CMA #2 was observed to prepare Resident #83's medications. They were observed to place one table of magnesium in the medication cup and administered it to the resident. On 12/20/23 at 8:29 a.m., CMA #2 was asked how they ensured medications were administered as ordered. They stated they checked the medication card and compared it to the physician's order. CMA #2 was asked if they recalled administering two pills this morning. They stated, Not to my knowledge. They were asked to look at Resident #83's physician order. CMA #2 stated, It says two. They were asked if they administered two tablets. They stated, No. 2. Resident #89 had diagnoses which included hypothyroidism. Resident #89's Consolidated Order summary, dated 11/24/23, documented the resident was to receive levothyroxine one time daily before meals. On 12/18/23 at 10:44 a.m., Resident #89 stated they received their morning medication late. They stated they were suppose to receive one medication before they ate breakfast, but sometimes they didn't receive it until 10:30 a.m. or later. A MedAid MAR, dated 12/01/23 to 12/19/23, documented levothyroxine was to be administered at 6:00 a.m. It documented the resident received levothyroxine late for 13 out of 19 administrations. On 12/20/23 at 8:26 a.m., Resident #89 was observed to receive their breakfast tray. They stated they hadn't received their medication today. A MedAid MAR, dated 12/20/23, documented Resident #89 received the levothyroxine at 8:34 a.m. On 12/20/23 at 10:35 a.m., the DON stated staff followed the eMAR and were to administer medication scheduled at 6:00 a.m. between 5:00 a.m. and 7:00 a.m.

Based on record review and interview, the facility failed to ensure medication regimen reviews were responded to by the physician in a timely manner for two (#30 and #72) of five sample residents reviewed for unnecessary medications. The Administrator identified 83 residents resided in the facility. Findings: A Medication Monitoring policy, dated 11/2017, read in part, .The consultant pharmacist and the nursing care center follows up on the recommendations .within 30 calendar days . 1. Resident #30's medication regimen review, dated 11/17/23, read in part, .This resident has been taking omeprazole 40 mg [every day] since 7/25/21 without a dose reduction. Please consider a trial dose reduction to 20 mg daily . There was no response from the physician. 2. Resident #72's medication regimen review, dated 09/06/23, read in part, .This resident has been taking the anxiolytic Risperdal Consta .every 14 days since March 2023. Please evaluate the current dose and consider a dose reduction . There was no response from the physician. On 12/21/23 at 2:09 p.m., the DON was asked what was the policy for obtaining a response from the physician for medication regimen reviews. She stated 30 days.

On [DATE] at 9:43 a.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide cardiopulmonary resuscitation (CPR) to a resident who had no pulse and no blood pressure and who was a full code. At 9:49 a.m., the facility administrator and the corporate nurse were informed of the IJ situation related to the facility's failure to provide CPR for a resident who had a full code status. A plan of removal for the IJ situation was requested. On [DATE] at 12:20 p.m., the administrator provided the survey team with an acceptable plan of removal. The facility's plan of removal, dated [DATE], documented the following: GARLAND ROAD NURSING & REHABILITATION CENTER IMMEDIATE JEOPARDY PLAN OF REMOVAL [DATE]. 1. All CPR/DNR (do not resuscitate) physician's orders [REDACTED]. 2. All resident rooms will be checked by noon to ensure all advance directive cards on the inside of the closet door have the residents name and appropriate code status per physician orders. 3. The Advanced Directive Policy and procedure will be reviewed to ensure it includes the following: a. The person finding the resident without vital signs will first check the closet door for the advanced directive sticker for Full Code or DNR, if Full Code they will then call out to other staff that there is a Code Blue and then immediately begin chest compressions until a CPR certified person comes to continue CPR with full CPR measures and the CPR emergency cart. b. The chart alert page will be marked with the appropriate DNR or Full Code/CPR stickers. These same stickers will be placed on a name card taped securely to the inside of the resident's closet door at eye level. b. These stickers will be updated each time a new advanced directive physician's orders [REDACTED]. c. When a change in advanced directive order is reviewed in daily QA meeting, the nurse manager will go and ensure the name card on the resident's closet door has between updated correctly to match the new order. 4. All staff present today will be in-serviced on the Advanced Directive/DNR policy as noted above by 3 pm. All other staff will be contacted to come in for an in-service on the DNR/CPR policy and procedure as noted above by 10 pm today. If they are unable to be reached due to illness, being out of town etc, they will be in-serviced immediately prior to coming back to work. 5. All elements of the Plan of Removal will be completed no later than [DATE] at 10pm. On [DATE], interviews were conducted with a total of 19 employees who worked different shifts and in different departments. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. At 1:34 p.m., the corporate nurse and the administrator was informed the IJ had been removed as of [DATE] at 10:00 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to provide CPR for one (#97) of one sampled resident who had no pulse, no blood pressure, and was designated as a full code. This resulted in an IJ situation. Findings: Resident #1 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A form titled 'ADVANCED DIRECTIVE ACKNOWLEDGEMENT' for resident #97 documented she did not execute an Advance Directive. A social service progress note, dated [DATE] at 9:15 a.m., documented, Called daughter to check on (Resident #97) daughter states she is still in hospital daughter (name-deleted) said she is very confused has really bad UTI (urinary tract infection) I asked her if I could set her up with home health and she stated her mother will return to Garland Road. A nurse's note, dated [DATE] at 12:09 p.m., documented, Returned to facility at 1115 via uplift. Taken in WC (wheelchair) to room [ROOM NUMBER]B. Assisted into bed with 2PA (person assist). Readmitting to SNF (skilled nursing facility) services under care of (Name-deleted physician). Post hospital stay for [MEDICAL CONDITION]. Hospital reports HgB (hemoglobin) of 7.9 yesterday. Iron supplements started and is currently 9.2 today. Resident is confused as to where she is but easily oriented. Able to recognize staff's faces Hospital reports CXRAY (chest X-Ray) done there and showed pleural effusions but resident refused for them to drain lungs . A nurse's note, dated [DATE] at 5:05 p.m., documented, 72 hour readmit to facility was in bed with oxygen on at 2 lpm (liters per minute) via nasal cannula, is awake and looks at you when spoke to. Asked her if I could do her fsbs (finger stick blood sugar) and she sticks up finger, note that her hand is cold and arms are cool, she is dusky color. vital signs done and are 97.0, 96%, 88, ,[DATE], 16, and fsbs is 124. Gave her her evening meds of [MEDICATION NAME] and apbaben and she drank ,[DATE] cup of water in small sips at a time. Covered her up and left call bell in her hand. A nurse's note, dated [DATE] at 5:09 p.m., documented, Late Entry: Note Text: When staff notified me to check client I went to her room found absence of vital signs and checke(sic) (her)er closet door no code status [REDACTED]. Also called hospital and was connected with (Name-deleted physician) immediately and he said no code due to her health status . A nurse's note, dated [DATE] at 5:30 p.m., documented, STAFF TOOK HER SUPPER TO HER AND PLACED EVERYTHING WITHIN REACH FOR HER TO EAT. 1808 (6:08 p.m.) STAFF WENT TO CHECK ON HER PROGRESS ON EATING AND SHE HAD NOT TOUCHED HER TRAY AND WAS SITTING UP AND HAD ABSENCE OF VITAL SIGNS AND THEY CALLED THE NURSE TO COME AND CHECK HER. CHECKED FOR VITAL SIGNS NONE PRESENT. NOTIFIED (name delete physician) AND HE STATED TO NOT START CPR. NOTIFIED DON AND DAUGHTER. DAUGHTER WANTS TO COME AND BE WITH HER THEN CALL FUNERAL HOME. DAUGHTER HERE AND STATED TO CALL (Name deleted funeral home) TO COME GET HER . (Name-deleted funeral home) HERE AND PICKED HER UP AT 830 pm. On [DATE] at 5:00 p.m., licensed practical nurse (LPN)#5 was asked about the incident with resident #97. She stated it was awful. She was acting as the medication aide (CMA) and LPN for the hall due to the CMA call in. She was asked what other staff were present during this shift. She stated she had a certified nurse aide. She was asked if she had received a report on the resident. when she arrived for her shift She stated she did and was told she was not doing very well. She was asked if she had performed an assessment on the resident since she was a just admitted back to the facility and was not doing good. She stated she did not do a thorough assessment, she just took her blood pressure and administered her three medications with sips of water. The residents skin was dusky yellow. She stated she had to leave her because she had other medications to pass and treatments to perform before supper. Certified nurse aide (CNA) #1 came and got her and told her she needed to come assess the resident. She stated she looked at the resident and went to the closet to find her code status. She and the CNA could not locate the sticker that was supposed to be there. She instructed the CNA to go and get the crash cart because the resident was a full code. LPN #5 further stated since she could not locate the code status and she did not have a chart yet, she attempted to get on the computer to locate the code status. The computer was being slow so she thought she would call the hospital and call her physician. She stated the physician immediately picked up the phone, she explained the situation to him, he stated he knew her condition, what her wishes were and to not perform CPR. After she hung up the phone she informed the CNA to take the crash cart back, they were not going to perform CPR per the doctors orders. The LPN was asked if the resident was a full code, why CPR was not initiated She stated since it was not on the closet door, she did not know if something changed while she was in the hospital so she called the physician to be sure. The nurse stated if she had known the resident's code status she would have immediately initiated CPR. At 6:35 p.m., CNA #1 stated another staff member had come out of the resident's room saying, Something is wrong with (Named resident), she is unresponsive. The CNA stated she looked inside the closet door (where the resident's code status was supposed to be posted) but the code status was not posted. The CNA added she started running to get the crash cart; but before she reached the cart the LPN yelled for her to come back. The CNA further stated if she had known the resident's code status she would have immediately initiated CPR. On [DATE] at 1:06 p.m., the corporate nurse was asked what the process was to ensure the code states was documented for a newly admitted resident. She stated the facility would talk with family and complete paperwork. If the family does not know, the facility considers the resident to be a full code until they find out for sure. Staff were to get a physician's orders [REDACTED]. At 5:00 p.m., the corporate nurse was asked what she would expect her staff to do if they discovered a resident who was unresponsive and the resident's code status was not readily available. She stated she would expect them to initiate CPR. On [DATE] at 11:18 a.m., the primary care physician returned our phone call. He stated the LPN called and stated the resident was unresponsive and gone. He stated he told her to use her nursing judgment. He did not care for her at the hospital as he no longer does inpatient and has not for over five years. He further stated he did not know what her code status was and told her to use her judgment because she was there. He did not know if they initiated CPR or not.

