Every finding on record at Highland Park Health Care

Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure food was labeled appropriately and failed to ensure leftovers were discarded according to the facility's procedures. The failures had the potential to affect all of the residents who received nourishment from the kitchen.Findings included: A facility policy titled, Food Storage, revised 02/06/2024, indicated, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. The policy revealed, 2. Refrigerator, which included, All foods are covered, labeled and dated. A facility policy titled, Nutrition/Dietary Services, revised 01/16/2025, indicated, The staff will utilize the Nutrition Services Guidelines and standard practice guidelines. The policy revealed the Procedure included C. Food must be obtained from sources that comply with all laws relating to food and food labeling. If food, subject to spoilage, is removed from its original container, it must be kept sealed, and labeled. Food subject to spoilage must also be dated. A facility document titled, Nutrition Services Manual, approved by the facility 01/23/2025, included a Sample Inservice Topics section, which included a document titled, Storage Times for the Refrigerator and Freezer, which revealed, These short but safe time limits for home-refrigerated foods will keep them from spoiling or becoming dangerous to eat. The document indicated that Soups & Stews with Vegetable and meat added could be in the refrigerator 3 to 4 days. 1. During an initial kitchen observation on 06/15/2026 at 8:45 AM, the following items were observed undated in the reach-in refrigerator:- One bag of sliced lunch meat (unopened)- One bag of diced chicken (opened)- One bag of shredded mild cheddar cheese (opened)- One bag of sausage patties (unopened)- One jug of barbeque sauce (opened)- One jug of chocolate syrup (opened)- One jug of ketchup (opened) During the observation on 06/15/2026 at 8:45 AM in the same reach-in refrigerator, there was a metal container covered with aluminum foil labeled as Mexican Soup, dated 06/08/2026. During an interview on 06/18/2026 at 1:41 PM, Dietary Aide (DA) #8 stated that before food was put in the refrigerator, it had to be labeled with the date it was received, and if the item was opened, the received date and the date opened also had to be labeled on the item. During an interview with the Nutritional Services Manager (NSM) and the Registered Dietician (RD) on 06/17/2026 at 3:39 PM, the NSM stated that there were signs all over the kitchen about dating food items, but she had a lot of new staff members, and she had been trying to make sure the staff were following the policies. The RD stated she had also been helping to make sure the staff were trained to date items and stayed compliant. The NSM stated that the items observed in the reach-in refrigerator without dates should have been dated and the Mexican soup should have been thrown away. The RD stated that her expectation was that items be dated and labeled when they were put in the refrigerator. The NSM stated her expectation was that all food items were to be labeled and discarded appropriately per policy. During an interview on 06/18/2026 at 9:34 AM, the Director of Nursing (DON) stated her expectation was food items to be dated and removed at the correct times. During an interview on 06/18/2026 at 9:43 AM, the Administrator stated his expectation was the food items to be all dated when the item was received and when the item was opened.

Based on facility policy review, facility document review, record review, observation, and interview, the facility failed to ensure a resident's right of a dignified existence for 1 (Resident #7) of 1 resident reviewed for dignity issues. Specifically, the staff failed to ensure a urinary catheter drainage bag was covered in order to protect the resident's dignity. Findings included: A facility policy titled, Resident Rights, revised 08/14/2022, indicated, The staff will abide by and protect resident rights in accordance with state and federal guidelines. An undated facility document titled, [Name of the facility] Resident & Family Handbook indicated, 6. Every resident shall receive respect and privacy in the medical care program of the resident. Case discussion, consultation, examination and treatment shall remain confidential andshall be conducted discreetly. The document further indicated, 11. Every resident shall have the right to receive courteous and respectful care and treatment and a written statement of the services provided by the facility, including those required to be offered on an as-needed basis, and a statement of related charges, including any costs for services no covered under Medicare or Medicaid, or not covered by the facility's basic per diem rate. A Record of Admission indicated the facility admitted Resident #7 on 09/12/2023. The Record of admission revealed the resident had a medical history that included a diagnosis of neuromuscular dysfunction of bladder (when an injury or disease interrupts the electrical signals between the nervous system and bladder function). A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2026, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had an indwelling catheter. Resident #7's Plan of Care-Current included a problem statement initiated 06/18/2025, that indicated the resident had an indwelling catheter. The Plan of Care-Current revealed no interventions for covering or placement of the catheter bag. Resident #7's Active Orders Report, dated 06/17/2026, contained an order, dated 05/15/2026, for an indwelling catheter and specified a continuous gravity drainage. The order indicated that the privacy bag was to be checked every shift. During a concurrent observation and interview during the initial tour of the facility an on 06/15/2026 at 10:12 AM, Resident #7's indwelling catheter drainage bag was hanging on their bed and facing the door with yellow urine inside and was visible from the hallway. Resident #7 stated it bothered them that the urine bag was exposed. Resident #7 stated staff did put the drainage bag in a privacy bag sometimes and stated that the privacy bag was at their bedside hanging on the wheelchair. During an observation on 06/16/2026 at 10:15 AM, Resident #7's room door was open, and the indwelling catheter drainage bag was visible from the hallway hanging on the bedframe. During an interview on 06/17/2026 at 3:22 PM, Licensed Practical Nurse (LPN) #7 stated it was important to use a privacy bag for the indwelling urinary collection bag for dignity purposes. LPN #7 stated Resident #7 should have had their drainage bag in a privacy bag on 06/15/2025 and 06/16/2026 when it was hanging on the bed and visible from the hallway. During an interview on 06/17/2026 at 3:40 PM, the Director of Nursing (DON) stated it was important to cover a urinary collection bag for dignity purposes. The DON stated she expected Resident #7's urinary drainage bag to be placed in a privacy bag for dignity purposes. During an interview on 06/17/2026 at 4:08 PM, the Administrator stated he would defer to the DON in regard to Resident #7's urinary drainage bag being seen from the hallway.

Based on interview, record review, and facility policy review, the facility failed to communicate with one resident prior to changing the resident's code status (designation to indicate life-saving interventions) for 1 (Resident #3) of twenty-two residents reviewed for advance directives. Specifically, the Director of Nursing (DON) changed Resident #3's code status to DNR (Do Not Resuscitate) without consulting with the resident. Findings included: A facility policy titled, Advanced Directives, revised 02/12/2022, in the section, Advanced Care Planning indicated, 1) In order for the resident to exercise his or her right to make informed choices about care and treatment in preparation for a time when the resident may not be able to make decisions, designated personnel and/or physician will assist with defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, in a language that the resident can understand, as appropriate. A Record of Admission revealed the facility admitted Resident #3 on 02/29/2024. Resident #3's Record of admission indicated, Advanced Directives: Code Status - Full Code, DNR. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Plan of Care - Current included a Problems/Strengths statement, effective 10/13/2025, that indicated, Advance Directive - [Resident #3's name] has chosen to be a DNR. Interventions directed staff to:- Ensure Advanced Directives were discussed and appropriate paperwork was obtained (effective 05/01/2025);- Notify the physician and representative of any changes in the resident's condition (effective 05/01/2025);- Discuss and confirm the resident's advanced directive choices with the resident and/or responsible party or representative upon admission, quarterly, or as indicated (effective 05/01/2025);- Ensure advance [sic] directives are discussed and appropriate paperwork is provided to resident and placed in medical record (effective 05/01/2025);- Keep a copy of the MOST [Medical Orders for Scope of Treatment, a portable, physician-signed medical order] form in the medical record; and- Send a copy of the MOST form with the resident when sending out to the hospital or to other nursing facility. Resident #3's Plan of Care - Current indicated, Code Status - Full Code; DNR at the bottom of each page. Resident #3's Physician's Orders, dated from 08/01/2025 through 06/17/2026, included: Code Status - Full Code and May use AED [automated external defibrillator], ordered 12/17/2025. Resident #3's Physician's Orders revealed Advanced Directives: DNR; Code Status - Full Code at the bottom of each page. Resident #3's Physician's Telephone Order[s] included orders:- Discontinue Code Status - Full Code, and Stop date 12/17/2025 time 12:52 [PM]; and- Code Status - DNR and Start date: 06/17/[20]26 09:19 [AM].During an interview on 06/16/2026 at 2:03 PM, Resident #3 stated that at one time they did not want to be resuscitated, but now they thought they did want to be resuscitated. During an interview on 06/17/2026 at 10:43 AM, Resident #3 again stated they wanted to be resuscitated and verified they had not spoken with facility staff that morning regarding their wishes for resuscitation. During an interview on 06/17/2026 at 11:01 AM, the Director of Nursing (DON) stated that morning she entered a physician's order for Resident #3's DNR status into the electronic medical record (EMR). The DON stated the facility identified Resident #3's dual code status in the EMR, and she cleaned it up. The DON stated she did not speak with the resident prior to entering the physician's order for the DNR. During an interview on 06/18/2026 at 12:49 PM, the Administrator stated, There is zero gray area when it comes to code status. It has to be correct, and that is my expectation.

Based on facility policy review, record review, observation, and interview, the facility failed to develop/implement a comprehensive person-centered care plan addressing a respiratory condition or the use of a nebulizer breathing treatment for 1 (Resident #72) of 1 resident reviewed for respiratory care.Findings included: A facility policy titled, Care Plan-Process, last reviewed 03/27/2023, indicated, The interdisciplinary teal will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required timeframes. The policy revealed, 4. Interdisciplinary Team meets & reviews the care plan as follows, which included With any change of condition. The policy revealed, 6. The Plan of Care identifies the, which included Problem; Goals, measurable and realistic; Interventions, discipline specific services, and frequency; and Resolution/Goal analysis. A Record of Admission revealed the facility admitted Resident #72 on 03/11/2024. According to the Record of Admission, the resident had a medical history that included diagnoses of unspecified dementia and unspecified lack of coordination. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2026, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #72's Active Orders Report, dated 06/17/2026, contained an order, dated 05/12/2026, for sodium chloride 0.9% solution (a miscellaneous respiratory agent), one vial inhalation three times a day for congestion. During an observation in Resident #72's room on 06/17/2026 at 9:31 AM, Licensed Practical Nurse (LPN) #1 added a vial of sodium chloride to a medication canister for administration of a nebulizer treatment, then applied the mask to Resident #72. Resident #72's Plan of Care-Current, dated 06/17/2026, did not include a focus area or interventions related to congestion or the use of a nebulizer. During an interview on 06/18/2026 at 12:56 PM, LPN #1 stated that she expected a resident to have a care plan for the use of a nebulizer treatment. She reviewed Resident #72's electronic medical record and stated the resident did not have a care plan for the use of a nebulizer. During a telephone interview on 06/18/2026 at 2:26 PM, the MDS Coordinator stated she had never thought of adding a care plan for nebulizer treatments. She stated she added care plans for diagnoses related to the use of a nebulizer, and the care plan would indicate administering medications per physician's orders. During an interview on 06/18/2026 at 1:30 PM, the Director of Nursing (DON) stated she expected a resident to have a care plan for the use of a nebulizer. She stated she expected the care plan to indicate the type of medication administered with the nebulizer and the reason for taking the breathing treatment. She stated that Resident #72 had an order for sodium chloride for congestion. The DON stated Resident #72 did not have a care plan that addressed congestion or the use of the nebulizer. During an interview on 06/18/2026 at 1:52 PM, the Administrator stated he expected there to be a care plan for the use of a nebulizer for breathing treatments. He stated that anything related to the resident's care required a care plan. The Administrator stated that the MDS Coordinator was responsible for care plans.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident in a memory care unit was supervised during a nebulizer treatment (the delivery of medication directly to the lungs) for 1 (Resident #72) of 5 residents reviewed for accidents. Findings included:A facility policy titled, Medication Administration Nebulizers, dated 01/2023, indicated, Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer.A Record of Admission revealed the facility admitted Resident #72 on 03/11/2024. According to the Record of Admission, the resident had a medical history that included diagnoses of unspecified dementia and unspecified lack of coordination. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2026, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. Resident #72's Plan of Care-Current, did not include a focus area for nebulizer use or care, treatment related to a respiratory diagnosis, or the self-administration of medical treatments. Resident #72's Active Orders Report contained an order, dated 05/12/2026, for sodium chloride 0.9% solution one vial inhaled three times a day for congestion. The Active Orders Report also indicated an order to admit Resident #72 to memory care (long-term care for residents with cognitive impairment), dated 04/21/2026. The Active Orders Report did not include an order for Resident #72 to self-administer medical treatments. During an observation in the memory care unit on 06/17/2026 at 9:31 AM, Licensed Practical Nurse (LPN) #1 added a vial of sodium chloride to a medication canister for administration of a nebulizer treatment and then applied the mask to Resident #72 in the resident's room. During an observation on 06/17/2026 at 9:36 AM, LPN #1 walked out of and away from Resident #72's room during the resident's nebulizer breathing treatment. The observation revealed Resident #72 removed the mask, placed the mask on the bedside table with the medication still in the chamber, and turned off the machine.During an observation on 06/17/2026 at 9:40 AM, LPN #1 returned to Resident #72's room and reapplied the nebulizer mask to the resident. During an observation on 06/17/2026 at 9:42 AM, LPN #1 walked out of Resident #72's room during the breathing treatment. During an observation on 06/17/2026 at 9:43 AM, LPN #1 returned to Resident #72's room. During an observation on 06/17/2026 at 9:46 AM, the Assistant Director of Nursing (ADON) was at Resident #72's doorway. The observation revealed LPN #1 told the ADON that the minute LPN #1 walked out of Resident #72's room the resident took off the mask so now LPN #1 was staying with the resident. During an interview on 06/17/2026 at 9:46 AM, the ADON stated a nurse was required to stay with the resident during the breathing treatments, and LPN #1 should not have walked away in a memory care unit. The ADON stated the dangers of leaving Resident #72 unattended included the resident might not complete the treatment or another resident could grab the mask and apply it to themselves. During an interview on 06/17/2026 at 9:56 AM, LPN #1 stated Resident #72 could not self-administer medications. LPN #1 stated Resident #72 had no assessments that indicated the resident was capable of administering the breathing treatment when LPN #1 walked away. LPN #1 stated dangers of the nurse walking away during the breathing treatment included Resident #72 could have forgotten they were receiving the breathing treatment and tried to walk away while still attached to the tubing, the resident could experience side effects such as a high heart rate, or if the resident took off the mask then another resident could apply it to themselves. During an interview on 06/18/2026 at 1:29 PM, the Director of Nursing (DON) stated her expectation was that a nurse stayed with a resident during the administration of a breathing treatment. The DON stated the dangers of a nurse leaving a resident during a breathing treatment included the resident could take the treatment off, trip over the tubing, or all the medication could not be administered. During an interview on 06/18/2026 at 1:49 PM, the Administrator stated his expectation was that a nurse did not leave a resident during a breathing treatment. The Administrator stated the danger of a nurse walking away during the treatment was that the mask could fall off and the resident would not be getting their full treatment or another resident could put the mask on their face and use the treatment.

