Every finding on record at Kingwood Skilled Nursing and Therapy

Based on record review and interview, the facility failed to clearly distinguish the arbitration agreement from the admission agreement and ensure residents or their representatives were able to sign the admission agreement without consenting to the facilities arbitration agreement.The administrator identified 68 residents resided in the facility. The administrator and the admissions coordinator identified 68 residents/representatives had agreed to arbitration.Findings:An Introductory Note, located on page 2 of the admission packet, read in part, This admission Agreement, including the Dispute Resolution Provision\Agreement, (the Agreement} represents an Agreement between the Resident, the Resident Representative (if applicable, as defined and to the extent explained herein and) [NAME] Skilled Nursing and Therapy.Item number 2 of the Dispute Resolution Provision\Agreement, located on page 21 of the admission packet, read in part, By entering into this agreement, both parties explicitly waive any right to have any Resident/Facility dispute decided in a court of law or equity, whether by or before a jury or by the court itself, and instead accept the use of neutral, binding arbitration as the sole means of dispute resolution.Item number 14 of the Dispute Resolution Provision\Agreement, located on page 24 of the admission packet, read in part, The Resident understands that agreement to arbitration by the resident is not a condition of admission to, or a requirement to continue receiving care at, the Facility. In other words, the resident has the right to reject arbitration and still be admitted to, or continue receiving care at, the Facility.The most recent assessments conducted for Residents' #2, 4, 5,13, 22, 23, 24, and 42 all showed the Residents had a BIMS score of 15, indicating intact cognition.The most recent assessment conducted for Residents' #17, 43, 75, and 85 all showed the Residents had a BIMS score of 14 indicating intact cognition. On 05/19/26 at 10:05 a.m., a resident council meeting was conducted between the surveyor and attendees which included Residents #2, 4, 5, 7, 13, 17, 22, 24, 31, 40, 51, 59, and #75. On 05/19/26 at 10:35 a.m., the consensus of the attendees of the resident council meeting was no one knew what an arbitration agreement was and they were unaware if they had signed one.On 05/20/26 at 9:56 a.m., the admissions coordinator stated if a resident did not want to sign the arbitration agreement, then the signatures would be stopped, and they would need to print the packet so the resident would not have to sign the arbitration agreement. The admissions coordinator stated they ensured residents understood their right not to sign the arbitration agreement by reading a script that stated the residents did not have to sign the arbitration agreement and they also had 30 days to rescind by written documentation. On 05/20/26 at 11:53 a.m., Resident #85 stated they had been in the facility a little over a year. Resident #85 stated they did not know what an arbitration agreement was and did not know if they had signed one. Resident #85 stated they went over the admission paperwork fast and they do not remember what was included. On 05/20/26 at 12:00 p.m., Resident #43 stated they had been in the facility for about eight months. Resident #43 stated the facility did not go through their paperwork for admission. Resident #43 stated they did not know what an arbitration agreement was and did not sign it. On 05/20/26 12:03 p.m., Resident #17 had been in the facility for about four years. Resident #17 stated they did not know what an arbitration agreement was and they do not remember anything about it. On 05/20/26 at 12:06 p.m., Resident #23 stated they had been in the facility for about six or seven years. Resident #23 stated they signed a bunch of stuff way back then. Resident #23 stated they did not know what an arbitration agreement was. On 05/21/26 at 11:46 a.m., the administrator stated a script was read to the residents when discussing the admission packet. The administrator stated If the resident says they understand, then I believe them. The administrator stated the arbitration agreement did not void the residents' rights to go to court because I have had lawsuits.On 05/21/26 at 12:00 p.m., Corporate Nurse Consultant #1 and #2 both stated signing an arbitration agreement did not take away the resident's rights.

Based on observation, record review, and interview, the facility failed to ensure:a. a discharge assessment was completed and transmitted for 2 (#25 and #54): b. an entry record was completed and transmitted for 2 (#54 and #81) of 17 sampled residents reviewed for timely encoding and transmitting of resident assessments.The administrator identified 68 residents resided in the facility. Findings: 1. The RAI manual, dated 10/2025, showed discharge assessments were to be completed no later than 14 days after the discharge. The assessment then must be transmitted no later than 14 days after the completion of the assessment. An admission assessment, dated 12/02/25, showed Resident #25 was admitted to the facility on [DATE] with a BIMS score of 11 which indicated moderate cognitive impairment. A nurse's progress note, dated 12/11/25 at 12:02 p.m., showed Resident #25 refused to enter the facility after returning from dialysis. A nurse's progress note, dated 12/12/25 at 12:10 p.m., showed Resident #25 had left the faciity on [DATE] without a proper discharge or their medications. The last assessment completed and transmitted was the entry tracking record, dated 12/09/25. There was no discharge assessment indicating Resident #25 had left the faciity on [DATE]. On 05/20/26 at 9:47 a.m., MDS Coordinator #1 stated Resident #25's discharge assessment should have been completed but was not. MDS Coordinator #1 stated they kept a calendar on their desk to track required assessments. MDS #1 stated the discharge assessment must have been missed by MDS Coordinator #2. 2. The Center for Medicare and Medicaid Services, Long Term Care Facility Resident Instrument 3.0 User's Manual, dated 10/2025, showed admission assessments must be encoded within 13 days of a resident's entry and transmitted within 14 days after a facility completes a resident's care plan assessment. A nurse's progress note, dated 02/26/26, showed Resident #54 left the facility with EMSA for the ER. Resident #54 was readmitted to the facility on [DATE]. There was no discharge return anticipated or reentry admission assessments completed for this date. A nurse's progress note, dated 03/15/26, showed Resident #54 was hospitalized . Resident #54 was readmitted to the facility on [DATE]. There was no discharge return anticipated or reentry admission assessments completed for this date. A nurse's progress note, dated 03/31/26, showed Resident #54 left the facility with EMSA to the ER. Resident #54 was readmitted to the facility on [DATE]. There was no discharge return anticipated or reentry admission assessments completed for this date. On 05/21/26 at 10:44 a.m., MDS Coordinator #2 stated Resident #54 was missing some MDS assessments, and they were behind and would get to them. MDS coordinator #2 stated the missing entry assessments should have been done. 3. A discharge return anticipated entry assessment, dated 04/13/26, showed Resident #81 was discharged from the facility and transferred to the hospital. A nurse's progress note, dated 04/17/26, showed Resident #81 returned from the hospital. There was no MDS entry assessment showing Resident #81 had returned to the facility. On 05/21/26 at 10:43 a.m., MDS Coordinator #2 stated they should have entered a record of entry upon Resident #81's return to the facility.

Based on observation, record review, and interview, the facility failed to provide nail care assistance for 1 (#20) of 4 sampled residents observed for ADLs.The administrator identified 68 residents resided in the facility. Findings:On 05/18/26 at 10:59 a.m., Resident #20 was observed lying in bed watching television. Resident #20's nails were observed to be long and had brown substance underneath. Resident #20 was observed trying to mumble a concern but could not be understood.On 05/21/26 at 11:33 a.m., Resident #20's nails were observed to be long and had brown substance underneath.A review of electronic health record from 2026 had no documentation Resident #20's family member had requested to come to the facility to provide nail trimming.Resident #20's undated medical record face sheet showed diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness following cerebral infarction, and dysarthria following cerebral infarction.An admission assessment, dated 04/15/26, showed Resident #20 needed partial/moderate assistance in shower/bathing, and needed substantial/maximal assistance in personal hygiene. The assessment showed Resident #20 had a BIMS score of 8, which indicated moderately impaired cognition.A care plan, dated 4/28/26, showed Resident #20 had a communication problem due to a diagnoses of dysarthria following cerebral infarction and facial weakness following cerebral infarction. The care plan did not include an ADL intervention for nail care. On 05/21/26 at 11:34 a.m., RN #1 stated Resident #20's nails looked like they had been growing for a month long. RN #1 stated some residents refuse nail care but would have to check if Resident #20 did.Om 05/21/26 at 1:18 p.m., CNA #1 stated they provided nail care for Resident #20 almost every day and did this by washing the resident's hands and cleaning under their nails with a nail care tool. CNA #1 stated they did not clip Resident #20's nails because the resident's family member requested to cut them and has told CNA #1 this.On 05/21/26 at 1:22 p.m., CNA #1 stated Resident #20's nails did not look clean and might have had food under them because the resident had just eaten.On 05/21/26 at 1:50 p.m., the DON stated their expectations for care nail from the CNAs were to clean and trim the nails for non-diabetic residents. The DON stated that nail care would be considered important for a resident who struggled to carry out ADLs. The DON stated CNAs told nurses if a resident refused nail care, and then staff tried to provide care again later or contact the resident's family for support. The DON stated they did not know about the resident's family member requesting to cut the nails and this would have to be care planned and they would need to add it in.

Based on observation, record review, and interview, the facility failed to ensure medications had a physician's order, were documented, and secured for 1 (#65) of 1 sampled resident observed for self-administration of medication.The administrator identified one resident self-administered medications in the facility. Findings:On 05/18/26 at 10:24 a.m., Resident #65 was observed sitting on their bed watching television with a bedside table full of supplements which included magnesium citrate 250 mg, black elderberry, Co Q-10 100 mg, Ashwagandha, and a fiber prebiotic.On 05/21/26 at 11:10 a.m., magnesium citrate 250 mg, black elderberry, Co Q-10 100 mg, Ashwagandha, and fiber prebiotic supplement medication bottles were observed on Resident #65's bedside table out in the open as before. Resident #65 was not observed in their room at this time, but their roommate was present.A review of Resident #65's active orders did not include those found on their bedside table or an order permitting the resident to self-administer medications.A facility policy titled Resident Self-Administration of Medications Guideline, dated June 2025, read in part, A written order from the physician is required to permit the resident to self-administer medications. The order should specify which medications may be self-administered. Self-administration of medications should be reflected on resident's care plan. Medications approved for self-administration must be stored safely and securely, either in resident's room (if safe to do so) or in a location accessible only to the resident and authorized staff.A medication self-administration assessment, dated 12/28/25, deemed Resident #65 safe to self-administer medications. The assessment did not list which medications were safe for the resident to self-administer.A quarterly MDS assessment, dated 03/31/26, showed Resident #65 had diagnoses which included pain due to internal orthopedic prosthetic device, history of falling, essential (primary) hypertension, and gastro-esophageal reflux disease without esophagitis. The assessment showed the resident had a BIMS score of 15, which indicated intact cognition.A care plan, dated 04/08/26, showed Resident #65 did not have a self-administration focus in place. On 05/18/26 at 10:24 a.m., Resident #65 stated they took their supplements to lose weight and maintain their health. They stated they did not get the chance to speak to their doctor about a weight loss regimen but were hoping to do so.On 05/21/26 at 11:14 a.m., RN #1, stated residents could not keep supplements in their room and all medication should be documented and kept in a medication cart. RN #1 stated if residents were taking medication that was undocumented, then the facility might not know what was going on if any negative health issues occurred. RN #1 stated they did not know Resident #65 had a bedside full of supplements and stated the resident was not allowed to have that. RN #1 stated CNAs were supposed to report to the nurses if they saw this kind of thing. RN #1 stated no residents have told them they were taking supplements to lose weight and all supplements a resident takes needs to have an order from their physician.On 05/21/26 at 1:50 p.m., the DON stated Resident #65 had purchased the medications today to take with them because they were getting discharged the next day and would not need an order or medication safety storage because they were getting discharged . The DON was informed Resident #65 was observed with the medications at their bedside since 05/18/26, to which the DON stated they did not know about this and the resident was known to go out and purchase supplements from a store near the facility.

Based on record review and interview, the facility failed to ensure an admission assessment was completed for 1 (#4) of 17 sampled residents reviewed for admission assessments. The administrator identified 68 residents resided in the facility. Findings: Centers for Medicare and Medicaid Services RAI Manual page 2-22, dated October 2025, read in part, The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. A discharge return anticipated entry assessment, dated 03/28/26, showed Resident #4 was discharged from the facility and transferred to the hospital. An MDS data entry assessment, dated 04/30/26, showed Resident #4 had returned to the facility. There was no comprehensive assessment for Resident #4's readmission to the facility. On 05/20/26 at 11:20 a.m., MDS Coordinator #1 stated Resident #4 should have had an admission assessment completed for readmission to the facility.