Based on observation, record review, and interviews, it was determined the facility failed to ensure a resident did not develop an avoidable pressure ulcer for one (#31) of two resident's who were reviewed for pressures ulcers. This resulted in the resident developing an unstageable pressure ulcer to the left heel. The facility identified three residents who had pressure ulcers. Findings: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden scale, dated 11/21/18 which documents the risk of pressure ulcer development, indicated the resident was a very high risk with a score of 7.0. A score of 9 or below indicated a very high risk for developing pressure ulcers. A skin integrity data collection sheet completed on admission, dated 11/21/18, documented the resident had contractures of bilateral knees and hands. No other skin issues were identified. An admission assessment, dated 12/06/18, documented the resident's cognition was severely impaired, required extensive assistance with bed mobility, and total assistance with transfers. The assessment documented the resident was at risk for pressure ulcers and had moisture associated skin damage (MASD). Pressure reduction devices were to be used in his chair/bed, and was on a turning and repositioning program. A weekly skin monitoring note, dated 12/10/18 at 8:43 p.m., documented, no new open areas noted, has pressure areas of discoloration on his coccyx area and left hip non open sites, has contractures of his hands and knees into a fetal position. Description:: Areas cleaned and lotioned and he is turned every 2 hours, has padded foot boots on to protect his heels, Notification of Physician/Family/New Orders:: continue to turn every 2 hours and reposition. A weekly skin monitoring sheet, dated 12/17/18 at 9:25 p.m. documented, no new open areas noted Description:: skin is warm and dry and fragile he is turned and re-positioned every 2 hours. Notification of Physician/Family/New Orders:: skin barrier cream applied to all red areas. A weekly skin monitoring sheet, dated 12/24/18 at 11:15 p.m., documented, skin is warm and dry and fragile Description:: applied wound bat=barrier cream to all red areas floating his heels which are showing red areas of pressure non open turn and reposition every 2 hours. Notification of Physician/Family/New Orders:: none. A weekly skin monitoring sheet, dated 12/31/18 at 6:54 p.m., documented, has red areas on the side of his feet skin prep being applied to areas at this time. Description:: Skin is warm and dry and intact and fragile. Turn every 2 hours and prn. Notification of Physician/Family/New Orders:: no new orders. A discharge return anticipated assessment, dated 01/06/19, documented no skin issues. A Braden scale dated 01/11/19, which documents the risk of pressure ulcer development, documented the resident had a score of 8.0 which indicated a very high risk. A skin integrity data collection sheet, dated 01/11/19, documented, Left and right heel; redness skin prep applied daily. No additional issues identified. A Baseline Care Plan, dated 01/17/19, did not address the resident's risk for pressure ulcers and documented the resident did not have any current skin issues. A weekly skin monitoring sheet, dated 02/06/19 at 7:06 p.m., documented, Open blister present to left heel, medial. Measuring 4 (centimeters) cm x 3 cm x 0.1 cm. Red granulation tissue underneath blister cap. No bleeding. Yellow, watery exudate. No odor. Afebrile. Notified (name-deleted physician). New orders to begin Bactrim liquid 40 (milligram) mg/200 mg per 5 (milileter) mL. Resident to start Bactrim liquid 10 mL via peg tube BID x 10 days. Also, new order for calcium alginate to left heel wound once daily and prn soiled/ removed dressing. An antibiotic treatment note, dated 02/10/19 at 1:45 p.m., documented, Res (resident) continues on bactrim BID (twice daily) for wound infection. No s/s (signs/symptoms) of adverse reactions. Dressing cleaned/dried/changed per order. Afebrile-98.4. No s/s of pain or discomfort. Will continue to monitor. A care plan, dated 02/20/19, documented the resident had thin/frail skin, and was at risk for actual skin breakdown. Interventions documented: ~ to assist the resident to turn and reposition frequently, ~ increase out of bed activity as tolerated, ~ complete a head to toe assessment every week and document the results, ~ inspect the skin daily with care and bathing and report any changes to the charge nurse. This was the first care plan developed, since admission on 11/21/18, to address the resident's risk for pressure ulcers. Another care plan, dated 02/21/19, documented the resident had a stage III pressure ulcer to the left heel. A quarterly assessment, dated 02/21/19, documented the resident had a stage three pressure ulcer. The assessment documented a pressure reducing device for the chair and bed, turning and repositioning program, hydration or nutrition interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressing other then to feet, application of ointments/medications other then feet. On 03/05/19, the care plan was updated to provide a low air loss mattress A Braden scale dated 03/31/19, which documents the risk of pressure ulcer development, documented the resident had a score of 9.0 which indicated a very high risk. A significant change assessment, dated 04/29/19, documented the resident had one stage three pressure ulcer. The resident had a pressure reducing device for chair/bed, turning/repositioning program, and hydration or nutrition interventions to manage skin problems. The assessment documented the resident received pressure ulcer care, application of nonsurgical dressing other than to feet, and application of ointments/medications other than feet. There was no documentation to indicate weekly skin evaluations were completed from 12/31/18 until 04/29/19. A weekly skin monitoring note, dated 04/29/19 at 8:36 a.m., documented, Resident cont (continues) to have wound to L (left) heel that is being treated by wound nurse. Skin prep applied to R (right) heel as prevention . A weekly skin monitoring note, dated 05/06/19 at 11:32 a.m. documented, Dressing to left heel CDI(clean, dry and intact). Reddish petechia area to back noted. Description:: Reddish/pink in color petechia area to back. No warmth noted. Notification of Physician/Family/New Orders:: Washed and dried and asked Hospice to evaluate. On 05/10/19 the care plan was updated for the resident to have heel lift boots on while in bed. A weekly skin monitoring note, dated 05/13/19 at 9:35 a.m., documented, Weekly skin assessment completed via this nurse. Resident con(continues) with wound to L heel. This area is being treated daily c (with) [MEDICATION NAME] et (and) clean bandage. Wound is being assessed weekly by wound physician. Skin prep applied to both heels. Resident skin is very oily . A weekly skin monitoring note, dated 05/20/19 at 2:27 p.m., documented the same information., A weekly skin monitoring note, dated 05/27/19 at 12:00 p.m., documented, Resident cont c wound to L heel. Being seen by wound physician weekly. No other apparent wounds at this time . A Wound Evaluation and Management Summary, dated 05/28/19, documented the residents stage three wound to the left heel had been resolved and to continue with the present skin care and breakdown preventions. There were no orders for any type of skin care to the left heel after it had been healed and the treatments had been discontinued. A weekly skin monitoring note, dated 06/03/19 at 1:31 p.m., documented the resident had no new wounds, but had red bumps to his back with no other areas of concern at this time. It further documented skin prep was being applied daily to both heels. The pressure ulcer log, dated 06/04/19, did not document the resident had any pressure ulcers. A Braden scale dated 06/06/19, which documents the risk of pressure ulcer development, documented the resident had a score of 9.0 which indicated a very high risk. A weekly skin monitoring note, dated 06/10/19 at 11:17 a.m., documented, Resident has blood filled unopened blister to L heel. Skin prep applied as ordered to bilateral heels. No other areas of concern at this time . There was no documentation to indicate the facility had notified the physician of the blood filled blister and obtained treatment orders. The was no documentation the weekly skin monitoring had been completed on 06/17/19, one week after the resident had developed another pressure ulcer to the left heel. The pressure ulcer log contained documented no skin issues on 06/11/19 and 06/18/1. A current physician's orders [REDACTED]. The order was written on 06/21/19. The facility did not notify the physician of the left heel pressure ulcer until eleven days after it was identified on 06/10/19. A weekly skin monitoring note, dated 06/24/19 at 11:04 a.m. documented, Resident has blood filled opened blister to L heel. Skin prep applied as ordered to bilateral heels. Wound nurse provides wound care to L heel c wound physician seeing him weekly. No other areas of concern at this time . The Pressure Ulcer Log, dated 06/25/19, documented the resident had an unstageable pressure ulcer of the left medial heel with 40% necrotic tissue and 60% other viable tissue. A Wound Evaluation and Management Summary, dated 06/25/19, documented the resident had an unstageable pressure ulcer of the left medial heel. The wound measured 3 cm X 2.6 cm X not measurable with 40% necrotic tissue and 60% other viable tissue. It documented the resident had necrotic tissue removed to establish the margins of viable tissue. The treatment plan was for Aliginate calcium with silver for 30 days. A weekly skin monitoring note, dated 07/01/19 at 1:09 p.m. documented, Wound Location: Left heel Wound Pain: No s/sx of pain or discomfort noted at this time. Dressing Status: No dressing in place at this time resident had shower before dressing change. Wound Notes: Granulation noted to wound bed, moderate sero-sanguineous drainage noted at this time. Cleansed with DWC, patted dry, skin prep to peri-wound et silver alginate to wound bed et covered with bordered gauze . On 07/08/19 at 10:49 a.m., a CNA stated the resident had pressure ulcers on his ankles and back, however, did not know how long he has had them. The CNA stated he was on a pressure relieving mattress and had heel protectors on the right foot and positioned on a pillow. The CNA stated the left foot was off the pillow and there was nothing on the foot. The mattress was not an air loss mattress. On 07/09/18 at 4:45 p.m., the resident was observed in bed. There was no air loss mattress observed on the bed. His left foot was on the bed without a boot or heel protector. The right foot had a heel protector on it and was floated by a pillow. A Wound Evaluation and Management Summary, dated 07/09/19, documented the resident continued to have an unstageable pressure ulcer of the left medial heel. The wound measured 1.6 cm X 1.4 cm X not measurable with 20% slough, 20% necrotic and 60% other viable tissue. It documented the resident had necrotic tissue removed to establish the margins of viable tissue. The treatment plan was for Aliginate calcium with silver to continue for 16 days. On 07/09/19 at 5:02 p.m., LPN #3 stated she started at the facility on 04/08/19. She was asked if the resident was at risk for the development of pressure ulcers. She stated yes, he basically was not able to move and he responded to moaning/groaning and received his feeding via a tube. The LPN was asked if the resident currently had a pressure ulcer. She stated yes, it was an unstageable pressure ulcer on his left heel which measured 1.6 centimeter (cm) X 1.4 c X no depth. She stated when she started he had one, it resolved and then he got another one three weeks later. She was asked if she resolved the pressure ulcers. She stated no, the wound doctor does, and there should be a note on 05/28/19 to go with her notes. The LPN provided a wound care note, dated 05/28/19, that documented the left heel had resolved. LPN #3 was asked what interventions were in place for the resident to prevent the reoccurrence of pressure ulcers. She stated he had a boot to his left foot and a moon boot on the other foot. He was to have them on at all times. She was asked when the boot was implemented. She stated it was ordered on [DATE]. She indicated the boot was used prior to 05/2019. She was asked for documentation the boot was being used prior to 05/10/19. She did not provide further information. The LPN was asked what kind of mattress the resident was to have. She stated a low air loss mattress. and currently had it on his bed as she looked at this morning, She was asked to provide documentation the mattress was a low air loss mattress. She went and looked and stated it was not a low air loss mattress. LPN #3 was asked who was responsible to perform the weekly skin evaluations. She stated the charge nurses were. Looking ahead, she probably should go behind and make sure they were being done and do them herself if they were not done. She acknowledged the weekly skin evaluations had not been completed prior to 04/29/19. There was no further documentation provided. On 07/09/19 at 6:03 p.m., LPN #4, the minimum data set and care plan coordinator, was asked if the resident was at risk for pressure ulcers. She stated, Yes. She was asked if a care plan should have been developed for the risk of the development of pressure ulcers. She state, Yes She was asked when the care plan was developed. She stated 02/20/19. She was asked when the low air loss mattress was care planned. She stated on 03/05/19, but the order was on 11/21/18. The LPN was asked when the boots were care planned. She stated they were implemented on 05/10/19, the order was for 05/09/19. On 07/10/19 at 8:54 a.m., the resident was observed in his bed and there was no air loss mattress observed. The resident was observed to have one boot heel protector in place on the left foot. The right foot did not have anything on it. A pillow was under the right foot only and the left was laying on the mattress. At 9:02 a.m., the director of nursing (DON) stated the resident had been on a regular mattress since he was admitted . It was a pressure relief mattress. She stated he could have had one with hospice when he came in on skilled when first admitted . The DON was shown the boots. She stated it was suppose to be on both feet all times. She would look and see when and if the resident had a low air loss mattress. At 11:35 a.m., the DON was asked if the physician had been notified of the blister to the left heel on 06/10/19. She stated she would look and let the surveyor know. At 2:30 p.m., no further information was provided the physician had been provided notification prior to 06/21/19.