Based on facility policy review, manufacturer instructions review, record review, observation, and interview, the facility failed to ensure the medication administration error rate was less than 5 percent (%). The facility had 2 medication errors out of 31 opportunities, resulting in a medication error rate of 6.45%, which affected 1 (Residents #2) of 5 residents reviewed during the medication administration task.Findings included: A facility policy titled, Medication Administration General Guidelines, dated 01/2024, indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The policy further indicated, Medication Administration included 1. Medications are administered in accordance with written orders of the prescriber. A Record of Admission, indicated the facility admitted Resident #2 on 01/29/2025. According to the Record of Admission, the resident had a medical history that included a diagnosis of type 1 diabetes mellitus (the body's inability to use or make insulin properly) with hyperglycemia (high blood sugar). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received insulin injections each day during the assessment's lookback period. Resident #2's Plan of Care-Current included a problem statement initiated 09/09/2025, that indicated the resident had a diagnosis of diabetes. Interventions directed staff to administer diabetic medications as ordered (initiated 09/05/2025). Resident #2's Active Orders Report, dated 06/17/2026, contained an order, dated 03/21/2026, for Novolin R (insulin regular; a short acting insulin) FlexPen 100 units per 1 milliliter (100 U/ 1ml) solution, with instructions to inject 7 units subcutaneously every six hours. The Active Orders Report also included an order, dated 03/19/2026, for Novolog (insulin aspart; a fast acting insulin) FlexPen 100 U/1 ml solution per sliding scale before meals and bedtime. Novolin R FlexPen's Instructions for Use, revised 11/2022, indicated, Preparing your Novolin R included A. Pull off the pen cap; B. Remove the protective tab from a disposable needle. Screw the needle tightly onto your Novolin R FlexPen; C. Pull off the big outer needle cap; and D. Pull off the inner needle cap and dispose of it. The instructions revealed, Giving the airshot before each injection included Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin, the instructions specified to E. Turn the dose to select 2 units; F. Hold your Novolin R FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; and G. Keep the needle pointing upwards, press the push-button all the way in [reference to a diagram]. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. The instructions specified, Selecting your dose included Check and make sure that the dose selector is set at 0; and H. Turn the dose selector to the number of units you need to inject. The instructions revealed, Giving the injection included I. Insert the needle into your skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer; and J. Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin [reference to a diagram]. This will make sure that the full dose has been given. Novolog injection pen's Instructions for Use revised 02/2023, indicated, Preparing your Novolog FlexPen included A. Pull off the pen cap; B. Attaching the needle, which specified, Remove the protective tab from a disposable needle. Screw the needle tightly onto your FlexPen; C. Pull off the big outer needle cap; and D. Pull off the inner needle cap and throw it away. The instructions revealed, Giving the airshot before each injection included Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, the instructions specified to E. Turn the dose selector to select 2 units; F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; and G. Keep the needle pointing upwards, press the push-button all the way in [reference to a diagram]. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. The instructions revealed, Selecting your dose included Check and make sure that the dose selector is set at 0; and H. Turn the dose selector to the number of units you need to inject. The instructions revealed, Giving the injection included I. Insert the needle into your skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer; and J. Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin [reference to a diagram]. This will make sure that the full dose has been given. During a medication administration observation on 06/17/2026 at 10:33 AM, Licensed Practical Nurse (LPN) #4 opened a Novolog FlexPen for Resident #2, then without first applying a needle, turned the dial to an unknown amount, pushed the button, then applied the needle and turned the dial to 8. LPN #4 then opened Novolin R FlexPen for Resident #2, then without first applying a needle, turned the dial, to an unknown amount, pushed the button, then applied the needle and turned the dial to 7. LPN #4 was stopped by the surveyor prior to entering the resident's room and was questioned if the needle had been primed. LPN #4 stated the needle had been primed, and that was how she was trained. She stated that by turning the dial up to the ordered dose, the insulin was set and ready to go. LPN #4 administered 8 units with the Novolog FlexPen to the right arm and 7 units with the Novolin R FlexPen to the abdomen, and both injections were removed immediately with no wait time following the injection rather than waiting the required six seconds before removing the needle after administration. During an interview on 06/17/2026 at 3:22 PM, LPN #7 stated that it was important to prime the needle prior to setting the dose for administration, so the dose of insulin was accurate. During an interview on 06/17/2026 at 3:34 PM, the Director of Nursing (DON) stated she expected the medication error rate to be 0%. The DON stated she expected the dial on an insulin injection pen to be turned to two units when staff placed the needle on the pen in order to prime the needle before turning the dial to the physician-ordered dose. She stated that when administering insulin, she expected the nurse to wait three to five seconds before removing the needle. The DON stated the nurse should have primed the needle and waited before removing the needle. The DON stated that the importance of waiting to remove the needle was to ensure all the insulin was administered. The DON stated the importance of priming the needle was to ensure the ordered dose of insulin was administered. During an interview on 06/17/2026 at 4:11 PM, the Administrator stated he expected the medication error rate to be less than 5%. The Administrator stated he expected the insulin needle to be primed and to wait to ensure the insulin was fully administered.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an accurate code status was reflected throughout the medical record for 1 (Resident #3) of 22 residents reviewed for advance directives.Findings included: A facility policy titled, Advanced Directives, revised 02/12/2022, indicated, 5) Resident wishes will be communicated to the staff via the care plan.6) The resident's physician will be notified of the resident's advance directive decisions.7) During the quarterly Resident Assessment Instrument (RAI) process and with any significant changes of condition, facility staff will:a) Identify, clarify and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directiveb) Define and clarify medical issue, review the resident's condition and existing choices and present information regarding relevant health care issues to the resident or resident representative as appropriate to determine continuation or modification of choices of care, ande) Changes to the resident choices for advanced directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable, and all items will be communicated to staff providing resident care. A Record of Admission revealed the facility admitted Resident #3 on 02/29/2024. Resident #3's Record of admission indicated, Advanced Directives: Code Status - Full Code, DNR [Do Not Resuscitate]. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Plan of Care - Current included a problems/strengths statement, effective 10/13/2025, that indicated, Advance Directive - [Resident #3's name] has chosen to be a DNR. Interventions directed staff to:- Ensure Advanced Directives were discussed and appropriate paperwork was obtained (effective 05/01/2025);- Notify the physician and representative of any changes in the resident's condition (effective 05/01/2025);- Discuss and confirm the resident's advanced directive choices with the resident and/or responsible party or representative upon admission, quarterly, or as indicated (effective 05/01/2025);- Ensure advance [sic] directives are discussed and appropriate paperwork is provided to resident and placed in medical record (effective 05/01/2025);- Keep a copy of the MOST [Medical Orders for Scope of Treatment, a portable, physician-signed medical order] form in the medical record; and- Send a copy of the MOST form with the resident when sending out to the hospital or to other nursing facility. Resident #3's Plan of Care - Current indicated, Code Status - Full Code; DNR at the bottom of each page. Resident #3's Physician's Orders, dated from 08/01/2025 through 06/17/2026, included: D/C [discontinue] Code Status - Full Code, ordered 03/05/2025 and discontinued 12/17/2025 and Code Status - Full Code and May use AED [automated external defibrillator], ordered 12/17/2025. Resident #3's Physician's Orders revealed Advanced Directives: DNR; Code Status - Full Code at the bottom of each page. Resident #3's Physician's Telephone Order[s] included orders:- Code Status - Full Code, started 03/05/2025 at 5:17 PM and discontinued 12/17/2025 at 12:52 PM;- Discontinue Code Status - Full Code, and Stop date 12/17/2025 time 12:52 [PM]; and- Code Status - DNR and Start date: 06/17/[20]26 09:19 [AM] and D/C [discontinue] date: 06/17/2026 12:00 [PM]. Resident #3's Care Plan Conference/Discharge Planning minutes, dated 04/13/2026, indicated the resident was present for the meeting and that code status was discussed, however, the code status listed was Full Code; DNR. Resident #3's Interdisciplinary Progress Notes, dated 08/26/2025, 09/29/2025, 02/26/2026, 03/30/2026, 04/30/2026, and 05/28/2026 indicated the resident remained, Full Code. An observation of the inside of Resident #3's closet door, on 06/17/2026 at 9:52 AM, revealed a sheet of red paper inside a sheet protector that read, Medical Alert, DNR. During an interview on 06/17/2026 at 11:01 AM, the Director of Nursing (DON) stated the inconsistent code status information could result in the resident not receiving resuscitation if they wanted it or receiving resuscitation when they did not want it. During an interview on 06/17/2026 at 11:30 AM, the Minimum Data Set (MDS) Coordinator stated she was responsible to update the care plan and MDS reports and she did not review physician's orders when completing that process. The MDS Coordinator indicated that an adverse outcome related to getting a code status incorrect would be death or the other way around. During an interview on 6/17/2026 at 2:35 PM, the Doctor of Osteopathic Medicine (DO) stated if the care plan was confusing for staff a resident who needed to be coded might not be coded. During an interview on 06/18/2026 at 12:49 PM, the Administrator stated, There is zero gray area when it comes to code status. It has to be correct, and that is my expectation.

Based on facility policy review, facility document review, a review of a sit-to-stand mechanical lift manufacturer's manual, observation, and interview, the facility failed to ensure 1 of 3 mechanical lifts at the facility were maintained in safe working condition and stored according to manufacturer instructions.Findings included: An undated policy titled, Maintenance Service, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy revealed, 1. The maintenance department is responsible for maintaining buildings, grounds, and equipment in a safe and operable manner at all times. An undated facility document titled, Emergency Procedures Lock-Out/Tag-Out revealed, Goal is to 'lock-out' machinery and equipment from its power source prior to maintenance to avoid accidents that occur from start-up or release of stored energy. The document revealed, Lock-out devices and tags should only be removed by the person who applied them or the person servicing them. The Owner's Operator and Maintenance Manual for the facility's sit-to-stand mechanical lift, dated 02/05/2018, revealed, Do not store the lift in a damp area or in a camp condition. Periodically inspect all components for signs of correction and replace those that are corroded or damaged. The manual revealed, If you question the safety of any part of the life, contact your dealer immediately and advise them of the problem. The manual revealed, Regular cleaning will reveal loose or worn parts, enhance smooth operation and extend the life expectancy of the lift. The manual included Section 7-Troubleshooting which included Symptoms, Faults, and Solution. The manual revealed an example of a symptom of Stand up life feels loose, which indicated Faults included Mast/base joint loose and Tie rods are loose. The manual revealed a Solution included to Tighten the bolt, washer and locknut that secure the mast to the base. During an interview on 06/16/2026 at 9:12 AM, Certified Nurse Aide (CNA) #3 stated mechanical lifts were stored in shower rooms. During an observation on 06/16/2026 at 9:20 AM, the facility's sit-to-stand mechanical lift was observed in a shower room. The lift exhibited peeling paint, a missing screw, and instability of the handles. Reddish-brown residue was present on portions of the equipment, and debris and hair accumulation were present in the wheels. During a concurrent observation and interview on 06/16/2026 at 11:58 AM, the Assistant Director of Nursing (ADON) evaluated the sit-to-stand mechanical lift and stated the equipment was missing a bolt and should not have been in service. The ADON stated the sit-to-stand lift was not being used for any residents at the time. She stated that she would put a tag on it for maintenance staff to follow up on. During a concurrent observation and interview on n 06/17/2026 at 12:05 PM, the Regional Director of Plant Operations (RDPO) stated shower rooms were considered damp environments due to steam, condensation, and humidity, and equipment not designed for such conditions should not be stored in those locations due to risk of deterioration and reduced function. The RDPO stated maintenance activities were tracked through an electronic system, and inspections were expected to be completed routinely. The RDPO stated equipment identified as not functioning properly should be removed from service. The RDPO stated that lock-out/tag-out procedures for mechanical lifts included removal of critical components, such as the battery and controller, and application of signage indicating the equipment was out of service. The RDPO stated routine cleaning of equipment was the responsibility of housekeeping staff. During the interview, the RDPO evaluated the sit-to-stand mechanical lift and stated the equipment exhibited instability of the handles and surface deterioration, and that debris and hair accumulation were present in the wheels. He revealed that the lift was also missing a pin in the mast, which supported the actuator and battery. The observation revealed that a Do Not Use had been placed on the lift. During a concurrent observation and interview on 06/17/2026 at 12:25 PM, the Director of Nursing (DON) stated equipment should not be stored in damp environments, such as shower rooms, when not in use. The DON stated equipment identified as broken must be removed from service, labeled with an Out of Order sign, documented in the maintenance log, reported to maintenance and leadership staff, and then stored safely until repaired. The DON evaluated the sit-to-stand mechanical lift and stated that rust, dirt, and hair were present on the sit-to-stand mechanical lift and that the condition was unacceptable. During an interview on 06/17/2026 at 2:25 PM, the Administrator stated staff were expected to report malfunctioning equipment immediately, enter concerns into a maintenance log, and notify a supervisor. The Administrator stated equipment must be stored according to facility policy and manufacturer guidance and should not be placed in damp environments, such as shower rooms. The Administrator stated storage limitations existed, and that efforts were in progress to increase storage capacity.

Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure the daily staff posting information was accurately completed for staff directly responsible for resident care for 17 (06/01/2026 through 06/17/2026) of 17 days reviewed. This had the potential to affect all 74 residents who resided in the facility.Findings included: A facility policy titled, Daily Nurse Staffing Information, revised 01/12/2020, revealed, The CMS [Centers for Medicare and Medicaid Services] required staffing information sheet will be posted in a public area of the nursing facility, as required. The policy revealed, 1. Daily including weekends and holidays, the number of FTEs [full time equivalents] for care staff will be calculated and documented on the facility's Daily Nurse Staffing form. The policy indicated, 2. The facility shall post the following information on a daily basis, which included A. Facility Name; B. Current Date; C. Resident census; and D. The actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift; which included i. Registered Nurses; ii. Licensed practical nurse or licensed vocational nurses (as defined under State Law; and iii. Certified nurse aides (including Certified Medication Aides [CMAs] if the CMAs are Certified Nursing Aides). The policy specified, E. The shift time are to be added and the calculated FTEs. FTEs are based on an 8-hour shift. The policy indicated, 4. The staffing sheet needs to be corrected as needed for staffing changes occurring throughout the 24-hour period. During an observation at the nurses' station on 06/15/2026 at 10:00 AM, the Daily Staffing Sheet-Clinical Department document that was posted revealed the census was left blank. During an observation at the nurses' station on 06/16/2026 at 10:30 AM, the Daily Staffing Sheet-Clinical Department document that was posted revealed the census was left blank. During an observation at the nurses' station on 06/17/2026 at 7:53 AM and 8:10 AM, the Daily Staffing Sheet-Clinical Department document that was posted revealed the census was left blank. The facility's Daily Staffing Sheet-Clinical Department documents, for the timeframe from 06/01/2026 through 06/17/2026, revealed the following:- 06/01/2026- The document only contained scheduled nursing hours, but not actual hours worked. The census and the total hours for each shift were left blank.- 06/02/2026- The document only contained scheduled nursing hours, but not actual hours worked for the night shift (11:00 PM to 7:00 AM). The total hours for each shift were left blank.- 06/03/2026- The document only contained scheduled nursing hours, but not actual hours worked for the evening shift (3:00 PM to 11:00 PM) and the night shift. The total hours for each shift were left blank.- 06/04/2026 through 06/14/2026- The documents only contained scheduled nursing hours, but not actual hours worked. The census and the total hours for each shift were left blank. During an interview on 06/17/2026 at 9:36 AM, Licensed Practical Nurse (LPN) #7 stated that the process for the daily staff posting was for the Staffing Coordinator to put out the schedule and nursing staff to assign the halls. She stated that the Staffing Coordinator left the sheet for the night shift nurse, and the nurse posted the sheet. She stated that the sheet was completed for the residents to know where the staff were working for the day. LPN #5 stated that the census should be filled, and actual hours worked should be completed. She stated that the daily staffing sheet was for anyone coming into the building to see how many staff were there, where the staff was working, and how many nursing hours were provided for each resident. During an interview on 06/17/2026 at 9:42 AM, the Staffing Coordinator stated that she filled out the staffing sheet, but she did not assign the staff. She stated that she did not fill out the actual hours because she was not sure if a staff member called in. She stated that the census should be filled out by the Administrator. She reviewed the daily posted staffing sheet for 06/17/2026 and stated that the census should be completed. The Staffing Coordinator stated that the form was completed for staff to know where they were assigned. She stated she received very little training on the daily staffing form due to being pulled to work the floor or the medication cart. During an interview on 06/17/2026 at 10:04 AM, The Director of Nursing (DON) stated the daily staffing sheets listed every person who was working and the hours they were to work. She stated the sheet was completed so that staff knew their assignment, and residents or their families knew who would be providing their care, and the facility could ensure sufficient staffing hours to cover the resident census. She stated her expectation for the daily staffing sheets was for the Staffing Coordinator or nursing staff to fill out the hours accurately and to make changes to them in the event of staff call-ins. During an interview on 06/17/2026 at 12:30 PM, the Administrator stated he had read the facility's policy regarding the daily staff posting, and his expectations were for the census and actual hours to be totaled each shift.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 03/20/25 related to the facility's failure to ensure Resident #1 was not physically or psychosocially abused. On 03/26/25, the Oklahoma State Department of Health was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents were not physically or psychosocially abused. The past noncompliance IJ was removed effective 03/20/25 after the facility performed one on one inservices for all staff regarding abuse on 03/20/25. On 03/20/25 employee #1 was suspended then terminated on 03/25/25. On 03/20/25 at 3:26 p.m., a quality assurance meeting was held via conference call. Based on record review and interview, the facility failed to ensure a resident was not physically or psychosocially abused for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 81 residents resided in the facility. Findings: A policy titled Abuse, Neglect and Exploitation and Misappropriations of Resident Property. dated 06/23/17, read in part, Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff. Resident #1 had diagnosis which included aphasia and they were nonverbal. A quarterly resident assessment, dated 03/04/25, showed the resident had a memory problem and was rarely/never understood. On 03/26/25 at 1:15 p.m., the housekeeping supervisor stated on 03/20/25 between 6:30 a.m. and 7:00 a.m., during the ambassador rounds, they asked Resident #1 if they were ok because they looked sad. The housekeeping supervisor stated the resident shook their head no. The housekeeping supervisor stated Resident #1's roommate spoke up and said a nurse aide slapped Resident #1 during activity of daily living care on the night shift. The housekeeping supervisor stated they asked Resident #1 if a nurse aide slapped them and the resident nodded yes pointing to the left side of their face. The housekeeping supervisor stated they then reported the incident to the DON. On 03/26/25 at 1:35 p.m., the DON stated they received a report of abuse from the housekeeping supervisor on 03/20/25 at 7:30 a.m. regarding Resident #1. The DON stated after interviewing Resident #1 and their roommate, a head to toe assessment was conducted which revealed no injuries. The DON stated since the incident happened the resident had been afraid to let the night shift check on them or change their brief. The DON stated resident was now receiving psychological counseling. On 03/26/25 at 2:41 p.m., Resident #1's roommate stated on 03/20/25 at 6:30 a.m., CNA #1 came into the room to answer the call light. Resident #1's roommate stated they went to Resident #1 first and stated, You are wet, I'm going to change you. Resident #1's roommate stated they heard Resident #1 become upset and started yelling way, way, way. Resident #1's roommate stated the yelling got louder and louder and then they heard a loud slap. Resident #1's roommate stated then CNA #1 left the room and they asked Resident #1 if CNA #1 had slapped them. Resident #1's roommate stated Resident #1 nodded their head and was crying. Resident #1's roommate stated after the incident happened Resident #1 gets scared and yells when staff try to change them on night shift.