Based on observation, record review, and interview, the facility failed to ensure discontinued and expired medications were disposed of for 1 (#6) of 1 sampled resident whose medication was observed in the medication storage room refrigerator.The administrator identified one medication storage room in the facility. Findings:On 05/20/26 at 10:44 a.m., four syringes of Lorazepam Oral Concentrate (an anti-anxiety medication) 2MG/ML for Resident #6 were observed in the medication room. The Lorazepam Oral Concentrate had an expiration date of 05/05/26.A Storage of Medications policy, effective January 2022, read in part, All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining.A nurse's progress note, dated 02/24/26, showed Resident #6 received a new order for Lorazepam Oral Concentrate 2MG/ML 0.5 ml every four hours as needed. A physician's order, dated 02/25/26, showed Resident #6's Lorazepam Oral Concentrate was discontinued on 02/25/26.On 5/20/26 at 10:45 a.m., Certified Medication Aide #1 reviewed the expired Lorazepam Oral Concentrate and removed it from the refrigerator. They stated it should have been removed from the medication storage room when the medication was discontinued. On 05/20/26 at 3:05 p.m., the DON stated the Lorazepam Oral Concentrate should have been removed from the refrigerator in the medication storage room when it was discontinued, but no later than the same day it expired.

On 12/10/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure their abuse policy was followed. On 12/10/24, the Oklahoma State Department of Health verified the existence of an IJ situation. On 12/10/24 at 1:13 p.m., the administrator was notified of the immediate jeopardy situation. On 12/11/24 at 8:41 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal documented: On 12/10/24, The facility will ensure residents are free from abuse, neglect, and misappropriation of resident property and exploitation. 1) Resident #117 assessed by APRN for any signs of sexual abuse and orders to be followed for further treatment or evaluation. 2) Resident #53 was placed on one-on-one increased supervision on 12/09/2024 at approximately 12:30 p.m. 3) The OKC police department was notified of an allegation of sexual abuse on 12/09/2024 at 1:47 p.m. 4) All nursing staff were in-serviced on the abuse, neglect, and misappropriation policies and procedures and ensure residents are free from abuse, neglect, and misappropriation by midnight on 12/09/2024. Any nursing staff not currently in the facility will be in-serviced before returning to work. 5) Staff members interviewed regarding any allegations of sexual abuse on 12/09/2024 no allegations reported. 6) Safe survey interview conducted with all residents with a BIMs of 9 or higher on 12/09/2024 no allegations reported. 7) Appropriate staff members suspended pending investigation of allegation. 8) Residents who are not able to be interviewed will be assessed for any signs of abuse. 9) Follow up assessments initiated every shift for Resident #117. 10) The likelihood for serious harm to any recipient no longer exists effective 12/9/2024. The IJ was lifted, effective 12/11/24 at 6:48 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated potential for harm to the residents. Based on interview and record review, the facility failed to implement the reporting of their sexual abuse allegation policy for one (#117) of four residents reviewed for abuse. The Administrator identified 67 residents resided in the facility. Findings: The facility's abuse policy, dated 11/02/24, read in part, .All employees of a nursing facility are mandated reporters of resident abuse, to appropriate personnel .and must report any and all incidents. All employees shall report any reasonable suspicion of a crime against any individual who is a resident of the facility without fear of retaliation . 1. Resident #117 had diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body which could affect the arms, legs, and facial muscles) following cerebral infarction affecting right dominant side. A Quarterly Assessment, dated 11/07/24, documented Resident #117 had no speech, was rarely or never understood, and rarely or never understands, BIMS score 99 (resident unable to complete interview), had severely impaired cognition ability to make daily decisions, had functional limitations to range of motion which included upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremity impairment to one side. Resident #117 was dependent on staff for ADL's which included bathing, dressing, toileting/incontinent care, transfers, repositioning, and locomotion of manual wheel chair. 2. Resident #53 had diagnoses to include encephalopathy with hemiplegia and hemiparesis. A Quarterly Assessment, dated 10/21/24, documented Resident #53 had a BIMS of 07 which indicated severe cognitive impairment. Resident #53 was able to self propel in a manual wheel chair with upper and lower extremity impairment to one side. A Care Plan, dated 12/02/24, documented Resident #53 had behaviors, undesirable behaviors would be monitored and managed, ensure the safety of Resident and others, establish boundaries and limits with Resident, evaluate medications, and inappropriate gestures. 35389 On 12/03/24 at 9:08 a.m., CNA #2 stated Resident #53 wheeled themselves into Resident #117's room and they had to remove Resident #53 from Resident #117's room at least 10 times. They stated the facility did not want the family to know. On 12/03/24 at 9:39 a.m., Res #117 was observed sitting in w/c, in the lobby, awake, alert, unable to answer yes or no questions, does not shake head yes or no, and not verbal. On 12/03/24 at 10:12 a.m., CNA #2 stated Resident #117's family did not know they were getting raped because the facility staff tried to hide it so they won't get in trouble. On 12/03/24 at 10:30 a.m., CNA #2 stated there were other staff members who wanted to speak to the survey team, but they were afraid of losing their job. On 12/03/24 at 10:45 a.m., CNA #3 stated Resident #53 was on Hall 400 but was moved to Hall 300 to make sure they were not around Resident #117. CNA #3 stated they had witnessed Resident #53 in Resident #117's room. On 12/03/24 at 11:23 p.m., CNA #10 stated they had seen Resident #53 transfer themselves, and the resident had taken themselves to the bathroom at times. They stated they were unsure of the reason the resident had changed halls. On 12/04/24 at 9:36 a.m., Resident #53 was observed transferring themselves from their bed into their manual wheelchair. On 12/04/24 at 9:45 a.m., Resident #53 stated they were able to transfer to the wheelchair on their own. They stated they went to the restroom on their own and got dressed on their own. On 12/04/24 at 9:48 a.m., Resident #53 was observed propelling themselves in the wheelchair out of their bedroom and down Hall 300, and into the dining room area independently. On 12/04/24 at 9:51 a.m., Resident #53 wheeled themselves over to the hydration station and obtained a cup of liquid out of the coffee machine on their own and placed in on the table. On 12/04/24 at 10:03 a.m., Resident #117 was accompanied by staff to the dining area. On 12/04/24 at 10:14 a.m., Resident #53 wheeled themselves close to the front foyer area. On 12/04/24 at 10:16 a.m., Resident #53 was observed in the front television room where Resident #117 was located. On 12/04/24 at 10:20 a.m., Resident #117 was seated in a red wheelchair in the television room with their eyes closed. No staff was observed approaching either resident. On 12/04/24 at 10:24 a.m., Resident #117 was observed with their eyes open, and began rubbing their left inner thigh and upper leg looking in the direction of Resident #53 and continued to rub their left leg and knee. Resident #53 was seated approximately six feet away from Resident #117. No staff were observed to approach either resident. On 12/04/24 at 10:07 a.m., CNA #1 stated Resident #53 was moved off the hall because they wandered into other Resident's rooms. CNA #1 stated Res #53 liked to go into Resident #117's room. My nurses have pulled him out of room. CNA #1 stated they didn't know if anything happened between them. They never saw anything. CNA #1 stated Resident #53 was fully clothed, but Resident #117 was not when they were in bed. On 12/04/24 at 10:31 a.m., Resident #117 continued to rub on their left upper thigh down to their knee looking in the direction of Resident #53. Resident #53 wheeled themselves away from the living room area. On 12/04/24 at 10:51 a.m., CNA #9 stated Resident #53 was pretty self-sufficient as far as transfers and toileting. They stated if they observed any signs or symptoms of abuse, they would report it to the charge nurse. On 12/04/24 at 11:16 a.m. Resident #117 was observed sitting in their w/c at a table playing bingo with staff. On 12/05/24 at 6:14 a.m., RN #1 stated Resident #53 was a wanderer. They stated the resident had been a wanderer since they had worked at the facility. They stated they know Resident #53 wandered the Halls and would come down Hall 400. They stated they know the resident had tried to go into one or two female residents' rooms before, but they were unsure of whom. They stated they were unaware of any sexual behaviors between Resident #53 and other residents. On 12/05/24 at 6:18 a.m., RN #1 stated if abuse was reported to them, they would call their boss. They stated if it was a resident touching another resident physically or verbally, they would call the police immediately. They stated they would report it to the DON and the Administrator and document it under behaviors. On 12/06/24 at 11:45 a.m., MDS Coordinator #1 stated they were asked by the DON to update their care plan. MDS Coordinator#1 stated if the resident had a behavior it would be documented in a behavior note, but they hadn't seen any behavior notes documented. MDS Coordinator #1 stated they didn't know what behaviors were exhibited if there were no notes documented. On 12/06/24 at 11:52 a.m., MDS Coordinator #2 stated Resident #53 could get up and use the bathroom themselves, but they were unsteady and needed assistance. On 12/06/24 at 11:53 a.m., MDS Coordinator #1 stated Resident #53 would sometimes move in bed sometimes would not. They stated Resident #53 could sit to stand, but needed assistance and could transfer independently, but just depended on them. On 12/06/24 at 12:40 p.m., the DON stated Resident #53's behavior included refusal of incontinent care. On 12/06/24 at 12:41 p.m., the regional nurse consultant stated behaviors were documented on the TAR, psych doctor notified, medications reviewed, Paxil reviewed. The regional nurse consultant stated inappropriate gestures included gesture with hand, like no, as if going to hit or refuse. On 12/06/24 at 2:39 p.m., RN #2 stated they were told Resident #53 got away with it and always tried to get the female resident down in a room by themselves. On 12/06/24 at 2:46 p.m., RN #2 stated the female resident Resident #53 molested was in a wheelchair. RN #2 stated they heard in passing Resident #53 was found in the female resident's room again and the staff pushed Resident #53 out. RN #2 stated if a staff member reported abuse, they would notify the Administrator. RN #2 stated the abuse was never reported to them, or they would have called Administration or the police. They stated they were unsure if anyone charted the rape or Resident #53's sexual behaviors. On 12/06/24 at 2:53 p.m., RN #2 stated the reason Resident #53 was moved from Hall 400 to Hall 300 was because the resident was trying to get to the female resident. They stated the move was to get Resident #53 away from the female resident. On 12/09/24 at 1:16 p.m., the Administrator stated if their staff overheard a male resident was getting a female resident into a room, raped they woud fully expect the alleged be assessed, police called and they would expect to be notified. The Administrator stated if they heard a male resident had sex with a female resident, it would depend on the residents, some are able to consent. We would look at BIMs scores. Residents have a right to conjugal visits if they are not in a room by their self. The Administrator stated if staff had told them a male resident had touched a females breast and had sex with them, they would expect both staff in their office, if it was not consensual, the abuse coordinator or DON would be notified with the alleged (victim) safe and other resident put on observation, relocate, and start investigation. The Administrator stated the staff should be following the abuse policy. Everyone in here should be following my abuse policy. The Administrator stated they would report who, where, what, when, inservice staff on abuse, and refresh who staff should report to. They all know who the chain of command are. The Administrator stated they would report an allegation of abuse within a two hour window, start an investigation and alert the authorities. On 12/09/24 at 2:28 p.m., RN #2 stated they overheard the Administrator say to keep an eye on him (#53). They were just coming in to work and the Administrator had staff at the nurses station. On 12/10/24 at 11:33 a.m., Family Member #1 stated to their knowledge Resident #53 was moved to a new room due to a disagreement with a roommate that was a bit aggressive. They stated the move was to help with the resolution. On 12/11/24 at 12:22 p.m., the Corporate Administrator stated they didn't need to print a resident list for those with a BIMS of nine or higher because all the residents who were below a nine were provided their assessments. They stated the only staff member suspended was the Administrator on 12/10 and they returned to work on 12/10.