Based on record review and interview, it was determined the facility failed to: ~ thoroughly assess, monitor and intervene with a change in condition for one (#97) of one sampled resident who had no pulse, no blood pressure, and was designated as a full code. Resident #97 expired. This had the potential to affect the 88 residents who resided in the facility; ~ ensure physician's orders [REDACTED].#74) of three sampled residents who were reviewed for FSBS. The facility identified 17 residents who had orders for FSBS. Findings: 1. Resident #97 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A form titled 'ADVANCED DIRECTIVE ACKNOWLEDGEMENT' for resident #97 documented she did not execute an Advance Directive. A social service progress note, dated [DATE] at 9:15 a.m.,documented, Called daughter to check on (Resident #97) daughter states she is still in hospital daughter (name-deleted) said she is very confused has really bad UTI (urinary tract infection) I asked her if I could set her up with home health and she stated her mother will return to Garland Road. A nurse's note, dated [DATE] at 7:08 a.m., documented, Late Entry: Note Text: As I was checking computer for code status as this wasn't posted inside her closet door aide was going for crash cart per my request. Obtained that she was cpr stats and called hospital and was immediately connected with (name-deleted physician) . A nurse's note, dated [DATE] at 12:09 p.m., documented, Returned to facility at 1115 via uplift. Taken in WC (wheelchair) to room [ROOM NUMBER]B. Assisted into bed with 2PA (person assist). Readmitting to SNF (skilled nursing facility) services under care of (Name-deleted physician). Post hospital stay for [MEDICAL CONDITION]. Hospital reports HgB (hemaglobin) of 7.9 yesterday. Iron supplements started and is currently 9.2 today. Resident is confused as to where she is but easily oriented. Able to recognize staff's faces Hospital reports CXRAY (chest X-Ray) done there and showed pleural effusions but resident refused for them to drain lungs . A nurse's note, dated [DATE] at 5:05 p.m., documented, 72 hour readmit to facility was in bed with oxygen on at 2 lpm (liters per minute) via nasal cannula, is awake and looks at you when spoke to. Asked her if I could do her fsbs (finger stick blood sugar) and she sticks up finger, note that her hand is cold and arms are cool, she is dusky color. vital signs done and are 97.0, 96%, 88, ,[DATE], 16, and fsbs is 124. Gave her her evening meds of [MEDICATION NAME] and apbaben and she drank ,[DATE] cup of water in small sips at a time. Covered her up and left call bell in her hand. A nurse's note, dated [DATE] at 5:09 p.m., documented, Late Entry: Note Text: When staff notified me to check client I went to her room found absence of vital signs and checke(SIC) er(SIC) closet door no code status [REDACTED]. Also called hospital and was connected with (Name-deleted physician) immediately and he said no code due to her health status . A nurse's note, dated [DATE] at 5:30 p.m., documented, STAFF TOOK HER SUPPER TO HER AND PLACED EVERYTHING WITHIN REACH FOR HER TO EAT. 1808 (6:08 p.m.) STAFF WENT TO CHECK ON HER PROGRESS ON EATING AND SHE HAD NOT TOUCHED HER TRAY AND WAS SITTING UP AND HAD ABSENCE OF VITAL SIGNS AND THEY CALLED THE NURSE TO COME AND CHECK HER. CHECKED FOR VITAL SIGNS NONE PRESENT. NOTIFIED (physician's name) AND HE STATED TO NOT START CPR. NOTIFIED DON AND DAUGHTER. DAUGHTER WANTS TO COME AND BE WITH HER THEN CALL FUNERAL HOME. DAUGHTER HERE AND STATED TO CALL (Name deleted funeral home) TO COME GET HER . (Name-deleted funeral home) HERE AND PICKED HER UP AT 830 pm. On [DATE] at 5:00 p.m., LPN#5 was asked about the incident with resident #97. She stated it was awful. She was acting as the medication aide (CMA) and LPN for the hall due to the CMA call in. She was asked what other staff were present during this shift. She stated she had a certified nurse aide (CNA). She was asked if she had received a report on the resident when she arrived for her shift She stated she did and was told she was not doing very well. She was asked if she had performed an assessment on the resident since she was just admitted back to the facility and was not doing good. She stated she did not do a thorough assessment, she just took her blood pressure and administered her three medications with sips of water. The residents skin was dusky yellow. She stated she had to leave her because she had other medications to pass and treatments to perform before supper. CNA #1 came and got her and told her she needed to come assess the resident. She stated she looked at the resident and went to the closet to find her code status. She and the CNA could not locate the sticker that was supposed to be there. and she instructed the CNA to go and get the crash cart because the resident was a full code. LPN #5 further stated since she could not locate the code status and she did not have a chart yet, she attempted to get on the computer to locate the code status The computer was being slow so she thought she would call the hospital and call her physician. She stated the physician immediately picked up the phone. She explained the situation to him and he stated he knew her condition and what her wishes were and to not perform CPR. After she hung up the phone she informed the CNA to take the crash cart back they were not going to perform CPR per the doctors orders. The LPN was asked if the resident was a full code, why CPR was not initiated She stated since it was not on the closet door, she did not know if something changed while she was in the hospital so she called the physician to be sure. At 6:35 p.m., CNA #1 stated another staff member had come out of the resident's room saying, Something is wrong with (Named resident), she is unresponsive. The CNA stated she looked inside the closet door (where the resident's code status was supposed to be posted) but the code status was not posted. The CNA added she started running to get the crash; but before she reached the cart the LPN yelled for her to come back. The CNA further stated if she had known the resident's code status she would have immediately initiated CPR. On [DATE] at 1:06 p.m., the corporate nurse was asked what the process was when a resident was admitted , to ensure the code status was documented. She stated the facility would talk with family and get paperwork. If the family does not know, the facility considers the resident to be a full code until they find out for sure. Staff were to get a physician's orders [REDACTED]. At 5:00 p.m., the corporate nurse was asked what she would expect her staff to do if they discovered a resident who was unresponsive and the resident's code status was not readily available. She stated she would expect them to initiate CPR. On [DATE] at 11:18 a.m., the primary care physician returned our phone call. He stated the LPN called and stated she was unresponsive and gone. He stated he told her to use her nursing judgment. He did not care for the resident at the hospital as he no longer does inpatient and has not for over five years. He further stated he did not know what her code status was and told her to use her judgment because she was there. He did not know if they initiated CPR or not. 2. Resident #74 had [DIAGNOSES REDACTED]. The care plan dated [DATE] documented the resident had a [DIAGNOSES REDACTED]. ~ fingerstick blood sugar (FSBS) via glucometer as ordered, The admission assessment dated [DATE] documented the resident was cognitively intact and had received insulin/injections 7 of 7 days prior to assessment date. The current physician's orders [REDACTED]. ~ FSBS before breakfast one time a day related to type 2 diabetes mellitus The Medication Administration Record [REDACTED]. On [DATE] at 3:30 p.m., the director of nurses was asked to review the physician's orders [REDACTED]. She stated they checked the FSBS before they administered insulin. She was asked if that was the facility policy. The corporate nurse walked in and stated, no, it's not policy. She was asked if the physician's orders [REDACTED].