Based on observation, record review, and interview, the facility failed to: a. store clean dishware inverted and on sanitary surfaces, b. maintain a clean and sanitary kitchen, and c. label, date, and cover food items in the refrigerators during one of two kitchen observations. The DON identified 77 residents received nutrition from the kitchen. Findings: The facility's Employee Infection Control policy, dated 08/01/18, read in part, All local, state, and federal standards and regulations are followed to ensure a safe and sanitary Nutrition Services Department. The policy also read, Store clean dishes inverted or in enclosed or covered storage units. The facility's Food Storage policy, dated 08/01/18, read in part, All foods are covered, labeled and dated. Defrosting meat, eggs, and milk shakes are labeled with date pulled for thawing. The facility's Use of Left Overs policy, dated 08/01/18, read in part, Leftovers should be covered, labeled, dated and stored appropriately. On 08/20/24 at 7:00 a.m., the Initial tour of the kitchen was conducted. The following observations were made in the walk-in refrigerator: a. cooked pork loin in a metal pan uncovered with foil torn and no date label indicating when it was pulled or cooked, b. raw uncooked pork loin not in a pan was on the bottom shelf of the walk-in refrigerator thawing out setting on top of a box of breakfast sausage with no date idicating when it was pulled top thaw out, and c. raw chicken in a plastic pan thawing out in the walk-in on the bottom shelf with no date indicating when it was pulled to thaw out. On 8/20/24 @ 7:15 a.m., [NAME] #1 number one was asked about the items above items. They stated that the cooked pork loin in the walk-in needed to be thrown away and she was not sure when it was cooked. [NAME] #1 was asked what the policy was regarding these items. They stated the raw meat should of been in a pan and dated the date, it was pulled and the chicken should have had a pulled date labeled on it and they were unsure when it was pulled to thaw. On 08/20/24 at 7:20 a.m., the following observations were made: a. next to the griddle on a wood dresser in a brown plastic bin and unknown substance was spilled with spices stored in the bin that had sticky and unsanitary lids, b. the wall behind the food preparation area next to the grill had three dead flies, food debris, a half a cup of unidentified, white powder, not covered, and plastic utensils in a cup with food debris in the bottom of the cup, c. a serving wheeled cart for condiments had food debris on the surface and the bottom shelf had plasticware and crackers with visible food debris and a wet and sticky unknown substance where the crackers and plasticware were stored, d. clean pans under the food prep table were stored and not inverted, e. dishware was stored on a wire rack upright and not inverted or covered, f. a 10 gallon plastic bucket with food debris inside, plastic bags, and aprons were stored on the top shelf above clean dishes, g. the trays used to stack clean glasses had food debris and an unknown sticky substance with clean glasses stacked on them, h. the cereal station had clean bowls stored underneath that were not inverted and had visible food debris in the clean bowls, i. the top of the cereal station had a sticky and white powdery residue on the lids, and j. the floors under the hand sink and three compartment sink had food debris, a black unknown substance, other unknown contaminants, and soiled dirty towels on the floor. On 8/20/24 at 7:36 a.m., dietary aid #2 was showed the above mention items and ask what the policy was. They stated it looks like they didn ' t clean up after themselves. On 8/20/24 at 7:40 a.m., Cook#1 was shown the above items and asked what was their policy. They stated, you should clean as you go. They don't do their job around here. On 8/20/24 at 8:21 a.m., the CDM was shown above items and asked what the policy was for maintaining a clean kitchen and labeling in the refrigerators. They stated the kitchen staff were supposed to follow a cleaning list and were not following the cleaning schedule. The CDM was asked what they thought about the kitchen. They stated the kitchen was not clean and sanitary. On 8/20/24 at 8:31 a.m., the Administrator walked through the kitchen with the surveyor and was shown the above items. The Administrator was asked what they thought about the kitchen. They stated they were very disappointed. The administrator was asked if they thought the kitchen was clean and sanitary. The Administrator stated they did not think the kitchen was clean and sanitary based upon the observations, all items should of been labeled in the refrigerator the date they were opened, and the kitchen should be cleaned after each meal.

Based on record review and interview the facility failed to notify the physician for out of parameters blood sugars for one (#41) of two sampled residents reviewed for insulin. The DON identified 31 residents who received insulin. Findings: The Bedside Blood Glucose Monitoring policy, revised on 02/12/20, read in part, If the glucose level is out of the established ranges ordered by the physician .The physician is contacted. Res #41 had diagnoses which included diabetes. The June physician's orders documented the physician was to be called for a blood sugar greater than 350. On the following dates in June, Res #41's blood sugar was above 350 with no documentation the physician was notified. 06/02/24 at 11:00 a.m., the blood sugar was 420. 06/10/24 at 11:00 a.m., the blood sugar was 368. 06/20/24 at 4:00 p.m., the blood sugar was 379. 06/24/24 at 11:00 a.m., the blood sugar was 484. 06/26/24 at 11:00 a.m. the blood sugar was 361. 06/28/24 at 4:00 p.m., the blood sugar was 544. The July physician's orders documented the physician was to be called for a blood sugar greater than 350 between 07/01/24 through 07/22/24. Between 07/22/24 and 07/31/24, the physician was to be called for a blood sugar greater than 501. On the following dates in July, Res #41's blood sugar was above 350 or 501 with no documentation the physician was notified. 07/02/24 at 4:00 p.m., the blood sugar was 415. 07/03/24 at 11:00 a.m., the blood sugar was 380. On 07/08/24 11:00 a.m., the blood sugar was 507. On 07/11/24 at 8:00 p.m., the blood sugar was 368. On 07/12/24 at 8:00 p.m., the blood sugar was 362. On 07/17/24 at 8:00 p.m., the blood sugar was 387. On 07/19/24 at 4:00 p.m., the blood sugar was 381. On 07/19/24 at 8:00 p.m., the blood sugar was 363. The August physician's orders documented the physician was to be called for a blood sugar greater than 501. On the following dates in August, Res #41's blood sugar was above 501 with no documentation the physician was notified. 08/16/24 at 8:00 p.m., the blood sugar was 522. 08/18/24 at 4:00 p.m., the blood sugar was 518. 08/18/24 at 8:00 p.m., the blood sugar was 590. There was no documentaion the facility called the physician when the blood sugars were out of parameter in June, July August 2024. On 08/23/24 at 12:50 p.m., the DON reported when a blood sugar is out of parameter, the nurses should follow the physician's orders and call the physician for guidance.

Based on record review and interview, the facility failed to ensure a psychotropic medication was used for a specific diagnosis for one (#71) of five residents who were reviewed for unnecessary medication. The DON identified 15 residents who received psychotropic medication. Findings: Resident #71 had diagnoses which included dementia without psychotic disturbance, cerebrovascular disease, and major depressive disorder. A physician order, dated 02/08/24, documented the resident received olanzapine 10 mg tablet one time a day at bedtime for major depressive disorder without psychotic features. A quarterly assessment, dated 05/22/24, documented the resident was receiving an antipsychotic medication. The assessment documented no potential indicators of psychosis or behaviors. On 08/20/24 at 9:33 a.m., the resident was in bed eating breakfast. The resident was calm and pleasant. The care plan, dated 03/01/24, documented psychotropic drug use. The care plan documented the staff was to monitor for resident behaviors and side effects of the medication every shift and document. On 08/22/24 at 11:24 a.m., the DON reviewed the resident's clinical record and stated the resident was receiving an antipsychotic medication (olanzapine) for the diagnosis of major depression without psychotic features. The DON reviewed the resident's diagnoses list and stated there was no diagnosis for the use of an antipsychotic medication.

Based on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued ABN and NOMNC notices for two (#38 and #45) of three residents reviewed for beneficiary notices. The facility identified 22 residents who were discharged from part A skilled services with benefit days remaining in the previous six months. Findings: 1. Res #38 was discharged from skilled services on 06/20/23 and remained in the facility. 2. Res #45 was admitted to part A skilled services on 04/06/23, discharged from skilled services on 04/27/23, and remained in the facility. On 07/25/23, the DON was asked to provide ABN and NOMNC notices for Res #38 and Res #45. On 07/25/23 at 4:40 p.m., the administrator stated the facility was unable to provide documentation the ABN or NOMNC notices were provided to Res #38 and Res #45.

Based on observation, record review, and interview, the facility failed to notify the physician related to resident oxygen needs and titrating oxygen without a physician order for one (#125) and failed to provide oxygen as ordered by the physician order for one (#22) of three sampled residents reviewed for oxygen therapy. The DON identified 13 residents with orders for oxygen. Findings: 1. Res #125 was admitted on [DATE] with diagnoses which included post COVID-19 condition, COPD, congested heart failure, atrial fibrillation, chronic hypoxic and hypercapnic respiratory failure, critical illness myopathy, chronic interstitial lung disease, O2 dependent, and history of lung cancer. A physician order, dated 07/07/23, documented to administer O2 6 lpm per nasal cannula for chronic diastolic heart failure. A nurse note by RN #1, dated 07/07/23, documented upon taking report for Res #125, was advised that the resident desaturated quickly with any transfers or movement. The note documented that during a transfer of the resident for a shower there was a brief moment in which the resident desaturated to 70%. The staff were able to keep a pulse oximetry on the resident the entire time and a mobile oxygen tank. They were able to keep his oxygen at 93%. The note documented the resident was able to eat, received respiratory treatments, and remained stable. When the night nurse arrived, they were advised of the resident's condition. The note documented they were able to get a non-rebreather mask and continued the oxygen treatment, as well as the 5-liter concentrator. The note documented the local hospital had offered anything they needed oxygen wise. No documentation related to notification of the physician of the resident's status and not having a oxygen concentrator that would go higher than 5 lpm. The care plan, last updated on 07/08/23, documented the resident had hi-flow oxygen and nebulizer use. The care plan documented the resident's goal was to demonstrate an effective respiratory rate, depth, and pattern over the next 90 days, establish a normal/effective respiratory pattern, and ABGs within the resident's normal range. The care plan documented the following interventions: a. Adjust the head of the bed and provide body positioning to assist with ease of respirations. b. Administer the medications, respiratory treatments, and oxygen as ordered. c. Administer the nebulizer treatments as ordered. d. Monitor the lung sounds, pallor, cough, and character of sputum. e. Monitor the respiratory rate, depth, and effort. f. Notify the physician and family of any change of condition. A nurse note by RN #1, dated 07/08/23 on the day shift, documented the night nurse advised that the resident had desaturated, so they had used a non-rebreather mask and O2 tanks in order to stabilize him. During the shift the resident had eaten food from local restaurant, had a breathing treatment, and had desaturated again. The note documented at that time staff monitored the saturation levels and administered oxygen via the non-rebreather mask to get the resident back to 90%. The note documented they had tried the CPAP to see if it could be used to force oxygen, but when they put it on the resident, the SpO2 dipped down to 60% once again. The note documented the ADON asked the resident if he wanted to go to the hospital and he refused. The resident said he wanted to remain at the nursing home. At that time the nurse put the rebreather back on him and increased the rate to 10 lpm and got the resident back up to 88%. The resident was sat up to a 45-degree angle in the bed. The note documented that later the resident's O2 was increased to 10 lpm after the SpO2 dropped to 70%. Once the nurse got them back up to 96% and then the O2 was tapered down to 8 lpm and the non-rebreather mask was left on. The note documented the resident was very coherent. Before each tapering down it was discussed and verified with the resident that they felt ready and comfortable to do so. The note documented the POA was present and stated the resident felt safe at the facility and asked if the resident could be taken home and would be able to pass peacefully at home. The note documented the nurse advised the family that the resident was on IV antibiotics and physical therapy. On this day there was no documentation the physician was notified about the resident's condition and no new order to titrate the oxygen. A nurse note by RN #1, dated 07/09/23 on the day shift, documented the resident was stable. The note documented resident ate some donuts and received a breathing treatment. The note documented that during the treatments the nurse would turn up the O2 to 10-15 liters, so that the resident would not desaturate. The note documented it was the resident's best day so far because they never dipped below 88 percent and was able to stand him up and transfer on a bedside commode to pass a bowel movement, got cleaned up, changed, and put fresh sheets on while remaining at a saturation of at least 91 percent on 15 liters. The resident also had an elevated temperature of 100.4 F and two 500 mg Tylenol were administered to bring down the fever to 99.2 degrees F but spiked again later in the evening before the resident was able to take any additional doses of Tylenol. The note documented they also turned the air on in the room to assist with cooling the resident down. The resident received another breathing treatment and wasn't able to finish his dinner because he would desaturate. The note documented the resident, who was a physician, was coherent and assisted in planning his care. The note documented a call to the pain specialist physician and received an order for a low dose morphine to assist with oxygenation and pain. The note documented a conversation the resident had with the nurse. A nurse note by LPN #1, dated 07/09/23 on the evening shift, documented the resident was sent to the ER r/t decreased oxygen saturation. The POA was present when the resident was sent out. The note documented they did not have a concentrator to deliver oxygen at 10 LPM. The concentrator had not been delivered yet. The note stated they were running low on oxygen tanks so the resident was sent out. The concentrator was delivered approximately two hours later along with some more oxygen tanks. The note documented the hospital called and asked if they received the concentrator and were told they had received the 10 lpm concentrator. The hospital replied that they needed to come and pick the resident up. The note stated staff went to get the resident. The hospital physician note, dated 07/09/23 at 9:34 p.m., read in part, .the patient is on 8 to 10 L nasal cannula at all times due to chronic respiratory failure associated with hospitalization months ago where he was in the ICU for COVID. The patient states that he has no new complaints and has been doing well but states that they told him they needed to send him here because they were concerned they would run out of oxygen. The hospital record, dated 07/09/23, read in part, .Temp 98.6, Heart Rate 83, Resp 18, BP 128/69, SpO2 .the patient is alert, has no immediate need for airway protection. Chronically ill appearing .Respiratory: There are no retractions, no wheezing. No hypoxia on 8 L nasal cannula. Cardiovascular: Regular rate and rhythm .no orders to display . The hospital record, dated 07/09/23, read in part, .The patient's airway, breathing, and circulation were assessed. They were placed on monitors. Vital signs were assessed and stable .He does have chronic respiratory failure and is on 8 to 10 L nasal cannula at all times. He states that he often desaturates with minimal activity. This is a chronic and ongoing issue .The patient was discharged back to the nursing home in stable condition . A 5-day PPS/discharge assessment, dated 07/10/23, documented the resident was understood, had clear speech, and had clear comprehension. The assessment documented the resident's memory was intact, required extensive assistance with ADLs, and was always continent of bowel and bladder. The assessment documented the resident had shortness of breath with exertion and sitting at rest; was 69 in and 113 lbs; received antidepressant, anticoagulant, and antibiotic medications; and received therapy services. The assessment documented the resident received chemotherapy while not a resident, received O2 therapy, and IV medications. RN #1 was unavailable for interview. On 07/18/23 at 3:18 p.m., LPN#1, stated they worked the Sunday 7:00 p.m. to Monday 7:00 a.m. shift, starting on 07/09/23. LPN #1 stated when they sent the resident out they had six O2 tanks left and a 5 L oxygen concentrator. They stated RN #1 had ordered a 10 L concentrator earlier that day, but it had not been delivered yet. They said the resident was sent out around 7:30 p.m. on 07/09/23. LPN #1 stated the resident was stable but concerned about having enough oxygen because they were going through tanks faster than normal. They stated the 10 L concentrator was delivered soon after the resident was sent out. The LPN stated the resident's O2 would drop with any movement, eating, and treatments. They stated they would have to give the resident more oxygen when that happened. They were asked if they had notified the physician related to the resident's condition and having to titrate the amount of oxygen since the order was for 6 lpm. The LPN stated they had not notified the physician. On 07/18/23 at 5:50 p.m., the DON was asked if the nurses should have notified the physician of the resident's condition and received an order to titrate the oxygen administered. The DON stated they could not find any documentation the physician was called. The DON stated the facility needed an order to titrate the oxygen. The DON stated she had called the physician on 07/10/23 at 12:47 a.m. The DON stated she told the physician the resident's SpO2 was at 90-91 on 10 lpm. The DON stated the physician said if the resident started to exhibit signs of distress with desaturation to go ahead and send him to the hospital. The DON stated when she spoke with the resident, they said they did not want to go to the hospital. The DON stated the resident said if he went to the hospital they would place him on a ventilator and they knew they would not come off of it this time. The DON stated the resident did not have an advanced directive except for a Do Not Resusitate document. 43023 2. Res #22 admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia. A physician order, dated 02/12/23, documented oxygen at 2 lpm via NC every shift to maintain O2 saturation above 92%. On 07/20/23 at 8:48 a.m., the resident was observed resting in bed with eyes closed, oxygen setting at 1 lpm via NC. On 07/24/23 at 2:32 p.m., the resident was observed resting in bed with eyes closed. The resident's oxygen setting was observed at 1 lpm. On 07/25/23 at 11:24 a.m., the resident was observed resting in bed with eyes closed. The resident's oxygen setting was observed at 1 lpm. On 07/25/23 at 11:31 a.m., LPN #1 was notified of the observations made throughout the survey. LPN #2 was asked if the resident's oxygen was at the correct setting. LPN #1 reported the oxygen should have been at 2 lpm.

Based on record review and interview, the facility failed to ensure the physician responded to pharmacist MRRs in a timely manner for four (#11, 22, 33, and #66) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/17/23, documented 73 residents resided in the facility. Findings: A Medication Regimen Review and Reporting policy, dated January 2023, read in part .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days . 1. Res #66 had diagnoses which included dementia, Alzheimer's disease, and anxiety. A physician order, dated 02/06/23, documented to administer buspirone 5 mg three times daily for anxiety. A MRR, dated 05/22/23, documented a request for a GDR on Res #66's buspirone. There was no documented response to the 05/22/23 GDR request. A MRR, dated 06/21/23, documented a request for a GDR on Res #66's buspirone. The MRR documented the recommendation status as Pending from the previous month's request on 05/22/23. There was no documented response to the 06/21/23 GDR request. On 07/25/23 at 10:06 a.m., the ADON stated the May 2023 and June 2023 GDR requests had not been addressed by the physician within 30 days per facility policy. 2. Res #33 had diagnoses which included GERD, anxiety, and other specified depressive episodes. A physician order, dated 01/08/23, documented to administer pantoprazole 40 mg daily for GERD. A physician order, dated 01/08/23, documented to administer mirtazapine 15 mg at bedtime for other specified depressive episodes. A physician order, dated 01/08/23, documented to administer duloxetine 30 mg daily for other specified depressive episodes. A MRR, dated 04/14/23, documented a request for a GDR on Res #33's mirtazapine and duloxetine. There was no documented response to the 04/14/23 GDR request. A MRR, dated 05/19/23, documented a request for a GDR for Res #33's pantoprazole. The MRR documented the recommendation status as Pending for the GDR response to mirtazapine and duloxetine from the previous month's request on 04/14/23. There was no documented response to the 05/19/23 GDR request. A MRR, dated 06/21/23, documented a request for a GDR on Res #33's mirtazapine, duloxetine, and pantoprazole. The MRR documented the recommendation status as No response for the GDR response to mirtazapine and duloxetine from the previous month's request on 05/19/23. The MRR documented the recommendation status as Pending for the GDR response to pantoprazole from the previous month's request on 05/19/23. There was no documented response to the 06/21/23 GDR request. On 07/25/23 at 10:10 a.m., the ADON stated the April 2023, May 2023, and June 2023 GDR requests had not been addressed by the physician within 30 days per facility policy. 43023 3. Res #22 had diagnoses which included schizoaffective disorder, bipolar disorder, and other specified depressive disorders. A MRR, dated 05/22/23, documented a request for a GDR on Res #22's lorazepam (an anti-anxiety medication). There was no documented response to the 05/22/23 request. A MRR, dated 06/21/23, documented a request for a GDR on Res #22's Seroquel (an antipsychotic medication). There was no documented response to the 06/21/23 GDR request. On 07/25/23 at 10:06 a.m., the ADON stated the May 2023 and June 2023 GDR requests had not been addressed by the physician within 30 days per facility policy. 4. Res # 11 had diagnoses which included mood disorder, and unspecified dementia with behavioral disturbance. A MRR, dated 03/09/23, documented a request for a GDR on Res #11's quetiapine (an antipsychotic medication). There was no documented response provided to the 03/09/23 request. A MRR, dated 04/14/23, documented a request for a GDR on Res #11's Depakote (an anticonvulsant). There was no documented response to the 04/14/23 GDR request. On 07/25/23 at 10:06 a.m., the ADON stated the GDR requests had not been addressed by the physician within 30 days per facility policy.