Based on record review and interview the facility failed to ensure resident assessments were accurately coded for two (#16 and #23) of 23 sampled residents reviewed for resident assessments. The Administrator identified a census of 67. Corporate Nurse Consultant #1 identified three residents with colostomies resided in the facility. Findings: 1. Resident #23 had diagnoses which included edema and end stage renal disease. Resident #23's weight record documented on: a. 11/02/23 296.2 pounds; b. 01/27/24 287.4 pounds; c. 04/02/24 296.2 pounds; d. 04/26/24 264.4 pounds; e. 05/02/24 272.2 pounds; f. 06/26/24 244 pounds; g. 07/26/24 241 pounds; h. 09/26/24 244 pounds; and i. 10/26/24 237.6 pounds. A Significant Change Resident Assessment, dated 05/02/24, documented Resident #23's height was 70 inches and weight was 272 pounds. It documented no or unknown for weight loss of five percent or more in the last month or ten percent or more in the last six months. It documented no or unknown for weight gain of five percent or more in the last month or ten percent or more in the last six months. A Quarterly Resident Assessment, dated 07/26/24, documented Resident #23's height in inches was 70 and weight was 242. It documented no or unknown for weight loss of five percent or more in the last month or ten percent or more in the last six months. It documented no or unknown for weight gain of five percent or more in the last month or ten percent or more in the last six months. A Quarterly Resident Assessment, dated 10/26/24, documented Resident #23's height was 74 inches and weight was 238 pounds. On 12/06/24 at 11:27 a.m., MDS Coordinator #2 stated they completed a risk assessment, spoke with residents, completed a brief interview for mental status, a risk assessment, and spoke with staff to ensure their resident assessments were accurately coded. On 12/06/24 at 11:28 a.m., MDS Coordinator #2 stated they reviewed resident weights in the electronic charting system to determine if a resident experienced weight loss or gain. They stated on Resident #23's significant change resident assessment dated [DATE], the resident had a height of 70 inches and weight of 272 pounds. MDS Coordinator #1 and MDS Coordinator #2 stated the assessment marked no for weight loss or weight gain. On 12/06/24 at 11:29 a.m., MDS Coordinator #1 stated on Resident #23's quarterly resident assessment dated [DATE], the resident had a height of 70 inches and 242 pounds. MDS Coordinator #1 stated it documented the resident had not experienced weight loss or gain. MDS Coordinator #2 stated the 07/27/24 should have documented weight loss. On 12/06/24 at 11:34 a.m., MDS Coordinator #1 stated Resident #23's quarterly resident assessment dated [DATE] documented a height of 74 inches and a weight of 238 pounds. MDS Coordinator #1 stated it documented no for weight loss or gain. MDS Coordinator #2 stated it should have documented weight loss as well. 34460 2. Resident #16 had a diagnoses which included a colostomy status. An Annual Resident Assessment, dated 11/22/24, documented Resident #16 did not have an ostomy or colostomy. On 12/11/24 at 11:03 a.m., MDS Coordinator #1 stated Resident #16 bowel continence was not rated because it was not marked. MDS Coordinator #2 stated Resident #16 had a colostomy.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#23) of five sampled residents reviewed for unnecessary medications. The DON identified seven residents who received losartan potassium. Findings: A Preparation and General Guidelines policy, dated 01/22, read in part, .Medications are administered as prescribed in accordance with good nursing principles and practices .If a dose of regularly scheduled medication is withheld .If two consecutive doses of a vital medication are withheld .the physician is notified. Nursing documents the notification and physician response . Resident #23 had diagnoses which included essential hypertension. A Physician Order, dated 06/04/24, documented losartan potassium 50 mg give one tablet by mouth two times a day related to essential hypertension. The order was on hold from 10/28/24 at 12:58 p.m. to 10/30/24 at 12:57 p.m. The October 2024 MAR documented an 11 for the 7:00 a.m. to 11:00 a.m. dose of losartan potassium on 6th and 19th. It documented an 11 for the 6:00 p.m. to 10:00 p.m. dose of losartan potassium on the 1st, 3rd, 4th, 5th, 8th, 9th, 10th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 30th, and 31st. The chart codes documented an 11 meant vital signs outside parameters. There was no documentation an order to hold this medication was obtained prior to the facility holding this medication for the above administrations. The November 2024 MAR documented an 11 for the 7:00 a.m. to 11:00 a.m. dose of losartan potassium on the 2nd and the 3rd. It documented an 11 for the 6:00 p.m. to 10:00 p.m. dose of losartan potassium on the 1st, 2nd, 5th, 6th, 7th, 8th, 11th, 12th, 14th, 15th, 19th, 21st, and 25th. The chart codes documented an 11 meant vital signs outside parameters. There was no documentation an order to hold the medication was obtained prior to the facility holding this medication for the above administrations. On 12/06/24 at 11:03 a.m., LPN #6 stated staff were to use the punch initial give method when administering medication. They stated when they put an order in, it would show up on the MAR. On 12/06/24 at 11:05 a.m., LPN #6 stated if staff didn't administer a medication, they were to notify the nurse. They stated staff couldn't just hold a medication, as those instructions would come from the physician. They stated Resident #23 was to receive 50 mg of losartan potassium two times a day at 7:00 a.m. to 11:00 a.m. and 6:00 p.m. to 10:00 p.m. On 12/06/24 at 11:09 a.m., LPN #6 stated they did not see any holding parameters for the medication. On 12/06/24 at 11:10 a.m., LPN #6 reviewed the November 2024 MAR for Resident #23 and stated the 11's meant vital signs outside of parameters. On 12/06/24 at 11:12 a.m., LPN #6 reviewed the October 2024 MAR and identified all of the 11's documented for the losartan potassium. They stated they did not see where the facility received an order to hold the medication. On 12/06/24 at 11:50 a.m., the Regional Nurse Consultant stated the electronic record system showed every resident with medications due for the shift. The Administrator stated the physician would be notified when a medication was held and the reason. On 12/06/24 at 11:51 a.m., the DON stated Resident #23 received losartan potassium 50 mg twice a day at 7:00 am to 11:00 a.m. and 6:00 p.m. to 10:00 p.m. On 12/06/24 at 11:55 a.m., the DON stated the losartan potassium did not have holding parameters. The DON reviewed the October 2024 MAR and the November 2024 MAR and stated 11 meant vital signs were outside parameters. On 12/06/24 at 11:59 a.m.,, the DON was asked if the physician was notified when the medication was held. The DON and the Regional Nurse Consultant stated there were standing orders to hold for a low blood pressure. The Administrator stated nursing staff knew not to give the medication when the blood pressure was low. Standing orders to hold this medication were never provided to the survey team.

Based on record review and interview the facility failed to obtain physician ordered labs for two (#24 and #37) of five sampled residents reviewed for unnecessary medications. The Administrator identified 67 residents resided in the facility. Findings: 1. Resident #37 had diagnoses which included major depressive disorder, liver disease, and unspecified viral hepatitis b without hepatic coma. A Physician Order, dated 10/10/21, documented CBC and CMP every six months in October and April. There was no documentation the above October 2024 labs were collected for Resident #37. On 12/05/24 at 8:19 a.m., LPN #6 stated staff would note an order first, put the ordered labs in the electronic lab system to be drawn, and document the date and time the lab showed up to the facility. They stated they would print it out and verify the lab was drawn. They stated the lab tech would place a copy of what was drawn in the lab book which stayed at the nurses' station. On 12/05/24 at 8:21 a.m., LPN #6 stated when lab results came in, staff would look them up in the lab portal electronically. They stated the provider came to the facility on Tuesday and Thursday and staff would place the results in the communication book for them to review. LPN #6 stated if the provider did not come to the facility that day, they would call the results to the provider. On 12/05/24 at 8:22 a.m., LPN #6 stated after the provider reviewed the labs, they would write an order on the lab slip. They stated staff would then transcribe the order and send it to pharmacy. They stated the lab results would go in the resident's chart. On 12/05/24 at 8:28 a.m., LPN #6 was asked to locate the April and October 2024 lab results for Resident #37. They looked in the electronic laboratory system and were unable to locate the results. They stated they would get back with the surveyor. On 12/05/24 at 11:37 a.m., the DON stated they did not see the labs on the monthly orders for Resident #37. The Regional Consultant stated, They didn't tell me about that one. On 12/05/24 at 11:40 a.m., the DON stated the facility drew labs on new admissions when they came in. They stated long term care residents would also have labs drawn. They stated the physician would view the results and they would be placed in the chart. 2. Resident #24 had diagnoses which included seizures. A Physician Order, dated 07/12/23, documented draw Keppra level every three months in July, October, January, and April. The October 2024 Keppra level results were not located in Resident #24's record. On 12/10/24 at 12:31 p.m., the Regional Nurse Consultant stated they did not have the October 2024 labs.

Based on observation, record review and interview, the facility failed to pass ice in a manner which prevented cross contamination during one of one ice passes observed. The Administrator identified 67 residents resided in the facility. Findings: A Hand Hygiene policy, reviewed 07/24, read in part, .The single most important step in the prevention of infection is hand hygiene .when to use Alcohol Based Hand Rub .After touching a resident or the resident's immediate surroundings . On 12/03/24 at 11:11 p.m., CNA #10 was observed going into room [ROOM NUMBER] obtained a resident's personal cup, placed ice from the ice chest in it and returned the cup to the resident's room. The CNA did not wash or sanitize their hands. On 12/03/24 at 11:13 p.m., CNA #10 knocked on room [ROOM NUMBER] went in and offered ice to the resident, then walked into room [ROOM NUMBER] and offered ice to the residents in the room. The CNA did not wash or sanitize their hands. On 12/03/24 at 11:16 p.m., CNA #10 knocked on room [ROOM NUMBER] walked into the room, obtained a resident's cup from the room, placed ice from the ice chest in it, and handed the cup to the resident. The CNA did not wash or sanitize their hands. On 12/03/24 at 11:19 p.m., CNA #10 knocked on room [ROOM NUMBER], the residents in the room did not accept ice. CNA #10 walked into room [ROOM NUMBER] removed a cup from the room, placed ice in it from the ice chest, and took the cup back into the room. The CNA did not wash or sanitize their hands. CNA #10 walked into room [ROOM NUMBER] took a cup from the resident, placed ice in it from the ice chest, and took it back into the resident's room. The CNA exited the room, sanitized their hands and stated they were done passing ice. On 12/03/24 at 11:21 p.m., CNA #10 stated if more than two residents asked for ice, they would pass it out to everyone on the hall. They stated they were supposed to use hand sanitizer between residents, but they were so far apart on the hall, they tried to use it every other room. On 12/06/24 at 8:35 a.m., the DON stated staff were to sanitize there hands when going from room to room passing ice. They stated staff should sanitize between each resident.