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to assess, monitor, and provide intervention for a diabetic resident in crisis. On [DATE], at 8:25 p.m., resident #1 became symptomatic of [DIAGNOSES REDACTED], she exhibited altered mental status, drowsiness and confusion. At 9:50 p.m., a finger stick blood sugar (FSBS) was obtained with results to be 61 milligrams/deciliter (mg/dl). One tablespoon of Glucose gel was administered (the dose was on container/tube). At 10:11 p.m., the resident continued to be symptomatic with drowsiness and confusion. The FSBS was obtained with results to be 46 mg/dl. The remainder of the glucose gel was administered. The oncoming charge nurse was to obtain a FSBS every ,[DATE] minutes. The initial FSBS following the administration of Glucose gel was to be obtained at 10:33 p.m. The FSBS was not obtained until [DATE] at 12:00 a.m., with results of 118 mg/dl. Another FSBS was obtained at 1:00 a.m., with results of 311 mg/dl. On [DATE] at 3:00 a.m., the resident was found to be cold, nonresponsive, bluish gray in color and not breathing. The resident expired in the facility on [DATE], at 3:31 a.m. A State of Oklahoma Certificate of Death, documented the resident expired on [DATE] at 3:31 a.m., and the immediate cause of death as Diabetes Mellitus Sequela (a condition which is the consequences of a previous disease or injury). On [DATE] at 4:02 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:05 p.m., the administrator, director of nurses (DON) and Registered Nurse (RN) #1 were notified of the IJ situation related to the facility's failure to assess, monitor and provide intervention for a diabetic resident in crisis. At 6:35 p.m., an acceptable plan of removal was provided. The plan of removal documented, The facility's response to the IJ called for the facility to implement a plan of removal to improve the critical thinking in response and administering insulin with Quality of Care and Nurse Competency. 1. An audit was done of all of the residents with diabetes, those on insulin were identified as being at risk. The DON/designee will audit hypoglycemic protocol orders and insulin orders for all residents who receive insulin and reconcile the orders with the TARs (treatment administration records) and ensure they all had hypoglycemic orders in place by 10 pm [DATE]. 2. Medical Director was contacted at 6 pm, the hypoglycemic protocol was reviewed and revised by 6 pm [DATE] with medical director input. 3. All nursing staff will be in-serviced on the importance of assessing, monitoring and intervening after a low or high finger stick reading. They will be in-serviced on the different types of insulin and onset of action and the facilities hypoglycemic protocol by 11pm [DATE]. 4. No licensed nursing staff will be allowed to administer insulin until passing a competency for insulin administration, including assessing, monitoring and intervening for low or high blood sugars no later than [DATE] at 5pm. Before the next insulin administration by each nurse, the nurse will be monitored by a nurse manager to assess the need, the physician's orders [REDACTED]. Then nurses will determine whether it is safe to continue with the administration. Insulin competency will be completed at that time by the nurse manager. If there is any questions, nurses will contact physician. The competencies will be completed by 5pm on [DATE]. The immediate jeopardy was removed on [DATE] at 5:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm Based on interview and record review, it was determined the facility failed to: ~ assess, monitor, and provide intervention for diabetic residents; ~ notify the physician when a resident exhibited a change in condition. On [DATE], at 8:25 p.m., resident #1 became symptomatic of [DIAGNOSES REDACTED], she exhibited altered mental status, drowsiness and confusion. At 9:50 p.m., a FSBS was obtained with results to be 61 mg/dl. One tablespoon of Glucose gel was administered (the dosage was one container/tube). At 10:11 p.m., the resident continued to be symptomatic with drowsiness and confusion. The FSBS was obtained with results to be 46 mg/dl. The remainder of the glucose gel was administered. The oncoming charge nurse was to obtain FSBS every ,[DATE] minutes. The initial FSBS following the administration of Glucose gel was to be obtained at 10:33 p.m. The FSBS was not obtained until [DATE] at 12:00 a.m., with results of 118 mg/dl. FSBS was obtained at 1:00 a.m., with results of 311. There were no other FSBS documented in the residents record. On [DATE] at 3:00 a.m., the resident was found to be cold, non-responsive, bluish gray in color and not breathing. The resident expired in the facility on [DATE], at 3:31 a.m. This affected three (#1, 4, and #5) of three sampled residents with [DIAGNOSES REDACTED]. This had the potential to affect 26 diabetic residents, including 18 residents with orders to receive insulin. Findings: A Hypoglycemic Protocol policy, documented, .If blood glucose level is less than 50 OR less than 70 and is symptomatic the licensed nurse shall administer an emergency dose of Glucose Gel orally .In all cases recheck the blood sugar in ,[DATE] minutes to ensure the blood sugar has reached an acceptable level, > (greater than) 70 .Always check again in 1 hour to ensure the blood glucose level has been maintained .document the blood glucose level, initial and subsequent, the actions taken, the resident's response/level of consciousness and the notification of the physician . 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan for admission on [DATE] documented the resident was alert, cognitively intact, and received insulin. The resident's long term goal was to return to her home/community. The admission assessment, dated [DATE], documented the resident was cognitively intact, required set up assist and supervision for eating, and received insulin 7 of 7 days of the assessment. The physician's orders [REDACTED]. ~FSBS before meals, follow hypoglycemic protocol. ~Elemi (Insulin) inject 40 units two times a day ~Insulin Lisper solution 100 unit/millimeter (ml). Inject per sliding scale before meals as follows: -FSBS 0 - 180 = no insulin. Follow hypoglycemic protocol. -FSBS 181 - 250 = administer 4 units. -FSBS 251 - 300 = administer 6 units. -FSBS 301 - 350 = administer 8 units. -FSBS 351 - 400 = administer 10 units. -FSBS greater than 400 = administer 10 units, ambulate, hydrate and give 5 units every hour until FSBS is less than 200. ~[MEDICATION NAME] administer 10 mg by mouth two times a day. On [DATE], the Medication Administration Record [REDACTED] ~FSBS before breakfast was 185 mg/dl. The resident was administered Elemi 40 units and Lisper 5 units. ~FSBS before the noon meal was 130 mg/dl. No insulin was administered. ~FSBS before the evening meal was 85 mg/dl. No insulin was administered. ~FSBS at bedtime was 72 mg/dl. Elemi 40 units was administered. A nurse's note, dated [DATE] at 11:33 p.m., written by LP #1 documented, .FSBS at 1922 (7:22 p.m.) was 72 Homology held. Elemi administer .was sitting up .getting ready to eat .2025 (8:25 p.m.) .refusing to eat .2104 (9:04 p.m.) FSBS 65 .refused sandwich and drank very little .slow to respond, when talked to loudly will open eyes and turn her head .administered glucose gel 1 tablespoon. FSBS 2150 (9:50 p.m.) 61. 1033 FSBS - 46 this nurse talking very loudly to res (resident) trying to get res (resident) to respond .administered 1 tube of glucose gel at 2211 (10:11 p.m.) .oncoming Nurse (LP #2) to follow up finger stick in 15 min (2226) (10:26 p.m.) . A nurse's note, dated [DATE] at 3:54 a.m., written by LP #2 documented, checked on rers (resident)) at 0000 (midnight) and retook fsbs and was 118 and res (resident) was alert and awake and awoke easily. rechecked the res at 0100 and retook fsbs and it was 311 and res was alert and awaken easily, was called to the res room from the aid at 0300 (3:00 a.m) report to the res .was cold to touch with no apparent pulse and bluish gray in color and not breathing. did a sternum rub to awake .did not wake .didn't get any viable vital ems (emergency medical services) pronounced death at 0331 (3:31 a.m) . Life EMS incident report dated [DATE] at 3:27 a.m., documented, Initial Patient Activity Dead without Resuscitation Efforts . Initial Scene Assessment: Dispatched priority one to the document location to find this 59 YOFM (year old female) supine in bed of local long term care resident facility, pale, mottled, with obvious lividity, pulseless and apnec. Nursing staff in attendance reports the patient was last seen at approximately ,[DATE] hours when staff rounded on patients during hours of rest. Nursing staff denies that approximately 0100 hours the patient had any verbalized or 'obvious complaints.' At approximately 0300 hours, staff detected the patient apnec and pulsless and activated [DATE]. Upon arrival, no CPR (cardiopulmonary resuscitation), Enid FD (Fire Department) in attendance reports the patient has dependent levidity with rigormortous of the jaw. Patient was placed on cardiac monitor and it was determined that she was in an asystolic rhythm, confirmed in two leads. Nursing staff provided a copy of the patient's medication list and it was determined she was type 1 diabetic. Finger stick blood sugar was obtained via capillary stick, blood sugar was determined to be 68 mg/dl. Pupillary response indicated bilateral fixed and dilated pupils, non-reactive to light. Discontinued ECG (electrocardiography) tracing at 0349 .Per OSDH (Oklahoma State Department of Health), protocol patient was left on scene and medical examiners office contact, Departed facility at 0350 . A State of Oklahoma Certificate of Death, documented the resident expired on [DATE] at 3:31 a.m., and the immediate cause of death as Diabetes Mellitus Sequela (a condition which is the consequences of a previous disease or injury). On [DATE] at 9:40 a.m., the DON and RN #1 were asked if a residents' FSBS was low would there be an order to administer the glucose gel. RN #1 provided a copy of the facility's hypoglycemic protocol. The DON and RN #1 were asked if the physician was notified of FSBS of 46 mg/dl per the facility's protocol. RN #1 stated, .They were probably focused on the FSBS which did come up with interventions. She was asked was the facility hypoglycemic policy was followed to ensure the resident's FSBS was re-assessed, monitored and intervention placed. She reviewed the record and stated, No. At 10:40 a.m., via telephone, the resident's physician was asked if he had been notified the resident exhibited a change of condition with low FSBS, altered mental status change on [DATE]. He stated he was not in his office and could not confirm notification. At 3:39 p.m., licensed practical nurse (LP) #1 was asked if she was the charge nurse for resident #1 on the evening of [DATE]. She stated, Yes. The LP was asked if she administered glucose and how many doses the resident received glucose. She stated the resident was given 1 tablespoon, when it did not seem to help, she had reviewed the label/orders and realized the dose was to administer the entire container/tube of glucose. She stated she had been on the telephone with the on call nurse/RN and not sure how much time had lapsed between the 1 tablespoon and administering the remainder of the tube. LP #1 was asked to clarify the nurse note which documented a finger stick was obtained at 1033. She stated she was not accustomed to using military time and probably would have been 10:33 p.m. LP #1 stated she provided report to the oncoming charge nurse (LP #2) who would have completed the initial follow up FSBS after the resident received the remainder of the full dose of glucose at 10:11 p.m. LP #1 was asked if the resident's physician had been notified of the hypoglycemic events. She stated, No, because (she) had been on the phone with the on call nurse (RN #2) and was instructed to only monitor the resident. LP #1 was asked if the on call RN was in the building at any time of the event. She stated, No, was only on the phone and I think they can document remotely. LP #1 stated since she was a new employee at the time of the even, she expected to receive additional in-service/education but the event had not been discussed. She stated the facility did not follow up with staff after the event. LP #2 was unable to be interviewed. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented the resident had moderate/severe cognitive impairment, required extensive assistance for eating, and received insulin injections on 7 of 7 days of the assessment. The physician orders [REDACTED]. ~FSBS before meals and at bedtime. Follow hypoglycemic protocol. ~[MEDICATION NAME] solution 100 unit/ml. Inject as per sliding scale before meals and at bedtime: -FSBS 0 - 199 = no units. -FSBS 200 - 299 = administer 2 units. -FSBS 300 - 399 = administer 4 units. -FSBS 400 - 599 = administer 5 units. -if FSBS is greater than 400, push fluids, administer 5 units every hour until FSBS is less than 200. ~Basaglar Kwik-Pen ([MEDICATION NAME]) 100 units/ml, inject 10 units at bedtime. ~[MEDICATION NAME] 10 mg, administer 1 tablet daily. ~[MEDICATION NAME] 500 mg, administer 1 tablet two times a day. The care plan last updated [DATE] documented: ~The resident received antidiabetic medications included [MEDICATION NAME], Basaglar Insulin and [MEDICATION NAME]. The goal was to have no signs/symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Interventions included to administer medications as ordered, long term need for sliding scale insulin, and monitor for [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. The care plan documented signs/symptoms of [MEDICAL CONDITION] included blood sugar more than 180 mg/dl. ~The resident had a [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED] ~A FSBS was greater than 500 mg/dl on [DATE]. ~FSBS were greater than 400 mg/dl on 3, 7, 8, 13, 20, 22, 23, 28 and 31. In ,[DATE], there were 10 events the FSBS was not re-assessed, monitored or interventions placed. The Medication Administration Record [REDACTED] ~A FSBS was greater than 500 mg/dl on [DATE]. ~FSBS were greater than 400 mg/dl on 1, 6, 9, 17, 18 (2 events), 19, 25, 27, and 30 (2 events) ~No FSBS results before breakfast on [DATE]. On [DATE], before the noon meal, the resident's FSBS was 430 mg/dl. At 12:00 p.m., a nurse's note documented, FSBS 394. [MEDICATION NAME] 5 units SQ (subcutaneous) given. Tol (tolerated) well. In ,[DATE], there was no documentation the resident was re-assessed, monitored or provided additional interventions as ordered by the physician. On [DATE], before the noon meal, the resident's FSBS was 503 mg/dl. At 12:00 p.m., a nurse's note documented, FSBS 457. Homology 5 units given. At 1:00 p.m., a nurse's note documented, FSBS 389. 5 units humalog given. In ,[DATE], there were 12 events that elevated FSBS was not re-assessed, monitored or interventions placed/followed physician order/protocol. The Medication Administration Record [REDACTED] ~FSBS were greater than 500 mg/dl on 3 (2 events), and 12. ~FSBS were greater than 400 mg/dl on 1 (2 events), 4, 9, 11, 12, 13, 15, 19, and 28. In ,[DATE], there were 13 events that elevated FSBS was not re-assessed, monitored or interventions placed/followed physician order/protocol. There was no documentation the physician had been notified of the elevated FSBS. On [DATE] at 10:35 a.m., the DON and RN #1 were shown the record for the FSBS greater than 400 mg/dl and greater than 500 mg/dl. They were asked if the facility re-assessed, monitored and/or provided intervention for the FSBS greater than ,[DATE] mg/dl. After reviewing the record, RN #1 stated, They started on 2 of them in (MONTH) but didn't follow through. After further review, RN #1 stated, It's not there. They were asked if the physician was notified of the elevated FSBS. RN #1 stated, It isn't there. 3. Resident #5 had [DIAGNOSES REDACTED]. The physician orders [REDACTED]. ~FSBS before meals and at bedtime. Follow hypoglycemic protocol. ~Elemi 100 unit/ml. Inject 63 units two times a day. ~[MEDICATION NAME] 100 unit/ml, inject per sliding scale as follows: -FSBS 0 - 149 = No insulin. Follow hypoglycemic protocol if FSBS is less than 60. -FSBS 150 - 199 = administer 8 units. -FSBS 200 - 249 = administer 9 units. -FSBS 250 - 299 = administer 11 units -FSBS 300 - 349 = administer 13 units -FSBS 350 - 399 = administer 14 units -FSBS 400 - 499 = administer 15 units. If FSBS is greater than 400 encourage to ambulate/exercise and give hydration. Recheck FSBS in 1 hour and if still above 400, administer 5 units every 1 hour until FSBS is less than 200. ~Bydureon Pen-Injector 2 mg subcutaneously every Thursday. The care plan last updated [DATE] documented: ~Resident received antidiabetic medications. Interventions included to administer medications as ordered, monitor for signs/symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. ~Resident has a [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented, the resident to have mild cognitive impairment, required supervision and set up assistance for eating, and received injections of insulin 7 of 7 days of the assessment. The Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. There were 13 events that elevated FSBS were not re-assessed, monitored or interventions placed as ordered by the physician for ,[DATE] and ,[DATE]. There was no documentation the physician had been notified of the elevated FSBS. On [DATE] at 10:45 a.m., the DON and RN #1 were shown the record for the FSBS greater than 400 mg/dl. They were asked if the facility re-assessed, monitored and/or provided interventions for the FSBS greater than 400 mg/dl. After review of the record, RN #1 stated, It's not there. The RN was asked if the physician was notified of the FSBS greater than 400 mg/dl. She stated, She was seen by the doctor on (MONTH) 8th. She acknowledged the record did not contain information the physician was aware the FSBS were greater than 400 mg/dl.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have competent nursing staff to assess, monitor, and provide intervention for diabetic a resident in crisis; identify a change in condition; and notify the physician of changes in condition. On [DATE], at 8:25 p.m., resident #1 became symptomatic of [DIAGNOSES REDACTED], she exhibited altered mental status, drowsiness and confusion. At 9:50 p.m., a finger stick blood sugar (FSBS) was obtained with results to be 61 milligrams/deciliter (mg/dl). One tablespoon of Glucose gel was administered (the dose was on container/tube). At 10:11 p.m., the resident continued to be symptomatic with drowsiness and confusion. The FSBS was obtained with results to be 46 mg/dl. The remainder of the glucose gel was administered. The oncoming charge nurse was to obtain a FSBS every ,[DATE] minutes. The initial FSBS following the administration of Glucose gel was to be obtained at 10:33 p.m. The FSBS was not obtained until [DATE] at 12:00 a.m., with results of 118 mg/dl. Another FSBS was obtained at 1:00 a.m., with results of 311 mg/dl. On [DATE] at 3:00 a.m., the resident was found to be cold, nonresponsive, bluish gray in color and not breathing. The resident expired in the facility on [DATE], at 3:31 a.m. A State of Oklahoma Certificate of Death, documented the resident expired on [DATE] at 3:31 a.m., and the immediate cause of death as Diabetes Mellitus Sequela (a condition which is the consequences of a previous disease or injury). On [DATE] at 4:02 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:05 p.m., the administrator, director of nurses (DON) and Registered Nurse (RN) #1 were notified of the IJ situation related to the facility's failure to assess, monitor and provide intervention for a diabetic resident in crisis. At 6:35 p.m., an acceptable plan of removal was provided. The plan of removal documented, The facility's response to the IJ called for the facility to implement a plan of removal to improve the critical thinking in response and administering insulin with Quality of Care and Nurse Competency. 1. An audit was done of all of the residents with diabetes, those on insulin were identified as being at risk. The DON/designee will audit hypoglycemic protocol orders and insulin orders for all residents who receive insulin and reconcile the orders with the TARs (treatment administration records) and ensure they all had hypoglycemic orders in place by 10 pm [DATE]. 2. Medical Director was contacted at 6 pm, the hypoglycemic protocol was reviewed and revised by 6 pm [DATE] with medical director input. 3. All nursing staff will be in-serviced on the importance of assessing, monitoring and intervening after a low or high finger stick reading. They will be in-serviced on the different types of insulin and onset of action and the facilities hypoglycemic protocol by 11pm [DATE]. 4. No licensed nursing staff will be allowed to administer insulin until passing a competency for insulin administration, including assessing, monitoring and intervening for low or high blood sugars no later than [DATE] at 5pm. Before the next insulin administration by each nurse, the nurse will be monitored by a nurse manager to assess the need, the physician's orders [REDACTED]. Then nurses will determine whether it is safe to continue with the administration. Insulin competency will be completed at that time by the nurse manager. If there is any questions, nurses will contact physician. The competencies will be completed by 5pm on [DATE]. The immediate jeopardy was removed on [DATE] at 5:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm Based on interview and record review, it was determined the facility failed to ensure staff were competent and possessed the necessary skills to : ~ assess, monitor, and provide intervention for diabetic residents; ~ notify the physician when a resident exhibited a change in condition. On [DATE], at 8:25 p.m., resident #1 became symptomatic of [DIAGNOSES REDACTED], she exhibited altered mental status, drowsiness and confusion. At 9:50 p.m., a FSBS was obtained with results to be 61 mg/dl. One tablespoon of Glucose gel was administered (the dosage was one container/tube). At 10:11 p.m., the resident continued to be symptomatic with drowsiness and confusion. The FSBS was obtained with results to be 46 mg/dl. The remainder of the glucose gel was administered. The oncoming charge nurse was to obtain FSBS every ,[DATE] minutes. The initial FSBS following the administration of Glucose gel was to be obtained at 10:33 p.m. The FSBS was not obtained until [DATE] at 12:00 a.m., with results of 118 mg/dl. FSBS was obtained at 1:00 a.m., with results of 311. There were no other FSBS documented in the residents record. On [DATE] at 3:00 a.m., the resident was found to be cold, non-responsive, bluish gray in color and not breathing. The resident expired in the facility on [DATE], at 3:31 a.m. This affected three (#1, 4, and #5) of three sampled residents with [DIAGNOSES REDACTED]. This had the potential to affect 26 diabetic residents, including 18 residents with orders to receive insulin. Findings: A Hypoglycemic Protocol policy, documented, .If blood glucose level is less than 50 OR less than 70 and is symptomatic the licensed nurse shall administer an emergency dose of Glucose Gel orally .In all cases recheck the blood sugar in ,[DATE] minutes to ensure the blood sugar has reached an acceptable level, > (greater than) 70 .Always check again in 1 hour to ensure the blood glucose level has been maintained .document the blood glucose level, initial and subsequent, the actions taken, the resident's response/level of consciousness and the notification of the physician . 