Based on record review and interview, the facility failed to ensure a gradual dose reduction of a medication was considered or attempted in a timely manner for two (#33 and #22) and signs and symptoms were present before antibiotic use for one (#34) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/17/23, documented 73 residents resided in the facility and seven residents received antibiotics. Findings: An Antibiotic Stewardship & Antibiotic Prescribing policy, dated December 2022, read in part .Providers will utilize the McGeer's Criteria when considering initiation of antibiotics .Surveillance definitions of skin and soft tissue infections: One of the following criteria must be met: a. Pus present at the wound, skin or soft tissue site b. The resident must have four or more of the following signs or symptoms: fever (100.4 F) or worsening mental/functional status, heat, redness, swelling, tenderness/pain, and/or serous drainage . A Medication Regimen Review and Reporting policy, dated January 2023, read in part .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days . 1. Res #33 had diagnoses which included GERD, anxiety, and other specified depressive episodes. A physician order, dated 01/08/23, documented to administer pantoprazole 40 mg daily for GERD. A MRR, dated 05/19/23, documented a request for a GDR for Res #33's pantoprazole. There was no documented response to the 05/19/23 GDR request. A MRR, dated 06/21/23, documented a request for a GDR on Res #33's pantoprazole. The MRR documented the recommendation status as Pending for the GDR response to pantoprazole from the previous month's request on 05/19/23. There was no documented response to the 06/21/23 GDR request. On 07/25/23 at 10:10 a.m., the ADON was asked to provide documentation a GDR had been considered or attempted for the pantoprazole. The ADON stated the GDR request for pantoprazole had not been addressed by the physician until today. 2. Res #34 had diagnoses which included dementia, Parkinson's disease, and diabetes mellitus. An annual assessment, dated 06/13/23, documented the resident was severely cognitively impaired, required extensive one person assistance with activities of daily living, and received antibiotics. A nurse note, dated 07/14/23 at 2:08 p.m., documented the resident was noted with open areas times three to the left outer knee due to the resident having picked a scab off of their leg. The physician was notified and a new order was received to cleanse open areas with normal saline or wound cleanser, pat dry, apply medi-honey, and cover with secondary bandage daily until resolved. A physician order, dated 07/15/23, documented to administer Bactrim DS 800 mg-160 mg every 12 hours for 10 days for a left knee abrasion. A nurse note, dated 07/15/23 at 11:43 p.m., documented the resident's initial dosed of Bactrim DS was upon arrival from pharmacy. No signs or symptoms of adverse reactions noted at this time. A skin assessment, dated 07/16/23, documented the resident had an abrasion to the left knee without redness or rash. There was no documentation in the clinical record of signs and/or symptoms of skin or soft tissue infection for Res #34. On 07/25/23 at 9:30 a.m., the DON was asked to provide documentation of signs and/or symptoms of a skin or soft tissue infection prior to antibiotic use for Res #34. On 07/25/23 at 10:37 a.m., the DON stated there was no documentation of signs or symptoms of a skin or soft tissue infection in the clinical record for Res #34. The DON stated McGeer's criteria for the use of an antibiotic was not met due to the lack of documentation prior to starting Res #34 on an antibiotic. 43023 3. Res #22 had diagnoses which included schizoaffective disorder, bipolar disorder, and other specified depressive disorders. A MRR, dated 05/22/23, documented a request for a GDR on Res #22's lorazepam (an anti-anxiety medication). There was no documented response to the 05/22/23 request. On 07/25/23 at 10:06 a.m., the ADON stated the GDR requests had not been addressed by the physician.

Based on record review and interview, the facility failed to ensure residents who received psychotropic medications received gradual dose reductions in a timely manner for four (#11, 22, 33, and #66) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/17/23, documented 63 residents received psychoactive medications. Findings: 1. Res #66 had diagnoses which included dementia, Alzheimer's disease, and anxiety. A physician order, dated 02/06/23, documented to administer buspirone (an anxiolytic medication) 5 mg three times daily for anxiety. A care plan, dated 02/06/23, documented a goal for the resident to be free of any discomfort or adverse reactions of buspirone with an intervention to ask the physician to review medication for possible dose reduction every three months. A quarterly assessment, dated 05/09/23, documented the resident had severe cognitive impairment, minimal depression, and received antianxiety medications. A MRR, dated 05/22/23, documented a request for a GDR on Res #66's buspirone. There was no documented response to the 05/22/23 GDR request. A MRR, dated 06/21/23, documented a request for a GDR on Res #66's buspirone. The MRR documented the recommendation status as Pending from the previous month's request on 05/22/23. There was no documented response to the 06/21/23 GDR request. The clinical record did not contain documentation a GDR had been attempted for the buspirone. On 07/25/23 at 10:06 a.m., the ADON was asked to provide documentation a GDR had been considered or attempted for the buspirone. The ADON stated the GDR request for buspirone had not been addressed by the physician until today. 2. Res #33 had diagnoses which included anxiety and other specified depressive episodes. A physician order, dated 01/08/23, documented to administer mirtazapine (an antidepressant medication) 15 mg at bedtime for other specified depressive episodes. A physician order, dated 01/08/23, documented to administer duloxetine (an antidepressant medication) 30 mg daily for other specified depressive episodes. A care plan, dated 01/08/23, documented a goal of the resident to be free of any discomfort or adverse reactions of duloxetine and mirtazapine with an intervention to monitor dosage due to the use of two or more antidepressants simultaneously may increase risks of side effects. An admission assessment, dated 01/13/23, documented the resident was cognitively intact, had mild depression, and received antianxiety and antidepressant medications. A MRR, dated 04/14/23, documented a request for a GDR on Res #33's mirtazapine and duloxetine. There was no documented response to the 04/14/23 GDR request. A MRR, dated 05/19/23, documented the recommendation status as Pending for the GDR response to mirtazapine and duloxetine from the previous month's request on 04/14/23. There was no documented response to the 05/19/23 GDR request. A MRR, dated 06/21/23, documented the recommendation status as No response for the GDR response to mirtazapine and duloxetine from the previous month's request on 05/19/23. There was no documented response to the 06/21/23 GDR request. The clinical record did not contain documentation a GDR had been attempted for the mirtazapine and duloxetine. On 07/25/23 at 10:10 a.m., the ADON was asked to provide documentation a GDR had been considered or attempted for the mirtazapine and duloxetine. The ADON stated the GDR request for mirtazapine and duloxetine had not been addressed by the physician until today. 43023 3. Res #22 had diagnoses which included schizoaffective disorder, bipolar disorder, and other specified depressive disorders. A MRR, dated 05/22/23, documented a request for a GDR on Res #22's lorazepam (an anti-anxiety medication). There was no documented response to the 05/22/23 request. A MRR, dated 06/21/23, documented a request for a GDR on Res #22's Seroquel (an antipsychotic medication). There was no documented response to the 06/21/23 GDR request. 4. Res # 11 had diagnoses which included mood disorder and unspecified dementia with behavioral disturbance. A MRR, dated 03/09/23, documented a request for a GDR on Res #11's quetiapine (an antipsychotic medication). There was no documented response provided to the 03/09/23 request. A MRR, dated 04/14/23, documented a request for a GDR on Res #11's Depakote (an anticonvulsant). There was no documented response to the 04/14/23 GDR request. On 07/25/23 at 10:06 a.m., the ADON stated the GDR requests had not been addressed by the physician within 30 days per facility policy.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 28 opportunities were observed with nine errors. Total medication error rate was 32.14%. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: 1. Res #6's physician order, dated 03/01/22, documented to administer metformin 500 mg with meals for diabetes at 5:00 p.m. On 07/25/23 at 3:06 p.m., CMA #2 was observed administering the metformin to the resident. 2. Res #36's physician order, dated 10/14/21, documented to administer metformin 500 mg with meals for diabetes at 5:00 p.m. On 07/25/23 at 3:13 p.m., CMA #2 was observed administering the metformin to the resident. 3. Res #15's physician order, dated 04/28/23, documented divalproex 250 mg, delayed release, for depression at 5:00 p.m. On 07/25/23 at 3:25 p.m., CMA #2 was observed administering the divalproex to the resident. 4. Res #22's physician order documented to administer carvedilol 3.125 mg for hypertension at 5:00 p.m. On 07/25/23 at 3:32 p.m., CMA #2 was observed administering the carvedilol to the resident. 5. Res #18's physician order, dated 02/02/21, documented to administer docusate sodium 100mg for constipation at 5:00 p.m. A physician order, date 05/12/20, documented to administer Eliquis 2.5 mg for chronic embolism and thrombosis at 5:00 p.m. A physician order, date 06/30/20, documented to administer ferrous sulfate 325mg for anemia at 5:00 p.m. A physician order, dated 12/03/19, documented to administer potassium chloride ER 10 meq, extended release, for acute kidney failure at 5:00 p.m. On 07/25/23 at 3:40 p.m., CMA #2 was observed administering the above medications to the resident. On 07/25/23 at 4:05 p.m., CMA #2 was asked about administering medications over an hour early. they reported that it was their understanding that if the medication shows up in blue that it was ok to give. They reported that all the CMAs give the medications this way. This surveyor asked her what the policy stated, they reported they did not know. On 07/25/23 at 4:42 p.m., the DON reported the medication policy says an hour before or an hour after. The DON reported the CMAs should know this.

Based on record review and interview, the facility failed to notify the OHCA of a new possible serious mental disorder diagnosis for one (#44) of four sampled residents reviewed for PASARR assessments. The Resident Census and Census and Conditions of Residents report, dated 07/17/23, documented 73 residents resided in the facility. Findings: A Level I PASARR, dated 04/06/22, documented Res #44 did not have a serious mental illness. On 12/26/22, Res #44 received a new diagnoses of delusional disorders and unspecified psychosis not due to a substance or known physiological condition. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 07/24/23 at 2:00 p.m., the MDS coordinator was asked to provide documentation the OHCA was notified when Res #44 had new diagnoses of delusional disorders and unspecified psychosis not due to a substance or known physiological condition to see if a Level II PASARR was required. On 07/24/23 at 3:07 p.m., the MDS coordinator stated the facility did not contact the OHCA but should have.

A past noncompliance immediate jeopardy (IJ) situation was determined to exist effective from 03/23/23 to 04/28/23 related to the facility's failure to ensure Res #3 had adequate supervision and updated interventions to prevent the recurrence of falls. Res #3 had experienced 19 falls from 01/14/23 to 04/28/23. Twelve of the falls did not have updated fall interventions documented. A fall on 03/23/23 resulted in six staples to a laceration to the head. A fall on 04/17/23 resulted in three staples to a laceration to the head. The most recent fall on 04/28/23 resulted in an intra-ventricular hemorrhage according to hospital records. On 05/09/23 at 5:20 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to have adequate supervision and updated interventions to help prevent falls. Based on observation, interview, and record review, it was determined the facility failed to ensure a resident had adequate supervision and updated interventions to prevent the recurrence of falls for one (#3) of four residents sampled for falls. Res #3 had two falls which resulted in lacerations and staples to the head and one fall which resulted in an intra-ventricular hemorrhage. The Resident Census and Conditions of Residents form, dated 05/05/23, documented 72 residents resided in the facility. The DON provided a fall log which documented 25 residents who had fallen in the last two months. Findings: Res #3 was admitted to the facility on [DATE] and had diagnoses which included Parkinson's disease, adult failure to thrive, dementia, disorder of bone density and structure, contracture of right and left hands, anxiety, repeated falls, and traumatic subdural hemorrhage without loss of consciousness. An admission assessment, dated 01/22/23, documented the resident was severely cognitively impaired; required extensive assistance with ADLs; did not walk; had ROM impairment in both upper and lower extremities; and had one fall with no injury. An incident report, dated 01/14/23 at 10:25 p.m., documented the resident had a fall in the hallway with no injury. The interventions to prevent further falls were to provide a well lit and clutter free room, call light in reach, needed and desired items in reach, bed in low position, and new w/c that would fit the resident more appropriate per hospice. Res #3's care plan related to falls, initiated on 01/16/23, documented the following interventions: a. Obtain Labs as ordered and abnormal labs addressed, b. Adequate lighting, provide night light if needed, c. Anticipate residents needs check frequently, d. Assess contributing factors related to fall history, e. Assess environment to maximize safety, f. Assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc., g. Assess medications for contributing factors and monitor side effects of pain medications, h. Assist resident with ADLs as needed, i. Assist resident with toileting as needed, j. Bed in lowest position, k. Bed wheels in locked position, l. GDR of Psychotropic medication, m. Keep call light and most frequently used personal items within reach, n. Maintain record of falls and evaluate for patterns, o. Maintain room and pathways free of clutter, p. Make sure that staff members are aware that resident is at high risk for falls, q. Monitor bowel movement, r. Monitor fluid intake, s. Monitor for signs and symptoms of UTI, t. Pain Management, u. Provide physical assistance to promote highest level of function, v. Remind resident to call when needing assistance, and w. Wheelchair. An incident report, dated 01/26/23 at 3:25 a.m., documented the resident had a fall in their room with no injury. Urine was found on the floor. The intervention documented was to do purposeful rounds. An incident report, dated 01/26/23 at 8:30 a.m., documented the resident had a fall in the dining room with no injury. The intervention documented to recline the w/c back. An incident report, dated 01/31/23 at 6:38 a.m., documented the resident fell in their room and received two skin tears to their back. The interventions documented were to place the resident in an open area for maximum observation opportunities. An incident report, dated 02/04/23 at 9:10 a.m., documented CNA witnessed resident attempting to get from bed to w/c and fell . The resident sustained two small skin tears on their back. The documented interventions were to wear non-skid and well fitting shoes. An incident report, dated 02/05/23 at 8:20 a.m., documented the resident was found on the floor in their room with no injury. No new interventions were documented. An incident report, dated 02/12/23 at 9:30 a.m., documented the resident fell in the dining room while attempting to get up from the w/c. The resident sustained a skin tear to the left elbow. No new interventions were documented. An incident report, dated 02/13/23 at 9:50 a.m., documented the resident was found next to the closet on the floor with a laceration on right side of their head and was sent out. The intervention documented was to, ''redirect.'' An incident report, dated 02/27/23 at 9:19 a.m., documented the resident fell six foot away from their w/c in the dining room. A housekeeper witnessed the fall. The injury was swelling and bruising to the right hip with no fracture. No interventions to prevent recurrence were documented. An incident report, dated 03/02/23 at 11:24 p.m., documented the resident had a fall at the nurse station with no injury. No interventions to prevent recurrence were documented. An incident report, dated 03/08/23 at 2:31 p.m., documented the resident had a fall in the hallway near their w/c. The resident sustained a skin tear on the left side of their neck and redness to left side of face and was sent out. No new interventions were documented. An incident report, dated 03/11/23, documented a nurse walking the hall saw the resident standing and immediately fell backwards before they could be reached. The injury was a dime sized hematoma on the back of their head. No new interventions were documented. An incident report, dated 03/23/23 at 8:50 a.m., documented a housekeeper found the resident on the floor in their room. The report documented the resident stated, ''I was trying to get up and fell . The resident was sent out and came back with six staples to back of left side of their head. The intervention documented to move resident to a room closer to nurse station and place a mat at the bedside. According to the incident reports, the room change happened sometime after 04/17/23 and before a fall on 04/21/23. The care plan, updated 03/23/23, documented to keep glasses clean and fit with adequate prescription. An incident report, dated 04/01/23 at 12:47 p.m., documented the resident fell in their room with no injury, but an x-ray was performed. No interventions were documented. An incident report, dated 04/17/23 at 6:15 a.m., documented the resident was found on the floor in their room. The injury was a laceration to the back right side of their head and required three staples. No interventions were documented. A quarterly assessment, dated 04/20/23, documented the resident was severely cognitively impaired; required extensive assistance with ADLs; did not walk; had ROM impairment in both upper and lower extremities; had two or more falls with with no injury; and two or more falls with minor injury. An incident report, dated 04/21/23 at 4:30 a.m., documented a room change had occurred. The report documented the resident fell in their room and hit the dresser. The resident sustained a laceration to the left side of their forehead and was sent out and came back with laceration closed with adhesives. No interventions were documented. An incident report, dated 04/23/23 at 12:51 a.m., documented the resident tried to get out of bed and fell while CNAs were with the resident's roommate. No injuries and no interventions documented. The care plan, updated 04/24/23, documented to monitor for side effects of anti-anxiety and anti-depressant medications. An incident report, dated 04/26/23 at 10:30 p.m., documented the resident had an unassisted fall from their w/c at the nurse station with no injury. No interventions were documented. An incident report, dated 04/28/23 at 10:10 p.m., read in parts, .This nurse was sitting at desk with resident 1:1 r/t multiple recent falls. Resident fell asleep in chair, at which time this nurse, as well as CNA/CMA staff, began to complete rounds. This nurse was then notified by CNA that resident had fallen onto floor. This nurse found resident lying in floor on her right side, with blood pooling around her head. Upon further assessment, resident was noted to have 2 lacerations to the right side of her forehead, one at the end of her right eyebrow, and one to the right side of her forehead. It was also noted that resident's left thumbnail was broken off, as well as a skin tear and swelling to the proximal thumb joint. Resident's pupils were unequal and sluggish, resident's gaze was also fixed to the right side .EMS contacted to transport resident to hospital for further evaluation . A nurse note, dated 04/29/23, documented the resident returned back from the hospital with a verified brain bleed and small volume intraventricular hemorrhage, right ocular hyphemia, and right scalp laceration. The past noncompliance IJ was removed, effective 04/29/23 at 11:32 p.m., after the facility in-serviced staff and put measures in place to help prevent the recurrence of falls for Res #3. In-services were conducted with staff on 04/28/23 and 04/29/23. The inservice document, dated 04/28/23, read in part, '' .Reviewed what happened, how to prevent = Res asleep alone at the desk in w/c - offer resident to lay down, switch with another staff member to complete one an one. What we already know about the resident: #1 Unsafe behaviors and unable to verbalize exact needs, #2 What can we do to aid resident with this deficit, #3 Begin interventions like one on one, take to the bathroom, offer snacks, offer puzzles .Interventions to be put into place: Decided after update from the hospital and aware .was returning on the Saturday 04-29-23. Place resident on Hall 2 for quiet and quality time with family. Chair changed from the regular w/c to a geri chair to aide with trunk control and positioning. Discussed with .and on coming shifts.'' Upon entrance to the facility, on 05/05/23 and throughout the survey, observations were conducted of Res #3 and interventions were in place and implemented. Interviews with staff were conducted and they verbalized interventions and their understanding of what was required to be in place for the resident to be safe. On 05/05/23 at 8:52 a.m., Res #3 was observed sitting in an upright position in a geri chair,being fed by CNA #6, in the Hall 2 dining room. The resident was observed with bruising to their left and right forehead. The CNA stated the resident had a fall several weeks ago and was moved to that unit. She stated they were to watch the resident continually, offer her activities, and they changed her to a geri chair for comfort. The resident would look at the surveyor but would not voice any comments. On 05/08/23 at 10:00 a.m., the resident was observed sitting in the geri chair in the small dining room on the unit. A staff member was sitting nearby at a nearby table with another resident. The resident had a cushion to her back for positioning and comfort. The resident was watching TV. On 05/09/23 at 1:30 p.m., LPN #2 was asked about Res #3's falls and interventions which were in place. The LPN stated that normally every day the resident was kept close to the nurse station because of all the falls the resident was having. The LPN stated late on the evening shift on the 28th, the resident was in her w/c by the nurse station. The LPN stated the resident was not on one on one supervision officially, but they would try to keep the resident close to the desk. LPN #2 stated when the resident fell asleep, they went down the hall to check on another resident. LPN #2 stated she would not have left her if the resident was awake. The LPN stated on her way down the hall a CNA was going toward the nurse station. The LPN stated she was only away from the station for three to five minutes when CNA #2 came and got her and told her the resident had fallen from the w/c to the floor. The LPN stated the resident did not like to go to bed. She stated she felt the resident was safe in her chair. LPN #2 stated the resident was leaned back in the w/c with her head leaned back also. The LPN stated the staff tried to keep the resident busy with tactile activities, snacks, and drinks. LPN #2 stated we know now not to leave her alone while asleep in the chair. On 05/09/23 at 2:15 p.m., CNA #2 stated they were working the night Res #3 fell and hit their head. CNA #2 stated they had tried to get her to go to bed a couple of times before that happened. They stated the resident told her, No, so they left her up. They stated the resident fell asleep in the w/c and fell out. CNA #2 stated they were inserviced over the resident's falls and informed of interventions to use with the resident to help prevent falls. They stated they were told to not let the resident sleep in the chair and leave Res #3 unattended. They stated if the resident was in their room the staff were to check on the resident every fifteen minutes and never leave the resident in her room if they were awake. On 05/09/23 at 12:42 p.m., the MDS/care plan cordinator was asked about the process of updating the care plans with interventions for falls. She stated she could pull up a fall report and get the interventions from the incident reports. She stated if it was a new intervention, not used before, she would add it to the care plan. She was asked about Res #3's falls and interventions. She stated if she was not informed, either in morning stand-up or the incident report, then the care plan was not updated. On 05/09/23 at 2:56 p.m., the DON was asked about the facility's process r/t falls. The DON stated the nurse should assess the resident, notify her, the physician, family, and fill out an incident report. She stated the nurse should put an immediate intervention in place and there were interventions listed on the incident report to choose from. She stated the interdisciplinary team will come up with a more appropriate one if needed. The DON stated during morning meeting each resident fall was discussed. She stated the care plan should be updated with the new interventions. She stated they would get therapy involved sometimes and conduct a root cause analyses. She stated they had a fall inservice in March and when Res #3 fell recently she did another one on 04/28/23 and 04/29/23. She stated she went over what needed to be in place for the resident such as constant monitoring, activities, a geri chair for comfort, and not to be left alone while sleeping in the w/c. She stated the QA committee had been monitoring falls recently. On 05/09/23 at 4:00 p.m., the resident was observed in a low bed just off the floor with eyes closed. A floor mat was at bed side. There were two CNAs on Hall 2 at that time. On 05/09/23 at 4:50 p.m., the administrator was asked about the process of what happens after a resident has a fall. She stated the nurse would report to the DON, there would be an investigation, and an incident report would be filled out. She stated also the QAPI committee had been monitoring falls recently. The administrator stated she did read the incident reports and signed off on them. She was asked if she had noticed the interventions had not been updated for Res #3. She stated she had not been paying close attention to the interventions until recently.