Based on record review and interview, the facility failed to ensure the physician was notified when holding a medication without holding parameters for one (#23) of five sampled residents reviewed for unnecessary medications. The DON identified seven residents who received losartan potassium. Findings: A Resident's Family or Physician Notification of Change policy, dated 12/01/09, read in part, .This is a guideline to know when it may be necessary to notify the resident's family or physician .The facility will inform the resident; consult with the resident's physician .of the following events .A need to alter treatment significantly .need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment . Resident #23 had diagnoses which included essential hypertension. A Physician Order, dated 06/04/24, documented losartan potassium 50 mg give one tablet by mouth two times a day related to essential hypertension. The order was on hold from 10/28/24 at 12:58 p.m. to 10/30/24 at 12:57 p.m. The October 2024 MAR documented an 11 for the 7:00 a.m. to 11:00 a.m. dose of losartan potassium on 6th and 19th. It documented an 11 for the 6:00 p.m. to 10:00 p.m. dose of losartan potassium on the 1st, 3rd, 4th, 5th, 8th, 9th, 10th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 30th, and 31st. The chart codes documented an 11 meant vital signs outside parameters. There was no documentation the physician was notified prior to the facility holding this medication for the above administrations. The November 2024 MAR documented an 11 for the 7:00 a.m. to 11:00 a.m. dose of losartan potassium on the 2nd and the 3rd. It documented an 11 for the 6:00 p.m. to 10:00 p.m. dose of losartan potassium on the 1st, 2nd, 5th, 6th, 7th, 8th, 11th, 12th, 14th, 15th, 19th, 21st, and 25th. The chart codes documented an 11 meant vital signs outside parameters. There was no documentation the physician was notified prior to the facility holding this medication for the above administrations. On 12/06/24 at 11:03 a.m., LPN #6 stated staff were to use the punch initial give method when administering medication. They stated when they put an order in, it would show up on the MAR. On 12/06/24 at 11:05 a.m., LPN #6 stated if staff didn't administer a medication, they were to notify the nurse. They stated staff couldn't just hold a medication, as those instructions would come from the physician. They stated Resident #23 was to receive 50 mg of losartan potassium two times a day at 7:00 a.m. to 11:00 a.m. and 6:00 p.m. to 10:00 p.m. On 12/06/24 at 11:09 a.m., LPN #6 stated they did not see any holding parameters for the medication. On 12/06/24 at 11:10 a.m., LPN #6 reviewed the November 2024 MAR for Resident #23 and stated the 11's meant vital signs outside of parameters. On 12/06/24 at 11:12 a.m., LPN #6 reviewed the October 2024 MAR and identified all of the 11's documented for the losartan potassium. They stated they did not see where the physician was contacted when this medication was held. On 12/06/24 at 11:50 a.m., the Regional Nurse Consultant stated the electronic record system showed every resident with medications due for the shift. The Administrator stated the physician would be notified when a medication was held and the reason. On 12/06/24 at 11:51 a.m., the DON stated Resident #23 received losartan potassium 50 mg twice a day at 7:00 am to 11:00 a.m. and 6:00 p.m. to 10:00 p.m. On 12/06/24 at 11:55 a.m., the DON stated the losartan potassium did not have holding parameters. The DON reviewed the October 2024 MAR and the November 2024 MAR and stated 11 meant vital signs were outside parameters. On 12/06/24 at 11:59 a.m.,, the DON was asked if the physician was notified when the medication was held. The DON and the Regional Nurse Consultant stated there were standing orders to hold for a low blood pressure. The Regional Nurse Consultant stated the physician didn't want to be notified every time the resident had a low blood pressure. Standing orders to hold this medication were never provided to the survey team.

Based on record review and interview, the facility failed to report an allegation of resident to resident abuse to OSDH for two (#25 and #39) of four sampled residents reviewed for abuse. The Administrator identified 67 residents resided in the facility. Findings: The facility's Resident Abuse, Neglect, and Misappropriation of Property policy, revised 11-01-22, read in part, The resident has the right to be free from verbal, sexual, physical, and mental abuse. The policy also read, All employees of a nursing facility are mandated reporters of resident abuse, neglect or misappropriation of property, as well as reasonable suspicion of a crime against a resident and must report any and all incidents. The policy also read, All allegations and incidents of abuse, neglect or misappropriation of resident's property, must be reported to QAPI committee, appropriate Federal and State Agencies including OSDH and investigated to establish a reasonable conclusion about the validity of the allegation. 1. Resident #25 had diagnosis which included schizophrenia. The 5-day resident assessment, dated 12/08/24, documented Resident #25's cognition was intact and Resident #25 had hallucinations and delusions 2. Resident #39 had diagnoses which included Alzheimer's disease and unspecified mood [affective] disorder. The quarterly resident assessment, dated 07/13/24, documented Resident #39's cognition was moderately impaired and Resident #39 had no behavioral symptoms. An Incident Report, dated 08/04/24, documented, This nurse noted Resident #39 bleeding from their left cheekbone at 9:30 a.m., when asked Resident #39 said someone hit them but they did not know who did, another resident from hall 100 stated it was Resident #25. The facility spoke to Resident #25 and they stated Resident #39 was in their way. The residents were immediately separated from each other and Resident #39 was to be monitored closely. Head to toe assessment done, skin tear noted to left cheekbone. There was no documentation an incident report was sent to OSDH. On 12/10/24 at 12:34 p.m., the Administrator stated they were unable to find a reportable on this incident and she would need to call the DON. On 12/10/24 at 12:34 p.m., the Administrator stated it was a resident to resident incident. On 12/10/24 at 12:59 p.m., the Administrator stated she had spoken to the DON and there was not a state report done, only the incident report.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident to resident abuse for two (#25 and #39) of four sampled residents reviewed for abuse. The Administrator identified 67 residents resided in the facility. Findings: A Resident Abuse, Neglect and Misappropriation of Property policy, revised 11-02-22, read in part, A member of the administrative staff will then conduct thorough investigation of the incident/allegation to obtain information about the incident and complete the ODH-283. The policy also read, Upon receiving an allegation of resident abuse .The facility will begin an investigation of the incident .All allegations and incidents of abuse .must be reported to QAPI committee, appropriate Federal and State agencies including OSDH and investigated to establish a reasonable conclusion about the validity of the allegation. 1. Resident #25 had diagnosis which included schizophrenia. The 5-day resident assessment, dated 12/08/24, documented Resident #25's cognition was intact and Resident #25 had hallucinations and delusions 2. Resident #39 had diagnoses which included Alzheimer's disease and unspecified mood [affective] disorder. The quarterly resident assessment, dated 07/13/24, documented Resident #39's cognition was moderately impaired and Resident #39 had no behavioral symptoms. An Incident Report, dated 08/04/24, documented, This nurse noted Resident #39 bleeding from their left cheekbone at 9:30 a.m., when asked Resident #39 said someone hit them but they did not know who did, another resident from hall 100 stated it was Resident #25. The facility spoke to Resident #25 and they stated Resident #39 was in their way. The residents were immediately separated from each other and Resident #39 was to be monitored closely. Head to toe assessment done, skin tear noted to left cheekbone. On 12/10/24 at 12:59 p.m., the Administrator stated she had spoken to the DON and there was not an investigation done, only the incident report.

Based on record review and interview the facility failed to coordinate care with a third party provider for one (#37) of three sampled resident reviewed for coordination of care. The DON identified one resident on (name-deleted) third party services resided in the facility. Findings: A contract between the facility and the third party provider, dated 12/16/16, read in part, .Medically Necessary Services shall mean those Covered Services provided by a health facility or health professional and which are appropriate for the symptoms and diagnosis or treatment of a condition .Provider agrees to .To render Covered Services to Participants only if Provider has obtained written authorization for such services from (third party provider) physician as described below .a (third party provider) physician must previously authorize all Covered Services in writing . Resident #37 had diagnoses which included major depressive disorder, liver disease, and unspecified viral hepatitis b without hepatic coma. A third party provider Communication Form, dated 07/05/24, documented Resident #37 needed labs and clarification on their chronic hepatitis b diagnoses. The form was signed by Provider #1. A third party provider Communication Form, dated 07/08/24, documented Resident #37 needed labs and documented the following new orders: CMP, Lipid, Hepatitis Panel, CBC, Prealbumin, Ferritin, Hem A1C, Iron and Total Iron Binding Capacity, Magnesium, TSH with T4 Free, PTH Intact and Calcium, and Vitamin D 25 Hydroxy with total 12 labs written at the bottom. A laboratory slip, dated 07/08/24, documented the above labs were ordered by Provider #1 for Resident #37. There was no documentation the above labs were collected for Resident #37. On 12/05/24 at 8:19 a.m., LPN #6 stated staff would note an order first, put the ordered labs in the electronic lab system to be drawn, and document the date and time the lab showed up to the facility. They stated they would print it out and verify the lab was drawn. They stated the lab tech would place a copy of what was drawn in the lab book which stayed at the nurses' station. On 12/05/24 at 8:21 a.m., LPN #6 stated when lab results came in, staff would look them up in the lab portal electronically. They stated the provider came to the facility on Tuesday and Thursday and staff would place the results in the communication book for them to review. LPN #6 stated if the provider did not come to the facility that day, they would call the results to the provider. On 12/05/24 at 8:22 a.m., LPN #6 stated after the provider reviewed the labs, they would write an order on the lab slip. They stated staff would then transcribe the order and send it to pharmacy. They stated the lab results would go in the resident's chart. On 12/05/24 at 8:24 a.m., LPN #6 reviewed the third party provider communication form dated 07/08/24 and stated, Wow 12 labs well lets look. LPN #6 went over to the computer and pulled up the lab system and stated they did not see a record for the labs. They stated the third party provider was an outside provider the resident would go and see. LPN #6 stated no one had noted the order. On 12/05/24 at 8:37 a.m., the Administrator stated the third party provider saw the resident monthly. The Administrator stated the third party provider provided Resident #37's medications, prescriptions and evaluations. They stated the resident went to the third party providers facility monthly and yearly. On 12/05/24 at 11:37 a.m., the DON stated the third party provider managed Resident #37's labs. They stated whenever the resident would see the provider, they would let the facility know if they were supposed to draw the labs. They stated they didn't. The DON stated they had called Physician #1 and lab came out today to draw the labs stat. On 12/05/24 at 11:40 a.m., the Regional Nurse Consultant stated the note was notification of what they were doing for the resident. The DON stated the forms were what the third party provider sent the facility for records of what they were doing. On 12/05/24 at 11:46 a.m., Third Party Representative #1 stated when they provided a lab slip to the facility, part of the contract was for the facility to complete the lab and send them the results. They stated if they left a lab slip and gave the order, that was for the facility to fill and the order needed to be drawn, They stated the facility was responsible for going over the labs needed with their provider, verifying it, having it drawn, and sending the results back to them. On 12/05/24 at 1:12 p.m., Third Party Representative #1 called back and stated both them and the facilty had dropped the ball. They stated they had residents who had labs drawn there and also had residents who had labs drawn through the facility. They stated the biggest problem was the above labs were never drawn. They stated it was a lack of communication on both sides that caused the situation. On 12/06/24 at 8:35 a.m., the Administrator stated the facility had terminated all contracts with the third party provider except for Resident #37 because they had had a lot of issues. They stated the facility did not have a coordination of care policy. They stated they went by the contract.

Based on record review and interview, the facility failed to ensure resident were transferred safely with a mechanical lift for one (#217) of one resident sampled resident reviewed for mechanical transfers. The Administrator identified 67 residents resided in the facility. Findings: Resident #217 had diagnoses which included Alzheimer's disease and muscle weakness. A quarterly resident assessment dated [DATE], documented Resident #217 was dependent upon staff for all transfers. An Incident Note, dated 10/28/24 at 6:15 p.m., documented, This nurse was summoned by CNA to Resident #217's room. When this nurse arrived the Resident was laying on their back by the sink, another CNA at their side to console this Resident. This nurse asked what happened. CNA stated we were trying to transfer them to their bed and the feet of the lift got hung under the geri chair. We were trying to get the feet free of the geri chair and the weight of the resident rocking back and forth caused the lift to flip over and they landed there (pointing at the resident on the floor). This nurse asked the aides did they hit their head. They both stated that it happened so fast, but did not notice. Neurological checks: WNL for this resident's ability. Head to toe assessment was done with no evitable injuries noted. This nurse contacted doctors on call and new order was given to send resident to ER for further treatment and evaluation. Residents family member [name withheld] was contacted and notified of incident. In-services regarding proper lift use were conducted on 10/28, 10/29, and 10/30/24. Resident #217's care plan, revised on 11/19/24, documented Resident #217 is to have three person assist with transfers. On 12/11/24 at 11:14 a.m., CNA #1 stated the policy for using the lift was to have another staff member with you. They stated they had been in-serviced on lift use. On 12/11/24 at 11:20 a.m., CNA #5 stated they had been in-serviced on lift use about a month ago. They stated the policy for using the lift was two persons at all times. On 12/11/24 at 11:25 a.m., CMA #2 stated the policy for using the lift was to always have two staff members. They stated they had received in-service on lift use recently. On 12/11/27 at 11:27 a.m., LPN #6 stated the policy for using the lift was two persons at all times and to tell the resident what you are doing and keep them comfortable. On 12/11/24 at 11:29 a.m., the Administrator stated QA was involved by going over policies and incidents.