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan for admission on [DATE] documented the resident was alert, cognitively intact, and received insulin. The resident's long term goal was to return to her home/community. The admission assessment, dated [DATE], documented the resident was cognitively intact, required set up assist and supervision for eating, and received insulin 7 of 7 days of the assessment. The physician's orders [REDACTED]. ~FSBS before meals, follow hypoglycemic protocol. ~Elemi (Insulin) inject 40 units two times a day ~Insulin Lisper solution 100 unit/millimeter (ml). Inject per sliding scale before meals as follows: -FSBS 0 - 180 = no insulin. Follow hypoglycemic protocol. -FSBS 181 - 250 = administer 4 units. -FSBS 251 - 300 = administer 6 units. -FSBS 301 - 350 = administer 8 units. -FSBS 351 - 400 = administer 10 units. -FSBS greater than 400 = administer 10 units, ambulate, hydrate and give 5 units every hour until FSBS is less than 200. ~[MEDICATION NAME] administer 10 mg by mouth two times a day. On [DATE], the Medication Administration Record [REDACTED] ~FSBS before breakfast was 185 mg/dl. The resident was administered Elemi 40 units and Lisper 5 units. ~FSBS before the noon meal was 130 mg/dl. No insulin was administered. ~FSBS before the evening meal was 85 mg/dl. No insulin was administered. ~FSBS at bedtime was 72 mg/dl. Elemi 40 units was administered. A nurse's note, dated [DATE] at 11:33 p.m., written by LP #1 documented, .FSBS at 1922 (7:22 p.m.) was 72 Homology held. Elemi administer .was sitting up .getting ready to eat .2025 (8:25 p.m.) .refusing to eat .2104 (9:04 p.m.) FSBS 65 .refused sandwich and drank very little .slow to respond, when talked to loudly will open eyes and turn her head .administered glucose gel 1 tablespoon. FSBS 2150 (9:50 p.m.) 61. 1033 FSBS - 46 this nurse talking very loudly to res (resident) trying to get res (resident) to respond .administered 1 tube of glucose gel at 2211 (10:11 p.m.) .oncoming Nurse (LP #2) to follow up finger stick in 15 min (2226) (10:26 p.m.) . A nurse's note, dated [DATE] at 3:54 a.m., written by LP #2 documented, checked on rers (resident)) at 0000 (midnight) and retook fsbs and was 118 and res (resident) was alert and awake and awoke easily. rechecked the res at 0100 and retook fsbs and it was 311 and res was alert and awaken easily, was called to the res room from the aid at 0300 (3:00 a.m) report to the res .was cold to touch with no apparent pulse and bluish gray in color and not breathing. did a sternum rub to awake .did not wake .didn't get any viable vital ems (emergency medical services) pronounced death at 0331 (3:31 a.m) . Life EMS incident report dated [DATE] at 3:27 a.m., documented, Initial Patient Activity Dead without Resuscitation Efforts . Initial Scene Assessment: Dispatched priority one to the document location to find this 59 YOFM (year old female) supine in bed of local long term care resident facility, pale, mottled, with obvious lividity, pulseless and apnec. Nursing staff in attendance reports the patient was last seen at approximately ,[DATE] hours when staff rounded on patients during hours of rest. Nursing staff denies that approximately 0100 hours the patient had any verbalized or 'obvious complaints.' At approximately 0300 hours, staff detected the patient apnec and pulsless and activated [DATE]. Upon arrival, no CPR (cardiopulmonary resuscitation), Enid FD (Fire Department) in attendance reports the patient has dependent levidity with rigormortous of the jaw. Patient was placed on cardiac monitor and it was determined that she was in an asystolic rhythm, confirmed in two leads. Nursing staff provided a copy of the patient's medication list and it was determined she was type 1 diabetic. Finger stick blood sugar was obtained via capillary stick, blood sugar was determined to be 68 mg/dl. Pupillary response indicated bilateral fixed and dilated pupils, non-reactive to light. Discontinued ECG (electrocardiography) tracing at 0349 .Per OSDH (Oklahoma State Department of Health), protocol patient was left on scene and medical examiners office contact, Departed facility at 0350 . A State of Oklahoma Certificate of Death, documented the resident expired on [DATE] at 3:31 a.m., and the immediate cause of death as Diabetes Mellitus Sequela (a condition which is the consequences of a previous disease or injury). On [DATE] at 9:40 a.m., the DON and RN #1 were asked if a residents' FSBS was low would there be an order to administer the glucose gel. RN #1 provided a copy of the facility's hypoglycemic protocol. The DON and RN #1 were asked if the physician was notified of FSBS of 46 mg/dl per the facility's protocol. RN #1 stated, .They were probably focused on the FSBS which did come up with interventions. She was asked was the facility hypoglycemic policy was followed to ensure the resident's FSBS was re-assessed, monitored and intervention placed. She reviewed the record and stated, No. At 10:40 a.m., via telephone, the resident's physician was asked if he had been notified the resident exhibited a change of condition with low FSBS, altered mental status change on [DATE]. He stated he was not in his office and could not confirm notification. At 3:39 p.m., licensed practical nurse (LP) #1 was asked if she was the charge nurse for resident #1 on the evening of [DATE]. She stated, Yes. The LP was asked if she administered glucose and how many doses the resident received glucose. She stated the resident was given 1 tablespoon, when it did not seem to help, she had reviewed the label/orders and realized the dose was to administer the entire container/tube of glucose. She stated she had been on the telephone with the on call nurse/RN and not sure how much time had lapsed between the 1 tablespoon and administering the remainder of the tube. LP #1 was asked to clarify the nurse note which documented a finger stick was obtained at 1033. She stated she was not accustomed to using military time and probably would have been 10:33 p.m. LP #1 stated she provided report to the oncoming charge nurse (LP #2) who would have completed the initial follow up FSBS after the resident received the remainder of the full dose of glucose at 10:11 p.m. LP #1 was asked if the resident's physician had been notified of the hypoglycemic events. She stated, No, because (she) had been on the phone with the on call nurse (RN #2) and was instructed to only monitor the resident. LP #1 was asked if the on call RN was in the building at any time of the event. She stated, No, was only on the phone and I think they can document remotely. LP #1 stated since she was a new employee at the time of the even, she expected to receive additional in-service/education but the event had not been discussed. She stated the facility did not follow up with staff after the event. LP #2 was unable to be interviewed. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented the resident had moderate/severe cognitive impairment, required extensive assistance for eating, and received insulin injections on 7 of 7 days of the assessment. The physician orders [REDACTED]. ~FSBS before meals and at bedtime. Follow hypoglycemic protocol. ~[MEDICATION NAME] solution 100 unit/ml. Inject as per sliding scale before meals and at bedtime: -FSBS 0 - 199 = no units. -FSBS 200 - 299 = administer 2 units. -FSBS 300 - 399 = administer 4 units. -FSBS 400 - 599 = administer 5 units. -if FSBS is greater than 400, push fluids, administer 5 units every hour until FSBS is less than 200. ~Basaglar Kwik-Pen ([MEDICATION NAME]) 100 units/ml, inject 10 units at bedtime. ~[MEDICATION NAME] 10 mg, administer 1 tablet daily. ~[MEDICATION NAME] 500 mg, administer 1 tablet two times a day. The care plan last updated [DATE] documented: ~The resident received antidiabetic medications included [MEDICATION NAME], Basaglar Insulin and [MEDICATION NAME]. The goal was to have no signs/symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Interventions included to administer medications as ordered, long term need for sliding scale insulin, and monitor for [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. The care plan documented signs/symptoms of [MEDICAL CONDITION] included blood sugar more than 180 mg/dl. ~The resident had a [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED] ~A FSBS was greater than 500 mg/dl on [DATE]. ~FSBS were greater than 400 mg/dl on 3, 7, 8, 13, 20, 22, 23, 28 and 31. In ,[DATE], there were 10 events the FSBS was not re-assessed, monitored or interventions placed. The Medication Administration Record [REDACTED] ~A FSBS was greater than 500 mg/dl on [DATE]. ~FSBS were greater than 400 mg/dl on 1, 6, 9, 17, 18 (2 events), 19, 25, 27, and 30 (2 events) ~No FSBS results before breakfast on [DATE]. On [DATE], before the noon meal, the resident's FSBS was 430 mg/dl. At 12:00 p.m., a nurse's note documented, FSBS 394. [MEDICATION NAME] 5 units SQ (subcutaneous) given. Tol (tolerated) well. In ,[DATE], there was no documentation the resident was re-assessed, monitored or provided additional interventions as ordered by the physician. On [DATE], before the noon meal, the resident's FSBS was 503 mg/dl. At 12:00 p.m., a nurse's note documented, FSBS 457. Homology 5 units given. At 1:00 p.m., a nurse's note documented, FSBS 389. 5 units humalog given. In ,[DATE], there were 12 events that elevated FSBS was not re-assessed, monitored or interventions placed/followed physician order/protocol. The Medication Administration Record [REDACTED] ~FSBS were greater than 500 mg/dl on 3 (2 events), and 12. ~FSBS were greater than 400 mg/dl on 1 (2 events), 4, 9, 11, 12, 13, 15, 19, and 28. In ,[DATE], there were 13 events that elevated FSBS was not re-assessed, monitored or interventions placed/followed physician order/protocol. There was no documentation the physician had been notified of the elevated FSBS. On [DATE] at 10:35 a.m., the DON and RN #1 were shown the record for the FSBS greater than 400 mg/dl and greater than 500 mg/dl. They were asked if the facility re-assessed, monitored and/or provided intervention for the FSBS greater than ,[DATE] mg/dl. After reviewing the record, RN #1 stated, They started on 2 of them in (MONTH) but didn't follow through. After further review, RN #1 stated, It's not there. They were asked if the physician was notified of the elevated FSBS. RN #1 stated, It isn't there. 3. Resident #5 had [DIAGNOSES REDACTED]. The physician orders [REDACTED]. ~FSBS before meals and at bedtime. Follow hypoglycemic protocol. ~Elemi 100 unit/ml. Inject 63 units two times a day. ~[MEDICATION NAME] 100 unit/ml, inject per sliding scale as follows: -FSBS 0 - 149 = No insulin. Follow hypoglycemic protocol if FSBS is less than 60. -FSBS 150 - 199 = administer 8 units. -FSBS 200 - 249 = administer 9 units. -FSBS 250 - 299 = administer 11 units -FSBS 300 - 349 = administer 13 units -FSBS 350 - 399 = administer 14 units -FSBS 400 - 499 = administer 15 units. If FSBS is greater than 400 encourage to ambulate/exercise and give hydration. Recheck FSBS in 1 hour and if still above 400, administer 5 units every 1 hour until FSBS is less than 200. ~Bydureon Pen-Injector 2 mg subcutaneously every Thursday. The care plan last updated [DATE] documented: ~Resident received antidiabetic medications. Interventions included to administer medications as ordered, monitor for signs/symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. ~Resident has a [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented, the resident to have mild cognitive impairment, required supervision and set up assistance for eating, and received injections of insulin 7 of 7 days of the assessment. The Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. There were 13 events that elevated FSBS were not re-assessed, monitored or interventions placed as ordered by the physician for ,[DATE] and ,[DATE]. There was no documentation the physician had been notified of the elevated FSBS. On [DATE] at 10:45 a.m., the DON and RN #1 were shown the record for the FSBS greater than 400 mg/dl. They were asked if the facility re-assessed, monitored and/or provided interventions for the FSBS greater than 400 mg/dl. After review of the record, RN #1 stated, It's not there. The RN was asked if the physician was notified of the FSBS greater than 400 mg/dl. She stated, She was seen by the doctor on (MONTH) 8th. She acknowledged the record did not contain information the physician was aware the FSBS were greater than 400 mg/dl.