On [DATE], an Immediate Jeopardy situation was determined to exist in regard to the facility's failure to follow their "Do Not Resuscitate Policy" to initiate CPR when a resident was found to be without V/S and had a full code status. The facility failed to ensure all direct care staff had knowledge of the facility's procedure for identifying residents' CPR status. The facility failed to ensure the code status for each resident was properly identified on the residents' medical record alert page to correlate with the physicians' order. On [DATE] at 1:30 p.m., the Oklahoma State Department of Health was notified and the Immediate Jeopardy situation was verified. At 1:45 p.m., the Administrator, the DON and the RN consultant were informed of the IJ situation. On [DATE] at 5:00 p.m., a plan of removal was accepted. The plan of removal documented the following: "Immediate Jeopardy Plan of Removal 1. All CPR/DNR orders were printed and verified with the residents records and their alert page in the front of the chart. 2. All resident rooms will be checked within the next 30 minutes to ensure all name cards on the head of the beds have been removed and placed securely on the inside of the closet door at eye level with the resident's name and appropriate sticker to match their physician's orders [REDACTED]. 3. The Advanced Directive Policy and Procedure will be updated to reflect the following: a. The person finding the resident without vital signs will 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 measures and the CPR emergency chart. 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. 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 been updated correctly to match the new order. 4. All staff present today will be in-serviced on the new Advanced Directive/DNR policy as noted by 3:30 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 5 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. The SSD will also monthly review all advanced directive records and orders to ensure all match as a QA check." The facility provided an inservice training for all staff titled, "CPR - FULL CODE VERSUS DNR," dated [DATE] and [DATE], with the last inservice ending on [DATE] at 10:30 a.m. The inservice documented the following: "CPR AND DNR STICKERS WILL BE PLACED ON THE INSIDE OF EACH RESIDENT'S CLOSET WITH THEIR NAME ON THE CARD. THESE WILL MATCH THEIR physician's orders [REDACTED]. IF YOU FIND SOMEONE WITHOUT VITAL SIGNS AND THEY ARE A FULL CODE DO THE FOLLOWING: a. The person finding the resident without vital signs will call out to other staff that there is a CODE BLUE. b. Then immediately begin chest compressions until a CPR-certified person comes to continue CPR with full CPR measures and the CPR emergency cart. c. CPR cannot be stopped until a physician is notified and orders it to be stopped or emergency personnel arrive and obtain the okay to stop from their physician. 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. These stickers will be updated each time a new advanced directive physician's orders [REDACTED]. 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 been updated correctly to match the new order." The last direct care staff had been inserviced on [DATE] at 10:30 a.m. The IJ was removed as of [DATE] at 10:30 a.m., after all direct care staff had been inserviced. The deficiency remained at a level of actual harm that was not immediate jeopardy and was isolated. On [DATE], staff were interviewed regarding knowledge of issues addressed in the inservice. The staff were able to verbalize knowledge related to CPR status determination found on the residents' closet door, when finding an unresponsive full code resident and they were to call out a Code Blue, and then immediately start chest compressions. All resident rooms were observed to have the correct CPR status stickers attached to the inside of the closet doors. All the residents' medical records were checked to see if the alert page had the correct sticker to correlate with the physicians' order for code status, and they did. Based on record review, observation and staff interview, it was determined the facility failed to: a) Follow their policy and procedure and initiate CPR for a resident who had a full code status and had been found without vital signs for one (#15) of nine sampled residents who had a full code status. The resident expired without CPR being initiated. This had the potential to affect 38 residents who had full code status, per the facility's 'Order Listing Report'. b) Ensure a system was in place to enable staff to quickly identify a resident's code status so CPR would be initiated immediately if a resident was a full code. c) Ensure the resident's medical record contained, on the alert page, a sticker code which correlated with the resident's physician's orders [REDACTED].#7) of 19 sampled residents. These had the potential to affect all 62 residents. d) Ensure a resident who was admitted with an indwelling urinary catheter, and had no [DIAGNOSES REDACTED].#2) of two sampled residents who had indwelling urinary catheters. This had the potential to affect five other residents who had indwelling urinary catheters. Findings: "POLICY: DO NOT RESUSCITATE POLICY STATEMENT: 1. It is the policy of this facility to initiate cardiopulmonary resuscitation (CPR) for residents who suffer unexpected [MEDICAL CONDITION] in this facility. CPR will continue until emergency personnel or a physcian direct the CPR measures to stop. 2. Any exception to this policy requires a signed Do Not Resuscitate (DNR) form by the resident or their legal representative for health care decisions. (Limited to an attorney-in-fact for health care decisions acting under the Durable Power of Attorney Act, a health care proxy acting under the Oklahoma Rights of the Terminally Ill or Persistently Guardianship and/Conservatorship Act)... PROCEDURE: 1. The DON or his/her designee will note on the medical record and communicate to the attending physician a resident's decision for a DNR and that the DNR has been signed appropriately. 2. DNR orders shall be entered in the appropriate form and shall bear the signature of the attending physician. Verbal or telephone orders must be received by a licensed nurse and signed by the attending physician within State licensure requirements. 3. Each resident with a signed DNR form will be identified by a DNR sticker on their chart. 4. The DNR order will be placed on the resident's monthly physician orders, to be signed and reviewed monthly by the physician. 5. A DNR order shall not affect the level of otherwise indicated medical and nursing care the resident receives. All forms of supportive care and pain relief shall be administered as the resident's physician orders [REDACTED]. 6. If the resident is transferred to another health care setting, a copy of the DNR will be sent with the resident to be given to the other health care setting. Review Date [DATE]" 1. Resident #15 was admitted to the facility on [DATE]. The resident expired on [DATE]. The resident's medical record, had a 'Full Code' sticker placed on the 'alert' page. Diagnoses for the resident included [MEDICAL CONDITION] and [MEDICAL CONDITION] in situ of prostate. A care plan, dated [DATE], documented, "I am a full code as this is my medical choice, I do have a healthcare proxy. Ensure that my choice to be a full code is respected and honored by next review. Please follow my wishes to be a full code and follow protocol if the need was to arise..." A quarterly assessment, dated [DATE], documented the resident had a severely impaired mental status, required extensive assistance of one person for bed mobility, dressing and toilet use, required total assistance of two plus persons for transfers, had ROM deficits on both sides of lower extremities, and was always incontinent of bowel and bladder. The [DATE], physician's orders [REDACTED]. The physician's progress note, dated [DATE], documented, "Continue to do good..." On [DATE] at 8:00 p.m., a nurse's note, documented, "Rsd in his rm awake watching his TV. Rsd appears weak and lethargic. Rsd responds to stuff when spoken to...peri-care given." At 8:30 p.m., a nurse's note, documented, "Rsd in bed c eyes closed. V/S 96.4 62 ,[DATE] 0 c/o pain, 0 s/sx distress, call light c in reach." At 9:30 p.m., a nurse's note, documented, "CMA in rsd room. Rsd alert and CMA gave rsd a drink of water & then he took his medications without any problems." At 10:15 p.m., a nurse's note, documented, "Staff enters rm. and comes and finds nurse. Nurse goes into rsd rm. - Rsd has 0 vital signs." At 10:25 p.m., a nurse's note, documented, "Nurse notified Director of Nurses & Dr. (Name deleted)." At 10:30 p.m., a nurse's note, documented, "(Hospice name deleted) notified. Rsd emergency contact (Name deleted) notified. Dtr. request that we wait until she arrives @ facility to call the funeral home. Dtr coming from Tulsa, Okla." At 11:25 p.m., a nurse's note, documented, "Hospice (Name deleted) here still waiting for family arrival." At 11:45 p.m., a nurse's note, documented, "Dtr here @ facility in rm c rsd." At 12:05 a.m., a nurse's note, documented, "Nurse placed call to (Name of Funeral Home deleted). Awaiting arrival of Funeral Home." On [DATE] at 10:40 a.m., the ADON informed the surveyor the resident had been admitted to hospice the day he died . The ADON was asked where the hospice paperwork was located. The ADON said she would call hospice to have them fax the paperwork. At 11:15 a.m., the hospice faxed a form labeled "Hospice Admission Service Agreement," dated [DATE]. The form documented the resident wanted to avoid further hospitalization s and did not want CPR. The form said the resident was unable to sign due to being confused, so the healthcare proxy had signed the form. There was no signed DNR form. On [DATE] at 11:45 a.m., the ADON was asked what should the nursing home charge LPN have done when she found the resident without vital signs with a full code status? She stated, "She should have initiated a full code." She said if the staff was CPR certified they should have started the CPR. On [DATE] at 12:00 p.m., LPN #3, who was the charge nurse the night the resident expired, was interviewed per telephone. She was asked what had happened the night the resident was found without vital signs. She said the CNAs had begun their rounds to check the residents. She said the aides, who found the resident unresponsive, called for her. She said she had gathered her equipment and went down to the resident's room. The LPN said she first checked the resident's pulse. She saw he had no pulse, so she didn't start CPR. The LPN was asked if she knew the resident was a full code. She said she had looked in his chart and knew he had a full code sticker, but she was confused because she knew hospice had been there earlier that day and maybe had changed him to a DNR status. The LPN was asked why she had not started CPR when she had seen the full code order in his medical chart. She stated, "I know I did wrong and should have started CPR, but I knew he was dead and gone." LPN #3 further stated, "Sometimes there's a mixed message in the charts." She was asked to clarify her statement. She reported sometimes different sections of the chart say one thing and another area says something else pertaining to code status. LPN #3 was asked what she did after she had left the resident's room. She said she had called hospice, the DON and the resident's physician. She stated, "I can't remember if I left the doctor a message or talked to him, but I think I left a message." She reported she talked to the physician sometime, but couldn't remember just what time it had been. On [DATE] at 12:15 p.m., CNA #4 was contacted per telephone. CNA #4 was the CNA who had found the resident unresponsive the night he had expired. CNA #4 was asked what had happened the night she had found the resident unresponsive? She replied she had been doing rounds with another CNA when they had found the resident unresponsive. The CNA stated, "He wasn't breathing." The CNA reported she called out for LPN #3, who was the charge nurse. The CNA said LPN #3 checked the resident's pulse and stated, "He's gone." The CNA was asked if the LPN had started CPR on the resident. The CNA said she didn't know, because she had not stayed in the resident's room. CNA #4 was asked what was the facility's policy if staff found a resident unresponsive and not breathing? She stated, "Tell our immediate supervisor." CNA #4 said she herself was CPR certified and had a CPR certification card. On [DATE] at 12:40 p.m., the hospice representative, whose name was on the hospice agreement was called per telephone. The hospice employee was asked what was her title for the hospice agency. She said she was the business manager. She said she had been in the facility in the afternoon of [DATE] (Saturday), to get the paperwork started for the resident to be signed up for hospice services. She said the resident's healthcare proxy had been there to visit the resident at that time. She said the healthcare proxy signed the starting hospice paperwork. The hospice business manager was asked if she had signed the resident up for hospice services the day she was there on [DATE] (Saturday). She said hospice did not have other staff available on the weekends for new admits, so she had gone to start the initial paperwork. She said she would have the hospice social worker return the signed forms on Monday. The hospice business manager was asked if she had told the facility the resident was going on hospice services. She stated she had not talked with any facility staff that day. She said another hospice employee was to come in the next day (Sunday, [DATE]), but the resident had expired before then. On [DATE] at 1:00 p.m., the DON was interviewed. The DON was asked what LPN #3 had told her when she called her the night the resident had expired. The DON stated, "She told me (Resident's Name deleted) had passed away. (CNA #4's Name deleted) found him." The DON said she asked her if hospice was there and the CNA told her they had been called. The DON was asked if anything had been mentioned regarding CPR. The DON stated, "She didn't mention CPR. She should have started it." On [DATE] at 1:50 p.m., the DON and the ADM were interviewed. They were asked what the staff were taught to do if they found a resident unresponsive. The DON said they were to use the call light and notify the nurse. The DON was asked how did the staff know what code status the residents were. She said on the residents' walls were either green or red dots, signifying each residents' code. She was informed not all the rooms had stickers on the wall for a code. The ADM stated, "Sometimes the residents peel the stickers off." 2. Resident #7 had been admitted to the facility on [DATE], with diagnosed including: [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, 'Problem: Advance Directive: DNR/Living Will...Interventions: Copy of Advance Directive will be in chart. Chart labeled with DNR and Living Will stickers...In case of [MEDICAL CONDITION], do not resuscitate. Notify physician and responsible party of death." A quarterly assessment, dated [DATE], documented the resident was cognitively intact, required limited assistance with bed mobility and transferring between surfaces, dressing and bathing and was not ambulatory. The [DATE], physician's orders [REDACTED]. The [DATE], treatment sheet documented, "Advanced Directive DNR- Do Not Resuscitate" On two of the pages of the treatment sheets the DNR had been marked out and hand written to say "Full Code". The resident's medical record was reviewed. Inside the front cover of the record was an orange sticker that stated, "DNR." On [DATE] at 3:00 p.m., the DON was asked if the resident's code status was full code or DNR. The DON reviewed the record and reported when the resident had been admitted to the facility the resident's spouse had requested the resident be a DNR. At 3:30 p.m., the DON reported she had placed a phone call to the spouse. The DON then reported the spouse reported he did not have any paperwork of the resident desiring to be a DNR or a Living Will. On [DATE] at 11:30 a.m., LPN #2 was asked how she determined the resident's code status. The LPN reported she would go to the treatment record or the resident's chart, which ever was closest at the time. The LPN then went to the treatment record and reported the resident was a full code. The LPN then went to the resident's medical record and it had the orange "DNR" sticker. The LPN was then asked what she would do if the resident coded with this situation. The LPN stated, "I would be in a bad position." On [DATE] at 11:00 a.m., the resident's code status had been placed inside the resident's closet. The inside of the resident's closet was observed to say "Full Code." The resident was then asked by the surveyor if anyone had talked with her about her code status. The resident reported the facility staff had and she desired to be a full code. 3. Resident #2 had been admitted to the facility on [DATE], with diagnosed including: [DIAGNOSES REDACTED]. On [DATE], an admitting nurses' note, documented, "...Stroke affected (R) side. Wt bearing ad lib. Has Foley cath & uses bedside commode for BM..." The [DATE], physician's orders [REDACTED]. Check Foley/SP cath & urine q shift...change 2 times monthly & prn..." A 14 day assessment, dated [DATE], documented the resident was cognitively intact, required limited assistance with bed mobility, extensive assistance with transferring between surfaces, dressing, hygiene and bathing. The assessment identified the resident as having an indwelling urinary catheter and always being continent of bowel. A care plan, dated [DATE], documented, "Problem: The resident has indwelling catheter...Approach: position catheter bag and tubing below the level of the bladder...Monitor/document for pain/discomfort due to catheter..." On [DATE] at 10:00 a.m., CNA #1 and CNA #2 were observed providing indwelling catheter care for the resident. On [DATE] at 10:30 a.m., the DON was interviewed regarding the medical justification for the use of the indwelling urinary catheter. The DON reviewed the resident's medical record and reported she did not have a [DIAGNOSES REDACTED]. The DON also reported she would work on getting the catheter discontinued.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure pain medication was administered for pain per the physician's orders [REDACTED]. This had the potential to affect 65 residents receiving prn pain medications per the DON. b) Ensure blisters on a resident's arm were assessed, monitored and a treatment was obtained for one (#6) of one sampled resident identified with blisters. This had the potential to affect 18 residents with skin issues for November 2012, per the DON. Findings: 1. The [DIAGNOSES REDACTED]. The care plan, dated 02/29/12, documented the resident had [MEDICAL CONDITION], had a [MEDICAL CONDITION] (R) sided [MEDICAL CONDITION], and had a potential for pain. 'The goal: to be free of pain. The end goal date: 05/24/12'. An approach was for pain medications to be administered as ordered by the physician. On 10/26/12, the care plan had been revised. The comment section documented, "No change in this area..." The quarterly assessment dated [DATE], documented the resident had disorganized thinking, did not talk, had the ability to understand others, had psychomotor [MEDICAL CONDITION], was easily annoyed, was totally dependant on one to two staff for ADL's, had PRN medication for pain. The November 2012, physician's orders [REDACTED]. A nurse's note, dated 11/26/12 at 1:45 p.m., documented, "CNA observed resi leaning forward in W/C and slid out landing on foot rest. No injury..." On 11/27/12 at 10:00 a.m., a nurse's note documented, "Resid ^ in recliner. Pleasant mood. Denies any pain. No new skin impairments/injuries r/t recent fall." No other nurse note had been documented for the day shift. The MAR for November 2012, documented the dayshift CMA, on the 27th, had administered [MEDICATION NAME] sulfate to the resident sometime during the day shift. No time had been documented. The back side of the MAR, used by the nurse/CMA when giving a PRN medication to document: "Date; Time; Initial; Drug; Strength; Dose; Method; Reason; Start; Pain Score; Results; Time; End Pain Score; Initial." These areas were blank for the entire month of November 2012. A nurse's note (by LPN #3), dated 11/27/12 at 4:30 p.m., documented, "Nurse summoned to rsd rm by staff. Rsd lying in bed with her side legs drawn up...Rsd kept hollering out in pain each time her right leg was moved. Nurse ask rsd if her Rt. leg hurt. Rsd shook her head up and down - meaning yes. Dr. (Name deleted) was called and a message was left on his answering machine. Waiting call back." There was no documentation anywhere in the medical records, including the 'Individual Patient's Narcotic Record' that the evening shift had administered a PRN pain medication. At 8:45 p.m., a nurse's note (by LPN #3), documented, "DON notified of rsds Rt. leg hurting. Dr. (Name deleted) still hasn't return call concerning rsd." At 10:00 p.m., a nurse's note (by LPN #3), documented, "Dr. (Name deleted) still hasn't call back." There was no documentation anywhere in the medical records, including the 'Individual Patient's Narcotic Record' that the evening or night shift had administered a PRN pain medication. A nurse's note, dated 11/28/12 at 2:45 p.m., documented, "...C/O (L) leg pain, refused pain med. Assisted to recliner and leg massaged..." A nurse's note (by LPN #3), dated 11/28/12 at 9:30 p.m., documented, "Rsd screamed out in pain when she was placed in bed this evening after dinner. Her (L) leg was hurting..." There was no documentation anywhere in the medical records, including the 'Individual Patient's Narcotic Record' the evening shift had administered a PRN pain medication. The 'Treatment Record' for November 2012, documented, "Pain score QS and PRN pain every shift Pain score 0-10 >3 Offer pain medication, re-evaluate in 30 min and chart effectiveness, if no relief or no prn pain med available report to charge nurse." All three shifts, for the month of November 2012, had put '0' (no pain) underneath the dates, meaning the resident had not had any type of pain the entire month of November 2012. On 12/06/12 at 2:00 p.m., the DON was interviewed. The DON was shown the nurse's note (by LPN #3) dated 11/27/12. She was asked what word exchange had occurred between herself and LPN #3. The DON reviewed the nurse's note. She stated, "I was told by (Name deleted LPN #3) the doctor had been called." The DON said she told the LPN if Dr. (Name deleted) had not called back by 10 p.m., she (the LPN) was to call Dr. (Name deleted medical director). The DON was asked if the resident had recently seen the physician. The DON said the resident's physician had been in the facility on 11/30/12, but had not seen the resident because the nurse had not told the physician the resident had been in pain earlier that week. At 2:30 p.m., the resident was observed sleeping peacefully in her recliner with the foot rest elevated. The blinds in her room were open allowing sunlight to come into the room. Bird sounds were being played from an audio system. At 2:35 p.m., CNA #1 was observed on the hall where the resident resided. The CNA was asked if she took care of the resident. She stated, "Yes." The CNA was asked if the resident ever experienced pain during care. The CNA stated, "Whenever you touch her left leg, she hollers." At 2:55 p.m., CMA #2, who worked the dayshift, was interviewed. She was asked about the resident's pain. The CMA stated, "She (resident) is not in pain all the time, but when she is, [MEDICATION NAME] is given." She was asked how many times she had administered [MEDICATION NAME] for pain to the resident. She stated, "I've only given it two times in the five months I've been here." At 3:15 p.m., LPN #3, the evening charge nurse, was interviewed. The LPN was asked about the evening of the 27th when the resident had complained of pain and she had attempted to get in touch with the resident's physician. The LPN said she had told CMA #1 to give the resident pain medication "around 6:30 p.m." She said she wasn't sure about the time. The LPN said she had continued to try to get in touch of the primary physician. The LPN said at 10:00 p.m., she had called the DON. She said the DON had told her to keep trying to get in touch with the primary physician. The LPN said she thought the resident could have done something to her leg when she had fallen a few days ago. She stated, "I felt like she may have been acting like she was in pain just to go to bed." At 3:25 p.m., CMA #1 was interviewed. The CMA was asked if she had worked on the evening shift on 11/27/12. She said she had worked that evening. She was asked what had occurred with (resident #5's Name deleted). The CMA said LPN #3 had told her to give the resident [MEDICATION NAME] sulfate because the resident was 'hollering out from her leg hurting.' The CMA said she had drawn the [MEDICATION NAME] up in a syringe and given it sublingual to the resident around 4:30 p.m. The CMA was asked why she had not signed out on the MAR that [MEDICATION NAME] had been administered and documented on the PRN medication form. The CMA said it was right at supper time and it was very hectic. She said she had planned on going back and initialing the administration and then to document on back of the PRN medication form. She stated, "I guess I just forgot to." The CMA was shown the [MEDICATION NAME] on the November MAR and asked her whose initials those were on the 27th. The CMA said that the initials were (Name deleted CMA #2's). She stated, "(Name deleted CMA #2) had given the resident an a.m. dose." The CMA said the [MEDICATION NAME] she had given had helped the resident because 'she had seen the resident in the dining room later and the resident was not hollering out anymore.' The CMA was asked if she had documented pain relief somewhere. She said she was busy and had not documented anything. She was asked who should document the results. The CMA said either she or the LPN should. 2. A quarterly assessment, dated 10/04/12, for resident #6, documented the resident was moderately cognitively impaired, needed assistance with ADLs, and had no skin conditions. A nurse's note, dated 11/10/12, documented, "Approximately 9 cm reddened area to left outer wrist observed, intact blisters observed to area, resident denies pain & states she doesn't know what happened. Area left open to air." A nurse's note, dated 11/11/12, at 9:00 a.m., documented, "Red area to L wrist still present. Some blisters had busted. Skin dry, area cleansed & left open to air." There was no documentation in the medical record where the physician had been notified or an order for [REDACTED]. There was not a skin assessment in the medical record for the resident. On 12/06/12, at 2:32 p.m., LPN #2 was asked if there was a skin assessment for the resident that included the blisters. The LPN looked through the 'Skin Book' and said there was not a skin assessment for the resident. The LPN said she was not aware the resident had any blisters. On 12/06/12, at 2:33 p.m., the resident was observed to be lying in bed under a blanket with her eyes open. The resident did not verbalize when spoken to. LPN #2 was asked to uncover the resident's arms. The resident's left outer arm right above the wrist had a smooth faint pink elongated area approximately 1 cm x 0.5 cm in size. On 12/06/12, at 3:00 p.m., LPN #1 was asked if she contacted the physician to receive a treatment order. She said she didn't, but should have. On 12/06/12, at 6:30 p.m., the DON was asked if the physician should have been notified and a treatment obtained after the blisters were discovered on the resident's arm. She said she had told LPN #1 who discovered the blisters to call the Dr. The DON said on Monday (11/12/12) when she learned the weekend nurse (LPN #1) had not notified the Dr., she told the nurse on duty (LPN #2) to notify the Dr. and get a treatment order.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure pain medication was administered for pain per the physician's orders [REDACTED].#5) of three sampled residents identified with pain. This had the potential to affect 65 residents receiving prn pain medications per the DON. b) Ensure blisters on a resident's arm were assessed, monitored and a treatment was obtained for one (#6) of one sampled resident identified with blisters. This had the potential to affect 18 residents with skin issues for November 2012, per the DON. Findings: 1. The [DIAGNOSES REDACTED]. The care plan, dated 02/29/12, documented the resident had [MEDICAL CONDITION], had a [MEDICAL CONDITION] (R) sided [MEDICAL CONDITION], and had a potential for pain. 'The goal: to be free of pain. The end goal date: 05/24/12'. An approach was for pain medications to be administered as ordered by the physician. On 10/26/12, the care plan had been revised. The comment section documented, No change in this area. The quarterly assessment dated [DATE], documented the resident had disorganized thinking, did not talk, had the ability to understand others, had psychomotor [MEDICAL CONDITION], was easily annoyed, was totally dependant on one to two staff for ADL's, had PRN medication for pain. The November 2012, physician's orders [REDACTED]. A nurse's note, dated 11/26/12 at 1:45 p.m., documented, CNA observed resi leaning forward in W/C and slid out landing on foot rest. No injury. On 11/27/12 at 10:00 a.m., a nurse's note documented, Resid ^ in recliner. Pleasant mood. Denies any pain. No new skin impairments/injuries r/t recent fall. No other nurse note had been documented for the day shift. The MAR for November 2012, documented the dayshift CMA, on the 27th, had administered [MEDICATION NAME] sulfate to the resident sometime during the day shift. No time had been documented. The back side of the MAR, used by the nurse/CMA when giving a PRN medication to document: Date; Time; Initial; Drug; Strength; Dose; Method; Reason; Start; Pain Score; Results; Time; End Pain Score; Initial. These areas were blank for the entire month of November 2012. A nurse's note (by LPN #3), dated 11/27/12 at 4:30 p.m., documented, Nurse summoned to rsd rm by staff. Rsd lying in bed with her side legs drawn up.Rsd kept hollering out in pain each time her right leg was moved. Nurse ask rsd if her Rt. leg hurt. Rsd shook her head up and down - meaning yes. Dr. (Name deleted) was called and a message was left on his answering machine. Waiting call back. There was no documentation anywhere in the medical records, including the 'Individual Patient's Narcotic Record' that the evening shift had administered a PRN pain medication. At 8:45 p.m., a nurse's note (by LPN #3), documented, DON notified of rsds Rt. leg hurting. Dr. (Name deleted) still hasn't return call concerning rsd. At 10:00 p.m., a nurse's note (by LPN #3), documented, Dr. (Name deleted) still hasn't call back. There was no documentation anywhere in the medical records, including the 'Individual Patient's Narcotic Record' that the evening or night shift had administered a PRN pain medication. A nurse's note, dated 11/28/12 at 2:45 p.m., documented, .C/O (L) leg pain, refused pain med. Assisted to recliner and leg massaged. A nurse's note (by LPN #3), dated 11/28/12 at 9:30 p.m., documented, Rsd screamed out in pain when she was placed in bed this evening after dinner. Her (L) leg was hurting. There was no documentation anywhere in the medical records, including the 'Individual Patient's Narcotic Record' the evening shift had administered a PRN pain medication. The 'Treatment Record' for November 2012, documented, Pain score QS and PRN pain every shift Pain score 0-10 >3 Offer pain medication, re-evaluate in 30 min and chart effectiveness, if no relief or no prn pain med available report to charge nurse. All three shifts, for the month of November 2012, had put '0' (no pain) underneath the dates, meaning the resident had not had any type of pain the entire month of November 2012. On 12/06/12 at 2:00 p.m., the DON was interviewed. The DON was shown the nurse's note (by LPN #3) dated 11/27/12. She was asked what word exchange had occurred between herself and LPN #3. The DON reviewed the nurse's note. She stated, I was told by (Name deleted LPN #3) the doctor had been called. The DON said she told the LPN if Dr. (Name deleted) had not called back by 10 p.m., she (the LPN) was to call Dr. (Name deleted medical director). The DON was asked if the resident had recently seen the physician. The DON said the resident's physician had been in the facility on 11/30/12, but had not seen the resident because the nurse had not told the physician the resident had been in pain earlier that week. At 2:30 p.m., the resident was observed sleeping peacefully in her recliner with the foot rest elevated. The blinds in her room were open allowing sunlight to come into the room. Bird sounds were being played from an audio system. At 2:35 p.m., CNA #1 was observed on the hall where the resident resided. The CNA was asked if she took care of the resident. She stated, Yes. The CNA was asked if the resident ever experienced pain during care. The CNA stated, Whenever you touch her left leg, she hollers. At 2:55 p.m., CMA #2, who worked the dayshift, was interviewed. She was asked about the resident's pain. The CMA stated, She (resident) is not in pain all the time, but when she is, [MEDICATION NAME] is given. She was asked how many times she had administered [MEDICATION NAME] for pain to the resident. She stated, I've only given it two times in the five months I've been here. At 3:15 p.m., LPN #3, the evening charge nurse, was interviewed. The LPN was asked about the evening of the 27th when the resident had complained of pain and she had attempted to get in touch with the resident's physician. The LPN said she had told CMA #1 to give the resident pain medication around 6:30 p.m. She said she wasn't sure about the time. The LPN said she had continued to try to get in touch of the primary physician. The LPN said at 10:00 p.m., she had called the DON. She said the DON had told her to keep trying to get in touch with the primary physician. The LPN said she thought the resident could have done something to her leg when she had fallen a few days ago. She stated, I felt like she may have been acting like she was in pain just to go to bed. At 3:25 p.m., CMA #1 was interviewed. The CMA was asked if she had worked on the evening shift on 11/27/12. She said she had worked that evening. She was asked what had occurred with (resident #5's Name deleted). The CMA said LPN #3 had told her to give the resident [MEDICATION NAME] sulfate because the resident was 'hollering out from her leg hurting.' The CMA said she had drawn the [MEDICATION NAME] up in a syringe and given it sublingual to the resident around 4:30 p.m. The CMA was asked why she had not signed out on the MAR that [MEDICATION NAME] had been administered and documented on the PRN medication form. The CMA said it was right at supper time and it was very hectic. She said she had planned on going back and initialing the administration and then to document on back of the PRN medication form. She stated, I guess I just forgot to. The CMA was shown the [MEDICATION NAME] on the November MAR and asked her whose initials those were on the 27th. The CMA said that the initials were (Name deleted CMA #2's). She stated, (Name deleted CMA #2) had given the resident an a.m. dose. The CMA said the [MEDICATION NAME] she had given had helped the resident because 'she had seen the resident in the dining room later and the resident was not hollering out anymore.' The CMA was asked if she had documented pain relief somewhere. She said she was busy and had not documented anything. She was asked who should document the results. The CMA said either she or the LPN should. 2. A quarterly assessment, dated 10/04/12, for resident #6, documented the resident was moderately cognitively impaired, needed assistance with ADLs, and had no skin conditions. A nurse's note, dated 11/10/12, documented, Approximately 9 cm reddened area to left outer wrist observed, intact blisters observed to area, resident denies pain & states she doesn't know what happened. Area left open to air. A nurse's note, dated 11/11/12, at 9:00 a.m., documented, Red area to L wrist still present. Some blisters had busted. Skin dry, area cleansed & left open to air. There was no documentation in the medical record where the physician had been notified or an order for [REDACTED]. There was not a skin assessment in the medical record for the resident. On 12/06/12, at 2:32 p.m., LPN #2 was asked if there was a skin assessment for the resident that included the blisters. The LPN looked through the 'Skin Book' and said there was not a skin assessment for the resident. The LPN said she was not aware the resident had any blisters. On 12/06/12, at 2:33 p.m., the resident was observed to be lying in bed under a blanket with her eyes open. The resident did not verbalize when spoken to. LPN #2 was asked to uncover the resident's arms. The resident's left outer arm right above the wrist had a smooth faint pink elongated area approximately 1 cm x 0.5 cm in size. On 12/06/12, at 3:00 p.m., LPN #1 was asked if she contacted the physician to receive a treatment order. She said she didn't, but should have. On 12/06/12, at 6:30 p.m., the DON was asked if the physician should have been notified and a treatment obtained after the blisters were discovered on the resident's arm. She said she had told LPN #1 who discovered the blisters to call the Dr. The DON said on Monday (11/12/12) when she learned the weekend nurse (LPN #1) had not notified the Dr., she told the nurse on duty (LPN #2) to notify the Dr. and get a treatment order.