Based on record review and interview, the facility failed to coordinate care with a dialysis provider for one (#23) of one sampled resident reviewed for dialysis. The DON identified four residents who received dialysis services resided in the facility. Findings: A Guideline for Dialysis After Care policy, effective 07/11/12, read in part, .Schedule visits to Dialysis Center and coordinate care accordingly . Resident #23 had diagnoses which included end stage renal disease and essential hypertension. A Physician Order, dated 06/04/24, documented Resident #23 went to an outside dialysis provider on Tuesday, Thursday and Saturday. A Physician Order, dated 06/04/24, documented losartan potassium 50 mg give one tablet by mouth two times a day related to essential hypertension. The order was on hold from 10/28/24 at 12:58 p.m. to 10/30/24 at 12:57 p.m. A Physician Order, dated 06/04/24, documented minoxidil 2.5mg give one tablet by mouth one time a day related to essential hypertension. The October, November, and December 2024 MAR documented this medication was administered during the 7:00 a.m. to 11:00 a.m. timeframe. A Physician Order, dated 06/04/24, documented nifedipine ER 90 mg give one tablet by mouth one time a day related to essential hypertension. The October, November, and December 2024 MAR documented this medication was administered during the 7:00 a.m. to 11:00 a.m. timeframe. A communication form from the outside dialysis center, undated, read in part, Please be advised that this patient should NOT be receiving HTN drugs prior to dialysis on dialysis days, this prevents the removal of excess fluids due to hypotension . On 12/02/24 at 9:54 a.m., Resident #23 stated they attended dialysis on Tuesday, Thursday, and Saturday. They stated they left the facility around 8:30 in the morning and returned around 2:00 p.m. On 12/06/24 at 10:51 a.m., LPN #6 stated Resident #23 went to dialysis on Tuesday, Thursday, and Saturday in the morning. They stated the resident returned around 1:30 p.m. They stated they were working yesterday when the resident returned form dialysis. On 12/06/24 at 10:52 a.m., LPN #6 stated the facility coordinated care with the dialysis center by sending the dialysis communication sheet with the resident for the dialysis center to complete their part. They stated if the dialysis center had any orders, they would send them back with the resident. On 12/06/24 at 11:05 a.m., LPN #6 identified Resident #23 received a clonidine patch weekly on Wednesday, losartan potassium 50mg twice a day at 7:00 a.m. to 11:00 a.m. and 6:00 p.m. to 10:00 p.m., nifedipine ER 90 mg daily at 7:00 a.m. to 11:00 a.m., and minoxidil 2.5 mg daily at 7:00 a.m. to 11:00 a.m. to treat hypertension. On 12/06/24 at 11:14 a.m., LPN #6 reviewed the dialysis communication form and stated they did not know where the note came from or when it got in the resident's chart. On 12/06/24 at 11:38 a.m., the DON stated Resident #23 went to dialysis on Tuesday, Thursday, and Saturday in the morning and arrived back to the facility in the afternoon. On 12/06/24 at 11:40 a.m., the DON stated the facility would send the dialysis communication form with the resident. They stated if there were any new orders, they would send them back with the resident. The DON stated the facility would also call the dialysis center if they received new orders for the resident. On 12/06/24 at 12:05 p.m., the DON was asked to explain the undated dialysis communication form that documented Resident #23 should not be receiving HTN drugs prior to dialysis. The Regional Nurse Consultant stated an RN was who wrote the note and the RN was not a doctor and was working outside of their practice. They were asked if the physician was made aware of the recommendation from the dialysis center. The Regional Nurse Consultant stated they would have to pull progress notes. The DON stated the note wasn't even dated. On 12/06/24 at 12:09 p.m., the DON walked over to the medical records department in search of provider visits for Resident #23. On 12/06/24 at 12:21 p.m., after going through stacks of papers, Medical Records stated they had not located any additional provider visits for Resident #23. On 12/10/24 T 10:44 a.m., Dialysis Representative #1 stated they were familiar with Resident #23. They stated generally the dialysis center had all residents hold all blood pressure medications except coreg or carvedilol whether they had low blood pressure or not so they could remove excess fluids. They stated they would instruct residents to take blood pressure medications after the treatment was completed.

Based on record review, observation, and interview the facility failed to ensure gloves were changed when going from dirty to clean during peri-care to avoid cross contamination for two (#29 and #114) of two sampled residents reviewed for infection control. The Resident Census and Conditions report, dated 11/14/22, documented a census of 59. It documented 32 residents required assistance from staff and 11 residents were dependent on staff for toilet use. Findings: The facility's Perineal Care policy, revised 03/03/06, read in part, .If the resident has been incontinent of bowel, remove the bulk of stool .remove and dispose of gloves .don clean gloves . 1. Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #29's admission assessment, dated 09/25/22, documented the resident's cognition was severely impaired, they required extensive assistance with personal hygiene, and were total dependent on staff for toilet use. It documented Resident #29 was always incontinent of bowel. On 11/16/22 at 8:57 a.m., CNA #1 was observed to assist Resident #29 with incontinent care. CNA #1 had donned gloves and rolled the resident on their side. A medium amount of bm was observed. CNA #1 was observed to clean the bm with several wipes. When no bm was observed, CNA #1 placed a clean brief under the resident. CNA #1 was not observed to change their gloves prior to placing the clean brief. CNA #1 rolled the resident onto their back and fastened the brief. CNA #1 was observed to place clean pants on the resident with the soiled gloves. CNA #1 was observed to have resident roll back and forth while CNA #1 pulled the resident's pants up. CNA #1 placed the resident's shoes on the resident's feet, then doffed the soiled gloves. 2. Resident #114 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #114's admission assessment, dated 10/12/22, documented the resident's cognition was intact, they were total dependent on staff for toilet use and personal hygiene. Resident #114's care plan, dated 10/18/22, documented the resident had incontinence of bowel and bladder. On 11/16/22 at 10:07 a.m., the WCN and IP were observed to assist the resident with care. Resident #114 requested the urinal. The WCN was observed to place the urinal. Resident #114 alerted the nurses when they were finished. The WCN removed the urinal and provided peri care to the resident. The WCN did not change their gloves after providing peri care. The resident was rolled on their side and the WCN placed a clean brief under the resident. The WCN pulled the resident's clean pants up with the soiled gloves. The WCN removed the bio hazard bag and took it to their treatment care and doffed their gloves. On 11/16/22 at 10:25 a.m., the IP was asked when staff were to change their gloves during peri care. The IP stated when the gloves became soiled. The IP was asked if staff should change their gloves after wiping bm and before touching clean items, such as a clean brief and clothes. The IP stated yes the gloves would have been soiled. The IP was asked if staff should change gloves after providing peri care and before touching a clean brief and clothes. The IP stated, I would say so.

Based on observation, record review, and interview, the facility failed to ensure nail care was provided to residents for one (#33) of two sampled residents reviewed for ADL care. The Residents Census and Condition report, dated 11/14/22, documented a census of 59. It documented 32 residents required assistance from staff. Findings: The facility's Fingernail Care policy, effective 10/01/01, read in part, . purpose .reduce spread of infections, maintain the resident's hygiene, and provide the resident with clean and well groomed appearance . Resident #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33's annual assessment, dated 08/20/22, documented the resident cognition was intact, and they needed assistance with bathing and hygiene. On 11/14/22 at 12:42 p.m., Resident #33 was observed with unkept and dirty nails. Nails appeared long, jagged edged with dark substance under all nails. On 11/16/22 at 8:12 a.m., Resident #33 was observed with nails which remained unkept and not clean. On 11/16/22 at 1:09 p.m., Resident #33 stated no help had been given with nail care. They stated their nails were long, jagged and would get caught in everything. They stated they preferred their nails short and clean. On 11/17/22 at 1: 28 p.m., the administrator #2 accompanied this surveyor to Resident #33's room. The administrator held Resident #33's hand and stated We need to get your nails manicured. Resident #33 stated they preferred their nails short and filed. The administrator #2 stated to Resident #33 We will get them cut, filed down and get all that gunk from under your nails.

Based on record review, and interview, the facility failed to ensure physician ordered lab service was obtained for one (#40) of four sampled residents reviewed for lab service. The Resident Census and Conditions of Residents report, dated 11/14/22, documented a census of 59. Findings: Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation the lab was collected as ordered. On 11/16/22 at 1:18 p.m., the RN #1 was asked to provide documentation the lab had been collected. On 11/16/22 at 1:48 p.m., the RN #1 was asked if they had located the requested lab. They stated the lab was entered incorrectly for the next day and not for the week later as ordered.

Based on observation, record review and resident and staff interviews, it was determined the facility failed to manage a resident's pain during wound care for one (#17) of one sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 03/26/19, documented seven residents with pressure ulcers. Findings: Resident #17 had [DIAGNOSES REDACTED]. A pain assessment, dated 12/29/18, documented the resident had pain in the past few months, had pain daily and reported pain to a wound on the left heel. A physician's orders [REDACTED].[MEDICATION NAME] HCl ([MEDICATION NAME]) 50mg (milligram) give 1 tablet by mouth two times a day for Pain . A physician's orders [REDACTED].[MEDICATION NAME] (Tylenol) Tablet give 650mg by mouth every 6 hours as needed for Pain . A care plan, last revised 03/17/19, documented, .is at risk for skin integrity .Ask me if I am having any pain associated with my pressure ulcer .Provide me with pain medication should I need it .Cleanse left heel with saline, pat dry, apply Iodsorb (sic), Durafiber, then ABD (abdominal), secure with Kerlix and tape Q (every) Monday, Thursday and prn (as needed). Every day shift every Mon (Monday), Thursday for prevention . At risk for pain r/t (related to) [MEDICAL CONDITION] and mobility .administer [MEDICATION NAME] Q 4 hour prn per order for pain .administer [MEDICATION NAME] BID (twice a day) per order for pain . A physician's orders [REDACTED].Cleanse left heel with saline, pat dry, apply iodosorb, durafiber, then ABD, secure with kerlix and tape Q Monday, Thursday, and prn . A nurse's note, dated 03/22/19 at 3:56 p.m., documented, . resident c/o (complains of) pain to L (left) heel, rated (3/10) on pain scale. Resident rec'd (received) Tylenol as ordered for pain management, no further complaints (0/10) at this time . On 03/28/19 at 7:35 a.m., the resident was observed receiving wound care to the left heel stage three pressure ulcer. Licensed practical nurse (LPN) #4 was observed cleansing the wound bed with gauze and normal saline. The resident was observed biting his bottom lip and had tears in his eyes. The resident was asked if he was in pain. He nodded his head yes. LPN #4 continued cleansing the wound bed. The resident was asked if it hurt when the nurse was cleansing his wound. He nodded his head yes. LPN #4 asked the resident to rate his pain on a pain scale of zero is you're fine, five if you feel like crying, 10 if you feel like dying. The resident held up his hand to indicate five. LPN #4 stated she was going to try and hurry to finish the wound care and would then go let the certified medication aide (CMA) know to get him something for pain. The resident was asked if he had pain each time staff performed wound care. The resident nodded his head yes. He was asked if staff offered pain medication or administered pain medication prior to wound care. The resident shook his head no. At 8:05 a.m., LPN #4 was asked how staff ensured residents had adequate pain relief during wound care. She stated she asked the resident before, during and after wound care. She stated if the resident said yes, she would alert the CMA to provide pain medication. LPN #4 was asked if residents received pain medication prior to wound care being performed. She stated if the resident complained of pain, they would receive medication and staff would wait 20-30 minutes before starting wound care. The (MONTH) 2019 Medication Administration Record [REDACTED] At 9:07 a.m., the resident was asked to rate his pain on a scale of zero to 10. He stated his pain was still at a level five. At 11:59 a.m., LPN #4 was asked to identify nonverbal signs or symptoms of pain. She stated facial grimacing, moaning, drawing up and pulling away. She was asked what staff would do if they observed a resident with these signs of pain. LPN #4 stated they would ask the resident if they were in pain, then go alert the CMA to provide something for pain. She was asked what she would do if she observed these signs of pain during wound care. LPN #4 stated she didn't want to leave the wound open because this increased the risk of infection. She stated she would try to get through the wound care quickly and then get the resident something for pain. LPN #4 was asked what pain medication the resident had ordered. She stated [MEDICATION NAME] 50mg twice a day and Tylenol 650mg every six hours as needed. LPN #4 was asked if she should have stopped wound care when the resident was showing signs of pain. She stated she had concerns about that and afterwards asked her consultant about this. She stated she was instructed to finish the treatment then go get the resident something for pain. LPN #4 was asked if residents received pain medication prior to wound care. She stated staff provided medication if a resident complained of pain or had a history of [REDACTED]. At 12:13 p.m., the DON (director of nursing) was asked how staff were instructed to assess pain for a resident with a pressure ulcer. The DON stated staff assessed new wounds and a registered nurse conducted a pain assessment. The DON was asked to locate the most recent pain assessment. The corporate nurse stated it had not been completed. The DON was asked if staff were instructed to pre-medicate residents prior to performing wound care for pressure ulcers. She stated if the resident had a PRN pain medication, the staff were required to ask and administer the medication. The DON was asked if a resident was showing signs of pain during wound care, what were staff instructed to do. She stated staff should ask the resident if they were having pain and if the resident was showing signs of pain, wound care should stop, and the staff should see if the resident has a PRN pain medication. The DON was made aware of the above observation. She acknowledged the findings.