On 02/10/15 at 9:21 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to unsafe hot water temperatures obtained in resident hand sinks on hall #4. The Oklahoma State Department of Health (OSDH) verified the existence of the IJ related to (R/T) the facility's failure to maintain hot water temperatures in resident hand sinks at a level to prevent accidental burns. At 10:30 a.m., the administrator (ADM), director of nursing (DON), and corporate nurse, were informed of the IJ R/T to the facility's failure to maintain hot water temperatures at a safe level. At 11:05 a.m., an acceptable Plan of Removal (POR) was provided by the facility's corporate nurse. The POR documented: "F323 1. All water heater valves were immediately turned off upon being notified of water temperatures being out of compliance. The water heaters were drained and a repair man was called to the facility to inspect the water heaters and make any needed repairs. The residents who were alert and oriented were notified of the water temperature issue and that the hot water would be temporarily unavailable. All staff were notified to monitor confused residents for any sanitary issues and provide care as needed with the use of disposable wipes, peri-wash, and alcohol gel. Disposable dishes were used until the hot (water) issue was resolved. 2. The repairs will be made and water heaters will be adjusted to desired temperature within guidelines (between 100 - 115 degrees). The water was initially tested by the maintenance supervisor for proper range. 3. The staff will monitor the water temperatures throughout the night every hour in random rooms on each hall to ensure it remains in compliance. They will be instructed to call the maintenance supervisor if any temperatures were out of range. 4. The Hot Water Temperature Policy was revised to increase the hot water temperature monitoring to twice daily at random on each hall, in the bathing area and dietary department by the Maintenance Staff and nursing staff on the weekends. 5. All staff will be inserviced today at the regular in-service for all staff on the Hot Water Policy and Procedure. Any staff not in attendance will be called and the policy and procedures reviewed with them by phone by the Administrator or a Nurse Manager by the end of today at 5 pm. 6. All dietary staff will be in-serviced today, 2-10-15 on how to check the temperature of water in the dish machine. They were in-serviced over proper temperature for the dish machine (125 degrees or greater) and what to do if reading is below 125 degrees, as well. 7. Water temperatures will continue to be tested daily at random on each hall, in the dietary department, at least one bathing areas (sic) and in the laundry by the maintenance supervisor. Sites will be rotated so that different rooms are checked. Temperatures will be documented on a log and any adjustments or repairs made will be documented. 8. The Administrator will monitor temperature logs daily and as needed. All temperature logs will be reviewed by the QA (Quality Assurance) Committee at least quarterly for any concerns and make any needed recommendations." On 02/10/15 at 4:45 p.m., the corporate nurse provided documentation to show all facility staff had been provided training on acceptable hot water temperatures, their responsibilities regarding monitoring the hot water temperatures, reporting elevated hot water temperatures to the charge nurse and/or the maintenance supervisor and monitoring of confused residents if water temperatures were elevated. She stated for those staff who had not attended the in-service, they were notified by telephone and the information was provided over the phone. She stated the staff person who notified the employee by phone signed and dated the information provided. She stated the mixing valves on the two hot water heaters for halls 1/2 and 3/4, were not the correct ones for those hot water heaters, and would have to be replaced. She stated they located one mixing valve in the Oklahoma City area and one in the Enid area, and were sending someone to each place to pick the valves up. She further stated the maintenance supervisor had re-set the hot water temperatures on the heaters so staff/residents could use the water, but they would be checking the water temperatures hourly and would continue to check the temperatures after the new mixing valves had been replaced to make sure there were no further problems with the hot water temperatures. On 02/12/15 at 8:35 a.m., interviews were conducted with staff in regards to their knowledge of the inservice to ensure their understanding of all aspects of the POR. The IJ was removed effective 02/11/15 at 8:00 a.m., when all components of the POR had been completed, including hourly monitoring of random hot water temperatures throughout the facility, for an appropriate amount of time, to determine if the problem had in fact been corrected. The deficient practice remained at a pattern level with a potential for more than minimum harm. Based on observation, record review, and interview, it was determined the facility failed to ensure hot water temperatures were maintained at a safe level to prevent accidental burns to residents on two (halls three/four ) of four halls. This had the potential to affect 23 residents who currently resided on halls three and four. Findings: A facility policy titled, "Hot Water Temperature Policy" documented, "Policy: Hot water temperatures will be maintained in acceptable range: Bathing and Resident rooms: 100-115 Degrees F (Fahrenheit) Dietary:120 Degrees F Laundry:160 Degrees F Rinse water temperature at automatic warewashing, no lower than 125 Degrees F Procedure: Water temperatures will be checked daily at random on each hall, in the dietary department, in at least one bathing area and in the laundry by the Maintenance Supervisor. Sites will be rotated so that different rooms are checked daily. These checks will be documented on the water temperature log and any needed adjustments documented. If water temperatures are at any time noted to be too high, the alert residents will be notified immediately until the problem is resolved. The staff will be alerted immediately to monitor the confused residents to prevent use of hot water alone. These measures will be documented on the water temperature log. Thermometers will be kept at the nurses station to enable them to check water temperatures if concern is noted after hours. If staff note elevated hot water temperatures above 115, they are to notify the administrator and maintenance supervisor immediately and put into effect the constant monitoring of confused residents to prevent hot water use alone. The plumber will be notified of any needed repairs to the water supply." On 02/10/15 at 9:00 a.m., an observation was made of the room for resident #86, who resided in room 46-A on hall 4. During the observation, the hot water was checked by allowing the water to run until it became hot. The water was too hot to be touched by hand. A thermometer was retrieved and the water temperature was taken, with a result of 136.5 degrees F. The water temperature was reported to the rest of the survey team and water temperatures were obtained from the hand sinks in all rooms on hall four. The following temperatures were obtained between 9:00 a.m. and 9:30 a.m.: At 9:00 a.m. the hot water temperature in room #42 was checked and a reading of 128.2 degrees F was obtained. Resident #72 resided in the room. The resident was noted to be non-ambulatory in a wheelchair. She was asked if she used the sink and she stated, "No." At 9:05 a.m., the hot water temperature in room #43 was checked and a reading of 119.7 degrees F was obtained. Resident #90 resided in the room, and was observed to be ambulatory. At 9:10 a.m., the hot water temperature in room #44 was checked and a reading of 134.0 degrees F was obtained. Resident #28 resided in the room. She was asked if she was able to access and use her hand sink. She stated she was able to use her hand sink. At 9:14 a.m., the hot water temperature in room #51 was obtained, with a reading of 119 degrees F. Residents #39 and #60 resided in the room. Resident #39 was observed to be bedfast, but #60 was ambulatory and able to access the hot water in the hand sink independently. He stated the water had to run for quite a while before it would get hot. At 9:15 a.m., the hot water temperature in room #53 was obtained, with a reading of 133.6 degrees F. Resident #42 stated she had no problems with the hot water and was able to self- adjust the faucet. She further stated her roommate #10 was unable to reach the faucet. At 9:18 a.m., the hot water temperature in room #46 was checked and a reading of 136.5 degrees F was obtained. Residents #86 and #38 resided in the room. Resident #86 was observed in bed with the side rail up. Resident #38 was asked if she was able to use the hand sink. She stated she used it to wash her hands sometimes. At 9:20 a.m., the hot water temperature was obtained in room #47, with a reading of 138.1 degrees F. The two residents residing in the room #15 and #3 were unable to use the faucet on their own. At 9:21 a.m., the hot water temperature in room #52 was obtained, with a fluctuating reading between 137.5 to 139.5 degrees F, after the water had ran for four minutes. Resident #6 resided in the room and was unable to independently use the hand sink. At 9:25 a.m., the hot water temperature was obtained in room #49, with a reading of 137.7 degrees F. Resident #71 was asked if she ever had any problems with the hot water. She stated she had no problems with the hot water. She further stated it took a long time for the water to heat up and at times the hot water was too cold. She stated she was able to adjust the faucet herself. At 9:30 a.m., the hot water temperature was checked in room #56. Within 15 seconds, the water became too hot for the surveyor to hold her hand in the water. The water temperature was obtained with a reading of 142.5 degrees F. The resident who resided in the room, #36 was asked if she used the hand sink in her room. She stated she did use the hand sink. She was asked if the water ever became too hot. She stated it did get too hot, but she mixed cold water with the hot water. She stated the water would be too hot if she didn't mix in cold water. At 9:36 a.m., the hot water temperature in room #55 was checked and a reading of 139.5 degrees F was obtained. Two residents resided in the room, #2 and #49. Resident #49 was asked if he ever used the sink in his room. He stated he didn't know. He was asked several questions and answered, "I don't know" to all of them. The resident was observed to be ambulatory. At 9:40 a.m., the DON was asked if there were any residents in the facility who were confused and wandered onto other halls and/or into other resident rooms. She identified residents #19 and #64 from hall one. She stated #19 used a walker and #64 used a wheelchair for mobility. She stated resident #51 from hall two used a wheelchair for mobility and resident #72 from hall four also used a wheelchair for mobility. She stated, "These residents are confused somewhat and do wind up on other halls at times." At 9:41 a.m., the maintenance supervisor was interviewed. He was asked how often he checked hot water temperatures. He stated, "Daily, in random rooms." He was asked how he checked the hot water temperatures. He stated with a thermometer that he calibrated weekly. He was asked when he last calibrated his thermometer. He stated he calibrated it last week. He was asked what type of thermometer he used. He stated it was a standard "Taylor" brand. He was asked how many hot water heaters were used in the facility. He stated there was an 80 gallon tank for halls one and two, an 80 gallon tank for halls three and four, an 