On 06/28/11, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide pudding thickened liquids during a medication pass. The resident (#5) was at high risk for aspiration with documented swallowing studies which indicated laryngeal penetration of liquids. The resident had physicians' orders for pudding thickened liquids. On 06/28/11 at 3:45 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified. At 3:50 p.m., the ADM and the DON were notified of the IJ situation which constituted substandard quality of care. At 5:30 p.m., an acceptable plan of removal was presented to the survey team. The plan of removal was as follows: "Plan for Removal of Immediate Jeopardy 6/28/11 1. All new nursing employees will be oriented to the Thickened Liquid Policy and Procedure upon hire prior to providing care to the residents. Orientation will include how to mix pudding thickened liquids and the use of pre-thickened nectar and honey consistency beverages. 2. A bright colored list of resident's requiring Thickened Liquids with the consistency ordered will be placed in the front of each MAR Book and an individual bright colored alert page will be placed in the front of each resident's MAR with the Thickened Liquid consistency required. 3. All current new nursing department employees hired within the last 60 days will be inserviced on the Thickened Liquid Policy and Procedure as well as how to thicken to pudding consistency and the use of pre-thickened nectar and honey thickened beverages by midnight tonight. 4. New CMA orientation to the medication pass will include side-by-side supervision and instruction for no less than 2 days regardless of previous experience and/or level of education by a previously trained licensed nurse. 5. Following at least 2 days of new employee CMA orientation to medication pass, the 3rd day will include Skills Observation Competency Test by a Nurse Manager / Educator designated by the DON. 6. Thickened Liquid Order will be added to each page of resident's MAR, for resident's requiring Thickened Liquids, to be an additional alert for medication pass. 7. Any employee who fails to pass a skills observation competency test will have at least 2 more days of orientation on medication cart. If unable to pass the second time, they will not be allowed to work as a medication nurse." The IJ was removed on 06/29/11 at 10:00 a.m., after the facility provided documentation to show all staff in the building had been inserviced. The staff were also interviewed to determine their knowledge regarding the thickened liquids. The deficiency remained at a pattern level with a potential for more than minimal harm. Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure a resident who was at high risk for aspiration and had physicians' orders for pudding thickened liquids, was offered pudding thickened liquids to take his medications for one (#5) of one sampled resident with pudding thickened liquids ordered. The facility also failed to ensure the medication administered to a resident was honey consistency, as ordered by the physician for one (#6) of three sampled residents identified with swallowing problems. This had the likelihood to affect nine residents who had been ordered thickened liquids by their physicians per dietary orders. b) Ensure water was not above 120 degrees Fahrenheit in three residents' rooms (#1, 11 and #12) on Hall 1. A wandering resident on Hall 1 was observed to be able to turn on a hot water faucet. This had the potential to affect one resident identified by the DON, as someone who would wander into residents' rooms and bathrooms. c) Provide a toileting program for one (#11) of one sampled resident who had been assessed with [REDACTED]. This had the potential to affect 26 residents who required the assistance of one or two staff to toilet, per the Resident Census and Conditions of Residents report. d) Ensure a table placed beside a resident's bed had been removed after the resident had fallen out of bed and had hit her head on the table for one (#11) of eight sampled residents experiencing falls. This had the potential to affect 27 residents dependent on toileting assistance, per the Resident Census and Conditions of Residents report. Findings: The facility's policy and procedure for "Thickened Liquids" follows: "Policy: All residents with a physician's orders [REDACTED]. Procedure: Obtain physician's orders [REDACTED].e., honey, nectar. Dietary will send out cups of pre-thickened liquids at the ordered consistency on the hydration/snack cart tid for each resident with a physician's orders [REDACTED]. During the hydration/snack cart pass, the nursing staff will offer each resident with an order for [REDACTED]. During the hydration/snack cart pass, the CNA will also add the TL to the resident's clearly marked pitcher for drinking in between meals and snacks. AT NO TIME IS ICE TO BE ADDED TO THE THICKENED LIQUID. If the resident prefers the TL to be cold, ice may be added to a bowl that the pitcher can sit in to keep cold. The night shift will offer TL to each resident 2 x night at a minimum and as desired or needed. Extra TL will be kept in a nursing area for use. A sign will be posted in each resident's room above the bed. The resident's water pitcher will be different than all other resident's with thin liquids and have a stop sign on the pitcher as a reminder to staff and visitors. All staff will be trained on this procedure during orientation." 1. Resident #5 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A Comprehensive Swallow Report, dated 03/01/11, was located in the resident's medical record. The report had been completed while the resident was in the hospital. The report documented, "Aspiration -Yes, Significant (>10%) aspiration of nectar, A-Sauce, secretions. Diet recommended non-Oral due to silent aspiration." The "Admission Start-up Orders," dated 03/02/11, documented, "...Diet: Pureed c Pudding Thick Liquid..." The Face Sheet in the resident's medical record had the resident's diet listed as Regular. There was no mention of the resident being on pudding thickened liquids. A physician's progress note, dated 03/09/11, documented, "...Aspiration Refused NG tube." A Speech Pathologist Note, dated 04/19/11, documented: "Education/Recommendation/Referrals Following Information Provided to: Patient, therapist, nursing, family, physician P.O. for all meals Compensatory Strategies/Swallow Precautions Body Position: Seated upright... Refer Patient To / For: Speech Pathologist for Dysphagia therapy Primary physician to Consider alternative method of feeding Chest X-Ray with follow-up in 3 days Compensatory Strategies / Swallow Precautions Body Position: Seated upright Head Position: Neutral Liquids from: Spoon Multiple swallow 2 times after each bite Small bites / Sips 1/2-1/3 tsp. Pt at high risk for aspiration c all PO intake." A Dysphagia Medical Work-Up - Clinical Evaluation, dated 04/19/11, documented: "Medical Diagnosis: [REDACTED]. I have examined the above patient and found him to have a swallow disorder involving the Pharyngeal, Oral and Esophageal Phase. Alert & cooperative. History of: Aspiration problems, aspiration pneumonia Definite risk for: Aspiration, chronic aspiration, nocturnal aspiration, aspiration pneumonia, choking, delayed or slow swallow reflex, wet or gurgling voice swallowing liquids. Oral food retention. Existence of other conditions such as: Cricopharyngeal dysfunction, Reduced or inadequate laryngeal closure Reduced or inadequate laryngeal elevation." On 05/01/11 to 05/07/11, speech therapy, documented, "...Pt. unsafe c PO intake secondary chronic aspiration but has refused alt. (alternative) means of nutrition/hydration. Educated pt..." A significant change assessment, dated 05/05/11, identified the resident had short and long term memory loss and had severe cognitive impairment problems. The "Narrative Report," dated 05/17/11, documented, "Nutritional Status: ...Diet order is puree with pudding thickened liquids with double portions...He is a high risk for aspiration with all PO intake. Continue to watch for aspiration precautions as well as reflux precautions. All staff has been alerted and in services have been done and is stressed all the time about his swallowing..." The resident's care plan, dated 05/20/11, documented: "Problem ...My diet order is puree with pudding thick liquids with double portions...I am at high risk for aspiration with all PO intake..." The physician's orders [REDACTED].***Thickened liquids*** Pudding Thickened Liquids." On 06/28/11 at 12:05 p.m., CMA #2 was observed taking the resident his medications in the dining room. The medications were mixed in applesauce. The CMA was carrying the medications in one hand and a cup of unthickened water in his other hand. The CMA gave the resident his medications mixed in the applesauce and then asked the resident if he would like a drink of water. The resident said, "Yes," so the CMA gave the resident the cup of unthickened water to take a drink. The resident took a couple of swallows of the unthickened water. The resident was not observed to choke. At 1:20 p.m., the CMA was interviewed. He was asked how long he had been working in the facility. The CMA said it was just his second day and he was still in training. The CMA was asked where his trainer had been while he had been administering the residents' medications. He said it was LPN #2 and he didn't know where she was while he was passing the medications. The CMA was asked if a resident was on thickened liquids how would he know. The CMA said it would be documented on the resident's MAR. The CMA was asked if he had been inserviced on thickened liquids and how to make the correct consistency. The CMA said he had not been inserviced, but stated, "I know how thick to make nectar from school." The CMA was asked if his trainer (LPN #2) had shown him where the thickener was located and how to check to see what resident was on thickened liquids. The CMA was asked if (Resident #5) was supposed to get thickened liquids. The CMA, stated, "Yes. I just made a mistake and poured him regular water." The CMA was asked if he had noticed the resident had thickened water setting next to his food plate. The CMA stated, "No. I didn't." The CMA was asked where his trainer had been during the time he poured the resident regular water to drink and mixed the medications in applesauce, instead of pudding. The CMA said a nurse had left the dining room and LPN #2 had to go help out in the dining room. At that time, LPN #2 came to watch the CMA pass medications. She was asked how she trained the CMA. She stated, "I usually go with him, but not everytime. I stay around the cart." The LPN was then informed of resident #5 getting his medications in applesauce and then being given unthickened water to drink. The LPN stated, "I pointed out the resident and told him (the CMA) who he was." The LPN was asked how would the CMA know the resident had an order for [REDACTED]. The LPN stated, "I didn't see him (the CMA) take the regular water. It may have slipped my mind." On 06/28/11 at 12:40 p.m., the DON was asked how the staff knew what consistency of liquids to give the residents. The DON said there was a list of residents on thickened liquids in the dining room, and in the kitchen. Another list was also on the salad bar. All the MAR's have documentation of who is on thickened liquids. On 06/28/11 at 2:00 p.m., CNA #4, who was working on Hall 4 where the resident resided, was interviewed regarding thickened liquids. She was asked what consistency of liquids (Resident #5) was to have. The CNA said she knew it was thickened, but did not know the consistency. The CNA said there was a sign by the resident's bed and on his cup. The CNA said the resident would get his thickened water when ice was passed. The CNA said the kitchen had the liquids already pre-thickened. The CNA said the resident could drink out of the cup by himself but stated, "I offer it to him as I do rounds every 1-2 hours or so." At 2:40 p.m., the DON was asked about pre-mixed jugs of thickened liquids. The DON said they had nectar and honey thickened premixed. She stated the powdered thickener had to be added to the honey consistency to make pudding thickened liquids. On 06/28/11 at 3:00 p.m., the DON was interviewed regarding the residents who were ordered thickened liquids. The DON was shown the MAR, where the only place the thickened liquid was documented, was on the very first page of the MAR. The thickened liquids were not highlighted to draw attention to the order. The DON said the thickened liquids needed to be on every page and needed to be highlighted. The DON was asked how long a CMA was trained before passing medications alone. The DON said 2 weeks if they were brand new, and 1 week if they had worked and knew the residents. The DON was informed of the new CMA being left alone and giving resident #5 a drink of unthickened water. The DON stated, "She (LPN#2), should not have left him alone. The DON was asked if he (CMA #2) should have known to look in the MAR and locate if the resident was to get thickened liquids. The DON stated, "Yes. He should have known." The DON was asked if the CMA had been inserviced on how to thicken liquids. The DON stated, "No." The DON reported support staff passed the liquids and the list was in the rooms. She stated only the dietary department served drinks along with the CMA's and the nurses. On 06/28/11 at 3:20 p.m., CMA #2 was interviewed. The CMA was asked what he had been taught on the thickened liquids. The CMA stated, "I know to look on the bottom of the cart for the pre-thickened liquids. If not there, the kitchen has supplies. I knew to look on the Face Sheet on the MAR for thickened liquids. I just made a mistake and the LPN didn't notice." The CMA was asked why he had used applesauce for the pill mixture. The CMA stated, "I don't know. I guess I should have mixed it in pudding." 2. The medical record for resident #6 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A dysphagia assessment, dated 11/17/10, documented the resident had moderate oral delay, moderate pre-spillage and mild delayed swallowing with nectar consistencies. A quarterly assessment, dated 04/22/11, documented the resident had moderately impaired cognition, required total assist with ADLs and had dysphagia. The resident's care plan, dated 08/24/10, documented the resident had dysphagia and was to receive a mechanical soft diet with honey thick liquids. The June 2011, physician's orders [REDACTED]. The first page of the MAR for June 2011, documented the resident was to receive honey thickened liquids. The MAR also documented the resident was to receive Miralax 25cc in 4-8 oz of fluid and Arginaid 1 packet. On 06/28/11 at 12:10 p.m., CMA #2 was observed preparing the medications for the resident. The CMA reported he was new and was in training. The CMA reported a nurse was training him. The CMA was observed to set up and crush four medications for the resident. There was not an LPN present while the CMA was setting up the medications. The CMA then mixed Miralax into a glass of water. He also placed the Arginaid packet into another glass of water. LPN #2, who was in the dining room, looked around the corner and asked the CMA how he was doing. The LPN then came to the medication cart. The CMA started toward the dining room with the medication. The LPN stopped the CMA and told him the liquids would have to be thickened by the dietary staff. The LPN took the two glasses with the medications to a dietary staff in the dining room. The dietary staff was informed the liquids needed to be thickened. The dietary staff placed a scoop of thickener in each glass and stirred. She then stated she did not know how thick to make the liquids. The LPN went to check the thickness. The LPN informed the dietary staff the liquids were to be honey thick. After the liquids had been thickened the CMA took them to the resident who was sitting at a table in the dining room. The CMA placed the liquids in front of the resident. The resident took a sip of the Miralax and was observed to cough. The resident then sipped the Arginaid. The Miralax and the Arginaid were checked for consistency and found to be nectar thick instead of honey. LPN #2 was shown the liquids, and was asked what consistency the liquids were. The LPN reported, it appeared to be nectar. She reported, it needed to be thicker. The LPN reported, it was hard to get the Miralax to a honey consistency. The LPN took the remaining Miralax and had additional thickener added. The consistency continued to remain a nectar consistency. At 1:20 p.m., CMA #2 was interviewed regarding the administration of the two liquid medications to the resident. The CMA reported the liquids were not thick enough and could have used more thickener. He was asked if the LPN was supposed to be with him at the cart when he was passing meds. He reported she had gone into the dining room to watch the residents, while the other nurse had gone on an errand. At 3:00 p.m., the DON was interviewed regarding the observation of the resident during the medication administration at lunch, and receiving the wrong consistency of fluids. The DON was asked how the CMA would know what the consistency of the fluids for the resident should be. The DON reported it was on the front sheet of the MAR. The DON reported she would talk to the staff regarding the residents on thickened liquids. 3. Resident #11 was admitted to the facility on [DATE]. On 03/31/11, an admission assessment documented the resident had inadequate short and long term memory, had severely impaired cognition, required limited assistance with bed mobility and transferring between surfaces, required extensive assistance with ambulation and was always incontinent of bowel and occasionally incontinent of bladder. On 04/17/11, a care plan documented, "Problem: My mind doesn't work as well as it use too. I am very forgetful and confused most times..." The June 2011, physician's orders [REDACTED]. On 06/11/11 at 11:00 a.m., a nurse's note documented the resident was wandering in and out of rooms. On 06/28/11 at 6:00 p.m., the hot water temperatures were checked by the survey team. The following were observed: Room #1 hot water temperature was 123 degrees F. Room #11 hot water temperature was 125 degrees F. Room #12 hot water temperature was 124 degrees F. On 06/28/11 at 6:15 p.m., CNA #3 was interviewed. The CNA was asked if she had any residents who wandered about the facility. She reported resident #11 was W/C bound but would go into other residents' rooms. She also reported she was not sure that the resident could turn on the water. She stated if she did turn the water on, she wouldn't know to turn the cold water on with it to prevent being burned. At 6:25 p.m., the staff was asked the location of resident #11. In approximately 10 minutes, the resident was found in another resident's room in the bathroom with the door closed. At 6:30 p.m., the DON was asked if the resident was able to turn the water on unassisted. The DON was observed to roll the resident over to the sink in the resident's room. The resident reached for the hot water faucet with her left hand and turned on the faucet. At that time, the DON turned off the hot water to prevent the resident from getting burned. At 7:00 p.m., the ADM was interviewed regarding the hot water temperatures. She reported she would turn the hot water tank down. 4. On 03/21/11, an evaluation for bowel and bladder training documented resident #11 required limited assistance from staff with toileting needs, did not need bowel and bladder training and just needed assistance with hygiene related to frequent UTIs. On 04/05/11 at 4:25 a.m., an incident report and nurses' note documented the resident had been on the floor in the hallway; had sustained a skin tear to the left forearm and stated she was going to the bathroom. The steps to prevent reoccurrence included bed alarm, steri strips to the skin tear on her arm and neuro checks. On 04/08/11 at 8:15 a.m., an incident report and nurse's note documented the resident had attempted to stand up from her W/C and the W/C had rolled backward causing the resident to sit on the floor. The steps to prevent reoccurrence were for the resident to be toileted every 2 hours during the day and evening. On 04/08/11, a toileting form documented the resident was toileted every 2 hours from 4:00 p.m. till 6:00 a.m. During this time, the resident had been continent of urine and had a large bowel movement. On 04/09/11, a toileting form documented the resident had been toileted every 2 hours from 6:00 a.m. till 2:00 p.m. She had been incontinent of urine one time and continent the remainder of the time. The resident was not toileted again until 10:00 p.m. through 6:00 a.m., during this time the resident was continent of urine. On 04/10/11, a toileting form documented the resident had been toileted every 2 hours from 6:00 a.m. through 2:00 p.m. The resident had been incontinent of urine one time and continent the remainder of times. The resident was not toileted the rest of the day. On 04/11/11, the facility did not have documentation of the resident being toileted. On 04/12/11, a toileting form documented the resident had been toileted every 2 hours. The resident had been incontinent of urine one time and continent the remainder of day. On 04/13/11, a toileting form documented the resident had been toileted sporadically throughout the day. The toileting sheet did not contain documentation of the resident being incontinent of bowel or bladder. On 04/14/11, a toileting form documented the resident had been toileted sporadically throughout the day. The toileting sheet did not contain documentation of the resident being incontinent of bowel or bladder. On 04/17/11, a care plan documented: "Problem: I am not able to do things for myself as I used too. Since I have been so confused and forgetful. I require supervision to extensive assist with my ADL...I have some trouble getting to the bathroom in time and end up dribbling on myself. Approach: Help me to the toilet often so maybe I won't have an accident. If I do, help me clean up and make sure my cloths are clean and dry..." On 04/29/11, a nurse's note documented, "Resident admitted ... this resident has issues c memory related to short & long term recall, resident must be continually remained of things and this doesn't work c this resident, noted behaviors by this resident is leaning forward, reaching side to side. Dr (Name deleted) notified of these behaviors. N.O. seat belt safety restraint while up in W/C. resi wears glasses to accommodate for difficulty seeing. Resident had 3 falls in April." On 04/29/11, a telephone physician's orders [REDACTED]." On 05/04/11 at 12:45 a.m., an "Incident/Accident Report," documented: "Observed res scooting on floor away from bed. Assessed for injury s injury noted. Bed was in low position at time of event. Bed alarm & floor mat in place but did not sound off. Recheck done on alarm et functioning w/out further problems. Steps to prevent reoccurrence: Recommend lab c UA et C&S as no recent data on chart. Bed placed in lowest position on c use of floor mat." On 05/17/11 at 11:00 a.m., an Incident/Accident Report documented, "Summoned by nurse aide of resident lying on floor next to bed. Resi stated, 'I wanted to be in bed.' Denies pain/discomfort. Steps to prevent reoccurrence: Cont c personal alarm & safety belt. Instructed staff to check hourly." On 05/17/11, a telephone physician's orders [REDACTED]." On 05/27/11 at 12:00 a.m., an Incident/Accident Report documented: "Personal alarm alerted staff to res room. Observed res on floor in sitting position. Assessed for injury noting hematoma to frontal cephalic region et skin tear to (R) lateral olecranon. Skin tear to (r) decanoin cleansed c NSS et gauze. Covered c nonstick telfa et OpSite. Ice pak to frontal cephalic regions... Neuro checks implemented... personal alarm intact and functioning properly, floor mat in place, bed in lowest position. Ice pack q 15 min on q 15 min off...Steps taken to prevent recurrence: Neuro checks, ice pack on 15 min, off 15 min- personal alarm on & function- low bed c mat in place q 30 min checks reminder of night r/t increased restlessness." The resident had experienced three falls between midnight and 1:00 a.m., during the time the resident was not on a toileting plan. The toileting sheets documented the resident had been continent of urine during the hours of night. On 06/30/11 at 3:00 p.m., the DON was interviewed. The DON was shown the consistency of time of falls and the toileting sheets. She reported she had noticed the consistency of times of the falls also. That was when she had the staff to start the toileting plan with the resident. The documentation was reviewed by the DON. The DON reported the resident was urinating every 2 hours and the falls had resolved. The DON then stated, "I don't know why she is not still on the toileting program. The girl that takes care of that is off work due to having a baby." 5. On 04/17/11, a care plan for resident #11 documented: "Problem: I can be unsteady on my feet and I have fallen recently, so I could fall again... Approach: Report any unsafe behaviors that could lead to falls so additional safety approaches can be implemented." On 04/24/11 at 12:30 a.m., an incident report and a nurse's note documented the resident had a hematoma to the right side of her face from climbing out of her bed and hitting her face on the dresser. At the time of the fall, the resident's personal alarm was noted as being activated. The steps to prevent reoccurrence included a hospital visit and the furniture in her room being re-arranged with the dresser away from the bed and obtaining a low bed and a mat beside the bed. On 04/24/11, a telephone physician's orders [REDACTED]. "Send to ER to eval & treat." On June 2011, the physician's orders [REDACTED]. "Low Bed: Low bed with mats on floor beside bed..." On 06/30/11 at 3:00 p.m., the resident's room was observed to have a bedside table next to the bed and the mat beside the bed was approximately 1/3 the size of a full size mat. On 06/30/11 at 3:30 p.m., the DON was shown the bedside table and the mat. She reported the falls had happened when the resident was first admitted . The resident had brought her bedroom furniture from home with a full size bed and a dresser in the room. Since that time, the facility had sent her furniture home with family and the resident was utilizing facility furniture. The DON stated, "That bedside table needs moved away from the bed and we will find her a full size mat for the floor beside the bed."