On [DATE], an IJ was determined to exist due to the facility's failure by staff to identify and honor residents' wishes, with a known DNR status, and for administering CPR to a resident with a known DNR status. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). On [DATE] at 2:15 p.m., the ADM and DON were notified of the IJ situation regarding the staff's lack of knowledge in identifying and honoring residents' wishes regarding whether to be resuscitated or not, when the resident had a signed DNR. This constituted substandard quality of care. The DON stated, "Residents with DNR's are identified by a red folder in the record, a red label on their door and a list posted near the crash cart." The DON was asked if she knew why a resident would have received CPR when they had all of the identifying markers to signify a DNR status. The DON stated, "The LPN checked the chart and wasn't sure if the form (DNR form) was signed. So she erred on caution and began CPR." The DON was asked what interventions had been implemented to prevent a recurrence of the action. She stated, "We started educating the staff today." She was asked if all of the residents with a DNR status had current physician's orders [REDACTED]." The DON was asked if the staff member who performed CPR had been educated on the facility's policy of recognizing a valid DNR. She stated, "We spoke with her the same day, but we don't have anything in writing." On [DATE] at 5:20 p.m., an acceptable plan of removal was provided by the ADM. The plan of removal documented: "Plan of Removal for Immediate Jeopardy related to staff education on DNR policy and procedure [DATE]. 1. The facility has identified all residents with DNR's signed. 2. The facility has placed all DNR's on the charts in red folders. 3. The facility has placed all residents with DNR's name in red paper on the nameplate to their room. 4. The facility has obtained a physician's orders [REDACTED]. 5. The facility has reviewed and/or updated all care plans for residents with DNR's. These care plans will be updated with any DNR changes and with MDS assessments. 6. The facility has inserviced all currently employed nursing staff on the DNR policy which includes: a. DNR orders are to be entered on the physician's orders [REDACTED]. b. Residents with DNR Orders are identified by placing a red nameplate on the door to the resident's room. c. The original or a copy of the DNR order will be placed in a red folder in the front of the resident's chart. d. Resident with no DNR order are identified by placing a green nameplate on the door to the residents room. e. If a resident's DNR status changes, the facility will update the resident's chart and the nameplate identification as described above. This has been completed by [DATE] at 5:16 p.m. 7. The facility will orient all nursing new hires on the DNR policy and procedure (above a-e). New hires will be oriented before administering resident care. 8. The facility will conduct "Code Drills" weekly for one month and den communicate outcomes to the Quality Assurance Committee to monitor effectiveness of the plan. 9. The Quality Assurance Committee will meet monthly to determine need for further code drills or interventions." After interviews were conducted with facility nursing staff from all three shifts, on [DATE], [DATE] and [DATE], it was determined the facility had removed the immediacy by educating the nursing staff on how to correctly identify residents with a DNR status and on Resident Rights regarding honoring resident' wishes. The immediate jeopardy was removed on [DATE] at 9:00 a.m., after the last interviewed staff member was able to verbalize knowledge of the facility's procedure for identifying residents with a DNR status and regarding Resident Rights. The deficient practice remained at a level of actual harm as a pattern with a potential for more than minimal harm. Based on observation, record review and interview, it was determined the facility failed to: a. ensure residents with physicians' orders for DNR status were easily identified and not resuscitated for one (#14) sampled resident who was resuscitated after being found unconscious and; b. ensure residents' DNR status was easily identifiable and on the current physicians' orders for four (#4, 7, 29 and #30) of 10 sampled residents who were documented to have a DNR. and c. ensure residents received Insulin administration when FSBS results indicated. Findings: A facility policy documented, "When medically indicated, CPR should be administered to a Resident in the event of cardiac or respiratory arrest; unless, the Resident has a properly executed DNR order stating the Resident's decision to withhold CPR or the physician caring for an incapacitated Resident in the exercise of reasonable medical judgement determines CPR would not prevent the imminent death of the Resident..." a. CPR on DNR 1. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. An Oklahoma State DNR consent form dated [DATE], was located in the clinical record. The form was signed by the PCP on the back side of the form. A annual assessment dated [DATE], documented the resident was severely impaired in cognition, had unclear speech, and had behaviors. The assessment further documented the resident required extensive assistance with meals, transfers, bed mobility and was totally dependent on staff for toileting. A care plan last updated [DATE], documented, "Problem: I am a DNR code status. Goal: my wishes will be honored this review period and staff will adhere to DNR. Plan of Approach: DNR code status will be identified in chart... educate staff to follow DNR order." A physician's monthly order summary dated [DATE], documented, "DNR STATUS." A facility nurse's note dated [DATE] (sic) (should have been [DATE]) documented, "6:35 p.m., Called to residents room at 1830 (6:30 p.m.) by CNA reporting that resident unresponsive -Upon entry to room, resident noted s/ respirations or pulse. Resident was lowered to the floor and CPR was initiated...CNA instructed to call 911. 6:40 p.m., EMSA (Local ambulance company) & Fire Dept arrive and takes over CPR. This nurse went to gather transfer paperwork. Attempted to call (POA) at (undisclosed number) x 4 attempts no answer. Called residents father...notified of changes, stated he was on his way. (Family member) arrived and requested to stop CPR. Responders advised staff and family member, if CPR stopped, local police and medical examiner would have to be contacted, family member stated that was okay. CPR stopped and local police contacted." The notes were signed by LPN #3. On [DATE] at 9:30 a.m., a tour of the facility was conducted. Surveyors asked the significance of the red label on the residents door tags. LPN #7 stated, "That means they have a DNR on file." On [DATE] at 2:40 p.m., the surveyor who conducted the medication pass, observed there were no airways of various sizes or oxygen available on the emergency cart. The surveyor asked LPN #2 where the supplies were for the emergency cart. LPN #2 stated, "We used them last night, we had a code." On [DATE] at 8:30 a.m., one of the surveyors asked the DON for a list of residents who were coded in the past six months. A list with one name was provided. The named resident was resident #14, who had been coded on [DATE]. On [DATE] at 12:25 p.m., an interview was conducted with the DON, RN Quality Manager and ADM, regarding resident #14 and how his DNR status was not honored on the evening of [DATE], when CPR was initiated on the resident. The DON was asked what happened the evening the resident was coded. She stated she couldn't say what happened since she wasn't there. She stated she was told the resident was found slumped over and "blue." She stated she was told when the resident's chart was checked the staff thought the DNR was unsigned, so they initiated CPR. She was asked why the facility's policy pertaining to Resident Rights and DNR status was not followed. She stated, "That would be a question for staff who were here Sunday ([DATE]) night." The DON was asked what interventions had been put into place to prevent a recurrence from happening again. She stated, "We have started inservicing staff." She was asked when the inservicing was started. She stated, "Today" She was asked what time the inservices had started, she stated, "9:30 a.m." The RN Quality Manager stated she started inservicing staff that day ([DATE]), on how they were to identify residents who were a DNR. When asked how staff were to identify residents with a DNR, she stated, "Red tab on door, red folder in resident's chart, on the MAR and TAR and on the emergency cart, a list of residents who are DNR." When asked why some of the residents identified as being a DNR did not have an order on the current monthly physician's orders [REDACTED]. The DON was asked if the LPN (#3 ) had been counseled regarding not honoring Resident's Rights regarding DNR's. She stated she had not done anything. She further stated, "Nothing on paper." She stated she had spoken with the LPN on Sunday evening. On [DATE] at 12:30 p.m., a telephone interview was conducted with LPN #4, regarding the events on the evening on [DATE]. He stated he was called to the room by CNA #7. Upon assessing the resident he found him to be breathless and without a pulse. He reportedly removed the resident from the bed, placed him on the floor and along with LPN #6, began CPR. He stated during CPR, LPN #3 advised him to stop the CPR because the resident was a DNR. He stated he stopped the CPR and placed the resident back into bed. He further stated when EMSA arrived, they were advised by LPN #3 the resident was a DNR. He stated the first responders informed the facility staff they were required to see the signed DNR form on the record. The front side of the DNR record contained the resident's name only. The bottom portion of the form was folded where the signature was not viewable. Unable to verify the DNR status, EMSA resumed the CPR. LPN #4 stated a family member of the resident arrived to the facility at 6:50 p.m., and requested the CPR be stopped immediately. The family member was advised by the EMSA personnel that once CPR was initiated and if there was no signed DNR, then the local medical examiner and police were to be contacted. He stated the family member agreed with the EMSA personnel and the CPR was stopped. On [DATE] at 1:35 p.m., LPN #6 was interviewed and asked if she knew what the facility procedure was to identify residents who had a DNR status. She stated, "Yes. The color coded tags on the door and a red folder in the record." At 1:45 p.m., LPN #3 was interviewed and asked if she knew what the facility procedure was to identify residents who had a DNR status. She stated, "Yes. They have color coded door tags, a red folder in the chart and they are posted by the crash cart." She was then asked if she knew if Resident #14 was a DNR. She stated, "Yes." At 3:20 p.m., CNA #7 was interviewed and asked about the evening of [DATE]. She stated she set up the resident's meal tray in his room, that the resident was in his bed, and he started eating. She stated she left the room to go assist two other residents, and was gone approximately 20 minutes. The CNA stated when she returned to the resident's room, he was slumped over in his bed. She stated she approached the resident, spoke his name, and shook him, but the resident did not respond. She stated she ran out of the resident's room and told two nurses, LPNs #4 and #6, who were in the medication room at that time. She stated the two LPNs and LPN #3 (the resident's nurse) went to the resident's room, checked for a pulse, then LPN #6 went to get the "crash cart." The CNA further stated she was assigned to go and call "911." She stated the resident was taken from the bed and placed on the floor where CPR was started on the resident by LPN #4, while LPN #3 went to check the resident's chart, where she found out the resident was a DNR. LPN #3 told LPN #4 about the DNR and the CPR was stopped and the resident was returned to the bed. The CNA stated EMSA arrived shortly after the resident was placed back into bed and did not think the resident's DNR was signed, so they started CPR on the resident themselves. She was asked how long CPR was performed by EMSA, she stated, "About 30 minutes." She stated a family member of the resident arrived while EMSA was performing CPR and asked them to stop, at which time the CPR was stopped. She was asked if she knew how to tell if a resident was a DNR or full code status. She stated, "You tell by the sticker on door, if red is a DNR, if green is a full code. If the resident is not in their room, look in their chart for a red folder." She stated she had CPR training, but her card was expired. At 3:40 p.m., an interview was conducted with LPN #3. She was asked if she knew the policy and procedure for DNR status of residents. She stated she was the on duty charge nurse the night they coded resident #14. She stated she knew the system, she just didn't do it. She stated CPR was started on the resident but when they found out he was a DNR, they stopped, but EMSA re-started it (CPR). At 3:45 p.m., CNA #11 was interviewed regarding the evening before when resident #14 was coded and CPR was initiated. She stated she was working the evening before, on hall three. She was asked what she would do if she found a resident unresponsive. She stated she would yell for help and start CPR. At 3:48 p.m., LPN #4 was interviewed regarding resident #14 and the events of the evening before. He stated he was passing medications that evening when the CNA reported the resident was unresponsive. He stated he initiated the CPR, but when he found out the resident had a DNR, he stopped the CPR and placed the resident back into the bed from the floor. He was asked how residents with a DNR were identified. He stated, "A red chart in the chart signifies a DNR." He stated he didn't look at the resident's chart before starting CPR. He stated he was in the medication room when the CNA reported the resident was unresponsive and didn't have time to look. At 3:53 p.m., LPN #5 was asked how to tell if a resident was a DNR status. She stated the only way to tell a resident's DNR status was to look in the chart. At 4:00 p.m., LPN #6 was asked about the events that took place Sunday night ([DATE]). She stated she was present when resident #14 was coded. She was asked how to identify a resident's DNR status. She stated the red tag on the door and in their chart. She was asked what she would do if she found a resident unresponsive. She stated she would start CPR. She stated she would rather error on the side of saving a life because she could always stop the CPR. At 4:30 p.m., each resident room on each hall was checked to determine which residents were DNR status. Eighteen residents were identified with red name plate tags. Residents #8, 13, 35, and #36 on the First hall, #3, 4, 7, 18, 29, and #37 on the Second Hall, #1, 16, and #38 on the Third Hall, and #25, 28, 30, 39, and #40 on the Fourth Hall. Of the 18 residents, four residents were found not to have the DNR order on their most current physician's orders [REDACTED]. On [DATE] at 7:58 a.m., LPN #8 was interviewed regarding inservice training she was provided by the facility. She stated she was given training on [DATE], regarding DNR's. She was asked how to identify residents with a DNR. She stated by the red folder in their charts, by the red tag on their doors, by the list on the crash cart and by their physician's orders [REDACTED]. She stated she would look outside the room door. She stated if it occurred in the dining room, she would be with the resident and would have someone else check the resident's chart. At 10:00 a.m., CNA #12 was interviewed regarding inservice training she was provided by the facility. She was asked how to tell which residents were a DNR. She stated, "Who?" She was asked again how to identify which residents had a DNR. She stated, "I check the ADL book." She was asked to show the surveyor what she meant. She stated, "Wait, I ask the nurses." She was asked if she had any way of knowing who was a DNR. She stated, "No." At 12:50 p.m., LPN #3 was interviewed by telephone. She was asked what the facility's procedure was if a resident was found unresponsive. She stated she hadn't been trained to do everything. She further stated, "We start CPR." She was asked how she knew who was a DNR. She stated by looking at the doorway labels. She stated, "Red DNR, green Go. Also red folder in charts." She was asked about the evening when resident #14 coded. She stated, "I didn't notice, it didn't register." She stated the CNA notified LPN #6 about the resident being unresponsive and when they entered the resident's room he was unresponsive, with no respirations and no pulse. She stated LPN #4 did chest compressions while LPN #6 did the respirations with the ambu-bag. She stated when EMSA arrived they took over the CPR. She stated she went to get the resident's chart and saw the doctor's order for DNR while copying the orders. LPN #3 stated she told EMSA of the DNR order and they discontinued the CPR while they checked the DNR form. She stated EMSA personnel resumed CPR after stating the DNR form had no signature, so therefore was not valid and they were obligated to continue CPR. At 2:05 p.m., CNA #3 was interviewed regarding inservice training she was provided by the facility and what the training was about. She stated she was given inservice training on DNR's and how to identify residents who had a DNR. She stated if the resident was a DNR, they would have a red name tag outside their door, their chart would have red marking on it, and a list by the crash cart highlighted in "pink." She stated as a CNA she wasn't allowed to get into a resident's chart. She was asked what she would do if she noticed a resident unresponsive. She stated she would "hit" the call light, look at the name tag outside the resident's door and notify the nurse. At 2:10 p.m., LPN #7 was interviewed regarding inservice training she was provided by the facility and what the training was about. She stated she was given inservice training on DNR's and how to identify residents who had a DNR. She stated there were color codes on the resident's door, a red folder in the chart and a list over by the crash cart identifying residents who were a DNR status. She was asked if she was told anywhere else to look for a resident's DNR status. She stated, "Not that I can think of." At 2:15 p.m., CNA #4 was interviewed regarding inservice training on DNR's and how to identify residents who had a DNR. She stated she was provided inservice training yesterday ([DATE]). She stated it was over "red and green stars" to identify if a resident was a DNR or not. She was asked if she was told anything else. She stated, "That's about it. short inservice over the phone." She stated she didn't sign the inservice sheet. At 2:20 p.m., CNA #5 was interviewed regarding inservice training on DNR's and how to identify residents who had a DNR. He stated he was provided inservice training yesterday ([DATE]), "Over DNR, I think." He further stated there were red and green tags outside residents' doors. He stated the red tag is do not resuscitate. He stated residents' charts had a red folder in them if the resident was a DNR and there was a list over by the crash cart. When asked if there were any other ways to identify residents with a DNR. He stated, "That's it." At 3:20 p.m., CNA #8 was interviewed regarding inservice training on DNR's and how to identify residents who had a DNR. She stated she was provided inservice training yesterday ([DATE]), "Code/DNR." She was asked what she was taught. She stated she was told the difference between the red and green tags on the doors and what they stood for. She further stated residents with a DNR would have a red folder in their charts and a list of DNR's was "above" the crash cart. She was asked what she would do if a resident in their room was found unresponsive. She stated, "If resident in room, look at door name tag. If in the dining room look above the crash cart." At 3:25 p.m., CNA #2 was interviewed regarding inservice training provided by the facility. He stated he started working at the facility on [DATE], and was given inservice training then. He was asked if he had been provided with inservice training on [DATE]. He stated he was off work on the 27th and had just came back to work that day. He was asked if anyone from the facility called to give him inservice training over the telephone, or since he returned to work that day. He stated he had not been called when he was off work nor had he received any inservice training since he came on duty at 3:00 p.m. (This employees name was included on the list given by the facility as having been provided inservice training by telephone on [DATE], over DNR's) At 4:20 p.m., CNA #2 was interviewed again. He was asked how he would identify if a resident was a DNR. He stated, "They'd have it on them somewhere." He was asked what he would do if he found a resident unresponsive. He stated, "Get my charge nurse." He was asked again how to identify a resident's DNR status. He stated, "Get my charge nurse." At 4:30 p.m., CNA #6 was interviewed regarding inservice training provided by the facility. She stated she was called by the facility yesterday ([DATE]). She stated she came up to the facility and was given an overview of her understanding of what a DNR was and how to identify if a resident was a DNR. She was asked what she was taught. She stated the resident's name on the door would be red if a DNR, a red "tag" would be on their chart, look in the med book for an order for [REDACTED]. On [DATE] at 6:45 a.m., CNA #1 was interviewed regarding inservice training provided by the facility. She stated she was given inservice training Wednesday ([DATE]) on DNR's. She stated everyone was told the resident's name tag outside their door would be in red if they were a DNR and if it was green they were to start CPR. She stated there was also a list by the crash cart, and in the residents' charts would be a red file if they were a DNR. On [DATE] at 8:20 a.m., the ADM and DON were interviewed regarding the IJ and when it would be lifted. They were told numerous interviews were conducted with staff from all shifts, regarding DNR's and how staff could identify residents who were a DNR status. They were told all staff with the exception of one, were able to affirm they had been inserviced and received training over DNR's and were knowledgeable over what they had been taught. Explained to the ADM and DON that facility documentation indicated CNA #2 was given the inservice training via telephone, but he denied receiving any training either by telephone or since returning to work on [DATE]. Explained that the CNA was asked questions pertaining to DNR and what to do in order to identify if a resident was a DNR status. Explained the CNA had no knowledge of the inservice information supposedly given to him. The ADM stated, "We will need to investigate." The ADM and DON were told the IJ would not be lifted until there was evidence to show CNA #2 had been inserviced and had a clear knowledge of how to identify residents with a DNR status. Both nodded their heads in an affirmative manner and the ADM stated, "OK. I understand." At 9:00 a.m., an interview was conducted with CNA #2. He stated he was called by the DON that morning ([DATE]) and asked if he had received a telephone call to come in for an inservice. He stated he told the DON he had not been called by anyone at the facility until that morning. He stated he was asked to come in for inservice training. He stated he came in and was given inservice training on DNR status. He was asked what he had been taught. He stated he was told to look at the residents name tags outside their doors. If the tag was green, then the resident wanted CPR. If the tag was red, the resident did not want to be resuscitated. He stated if a resident was in the dining room and became unresponsive, then they could identify which residents were a DNR by the list of resident names at the crash cart. He further stated the resident's charts contained a red folder which indicated the resident was a DNR. b. DNR on physicians orders 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was cognitively intact and independent with most ADL's. The August monthly physician's orders [REDACTED]. 3. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition and required limited assistance with most ADL's. The August monthly physician's orders [REDACTED]. 4. Resident #29 was admitted to the facility with [DIAGNOSES REDACTED]. The August monthly physician's orders [REDACTED]. 5. Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. The August monthly physician's orders [REDACTED]. c. Insulin administration 6. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident was cognitively impaired in cognition but able to make his needs known. A physician's orders [REDACTED]. ,[DATE] = NONE ,[DATE] Give 2 Units SQ chart site. ,[DATE] Give 4 units SQ chart site. ,[DATE] Give 6 units SQ chart site. ,[DATE] Give 8 units SQ chart site. above 400 give 12 units SQ and call MD re-check Q 2 hr, call MD if BS remain above 400." On [DATE] at 6:30 a.m., FSBS of 222, which required the resident to receive 4 units of insulin. The record did not document the administration of the required dose. On [DATE] at 11:30 a.m., FSBS of 300, which required the resident to receive 6 units of insulin. The record did not document the administration of the required dose. On [DATE] at 4:30 p.m., FSBS of 421, which required the resident to receive 12 units of insulin. The record did not document the administration of the required dose. On [DATE] at 6:30 a.m., FSBS of 247, which required the resident to receive 6 units of insulin. The record did not document the administration of the required dose. On [DATE] at 4:30 p.m., FSBS of 456, which required the resident to receive 12 units of insulin. The record did not document the administration of the required dose. On [DATE] at 8:00 p.m.,FSBS of 313, which required the resident to receive 8 units of insulin. The record did not document the administration of the required dose. On [DATE] at 6:30 a.m., FSBS of 210, which required the resident to receive 4 units of insulin. The record did not document the administration of the required dose. On [DATE] at 4:30 p.m., FSBS of 230, which required the resident to receive 4 units of insulin. The record did not document the administration of the required dose. On [DATE] at 8:00 p.m., FSBS of 210, which required the resident to receive 4 units of insulin. The record did not document the administration of the required dose. [DATE] [DATE] at 4:30 p.m., FSBS of 380. Twelve units of insulin were required. The record did not document the administration of the required dose. [DATE] at 8:00 p.m., FSBS of 365. Twelve units of insulin were required. The record did not document the administration of the required dose. [DATE] at 8:00 p.m., FSBS of 384. Twelve units of insulin were required. The record did not document the administration of the required dose. [DATE] at 4:30 p.m., FSBS of 350. Eight units of insulin were required. The record did not document the administration of the required dose. On [DATE] at 6:30 a.m., FSBS of 229. Four units of insulin were required. The record did not document the administration of the required dose. [DATE] at 8:00 p.m., FSBS of 271. Six units of insulin were required. The record did not document the administration of the required dose. On [DATE] at 11:30 a.m., FSBS of 159. Two units of insulin were required. The record did not document the administration of the required dose. [DATE] at 8:00 p.m., FSBS of 200. Four units of insulin were required. The record did not document the administration of the required dose. [DATE] at 4:30 p.m., FSBS of 272. Six units of insulin were required. The record did not document the administration of the required dose. [DATE] at 8:00 p.m., FSBS of 223. Four units of insulin were required. The record did not document the administration of the required dose. [DATE] at 11:30 a.m., FSBS of 184. Four units of insulin were required. The record did not document the administration of the required dose. [DATE] at 4:30 p.m., FSBS of 264. Six units of insulin were required. The record did not document the administration of the required dose. [DATE] at 8:00 p.m., FSBS of 416. Twelve units of insulin were required. The record did not document the administration of the required dose. On [DATE] at 6:30 a.m., FSBS of 326. Eight units of insulin were required. The record did not document the administration of the required dose. On [DATE] at 4:30 p.m., FSBS of 295. Six units of insulin were required. The record did not document the administration of the required dose. On [DATE] at 3:55 p.m., an interview with LPN #5 was conducted. She was asked what the process was when a resident's FSBS was > than 400. She stated the physician would be called and the FSBS would be rechecked after two hours. She also stated she would check the parameters for the sliding scale and give insulin as ordered. She was asked why the information regarding the FSBS results and/or insulin injections were missing from the diabetic flow sheet. She stated "The night shift forgot to chart it." At 4:02 p.m., an interview was conducted with the DON. She was asked what documentation was required if a resident had a FSBS and sliding scale insulin ordered. She stated the results of the FSBS needed to be recorded, as well as the type and amount of sliding scale insulin administered.