80 gallon tank for the laundry, and an 80 gallon tank for the kitchen. He was asked how many rooms he tested on each hall. He stated, "Two." He was asked what the acceptable hot water temperature range was for the facility. He stated, "100 to 110 is what I understand." He stated in the summer the water is warmer because the tubing is in the attic. He was asked when was the last time he found hot water temperatures out of parameters. He stated, "It's been quite a while back, because I had to put a piece in the mixing valve." He was asked if he was the only person who took hot water temperatures. He stated the nurses take them occasionally or if he gets called in for something else, he will take some temperatures then. He was asked if the nurses had a thermometer. He stated, "Yes, they keep it at the desk." He was asked if he had taken the hot water temperatures that day. He stated, "No." He was asked what time of day he took hot water temperatures. He stated, "It varies. No specific time to take." He stated he didn't pay attention if the hot water temperatures were taken before or after the showers/baths were given. He stated, "I don't pay any attention what's going on. I have too much going on." At 9:49 a.m., the maintenance supervisor's thermometer and two surveyor's thermometers were calibrated in a Styrofoam cup of ice and water. The facility thermometer read 32 degrees F, and the two surveyors thermometers read 35 degrees F. These same thermometers were re-tested at 9:52 a.m. in the same container and both had a reading of 32.5 degrees F. The maintenance supervisor was asked if there was a policy for the hot water temperature parameters. He stated, "Yes." He stated he thought the parameters were 100 to 115 degrees F. He was asked to describe his procedure when he took hot water temperatures. He stated, "I go in, turn the water on, stand there a little bit, and let it run for a while. Then I test it and go to the next room." At 10:20 a.m., the maintenance supervisor and the surveyor went to room #53 to take the hot water temperature together. The thermometer used by the maintenance supervisor showed 119 degrees F, while the surveyor's thermometer showed 119.6 degrees F. The water temperature suddenly spiked to 146.4 degrees F on the surveyor's thermometer and had gotten up to 141 degrees F on the maintenance supervisor's thermometer. He then removed the thermometer from the water and immediately went to call a plumber. At 10:24 a.m., LPN #2 was asked if residents #49 and #36 were ambulatory. She stated resident #49 used a cane to ambulate in his room and he was able to use his sink. She stated resident #36 used a wheelchair, but was able to stand at the sink and wash her hands. At 10:30 a.m., an interview was conducted with the ADM., DON, corporate nurse, and maintenance supervisor, regarding the elevated hot water temperatures. The corporate nurse stated the plumber had already been notified and the maintenance supervisor was turning off the water so there would be no accidents. At 11:00 a.m., the maintenance supervisor informed the survey team he had drained the two hot water tanks for halls one/two and three/four. On 02/12/15 between 7:50 a.m. and 10:17 a.m., hot water temperatures were taken on halls one, two, and four. The following readings were obtained: 7:50 a.m. - room 56 - 115.8 degrees F. 8:07 a.m. - room 51 - 99.8 degrees F. 8:27 a.m. - room 14 - 123.0 degrees F and at 9:03 - 113.0 degrees F. 8:35 a.m. - room 54 - 98.8 degrees F. 8:43 a.m. - room 50 - 97.6 degrees F - no resident resided in this room. 8:46 a.m. - room 48 - 96.0 degrees F - no resident resided in this room. 9:06 a.m. - room 8 - 117.0 degrees F. and at 9:11 a.m. - 120.0 degrees F. 9:09 a.m. - room 9 - 118.5 degrees F. and at 9:14 a.m. - 121.4 degrees F. At 9:30 a.m., while in the DON's office, a certified nurse aide (CNA) #1 entered the office and informed the DON the hot water temperatures in the shower room for halls one/two were fluctuating. She told the DON they had just obtained a temperature of 120 degrees F. The DON informed the CNA to hold off on giving showers. At 10:35 a.m., the maintenance supervisor was interviewed regarding the fluctuating hot water temperatures. He stated they were going to be replacing the circulating pumps on halls one/two. He stated they had already replaced the circulating pump on halls three/four on 02/10/15, but they were still having fluctuating water temperatures. He stated they were thinking this might be the reason the water temperatures were fluctuating.

On 11/05/12, an immediate jeopardy (IJ) situation was determined to exist related to the facilities failure to maintain safe hot water temperatures on two of four halls. Nineteen resident rooms had hot water temperatures which exceeded 130 degrees F, and were up to 151 degrees F. The Oklahoma State Department of Health verified the existence of the IJ related to hot water temperatures. At 3:36 p.m., the administrator and the DON were informed of the IJ related to the hot water temperatures. On 05/08/12 at 4:38 p.m., an acceptable plan of removal for the IJ situation was received from the facility. The plan of removal documented: "Plan for Removal of Immediate Jeopardy Deficiency 11/5/12. Plan for removal: At 3:45pm all hot water valves on the water heaters were turned off on all halls. All water heaters on hallways have been drained and temperatures turned down. A plumber has been notified and is in route to the facility as of 4:20 pm. Repairs will be made as indicated in order for water temperatures to be maintained within proper range. At 3:45pm all staff and residents have been notified that hot water is temporarily off and staff have been instructed to monitor residents for sanitary needs until water heaters are back on and working properly to keep water temperatures within proper range. Any sanitary needs will be taken care of with the use of alcohol gel, peri-wash, and disposable wipes. Disposable dishes will be used for all meals until hot water is back on. When hot water is turned back on and temperatures in each room on each hallway are within proper range, testing will continue to be done in random rooms on each hallway every 1 hour for at least 12 hours by assigned staff and documented on a log. If temperatures are found to be above recommended guidelines, the maintenance supervisor will be notified and water temperatures readjusted on water heater. All staff will be in-serviced on proper water temperatures and recognizing when water temperatures are too high or too low. They will be provided a thermometer to test water temperatures as needed. If temperatures are not within proper range, they will be instructed to notify their supervisor and to monitor residents closely to prevent them from using water until the temperature has been corrected. Water temperatures will continue to be tested daily, at least 5 random rooms on each hall, by the maintenance supervisor or designee for proper tempertaure (sic). Water heaters will be adjusted as needed to maintain proper temperatures." The IJ was removed on 11/06/12 at 3:45 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observations, interviews, and record review, it was determined the facility failed to ensure hot water temperatures were maintained at safe levels and were not an accident hazard on three (Halls One, Three and Four) of four halls. Nineteen resident rooms had hot water temperatures which exceeded 130 degrees F, and were up to 151 degrees F. This resulted in an Immediate Jeopardy Situation. This had the likelihood to affect 46 of 58 residents who resided in the facility on Halls One, Three, and Four and who had access to hot water. Two residents were bedfast most or all of the time and ten residents resided on Hall Two and did not wander the facility. Findings: The Interpretive Guidelines from the State Operations Manual for F323 includes a table that describes "Time and Temperature Relationship to Serious Burns", taken from, "Moritz, A.R., Henriques F.C. Jr. (1947). Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720." The table defines the time required for a 3rd Degree burn to occur related to the water temperature. The table defines a 3rd degree burn occurs in: ~ 15 seconds with a water temperature of 133 degrees F, ~ 5 seconds with a water temperature of 140 degrees F, ~ 2 seconds with a water temperature of 148 degrees F, and ~ 1 second with a water temperature of 155 degrees F. 1. The following water temperatures were measured on Hall Four during an environmental tour which began on 11/05/12 at 2:20 p.m.: ~ A water temperature of 125 degrees F was measured in room 48. ~ A water temperature of 132 degrees F was measured in room 51. 2. At 2:30 p.m., a water temperature of 123 degrees F was measured in room 9 on Hall One. 3. The following water temperatures were measured on Hall Three beginning at 2:30 p.m.: ~ A water temperature of 151 degrees F was measured in room 35A. ~ A water temperature of 149 degrees F was measured in room 35. 4. The following water temperatures were measured on Hall Four beginning at 3:15 p.m.: ~ A water temperature of 128 degrees F was measured in room 42. ~ A water temperature of 138 degrees F was measured in room 56. ~ A water temperature of 132 degrees F was measured in room 57. ~ A water temperature of 146 degrees F was measured in room 43. ~ A water temperature of 139 degrees F was measured in room 47. ~ A water temperature of 129 degrees F was measured in room 44. ~ A water temperature of 149 degrees F was measured in room 55. ~ A water temperature of 146 degrees F was measured in room 46. ~ A water temperature of 149 degrees F was measured in room 53. ~ A water temperature of 143 degrees F was measured in room 52. 5. At 3:20 p.m., a hot water temperature of 121.0 degrees F was measured in room 14B on Hall One. 6. The following water temperatures were measured on Hall Three beginning at 3:20 p.m.: ~ A water temperature of 144.7 degrees F was measured in room 34A. ~ A water temperature of 143.9 degrees F was measured in room 36. ~ A water temperature of 146.2 degrees F was measured in room 33. ~ A water temperature of 149.5 degrees F was measured in room 32. ~ A water temperature of 145.9 degrees F was measured in room 37. ~ A water temperature of 147.0 degrees F was measured in room 38. ~ A water temperature of 145.2 degrees F was measured in room 40. ~ A water temperature of 143.0 degrees F was measured in room 41. 7. The following water temperatures were measured on Hall One beginning at 3:25 p.m.: ~ A water temperature of 122.6 degrees F was measured in room 2. ~ A water temperature of 122.9 degrees F was measured in room 4. ~ A water temperature of 123.4 degrees F was measured in room 5. ~ A water temperature of 124.2 degrees F was measured in room 6. 8. At 3:35 p.m., a water temperature of 121.0 degrees F was measured in room 10 on Hall One. 9. At 3:40 p.m., a water temperature of 126 degrees F was measured in room 8 on Hall One. At 2:55 p.m., the administrator was asked what should be the hottest temperature for water. She stated, "115 degrees." At 3:15 p.m., a family member of resident #1 was asked if the hot water in the resident's room was too hot. He stated, "Pretty hot, you could burn yourself." At 3:20 p.m., the DON was asked if there were residents who wandered in the facility. She reported there were two residents who wandered. Resident #23, who resided on Hall One and resident #24, who resided on Hall Three. At 3:35 p.m., CNA #6 was asked if there were residents who wandered in the facility. She reported that resident #25 wandered. At 3:36 p.m., the maintenance man was asked if had any problems with water temperatures that had been too hot. He stated, "No." He was asked how often he records water temperature. He stated, "Almost every day."