Based on record review, observation and staff interview, it was determined the facility failed to notify the resident's physician of the resident's low blood pressures of 89/46, 93/46, 86/54 and 78/47 for one (#18) of nine sampled residents taking hypertensive medications. This had the potential to affect 32 residents on blood pressure medications per the DON. Resident #18 had been admitted to the facility, on 06/27/11. The resident's [DIAGNOSES REDACTED]. The resident's baseline blood pressure on admission was 113/72. The resident had not been in the facility long enough for an MDS or careplan to be completed. The resident's medications for the [DIAGNOSES REDACTED].= 80 mg. QD, [MEDICATION NAME] 6.25 mg 2 to = 12.5 mg QD and [MEDICATION NAME] 5 mg. 1 PO QD." On 06/28/11, on the evening shift, a skilled nurse's note documented the resident's B/P of 93/46. There was no documentation the physician had been notified of the low B/P. On 06/29/11, on the day shift, a skilled nurse's note documented the resident's B/P of 89/46. There was no documentation the physician had been notified of the low B/P. On 06/30/11, on the day shift, a skilled nurse's note documented, "B/P 86/54. Spoke with wife about low B/P. States res B/P runs low. Will cont. to monitor..." There was no documentation the physician had been notified of the low B/P. On 07/01/11, during the night shift, the resident's B/P registered 78/47. There was no documentation the physician had been notified of the low B/P On 07/01/11, during the day shift, a nurse documented, "Checked B/P reading was 66/34...Paged for (Dr's Name deleted). He is out of office. Will be in (Name of town deleted) at 1:45 p.m. Rechecked B/P @ 11:15 a.m. B/P was 80/50, after taking [MEDICATION NAME]. Spoke with DON and (Name deleted) got ahold of (Dr's Name deleted). N/O to send to ER..." On 07/01/11 at 11:00 a.m., the surveyor observed some activity going on in the hallway near the resident's room. The surveyor observed a family member of the resident, go down the hall with a staff member. The family member was overheard telling the staff member she would like the resident's B/P retaken. On 07/01/11 at 11:05 a.m., the family member was interviewed. The family member was asked if there was a problem. The family member said the resident's B/P had been 66/44 earlier and the resident didn't feel like going to therapy. The family member was concerned. The resident was observed lying in bed. The family member was asked if the facility had reported the resident's low B/P's of the past few days. The family member stated, "No." At 11:15 a.m., LPN #2, who had given the resident his morning B/P medications was asked if she had taken the resident's B/P before giving him his hypertensive medication that morning. The LPN stated, "It doesn't say to take it (the blood pressure)." The LPN was asked if she realized the resident had a low B/P reading the night before. She said she had not heard about it. The LPN stated, "If I had known it had been low last night, I would have held the B/P medications and called the doctor." The LPN said she only got a partial report from the night nurse and then was put on the medication cart. On 07/01/11 at 11:20 a.m., LPN #1 was interviewed. The LPN had taken report that morning on the resident. In report she said it was reported his B/P had been low the night before. The LPN said she had not known LPN #2 had started passing medications or she would have warned the LPN about the resident's low B/P reading the night before. At 3:00 p.m., the resident returned from the ER with the following orders, "Continue current care. Hold [MEDICATION NAME] ([MEDICATION NAME]). Monitor B/P q 4 hours. Contact (Physician's Name deleted) PRN. Humidify O2 supply."