Based on observation, record review and interview, it was determined the facility failed to ensure residents' were showered in water at a comfortable temperature. This resulted in actual harm for one (#28) sampled resident observed being showered in water that was below normal body temperature, who was unable to verbalize discomfort, but made jerking movements and facial grimacing. This affected three (#8, 11, and #13 ) of 28 sampled residents who complained of the water temperatures in the shower being too cold. This had the potential to affect an additional 42 residents in the facility who were bathed in the showers. Findings: The facility policy titled "Water Temperature" documented, "State licensure requires water temperature in the resident bath and toilet areas to fall in a range between 100 degrees and 115 degrees... " 1. On 08/26/13, between 10:08 a.m. and 10:33 a.m., water temperatures were obtained on the first hall, fourth hall and the shower/sink on the fourth hall. The following results were obtained: 10:08 a.m. - the water temperature in the hand sink of room eight on the first hall - 96 degrees Fahrenheit after running for two minutes. 10:12 a.m. - the water temperature in the hand sink of room [ROOM NUMBER] on the first hall - 93.6 degrees Fahrenheit after running for three minutes. 10:14 a.m. - the water temperature in the hand sink of room [ROOM NUMBER] on the first hall - 94 degrees Fahrenheit after running for three minutes. 10:18 a.m. - the water temperature in the hand sink of room [ROOM NUMBER] on the fourth hall - 91.8 degrees Fahrenheit after running for four minutes. 10:23 a.m. - the water temperature in the hand sink of room [ROOM NUMBER] on the fourth hall - 92 degrees Fahrenheit after running for two minutes. 10:26 a.m. - the water temperature in the hand sink of room [ROOM NUMBER] on the fourth hall - 89.2 degrees Fahrenheit after running for two minutes. 10:31 a.m. - the water temperature in the shower located on hall four - 75.5 degrees Fahrenheit after running for seven minutes. 10:33 a.m. - the water temperature in the hand sink in the shower room located on hall four was - 92.1 degrees Fahrenheit after running for four minutes. 2. Resident #28 was admitted to the facility with [DIAGNOSES REDACTED]. An annual comprehensive assessment dated [DATE], documented the resident had severe cognitive deficits and required total staff assistance with dressing, hygiene and bathing. The resident's care plan dated 08/30/12 ,and last updated 08/26/13, documented, "Problem: I am incontinent of urine. Plan of Approach: ...Shower or bath as schedule (sic)... " On 08/28/13 at 9:34 a.m., the resident was taken to the shower room to be showered. The water temperature was tested by the surveyor. The reading was 95.1 degrees Fahrenheit after being ran for eight minutes by CNA #10 (a Hospice CNA). When placed into the water by the CNA, the resident grimaced and pulled her lower left extremity away from the water. The water temperature was re-tested six minutes after the shower was started. The temperature reading was 94.2 degrees Fahrenheit. The resident was fully bathed in water temperatures that were less than a person's normal body temperature of 98.6 degrees Fahrenheit. The Hospice nurse was overheard asking the Hospice CNA, "How's the water doing?" The Hospice CNA stated, "OK, I guess." 3. During a confidential resident group interview conducted on 08/27/13 at 9:00 a.m., the residents were asked about dignity and how they were treated by staff, including residents who were unable to speak for themselves. They all stated residents who were unable to speak for themselves, were "ignored." They stated some staff talked "down" to them. The residents were asked if they were able to voice grievances to the facility and have their grievance resolved. The residents stated there had been problems with cold showers and they had voiced this problem to staff and during their resident council meetings, but the problem had not been resolved. They stated the water in the showers was still cold. 4. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 08/27/13 at 4:45 p.m., a quality of life interview was conducted. The resident was asked if she had ever refused care from the staff. She stated, "Only when I'm supposed to shower and the water is too cold." 5. On 08/28/13 at 10:29 a.m., resident #11 was interviewed regarding the water temperature in the shower. He stated his showers were "lukewarm, never hot." 6. On 08/28/13 at 10:47 a.m., facility water temperature logs were reviewed from January 2013 through July 2013, the following temperature ranges were documented. There was no documentation to identify the source of the temperatures: January 4, 2013 - hall three 116 degrees Fahrenheit and hall four 120 degrees Fahrenheit. January 23, 2013 - the shower on hall three was 111 degrees Fahrenheit and the shower on hall four was 112 degrees Fahrenheit. January 24, 2013 - hall three and hall four 112 degrees Fahrenheit. January 28, 2013 - hall four 103 degrees Fahrenheit and hall three 102 degrees Fahrenheit. February 6, 2013 - hall three 103 degrees Fahrenheit and hall four 105 degrees Fahrenheit. February 25, 2013 - hall three 93 degrees Fahrenheit and hall four 102 degrees Fahrenheit. February 26, 2013 - hall three 99 degrees Fahrenheit. March 2013 - hall three 100 degrees Fahrenheit and hall four 98 degrees Fahrenheit. April 22, 2013 - hall three 102 degrees Fahrenheit and hall four 105 degrees Fahrenheit. May 2013 - hall four 104, 102 and 105 degrees Fahrenheit. June 2013 - hall four 108 degrees Fahrenheit. July 2013 - hall four 110 degrees Fahrenheit. This was the only documentation of water temperatures provided by the facility maintenance supervisor. There was no documentation of any water temperatures being obtained for the month of August 2013. 7. On 08/28/13 at 2:08 p.m., hot water temperature in the hand sink of room [ROOM NUMBER] was obtained. The temperature was 83.5 degrees Fahrenheit after the water was ran for two minutes. At 2:14 p.m., the hot water temperature in the hand sink of room [ROOM NUMBER] was obtained. The temperature was 95.6 degrees Fahrenheit after the water was ran for two minutes. At 2:15 p.m., the hot water temperature in the hand sink of room [ROOM NUMBER] was obtained. The temperature was 98 degrees Fahrenheit. 8. Resident # 13 was admitted to the facility with [DIAGNOSES REDACTED]. On 08/28/13 at 4:00 p.m., a quality of life interview was conducted. The resident was asked what the staff's response was if he happened to refuse care. He stated they would come back later. He was then asked what the reason was for the refusal of care. He stated, "Well.. the shower water is real cold sometimes, and I won't get in it." The surveyor asked if he had notified the staff of the cold water. He stated, "Shoot, they know, they right there with us." 9. On 08/29/13 at 4:02 p.m., an interview was conducted with the DON regarding cold water in the showers. She stated, "In past we've had problems numerous times. Have tried to fix it. To my knowledge it was fixed." She stated someone had been called that day regarding the cold water temperatures.

Based on observation, record review and interview, it was determined the facility failed to: a. implement the care plan to provide assistance during meals for one (#14) of two sampled residents who required staff assistance with meals. b. follow the care plan for DNR status for one (#14) sampled resident who had a signed DNR on record. The facility Census and Condition of Residents report identified an additional eight residents who required assistance with meals. The DON identified 19 additional residents who had a signed DNR status on record. The facility's failure to ensure the resident was assisted with meals resulted in an actual harm for resident #14. Findings: Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. A monthly ADL tracking record dated [DATE], documented the resident received supervision with limited assistance with every meal and physical assistance from a staff member eight times during the same 30 day time period. A annual assessment dated [DATE], documented the resident was severely impaired in cognition, had unclear speech, and had behaviors. The assessment further documented the resident required extensive assistance with meals, and was totally dependent on staff for toileting. A care plan last updated [DATE], documented, "Problem: I am on a regular diet, NCS with large portions, I eat in the dining room at the feeders table... Goal: I will be properly hydrated and nourished to potential as tolerated. Plan of approach: ...Assist with all meals as needed... Problem: I am a DNR code status. Goal: my wishes will be honored this review period and staff will adhere to DNR. Plan of Approach: DNR code status will be identified in chart... educate staff to follow DNR order." A monthly physician's orders [REDACTED]. Regular diet, NCS. Nectar Thick liquids keep HOB ^ 30 degrees when eating." A monthly ADL tracking record dated [DATE], documented the resident received supervision with limited assistance with every meal from [DATE] through [DATE]. The record further documented the resident was totally dependent on staff for two evening meals during the month, and required physical assistance eight times during the same time frame. A facility nurse's note dated [DATE] (sic-should have been [DATE]), documented, "6:35 p.m., Called to residents room at 1830 (6:30 p.m.) by CNA reporting that resident unresponsive -Upon entry to room, resident noted s/ respirations or pulse. Resident was lowered to the floor and CPR was initiated...CNA instructed to call 911. 6:40 p.m., (Local ambulance company) & Fire Dept arrive and takes over CPR. This nurse went to gather transfer paperwork. Attempted to call (POA) at (undisclosed number) x 4 attempts no answer. Called residents father...notified of changes, stated he was on his way. (Family member) arrived and requested to stop CPR. Responders advised staff and family member, if CPR stopped, local police and medical examiner would have to be contacted, family member stated that was okay." CPR stopped and local police contacted." The notes were signed by LPN #3. CNA #7 was interviewed and asked about the above nursing notes. She stated the resident was eating his dinner in his room, on the side of his bed. She further stated she was called away by another resident and when she returned she found the resident to be unresponsive. Surveyors asked the CNA if the resident was still eating when she left him. She stated he was. On [DATE] at 09:30 a.m., a confidential staff interview was conducted regarding the above nursing note. The staff member was asked if the resident often ate his meals in the room. They stated, "Mr (Resident), oh my God. No! He ate in the dining room, he had to be fed." The staff person was then asked if the resident's care plan documented he was to be assisted with meals. They stated, "Oh, yes." They were then asked if they thought the resident could have aspirated while eating. They stated, "Oh yes. Definitely, there was food all over the room. I'm sure he choked." At 1:45 p.m., LPN #3 was interviewed by phone and asked if she knew what the facility policy was for identifying residents with a DNR status. She stated, "Yes, they have color coded door tags, a red folder in the chart and their name is posted by the crash cart." She was then asked if she knew if resident #14 was a DNR. She stated, "Yes." When asked if the resident was eating dinner in his room, she stated, "No." When asked why CPR was initiated on the resident, she stated, "That's what we're trained to do..." On [DATE] at 5:30 p.m., an interview was conducted with the DON. She was asked if it was facility policy to care for the residents based on the care plan. She stated, "The care plan drives the care, so yes it is."