Based on record review, observation and staff interview, it was determined the facility failed: a) To ensure blood pressures were monitored for residents receiving antihypertensive medications and ensure a resident's blood pressure remained in a therapeutic range for two (#12 and #18) of nine sampled residents with hypertension. This resulted in harm for resident #18 who was given an antihypertensive medication without checking the resident's B/P. The resident's blood pressure had been low the previous shift. This resulted in the resident having to be sent to the hospital with [MEDICAL CONDITION]. This had the potential to affect 32 residents identified by the DON as receiving antihypertensive medications. b) To ensure the resident's pulse rate was monitored, as ordered by the physician, before administering [MEDICATION NAME] for one (#12) of nine sampled residents with hypertension. This had the potential to affect 32 residents identified by the DON as receiving antihypertensive medications. c) To ensure the resident's pain was monitored after administering pain medication and ensure the resident's pain was relieved and/or determine if the resident might require additional pain relieving measures for two (#7 and #12) of nine sampled residents identified with pain. d) To ensure the reason and the time of administration of a pain medication was documented on the MAR making it possible to identify when the medication could be administered again for one (#12) of nine sampled residents identified with pain. This had the potential to affect 57 residents identified by the DON as receiving pain medications. The facility's pharmacy policy documented, "Always document your PRN medications at the time you administer them and remember to document reason for the administration, quantity (# of tablet if order allows choice) and effectiveness." Findings: 1. Resident #18 had been admitted to the facility, on 06/27/11. The resident's [DIAGNOSES REDACTED]. The resident's baseline blood pressure on admission was 113/72. The resident had not been in the facility long enough for an MDS or careplan to be completed. The resident's medications for the [DIAGNOSES REDACTED].= 80 mg. QD, [MEDICATION NAME] 6.25 mg 2 to = 12.5 mg QD and [MEDICATION NAME] 5 mg. 1 PO QD." On 06/28/11, on the evening shift, a skilled nurse's note documented the resident's B/P of 93/46. There was no documentation the physician had been notified of the low B/P. On 06/29/11, on the day shift, a skilled nurse's note documented the resident's B/P of 89/46. There was no documentation the physician had been notified of the low B/P. On 06/30/11, on the day shift, a skilled nurse's note documented, "B/P 86/54. Spoke with wife about low B/P. States res B/P runs low. Will cont. to monitor..." There was no documentation the physician had been notified of the low B/P. On 07/01/11, during the night shift, the resident's B/P registered 78/47. There was no documentation the physician had been notified of the low B/P On 07/01/11, during the day shift, a nurse documented, "Checked B/P reading was 66/34...Paged for (Dr's Name deleted). He is out of office. Will be in (Name of town deleted) at 1:45 p.m. Rechecked B/P @ 11:15 a.m. B/P was 80/50, after taking [MEDICATION NAME]. Spoke with DON and (Name deleted) got ahold of (Dr's Name deleted). N/O to send to ER..." On 07/01/11 at 11:00 a.m., the surveyor observed some activity going on in the hallway near the resident's room. The surveyor observed a family member of the resident, go down the hall with a staff member. The family member was overheard telling the staff member she would like the resident's B/P retaken. On 07/01/11 at 11:05 a.m., the family member was interviewed. The family member was asked if there was a problem. The family member said the resident's B/P had been 66/44 earlier and the resident didn't feel like going to therapy. The family member was concerned. The resident was observed lying in bed. The family member was asked if the facility had reported the resident's low B/P's of the past few days. The family member stated, "No." At 11:15 a.m., LPN #2, who had given the resident his morning B/P medications was asked if she had taken the resident's B/P before giving him his hypertensive medication that morning. The LPN stated, "It doesn't say to take it (the blood pressure)." The LPN was asked if she realized the resident had a low B/P reading the night before. She said she had not heard about it. The LPN stated, "If I had known it had been low last night, I would have held the B/P medications and called the doctor." The LPN said she only got a partial report from the night nurse and then was put on the medication cart. On 07/01/11 at 11:20 a.m., LPN #1 was interviewed. The LPN had taken report that morning on the resident. In report she said it was reported his B/P had been low the night before. The LPN said she had not known LPN #2 had started passing medications or she would have warned the LPN about the resident's low B/P reading the night before. At 3:00 p.m., the resident returned from the ER with the following orders, "Continue current care. Hold [MEDICATION NAME] ([MEDICATION NAME]). Monitor B/P q 4 hours. Contact (Physician's Name deleted) PRN. Humidify O2 supply." 2. The medical record for resident #12 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A significant change assessment, dated 04/11/11, documented the resident had moderately impaired cognition, required extensive assist with ADLs, had a [DIAGNOSES REDACTED]. The resident's care plan, dated 04/17/11, addressed the resident's need for assistance with ADLs. At the bottom of the approach list a handwritten entry documented, "[MEDICATION NAME] 25 mg at bedtime." The June 2011, physician's orders [REDACTED]. The order documented to check the resident's pulse and hold the medication if below 60. There was also an order [REDACTED]. On 06/22/11, an order was written for the resident to receive [MEDICATION NAME] 50 mg q AM for HTN. The MAR was reviewed for documentation of the resident's B/P and pulse. The area under the B/P medication did not address the resident's blood pressure. There was no documentation on the front of the MAR, the B/P was monitored to ensure a therapeutic range was maintained. There was no documentation of the resident's pulse on the MAR as ordered, before the administration of the [MEDICATION NAME]. On 06/14/11, the resident's vital signs were documented on the back of the MAR. The resident's B/P was 135/90. Also documented on the back of the MAR was an entry dated 06/16/11 at 10:00 a.m., which documented the B/P as 174/90. An entry on the back of the MAR at 1:00 p.m., that afternoon, documented the resident had requested his B/P be taken. The resident's B/P was 161/90. There was no further monitoring documented to address the elevated B/P readings, to ensure the resident's B/P had gone down. There was no therapeutic range for the resident's B/P documented. The nurses' notes were reviewed for any documentation of blood pressure monitoring. The nurses' notes did not document the resident's blood pressure was being monitored. On 06/30/11 at 9:45 a.m., the resident was observed in his room. The resident was upset and reported he had not received his blood pressure medication. He reported he should have taken his medication at breakfast. At 5:50 p.m., the DON was interviewed regarding the lack of monitoring of the resident's blood pressure. The resident was receiving three different blood pressure medications. The DON reviewed the resident's MAR and reported the blood pressure should have been monitored. The DON reported it should have been added to the MAR, so the CMA's would know to obtain the blood pressure and document it on the MAR. 3. The medical record for resident #12 documented the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE], documented the resident had moderately impaired cognition, required extensive assist with ADLs, had a [DIAGNOSES REDACTED]. The resident's care plan dated 04/17/11, documented the resident could have pain due to his disease. Approaches included asking the resident if he is in pain every shift and administering pain medications as ordered, or a change in his position for comfort. The care plan listed Tylenol 325 mg two tabs every four hours prn pain, [MEDICATION NAME] 250 mg one daily and [MEDICATION NAME] 50 mg every 4 hours. The June 2011, physician's orders [REDACTED]." The June 2011, MAR documented the resident had received the above scheduled medications and had received the prn Tylenol, 13 times. The back of the MAR was reviewed for documentation regarding the administration of the Tylenol. There was no documentation of what time the medication had been administer, why the medication had been given or any results from the administration of the medication. The nurses' notes were reviewed for documentation of the Tylenol administration. The nurses' notes did not address the Tylenol or if the resident had experienced any pain. On 06/30/11 at 9:45 a.m., the resident was observed in his room. The resident was upset and reported he had not received his medications. He reported he should have taken his medication at breakfast. On 06/30/11 at 9:50 a.m., LPN #4 was interviewed regarding the administration of the Tylenol. The LPN reported the charge nurse was suppose to do a pain assessment before a prn pain med was given. The LPN reported the LPNs were to document on the resident's pain every shift on the treatment sheet. The treatment sheet for June 2011, was reviewed for documentation of the resident's pain. The treatment sheet documented, "Pain score QS and PRN pain..." Each shift had documented, "0" for no pain during the entire month. On 06/30/11 at 5:25 p.m., the DON was interviewed regarding the lack of documentation, when the Tylenol was given, why it was given and if there was any results after the medication was given. The DON reported they should be documenting when and why the medication was given and what the results were. The DON was asked if it could have been documented somewhere else. The DON reported it would not be documented anywhere else and if it was not on the back of the MAR, then it was not done. 4. Resident #7 had been admitted to the facility on [DATE]. On 08/30/10, a care plan documented: "Problem: Due to multiple health issues I have the potential for pain. Goal: Pain level will remain in control. Approach: Administer pain meds/muscle relaxers per orders. Monitor pain level q shift..." On 11/30/10, the care plan had been updated documenting, "[MEDICATION NAME] Patch was dc' d." On 04/25/11, a quarterly assessment documented the resident had inadequate short term memory, adequate long term memory, had moderately impaired cognition, was on a PRN pain medication for pain which occurred almost constantly and was rated at a 7 on a 1-10 pain scale. The June 2011, physician's orders [REDACTED]. The orders also contained an order for [REDACTED]. The June 2011, MAR was reviewed. The resident had received the PRN [MEDICATION NAME] 7.5 mg 52 times during the month of June. The back of the medication record documented the reason for the medication being administered as body pain. The resident had reported the pain between 5 to a 9 on a scale of 1-10 (10 being the worse pain ever experienced). The pain medication had been administered 52 different times and there were only 11 times the pain had been documented as being relieved. There were 42 times the medication had been administered when no assessment for the relief of the pain had been documented. The residents pain had not been reassessed on a numeric pain scale to determine the efficacy of the pain medication. On 06/28/11 at 10:20 a.m., during the initial tour, the resident was observed sitting in a recliner in her room. The DON identified the resident as being on a pain management program. On 07/01/11 at 10:45 a.m., the corporate RN and DON were interviewed regarding the lack of documentation on the result of pain relief after the administration of the PRN pain medication. The RN and DON reported the current system was not a good way of evaluating the results of the pain medication. The corporate RN stated, "We will develop a better method, one with a number scale."